Primary cardiac and pericardial neoplasms: radiologic-pathologic correlation

Lobulated Hemangioma as a Rare Cause of Tricuspid Regurgitation

Introduction

Cardiac hemangioma is one of the rarest tumors, with only a few cases described. Unlike other cardiac tumors, its symptoms are nonspecific, making misdiagnosis easy. Cardiac hemangioma can present with various clinical manifestations, including valve disorder, arrhythmia, pericardial effusion, and embolism. Echocardiography is the most direct examination, and surgical resection the simplest and most effective treatment.

Patients and methods

We present a new case of lobulated cardiac hemangioma causing tricuspid regurgitation and discuss the clinical features, diagnosis, and treatment of this rare tumor.

Results

After surgical resection and tricuspid valve replacement, the patient recovered well.

Conclusion

For cardiac hemangiomas involving the tricuspid valve, tumor resection combined with valve surgery is an effective treatment option.

Cardiac Mass in a 78-Year-Old Patient With a History of Cancer: Diagnostic and Treatment Challenges

Primary cardiac angiosarcoma is a rare, aggressive malignancy that commonly metastasizes to various organs. The presenting symptoms are typically nonspecific, so a comprehensive examination is required to confirm the diagnosis promptly. This case report describes the presentation of an older patient with a history of neoplasms. Echocardiography and biopsy were performed, but despite surgical intervention to resect a large right atrial mass, the patient died. A final diagnosis of primary angiosarcoma was made based on the resected specimen.

Malignant cardiac neoplasms and associated malignancies over 16 years in the USA

BACKGROUND

Malignant cardiac neoplasms (MCNs), both primary and metastatic, are rare with few epidemiologic studies.

METHODS

This retrospective study used the Healthcare Utilization Project/Nationwide Inpatient Sample database from 2002 to 2018 to evaluate the co-occurrences with other malignancies, and mortality of MCNs in the USA.

RESULTS

The data contained 7207 weighted discharges of MCN. Median patient age was 51.4 years, 52.29 % were male, in-hospital mortality was 10.51 %, mean cost of hospitalization was $34,280 USD. Lung, mediastinum, and airways were the most common primary cancers associated with metastatic MCN.

CONCLUSIONS

MCN are rare in the USA, however they carry a high in-hospital mortality, high morbidity, and hospital cost.

Brain radiotherapy and anlotinib control primary cardiac angiosarcoma with metastases: A case report

RATIONALE

Primary cardiac angiosarcoma (PCA) is a rare and fatal disease with a poor prognosis. Whether the survival of PCA patients can be prolonged with additional treatment following complete surgical excision is controversial.

PATIENT CONCERNS

In this case study, a 52-year-old male complained of chest tightness and pain for 7 days before admission into the hospital. Subsequently, he revisited the hospital because of dizziness and headache.

DIAGNOSES

Initially, the patient was diagnosed with PCA in the right atrium by thoracic computed tomography (CT). Palliative resection identified brain, lung, and liver metastases.

INTERVENTION

The patient accepted multimodal combination therapy, including first-line chemotherapy and then second-line anlotinib concurrent with brain radiotherapy and immunotherapy.

OUTCOME

Although anlotinib combined with brain radiotherapy controlled the growth of intracranial lesions, progression-free survival (PFS) was only 5 months, and the overall survival (OS) was only 12 months.

LESSON

The treatment for metastatic PCA needs an in-depth exploration.

Renal Embolism Associated with the Atrial Myxoma: A Case Report and Literature Review

Renal embolisms due to cardiac myxomas are extremely rare; the clinical course, treatment, and prognosis of this disease are not established. A 69-year-old Japanese woman who underwent a nephrectomy for renal cell carcinoma 3 years earlier was hospitalized with a right occipital lobe cerebral infarction. Her renal function suddenly worsened 3 days post-admission: her serum creatinine rose from 1.46 mg/dL to 6.57 mg/dL and then to 8.03 mg/dL the next day, and hemodialysis therapy was started. Abdominal computed tomography (CT) scans showed patchy non-contrasted low-density areas in the right kidney, and chest CT scans and transesophageal ultrasonography revealed a left atrial tumor. We diagnosed renal infarction due to a left atrial myxoma. Hemodialysis and anticoagulant therapy (heparin) were continued, followed by the cardiac myxoma's resection. The patient's renal function gradually improved post-surgery, and the hemodialysis was discontinued. Considering our patient and 19 other case reports of renal infarction associated with cardiac myxoma, the treatment for such a renal infarction and the outcomes differ depending on the embolus site. The poor outcome of abdominal aortic embolism requires a prompt embolectomy, whereas a branch renal artery embolism requires anticoagulation therapy to prevent thrombosis formation around the myxoma.

Clinical characteristics and surgical outcomes of cardiac myxoma: A meta-analysis of worldwide experience

Cardiac myxoma is the most common primary cardiac tumor. However, existing literature mainly consists of single-center experiences with limited subjects. This systematic review aimed to provide data on clinical characteristics and surgical outcomes of cardiac myxoma. We performed a thorough literature search on May 23, 2023 on PubMed, ProQuest, ScienceDirect, Scopus, and Web of Science. The inclusion criteria were English full-text, observational studies, and included >20 subjects. From the search, 112 studies with a total of 8150 patients were included in the analysis. The mean age was 51 years (95 % confidence interval [95%CI] = 49.1-52.3), and the majority were females (64.3 % [95 % CI = 62.8-65.8 %]). The most common clinical manifestation was cardiovascular symptoms. Echocardiography can diagnose almost all cases (98.1 % [95 % CI = 95.8-99.6 %]). Cardiac myxoma was mostly prevalent in left atrium (85.3 % [95%CI = 83.3-87 %]) and predominantly with pedunculated morphology (75.6 % [95%CI = 64.1-84.3 %]). Post-tumor excision outcomes were excellent, with an early mortality of 1.27 % (95 % CI = 0.8-1.8 %), late mortality rate of 4.7 (95 % CI = 2.5-7.4) per 1000 person-years, and recurrence rate at 0.5 (95 % CI = 0.0-1.1) per 1000 person-years. Tumor excision is warranted in a timely manner once the cardiac myxoma diagnosis is established.

A Rare Case of Atrial Septal Mass Secondary to Lymphoma: Case Report and Review of Literature

The antemortem diagnosis of secondary cardiac involvement by lymphoma remains suboptimal. Prognosis is worse with delayed diagnosis as the tumor burden increases with the multicompartment participation. Chemotherapy may improve survival, but there is a risk of mortality due to treatment-related complications, such as myocardial rupture and fatal arrhythmias. Modified chemotherapy regimens may prevent such complications, but the data are limited. We report the case of a 72-year-old woman diagnosed with diffuse large B-cell lymphoma with cardiac involvement, where early diagnosis prevented cardiac complications from the disease and its treatment as well. The aim of this case report is to highlight the fact that cardiac involvement in lymphoma is frequent and can be easily missed, leading to complications. Treatment requires an individualized approach.

Case series: cardiac sarcoma

Background

Cardiac masses encompass a wide differential including primary and secondary malignancies and can present with a variety of symptoms, many of which are non-specific. Early identification and classification are important, particularly for cardiac malignancies such as sarcomas as these are aggressive tumours with exceptionally poor prognoses when metastases are present at diagnosis.

Case summary

We report two cases of patients who presented with dyspnoea and were diagnosed with cardiac sarcomas; the former a primary sarcoma (undifferentiated pleomorphic subtype) and the latter a secondary sarcoma (round cell myxoid liposarcoma) that serve as comparisons for presentation and management of different types of this disease. Computed Tomography (CT) and echocardiography imaging findings are demonstrated showing the typical location and morphology of each subtype.

Discussion

Cardiac sarcomas are the most common primary cardiac malignancy, of which undifferentiated pleomorphic sarcoma is a common subtype. Undifferentiated pleomorphic sarcomas are aggressive, have a tendency to arise in the left atrium, and can appear similar to benign cardiac masses. Round cell myxoid liposarcomas by contrast are rare causes of secondary cardiac malignancies, metastasizing to the heart from soft tissues. Both diagnoses carry poor prognoses and although rare, are important to recognize as timely intervention with surgery, radiotherapy, and consideration of chemotherapy is key to maximizing survival.

Cardiac and Pericardial Neoplasms in Children: Radiologic-Pathologic Correlation

Primary cardiac and pericardial neoplasms are rare in the pediatric population and can include both benign and malignant lesions. Rhabdomyomas, teratomas, fibromas, and hemangiomas are the most common benign tumors. The most common primary cardiac malignancies are soft-tissue sarcomas, including undifferentiated sarcomas, rhabdomyosarcomas, and fibrosarcomas. However, metastatic lesions are more common than primary cardiac neoplasms. Children with primary cardiac and pericardial tumors may present with nonspecific cardiovascular symptoms, and their clinical presentation may mimic that of more common nonneoplastic cardiac disease. The diagnosis of cardiac tumors has recently been facilitated using noninvasive cardiac imaging. Echocardiography is generally the first-line modality for evaluation. Cardiac MRI and CT are used for tissue characterization and evaluation of tumor size, extension, and physiologic effect. The varied imaging appearances of primary cardiac neoplasms can be explained by their underlying abnormality. Treatment of these lesions varies from conservative management, with spontaneous regression of some lesions such as rhabdomyomas, to surgical resection, particularly in patients with associated heart failure. With adequate imaging techniques and knowledge of the pathologic basis of the neoplasm, it is often possible to differentiate benign from malignant tumors, which can greatly affect adequate and timely treatment. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

A Case of Pericarditis and Pericardial Masses Associated With Mycobacterium Paragordonae

Tuberculosis is a common cause of pericarditis worldwide and has been associated with pericardial masses. Non-tuberculous mycobacteria are uncommonly associated with cardiac disease, having primarily been described in cases of endocarditis. Here we describe a case of an immunocompetent patient with Mycobacterium paragordonae infection causing pericarditis with a large effusion containing pericardial masses. The patient presented with chest pain, hypoxia and biochemical evidence of inflammation (CRP 216.1 mg/L). This report illustrates a rare case of pericarditis with pericardial masses associated with non-tuberculous mycobacteria and the first example of pericarditis associated with M. paragordonae.

Case report and analysis of the literature on sarcomatous mesothelioma of the left atrium

INTRODUCTION AND IMPORTANCE

Primary intracardiac malignant mesothelioma is an extremely uncommon condition with a terrible prognosis. Because of its rarity, there have been extremely few examples described in the literature.

CASE PRESENTATION

We are reporting the instance of a 44-year-old lady who was referred to the department of cardiology for worsening dyspnea, palpitations, and a recent syncopal episode. On examination, the patient had signs of global heart failure. Cardiac imaging showed a tissue mass infiltrating the atrioventricular sulcus at the mitral valve level, responsible for severe mitral stenosis. Pleural effusion without an intrapleural mass was also noted. Urgent surgery was performed, including excision of the tumor mass, mechanical replacement of the mitral valve, and tricuspid plasty. The anatomo-pathological study concluded in cardiac mesothelioma. The patient was transferred back to the cardiology department 9 months after surgery due to severe left heart failure. TTE and TOE were performed and revealed tumor recurrence responsible for severe mitral stenosis. The course was marked by the onset of cardiogenic shock refractory to treatment, followed by the death of the patient. The case we are reporting seems to be the initial instance documented as exclusively primary intracardiac mesothelioma especially its lack of association with any other pleural sarcomatoid mesothelioma or asbestos exposure.

CLINICAL DISCUSSION

In cases where a large atrial tumor is present, prompt surgical intervention is recommended to mitigate the risk of catastrophic embolization or valve orifice obstruction. The objective of surgical intervention is to excise the entire neoplasm with sufficient surrounding tissue, a feat that is infrequently achievable. Palliative debulking may be a beneficial intervention for patients who do not necessitate complete resection, particularly those experiencing relevant or rapidly escalating symptoms. Cardiac transplantation remains a viable option in the event of an unresectable malignant tumor.

CONCLUSION

The short-term prognosis is poor. Surgical treatment remains the best treatment for this type of tumor. Total excision should be considered, but may not be feasible in all cases. Adjuvant chemotherapy may be considered.

The Evolving Etiologic and Epidemiologic Portrait of Pericardial Disease

Pericardial disease includes a variety of conditions, including inflammatory pericarditis, pericardial effusions, constrictive pericarditis, pericardial cysts, and primary and secondary pericardial neoplasms. The true incidence of this varied condition is not well established, and the causes vary greatly across the world. This review aims to describe the changing pattern of epidemiology of pericardial disease and to provide an overview of causative etiologies. Idiopathic pericarditis (assumed most often to be viral) remains the most common etiology for pericardial disease globally, with tuberculous pericarditis being most common in developing countries. Other important etiologies include fungal, autoimmune, autoinflammatory, neoplastic (both benign and malignant), immunotherapy-related, radiation therapy-induced, metabolic, postcardiac injury, postoperative, and postprocedural causes. Improved understanding of the immune pathophysiological pathways has led to identification and reclassification of some idiopathic pericarditis cases into autoinflammatory etiologies, including immunoglobulin G (IgG)4-related pericarditis, tumour necrosis factor receptor-associated periodic syndrome (TRAPS), and familial Mediterranean fever in the current era. Contemporary advances in percutaneous cardiac interventions and the recent COVID-19 pandemic have also resulted in changes in the epidemiology of pericardial diseases. Further research is needed to improve our understanding of the etiologies of pericarditis, using the assistance of contemporary advanced imaging techniques and laboratory testing. Careful consideration of the range of potential causes and local epidemiologic patterns of causality are important for the optimization of diagnostic and therapeutic approaches.

Imaging of Malignant Pleural, Pericardial, and Peritoneal Mesothelioma

Malignant mesothelioma is a rare tumor arising from the mesothelial cells that line the pleura, pericardium, peritoneum, and tunica vaginalis. Imaging plays a primary role in the diagnosis, staging, and management of malignant mesothelioma. Multimodality imaging, including radiography, computed tomography (CT), magnetic resonance imaging (MRI), and F-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT), is used in a variety of scenarios, including diagnosis, guidance for tissue sampling, staging, and reassessment of disease after therapy. CT is the primary imaging modality used in staging. MRI has superior contrast resolution compared with CT and can add value in terms of determining surgical resectability in equivocal cases. MRI can further assess the degree of local invasion, particularly into the mediastinum, chest wall, and diaphragm, for malignant pleural and pericardial mesotheliomas. FDG PET/CT plays a role in the diagnosis and staging of malignant pleural mesothelioma (MPM) and has been shown to be more accurate than CT, MRI, and PET alone in the staging of malignant pleural mesothelioma. PET/CT can also be used to target lesions for biopsy and to assess prognosis, treatment response, and tumor recurrence.

Multimodality Imaging Appearance of Intrapericardial Paragangliomas

Paragangliomas are neuroendocrine tumors of the sympathetic and parasympathetic nervous system that originate from neural crest cells. Less than 1% of paragangliomas are found in the heart, originating from intrinsic cardiac ganglia cells in the posterior wall the atria, atrioventricular groove, and along the root of the great vessels. A 10-year review of our institution's database identified nine patients who had documented intrapericardial paragangliomas. We describe the multimodality imaging appearance of these tumors. The most common findings include embedment and wrapping around the great vessels and atrioventricular groove within the confines of the pericardium, markedly avid heterogeneous enhancement, distinct engorged neovascularization, and in large lesions, central low attenuation areas compatible with hemorrhage, necrosis, or cystic degeneration.

Tissue characterization of benign cardiac tumors by cardiac magnetic resonance imaging, a review of core imaging protocol and benign cardiac tumors

Generally, cardiac masses are initially suspected on routine echocardiography. Cardiac magnetic resonance (CMR) imaging is further performed to differentiate tumors from pseudo-tumors and to characterize the cardiac masses based on their appearance on T1/T2-weighted images, detection of perfusion and demonstration of gadolinium-based contrast agent uptake on early and late gadolinium enhancement images. Further evaluation of cardiac masses by CMR is critical because unnecessary surgery can be avoided by better tissue characterization. Different cardiac tissues have different T1 and T2 relaxation times, principally owing to different internal biochemical environments surrounding the protons. In CMR, the signal intensity from a particular tissue depends on its T1 and T2 relaxation times and its proton density. CMR uses this principle to differentiate between various tissue types by weighting images based on their T1 or T2 relaxation times. Generally, tumor cells are larger, edematous, and have associated inflammatory reactions. Higher free water content of the neoplastic cells and other changes in tissue composition lead to prolonged T1/T2 relaxation times and thus an inherent contrast between tumors and normal tissue exists. Overall, these biochemical changes create an environment where different cardiac masses produce different signal intensity on their T1- weighted and T2- weighted images that help to discriminate between them. In this review article, we have provided a detailed description of the core CMR imaging protocol for evaluation of cardiac masses. We have also discussed the basic features of benign cardiac tumors as well as the role of CMR in evaluation and further tissue characterization of these tumors.

Point-of-Care Ultrasound, an Unexpected Cardiac Mass in a Neonate

ABSTRACT

Neonatal cardiac masses are uncommon and often not obvious based on physical examination or plain radiography. The objective of this clinical case report is to demonstrate how cardiac point-of-care ultrasound was pivotal in the clinical course of a seemingly well neonate with vague symptoms. A 6-week-old male infant presented to the emergency department with fatigue and pallor that was reported to have resolved before arrival. In the emergency department, he had a normal physical examination and stable vital signs. Cardiac point-of-care ultrasound was performed and demonstrated a mass near the mitral valve. These ultrasound findings prompted additional evaluation, cardiology consultation, admission, and subsequent diagnosis of a rhabdomyoma due to tuberous sclerosis.

Practical Guide to Interpreting Cardiac Magnetic Resonance in Patients with Cardiac Masses

It is common for a cardiac mass to be discovered accidentally during an echocardiographic examination. Following the relief of a cardiac mass, being able to evaluate and characterize it using non-invasive imaging methods is critical. Echocardiography, computed tomography (CT), cardiac magnetic resonance imaging (CMR), and positron emission tomography (PET) are the main imaging modalities used to evaluate cardiac masses. Although multimodal imaging often allows for a better assessment, CMR is the best technique for the non-invasive characterization of tissues, as the different MR sequences help in the diagnosis of cardiac masses. This article provides detailed descriptions of each CMR sequence employed in the evaluation of cardiac masses, underlining the potential information it can provide. The description in the individual sequences provides useful guidance to the radiologist in performing the examination.

Monophasic pericardial synovial sarcoma in a turkish female patient: a very rare case with cyto-histopathological findings

BACKGROUND

The aim was to present a 35-year-old female patient with diagnosis of monophasic primary pericardial synovial sarcoma (PSS) with cytopathological findings.

CASE PRESENTATION

The case with back pain, palpitation and weakness, was diagnosed with pericardial effusion and suspicious mass adjacent to right heart in ultrasonography. Computerized tomography showed mass 12 × 11 × 6.5 cm in size, located in right mid-anterior pericardial area, with heterogeneous internal structure, heterogeneously contrasting right heart and prominent pressure on superior vena cava. Cytopathology of pericardial effusion showed monotonous cells with oval-spindle vesicular nuclei, less amphophilic cytoplasm, evenly distributed chromatin and inconspicuous nucleoli. The pericardial mass was resected incompletely, spindle cell mesenchymal tumor with hypercellular fascicular structure and with infiltrative margins, containing a small amount of loose myxoid stroma, occasionally necrotic areas was observed histopathologically. Immunohistochemical positive reaction was for vimentin, Bcl-2, TLE-1. Accordingly, the case was diagnosed with monophasic PSS.

CONCLUSIONS

This case of monophasic primary PSS was an extremely rare malignancy diagnosed with the cytopathological findings.

Cardiac lipoma of the interventricular septum presenting with chest pain

In this case report, we describe an incidental finding of interventricular septum lipoma in a 55-year-old man who came to our attention for chest pain. The ECG showed no changes compatible with ongoing ischemia. While laboratory tests documented increased troponin levels with normal D-dimer levels. Due to the technical difficulties encountered during the performance of the transthoracic echocardiogram, a cardiac CT scan was requested, which ruled out significant coronary artery disease and acute aortic syndromes and showed the presence of a circumscribed fat-dense mass located in the basal portion of the interventricular septum. Subsequent cardiac MRI confirmed the diagnosis of lipoma of the interventricular septum.

Massive myocardial infiltration by primary anaplastic T-cell lymphoma: a case report

Background

Myocardial infiltration by primary cardiac neoplasm is a rare entity, providing diagnostic and therapeutic challenges. The pathological spectrum includes more frequently benign forms. Refractory heart failure, pericardial effusion, and arrhythmias due to infiltrative mass are the most common clinical manifestations.

Case summary

We describe the case of a 35-year-old man complaining of shortness of breath and weight loss in the last 2 months. A previous acute myeloid leukaemia treated with allogenic bone marrow transplant was reported. Transthoracic echocardiography revealed an apical thrombus in the left ventricle, with inferior and septal hypokinesia conditioning a mildly reduced ejection fraction, circumferential pericardial effusion, and abnormal right ventricular thickening. Cardiac magnetic resonance confirmed diffuse thickening of the right ventricular free wall due to myocardial infiltration. Positron emission tomography showed the presence of neoplastic tissue with increased metabolic activity. A pericardiectomy was performed showing a widespread cardiac neoplastic infiltration. Histopathological analysis done on right ventricular pathological samples obtained during cardiac surgery revealed the presence of a rare and aggressive cardiac anaplastic T-cell non-Hodgkin lymphoma. Few days after the operation, the patient developed refractory cardiogenic shock and unluckily died before initiating an adequate antineoplastic therapy.

Discussion

Primary cardiac lymphoma is not frequent, and the lack of specific symptoms makes the diagnosis extremely challenging and often limited to autopsy findings. Our case highlights the importance of an appropriate diagnostic algorithm, requiring non-invasive multimodality assessment imaging and then invasive cardiac biopsy. This approach may allow an early diagnosis and an adequate therapy for this otherwise fatal pathology.

Gender-Related Outcomes after Surgical Resection and Level of Satisfaction in Patients with Left Atrial Tumors

BACKGROUND

Cardiac tumors are rare, with a low incidence of between 0.0017 and 0.19%. The majority of cardiac tumors are benign and predominantly occur in females. The aim of our study was to examine how outcomes differ between men and women.

METHODS

From 2015 to 2022, 80 patients diagnosed with suspected myxoma were operated on. In all patients, preoperative, perioperative, and postoperative data were recorded. Such patients were identified and included in a retrospective analysis focused on gender-related differences.

RESULTS

Patients were predominantly female (n = 64; 80%). The mean age was 62.76 ± 13.42 years in female patients and 59.65 ± 15.84 years in male patients (p = 0.438). The body mass index (BMI) was comparable in both groups: between 27.36 ± 6.16 in male and 27.09 ± 5.75 (p = 0.945) in female patients. Logistic EuroSCORE (LogES) (female: 5.89 ± 4.6; male: 3.95 ± 3.06; p = 0.017) and EuroSCORE II (ES II) (female: 2.07 ± 2.1; male: 0.94 ± 0.45; p = 0.043), both scores to predict the mortality in cardiac surgery, were significantly higher in female patients. Two patients died early, within 30 days after surgery: one male and one female patient. Late mortality was defined as the 5-year survival rate, which was 94.8%, and 15-year survival rate, which was 85.3% in our cohort. Causes of death were not related to the primary tumor operation. The follow up showed that satisfaction with surgery and long-term outcome was high.

CONCLUSION

Predominately female patients presented with left atrial tumors over a 17-year period. Relevant gender differences aside from that were not evident. Surgery could be performed with excellent early (within 30 days after surgery) and late results (follow up after discharge).

A Giant Cardiac Hemangioma Encroaching on the Right Coronary Artery

The cardiac hemangioma is a relatively rare cardiac tumor. It can occur in different locations in the heart. We describe a patient with a giant cardiac hemangioma encroaching on the right coronary artery who underwent a successful surgical resection. Complete resection of the tumor was achieved without damaging the function of the right coronary artery. Nonetheless, meticulous follow-up is required as recurrence is possible.

Hybrid imaging of neuroendocrine tumors in the heart: Union is strength

Cardiac neuroendocrine tumors (NETs) are particularly rare tumors that can lead to a very poor clinical outcome, partly because of metastases but mainly because of manifestations of the hormonal activity they exhibit. Prompt diagnosis is important in order to start the most effective treatment for their removal or management, with the fewest complications. They are often difficult to diagnose, especially in their early stages. One of the reasons for this is that the heart is an organ with a high rate of metabolism and is located in close proximity to other high-metabolism organs. In addition, the anatomic location and their small size render their diagnosis extremely challenging. In recent years, hybrid imaging methods have revolutionized the diagnostic approach to oncology patients and have established a place in the diagnosis of cardiac NETs, because they provide both anatomical and functional information at the same time. Positron emission tomography/computed tomography (PET/CT), PET/magnetic resonance imaging (PET/MRI) and single-photon emission computed tomography/CT (SPECT/CT) are widely used in clinical practice because of the very important metabolic information, the high sensitivity and specificity. However, prospective studies are needed to confirm the true clinical and prognostic value of various hybrid imaging diagnostic techniques in cardiac NETs.

A rare case of left atrial myxofibromyosarcoma

Myxofibrosarcoma is an aggressive soft tissue sarcoma, previously known as myxoid variant of malignant fibrous histiocytoma. Primary cardiac myxofibrosarcomas are the rarest forms of cardiac malignant tumors that often remain asymptomatic until metastasis occurs. In this case report, we describe a rare left atrial cardiac myxofibrosarcoma in a patient with recurrent renal cell carcinoma. We discuss the multimodality imaging approach to diagnose and evaluate cardiac masses as well as imaging characteristics to differentiate cardiac masses from thrombus.

Cardiac lymphoma with early response to chemotherapy: A case report and review of the literature

Cardiac tumors are rare and benign masses account for the most part of the diagnosis. When malignant cancer is detected, primary or secondary cardiac lymphoma are quite frequent. Cardiac lymphoma may present as an intra or peri-cardiac mass or, rarely, it may diffusely infiltrate the myocardium. Although often asymptomatic, patients can have non-specific symptoms. Acute presentations with cardiogenic shock, unstable angina, or acute myocardial infarction are also described. Modern imaging techniques can help the clinicians not only in the diagnostic phase but also during administration of chemotherapy. A multidisciplinary counseling and serial multi-parametric assessment (echocardiography, cardiac troponin) seem to be the most effective approach to prevent possible fatal complications (i.e., cardiac rupture). Currently, only chemo- and radiotherapy are available options for treatment, but the prognosis remains poor. This is a case of secondary cardiac lymphoma presenting as a mediastinal mass with large infiltration of the heart and the great vessels with a good improvement after only one cycle of chemotherapy. It demonstrates the importance of an early diagnosis to modify the natural history of the disease.

Malignant Melanotic Nerve Sheath Tumor

Malignant melanotic nerve sheath tumors are uncommon pigmented tumors of Schwann cell origin, most often found along the spinal nerves. Although well-described in the literature, the tumors are quite rare, making up <1% of nerve sheath tumors. Physicians are, therefore, often unfamiliar with both the appearance and the optimal treatment of such tumors. Morphologically, many imaging features overlap with schwannomas and neurofibromas. Nevertheless, the malignant melanotic nerve sheath tumors are crucial to identify. They can be extremely aggressive, and the management of these tumors is considerably different from their benign counterparts. In this radiology-pathology review, we will highlight the imaging appearance, histologic features, surgical resection, and subsequent therapeutic strategies in a patient with a lumbar malignant melanotic nerve sheath tumor.

Current status of diagnosis and treatment of primary benign cardiac tumors in children

Primary cardiac tumors in children are exceedingly rare overall, which benign account for most part. The onset of the disease is occult, while the clinical manifestations are non-specific-patients may be asymptomatic or show a range of obstructive, arrhythmic, embolic or systemic symptoms. The clinical presentations generally depend on the tumors’ size, localization, and pace of growth of the tumor. Moreover, the diagnosis needs comprehensive judgment based on imaging results and pathological examination. With advances in cardiac imagining and the introduction of cardiopulmonary support, the diagnosis and treatment of these rare tumors have improved the prognosis and outlook for benign tumors. To sum up the above, we sought to integrate articles from recent years for the latest comprehensive review of the clinical manifestations, imaging characteristics, clinic pathologic features and treatment of benign cardiac tumors in children to provide a broader idea for pediatricians to recognize and treat such diseases.

Multimodality imaging appearance of intrapericardial paragangliomas

Paragangliomas are neuroendocrine tumours of the sympathetic and parasympathetic nervous systems originating from neural crest cells. Less than 1% of paragangliomas in the heart originate from intrinsic cardiac ganglia cells in the posterior wall of the atria, atrioventricular groove, and along the root of the great vessels. We describe the tumour characteristics, patient demographics, presentation, means of diagnosis, pathology correlation, management, and outcome in 11 patients with intrapericardial paragangliomas. To the authors' knowledge, this is the largest case series reported, with emphasis on multimodality imaging findings.

A rare left ventricular cardiac myxoma mimicking fibroma

BACKGROUND

In most cases, it is not difficult to differentiate common left ventricular (LV) cardiac myxomas from fibromas because they are different disease entities and have different imaging findings. Herein, we present a case of a tumor with histological characteristics of a LV cardiac myxoma even though its imaging and macroscopical views were similar to that of fibroma.

CASE PRESENTATION

A 65-year-old woman was admitted to the hospital with chest tightness and palpitations which persisted for 2 years. Transthoracic echocardiogram and transesophageal echocardiography revealed a 23 mm × 8 mm, polyp-like-shaped, homogeneous, firm, solitary, mobile and solitary LV mass, which protruded into the left atrium during systole, resulting in mild mitral regurgitation. LV contrast-enhanced echocardiography revealed that there was little contrast agent filling in the LV mass. To further clarify the nature of the mass, non-enhanced and contrast-enhanced coronary computed tomography (CT) angiograms showed a 19 mm × 8 mm relatively homogeneous low density with punctate calcifications mass and no significant enhancement. Thus, we preoperatively diagnosed her condition as a LV fibroma and performed excision of the tumor under cardiopulmonary by-pass by using port-access approach through right mini-thoracotomy. The postoperative pathological diagnosis of the tumor was in fact a LV myxoma.

CONCLUSIONS

LV cardiac myxomas mimicking fibroma makes diagnosis difficult, and sonographers should be aware of this imaging changes.

Genetic insights into cardiac tumors: a comprehensive review

Cardiac neoplasms are rare, however, also a curable form of the disease once detected early. In recent years the viscus tumors have gained their highlights, due to the advancement in techniques like echocardiography both 2D and 3D, MRI, etc. These cardiac tumors are divided based on their benign and malignant nature and also as well as primary and secondary cardiac tumors. Largely the primary cardiac tumors are often than secondary cardiac tumors. The secondary tumor happens anywhere in the body involving the heart. The most common malignant tumors are sarcoma, some are angiosarcomas, fibromas, rhabdosarcoma, and leiomyosarcoma. The primary sarcoma affects both men and women at an equal rate with non-specific symptoms. These conditions led to high demand in genomic testing that helps in spot the mutation that leads to the particular type of cardiac neoplasm and it additionally helps to screen the mutated sequence and stop it from being inherited. Recent studies on cardiac tumors have revealed many genes that are involved in tumorigenesis and technologies have enabled the right screening of the tumor location within the heart and their histopathological studies were also studied. This review principally focuses on the understanding of the various forms of cardiac tumors, genetic variants involved and their influence, genetic testing, and different diagnostic approaches in cardiac tumors.

Percutaneous ultrasound-guided core needle biopsy for the diagnosis of cardiac tumors: Optimizing the treatment strategy for patients with intermural and pericardial cardiac tumors

Objective

The aims of this study are to investigate the clinical value and practical safety of ultrasound-guided percutaneous core needle biopsy on diagnosing cardiac tumor and to discuss the treatment strategy for cardiac intermural and pericardial tumors.

Methods

The clinical data were retrospectively collected for patients with intermural and pericardial cardiac tumors. The patients were divided into groups of surgical resection, surgical resection after obtaining pathological tissue by PUS-CNB, and/or radiotherapy according to the treatment modality. Ultrasound-guided aspiration biopsy was divided into cardiac tumor biopsy and extracardiac lesion biopsy according to patient conditions. The surgical time was recorded, and the safety and clinical application value of PUS-CNB for the diagnosis of cardiac tumors were evaluated in terms of complications and satisfaction with pathological sampling.

Results

A total of 18 patient cases were collected, and PUS-CNB of cardiac tumors was performed in 8 cases, with sampling times averaging 15.6 ± 3.0 min. Four cases of cardiac tumors combined with extracardiac tumors were biopsied, with puncture times averaging 13.0 ± 2.9 min. All 12 biopsied patients had no postoperative complications. Except for 1 failed biopsy, the biopsies were successful and the pathological results were consistent with the clinical diagnosis with a satisfaction rate of 91.7%. Except for two cases of surgical resection, the rest were considered for conservative treatment. Surgical resection and/or biopsy were performed in six cases, and two cases were aggravated after surgery. The final pathology of all 17 cardiac tumors was malignant.

Conclusion

PUS-CNB is safe and effective, providing a simple and undemanding method for accurate diagnosis of cardiac intermural and pericardial tumors while avoiding unnecessary open-heart surgery.

Cerebral Embolic Protection During Transseptal Biopsy of Left Atrial Mass

Diagnostic biopsy of a left atrial mass is technically feasible but has the risk of tumor embolization causing stroke or seeding. In this case report, we highlight the technical steps for left atrial mass biopsy under transesophageal echocardiography guidance by using cerebral embolic protection. Pathologic examination disclosed low-grade B-cell lymphoma. (Level of Difficulty: Advanced.)

A Right Atrial Mass with Fever and Cutaneous Nodules

Primary cardiac tumors, although exceedingly rare, should be considered in the differential diagnosis during workup of any cardiac mass. Extranodal cardiac lymphomas have a natural aggressive course due to delayed diagnosis. We present a 71-year-old male with a dual-chamber pacemaker who presented with fevers and new cutaneous nodules. He was found to have a right atrial primary anaplastic large-cell lymphoma and had a complete metabolic response after chemotherapy. Our case highlights the importance of a multimodality approach in the diagnosis of cardiac tumors and during follow-up after treatment.

Left ventricular chordae tendinae myxoma causing stroke: A rare finding

A 52-year-old woman presented with dysarthria and right-sided weakness in her upper and lower extremities prompting thrombolytic therapy with mild resolution of symptoms. Further work-up revealed (the source) a left ventricular myxoma on the chordae tendinae of the posterior medial papillary muscle, confirmed with transesophageal echocardiography and pathology. Herein, we present a rare case of embolic stroke from a myxoma originating on the chordae tendinae. To the best of our knowledge, the literature on the location and presentation of this tumor as seen in our patient is sparse in contemporary findings.

Cardiac Rhabdoid Tumor—A Rare Foe—Case Report and Literature Review

Intracardiac masses are unusual findings in infants, and most of them are benign. Nevertheless, they may be associated with a significant degree of hemodynamic instability and/or arrhythmias. Malignant tumors of the heart rarely occur in children. Rhabdoid tumors are aggressive tumors with a dismal prognosis even when diagnosed early. Although rhabdomyomas are common cardiac tumors in infants, they are mostly benign. The most common sites of involvement are the kidneys and central nervous system, but soft tissues, lungs, and ovaries may also be affected. The diagnosis can be challenging, particularly in sites where they do not usually occur. In the present paper, we report the case of a 2-year-old boy diagnosed with cardiac rhabdoid tumor highlighting the importance of molecular studies and recent genetic discoveries with the purpose of improving the management of such cases. The aim of this educational case report and literature review is to raise awareness of cardiac masses in children and to point out diagnostic hints toward a cardiac tumor on various imaging modalities. Given the rarity of all tumors involving the heart and the lack of symptom specificity, a high degree of suspicion is needed to arrive at the correct diagnosis.

Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the use of cardiovascular magnetic resonance in pediatric congenital and acquired heart disease : Endorsed by The American Heart Association

Cardiovascular magnetic resonance (CMR) has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of CMR in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of CMR in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.

Case Report: Primary Cardiac T-Cell Lymphoma With Complete Atrio-Ventricular Block Diagnosed by Endomyocardial Biopsy

Primary cardiac lymphoma (PCL) is a rare disease, the definite diagnosis of which is sometimes difficult and mainly relies on endomyocardial biopsy. Primary cardiac T-cell lymphoma (PCTL) is an extremely rare sub-type of PCL. Here, we report on a 47-year-old female with PCTL who presented with fever, syncope, palpitations, and a third-degree atrioventricular block (AVB) on electrocardiogram. Chemotherapy was administered with two courses of methotrexate, cyclophosphamide, liposomal doxorubicin, vincristine, and dexamethasone (MTX-CHOP). As the tumor vanished, AVB changed from third degree to second degree and finally to sinus rhythm. In conclusion, endomyocardial biopsy is valuable in the diagnosis of primary cardiac lymphoma. It is worth noting that alterations in the electrocardiogram may indicate an attack on the heart by PCTL.

Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the Use of Cardiac Magnetic Resonance in Pediatric Congenital and Acquired Heart Disease: Endorsed by The American Heart Association

Cardiovascular magnetic resonance has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of cardiovascular magnetic resonance in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of cardiovascular magnetic resonance in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.

Cardiac angiosarcoma: a case report of a young female with pulmonary metastasis

Background

Angiosarcoma is a malignant rare tumor that originates from vascular endothelial cells that cover lymphatic or blood vessels. Cardiac angiosarcoma is the most prevalent sarcoma entail the heart. It has low incidence rate and poor prognosis. Our effort through this report was raising awareness of uncommon manifestations of this disease and showing the importance of appropriate diagnosis and treatment.

Case presentation

We present a case of cardiac angiosarcoma in a young female whose symptoms included dyspnea and hemoptysis with a history of pericardial effusion and a past history of cardiac surgery for suspected atrial Myxoma. She had history of several hospitalizations and relapse of symptoms a few months after each hospital discharge.

Conclusions

The unspecific symptoms of cardiac angiosarcoma made it difficult to make in time diagnose and appropriate treatment. Awareness of unspecific presentations of cardiac angiosarcoma is necessary for proper diagnosis and treatment while delayed diagnosis may worsen the prognosis and even lead to death.

Cardiac myxomas: A narrative review

Cardiac myxomas are common primary neoplasms of the heart. They are biologically benign but “functionally malignant” because of the potential for embolization. They arise most commonly from the left atrium, but no chambers of the heart are immune. They may be sporadic in the majority but also familial as a part of the Carney complex. Two morphological forms exist: polypoid and papillary. Polypoid myxomas often present with obstructive features, while the papillary forms are more prone to embolization. Histogenesis is still controversial; the current view centres around origin from the primitive pluripotent mesenchymal cells. They may be of giant proportion, be calcified or get infected. Clinical presentation typically involves the triad of intracardiac obstruction, embolic events and constitutional symptoms. Precordial examination findings may simulate those of mitral or tricuspid stenosis. The presence of tumour plop and change of the physical findings with changing position may help differentiation between the two. Echocardiography is the investigation of choice. Echogenic polypoid or papillary mobile mass within the atrial cavity remaining attached to the interatrial septum through a stalk are the tell-tale echocardiographic features. Cardiac magnetic resonance and computed tomographic scanning may have incremental diagnostic value. Histopathological examination reveals abundant loose myxoid stroma with scattered round, polygonal or stellate cells with dense irregular nuclei. Genetic testing may detect mutations in the PRKAR1A gene in the familial form of cardiac myxoma, i.e. the Carney complex. Surgical excision is the mainstay of treatment with low operative mortality, excellent postoperative survival and low recurrence rate. The current trend favours minimal-access surgery with or without robotic assistance. Physicians should have appropriate preparedness to make a timely diagnosis and enthusiastic treatment to avoid potentially fatal complications.

Incidentally Detected Asymptomatic Cardiac Myxoma in a Patient With COVID-19

Primary cardiac tumors, such as myxomas, are rare. About 75% of myxomas occur in the left atrium of the heart. Myxomas can have a broad clinical spectrum. The clinical presentation varies from asymptomatic to sudden cardiac death. Sometimes, a diagnosis is difficult. Cardiac myxoma can cause hemodynamic disturbances in the setting of pneumonia and hypercoagulable state in patients with Coronavirus disease 2019(COVID-19) and make treatment decisions difficult. We present a case of unusually huge left atrial mass discovered incidentally in a patient with COVID-19. Upon workup, an echocardiogram revealed an incidental 7 × 5 cm left atrial myxoma. Preoperatively, the patient was monitored closely in the ICU. After stabilization in the ICU, the patient was taken to surgery and the tumor was successfully removed. Pathohistological results after surgical removal of the tumor confirmed the diagnosis of cardiac myxoma. We consider our case extremely rare due to the asymptomatic course despite the large size of the tumor.

Expansive intracardiac leiomyosarcoma - a combined therapeutic approach resulting in survival with complete remission. A literature review and case report

Primary cardiac sarcomas are extremely rare and often with dismal prognosis. Only a few case series and retrospective studies regarding its biological characteristics, diagnostics, and treatment were reported. The multi-modality therapeutic strategy has been discussed in the published literature, but often with contradictory results. There is thus, no consensus on the optimal therapeutic approach to date. We present the case report of the 66-year old female endangered by a large primary leiomyosarcoma expanding in the right-sided heart chambers with imminent risk of acute obstruction of blood flow. The patient was managed by urgent surgical resection. After the histological confirmation of incomplete R1 resection, the treatment was supplemented by adjuvant CT-targeted radiotherapy, resulting in extraordinary survival with complete remission over a 24-month follow-up period. Our case report aims to demonstrate a favorable result of an individually suited complex surgical and oncological treatment to support the multidisciplinary therapeutic approach to these patients. The article is supplemented by a detailed literature review providing a theoretical background and an overview of the acquired knowledge and possible strategies.

Rare Case of Cavernous Haemangioma of the Right Atrium with Probable Hepatic Haemangioma

Cardiac haemangiomas are rare causes of atrial masses. This case report is of a 44-year-old male who presented with a right atrial mass that was found incidentally on a CT performed for renal colic. The mass was further investigated with a transthoracic echocardiogram that showed that it was echodense and arising from the Eustachian valve in the right atrium. Coronary angiogram revealed large well-developed atrial branches that crossed superiorly over the left atrium and entered the mass in the right atrium. Surgical resection was undertaken, and this confirmed that the mass had a fleshy, encapsulated appearance with a sessile stalk. Histology demonstrated a cavernous haemangioma. The patient had a residual small defect in the interatrial septum postoperatively but otherwise made a good recovery.

Diagnostic mystery-a rare right ventricular cardiac hemangioma: a case report

BACKGROUND

Cardiac hemangiomas are rare in all kinds of benign cardiac tumors. Although cardiac hemangiomas affect all ages and may occur anywhere within the heart, right ventricular hemangiomas are extremely uncommon.

CASE PRESENTATION

We report a 56-year-old woman presented with chest tightness and breath shortness for 3 months. Transthoracic echocardiography and coronary computed tomography angiography showed a mass located adjacent to the apex of the right ventricle but both failed to figure out where the mass originated from, remaining a diagnostic mystery preoperatively. The mass was removed successfully and the histopathological examination confirmed it was hemangioma.

CONCLUSIONS

Cardiac magnetic resonance should be the ultimate diagnostic tool of cardiac tumors. Surgical removal, associated with a low recurrence rate and long-term survival benefits, should be the first choice of therapy for cardiac hemangiomas.

Cardiovascular magnetic resonance of cardiac tumors and masses

Cardiac masses diagnosis and treatment are a true challenge, although they are infrequently encountered in clinical practice. They encompass a broad set of lesions that include neoplastic (primary and secondary), non-neoplastic masses and pseudomasses. The clinical presentation of cardiac tumors is highly variable and depends on several factors such as size, location, relation with other structures and mobility. The presumptive diagnosis is made based on a preliminary non-invasive diagnostic work-up due to technical difficulties and risks associated with biopsy, which is still the diagnostic gold standard. The findings should always be interpreted in the clinical context to avoid misdiagnosis, particularly in specific conditions (e.g., infective endocarditis or thrombi). The modern multi-modality imaging techniques has a key role not only for the initial assessment and differential diagnosis but also for management and surveillance of the cardiac masses. Cardiovascular magnetic resonance (CMR) allows an optimal non-invasive localization of the lesion, providing multiplanar information on its relation to surrounding structures. Moreover, with the additional feature of tissue characterization, CMR can be highly effective to distinguish pseudomasses from masses, as well as benign from malignant lesions, with further differential diagnosis of the latter. Although histopathological assessment is important to make a definitive diagnosis, CMR plays a key role in the diagnosis of suspected cardiac masses with a great impact on patient management. This literature review aims to provide a comprehensive overview of cardiac masses, from clinical and imaging protocol to pathological findings.

Benign Pericardial Hemangioma-A Rare Cause of Cardiac Tamponade

Pericardial tumors are very rare. It can be primary or secondary, of which secondary tumors are more common. Pericardial hemangiomas are extremely rare primary neoplasms and there are only very few cases published in the literature. These patients can be asymptomatic. When symptomatic, they present with dyspnea, palpitation, or atypical chest pain. Severity of symptoms depends on the size and location of the tumor. Pericardial effusion with features of cardiac tamponade can lead to a life-threatening situation. Here, we report a case of pericardial hemangioma in a patient who presented with breathlessness and tamponade which was diagnosed preoperatively with computed tomography.