Radiologic-Pathologic Correlation of Cardiac Tumors: Updated 2021 WHO Tumor Classification

Cardiac tumors, although rare, carry high morbidity and mortality rates. They are commonly first identified either at echocardiography or incidentally at thoracoabdominal CT performed for noncardiac indications. Multimodality imaging often helps to determine the cause of these masses. Cardiac tumors comprise a distinct category in the World Health Organization (WHO) classification of tumors. The updated 2021 WHO classification of tumors of the heart incorporates new entities and reclassifies others. In the new classification system, papillary fibroelastoma is recognized as the most common primary cardiac neoplasm. Pseudotumors including thrombi and anatomic variants (eg, crista terminalis, accessory papillary muscles, or coumadin ridge) are the most common intracardiac masses identified at imaging. Cardiac metastases are substantially more common than primary cardiac tumors. Although echocardiography is usually the first examination, cardiac MRI is the modality of choice for the identification and characterization of cardiac masses. Cardiac CT serves as an alternative in patients who cannot tolerate MRI. PET performed with CT or MRI enables metabolic characterization of malignant cardiac masses. Imaging individualized to a particular tumor type and location is crucial for treatment planning. Tumor terminology changes as our understanding of tumor biology and behavior evolves. Familiarity with the updated classification system is important as a guide to radiologic investigation and medical or surgical management. ©RSNA, 2024 Supplemental material is available for this article.

Rare case of cardiac angiosarcoma and alveolar hemorrhage in an adolescent patient initially suspected COVID19 infection: A case report and literature review

Primary cardiac tumors are a rarity, and sarcomas emerge as the prevailing form of primary malignant cardiac tumors across age groups, encompassing both children and adults. Within this category, angiosarcoma stands out, constituting around 31% of all primary malignant cardiac tumors. Primary cardiac angiosarcoma displays a notably aggressive nature, characterized by early systemic metastasis, and is accompanied by a generally unfavorable prognosis. We describe a case concerning a previously healthy teenage girl who displayed persistent constitutional symptoms and hemoptysis for 15 days. Subsequent investigation uncovered alveolar hemorrhage, ultimately linked to a cardiac angiosarcoma. The difficulty in this instance arose from the vague nature of the initial symptoms, posing a challenge to promptly and accurately diagnose the condition. This case highlights the aggressive nature of primary cardiac angiosarcoma. The vague initial symptoms underscore the need for early detection and optimized treatment to improve the generally unfavorable prognosis associated with this condition. Increased awareness and a multidisciplinary approach are crucial in addressing the diagnostic and therapeutic challenges posed by primary cardiac angiosarcoma.

Incidental finding of atrial myxoma following curative treatment for paediatric neuroblastoma

Cardiac tumours are uncommon in the general population and even more so in the paediatric population. Here we present a case of an asymptomatic 7-year-old male with history of high-risk neuroblastoma who underwent 1-year post-treatment surveillance scan with an incidental finding of intracardiac lesion found to be an atrial myxoma.

Large Symptomatic Ventricular Fibromas: A Surgical Challenge

•Cardiac fibromas are benign clinical entities that are rarely diagnosed in adulthood. •Echocardiography is considered the first imaging modality used for evaluation. •Multimodality imaging is critical for diagnosis and perioperative intervention. •Management remains largely case by case. •Tumor burden and surgical feasibility guide aggressiveness of management strategy.

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.

MR imaging of primary benign cardiac tumors in the pediatric population

Primary cardiac tumors are rare in all ages, especially in children, with a reported prevalence range of 0.0017-0.28% in autopsy series. Due to their rarity, the diagnostic and therapeutic pathways reserved to them are usually described by single case reports, leading to the point where a common diagnostic protocol is imperative to obtain a differential diagnosis. The first diagnostic approach is done with transthoracic echocardiogram (TTE), due to its wide availability, low cost, absence of ionizing radiations and non-invasiveness. Several tumors are discovered incidentally and, in many cases, TTE is helpful to determine location, size and anatomical features, playing a key role in the differential diagnosis. In the last few years, cardiac magnetic resonance imaging (CMR) has had an increased role in the diagnostic pathway of pediatric cardiac masses, due to its high accuracy in characterizing mass tissue properties (especially for soft tissue), and in detecting tumor size, extent, pericardial/pleural effusion, leading to the correct diagnosis, treatment and follow-up. Therefore, nowadays, several consensus statements consider CMR as a leading imaging technique, thanks to its non-invasive tissue characterization, without the use of ionizing radiation, in an unrestricted field of view. As suggested by the most recent literature, the pediatric protocol is not so different from the adult one, adapted to the size and cardiac frequency of the patient, sometimes requiring special conditions such as free-breathing sequences and/or sedation or general anesthesia in non-cooperating patients.

Cardiac rhabdomyomas and cerebral lesions in 4 pediatric patients with tuberous sclerosis

Rhabdomyoma is the most common primary cardiac tumor in pediatric patients. A strong association exists between cardiac rhabdomyomas and tuberous sclerosis (TS), an autosomal dominant disease, characterized by diffuse lesions in the nervous system, such as cortical-subcortical tubers and subependymal nodules. In TS, cardiac rhabdomyomas typically are diagnosed in childhood, but they could be detected in the neonatal period with echocardiography and magnetic resonance imaging and may precede cerebral lesions. Therefore, the precocious detection of cardiac rhabdomyomas in pediatric patients can suggest the diagnosis of TS and the early detection of cerebral lesions, improving the management of the related symptoms. We reported the cases of 4 pediatric patients, in which the detection of cardiac rhabdomyomas lead to the early discovery of cerebral lesions and the diagnosis of the TS.

Common benign primary pediatric cardiac tumors: a primer for radiologists

Cardiac tumors are neoplasms arising from or located in the heart or the pericardium. Although rare, primary cardiac tumors in children require an accurate and timely diagnosis. Most pediatric primary cardiac tumors are benign (around 90%). Echocardiography is the first imaging modality used due to its availability, noninvasiveness, inexpensiveness, and absence of ionizing radiation. Computed tomography (CT) and magnetic resonance imaging (MRI) offer better soft tissue visualization as well as better visualization of extracardiac structures. A great advantage of MRI is the possibility of measuring cardiac function and blood flow, which can be important for obstructing cardiac tumors. In this article, we will offer a brief review of clinical, echocardiographic, CT, and MRI features of cardiac rhabdomyomas, fibromas, teratomas, and lipomas providing their differential diagnosis.

Multimodality Imaging of Benign Primary Cardiac Tumor

Primary cardiac tumors (PCTs) are rare, with benign PCTs being relatively common in approximately 75% of all PCTs. Benign PCTs are usually asymptomatic, and they are found incidentally by imaging. Even if patients present with symptoms, they are usually nonspecific. Before the application of imaging modalities to the heart, our understanding of these tumors is limited to case reports and autopsy studies. The advent and improvement of various imaging technologies have enabled the non-invasive evaluation of benign PCTs. Although echocardiography is the most commonly used imaging examination, it is not the best method to describe the histological characteristics of tumors. At present, cardiac magnetic resonance (CMR) and cardiac computed tomography (CCT) are often used to assess benign PCTs providing detailed information on anatomical and tissue features. In fact, each imaging modality has its own advantages and disadvantages, multimodality imaging uses two or more imaging types to provide valuable complementary information. With the widespread use of multimodality imaging, these techniques play an indispensable role in the management of patients with benign PCTs by providing useful diagnostic and prognostic information to guide treatment. This article reviews the multimodality imaging characterizations of common benign PCTs.

Case report: multi-modality imaging of a right ventricular fibroma in a teenager

Background

Cardiac fibroma is a rare primary benign tumour of the heart. It often causes arrhythmia, endangers the lives of patients, and has a worse prognosis than other benign tumours. We report a 14-year-old female patient with a right ventricular fibroma. Various preoperative imaging examinations showed that the lesion was benign, and postoperative pathology confirmed that the lesions were fibroma.

Case summary

A 14-year-old female patient visited her doctor for more than 5 months because of a heart murmur. Echocardiography revealed a slightly hyperechoic mass in the right ventricle, and on myocardial perfusion contrast imaging, the lesion showed equal enhancement. And the lesion also showed enhancement on contrast-enhanced gated cardiac computed tomography (CT). Contrast-enhanced magnetic resonance imaging (MRI) of the heart revealed that the lesion was isointense on T₁-weighted image (T₁WI), and isointense to slightly hyperintense on T₂-weighted image (T₂WI). The lesion was significantly homogeneously enhanced on a delayed enhancement scan. A positron emission tomography-CT (PET-CT) with 18F-fluorodeoxyglucose (18F-FDG) demonstrated that the mass showed lower levels of 18F-FDG uptake. These features suggested this lesion was a benign lesion. The postoperative pathology suggested the lesion was a right ventricular fibroma. The patient was discharged 14 days after surgery and remains disease-free and asymptomatic 14 months after surgery.

Discussion

Cardiac fibromas are histologically benign, but they can cause obstruction and malignant arrhythmia. The gold standard for diagnosing fibroma is pathology. However, in the absence of pathology, it is necessary to use various imaging methods to evaluate the lesions to distinguish between benign and malignant tumours.

A spiral cystic fibroma originating from left ventricular fascicular muscle: a case report

Background

In adults, cardiac fibromas are fairly rare, mostly round in shape, and few cases of ventricular fibromas of other morphology have been reported.

Case presentation

We report a case of a 47-year-old male patient admitted with recurrent nocturnal paroxysmal dyspnea, diagnosed by transthoracic cardiac ultrasound, transesophageal ultrasound, and computed tomography (CT) as a left ventricular occupancy with a spiral shape resembling a conch with a fixed base and a free distal end.

Conclusion

This case reports a rare but noteworthy morphological features of the adult uncommon ventricular tumor pathological type. Furthermore, the patient had no notable postoperative issues and was followed up on for a year following surgery, with no residual tumors or arrhythmias discovered during the examination.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01616-w.

A Case Report of Intracardiac Hodgkin Lymphoma in an Adolescent Female

Primary cardiac tumors are quite rare in children, and only a small portion are malignant. Presenting symptoms may be nonspecific, often mimicking those of congestive heart failure, pulmonary embolism, and syncope. Due to location and potential detrimental outcomes, diagnosis and management are of the utmost importance. Secondary and metastatic cardiac tumors are more frequent in comparison to primary tumors of the heart. Primary Hodgkin lymphoma of the heart is exceedingly rare with no standardized approach for treatment. Here we describe a case of an adolescent girl with primary cardiac Hodgkin lymphoma.

Cardiac tumours in children: a single-centre experience and literature review

Cardiac tumours are extremely rare in children. Although more than 90% are benign, children can develop obstructive or embolisation derived symptoms, arrhythmias, constitutional symptoms, cardiac tamponade, or even sudden death. Although the majority are asymptomatic, and some spontaneously regress, appropriate follow-up is needed on a case-by-case basis, as patients may develop late symptoms. Definitive diagnosis is only possible through histological analysis; however, it is possible to infer tumour type with a high grade of certainty based on imaging features, particularly cardiac magnetic resonance. Surgical resection is advocated for those causing symptoms, obstruction, cardiac dysfunction, and high risk of embolisation. The aim of this review is to present the state of the art related to cardiac tumours in the paediatric population, in the context of our own experience.

Imaging of cardiac masses: An updated overview

Studying cardiac masses is one of the most challenging tasks for cardiac imagers. The aim of this review article is to focus on the modern imaging of cardiac masses proceeding through the most frequent ones. Cardiac benign masses such as myxoma, cardiac papillary fibroelastoma, rhabdomyoma, lipoma, and hemangioma are browsed considering the usefulness of most common cardiovascular imaging tools, such as ultrasound techniques, cardiac computed tomography, cardiac magnetic resonance, and in the diagnostic process. In the same way, the most frequent malignant cardiac masses, such as angiosarcoma and metastases, are highlighted. Then, the article browses through nontumoral masses such as cysts, mitral caseous degenerative formations, thrombi, and vegetations, highlighting the differential diagnosis between them. In addition, the article helps in recognizing anatomic normal variants that should not be misdiagnosed as pathological entities.

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.

Society for Cardiovascular Magnetic Resonance 2020 Case of the Week series

The Society for Cardiovascular Magnetic Resonance (SCMR) is an international society focused on the research, education, and clinical application of cardiovascular magnetic resonance (CMR). Case of the week is a case series hosted on the SCMR website ( https://www.scmr.org ) that demonstrates the utility and importance of CMR in the clinical diagnosis and management of cardiovascular disease. Each case consists of the clinical presentation and a discussion of the condition and the role of CMR in diagnosis and guiding clinical management. The cases are all instructive and helpful in the approach to patient management. We present a digital archive of the 2020 Case of the Week series of 11 cases as a means of further enhancing the education of those interested in CMR and as a means of more readily identifying these cases using a PubMed or similar search engine.

Intracardiac Teratoma in a Child: A Rare Site of a Common Tumor

Primary intracardiac teratoma is a rare cardiac tumor with few cases reports in neonates and children. The authors present a case of an 8-year-old boy diagnosed with a cystic mass within the heart. The mass lesion was originating from the interventricular septum and was obliterating the ventricular chambers. Clinically, the mass was suspected to be a hydatid cyst. Surgical excision of the cyst was done that was confirmed histopathologically as mature teratoma. Although rare, it should be considered in the differential diagnosis of cystic lesions of heart when evaluating mass lesions in the pediatric age group.

Society for Cardiovascular Magnetic Resonance 2019 Case of the Week series

The Society for Cardiovascular Magnetic Resonance (SCMR) is an international society focused on the research, education, and clinical application of cardiovascular magnetic resonance (CMR). The SCMR web site ( https://www.scmr.org ) hosts a case series designed to present case reports demonstrating the unique attributes of CMR in the diagnosis or management of cardiovascular disease. Each clinical presentation is followed by a brief discussion of the disease and unique role of CMR in disease diagnosis or management guidance. By nature, some of these are somewhat esoteric, but all are instructive. In this publication, we provide a digital archive of the 2019 Case of the Week series as a means of further enhancing the education of those interested in CMR and as a means of more readily identifying these cases using a PubMed or similar search engine.

Case Report: Unusual Clinical Presentation of a Rare Cardiac Inflammatory Myofibroblastic Tumor in Children: The Differential Diagnosis With Pediatric Emergencies

Introduction: There are still no guidelines about pediatric cardiac cancers. The purpose of this work is to provide new scientific data facilitating the differential diagnosis of a rare cardiac tumor with an unusual presentation, such as the cardiac inflammatory myofibroblastic tumor (IMT). Case Presentation: A 3-year-old male child presented with several symptoms including unconsciousness, vomiting, and drowsiness. A clinical and neurological examination revealed a unilateral (right) motor delay and positive unilateral Babinski sign. Electrocardiogram (ECG) was normal. Diagnostic Assessment: The total body computed tomography (CT) scans showed hypodensity in the left temporal-parietal lobe, a large hypodense area in the right frontal lobe, and a second area in the left frontal lobe were found with head CT. A magnetic resonance (MR) also noted cerebral areas of hypointensity. The echocardiographic images revealed an ovoid mass, adherent to the anterolateral papillary muscle. The histological exams, performed with hematoxylin-eosin, Masson's trichrome, Alcian blue PAS, Weigert and Van-Gieson stain, allowed observing the microscopic structure of the neoplastic mass. The immunohistochemical analysis was performed through subsequent antibodies: anti-vimentin, anti-actina, anti-ALK, anti-CD8, anti-CD3, anti-CD20, anti-kappa and lambda chains, and anti CD68 antibodies. The healthcare professionals diagnosed a cardiac IMT with brain embolism. Differential Diagnosis: The ventricular localization, observed through radiological exams, required a differential diagnosis with fibroma and rhabdomyoma, the presence of brain embolism with sarcoma, and its morphology with fibroma. Neurological symptoms might be attributed to encephalitis, primitive cerebral cancer, such as astrocytoma or neuroblastoma, cerebral metastases due to any malignancy, or embolic stroke. Conclusion: New studies are encouraged to better define IMT behavior and draw up guidelines confirming the crucial role of multidisciplinary approach and treatment protocol selected on the basis of the characteristics of the tumors, in the case of this rare type of cancer.

Cardiac Neoplasms: Radiologic-Pathologic Correlation

Cardiac neoplasms are a diagnostic challenge on many levels. They are rare, their clinical presentation may mimic other much more common cardiac diseases, and they are at an uncommon intersection of oncologic and cardiac imaging. The pathology of primary cardiac neoplasms explains their varied imaging features, for example, calcification in primary cardiac osteosarcomas and T2 hyperintensity in myxomas. Integrating the imaging and pathologic features of cardiac tumors furthers our understanding of the spectrum of appearances of these neoplasms and improves the clinical imager's ability to confidently make a diagnosis.

Hemopericardium in the acute clinical setting: Are we ready for a tailored management approach on the basis of MDCT findings?

The clinical spectrum of pericardial effusions varies from innocuous serous fluid to life-threatening hemopericardium. A misdiagnosis may be made by similar clinical presentation of acute chest pain/hypotension. Echocardiography is the first-line test for diagnosis of pericardial effusion and its etiology, but sometimes there are different drawbacks to the correct cardiovascular ultrasound diagnosis. Radiologists are reporting an increasing amount of thoracic Multidetector CT examinations at the emergency department. Multidetector CT has now become an established and complementary method for cardiac imaging, and diseases of the pericardium can now be quickly identified with increasing certainty. The aim of this review is to discuss the hemopericardium key Multidetector CT features in acute clinical setting which indicate the need to proceed with predominantly medical or surgical treatment, however, being able to identify forms of bleeding pericardial effusion for which only "a watch and wait strategy" and/or deferred treatment is indicated. In the emergency care setting, radiologists must be aware of different findings of hemopericardium in order to address a tailored and timely management approach.

Cardiac Hemangioma in an Asymptomatic Teenager with a History of Congenital Heart Disease

• Cardiac hemangiomas constitute <10% of all pediatric cardiac tumors. • More than two thirds of patients with cardiac masses may present with symptoms. • Association between congenital heart disease and heart tumors is very uncommon. • Echocardiography is the first-line imaging modality for identifying cardiac masses. • CMR is an excellent imaging technique for cardiac tumor characterization.

Surgical treatment of left ventricular fibroma in adult: case report and literature review

Cardiac fibroma is a rare benign primary tumour of the heart. In the paediatric population, it has been reported as the second most common benign cardiac tumour following rhabdomyoma. However, the prevalence of cardiac fibroma is rarely reported in the adult population. Signs and symptoms are nonspecific, including palpitations, cardiac murmur, arrhythmias, dyspnoea, cyanosis, chest pain, and sudden mortality, whereas, a number of patients with cardiac fibroma are asymptomatic. Surgical resection should be considered as the best option in symptomatic patients. This study reported four surgical cases of adults with cardiac fibroma arising from the left ventricle and a literature review regarding the clinical and pathological features, diagnostic modalities, therapeutic aspects, and prognosis of this rare entity.

Echocardiography and Newer Imaging Techniques in Diagnosis and Long-Term Follow-Up of Primary Heart Tumors in Children

Background: Primary heart tumors (PHTs) in the pediatric population are very rare and do not manifest any characteristic symptoms. Methods: A retrospective analysis of 61 cases was undertaken. Data from three centers for the years 2003–2018 were gathered. The tumors’ clinical course, location, number, hemodynamic, treatment, and follow-up were evaluated. Echocardiography was complemented with magnetic resonance imaging, computer tomography, and histopathological examination. Results: Out of 61 PHT diagnoses, 56 (91.8%) were circumstantial including all 16 (26.2%) prenatal tumors. The reasons for cardiological consultations were arrhythmia, syncopes, lowered physical performance, and murmurs. Only five patients (8.2%) were suspected of tumors based on previous symptoms of sclerosis tuberosa. Rhabdomyoma was the most frequently found PHT (60.7%). The tumors were predominantly located in the ventricles (49.1%) and intraventricular septum (14.9%) and tended to be single (70.5%). About 37.7% of patients suffered from coexistent multi-organ problems, two (3.28%) from congenital heart defects and one (1.64%) from Carney’s syndrome. Tumor resection was performed on 26 (42.7%) patients, of which 16 (61.5%) underwent total and 10 (38.5%) partial tumor resection. During the follow-up (mean 4.3 years), 54 patients (88.5%) have improved or were stable, while seven (11.5%) died. Conclusions: Primary pediatric heart tumors are diagnosed completely circumstantially, and the most common is rhabdomyoma, although arrhythmia may suggest fibroma. Diagnosis of a heart tumor in children is not synonymous with fatal prognosis, and most of them require only constant observation. Life-saving operation allows improvement, while the prognosis for malignant tumors in children is definitely unfavorable.

A case of surgically resected cardiac rhabdomyoma with progressive left ventricular outflow tract obstruction

Cardiac rhabdomyoma is the most prevalent cardiac tumors in the pediatric population, in close association with tuberous sclerosis complex. It is usually detected antenatally or postnatally by echocardiography. Clinical presentations depend greatly on the size and position of the tumor mass. Interestingly, rhabdomyoma has a propensity to regress spontaneously and is not usually operated upon, unless the patient becomes hemodynamically compromised. Herein, we report an unusual case of surgically treated cardiac rhabdomyoma in a baby boy presented at birth with a progressive enlarging intraventricular mass, complicated with left ventricular outflow tract obstruction 7 weeks later. Histopathological examination of the intracardiac mass revealed sheets of tumor cells with spider-like morphology (known as "spider cells"), confirmed the diagnosis of rhabdomyoma. Close disease monitoring of patient's hemodynamic status in a newly diagnosed cardiac rhabdomyoma is inevitable as the tumor, although rare, may progress.

Large Left Ventricular Fibroma: Case Report and Literature Review

Benign cardiac tumors are rare and fibroma is second to rhabdomyoma in frequency in pediatric cardiac tumors. We report a case of a 14-year-old male patient, who presented with shortness of breath for 2 years. Echocardiogram and cardiac magnetic resonance imaging indicated a large mass located in the left ventricular lateral wall. The patient underwent surgical excision of the tumor, and histopathological examination confirmed the diagnosis of a cardiac fibroma. The patient had a good postoperative recovery and was discharged on sixth postoperative day.

A Case of Ewing Sarcoma Presenting With Cardiac Metastasis

Ewing sarcoma is the second most prevalent primary malignant bone tumor. Metastases from Ewing sarcoma to the heart are very rare. Herein, we present a case of undiagnosed Ewing sarcoma in a 12-year-old boy who presented with metastasis to the left atrium. The mass was prolapsing across the mitral valve. In view of the potential risk of embolization, urgent cardiac surgery was performed before the establishment of a definitive diagnosis. Histopathology was consistent with Ewing sarcoma. Subsequent magnetic resonance imaging revealed a mass in his left fibula. The patient was referred to the oncology center and received chemotherapy. One year later, he is alive with no evidence of recurrent cardiac involvement.

Cardiac magnetic resonance imaging of primary cardiac tumors

Cardiac magnetic resonance (CMR) offers superior advantages in cardiac imaging due to supplying a greater field of view, excellent soft-tissue imaging, and multiplanar imaging capabilities. CMR imaging can evaluate the characteristics of cardiac tumors by visualizing the relationship between the tumor and surrounding tissues, and plays a vital role in assisting the formulation of the surgical plan, the assessment of tumor progression, and the monitoring of postoperative tumor recurrence and metastasis. In this review, we present the clinical manifestations and imaging features of different cardiac tumors. The superior performance of CMR in preoperative diagnosis, surgical treatment, and postoperative follow-up of patients with heart tumors are also highlighted.

Incidence, prognostic significance, and survival outcomes of primary cardiac sarcoma: An updated population-based retrospective study

OBJECTIVE

Primary cardiac sarcoma, a rare tumor with an aggressive course and imprecise prognosis, constitutes over 95% of all malignant cardiac tumors. Given the sparsely available evidence, there is a paucity of information regarding current knowledge on cardiac sarcoma. This study aimed to determine the incidence and incidence-based rates, patient characteristics, treatment modalities, and survival factors of cardiac sarcoma.

METHODS

A retrospective analysis of the incidence, incidence-based mortality rates and characteristics of cardiac sarcoma between 1975 and 2016 was carried out using the Surveillance, Epidemiology, and End Results (SEER) database. The National Cancer Institute's Joinpoint Regression program was used to calculate the Annual Percentage Changes (APC). Univariate and multivariate regression analysis were used to determine the survival characteristics.

RESULTS

A total 408 patients were identified for the incidence analysis, while 385 eligible patients were identified for the survival analysis. The mean age at diagnosis was 46.3±17.9 years. The incidence rate (per 100.000 per year) of cardiac sarcoma within the indicated years was 0.22, with an increased APC of 1.7 (p=0.013, 95% CI=0.5-2.9). A total of 251 (61.5%) patients underwent surgery, 93 (22.8%) patients received adjuvant radiotherapy, and 197 (50.2%) patients received chemotherapy. Surgical resection, chemotherapy, stage of tumor, and younger age significantly improved the survival outcomes (p<0.001).

CONCLUSION

Cardiac sarcoma is a rare type of soft tissue sarcomas with poor prognosis. Over the past 30 years, the incidence of cardiac sar-coma has been on the increase. Surgery remains the mainstay of management. Further studies are needed to compare different diagnostic and treatment modalities so as to ascertain the best treatment option that would enhance survival and prognosis of cardiac sarcoma.

Radiologist's Guide to Diagnosis of Fetal Cardiac Anomalies on Prenatal Ultrasound Imaging

Congenital cardiac anomalies are a common finding during prenatal anatomical survey ultrasound examination. Cardiac anomalies are a major cause of prenatal and neonatal mortality and morbidity. If the anomaly is not lethal, most would require surgical correction. Therefore, early recognition of these abnormalities is essential for parental counseling and delivery planning, as well as analysis of neonatal treatment options. Although prenatal ultrasound plays an important role in identification of such anomalies, diagnosis and interpretation of imaging findings require familiarity and knowledge of the common imaging features. In this article, we provide a comprehensive review of ultrasound appearance of common fetal cardiac anomalies.

Cardiovascular recurrence of high-grade osteosarcoma presenting as atrial thrombosis and pulmonary embolism: A case report and review of the pediatric literature

In the era of neoadjuvant and adjuvant chemotherapy, extrapulmonary involvement by high-grade osteosarcoma (HGOS) is rare. Importantly however, HGOS metastasis in the form of cardiovascular tumor thrombus portends a dismal prognosis. Thus, prompt and accurate identification of tumor thrombus is crucial. We report here two unique cases of recurrent HGOS, presenting as thrombotic events, in order to increase awareness and index of suspicion among practitioners regarding this presentation. Additionally, we review 14 previously reported pediatric cases of cardiovascular metastatic HGOS.

A Rare Case of an Intracardiac Myoepithelial Carcinoma in an Infant

Myoepithelial carcinomas (MC) represent aggressive tumors that occur in a myriad of ages and anatomic locations. The rarity and histologic similarity with other tumors make them difficult to diagnosis. We report an extremely rare case of a right ventricular outflow tract mass identified to be an intracardiac MC in a 4-month-old male infant. Pathology revealed an EWS-KLF15 translocation. Treatment included gross total resection and intensive chemotherapy. Recurrent cardiac mass with brain metastasis was seen 16 months after primary diagnosis. We describe the rarity of intracardiac MC in pediatric patients and the challenges encountered in the multimodal management of this patient.

Left ventricle primary cardiac fibroma in an adult: A case report

There is a very low prevalence of cardiac fibroma in the adult population. Cardiac fibromas arise from heart fibroblasts, and these tumors are primarily located in the ventricles or in the interventricular septum. Symptomatic tumors are treated by resection. By contrast, asymptomatic tumors require a long-term follow-up or surgical resection as a preventive measure to avoid complications. The present study reports the case of a 43-year-old man, who presented with a cough and shortness of breath for 2 months. Echocardiogram and cardiac magnetic resonance imaging indicated a large mass located in the left ventricular lateral wall. The patient underwent surgical excision of the tumor, and histopathological examination confirmed the mass to be a fibroma. The patient had a good postoperative recovery and was discharged on day 9 post-surgery.

Emergency Ross Procedure for Pediatric Aortic Valve Myxofibrosarcoma

Primary cardiac tumors in children are uncommon and rarely demand surgical intervention. We report a malignant tumor arising from the aortic root in a 5-year-old boy presenting with left ventricular outflow tract obstruction and tumor embolism, its surgical management using the Ross procedure, and the unique histopathological aspects of the tumor.

3D-printed models optimize preoperative planning for pediatric cardiac tumor debulking

BACKGROUND

This study reports the first known application of 3-dimensional (3D) printing of cardiac tumors to preoperatively plan debulking in infants. 3D-printed cardiac tumor models were used to identify the spacial relationship between the tumors and coronary arteries as well as understand the depth and infiltration of the tumors.

METHODS

Physical 3D cardiac tumor models of two children were obtained using medical imaging, image 3D rendering and modeling, and 3D printing. The hearts were 3D-printed in an opaque material while the tumors were made transparent to allow optimal visualization of the cardiovascular anatomy within the tumor. The surgical team used these models to plan exposure of the tumor, as well as, the extent of debulking.

RESULTS

Patient 1 had a cardiac tumor arising from the anterior surface of the right ventricle causing significant right ventricular outflow tract obstruction and involving the right and left coronary artery courses. Patient 2 had a cardiac tumor arising from the left ventricle and extending beyond the left atrium compressing the airway preventing extubation, and surrounding the left coronary artery system. In both patients, 3D-printed models were used to maximize debulking and avoid injury to the coronaries.

CONCLUSIONS

3D-printed cardiac tumor and anatomic models were effectively used to preoperatively plan two pediatric tumor debulkings. Both patients had tumors that were integrally involved with the coronary arteries. The 3D models helped devise a safe surgical strategy for maximal tumor debulking while protecting the coronary circulation.

Evaluation and Management of Cardiac Tumors

PURPOSE OF REVIEW

Our purpose is to discuss the importance of multimodality imaging in the assessment of cardiac tumors and management. We have compiled a recent review of the scientific literature and embedded our clinical pathways and recommendations based on data and clinical experience.

RECENT FINDINGS

The use of contrast echocardiography in the assessment of cardiac masses has been shown to be helpful in distinguishing tumor from thrombus. Deformation imaging of cardiac tumors has been shown to differentiate better rhabdomyomas from fibromas in pediatric patients. Cardiac MRI (CMR) appears to be helpful in determining whether cardiac tumors are benign or malignant by identifying presence of infiltration, uptake of contrast in first pass perfusion and gadolinium enhancement. Patients with evidence of cardiac metastases by CMR show similar survival to stage IV cancer without cardiac metastases. In our institution, we use a standardized approach for the evaluation of cardiac masses, which includes multimodality imaging in the appropriate clinical context. The autotransplantation surgical technique has shown some promise in improving survival in patients with primary cardiac sarcomas. In our institution, we do not routinely recommend anticoagulation for "tumor-thrombus" in renal cell carcinoma due to risk of bleeding from primary tumor. Cardiac masses are often found incidentally, but sometimes can present with cardiovascular symptoms due to obstruction and valvular dysfunction, which may prompt imaging. It is important to determine whether the mass is a normal variant, imaging artifact, vegetation, thrombus, or tumor. Transthoracic echocardiography is ideally suited to be the initial imaging modality because of the portability, wide availability, lack of radiation, and relatively low cost. The gold standard cardiac imaging technique to distinguish tumor from thrombus is contrast enhanced CMR with prolonged inversion time. Advantages of CMR when compared to echocardiography regarding characterization of cardiac tumors are as follows: larger field of view, better spatial resolution, better tissue characterization, lack of attenuation, and ability to image at any prescribed plane. Primary and secondary cardiac tumors have particular characteristics in echocardiography and CMR. Imaging of cardiac tumors plays an important role in establishing a diagnosis and in planning management.

Primary cardiac tumors associated with genetic syndromes: a comprehensive review

Various cardiac tumors occur in the setting of a genetic syndrome such as myxomas in Carney complex and rhabdomyomas in tuberous sclerosis. Tumor biology can be different in syndromic forms, and on imaging children sometimes demonstrate additional manifestations of the underlying syndrome. We discuss the imaging appearance of cardiac tumors occurring in the framework of a genetic syndrome, the findings that suggest an underlying syndrome, and the impact on management.

Homocystinuria presenting as a calcified right atrial mass

Homocystinuria is a genetic inborn error of metabolism due to the deficiency of cystathionine β-synthase resulting in increased serum homocysteine and methionine and decreased cysteine which predisposes affected individuals to arterial and venous thromboembolic phenomena. We present a case of homocystinuria who presented to us as a calcified right atrial mass during the evaluation for lower respiratory tract infection. Our case reveals an unusual mix of findings using imaging with multiple detector computed tomography and radiographs.

Cardiac Tumors in Pediatric Patients: A Systematic Review

This systematic review sought to investigate the current evidence regarding surgical management of primary cardiac tumors in children and adolescents. Twenty-eight studies were deemed eligible, reporting on 745 pediatric patients. Rhabdomyoma was the most prevalent histologic type and echocardiography was the most common diagnostic tool. Cumulative 30-day mortality rate was 6.7%. Rhabdomyomas and teratomas had the highest 30-day mortality. The higher percentage of tumor relapse was noted for myxoma and teratoma. Although cardiac tumors are rare, their atypical clinical presentation, potential for recurrence, and the poor prognosis associated with recurrence elucidate the need for reliable diagnostic and therapeutic management.

Efficacy of Paclitaxel in a Patient with Inoperable Pulmonary Vein Leiomyosarcoma

Pulmonary vein leiomyosarcoma is extremely rare and has a poor prognosis. Surgical resection with a wide margin seems to offer the only chance of cure. The role of adjuvant therapy is controversial, and the exact efficacy of chemotherapy has not been observed. In this report, we present an 18-year-old male patient with pulmonary vein leiomyosarcoma in whom the use of paclitaxel (PAX) proved to be effective. Because the tumor originated from the left superior pulmonary vein and diffused into the left atrial wall and the junction of the right superior pulmonary vein and left atrium, the en bloc excision of the tumor was impossible. The first-line chemotherapy, including ifosfamide, doxorubicin, and dacarbazine, in conjugation with radiation therapy could not demonstrate any effect on the tumor size. However, the following PAX-containing regimen provided complete regression of the tumor. After PAX-based high-dose chemotherapy with autologous peripheral blood stem cell transplantation, the patient showed complete remission for 2 years. Although he suffered metastatic recurrences and died 4 years after the onset of symptoms, our patient's clinical course clearly reveals the efficacy of PAX.

Primary Cardiac Tumors in Infancy: A Case Report and Literature Review

Sudden death in infants due to primary cardiac tumors is extremely rare. Herein we describe a case of an 8-month-old male infant, without any previous medical history, who died in a hospital in the city of Medellín-Antioquia, Colombia. The family stated that approximately 15 minutes after he received a bottle, the baby became cyanotic and subsequently lost consciousness. He was taken to the hospital immediately; however, he arrived lifeless. As this was a sudden death case, the child was referred to the Institute of Legal Medicine and Forensic Sciences in the city of Medellín to clarify the cause, manner, and mechanism of death. The forensic autopsy revealed a eutrophic infant with central and peripheral cyanosis, without signs of trauma, and the internal examination found a single cardiac tumor in the anterior wall of the left ventricle. The mass was white and whorled; histological evaluation diagnosed a fibroma. The manner of death was natural due to a cardiogenic shock caused by a primary tumor.

Identification and clinical course of 166 pediatric cardiac tumors

The aim of this study was to investigate the pathological classifications, clinical features, and natural history of pediatric cardiac tumors to provide a basis for the selection of an appropriate therapeutic method. The medical records of in- or outpatients with cardiac tumors at four hospitals were classified to analyze various types of tumor growth locations, clinical manifestations, surgical indications, and long-term follow-up results. There were 166 patients, including 158 with primary cardiac tumors, six with metastatic cardiac tumors, and two with unclassified cardiac tumors. Among the 158 cases of primary cardiac tumor, 150 were benign and eight were malignant. The rhabdomyoma, fibroma, and myxoma are the most common types of benign cardiac tumors. The major clinical manifestations of cardiac tumors include outflow tract obstruction, arrhythmia, dyspnea, pericardial effusion, heart failure, and seizures. Among the 59 patients who underwent surgery, 49 had primary benign cardiac tumors, eight had primary malignant tumors, and two had malignant metastatic tumors. Post-surgery, nine of the patients had residual tumor tissues that did not significantly affect their hemodynamics. Following surgery, there were two cases of recurrence and nine deaths, including four of benign and five of malignant tumors with mortality rates of 8.2 and 50.0 %, respectively. Of the remaining 107 cases of patients who did not undergo surgery, five (4.7 %) died.

CONCLUSION

The primary benign cardiac tumors are the predominant pediatric cardiac tumors, of which rhabdomyoma, fibroma, and myxoma are the most common types. If severe symptoms are nonexistent and the hemodynamics is unaffected, most of the patients can survive in the long term despite the tumors. What is known: • Pediatric cardiac tumors are rare and are predominantly primary and benign. • The symptoms of heart failure, arrhythmia, and outflow obstruction are the most severe complications of cardiac tumors. What is new: • The rhabdomyoma, fibroma, and myxoma are the most common types of primary benign cardiac tumors. • If severe symptoms are not present and the hemodynamics are unaffected, most of the patients can survive in the long term despite the tumors.

Hamartomas from head to toe: an imaging overview

Hamartomas are tumours composed of mesenchymal tissues such as cartilage, fat, connective tissue and smooth muscle and can be found in virtually any organ system. These masses commonly develop sporadically, but are also seen in certain syndromes such as tuberous sclerosis or Carney triad. While their imaging appearance varies depending on the organ they arise from, findings are usually unique and a diagnosis can be confidently made. Radiologists must be aware of the clinical and imaging presentations of these lesions with the particular goal of avoiding unnecessary studies or invasive procedures. Furthermore, knowledge of common syndromic entities is crucial, as the radiologist may be the first to suggest the diagnosis.