Unusual Finding in a Patient Presenting with Abdominal Pain and Dyspnea

This article discusses the rarity of primary cardiac tumors, particularly angiosarcomas, accounting for 10% of primary cardiac neoplasms. The article highlights the challenge of early diagnosis due to nonspecific symptoms. The importance of sectional imaging, particularly computed tomography (CT) scans, in emergent situations is emphasized. Teaching point: Despite the rarity of primary cardiac tumors, radiologists should remain alert, especially when pericardial effusion is present.

Case Report: Two cases of advanced primary cardiac angiosarcoma treated with anlotinib and a retrospective analysis of the literature

Primary cardiac angiosarcoma is a rare malignant soft-tissue sarcoma derived from vascular endothelial cells or lymphatic endothelial cells, with a high malignancy, poor prognosis, and a lack of effective medical therapy. This article reports on two patients with primary cardiac angiosarcoma who received first-line treatment with multi-targeted anti-angiogenic agent, anlotinib monotherapy. The treatment rapidly controlled pleural and pericardial effusion, significantly reduced the tumor, improved symptoms, and showed satisfactory recent efficacy. This indicates that anlotinib offers a new first-line treatment option for advanced primary cardiac angiosarcoma.

Multimodal imaging of primary cardiac angiosarcoma with brain metastasis

Angiosarcoma is an extremely rare primary cardiac malignant tumor, with characteristics of early blood metastasis and radiochemotherapy resistance. Early diagnosis and timely treatment are of great significance to the prognosis of patients. Hereinafter, we report a case of angiosarcoma in the left atrium of a 61-year-old woman who underwent multimodality imaging and successful resection of the angiosarcoma. Results of the present case suggest that multimodal imaging plays an important role in detecting angiosarcoma and determining the treatment plan and prognosis for patients after treatment.

Primary Cardiac Sarcoma: Angiosarcoma Compressing the Right Coronary Artery

Cardiac tumors are uncommon and can be classified as either primary benign, primary malignant, or metastatic. Cardiac tumors have a wide range of presentations, which can lead to delays in diagnosis and treatment. Primary cardiac tumors can also affect nearby structures, and there have been a few reported cases of coronary artery involvement with various underlying causes. In this case report, we describe a patient with a primary cardiac sarcoma (angiosarcoma) that had spread to other parts of the body and caused occlusion of the right coronary artery.

Surgical resection of a giant cardiac angiosarcoma and reconstruction of involved right heart structures: A case report

We present the case of a young woman without a medical history who presented with a giant right atrial, transtricuspid, and right ventricular mass and in a severe clinical state. Multimodal imaging raised the suspicion of primary cardiac angiosarcoma. Due to rapid hemodynamic and respiratory deterioration, we were forced to perform surgical removal of the mass with a concomitant reconstruction of the involved right heart structures, only 48 h after presentation. The postoperative course was uneventful, and the patient was discharged from the intensive care unit 2 days later. Radical surgical resection with reconstruction of the resected heart structures was the only possible salvage option for giant angiosarcoma, which led to hemodynamic instability. Followed by chemotherapy, this radical approach may prolong survival.

A case report of primary cardiac angiosarcoma with DNMT3A gene mutation

Cardiac angiosarcoma is a rare disease with a high mortality rate despite its low incidence. Surgery is currently the mainstay treatment strategy for patients with this condition. Herein, we describe a case of primary cardiac angiosarcoma, including symptoms, examination findings, treatment strategy and prognosis. In 2020, the patient was admitted to our hospital, and Next-Generation Sequencing (NGS) revealed a mutation in the DNMT3A gene. Generally, DNMT3A mutations are most commonly seen in atherosclerosis and myeloid leukemia. To our knowledge, this is the first reported case of primary cardiac angiosarcoma with DNMT3A gene mutation.

Role of 18F-FDG PET/CT imaging in cardiac and pericardial masses

BACKGROUND

Considering the few reported cardiac masses, PET/CT in the imaging workup of cardiac masses is not well established. This retrospective study analyzed the role of 18F-FDG PET/CT imaging in cardiac/pericardial masses.

METHODS AND RESULTS

Fifty-nine patients with newly diagnosed cardiac/pericardial masses who underwent PET/CT and transthoracic echocardiography (TTE) were recruited. Echocardiographic and PET/CT characteristics were evaluated for predictive value in differentiating malignant and non-malignant lesions using histologic confirmation as the gold standard. The McNemar test was used to test the differences in sensitivity between PET/CT and TTE. 18F-FDG PET/CT had higher sensitivity in determining the malignancy of cardiac/pericardial masses compared to TTE (sensitivity, 96.6% vs 72.4%, P = .039). However, when pericardial masses were excluded from the analysis, the difference in sensitivity between the two was not statistically significant (sensitivity, 95.6% vs 78.3%, P = .219). 18F-FDG PET/CT identified two malignant pericardial masses missed on TTE, changed the diagnostic orientation of TTE in 15 patients, and found seven patients with extracardiac lesions in 29 malignant patients.

CONCLUSIONS

PET/CT was an effective additional image modality in patients with suspected malignant cardiac mass for further confirmation and to screen for potential metastasis.

Case Report: An Unusual Cause for Recurrent Hemopericardium in a Patient With Dyspnea

The case concerns a female presenting with dyspnoea resulting from recurrent hemopericardium. Pericardiocentesis, coronary angiography, and extensive laboratory and imaging studies did not reveal the underlying etiology of the hemopericardium. Only after repeat and exploratory surgery, diffuse venous pericardial hemorrhages with localized thrombi typical of angiosarcoma were discovered.

Pericardial Angiosarcoma: A Diagnostic Challenge

Cardiac angiosarcomas are the most common malignant primary cardiac tumors accounting for 31% of all primary cardiac tumors. However, primary pericardial angiosarcomas are extremely rare and are associated with high mortality.

A 41-year-old male with a past medical history of end-stage renal disease (ESRD) on hemodialysis, follicular thyroid carcinoma, hypertension, and asthma presented with recurrent pericardial effusions. Previously, different imaging modalities had shown small hemodynamically stable pericardial effusions with pericardial thickening. His pericardial effusion was attributed to his ESRD until this presentation. However, during the current admission, chest X-ray showed cardiomegaly with lobulated left heart border. Computed tomography (CT) and transthoracic echocardiogram showed an increased posterior complex pericardial effusion when compared to previous imaging. A pericardial window was created and the space was evacuated. Pericardial fluid cytology reported rare atypical cells, which were indeterminate for malignancy. Histopathology from the pericardial biopsy revealed fibrous tissue with cellular proliferation, consistent with an angiosarcoma. A positron emission tomography revealed findings of angiosarcoma (hypermetabolic pericardial soft tissue nodularity and complex pericardial fluid) limited only to the pericardium. Unfortunately, the angiosarcoma was deemed unresectable, and the patient underwent one cycle of chemotherapy with paclitaxel. The patient’s hospital course was further complicated by myelosuppression from chemotherapy and disseminated intravascular coagulation. Therefore, no further chemotherapy was pursued. A repeat echocardiogram showed constriction of both ventricles with loculated pericardial effusion. The patient eventually transitioned to comfort care and passed away.

Through this case report, we would like to highlight that multiple confounders can be present when considering the etiology of persistent pericardial effusions. We suggest contemplating alternate diagnosis, such as malignancy, and initiate aggressive work-up especially in young individuals with recurrent, unexplained pericarditis.

A 30-Year-Old Man With Primary Cardiac Angiosarcoma

A previously fit and well 30-year-old man presented with palpitations, fever, and pleuritic chest pain. Multimodality imaging and histopathology confirmed the diagnosis of primary cardiac angiosarcoma. We present the details of the presentation, diagnostic process using multimodality imaging, and clinical management. (Level of Difficulty: Beginner.)

Incessant Atrial Tachycardia as First Presentation of Cardiac Angiosarcoma

Primary cardiac angiosarcomas are rare malignant tumors with a very poor prognosis. We present a case of a 48-year-old man with no previous cardiac history who developed an incessant focal atrial tachycardia complicated by tachycardia-mediated cardiomyopathy as a consequence of cardiac angiosarcoma. (Level of Difficulty: Beginner.)

Right atrial cardiac angiosarcoma treated with concurrent proton beam therapy and paclitaxel: A novel approach to a rare disease

Cardiac angiosarcoma is a rare malignancy with an aggressive course and poor prognosis. We present a 26‐year old man who came to our clinic with shortness of breath and was diagnosed with a right‐sided atrial mass. He underwent urgent resection of the mass. The pathology confirmed the mass to be cardiac angiosarcoma with positive microscopic margins (R1 resection). Since reresection was not feasible, the patient started treatment with concurrent paclitaxel (80 mg/m² weekly) and proton beam therapy (61 Cobalt equivalent delivered over five weeks). After completing the concurrent chemotherapy and radiation therapy, he was treated with adjuvant chemotherapy using gemcitabine (900 mg/m² on Days 1 and 8) and docetaxel (100 mg/m² on Day 8) every three weeks. After three cycles, the patient developed severe dermatitis, and hence further chemotherapy was withheld. The patient is alive at 26 months since receiving his surgery and 18 months since the completion of treatment. Patients with cardiac angiosarcoma who undergo R1 resection have a median survival of six months. More radical approaches such as orthotopic heart‐lung transplant or prolonged durations of chemotherapy lead to minimal improvement in survival at the cost of increased morbidity. Here, we describe a novel approach to a rare disease that resulted in prolonged survival and led to a better quality of life without any long‐term morbidity to the patient.

Case Report: Thromboembolism and Hemorrhagic Pericardial Effusion-The Janus Face of Primary Pericardial Angiosarcoma

Background: Primary cardiac angiosarcomas, especially those originating in the pericardium, are extremely rare and aggressive tumors with poor prognosis. These types of malignant tumors have diverse clinical presentations and are often masked by other comorbidities. Case Summary: Our hospital reported a 59-year-old woman who initially presented with pulmonary thromboembolism (PTE) and was subsequently treated with low-molecular-weight heparin. However, she experienced acute pericardial tamponade after anticoagulation therapy, where no obvious mass was primarily identified upon imaging, both in the pericardium or within the heart. Emergency pericardiocentesis and drainage were performed, where a total of 210 mL of bloody effusion was drained. Four months later, she was hospitalized with progressive hemoptysis and dyspnea. A large mixed mass occupying the right pericardium was later identified by coronary computed tomography angiography (CCTA). The mass was consistent with the right atrium, with heterogeneous thickened pericardium and localized moderate pericardial effusion. CCTA and positron emission tomography scans later showed metastases in both lungs and bilateral pleura. Nodules in hilar and mediastinal lymph nodes were also significant. Ultrasound-guided biopsy was performed, and the patient was ultimately diagnosed with an angiosarcoma based on final positive results for both CD31 and CD34 markers. The patient refused chemotherapy and passed away while waiting for her pathology results. The patient survived for 6 months since the first reported episode of PTE. Conclusions: Our case indicates that patients presenting with both embolism and hemorrhage should urgently be channeled to a clinical specialist to confirm any malignant etiology. This would be beneficial to confirm an early diagnosis and lengthen the duration of patient survival. However, the diagnosis of primary cardiac angiosarcoma is still challenging and requires multiple imaging modalities and biopsies in order to assist the accurate diagnosis of disease and achieve effective patient management.

Dramatic Recovery from Cardiovascular Collapse: Paclitaxel as an Urgent Treatment for Primary Cardiac Angiosarcoma

We herein report three patients with cardiac angiosarcoma who were directly admitted to the intensive-care unit for hemodynamic instability with circulatory collapse. Using a multidisciplinary cardio-oncologic approach, we diagnosed their condition as angiosarcoma by an invasive biopsy and urgently started weekly paclitaxel administration despite their poor performance status. Their vital signs were soon stabilized, leading to the patients' discharge from the hospital. Although no treatment guidelines for cardiac angiosarcoma have been established, chemotherapy with paclitaxel can be an option for cases presenting with hemodynamic instability.

[Diagnostic difficulties and legal analysis of potential claims to occupational medicine specialists based on a case of unrecognizable cardiac angiosarcoma]

The article presents a case of sudden death of a 56-year-old woman at the workplace, caused by a very rare primary cardiac tumor. The patient's family reported a crime to the prosecutor's office suggesting participation of third parties in causing the death or malpractice in physical examinations before the death. A review of clinical data concerning cardiac angiosarcoma, available in electronic databases (e.g., Web of Science, PubMed), was presented, which could be useful in the practice of occupational medicine specialists. A legal analysis of potential claims to occupational medicine specialist in the case of failure to recognize primary cardiac tumors was also included in the article. Med Pr. 2020;71(6):757-64.

Cardiac angiosarcoma: A case report and review of current treatment

RATIONALE

Primary cardiac angiosarcoma is a rare malignant cardiac neoplasm with early metastasis and poor prognosis. As there are currently no guidelines or effective therapeutic strategies, management of this condition depends on previous experiences of the clinician treating and the consideration of reported cases.

PATIENT CONCERNS

A 65-year-old male presented to our department with a 4-day history of chest tightness, dyspnea, lower extremity weakness and occasional dizziness, and a transthoracic echo (TTE) revealed a right atrium occupying mass.

DIAGNOSES

TTE showed right atrium occupation, and the post-operative histopathology showed the tumor to be a primary cardiac angiosarcoma.

INTERVENTIONS

Right atrium tumor resection and right atrium reconstruction with a bovine pericardium were performed.

OUTCOMES

The patient recovered from surgery and discharged but died 10 months after surgery because of complete resection was impossible and adjuvant therapy was not performed.

LESSONS

Resection of primary cardiac angiosarcomas should be integrated with a combination of chemotherapy, radiotherapy, and targeted therapy based on tumor cell gene mutation and altered expression.

POT1 and Damage Response Malfunction Trigger Acquisition of Somatic Activating Mutations in the VEGF Pathway in Cardiac Angiosarcomas

Background Mutations in the POT1 gene explain abnormally long telomeres and multiple tumors including cardiac angiosarcomas (CAS). However, the link between long telomeres and tumorigenesis is poorly understood. Methods and Results Here, we have studied the somatic landscape of 3 different angiosarcoma patients with mutations in the POT1 gene to further investigate this tumorigenesis process. In addition, the genetic landscape of 7 CAS patients without mutations in the POT1 gene has been studied. Patients with CAS and nonfunctional POT1 did not repress ATR (ataxia telangiectasia RAD3-related)-dependent DNA damage signaling and showed a constitutive increase of cell cycle arrest and somatic activating mutations in the VEGF (vascular endothelial growth factor)/angiogenesis pathway (KDR gene). The same observation was made in POT1 mutation carriers with tumors different from CAS and also in CAS patients without mutations in the POT1 gene but with mutations in other genes involved in DNA damage signaling. Conclusions Inhibition of POT1 function and damage-response malfunction activated DNA damage signaling and increased cell cycle arrest as well as interfered with apoptosis, which would permit acquisition of somatic mutations in the VEGF/angiogenesis pathway that drives tumor formation. Therapies based on the inhibition of damage signaling in asymptomatic carriers may diminish defects on cell cycle arrest and thus prevent the apoptosis deregulation that leads to the acquisition of driver mutations.

Debulking and three-dimensional reconstruction of a rare case of right atrium-ventricular angiosarcoma

A 48-year-old man presented with chest pain and ischemic manifestations according to an electrocardiogram due to coronary artery compression from a cardiac mass and was admitted to the emergency room and underwent extensive debulking followed by right atrium and ventricular three-dimensional reconstruction with concomitant tricuspid valve remodeling. He recovered a normal sinus rhythm and was discharged from the hospital a week later with a diagnosis of cardiac malignant angiosarcoma according to the pathological examination. He survived and had a normal cardiac structure and function performance, but vertebral metastasis was suspected after more than 4 months of follow-up after the procedure.

Surgical Resection and Pazopanib Treatment for Recurrent Cardiac Angiosarcoma

Cardiac sarcoma treatment is challenging for surgeons because of frequent tumor recurrence and poor prognosis. In addition, optimal management of recurrences is not well established. The multi-targeted tyrosine kinase inhibitor, pazopanib, was recently approved for soft-tissue sarcoma. Herein, we present a case involving recurrent cardiac angiosarcoma where the patient survived for 2 years with complete remission of disease after repeated surgical resection and treatment with oral pazopanib. Based on our experience, aggressive surgical resection combined with pazopanib may be a valid treatment for recurrent cardiac angiosarcoma to improve patient survival.

A successful insertion of PICC in patient with cardiac angiosarcoma and neoplasty of right atrium and pacemaker: A case report

INTRODUCTION

Primary cardiac angiosarcoma is a rare tumor and the common treatment is surgical resection followed by chemotherapy. Peripherally inserted central venous catheters (PICCs) are widely used in cancer patients and ultrasound-guided PICC insertion could improve success rate especially in patient with abnormal anatomy structure. Reports about PICCs being placed in patient who had suffered from the cardiac angiosarcoma and neoplasty of right atrium with an ipsilateral cardiac permanent pacemaker are rarely.After patient's informed consent, we present a case of the successful insertion of PICC into a patient with the ipsilateral cardiac disease with a pacemaker placement, which has not been previously reported.

CONCLUSIONS

This report highlights PICC could be used in patient with cardiac disease with a pacemaker placement for chemotherapy.

Clinical and diagnostic features of angiosarcoma with pulmonary metastases: A retrospective observational study

Angiosarcoma with pulmonary metastasis is a rare, fatal disease that often presents with multiple pulmonary nodules and diffuse alveolar hemorrhage. We herein review the detailed clinical characteristics of pulmonary metastatic angiosarcoma and determine a reasonable diagnostic strategy.The medical records of 11 patients with pulmonary angiosarcoma were reviewed.The mean age of the patients was 45.7 years (range, 30-71 years). All patients were male. The most common symptom was hemoptysis (8/11). Common initial misdiagnoses were tuberculosis (5/11), vasculitis (2/11), nontuberculous infectious disease (1/11), and constrictive pericarditis (1/11). Chest computed tomography (CT) of patients with hemoptysis showed bilateral, randomly distributed, variably shaped, and differently sized nodules, as well as ground-glass opacities (GGO) (8/11). The right heart was the most common primary tumor site (8/11), but the sensitivity of echocardiography was limited; CT angiography and cardiac magnetic resonance imaging (MRI) revealed more atrial masses. CT-guided needle biopsy was difficult to perform in most patients because of the small size of the nodules. The diagnosis was made by surgical biopsy of either the lung (3/9) or heart (6/9). The median overall survival of patients who underwent lung biopsy and those who underwent cardiac/pericardiac biopsy was 4.1 and 1.4 months, respectively (P = .098). The median overall survival of the 9 available patients was 5.0 months (95% confidence interval, 0.500-8.544).Angiosarcoma with pulmonary metastases should be considered in patients with hemoptysis and concurrent GGO and nodules on their chest CT scan. Careful cardiologic monitoring is necessary for these patients, even without any cardiac symptoms or signs, and enhanced cardiac MRI is the first recommendation. Surgical biopsy is reliable for histological diagnosis, but the safety of the lung biopsy should be carefully assessed. When primary cardiac tumors are identified, heart biopsy should be preferentially considered.

Comprehensive treatment of unresectable cardiac angiosarcoma: A case report and review of literature

Cardiac angiosarcoma is a rare but lethal tumor that is difficult to diagnose and treat, due to its rapid local relapse and high incidence of systemic metastasis. The prognosis of cardiac angiosarcoma is dismal, with a mean life expectancy of only a few months. We herein report a case of unresectable angiosarcoma arising from the right atrium. The patient received first-line chemotherapy with weekly paclitaxel, and second-line therapy with vinorelbine and bevacizumab upon disease progression. The progression-free survival was 6 months and the overall survival was 7 months. The patient eventually succumbed to respiratory failure. A study of the present case and a review of the relevant literature suggest that treatment decisions for unresectable locally advanced or metastatic cardiac angiosarcoma are difficult, as the published literature on this disease mainly consists of case reports without sufficient data. Therefore, further clinical trials specific to the treatment of unresectable cardiac angiosarcoma are warranted.

Cardiac magnetic resonance in cardiac angiosarcoma

BACKGROUND

While echocardiography is effective for initial identification of anatomic location, magnetic resonance imaging (MRI) is a more advantageous modality for delineating tumor expanse, spread, and blood supply preoperatively. Emerging patterns may even help generate a specific diagnosis prior to biopsy and histopathology.

CASE PRESENTATION

Our case of a 67-year-old male referred for cardiac magnetic resonance to further evaluate a cardiac mass highlights the sophisticated level of data which can be collected. Our case highlights the perfusion related findings associated with cardiac angiosarcoma.

CONCLUSION

In this case, we present the diagnosis of right atrial cardiac angiosarcoma by multiple imaging modalities including MRI and subsequent angiography, allowing for prompt surgical intervention and initiation of adjuvant therapy that resulted in a survival time of 19 months.

Treating the Critically Ill with Radiotherapy: Lessons Learned from a Young Woman with Cardiac Angiosarcoma

Background

Treating patients who are critically ill with radiotherapy (RT) brings a unique set of challenges as it involves treating patients who require mechanical life support, unconventional positioning, and a multidisciplinary team approach to ensure safety. However, when the benefits of such treatment outweigh the risks, the challenges can be overcome, as demonstrated in this unique case of cardiac angiosarcoma.

Case description

This is a case of a 42-year-old female with a right sided cardiac angiosarcoma who quickly developed cardiac tamponade and respiratory failure related to compression of her right heart by the tumor. She was treated with high dose single fraction RT initially and had a clinical response allowing further conformal RT with concurrent chemotherapy.

Discussion

Managing critically ill patients requires creativity, improvisation, and careful consideration of existing evidence. Although limited, the data suggest that multi-modality therapy with a combination of surgery, RT, and chemotherapy provide the best outcomes.

Rare tumors of the heart--angiosarcoma, pericardial lipoma, leiomyosarcoma. Three case reports

Primary tumors of the heart, pericardium and inferior vena cava are extremely rare. Three cases of surgically/biopsy proven angiosarcoma of the right atrium, pericardial lipoma and leiomyosarcoma of inferior vena cava--demonstrated by ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI)--are presented here.