Malignant tumours of the heart: a review of tumour type, diagnosis and therapy

[Metastatic tumor of the right ventricle: an unusual location of tumor involvement in laryngeal carcinoma]

Secondary tumors are much more frequent than primary tumors, but cardiac metastasis of laryngeal carcinoma is uncommon. The authors report the case of a 71-year-old man, with a history of laryngeal carcinoma, admitted to the emergency room with symptoms of two weeks' evolution suggestive of respiratory infection. Due to lack of therapeutic response and progressive clinical deterioration, a transthoracic echocardiogram was performed which revealed a large infiltrating mass within the right ventricle, involving the apex, interventricular septum and free wall, not causing significant right ventricular outflow tract obstruction. Evaluation by computed tomography showed signs of widespread metastasis from the previously diagnosed laryngeal cancer.

Metastasizing primary atrial leiomyosarcoma causing a functional high-grade mitral stenosis

We report the case of a 43-year-old man who presented with a primary cardiac leiomyosarcoma and multiple metastases. Despite the severely poor prognosis, cardiac surgery was performed as part of a multidisciplinary palliative approach, which paved the way for further chemotherapy and radiation therapy.

Tachyarrhythmia secondary to cardiac metastasis as first presentation of non-small-cell lung cancer

We describe a man who presented at our institution with tachyarrhythmia and dyspnea. Echocardiography, magnetic resonance imaging (MRI) and computed tomography (CT) of the chest performed during hospitalization revealed a mass within the left atrium. A biopsy of the mass showed a non-small-cell lung cancer, adenocarcinoma G3. Metastatic involvement of the heart is rare; most cases are asymptomatic and diagnosed only during autopsies. Echocardiography, CT scan and MRI are complementary investigations in the evaluation of cardiac lesions. In the setting of cardiac metastatic cancer, all management is palliative.

Fatal thrombocytopenia: A rare case with possible explanation

A 22 year old male presented with breathlessness on exertion, ecchymosis, jaundice and features of worsening right heart failure for the last fifteen days. On physical examination, he had a mid diastolic murmur in the tricuspid area and an ejection systolic murmur in the pulmonary area. Bone marrow histopathology report showed an increased in megakaryocytes count. Routine investigations reports were normal. Echocardiography and computerized tomography (CT) revealed a single mobile large intra cardiac mass originating from the right atrium and causing dynamic obstruction of the right ventricular inflow and outflow tract. Associated fatal thrombocytopenia did not respond to intravenous steroids or platelet transfusion. Patient could not be operated because of very low platelet count, and died during hospital stay before excision biopsy could be done. Pathological autopsy was not done. This is a rare case, as the fatal thrombocytopenia observed here was the result of mechanical effects like frictional and shear force, which can be attributed to the physical presence of a large intra cardiac mass resulting in obstruction to flow.

A rare cause of recurrent stroke in childhood: left atrial rhabdomyosarcoma

We present a case of recurrent stroke secondary to cardiac rhabdomyosarcoma. The detected prothrombotic mutations at the first attack had seemed to be the main cause, but the echocardiography performed at the recurrence revealed the actual underlying cause of stroke.

CONCLUSION

The aetiological investigation into childhood stroke should absolutely include echocardiography regardless of the presence of other risk factors.

Outcomes after right-side heart sarcoma resection

BACKGROUND

In patients with primary cardiac sarcoma, the tumor's location is more important than cell type in determining patient presentation, therapy options, and outcomes. The purpose of the current study was to investigate the outcomes after right-side heart sarcoma resection.

METHODS

Clinicopathologic data from patients who underwent right-side heart sarcoma resection at our institution and patients identified in a literature search were examined. Morbidity and the 30-day mortality rate and survival were determined. We used univariate and multivariate analyses to identify independent predictors of overall survival.

RESULTS

We identified 57 patients who underwent right-side heart sarcoma resection. Right-side heart failure was the most common complication (4 patients, 19%), and the 30-day mortality was 14% (3 patients). The overall 5-year survival rate was 17%, and the median overall survival duration was 9 months. Multivariate analyses revealed that surgical margin status was the only independent predictor of survival. Patients with negative surgical margins had a longer median overall survival duration (27 months versus 4 months) and a significantly higher overall 5-year survival rate (36% versus 0%; p = 0.0003) than patients with positive surgical margins.

CONCLUSIONS

The patients with right-side heart sarcoma resection had worse survival after resection than that reported for our patients who underwent resection for left-side heart sarcoma or pulmonary artery sarcoma. Because positive surgical margin status is an independent predictor of reduced survival, induction chemotherapy should considered to enhance resectability in right-side heart sarcoma patients, thus maximizing the possibility of obtaining negative surgical margins.

Surgical treatment of cardiac myxosarcoma

A 36-year-old man suffering from exertional dyspnea was admitted to our hospital. An echocardiogram showed a left atrial tumor, which was excised via the left atrial approach. Histological examination of the surgical specimen revealed that it was a myxosarcoma. Twelve months after the surgery, the tumor recurred in the left atrium, and metastatic tumors were found in the right atrium and right ventricle. Surgery was performed once again, but examinations 5 months after the second surgery showed local recurrences and multiple metastases. Although the patient had received chemotherapy, he died 30 months after the first operation.

Leiomyosarcoma with partial rhabdomyoblastic differentiation: first case report of primary cardiac origin

BACKGROUND

Leiomyosarcoma occurring as a primary cardiac tumor has been known as an extremely rare condition. Previous studies of leiomyosarcoma with rhabdomyoblastic differentiation have conducted to those arisen from another site, and they indicated a poorer prognosis of this tumor.

CASE PRESENTATION

A 69-year-old woman was referred to our hospital for an operation concerning umbilical hernia. Subsequent imaging examinations before an operation indicated the presence of primary cardiac malignant tumor due to its atypical shape. And then, it was surgically removed. Histopathologically, tumor cells consisted of two different types: spindle and polyhedral cells. Immunohistochemically, it is interesting to note that 2.1% of spindle cells and 23.1% of polyhedral cells showed positive reactivity for myogenin. Furthermore, we performed double-immunostaining for alpha-smooth muscle actin (SMA) and myogenin. The rates of alpha-SMA and myogenin double negative, alpha-SMA single positive, myogenin single positive, and alpha-SMA and myogenin double positive in spindle cells were estimated as 69.1%, 28.8%, 1.1% and 1.0%, respectively. In contrast, the rates in polyhedral cells were estimated as 76.9%, 0.0%, 23.1%, and 0.0%, respectively.

CONCLUSION

Our immunohistochemical evaluation suggested that rhabdomyoblastic differentiation in leiomyosarcoma might be generated not only by de novo generation from mesenchymal cells. To the best of our knowledge, this is the first case of primary cardiac leiomyosarcoma with partial rhabdomyoblastic differentiation.

Mature fat cells in the myocardium of patients with tuberous sclerosis complex: Figure 1

Aim

Routine abdominal CT scans in patients with tuberous sclerosis complex (TSC) showed characteristic fatty foci in the depicted caudal portions of the myocardium. The purpose of this study was to investigate if areas of abnormal myocardium in patients with TSC could also be found in post-mortem specimens.

Methods

A retrospective search of our histopathology database was performed to identify specimens of the heart of patients with TSC. Institutional review board approval was obtained, and patient informed consent was waived. Four specimens were included (mean age, 44 years; range 32–68 years; 2 females).

Results

Two specimens (50%) of the heart showed areas of mature fat cells in the myocardium, without associated inflammation, without associated fibrosis, without entrapped myocardial cells and without a capsule.

Conclusion

Post-mortem specimens of the heart of patients with TSC showed areas of mature fat cells in the myocardium which seem to be unique for TSC.

Extraskeletal myxoid chondrosarcoma of the heart and review of current literature

Extraskeletal myxoid chondrosarcoma (EMS) is a rare oncologic phenomenon characterized by chondroid and neurogenic differentiation in extraskeletal locations. These tumours represent fewer than 2.5% of all soft-tissue sarcomas and are most commonly found in the lower extremities, limb girdles, distal extremities, and trunk. Their presence in cardiac tissue is exceedingly unusual; just a single case of ems metastatic to the heart has been reported, and no cases of primary cardiac EMS are known.Here, we report the case of a 26-year-old man who presented to his physician with a chest wall mass. Further evaluation led to the discovery of a large intracardiac mass with multiple end-organ growths. Complete work-up of this patient included cardiac biopsy, echocardiography, magnetic resonance imaging, positron-emission tomography, computed tomography, and fluorescence in situ hybridization studies for the translocation involving the EWSR1 gene locus (22q12). Results of the foregoing studies confirmed the diagnosis of ems, but the origin of this patient's tumours remains elusive and the contention between a primary cardiac source and cardiac metastasis has yet to be resolved.This article describes the histopathology, immunohistochemistry, and chromosomal aberrations common to ems, together with the common presenting features, natural history, and prognosis.

Primary cardiac angiosarcoma arising from the interatrial septum: magnetic resonance imaging appearances

We present a case of primary cardiac angiosarcoma arising from the interatrial septum that had imaging features overlapping with those of right atrial myxoma. The mass was initially discovered on a thoracic CT study. Further evaluation with echocardiography was limited by poor acoustic windows and cardiac magnetic resonance (CMR) imaging was performed prior to surgical resection. CMR provided a detailed morphological assessment; imaging features included a frond-like surface architecture, a narrow attachment point at the interatrial septum, mild signal hyperintensity compared with that of myocardium on T(1) weighted sequences, patchy foci of delayed gadolinium enhancement and a haemorrhagic pericardial effusion. To the best of our knowledge, this is the first reported case of angiosarcoma arising from the interatrial septum that has undergone evaluation with CMR.

A novel kind of tumor type-characteristic junction: plakophilin-2 as a major protein of adherens junctions in cardiac myxomata

Using novel antibodies of high avidity to--and specificity for--the constitutive desmosomal plaque protein, plakophilin-2 (Pkp2), in a systematic study of the molecular composition of junctions connecting the cells of soft tissue tumors, we have discovered with immunocytochemical, biochemical and electron microscopical methods, a novel type of adherens junctions in all 32 cardiac myxomata examined. These junctions contain cadherin-11 as their major transmembrane glycoprotein, which we could repeatedly show in colocalization with N-cadherin, anchored in a cytoplasmic plaque formed by α- and β-catenin, together with the further armadillo-type proteins plakoglobin, p120, p0071 and ARVCF. Surprisingly, all adherens junctions of these tumors contained, in addition, another major armadillo protein Pkp2, hitherto known as an obligatory and characteristic constituent of desmosomes in epithelium-derived tumors. We have not detected Pkp2 in a series of noncardiac myxomata studied in parallel. Therefore, we conclude that this acquisition of Pkp2, which we have recently also observed in some mesenchymally derived cells growing in culture, can also occur in tumorigenic transformations in situ. We propose to examine the marker value of Pkp2 in clinical diagnoses of cardiac myxomata and to develop Pkp2-targeted therapeutic reagents.

Primary leiomyosarcoma of the right atrium: a case report and literature update

Leiomyosarcoma of the right atrium is a very rare cardiac tumor. Various combinations of treatments including resection or transplant surgery and Chemotherapy have been advocated. We report a case of a man who presented with pulmonary embolism secondary to right atrial leiomyosarcoma. He was managed by excision of the tumor and reconstruction of the right atrium with autologous pericardium. Postoperatively tumor dissemination was controlled with adjuvant chemotherapy.A vigorous attempt aiming at tumor clearance followed by adjuvant multimodality therapy along with a tumor surveillance program may improve survival.

Cardiac epithelioid leiomyosarcoma and the role of cardiac imaging in the differentiation of intracardiac masses

Primary malignant cardiac neoplasms are extremely rare and can be difficult to differentiate from other intracardiac masses. We present a case of left atrial epithelioid leiomyosarcoma and review the imaging modalities available to diagnose and characterize intracardiac masses. We demonstrate how multimodal imaging aided diagnosis and proved crucial to establishing the tumor's location, degree of invasion, and involvement of surrounding structures prior to surgical resection.

Left ventricular metastasis from renal cell carcinoma causing left ventricular outflow tract obstruction

Most cases of cardiac metastasis from renal cell carcinoma (RCC) involve the vena cava or right atrium. Left ventricular metastases from RCC without involving the vena cava or right atrium are extremely rare. Herein we report a case of RCC with left ventricular metastasis causing left ventricular outflow obstruction (LVOT).

Transseptal fine needle aspiration of a large left atrial tumour

The diagnosis of cardiac tumours is often based on images without tissue diagnosis or tissue obtained at surgery. Percutaneous myocardial biopsy via a transvenous approach has been described in literatures but this technique is not feasible with left atrial tumours. We report a patient presenting with heart failure and left atrial tumour. The diagnosis of spindle cell neoplasm was established pre-operatively via successful transseptal fine needle aspiration of cells from a left atrial tumour. We believe this technique worth consideration to aid pre-surgery diagnosis.

Severe thrombocytopenia complicating giant left atrial rhabdomyosarcoma

We report an adult patient with a large left atrial rhabdomyosarcoma causing intracardiac blood flow obstruction and thrombocytopenia, in whom platelet count normalized after surgical excision of the tumor. The patient presented a fatal intracranial hemorrhage 2 weeks after surgery.

Detection of an asymptomatic right-ventricle cardiac metastasis from a small-cell lung cancer by F-18-FDG PET/CT

A right heart metastasis of a small-cell lung cancer was found on the whole-body F-fluoro-deoxy-glucose positron emission tomography/computed tomography (F-FDG-PET/CT) of a 69-year-old smoker investigated for a right pulmonary mass discovered on chest radiography after a fracture of the right humerus. The PET scan showed an increased FDG uptake by the mass in the right lung and an intense, atypical focal activity of the right ventricle strongly suggestive of a neoplastic process. CT-guided lung biopsy revealed a small-cell lung cancer and myocardial biopsy confirmed the presence of a cardiac metastasis. The patient was treated with six cycles of chemotherapy followed by radiation therapy, which included the heart lesion. At follow-up PET/CT 2 months after the end of treatment, the abnormal cardiac uptake had disappeared, whereas increased FDG uptake persisted in the pulmonary residual mass.

Huge primary pleomorphic leiomyosarcoma in the right ventricle with impending obstruction of both inflow and outflow tracts

Primary cardiac leiomyosarcoma is an extremely rare disease entity that is associated with very poor prognosis. We describe here a 45-year-old man who had a huge pleomorphic leiomyosarcoma in the right ventricle (RV) that presented with signs of acute pressure and volume overload and impending obstruction of both outflow and inflow tracts of the RV. The tumor was attached to the RV apex and the interventricular septum, and extended into the main pulmonary trunk just above the pulmonary valve as well as into the right atrium through the tricuspid valve. We evaluated the extent of the tumor using various imaging modalities including transthoracic and transesophageal echocardiography, magnetic resonance imaging, computed tomography, and positron emission tomography-computed tomography. Although he underwent urgent debulking surgery to relieve the obstruction, the tumor could not be resected completely because of its extensive local invasion. The tumor has shown aggressive regrowth after surgery despite adjuvant chemotherapy.

Early detection and efficient therapy of cardiac angiosarcoma due to routine transesophageal echocardiography after cerebrovascular stroke

Primary malignant cardiac tumors (cardiac angiosarcomas) are exceedingly rare. Since there are initially nonspecific or missing symptoms, these tumors are usually diagnosed only in an advanced, often incurable stage, after the large tumor mass elicits hemodynamic obstructive symptoms. A 59-year-old female presented with symptoms of cerebral ischemia. A computed tomography (CT) scan showed changes suggestive of stroke. Transesophageal echocardiography revealed an inhomogeneous, medium-echogenic, floating mass at the roof of the left atrium near the mouth of the right upper pulmonary vein, indicative of a thrombus. At surgery, a solitary tumor was completely enucleated. Histologically, cardiac angiosarcoma was diagnosed. The patient received adjuvant chemotherapy and was free of symptoms and recurrence of disease at 14 months follow-up. Due to the fortuitous appearance of clinical signs indicative of stroke, cardiac angiosarcoma was diagnosed and effectively treated at an early, nonmetastatic, and therefore potentially curable stage. Although cardiac angiosarcoma is a rare disease, it should be taken into consideration as a potential cause of cerebral embolic disease.

Fine-needle aspiration biopsy of primary osteosarcoma of the thyroid: report of a case and review of the literature

Primary osteosarcoma of the thyroid is an extremely rare tumor, with only 27 well-documented cases reported in the literature, including only one in the cytology literature. We describe here an additional case with fine-needle aspiration biopsy findings. A 60-year-old woman presented with a 1-month history of progressive midline neck swelling. CT and ultrasound demonstrated a large thyroid mass with tracheal compression. Fine-needle aspiration biopsies were performed and showed pleomorphic spindle and epithelioid neoplastic cells, multinucleated giant cells, and scant metachromatic extracellular matrix material. Cell block sections contained minute tissue fragments with neoplastic spindle cells. Immunohistochemical stains showed the tumor cells to be positive for vimentin and negative for cytokeratins, TTF-1, calcitonin, synatophysin, chromogranin, and S-100 protein, suggesting a sarcoma; however, the differential diagnosis also included anaplastic thyroid carcinoma and medullary thyroid carcinoma. Tissue biopsy revealed a high-grade spindle cell neoplasm with osteoid production, consistent with osteosarcoma of the thyroid. The patient developed a large pulmonary embolus and superior vena cava syndrome and no further surgical intervention was performed. She died 5 weeks after the initial diagnosis. Upon retrospective review, the cytologic features resemble osteosarcoma in other areas. Although cytologic features on fine-needle aspiration biopsy may suggest a diagnosis of this rare entity, definitive diagnosis should be deferred to histologic examination.