Primary cardiac tumors: early and late results of surgical treatment in 91 patients

CT and MRI of pericardial and cardiac neoplastic disease

This article reviews the pathological classification of cardiac and pericardial neoplasms, the incidence of the various tumor types, and the role of CT and MRI, including their major differences and clinical impact on patient management.

Surgical experience of cardiac tumors: early and late results

PURPOSE

Cardiac tumors include benign and malignant neoplasms that arise within the cardiac chambers or myocardium. This study summarizes our surgical experiences with cardiac tumors.

METHODS

Between 1975 and 2003, 51 patients with cardiac tumors were surgically treated.

RESULTS

Myxomas. Forty-seven cardiac myxomas were excised in 46 patients with an average age of 51.7 +/- 18 years. The preoperative symptoms included congestive heart failure (37%) and embolism (30%). The incidence of preoperative embolization was significantly higher in the gelatinous and lobated myxomas than in the solid and smooth form (P = 0.017). The early mortality rate was 2.2%. Although the late mortality rate was 9.7%, no patients died from cardiological causes (mean follow-up, 11.2 years). Only 1 patient required surgery for recurrence. Benign nonmyxomatous tumors. Three patients with a mean age of 26.3 +/- 19.0 years showed benign nonmyxomatous tumors. There were no perioperative or late deaths. Malignant tumors. Two patients were diagnosed to have malignant tumors and although there was no perioperative death, both died postoperatively within 6 months.

CONCLUSIONS

Cardiac myxomas and nonmyxomatous benign cardiac tumors show excellent results after a surgical excision, with a low morbidity and mortality. A surgical resection should thus be considered as a treatment option for patients with malignant tumors.

Heart tumors in children and adults: clinicopathological study of 59 patients from a surgical center

BACKGROUND

Heart tumors are rare lesions with variegated histological types. Their clinicopathological features could be more comprehensively categorized.

METHODS

This is a 19-year retrospective study of 17 infants/toddlers (<2 years of age) and 42 patients aged between 14 and 79 years (mean = 51.5) in a surgical center.

RESULTS

Congenital tumors (n = 17; 29%), including rhabdomyomas (n = 9), ventricular fibromas (n = 6), and hemangiomas (n = 1), required surgery mainly because of mass effect. Familial myofibromatosis was the only embolic congenital lesion. Acquired benign tumors (n = 28; 47%) included myxomas (n = 21), fibroelastomas (n = 3), myofibroblastic inflammatory tumors (n = 2), and lipomas (n = 2). Eight (29%) were revealed by systemic embolization. These benign noncongenital tumors were all treated by complete resection, except for an incompletely resected lipoma of the mitral valve. Postoperative arrhythmia (n = 1) and pericardial effusion (n = 3) were the only complications. Primary sarcomas (n = 8; 14%) were mostly vascular tumors (five of eight), and patients with high-grade tumors had a mean survival of 15 months (n = 5). Cardiac metastases (n = 6; 10%) were from carcinomas (n = 3) or sarcomas (n = 3); apart from a necrotic metastasis, all patients died (mean survival of 6 months).

CONCLUSIONS

This study shows that, regardless of patients' age, heart tumors can be classified as: (a) congenital lesions, which are spontaneously nonprogressive or regressive lesions possibly requiring surgery mainly because of mass effect; (b) acquired benign tumors, which are lesions requiring surgery often because of embolization risk; and (c) primary and secondary malignant tumors, which are lesions with globally poor prognosis but with some indications for resection.

Atrial myxomas: pathologic types, tumor location, and presenting symptoms

BACKGROUND

Atrial myxoma is the most common cardiac neoplasm. Although not widely reported, two anatomic types have been observed: solid and papillary. We examined whether differences in gross or microscopic appearance and location correlated with symptomatology, specifically congestive heart failure (CHF), neurologic symptoms, and embolic events.

METHODS

We performed a retrospective review of atrial myxomas removed from 1972 to 2002, recording the clinical presentation, diagnostic modality, tumor location, gross, and microscopic features for each patient. Twenty-six patients (16 females and 10 males) had atrial myxomas excised. Two patients (one female and one male) were excluded due to unavailable pathologic slides.

RESULTS

In 24 patients there were 15 solid and 9 papillary tumors. CHF was more prevalent in solid myxomas, while neurologic symptoms and embolic events were more common in papillary tumors. Tumor location further correlated with presenting symptoms. Ninety-two percent of patients presenting with CHF had tumors attached to the atrial septum. Extraseptal myxomas more frequently presented with neurologic (80% vs. 29%) and embolic features (50% vs. 25%). All patients exhibiting clefted tumor surface had a history of embolization. A higher percentage of solid myxomas (93%) showed hemorrhage within the tumor than with papillary (56%).

CONCLUSIONS

CHF was more common with solid myxomas, and neurologic and embolization events were more common in the papillary type. Septal tumor location showed strong association with CHF, while extraseptal location correlated with neurologic events. We speculate that the various gross and microscopic patterns reflect secondary changes within these neoplasms over the course of their natural history.

A very rare cardiac hibernoma in the right atrium: a case report

Cardiac lipomas are rare tumors often detected incidentally during routine examinations. They usually remain asymptomatic for a long time and cause arrhythmia, heart valve dysfunction, or embolization in the later stages. In this article, we report a case of a 64-year-old patient with a very rare cardiac hibernoma located in the right atrium. Transesophageal echocardiography and computed tomography have been shown to be useful for differentiating between benign and malignant tumors in order to plan surgery. The treatment of choice for these tumors is resection. The tumor was excised with the use of cardiopulmonary bypass surgery. Histology confirmed diagnosis of a benign cardiac hibernoma.

Symptomatic lipoma in the interventricular septum

Cardiac lipomas, which are benign nonmyxomatous neoplasms of the heart, are rare and among those least often encountered. Because they normally cause no symptoms, diagnosis is often purely accidental. We report the case of a 24-year-old woman who presented with palpitations of recent onset and was found to have a lipoma attached to the left side of the interventricular septum (IVS). Transthoracic and transesophageal echocardiograms were performed and showed a mass in the left side of the IVS. During successful surgical excision of the mass, intraoperative histologic diagnosis showed the tumor was lipoma. Our review of the English literature revealed that our case is only the seventh of removal of lipoma in the IVS. The postoperative course was uneventful, and an echocardiogram taken 6 months after the operation showed no evidence of enlargement of the tumor tissue.

Fatal outcome of a calcified amorphous tumor of the heart (cardiac CAT)

Calcified amorphous tumor of the heart (cardiac CAT) is an unusual non-neoplastic cardiac mass that can mimic a more malignant lesion. We describe a case of cardiac CAT in a 60-year-old female who presented with syncope. Workup revealed a 2.1-cm mass in the right ventricular wall involving the chordae tendineae of the tricuspid valve, impacting right ventricular function. Magnetic resonance imaging, echocardiography, angiography, and histologic descriptions of the lesion are described.

Cardiac lipoma in a patient with proven arrhythmogenic right ventricular dysplasia: a case report. A huge intramyocardial lipoma

Arrhythmogenic right ventricular dysplasia (ARVD) and primary cardiac tumours are rare conditions among heart diseases. In this case report we present an 18-year-old woman with ventricular tachycardia and intracardiac mass originating from interventricular septum. Clinical and pathological evaluation led to the diagnosis of invasive intramyocardial lipoma originated in an ARVD background. To our knowledge, this is the first case with a huge intramyocardial lipoma developed in a patient with ARVD.

Cardiac Autotransplantation for Primary Cardiac Tumors

BACKGROUND

Complete tumor resection is the optimal treatment of cardiac tumors. Anatomic accessibility and proximity to vital structures complicates resection of tumors involving the left heart. The results of standard resection and resection with orthotopic heart transplantation are dismal. We, therefore, reviewed our series of patients with complex left-sided primary cardiac tumors who underwent tumor resection with cardiac autotransplantation.

METHODS

Since April 1998, 11 consecutive patients with complex left atrial or left ventricular intracavitary cardiac tumors underwent 12 resections using cardiac autotransplantation-cardiac explantation, ex vivo tumor resection with cardiac reconstruction, and cardiac reimplantation. Demographics, tumor histology, operative data, and mortality were analyzed. Follow-up was complete in all patients.

RESULTS

Complete resection by cardiac autotransplantation was used in 7 patients with left atrial sarcoma, 1 patient with left ventricular sarcoma, 2 patients with left atrial paraganglioma, and 1 patient with a complex giant left atrial myxoma. Eight patients had previous resection of their cardiac tumor, and 1 patient had a repeat autotransplantation for recurrent disease. There were no operative deaths. Median overall survival was 18.5 months in patients with sarcomas. All patients with benign tumors are alive without evidence of recurrence.

CONCLUSIONS

Cardiac autotransplantation is a feasible technique for resection of complex left-sided cardiac tumors. Recurrent disease after previous resections can be safely treated with this technique. Operative mortality and overall survival seems favorable in this series of patients. Benefits of this technique include improved accessibility and ability to perform a complete tumor resection with reliable cardiac reconstruction.

Clinical experiences of cardiac myxoma

Although cardiac myxoma is rare, it is the most common primary cardiac tumor. Seventy-four cases of cardiac myxoma that were surgically treated in our center between August 1980 and February 2005 were retrospectively reviewed. The mean patient age was 50.4 +/- 15.0 (range 7-80) years, and 53 patients (71.6%) were female. The most common preoperative symptom, occurring in 44 patients, was dyspnea. The interval from onset of symptoms to surgery was 9 months. Seventy cases were located in the left atrium, 3 in the right atrium and 1 in the right ventricle. The myxoma in the right ventricle could not be resected completely, due to severe infiltration. Cardiopulmonary bypass and aortic cross clamp times were 100.4 +/- 37.1 and 64.8 +/- 29.8 minutes, respectively. There were no hospital deaths, and 7 patients suffered from postoperative complications including atrial fibrillation in 2 cases. During the follow up period (mean 105.7 +/- 73.6 months), there was no tumor recurrence and 6 late deaths that were not related to the underlying tumor. There was no evidence of tumor growth in the cases with incomplete resection during the 14-month follow-up. In conclusion, in this study there was no recurrence of tumors after complete resection and surgical resection is considered to be the curative method of treatment for cardiac myxoma.

[Cardiac myxoma. Surgical treatment. About 20 cases]

INTRODUCTION

Cardiac myxoma is the commune cardiac tumors. Their clinical status depends in the anatomic type. The aim of this study is to evaluate our results and to compare them for literature.

PATIENTS AND METHODS

From January 1990 to June 2004, 20 patients (8 males and 12 females) with mean age of 49 years underwent surgical treatment of cardiac myxoma. The tumors were in left atrium in 14 cases, in right atrium in 4 cases and biatrial in 2 cases. Surgical treatment consisted in complete resection of the tumor in all cases associated with partial atrial septal resection in 9 cases.

RESULTS

There is not death in the postoperative outcome. The mean follow up is 50 months. The late mortality rate was 10%. All patients are asymptomatic and the echocardiography control showed no tumor recurrence.

CONCLUSION

Cardiac myxoma is the communist primary tumor of the heart. Diagnosis is based upon echocardiography. Surgical management has well out come with low morbidity and mortality. Late results are satisfactory but regular screening is recommended although risk of recurrence is low.

Cardiac tumours: diagnosis and management

Primary cardiac tumours are rare, with an autopsy incidence ranging from 0.001% to 0.030%. Three-quarters of these tumours are benign and nearly half of the benign tumours are myxomas. Metastases to the heart are far more common than primary cardiac tumours. Primary cardiac tumours present with one or more of the symptoms of the classic triad of: cardiac symptoms and signs resulting from intracardiac obstruction; signs of systemic embolisation; and systemic or constitutional symptoms. They are diagnosed by use of transthoracic and transoesophageal echocardiograms, MRI, and CT scan. Whereas surgery is indicated in patients with benign tumours, systemic chemotherapy is indicated in those who have widespread or unresectable malignant disease, and chemotherapy and radiotherapy are usually combined in treatment of patients with primary cardiac lymphomas. The prognosis after surgery is usually excellent in the case of benign tumours but is unfortunately still limited in localised malignant diseases. Patients with sarcomas live for a mean of 3 months to 1 year, and those with lymphomas live up to 5 years if treated, but usually die within 1 month if untreated.

Surgical Management of Cardiac Myxoma

OBJECTIVE

Between 1994 and December 2003, 55 patients were operated for cardiac myxoma in Kosuyolu Heart and Research Hospital in Istanbul.

METHODS

We retrospectively analyzed our results according to the preoperative characteristics, operative procedures, and postoperative courses.

RESULTS

Of 55 patients operated, 36 (65.4%) were female and 19 (34.6%) male. The average age of the patients was 48 +/- 15.5 years (range, 12-75). Thirteen patients (23.6%) previously had cerebrovascular accidents. Peripheral arterial emboli had occurred in 11 (20%) patients. The majority of the patients (44.4%) were in NYHA Class II preoperatively. One patient was presented with Carney's complex. Most frequent location was the left atrium (85.2%). Eight patients had concommitant surgery together with myxoma extirpation. Postoperative courses were uneventful. Three patients had a new onset atrial fibrillation, two had transient conduction disturbances. There were two (3.6%) in-hospital deaths. No recurrences have been noted during the 82.4 +/- 40.6 months (a total of 315.75 patient/years) follow-up.

CONCLUSIONS

Surgical management of cardiac myxoma gives excellent results. In selected cases, a conservative approach may be adequate. Despite the scarcity of the neoplastic properties, careful follow-up is necessary.

How to diagnose and treat secondary forms of vasculitis

Vasculitis is considered to be secondary when it arises either in the context of a pre-existing connective tissue disease, as a result of direct infection with a limited range of organisms, especially viruses, or when it arises in response to exposure to a number of medications. Rheumatoid vasculitis is probably the most widely recognised form of secondary vasculitis, and in this article we review the incidence, clinical features and management of this condition. Infections may either trigger or cause some types of vasculitis. Drug therapy is a common cause of limited forms of vasculitis and may enhance our understanding of the mechanism of these diseases. The premature development of atherosclerosis in patients with existing connective tissue diseases or indeed primary vasculitis has been recognised for some time, and the underlying mechanisms are currently being studied. An appreciation of the complex and varied pathophysiology of secondary vasculitis may further our understanding of primary vasculitis.

Surgical pathology of cardiac tumors. Two decades at an urban institution

BACKGROUND

As better diagnostic techniques and new operative approaches are developed pathologists will be called upon more often for intraoperative consultation to render a pathologic diagnosis and assess adequacy of resection.

METHODS

We conducted a retrospective survey of all patients presenting to our institution from 1979 to 1999. The surgical pathology and cardiothoracic surgery databases were used to identify these patients.

RESULTS

Of the 29 patients with primary cardiac neoplasms, 15 were male and 14 female. The mean age at surgery was 51.9 years (range, 7 months to 84 years). Twenty-six of 29 patients had a benign pathological diagnosis. The majority (20/26) of the benign tumors were myxomas. Other benign pathologic diagnoses included rhabdomyoma, fibroma, papillary fibroelastoma, localized fibrous tumor and lipoma. Three out of 29 were malignant: 1 fibrosarcoma, 1 malignant mesenchymoma, and 1 rhabdomyosarcoma. Six of the patients presented with thrombo-embolism, 8 with congestive heart failure symptoms, and three with chest discomfort. Five were asymptomatic or the neoplasm was an incidental finding. 2-D echocardiography established the diagnosis in all of the patients except one. Twenty-two of the 29 tumors were located in the atria (LA=15, RA=6, biatrial=1) and 5 in the ventricles (LV=1, RV=2, biventricular=2). Two patients in this series were referred for reresection. A median sternotomy approach was used for tumor extirpation in all patients. Three of the 29 patients have died at a mean follow-up period of 757 days (median, 118 days). There were two late deaths and one hospital (early) death in a reoperation for recurrent malignancy employing cardiac autotransplantation. One additional patient required cardiac reoperation.

CONCLUSIONS

Primary cardiac neoplasms are rare and occur less commonly than metastatic disease of the heart. Congestive heart failure symptoms and thrombo-embolism account for close to half of the presenting signs and symptoms. 2-D echocardiography remains the mainstay of detection. Distinguishing between benign and malignant, thrombus and vegetation, and extracardiac structure is usually established by the size, shape, mobility and attachment of the mass. Clinical presentation and transesophageal echocardiographic views are extremely helpful in sharpening the accuracy of the diagnosis. Since surgery is the only reliable therapy pathologists will be called upon for intraoperative consultation. The majority of the neoplasms are benign. Malignant neoplasms are difficult to excise completely and portend a grave prognosis.

Surgical outcome in 85 patients with primary cardiac tumors

BACKGROUND

We present a large, single institution experience with adult cardiac tumors and address factors affecting outcome.

METHODS

A retrospective review was made of all patients who underwent surgery for primary cardiac tumors from April 1975 through August 2002.

RESULTS

Eighty-five patients (33 male and 52 female) with a mean age of 54 years were identified with follow-up available for 80 (94%) patients. There were 68 (80%) benign tumors and 17 (20%) malignant tumors. Three tumors recurred and were resected giving a total of 88 surgeries. All benign tumors were grossly resected and the extent of resection for malignant disease ranged from 14 (78%) gross resections and 3 (17%) debulkings to 1 (5%) biopsy. There were 4 (5%) early hospital deaths. Median survival was 9.6 months and 322 months for patients with malignant and benign diseases, respectively. Significant predictors of long-term mortality were malignant disease (P <0.0001) and New York Heart Association class (P <0.03).

CONCLUSIONS

Surgical resection provides excellent outcome in patients with benign cardiac tumors. Malignant tumors continue to pose a challenge with good local tumor control but limited survival owing to metastatic disease.

Echocardiographically evaluated site of attachment of atrial myxoma may predict recurrence

We explore the association between the site of attachment of nonfamilial left atrial myxoma and it's recurrence. Forty-three (11 male and 32 female; mean age, 55.9±13.6 years) of 49 consecutive patients with nonfamilial left atrial myxoma who had been evaluated with preoperative echocardiography, X were available for postoperative follow-up with transthoracic echocardiography, transesophageal echocardiography, or both, for an average period of 85.2±54.2 months (range, 6.5 to 215.5 months). We compared preoperative clinical and echocardiographic features of recurrent and nonrecurrent myxomas. Three (7%) of the 43 cases of atrial myxoma recurred at the same site after 24.1±7.6 months. Involvement of the mitral valve annulus or mitral valve leaflet (3 vs 0,p<0.001) was observed in the recurrent myxomas, but the two groups did not differ significantly in any other clinical features, laboratory data, or echocardiographic features of the recurrent and nonrecurrent myxoma. Preoperative echocardiographic observation of involvement of the mitral valve annulus or mitral valve leaflet may predict recurrence after surgery. Regular follow-up echocardiography was useful in the early detection of recurrence.

Assessment of the vascularity of a left ventricular mass using myocardial contrast echocardiography

In addition to a thrombus, an intracardiac mass lesion can represent a primary cardiac tumor, or a metastatic lesion to the heart. The echocardiographic appearance and location of the mass, as well as the associated clinical scenario provide useful clues regarding cause, but these echocardiographic features alone may not always be diagnostic. Because most benign cardiac tumors are relatively avascular, the vascularity of a mass may be a feature that can help differentiate benign from malignant tumors. We present a case of a patient with a history of malignant melanoma who was found incidentally to have a cardiac mass on echocardiography. Contrast echocardiography (CE) was used to evaluate the vascularity of the mass. This case is compared with another patient with an apical thrombus, which represents an "avascular" intracardiac structure.

Trends in the clinical and morphological characteristics of cardiac myxoma: 20-year experience of a single tertiary referral center in Japan

The purpose of this study was to clarify whether or not a change in the clinical characteristics of cardiac myxoma has occurred during the past 2 decades. The clinical records of 57 patients (22 men, 35 women; age, 52+/-14 years) with myxoma that had been surgically treated between May 1978 and July 1997 at the National Cardiovascular Center in Japan were reviewed. All myxomas were discovered by transthoracic echocardiography. They were divided into an early group (n=30) treated in the first decade (1978-1987) and a late group (n=27) treated in the second decade (1988-1997). The incidence of myxoma, patient characteristics, preoperative symptoms and echocardiographic features did not differ between the 2 groups. In contrast, the maximal dimensions of myxoma in the early group were significantly larger than those in the late group (6.3 +/-2.7 cm vs 4.3+/-1.3 cm, p=0.012). The weight of myxoma in the early group tended to be heavier than that in the late group (76+/-80 g vs 25+/-18 g, p=0.054). The incidence of patients with asymptomatic myxoma also tended to increase in the late group (7% vs 26%, p=0.07). Although there was no difference in the incidence of myxoma, smaller and asymptomatic myxomas were more frequent during the last decade, probably as a result of the development of cardiac imaging, particularly echocardiography.

Surgical treatment of primary cardiac tumors: 28 years' experience in Kanazawa University Hospital

To examine the clinical features of primary cardiac tumors, 34 patients who underwent surgical treatment from 1973 to 2000 at the Kanazawa University Hospital were analyzed and the literature was reviewed. The 34 patients were divided into 3 categories: (i) myxomas; (ii) benign non-myxomas; and (iii) malignant tumors. Twenty-three patients (70%) were diagnosed with myxomas, including 22 left atrial myxomas and 1 right atrial myxoma. Seven patients (18%) were diagnosed with benign non-myxoma tumors, including 3 hemangiomas, 1 fibroma, 1 rhabdomyoma, 1 pheochromocytoma, and 1 lipoma. Four patients (12%) were diagnosed with malignant tumors, including 2 angiosarcomas, 1 rhabdomyosarcoma, and 1 malignant fibrous histiocytoma. Among the myxoma patients, in-hospital mortality was 9% (2/23), late mortality was 10% (2/21), and no recurrent myxomas have been identified. Among benign non-myxoma patients there were no perioperative deaths; however, 1 patient died 11 years after surgery, with no linked cause. No recurrent tumors have been identified. Among malignant tumor patients, 1 patient died the day following surgery and the rest died within 14 months. Early and late results of surgery were acceptable for those patients with benign tumors, while the prognosis for patients with malignant tumors was very poor.

Massive pulmonary embolus complicating left atrial myxoma

Atrial myxomas may present with a classic triad of constitutional symptoms, embolic events, and intracardiac obstruction (1). We report a case of a massive pulmonary thromboembolus complicating a left atrial myxoma in the absence of an atrial or ventricular septal defect.

Cardiac angiosarcoma: Too little known, too late treatment or just too bad a tumour?

Cardiac angiosarcoma is a rare tumour. Current imaging techniques (magnetic resonance imaging, MRI; computed axial tomography, CAT; 2-D echocardiography), although useful in delineating the extent of tumour involvement, do not correlate well with intraoperative findings of resectability. We report a case were palliative surgical resection was technically possible, contrary to expectations from CAT and MRI findings. However, the patient was clinically in extremis, with advanced ventricular dysfunction, and died. Despite the short-term risk involved in surgery, if palliative resection is possible, a multidisciplinary approach with adjuvant chemotherapy and radiation can result in mid-term survival.