Primary and secondary cardiac tumors: clinical presentation, diagnosis, surgical treatment, and results

Neurologic symptoms as first manifestation of primary cardiac tumors

INTRODUCTION

Primary cardiac tumors are very infrequent, usually benign, and occasionally present with neurological symptoms.

METHODS

We retrospectively analyzed a series of 107 patients diagnosed of primary cardiac tumors who underwent cardiac surgery between 1994 and 2024.

RESULTS

Stroke was the debut form of tumor in 14 patients. Multiple ischemic lesions on neuroimaging were identified in 50% of patients, but no aneurysms or brain tumor metastases were observed at the time of diagnosis. Neurological symptoms were more frequent in patients with villous tumors (33.3 vs. 7.2%) (p=0.001), regardless of tumor diameter. In the multivariate analysis, patients with neurological debut presented NYHA I functional class (RR: 11.9; 95% CI [2.3-60.5]; p=0.003) and villous tumor morphology (RR: 6.78; 95% CI [1.8-25.3]; p=0.004). No patient underwent reperfusion treatment and surgical excision of the tumor was performed (median stroke-surgery: 19 days) without early postoperative or late neurological complications during follow-up.

CONCLUSIONS

Neurological symptoms can be the first manifestation of primary cardiac tumors in patients with good functional class and a history of multiple peripheral embolisms. Villous morphology favors neurological manifestations of embolic origin, despite tumor size. Late neurological complications, due to brain aneurysms or tumor metastases, are extremely rare and have not seen in our series.

Surgical and multimodal approaches to right-sided cardiac tumours

PURPOSE OF REVIEW

Cardiac tumours present significant clinical challenges due to their wide differential, complex anatomical and physiological implications, as well as the potential for widespread invasion in the case of malignancies. This review synthesizes recent findings surrounding the diagnosis and management of specifically right-sided cardiac tumours, with a particular focus on surgical resection and reconstructive techniques.

RECENT FINDINGS

Management of cardiac tumours can be categorized into three key phases. First: early and accurate diagnosis is critical for improving outcomes, especially in malignancies. Advances in imaging modalities like MRI, CT, PET-CT, and biopsy techniques enhance diagnostic accuracy. Second: surgical resection is a cornerstone treatment for both benign and malignant right-sided cardiac tumours. Surgery is often curative for benign tumours, while for malignant tumours, R0 resection (complete microscopic removal) in appropriate candidates correlates with better survival. Third: managing cardiac malignancies necessitates a multidisciplinary approach, integrating additional therapies such as chemotherapy, radiation, and emerging immunotherapies tailored to patient and tumour characteristics.

SUMMARY

Managing right-sided cardiac tumours demands interdisciplinary expertise. Standardized protocols are limited by the rarity of cases and insufficient high-quality data. International collaboration and sharing of experiences through prospective registries and clinical studies are essential to advancing knowledge and improving patient outcomes.

CARDIAC TUMORS: UPDATED CLASSIFICATIONS AND MAIN CLINICO-PATHOLOGIC FINDINGS

This review article - which is devoted to a wide range of physicians, e.g., pathologists, clinicians, radiologists, and general practitioners - is an up-to-date clinico-pathological description of cardiac tumours. Although rare, cardiac tumours are key components in oncology practice since both their early diagnosis and appropriate management denote urgent needs. Primary cardiac tumours (PCTs) are categorized in recent WHO classifications as well as in other scientific contributions. Their incidence is around 0.02% while their prevalence is between 0.001% and 0.03%. Among PCTs, benign lesions account for 85% of cases, while malignant neoplasms for 15%. Compared to PCTs, secondary cardiac tumours are 20-30-fold more common. The most frequent PCTs in adulthood are papillary fibroelastoma and cardiac myxoma, while, in childhood, cardiac rhabdomyoma. Heart metastases may occur through direct extension, or, indirectly, via bloodstream, lymphatics or intracavitary diffusion. Thoracic cancers (e.g. from pleura, lung, breast) are the most frequent cause of cardiac metastasis followed by oesophageal and haematological malignancies. Symptoms of PCTs (e.g. arrhythmias, dyspnoea, chest discomfort, syncope) are usually the result of both their regional involvement and location. Non-invasive imaging techniques (e.g. echocardiography, MRI, CT) and biopsy are key means in delineating tumour characteristics, size, and adjacent structure involvement. Most PCTs require surgery, which is recommended to prevent life-threatening complications. While many benign cardiac neoplasms may be completely resected, the treatment of choice for malignant PCTs and metastases is a combination of surgery, radio- and/or chemotherapy, as well as new alternative treatments, which may prolong survival in a small patient subset.

Cardiac Tumors Causing Sudden Cardiac Death: A State-of-the-Art Review in Pathology

Cardiac tumors (CTs), although rare, can be a significant cause of sudden cardiac death (SCD), particularly when not diagnosed early. The tumors most associated with SCD include myxomas, fibromas, rhabdomyomas, and sarcomas, which can cause fatal arrhythmias, blood flow obstruction, or embolization. Myxomas, which often develop in the left atrium, can cause valvular obstruction or cerebral emboli, while malignant tumors, such as sarcomas, can infiltrate the myocardium or conduction system, causing serious arrhythmias. Rhabdomyomas, which are common in children and associated with tuberous sclerosis, can lead to ventricular tachyarrhythmias. Early diagnosis using advanced imaging techniques such as echocardiography and magnetic resonance imaging is crucial for preventing SCD. Timely diagnosis and precise characterization of lesions can help reduce the risk of SCD, thus improving the clinical management of patients, with the aim of supporting personalized treatment and improving life prospects. In this state-of-the-art review, we analyze the association between CTs and SCD, with particular attention to the histological features of benign and malignant neoplasms. Through an updated overview of the pathological aspects, we aim to improve the understanding of these tumors and promote a more effective multidisciplinary diagnostic and therapeutic approach to prevent fatal events.

Cardiac Computed Tomography as a Method of Diagnosing the Type of Cardiac Tumor-Example of Interatrial Septal Lipoma Filling the Right Atrium

Cardiac tumors present substantial diagnostic challenges due to their diverse manifestations and similarity to other cardiac pathologies. Cardiac lipomas are rare tumors that originate from adipose cells and can develop in any location within the heart. Cardiac lipomas account for 2.4% of all primary cardiac tumors. Most lipomas are located within the cardiac chambers. Among the lipomas occurring within the cardiac chambers, the most common localization is the right atrium. Currently, the gold standard for imaging cardiac tumors is cardiac magnetic resonance (CMR). Despite the significant advantages of CMR, cardiac computed tomography angiography (CCTA) continues to be a valuable technique when CMR is either unavailable or contraindicated. In some cardiac tumors, CCTA can identify the type of tumor. A classic example of this type is a lipoma. We present images of a large interatrial septal lipoma filling the right atrium diagnosed by CCTA in a 57-year-old female Caucasian patient. In summary, CCTA effectively identifies lipomas' characteristic features and provides crucial information for appropriate management.

Cardiac Tumors: Review

Cardiac tumors are rare and encompass a variety of presentations. Clinica symptoms are usually nonspecific, but they can present as obstructive, embolic, or constitutional symptoms. Treatment options and prognosis vary highly depending on the subtype, tumor size, and location. Surgical resection is usually the first-line therapy, except for cardiac lymphomas, and provides favorable long-term prognosis in most benign tumors. Cardiac sarcomas, however, are usually diagnosed in advanced stages, and the treatment relies on a multimodal approach with chemotherapy and radiotherapy. Metastatic cardiac tumors are usually related to advanced disease and carry an overall poor prognosis.

Ten-year survival after resection of a huge rhabdomyosarcoma in the pericardial cavity

BACKGROUND

Primary malignant cardiac tumors are exceedingly rare and cardiac rhabdomyosarcoma among them is an exceptional rarity characterized by a dismal poor prognosis.

CASE PRESENTATION

A 48-year-old man had suffered from a persistent cough lasting for more than 6 months and computed tomography showed a huge mass in the pericardial cavity with heterogeneous content. Following referral to our department for suspected cardiac malignancy, cardiac magnetic resonance imaging revealed a lucent layer on the boundary around the mass, suggesting the feasibility of surgical resection. A baby-head-sized mass in the pericardial cavity was entirely resected and the pathological examination confirmed a tumor as a spindle cell type rhabdomyosarcoma. The patient underwent adjuvant chemotherapy and has well survived over a decade after surgery without any sign of recurrence.

CONCLUSION

Radical resection with adjuvant chemotherapy may achieve a favorable outcome for patients with massive rhabdomyosarcomas inside the pericardial cavity.

Percutaneous Intracardiac Mass Extraction in High Surgical-Risk Patients

Large intracardiac masses including tumors, thrombi, and vegetations result in detrimental embolic or obstructive sequelae and present a management dilemma. Open heart surgery, the traditional approach, may not be an option for many patients with a prohibitive surgical risk due to multiple comorbidities. Recently, percutaneous options have emerged with reported success in extracting such intracardiac masses. A 42-year-old female with history of advanced primary sclerosing cholangitis with decompensated liver cirrhosis causing ascites and variceal bleed presented to the emergency department with fatigue, subjective fevers, chills and melena. Laboratory results revealed neutrophil-predominant leukocytosis and normocytic anemia, and blood cultures were positive for Candida albicans. Electrocardiography showed sinus tachycardia. Chest X-ray was unremarkable. She underwent packed red blood cell transfusion and esophageal banding for variceal bleeding. Transthoracic echocardiogram revealed normal left ventricular ejection fraction and no wall motion abnormalities. A right atrial mobile mass measuring approximately 1.0 × 3.0 cm was noted. Multidisciplinary heart team discussion concluded that while the mass posed a high embolic risk, the patient had a prohibitive risk for surgical intervention. Successful percutaneous removal of the mass using Penumbra system device (Penumbra Incorporated, Alameda, CA) was accomplished. This case report details the procedure and outcomes, as well as presents a literature review.

Totally thoracoscopic surgical resection of left ventricular benign tumor

OBJECTIVE

The study objective was to explore the feasibility and safety of totally endoscopic resection of a left ventricular tumor through small chest incisions without robotic assistance.

METHODS

Four patients with a left ventricular tumor (1 papillary fibroelastoma, 1 lipoma, and 2 myxomas) underwent surgery with peripheral cardiopulmonary bypass. The mean age of patients was 58 ± 15 years. There were 3 female patients and 1 male patient. Through 3-port incisions in the right chest, pericardiotomy, bicaval cannulation, cardiac arrest, and atriotomy, left ventricular tumor resection was performed under thoracoscopy.

RESULTS

All patients had successful resections. The cardiopulmonary bypass and aortic crossclamp times were 110 ± 14 minutes and 58 ± 19 minutes, respectively. The length of stay in the intensive care unit was 38 ± 27 hours. There were no mortalities or complications in this cohort. Patients were discharged 7 days after the operation. Transthoracic echocardiography showed that the cardiac tumor was completely removed without any residue 3 months after surgery.

CONCLUSIONS

Totally endoscopic left ventricular tumor resection without a robotically assisted surgical system is feasible and reproducible. This technique could minimize surgical trauma and achieves complete tumor resection.

Cardiac cavernous hemangioma with high fluorodeoxyglucose uptake on preoperative positron emission tomography/computed tomography: a case report

BACKGROUND

Reports on cardiac hemangioma detection by F-18-deoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) are extremely rare.

CASE PRESENTATION

Here we describe a case of a 61-year-old man with hemangioma. CT revealed a tumor with a size of 60 mm. Magnetic resonance imaging showed high signal intensity on T2-weighted images. Hemangioma was initially suspected. However, PET/CT showed high FDG absorption, which led us to suspect a malignant tumor. The tumor was resected, and a cavernous hemangioma diagnosis was made by postoperative histopathological examination.

CONCLUSIONS

This case may serve as a reference for clinicians to become more aware of the potential application of FDG PET/CT for cardiac hemangioma detection.

Primary Cardiac Tumor in the Left Atrium: A Diagnostic Challenge

An elderly man presented to the emergency department with shortness of breath, peripheral edema, and significant weight loss. Blood tests revealed anemia and elevated inflammatory markers, and chest imaging showed a massive left pleural effusion. During hospitalization, he developed subacute cardiac tamponade, and pericardiocentesis was performed. Further imaging revealed a primary malignant cardiac tumor with extensive infiltration of the cardiac tissue, and biopsy was deemed impossible due to the tumor's location. The most likely diagnosis was angiosarcoma. The cardiac surgery team evaluated the case and considered it inoperable due to the tumor's extensive infiltration. The patient is currently under the regular care of a palliative care team. This case underscores the difficulties of diagnosing primary cardiac tumors, particularly in elderly patients with comorbidities. Despite advances in imaging and surgical techniques, the prognosis for malignant cardiac tumors remains poor.

Neonatal Myxomas: Case Report and Literature Review

Myxomas are rare tumors in neonates and tend to have a different presentation compared to adults. We present an infant with a left atrial myxoma presenting with episodic tachycardia who underwent successful surgical excision. In addition, we performed a review of the literature, identifying 17 cases of neonatal myxomas. Unlike adults, neonatal myxomas are more common in males and occur more often on the right side of the heart. Constitutional symptoms such as fever or embolism are rare among neonates. Most patients have favorable outcomes following surgical excision, refuting earlier claims that neonatal myxomas are associated with poor outcomes.

Cardiac metastasis from small cell lung cancer origin: A case report and review of the literature

BACKGROUND

Cardiac metastasis from small cell lung cancer (SCLC) origin is rare, whereas the incidence is anticipated to increase with the extended survival rates.

CASE

We here describe a case report of a 48-year-old male patient diagnosis with SCLC in 2020. In June 2021, he resorted to hospital due to shortness of breath, no obvious changes were found in repeated echocardiography, electrocardiogram and chest computer tomography from June 2021 to September 2021. Due to the persistence of the complaints, cardiac magnetic resonance (CMR) imaging was performed in September 30th, 2021, which showed a mass in the right atrioventricular groove. The patient underwent pericardiocentesis and small cell carcinoma cells were found in the pericardial effusion, confirming the diagnosis of cardiac metastasis.

CONCLUSION

Patients with a history of SCLC who develop new cardiac symptoms of unknown etiology should undergo imaging studies such as CMR. The importance of CMR for patients with SCLC is highlighted. The literature regarding metastatic cardiac tumors is reviewed.

The Interventricular Septum: Structure, Function, Dysfunction, and Diseases

Vertebrates developed pulmonary circulation and septated the heart into venous and arterial compartments, as the adaptation from aquatic to terrestrial life requires more oxygen and energy. The interventricular septum (IVS) accommodates the ventricular portion of the conduction system and contributes to the mechanical function of both ventricles. Conditions or diseases that affect IVS structure and function (e.g., hypertrophy, defects, other) may lead to ventricular pump failure and/or ventricular arrhythmias with grave consequences. IVS structure and function can be evaluated today using current imaging techniques. Effective therapies can be provided in most cases, although definitions of underlying etiologies may not always be easy, particularly in the elderly due to overlap between genetic and acquired causes of IVS hypertrophy, the most common being IVS abnormality. In this review, state-of-the-art information regarding IVS morphology, physiology, physiopathology, and disease is presented.