Cardiac Autotransplantation for Primary Cardiac Tumors

Radiotherapy combined with anti-PD-1 and TKI for primary cardiac angiosarcoma considering the joint assessment of TLSs and PD-L1: a case report

BACKGROUND

Primary cardiac angiosarcoma(PCA) has a low incidence rate and poor prognosis. Currently, no unified clinical treatment standards are available.

CASE PRESENTATION

We report the case of a 48-year-old man presenting chest tightness, breathlessness, and dyspnea. Imaging and postoperative histopathologic studies confirmed PCA and that the tumor had invaded the entire right atrium. The patient developed progressive disease (PD) during postoperative radiotherapy. We used immunotherapy combined with targeted therapy based on the results of molecular profile and evaluation of tertiary lymphoid structures (TLSs) and programmed cell death-ligand 1 (PD-L1). After treatment, the metastatic lymph nodes of the patient were reduced to a certain extent, indicating that combination therapy was effective.

CONCLUSION

To the best of our knowledge, this is the first report of radiotherapy combined with anti-PD-1 and tyrosine kinase inhibitors(TKI) for PCA. In addition, this is the first report on immunotherapy for PCA based on new evaluation methods, including TLSs, PD-L1, and genomic profile.

Genetic insights into cardiac tumors: a comprehensive review

Cardiac neoplasms are rare, however, also a curable form of the disease once detected early. In recent years the viscus tumors have gained their highlights, due to the advancement in techniques like echocardiography both 2D and 3D, MRI, etc. These cardiac tumors are divided based on their benign and malignant nature and also as well as primary and secondary cardiac tumors. Largely the primary cardiac tumors are often than secondary cardiac tumors. The secondary tumor happens anywhere in the body involving the heart. The most common malignant tumors are sarcoma, some are angiosarcomas, fibromas, rhabdosarcoma, and leiomyosarcoma. The primary sarcoma affects both men and women at an equal rate with non-specific symptoms. These conditions led to high demand in genomic testing that helps in spot the mutation that leads to the particular type of cardiac neoplasm and it additionally helps to screen the mutated sequence and stop it from being inherited. Recent studies on cardiac tumors have revealed many genes that are involved in tumorigenesis and technologies have enabled the right screening of the tumor location within the heart and their histopathological studies were also studied. This review principally focuses on the understanding of the various forms of cardiac tumors, genetic variants involved and their influence, genetic testing, and different diagnostic approaches in cardiac tumors.

Modified autotransplantation technique for surgical resection of complex pericardial synovial sarcoma

Technical details for complex cardiac tumor resection are sparse. We describe the operative technique of modified autotransplantation for resection of a complex pericardial synovial sarcoma in a 63-year-old, Caucasian female. Surgical exposure demonstrated tumor origin at the superior cavoatrial junction and invasion of the aorta, main pulmonary artery, superior pulmonary veins, and left atrial roof. Full macroscopic surgical resection was achieved. The patient received adjuvant radiation for microscopic positive margins and remains alive and with no tumor progression at one year postoperatively. We conclude that modified autotransplantation is a challenging but effective surgical technique when performed with careful patient selection and availability of skilled, cardiothoracic surgeons at a cardiac center of excellence.

Case Report: 3D Printing Guided Cardiac Autotransplantation for Treatment of a Giant Complex Primary Left Atrial Tumor

Primary cardiac tumors are rare and complete surgical resection is the optimal treatment. However, it is a great challenge to resect some malignant or complex benign left-sided cardiac tumors situated on the posterior aspect of the heart using conventional surgical resection techniques. Previous studies reported that cardiac autotransplantation is a feasible and safe technique for resection of such cardiac tumors. We report a successful case of cardiac autotransplantation with 3-dimensional (3D) printing technique for complete resection of a giant complex primary left atrial tumor.

Primary Soft Tissue Sarcoma of the Heart: An Emerging Chapter in Cardio-Oncology

Primary malignant cardiac tumors are rare, with a prevalence of about 0.01% among all cancer histotypes. At least 60% of them are primary soft tissue sarcomas of the heart (pSTS-h) that represent almost 1% of all STSs. The cardiac site of origin is the best way to classify pSTS-h as it is directly linked to the surgical approach for cancer removal. Indeed, histological differentiation should integrate the classification to provide insights into prognosis and survival expectancy of the patients. The prognosis of pSTS-h is severe and mostly influenced by the primary localization of the tumor, the difficulty in achieving complete surgical and pharmacological eradication, and the aggressive biological features of malignant cells. This review aims to provide a detailed literature overview of the most relevant issues on primary soft tissue sarcoma of the heart and highlight potential diagnostic and therapeutic future perspectives.

Left atrial spindle cell sarcoma: A case report and literature review

RATIONALE

Cardiac primary spindle cell sarcoma is 1 of the rarest cardiac malignancies, with only a few cases reported so far. Herein, we reported a case of left atrial spindle cell sarcoma diagnosed and treated by a multidisciplinary approach, and retrospectively reviewed other reported cases.

PATIENT CONCERNS

A 49-year-old woman presented to our hospital with 2 weeks of gradual onset of dyspnea on exertion, dry cough and subacute fever.

DIAGNOSIS

The patient was initially revealed a left atrium mass by 2-dimensional transthoracic echocardiography. Based on the contrast-enhanced echocardiography and cardiac magnetic resonance imaging, she was subsequently suggested to have a cardiac malignant tumor. And the post-operative histopathology confirmed the tumor to be a cardiac primary spindle cell sarcoma.

INTERVENTIONS

The tumor was completely resected using autotransplantation. The patient was referred for polychemotherapy afterwards.

OUTCOMES

Our patient underwent the tumor resection, with subsequent adjuvant polychemotherapy, and the tumor has not recurred during 12 months of follow-up.

LESSONS

Due to the rarity of these tumors and nonspecific symptoms, they are often difficult to diagnose preoperatively and missed occasionally. Thus, improving our understanding of the disease and facilitating its early diagnosis are essential.

Cardiac Fibroma with Asymptomatic Ventricular Arrhythmia in an Adolescent with Gorlin's Syndrome

Nevoid basal cell carcinoma syndrome (NBCCS), also referred to as Gorlin's syndrome, is an autosomal dominant inherited condition that predisposes affected individuals to various tumors such as cardiac fibromas. Though technically benign, cardiac fibromas may result in malignant arrhythmias and sudden death. The pertinent literature pertaining to pediatric cases of cardiac fibromas and their clinical features were reviewed. We present the case of an asymptomatic teenage with de novo NBCCS who was diagnosed with both NBCCS and cardiac fibroma later in life. The patient was noted to have clinically significant ventricular arrhythmias that were eliminated with tumor resection. There are no established best practice guidelines for the management of cardiac fibromas in patients with NBCCS. Given the risk of sudden arrhythmic death, the presence of ventricular arrhythmias should prompt strong consideration of tumor resection.

Primary pericardial angiosarcoma: case report and review of treatment options

A primary cardiac angiosarcoma is a rare type of soft-tissue sarcoma with a high mortality rate. This report describes a young woman who presented with chest pain and worsening shortness of breath over the course of a year. She was diagnosed with and treated for latent tuberculosis and autoimmune pericarditis over the last year, however, her condition kept worsening. Further workup revealed a large pericardial and right atrial mass associated with multiple lung nodules. The biopsy from the lung mass showed angiosarcoma, and she was diagnosed with primary metastatic angiosarcoma of the pericardium. She was treated with doxorubicin and Ifosfamide (AIM-75 regimen), which led to a partial response. However, soon after completion of six cycles, the tumour progressed rapidly, leading to cardio-respiratory failure. In this report, we will discuss the clinical challenges and treatment options (surgical and medical) that are available for treating patients with angiosarcoma of the heart.

Cardiac tumors invading the right ventricle; Aggressive Surgical Management with backup mechanical circulatory support if necessary

BACKGROUND

Primary cardiac tumors are exceedingly rare. Amongst the malignant types, sarcomas are the most frequently encountered. Treatment includes attempted aggressive surgical resection as the only curative option. We report our experience.

METHODS

During the last five years, six patients presented at our institution with complex cardiac tumors with different underlying diagnoses and were at different stages of their disease.

RESULTS

6 patients with median age of 30-years-old underwent surgery in our centre. 3 patients had undergone debulking prior to surgery at our institution. In all patients, the tumor involved the right ventricle. One patient had biventricular involvement, the septum was involved in 4 patients, 2 patients had extracardiac growth, one invading both great vessels, one involving the pericardium and the hilar structures on the right side. Complete resection was achieved in 4 cases, 3 with successful resection-reconstruction, one with cardiectomy and implantation of a total artificial heart. 5 patients are currently alive, 4 free of recurrence.

CONCLUSIONS

Complete radical surgery is the only curative treatment for patients suffering from cardiac tumors. The availability of mechanical circulatory support allows for a more radical surgical approach even including total cardiectomy, possibly resulting in a significant increase in R0 resections.

Maneuvering the Management of a Rare Case of Primary Undifferentiated Cardiac Sarcoma

BACKGROUND Primary cardiac tumors are rare and mostly benign. Cardiac sarcomas are the most common malignant neoplasms of the heart and harbor a dismal prognosis of 6 to 12 months. The diagnosis of cardiac sarcomas may be challenging. Treatment entails surgical resection despite the high rate of recurrence, as well as adjuvant chemotherapy. CASE REPORT In this report, we discuss a case of a 58-year-old male with undifferentiated pleomorphic primary cardiac sarcomas who received multiple lines of treatment that included surgery, chemotherapy, and targeted therapy and was alive more than 4 years after his diagnosis. Herein, we discuss the different treatment regimens utilized and we present detailed imaging of his case findings at different treatment stages. CONCLUSIONS Treatment of undifferentiated pleomorphic cardiac sarcoma requires a multidisciplinary approach. Surgery and adjuvant treatment are commonly utilized, while neoadjuvant treatment is under investigation.

Atrial Hemangioma: A Case Report and Review of the Literature

A primary cardiac tumor is a rare clinical entity which was reported an incidence of 0.03% in previous autopsy series. 75% cardiac tumors are cardiac myxoma and cardiac hemangiomas constitute only 1–2% of primary cardiac tumors. With the development of modern medical imaging technology and the enhancement of people’s health awareness, more and more asymptomatic cardiac hemangiomas were found and confirmed eventually. Here, we described a case of a 71-year-old man, who was hospitalized with intermittent palpitation for 1 year and a large mass of the heart was removed successfully via sternotomy which was confirmed as atrial hemangioma by postoperative histopathology. Furthermore, a comprehensive review of atrial hemangioma was conducted to date and a few recommendations for the diagnosis and treatment of this uncommon disorder were provided for clinicians.

MR Imaging of Cardiac Masses

Cardiac masses present a diagnostic challenge given their relative rarity and the overall difficulty imaging the heart. With the increasing frequency and quality of imaging in general, however, the incidental discovery of cardiac masses is increasing. Cardiac masses seldom produce symptoms, and they are more commonly found during imaging for noncardiac indications. While echocardiography is useful in the initial evaluation of a suspected mass, cardiac magnetic resonance (MR) imaging is the best imaging modality to characterize cardiac tumors due to its superior tissue characterization and its higher contrast resolution. Due to the risk of embolization and arrhythmia, most benign cardiac tumors are removed, and imaging plays an important role in treatment planning. While primary resection remains the mainstay of treatment, new treatment strategies may prolong survival and slow the growth of metastases. A fundamental knowledge of common cardiac masses is vital to all radiologists, and here, we discuss the most pertinent imaging approach to cardiac masses emphasizing MR imaging.

Left Atrial and Carotid Body Paraganglioma

We report a rare case of left atrial paraganglioma with a synchronous carotid body paraganglioma in a 30-year-old man with succinate dehydrogenase B gene mutation. The patient initially presented with a neck mass and palpitations. Laboratory test results showed elevated catecholamine levels. A cardiac paraganglioma was identified by computed tomography, meta-iodobenzylguanidine scintigraphy, and magnetic resonance imaging. Surgical resection of both paragangliomas were performed on two separate occasions. Serum and urine catecholamine levels returned to normal range. On follow-up, there was no recurrence of the cardiac paraganglioma. Radiotherapy was subsequently initiated for recurrence in the carotid body paraganglioma.

Successful Re-Repeat Resection of Primary Left Atrial Sarcoma After Previous Tumor Resection and Cardiac Autotransplant Procedures

Primary cardiac sarcomas are rare but aggressive tumors and can present a technical challenge with regard to surgical approach and resection. Complete surgical resection, when feasible, remains crucial for palliation of symptoms and for its role as the mainstay of cardiac sarcoma therapy. Surgical resection of recurrent cardiac sarcomas, though formidable, is technically feasible and may provide reasonable survival, especially when the recurrence is local and the metastatic load is limited. In this case report, we describe a successful third cardiac sarcoma resection procedure in a young patient with previous cardiac autotransplantation and excision of left atrial sarcoma.

Cardiac tumors--diagnosis and surgical treatment

BACKGROUND

Primary tumors of the heart are rare even in major cardiac surgery centers. Because of the low case numbers, there is an insufficient evidence base to determine the optimal treatment, particularly for malignant tumors.

METHOD

The authors review the pertinent literature retrieved by a selective PubMed search on the terms "cardiac tumor," "heart tumor," "cardiac myxoma," and "cardiac sarcoma." They also present operative techniques and their own long-term results in 181 patients with cardiac tumors.

RESULTS

Patients with cardiac tumors generally have nonspecific symptoms depending on the site of the tumor and the extent of infiltration into the neighboring tissue. The diagnosis is based on the clinical history, echocardiography (in most cases), and, sometimes, computerized tomography and magnetic resonance imaging. Autopsy studies reveal a 0.02% prevalence of cardiac tumors, of which 75% are benign and 25% malignant. Myxoma is the most common benign tumor (50-70%); angiosarcoma is the most common malignant one (30%), followed by rhabdomyosarcoma (20%). About 10% of all tumor patients develop cardiac metastases, but these are only rarely clinically manifest. From 1989 to 2012, 181 patients underwent surgery for cardiac tumors in the authors' institution. The 5-year survival rates were 83% for benign tumors (139 patients), 30% for malignant tumors (26 patients), and 26% for cardiac metastases (16 patients).

CONCLUSION

Patients with cardiac tumors should undergo surgery in a timely fashion in a specialized center. This holds for both malignant and benign tumors, particularly for atrial myxoma, which can cause serious secondary complications by embolization.

Primary malignant cardiac tumors

PURPOSE

The literature on primary malignant cardiac tumors is relatively limited because of their rare incidence. This study aimed to provide a proposed treatment strategy for primary malignant cardiac tumors.

METHODS

The follow-up outcomes of 29 patients with primary malignant cardiac tumors operated, and 8 primary malignant cardiac tumors considered not operable from 1985 to 2013 in the First Affiliated Hospital of China Medical University were retrospectively analyzed.

RESULTS

Of operation receivers, ten patients had positive surgical margins and nineteen patients had negative surgical margins. Eleven patients received a post-operative neoadjuvant chemotherapy. Patients rejected to surgery had a lower survival compared with operation receivers (15 vs 23 months, P = 0.011). However, there were no significant differences in survival in patients rejected to surgery than in patients who had positive surgical margins (15 vs 16 months, P = 0.874). Patients who had positive surgical margins had a median overall survival duration of only 16 months, whereas patients with negative surgical margins had a median overall survival duration of 27 months (P = 0.002). There were no significant differences in survival in patients with receiving a post-operative adjuvant chemotherapy than in the rest of the population (20 vs 25 months, P = 0.150).

CONCLUSIONS

The prognosis for patients with primary malignant cardiac tumors remains very poor. Each patient should be managed on an individual basis, and variety of treatment strategy should be performed. Maximizing the possibility of obtaining negative surgical margins may prolong survival.

Recurrent cardiac myxoma in a 25 year old male: a DNA study

We present a 25 year old Caucasian male patient with multiple recurrences of cardiac myxomas after surgical removal of the original tumor. His mother was operated on for right ventricular myxoma. The genetic analyses disclosed an aneuploid DNA content by flow cytometry analysis. The familial form of the cardiac myxomas must be distinguished from Carney complex syndrome. A long- term echocardiographic follow up is recommended to patients and their first degree relatives with cardiac myxomas.

Cardiac tumors in infants and children: study of 120 operated patients

Cardiac tumors in children are rare, and patient series are limited in size. We report 120 children who underwent surgery to treat a cardiac tumor; the tumor type was known in 108 instances. The patients represented <0.1 % of 130,000 cardiac surgeries performed in children from a multi-institutional data base. The most common tumors and the number of patients were rhabdomyoma (n = 42), myxoma (n = 28), and fibromas (n = 10). The remaining 18 tumors of various types occurred in smaller numbers of patients. Nine patients (7 %) died after surgery. The mean age of death was 14 days, and death was most frequent in patients with fibromas (n = 4). Considering the variety of tumors, their varied location in cardiac structures, the patient ages, and the infrequent occurrence in an individual surgeon's experience, the operative mortality was low.

Atrial Myxoma: A Case Presentation and Review

Myxomas are the most common primary cardiac tumors, most frequently found in the left atrium. We present a case of an atrial myxoma. An in-depth review of atrial myxoma is presented, examining the important clinical symptoms and diagnostic indicators. The treatment of atrial myxoma is then discussed, with an emphasis on current therapies. An extensive literature review has been performed to present a comprehensive review of the causes, pathophysiology of atrial myxoma.

Primary cardiac valve tumors

To assess the prevalence, characteristics, and outcome of surgical treatment of primary cardiac valve tumors in a single center, we reviewed our experience in 6 women and 1 man, aged 49 to 76 years (mean, 64.7 years) who presented between 1999 and 2006. In one patient, the diagnosis of cardiac valve tumor was made incidentally on transesophageal echocardiography during aortocoronary bypass surgery. The others had clinical symptoms: angina or myocardial infarction in 3, congestive heart failure in 2, dyspnea and cerebrovascular ischemia in 1 patient each. Four of the 7 tumors were benign, and 3 were malignant. All patients survived the operation and recovered uneventfully. Midterm follow-up was available in all patients. Two patients with malignant tumors were considered unsuitable for adjuvant therapy by the oncologist; both died during follow-up from local tumor recurrence. All 5 survivors were categorized at the last follow-up as functional class I, with normal exercise tolerance. Excellent early and midterm surgical results can be obtained in patients with benign cardiac valve tumors, but the prognosis for those with a malignant tumor is poor.

Large primary cardiac sarcoma on the left ventricular free wall: is total excision contraindicated?

A case of a large primary cardiac sarcoma on the left ventricular free wall is reported. Although the definitive diagnosis of this tumor was not made preoperatively, total excision was planned for rapid diagnosis and optimal procedure. However, the operation was discontinued due to intraoperative diagnosis of malignancy. As a result, the patient suffered from the symptoms of cardiac tamponade caused by the large tumor. We discuss the surgical strategy to provide therapeutic benefit for possible patients in the future. In conclusion, an aggressive attempt at volume reduction such as cardiac autotransplantation may relieve the symptoms, even though such surgery would only be palliative.

Cardiac autotransplantation for removal of left atrial hemangioma and a review of the literature

We describe the management of a patient who presented with symptoms of severe congestive heart failure. A 48-year-old man was initially seen in the emergency room, admitted to the hospital, and worked up with a transthoracic echocardiogram, a transesophageal echocardiogram, and a computer tomography scan of the chest. All cardiac valves were normal, as was the left ventricular ejection fraction. A mobile left atrial tumor measuring 6 x 4 x 5 cm was found attached to the left atrial dome, left atrial cuff, and left pulmonary veins. With each systolic atrial contraction, the mass prolapsed into the left ventricle across the mitral valve annulus, inducing a gradient of 19 mm Hg. The workup of the patient was negative for malignancy. The only feasible therapy for this patient was to excise the mass on cardiopulmonary bypass and cardioplegic arrest. At the time of surgery, the findings confirmed that the mass was attached broadly to the left atrial dome wall-epicardium, and the attachments were similar to those of the transesophageal echocardiographic findings. Atrial attachments extended from the base of the heart, along the atrioventricular groove, the left dome of the left atrium, the left atrial cuff, and the anterior aspect of both left pulmonary veins. The tumor could not be adequately excised, and reconstruction of the defect was not feasible with the heart in situ. We therefore decided to explant the heart and excise the tumor with a 0.5-cm margin of healthy tissue. The broad left atrial defect was reconstructed with bovine pericardium. The reconstruction encompassed the dome of the left atrium, the left atrial cuff, and the pulmonary veins. The heart was reimplanted back into the pericardial cavity. The superior vena cava with the retained sinus node was also anastomosed. The pathology diagnosis was a benign cavernous hemangioma. The sinus rhythm recovered following removal of the aortic cross-clamp and reperfusion of the heart. The patient had a rapid recovery and was discharged home on the 12th postoperative day. Placement of a pacemaker was not required because the patient retained the sinus rhythm. A review of the literature on cardiac autotransplantation revealed that this type of surgery has been performed frequently in centers that have a cardiac transplantation program or a surgeon who has cardiac transplantation experience. To our knowledge, this report is the first of cardiac autotransplantation for benign hemangioma.

Management of primary pulmonary artery sarcomas

The objective of this review is to determine the outcome of patients with sarcomas involving the main pulmonary artery, pulmonic valve, or right ventricular outflow tract. Survival data were analyzed using an aggregate series derived from the published literature in conjunction with a current series. Median survival was 36.5 +/- 20.2 months for patients undergoing an attempt at curative resection compared with 11 +/- 3 months for those undergoing incomplete resection. Median survival was 24.7 +/- 8.5 months for patients undergoing multimodality treatment compared with 8.0 +/- 1.7 months for patients having single-modality therapy. A complete review of diagnosis, evaluation, treatment, and surveillance of primary pulmonary artery sarcomas follows.

Management of primary cardiac sarcomas

Cardiac sarcomas are rare entities. The biological behavior of cardiac sarcomas is similar to all soft-tissue sarcomas. Aggressive local growth and metastatic spread are common. Although histologic type affects behavior, survival is dependent on the histologic grade. Chemotherapy and radiation therapy are not adequate for long-term survival. Although surgery provides the best modality for local control it is limited by its inability to control distant metastatic disease. Right heart sarcomas tend to be bulky, infiltrative, cause heart failure late and metastasize early. Based on the surgical approach and clinical behavior, cardiac sarcomas can be classified as right heart sarcomas, left heart sarcomas and pulmonary artery sarcomas. Our limited - albeit the most extensive - experience with cardiac sarcomas has helped improve survival compared with chemotherapy alone. They are usually treated with chemotherapy prior to extensive resection. Left heart sarcomas tend to be more circumscribed, less infiltrative, cause heart failure early and metastasize later. They are usually treated with surgery first, given the possibility of cardiac failure. Pulmonary artery sarcomas tend to be confined to the pulmonary artery, often causing severe right heart failure and metastasize later than right heart sarcomas. They are usually treated with complete resection. Adjuvant therapy is recommended for all patients given that excellent local control is often achieved with surgery, yet long-term survival is often poor due to metastatic recurrence. Cardiac autotransplantation is an excellent technique for resection of posterior or left heart cardiac sarcomas. Surgical outcomes with cardiac autotransplantation are excellent in patients who do not require concurrent pneumonectomy. Pulmonary artery sarcomas allow for radiation therapy in addition to chemotherapy for neoadjuvant control, as the myocardium can be avoided. However, overall, long-term survival after cardiac sarcoma requires improved systemic control. This progress awaits the development of novel chemotherapeutics.

An unusual case of spinal column metastasis after orthotopic transplantation for cardiac sarcoma

The authors describe a patient who underwent orthotopic cardiac transplantation after an undifferentiated cardiac sarcoma was diagnosed. While receiving immunosuppressive therapy, the patient developed spinal column metastases and cauda equina syndrome requiring surgical decompression and stabilization. This occurred despite an exhaustive search for metastatic disease prior to the transplantation. To the authors' knowledge, this represents the first reported case of an undifferentiated cardiac sarcoma metastasis to the spine. This previously healthy 18-year-old woman presented with a myocardial infarction. Investigations revealed a left atrial tumor, which was resected. Following local recurrence, the patient underwent extensive studies to rule out systemic disease. Orthotopic heart-lung transplantation was then performed. While receiving postoperative immunosuppressive therapy the patient presented with cauda equina syndrome secondary to metastatic tumor compression at the L-5 level. Despite a comprehensive screening process to exclude metastatic disease prior to transplantation, spinal metastases occurred while this patient was receiving immunosuppressive therapy. This represents a previously unreported and clinically significant complication for undifferentiated cardiac sarcoma.

Myxoma of donor origin in a transplanted heart

Myxomas are the most common primary cardiac tumors but their presence in the transplanted heart is extremely rare. We report a case of left atrial myxoma in a patient after heart transplantation. DNA analysis confirmed a donor origin. To our knowledge, this is the first report of myxoma of donor origin in a transplanted heart.

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

Primary cardiac neoplasms are rare and occur less commonly than metastatic disease of the heart. In this overview, current published studies concerning malignant neoplasms of the heart are reviewed, together with some insights into their aetiology, diagnosis and management. We searched medline using the subject 'cardiac neoplasms'. We selected about 110 articles from between 1973 and 2006, of which 76 sources were used to complete the review. Sarcomas are the most common cardiac tumours and include myxosarcoma, liposarcoma, angiosarcoma, fibrosarcoma, leiomyosarcoma, osteosarcoma, synovial sarcoma, rhabdomyosarcoma, neurofibrosarcoma, malignant fibrous histiocytoma and undifferentiated sarcoma. The classic symptoms of cardiac tumours are intracardiac obstruction, signs of systemic embolisation, and systemic or constitutional symptoms. However, serious complications including stroke, myocardial infarction and even sudden death from arrhythmia may be the first signs of a tumour. Echocardiography and angiography are essential diagnostic tools for evaluating cardiac neoplasms. Computed tomography and magnetic resonance imaging studies have improved the diagnostic approach in recent decades. Successful treatment for benign cardiac tumours is usually achieved by surgical resection. Unfortunately, resection of the tumour is not always feasible. The prognosis after surgery is usually excellent in the case of benign tumours, but the prognosis of malignant tumours remains dismal. In conclusion, there are limited published data concerning cardiac neoplasms. Therefore, a high level of suspicion is required for early diagnosis. Surgery is the cornerstone of therapy. However, a multi-treatment approach, including chemotherapy, radiation as well as evolving approaches such as gene therapy, might provide a better palliative and curative result.

Primary cardiac sarcoma: reports of two cases and a review of current literature

Primary cardiac sarcomas are rare tumors with an unfavourable prognosis. Complete surgical resection is currently the only mode of therapy proven to show any benefit. We report the cases of two patients presenting with features of obstruction and embolism and a presumed diagnosis of left atrial myxoma. At operation they were unexpectedly found to have large tumours raising strong suspicions of malignancy. Due to the extensive involvement of intracardiac structures with little possibility of reconstruction together with poor general condition of the patient, debulking was deemed to be the only viable option. Subsequent histology confirmed the diagnosis of sarcoma in both patients. Surgery produced immediate and effective symptom relief. The first patient died four months after the operation and second patient is still alive at 12 months after her operation. A brief review of literature on cardiac sarcoma is presented.

Cardiac Paraganglioma Presenting With Acute Myocardial Infarction and Stroke

We report an unusual presentation of cardiac paraganglioma with acute myocardial infarction and stroke induced by exercise and review the literature regarding this rare cardiac tumor.

Therapy insight: malignant primary cardiac tumors

Benign cardiac tumors are resected with a high degree of success with modern cardiac surgical techniques. Malignant cardiac tumors, however, continue to pose a therapeutic challenge to cardiac surgeons and oncologists because of the technical difficulty involved in extensive cardiac resections and the aggressive biological nature of the tumors. The majority of malignant cardiac tumors are sarcomas and can be categorized as right heart sarcoma, left heart sarcoma or pulmonary artery sarcoma. Right heart sarcomas are generally angiosarcomas, which infiltrate widely and metastasize early. A combination of chemotherapy and surgical resection is the preferred therapy. Left heart sarcomas, although large, are often less infiltrative and metastasize later than right heart sarcomas, but a similar approach to treatment is usually employed. Surgical resection is more-frequently necessary for left heart sarcomas because of intracardiac blood flow obstruction and congestive heart failure, although the anatomic position and relation of these tumors to cardiac structures can complicate surgery. We have developed and employed the technique of cardiac autotransplantation, which involves cardiac excision, ex vivo tumor resection with cardiac reconstruction, and cardiac reimplantation, to lessen these technical difficulties. Pulmonary artery sarcomas can be treated by radiotherapy, as well as by the other therapies, because the myocardium can be avoided by the radiation fields. Surgical resection of this sarcoma type often requires pneumonectomy and can require pulmonary root replacement.