Primary cardiac tumors: 32 years of experience from a Spanish tertiary surgical center

Clinical characteristics and surgical outcomes of cardiac myxoma: A meta-analysis of worldwide experience

Cardiac myxoma is the most common primary cardiac tumor. However, existing literature mainly consists of single-center experiences with limited subjects. This systematic review aimed to provide data on clinical characteristics and surgical outcomes of cardiac myxoma. We performed a thorough literature search on May 23, 2023 on PubMed, ProQuest, ScienceDirect, Scopus, and Web of Science. The inclusion criteria were English full-text, observational studies, and included >20 subjects. From the search, 112 studies with a total of 8150 patients were included in the analysis. The mean age was 51 years (95 % confidence interval [95%CI] = 49.1-52.3), and the majority were females (64.3 % [95 % CI = 62.8-65.8 %]). The most common clinical manifestation was cardiovascular symptoms. Echocardiography can diagnose almost all cases (98.1 % [95 % CI = 95.8-99.6 %]). Cardiac myxoma was mostly prevalent in left atrium (85.3 % [95%CI = 83.3-87 %]) and predominantly with pedunculated morphology (75.6 % [95%CI = 64.1-84.3 %]). Post-tumor excision outcomes were excellent, with an early mortality of 1.27 % (95 % CI = 0.8-1.8 %), late mortality rate of 4.7 (95 % CI = 2.5-7.4) per 1000 person-years, and recurrence rate at 0.5 (95 % CI = 0.0-1.1) per 1000 person-years. Tumor excision is warranted in a timely manner once the cardiac myxoma diagnosis is established.

Reduced Risk of All-Cause, Cancer-, and Cardiovascular Disease-Related Mortality among Patients with Primary Malignant Cardiac Tumors Receiving Chemotherapy in the United States

Primary malignant cardiac tumors (PMCTs) are rare but lethal neoplasms. There are limited evidence-based treatment guidelines for PMCTs. We evaluated the relation of chemotherapy with mortality outcomes in patients with PMCTs in the United States. Data were from patients aged ≥ 20 years from the Surveillance, Epidemiology, and End Results program who were diagnosed with PMCTs from 2000 to 2020. Cox regression, competing risk, and propensity score analyses were performed to estimate hazard ratios (HR) and confidence intervals (CI). About 53% of the 563 patients with PMCTs received chemotherapy as the first course of treatment. During a mean follow-up of 24.7 months (median: 10), 458 deaths occurred with 81.7% and 9.4% due to cancer and cardiovascular disease (CVD), respectively. In models adjusted for sociodemographic and clinico-pathophysiological factors including histology, receipt of chemotherapy was associated with low risk for all-cause (HR: 0.56, 95%CI: 0.45-0.69), cancer (HR: 0.63, 95%CI: 0.50-0.80) and CVD mortality (HR: 0.27, 95%CI: 0.12-0.58). Patients who had both chemotherapy and surgery had the lowest risk for all-cause and cancer mortality. This study suggests that the subpopulations of patients with PMCTs who receive chemotherapy may have better prognosis than those who do not receive this therapy regardless of histology.

Surgical treatment of rare pediatric cardiac myxomas:12 years clinical experience in a single institution

BACKGROUND

Primary cardiac tumors are rare, and cardiac myxoma (CM) accounts for the majority of these tumors. Most of the reports in the literature are case reports. This study summarizes our clinical experience in the surgical treatment of CM over the past 12 years.

METHODS

We retrospectively analyzed the clinical data of 23 children with CM(8 boys, 15 girls; median age: 8.92 months, range: 2 years 5 months-12 years 9 months; body weight: 11-45 kg, median body weight: 28.21 kg) admitted to our hospital in the previous 12 years, and we statistically analyzed their clinical manifestations and surgical methods.

RESULTS

23 cases underwent myxoma excision under cardiopulmonary bypass(CPB). The follow-up period was 0.2 to 12.6 years (mean:7.2 years). Two patients could not be traced, and the follow-up completion rate was 91.30%. One patient (4.35%) died of myocardial infarction early after surgery with low continuous cardiac output. There were no cerebral embolism, acute heart failure, atrioventricular block and other related complications in 19 cases. A patient with cerebral infarction complicated with right hemiplegia recovered well after rehabilitation treatment. There was no recurrence of CM in 19 cases and all patients recovered after surgery. One patient relapsed 5 years after surgery, and no tumor recurrence was observed after the second surgery. Among the 20 long-term survivors, 13 (65.00%) were NYHA Class I patients and 7(35.00%) were NYHA Class II patients.

CONCLUSIONS

Although CM in children is rare, it may cause cerebral infarction and other multi-organ embolism. Once CM is found and removed as soon as possible, it can reduce serious complications. If the complete resection is possible, surgery provides better palliation. Follow-up echocardiographic should be paid attention to after surgery.

A case report of an ischaemic stroke, caused by a primary cardiac intimal sarcoma

BACKGROUND

Intimal sarcomas are an extremely rare type of primary cardiac malignancy. They most commonly present with symptoms of cardiac dysfunction. We present a case of intimal sarcoma identified without any cardiac signs or symptoms. Cardiac sarcomas historically carry a very poor prognosis.

PRESENTATION

A 57-year-old man presented with a sudden onset of left limb weakness and disorientation. MRI brain identified an acute ischaemic stroke in the right anterior temporal lobe. Four months later, he presented again with transient left arm weakness. The patient had a normal cardiovascular examination and ECG. All other initial investigations for cryptogenic stroke were non-contributory. The patient did not initially get an echocardiogram. When this investigation was performed, after his second presentation, a large pedunculated mass was present in his left atrium. This was resected and identified histologically as a primary intimal sarcoma of his left atrium. The patient was treated with post-operative radiotherapy but declined chemotherapy. He recovered well post-operatively but subsequently passed away 14 months after diagnosis.

CONCLUSIONS

It is possible for primary cardiac malignancies to present with only symptoms of systemic emboli. For this reason, echocardiography is a crucial investigation in cases of cryptogenic stroke. Some stroke guidelines do not definitively support routine echocardiography. Primary intimal cardiac sarcoma is a very rare condition with a poor prognosis. The literature is limited to case reports and optimal management is with surgical resection where possible. The role of post operative radiotherapy and chemotherapy is uncertain.

An undifferentiated, pleomorphic cardiac sarcoma masquerading as myxoma

Cardiac sarcoma is a very rare cause of primary cardiac tumor. We present a case of an undifferentiated, pleomorphic cardiac sarcoma, masquerading as a cardiac myxoma on multimodal imaging evaluation, which was definitively diagnosed on intra-operative histopathologic examination followed by surgical resection.

Learning objective

Evaluate and diagnose a rare primary cardiac tumor via multimodal imaging and a multidisciplinary approach.

Racial and ethnic characteristics and cancer-specific survival in Primary Malignant Cardiac Tumors

Background

There is limited insight into the epidemiological characteristics and effect of race and ethnicity on Primary Malignant Cardiac Tumors (PMCTs).

Objectives

Comparison of clinical characteristics and cancer-specific survival outcomes of major races in the United States from the Surveillance, Epidemiology and End-Result (SEER) registry.

Methods

ICD-O-3 codes were used to identify PMCTs for the years 1975 to 2015. Three major races were identified—“White”, “Black”, and “Asian/Pacific Islander”. Cancer-specific survival outcomes were compared using Kaplan-Meier analysis across and amongst races, based on tumor histology. A subgroup analysis of cancer-specific survival was performed between “Hispanics” and “non-Hispanics.”

Results

Seven hundred and twenty patients were identified−47% females and 79% White, mean age at diagnosis (47 ± 20 years). Black patients were significantly younger (39 ± 18 years) and presented more commonly with angiosarcomas (53%). Non-angiogenic sarcomas and lymphomas were the most common tumors in the White (38%) and Asian/Pacific Islander (34%) cohorts. For a median follow-up period of 50 (IQR3-86) months, cancer-specific survival (mean ± SD, in months) was worse in Blacks (9 ± 3) as compared to Whites (15 ± 1) and Asian/Pacific Islander (14 ± 1) (p-value; Black vs. White <0.001; Black vs. Asian/Pacific Islanders = 0.017, White vs. Asian/Pacific Islanders = 0.3). Subgroup analysis with 116 (16%) Hispanics (40% females; mean age of 40 ± 20 years) showed a longer mean cancer-specific survival of 16.9 ± 2.4 months as compared to 13.6 ± 1.1 months in non-Hispanics (p = 0.011).

Conclusion

Black and non-Hispanic patients have poorer cancer-specific survival in PMCTs.

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.

Diagnosis and survival analyses of patients with space-occupying cardiac lesions: a 10-year retrospective single-center study

Background

Space-occupying cardiac lesions are uncommon but fatal. Echocardiography can identify diseases quickly in the clinic. This study reviews the clinical data of patients with space-occupying cardiac lesions in the past 10 years and analyzes their echocardiographic features, pathological diagnosis, and prognosis.

Methods

We performed a retrospective analysis of 412 patients admitted to Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing from 2011 to 2020. All patients were diagnosed with cardiac masses based on transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE). We compared the diagnostic results of echocardiography and the postoperative pathological diagnosis and analyzed the characteristics of different types of space-occupying cardiac lesions. We also compared the mortality of patients with different types of space-occupying cardiac lesions through follow-up results of postoperative patients.

Results

The 412 patients included 189 males and 223 females. Among them, 214 patients had benign tumors (including 176 patients with myxomas), 29 had primary malignant tumors, 32 had metastatic tumors, 41 had thrombi, 92 had infectious neoplasms, and 4 patients had special types of space-occupying lesions. A total of 376 lesions were correctly characterized by TTE, with an accuracy of 91.3%. Patients with benign tumors (9/214), thrombi (4/41), infectious neoplasms (5/92), or special types of space-occupying lesions (0/4) exhibited low rates of mortality or recurrence. In contrast, patients with primary malignant tumors (16/29) or metastatic tumors (16/32) exhibited high mortality rates.

Conclusions

Echocardiography is a valuable tool for characterizing space-occupying cardiac lesions. It can provide important preoperative diagnostic information for cardiothoracic surgeons.

Dysphonia as a Presenting Symptom of a Giant Left Atrial Sarcoma Developing within Five Years

An 83-year-old woman presented with a new onset of dyspnea and dysphonia. Physical examination revealed no abnormalities. Computerized tomography, bidimensional echocardiography, and cardiac magnetic resonance confirmed the presence of a cardiac mass in the left atrium. Surgical resection was uneventful and showed the origin of the mass in the ostium of the left inferior pulmonary vein. Histological evaluation revealed undifferentiated pleomorphic sarcoma with myxoid features. This case highlights the importance of considering cardiac neoplasms as a rare differential diagnosis, including rare and misleading clinical presentations.

Sarcoma of the Heart Treated with Stereotactic MR-Guided Online Adaptive Radiation Therapy

We present the first case in the literature of a patient with a histology-proven intimal sarcoma of the heart, recurrent after surgery, treated with stereotactic MR-guided online adaptive radiation therapy on an MR-Linac machine. The treatment was feasible and well tolerated. The CT scan 6 months after the last treatment showed stable disease.

Long-Term Outcomes of Primary Cardiac Malignancies: Multi-Institutional Results From the National Cancer Database

BACKGROUND

Data on primary cardiac malignancies are limited to small single-center studies.

OBJECTIVES

The aim of the current study was to provide detailed outcomes for treatment of primary cardiac malignancies from a multi-institutional database.

METHODS

Outcomes were acquired from the National Cancer Database for all solid primary cardiac malignancies from 2004 to 2016. The primary outcome was long-term survival. Logistic regression was used to determine factors associated with mortality.

RESULTS

A total of 100,317 cardiac tumors were identified, of which 826 (0.8%) were primary malignant tumors. After exclusion criteria, the cohort consisted of 747 patients (median age 53 years, 47.5% women). Most tumors were primary sarcomas (88.5%), the majority of which were hemangiosarcoma (40.4%). A total of 136 patients received no therapy, 113 received just chemotherapy, and 20 received just radiation. Surgery was performed in 442 (59.2%) patients including 255 patients undergoing multimodal therapy (surgery with chemotherapy, radiation, or chemoradiation). With surgery alone, 90-day mortality was 29.4%. Overall 30-day, 1-year, and 5-year survival rates were 81.2%, 45.3%, and 11.5%, respectively. The surgery group as compared with the no surgery groups had significantly better long-term survival (p < 0.0001). For stage III disease, there was a statistically significant improvement in survival with the addition of chemotherapy to surgery.

CONCLUSIONS

Primary cardiac malignancies are rare cancers with dismal long-term survival despite mode of treatment. Patients who underwent surgery and those with stage III disease who received peri-operative chemotherapy had better survival compared with those who did not. However, there was likely a significant selection bias in patients chosen for surgical or medical therapy.

Removal of unusual multiple aortic valve fibroelastoma using right mini-thoracotomy

Papillary Fibroelastomas are rare, primary cardiac tumors. They are typically diagnosed as an incidental finding but can also present as thrombo-embolic events. We present the case of 78-years- old man who presented to emergency room with a cerebrovascular event (CVE). Transesophageal echocardiography (TEE) revealed e presence of a mass on the aortic valve. Intra-operatively, two masses where found: one was highly mobile attached to left ventricular (LV) side of the left coronary cusp, another small size mass attached to the non-coronary cusp, and there was suspicion of a mass attached to the mitral valve. The two masses were surgically excised using a right mini-thoracotomy, and histopathological examination confirmed the diagnosis.”

Primary Undifferentiated Pericardial Sarcoma after Radiоtherapy for Hodgkin Lymphoma

Various types of sarcomas arise as a result of postradiation chronic fibrous pericarditis. A primary undifferentiated spindle cell pericardial sarcoma is a rare type of sarcoma after radiotherapy. The risk of sarcoma increases with time after treatment of cancer. A 55-year-old woman underwent successful radiation and chemotherapy for Hodgkin lymphoma 20 years ago. She was hospitalized with typical manifestations of severe heart failure. Echocardiography, сomputed tomography of the chest and magnetic resonance imaging scan of the heart detected neoplastic formations of the pericardium. A biopsy of the pericardium was performed. Histological, immunohistochemical, and genetic studies showed a primary undifferentiated spindle cell pericardial sarcoma (an extremely rare type of sarcoma).

Fibrin-associate diffuse large B-Cell lymphoma arising in a left atrial myxoma: A case report and literature review✰,✰✰

We report a 60-year-old male with fibrin-associated diffuse large B-cell lymphoma (fa-DLBCL) in left atrial myxoma. Echocardiography showed a mass (63 mm × 33 mm) in the left atrium. Histological inspection indicated fa-DLBCL on the surface of atrial myxoma incidentally, together with extensive fibrinous like exudation on myxoma surface. Malignant cells were localized in solid sheets and nests at the peripheral area of the fibrinous exudation which were positive for B-lineage markers (CD20+, CD79a+, PAX-5+) and in situ hybridization of EBV-encoded RNA (EBER). PCR amplification showed clonal rearrangement of immunoglobulin heavy chain (IgH) genes. The patient was still alive with no recurrence in the 35-month follow-up after surgery. We also did a detailed clinicopathological analysis and literature review, which indicated that fa-DLBCL was a heterogeneous entity.

Survival Differences in Men and Women With Primary Malignant Cardiac Tumor: An Analysis Using the Surveillance, Epidemiology and End Results (SEER) Database From 1973 to 2015

Background No data are available on sex disparities in prevalence and survival for primary malignant cardiac tumors (PMCT). This study aimed to compare male and female PMCT prevalence and long-term survival rates. Methods and Results We utilized the Surveillance, Epidemiology, and End Results (SEER) 18 database from the National Cancer Institute for all PMCTs diagnosed between 1973 and 2015. From a total of 7 384 580 cases of cancer registered in SEER, we identified 327 men and 367 women with PMCTs. The majority (78%) of patients were white. Sarcoma was the most common type of PMCT in both men and women (≈60%). Individuals diagnosed with lymphoma exhibited better survival than those with other types of PMCTs. Men were diagnosed at a younger age than women; however, there was no significant difference in overall survival between the sexes. Men diagnosed with PMCT between the ages of 51 and 65 years demonstrated prolonged survival compared with those diagnosed at younger or older ages. There was no difference in survival rates among women based on age at diagnosis. Conclusions PMCTs are rare in both men and women. Tumors tend to be diagnosed at an earlier age in men compared with women, but there is no sex disparity in survival rate. Sarcoma is the most common type of PMCT, and lymphoma is associated with the highest survival rate among both sexes.

Solitary neurofibroma of the heart

Solitary neurofibroma of the heart is extremely unusual. Few reports of neurofibroma in the left ventricle have been published. In this case report, we present the results of transthoracic echocardiography, myocardial contrast echocardiography, cardiac magnetic resonance imaging, and histopathologic examination of a patient with a neurofibroma of the heart. The patient had no evidence of any other metastasis or primary tumor in other organs, which is clinically rare.

Cardiac tumors prevalence and mortality: A systematic review and meta-analysis

OBJECTIVES

Cardiac tumors and their associated outcomes are poorly characterized. This study sought to comprehensively assess the epidemiology and natural history of primary and secondary malignant cardiac tumors (PMCT and SMCT), a well as establish predictors of mortality.

METHODS

A comprehensive literature review was performed to identify articles reporting on PMCTs and SMCTs. The prevalence of important cardiac tumor (CT) subtypes was evaluated and further stratified based on the continental region. Outcomes of interest included short- and long-term mortality and utilization of heart transplantation (HTX). A random effect model was adopted, and a meta-regression was performed to determine predictors of the prevalence of CTs as well as predictors of operative mortality.

RESULTS

Of the 1,226 retrieved articles, 74 were included in our study (n = 8,849 patients). The mean follow-up was 2.27 years, mean age was 42.9 years, and 55% of the patients were females. There was a total number of 7,484 benign primary cardiac tumors (PCTs) (5,140 were myxoma), 862 (9.7%) malignant PCTs, and 355 secondary cardiac tumors. The prevalence of PMCTs among PCTs was 10.83% [95%CI = 09.11; 12.83%] with a trend towards being lower in South America compared to other continents (Prevalence = 5.80%). The prevalence of HTX among all patients was 2.45% [1.36; 4.38%]. The pooled short-term mortality was 5.90% [4.70; 7.39%] and the incidence of late mortality in all CTs, benign CT and PMCTs was 2.55% [1.76; 3.72%], 0.79% [0.46; 1.37%] and 14.77% [9.32; 23.40%], respectively. On meta-regression, the annual volume of cardiac tumor cases per center was the only predictor of lower early mortality (Beta = -0.14 ± 0.03, P < 0.0001).

CONCLUSIONS

PMCTs represent the minority of PCT (~10%) and have a higher prevalence in Europe and North America. Survival is higher in benign pathology and is significantly improved by treatment in specialized high-volume centers. Approximately 2% of patients with CTs undergo heart transplantation.

Surgical management of large undifferentiated cardiac sarcoma involving the right ventricle to pulmonary trunk

A large intra-cardiac tumor from the right ventricle to pulmonary trunk was detected by contrast-enhanced computed tomography and transthoracic echocardiography in a 59-year-old woman with progressive dyspnea on effort and acute congestive right-sided heart failure. Emergent surgical management was performed with cardiopulmonary bypass under cardiac arrest, however, tumor resection was incomplete, because it originated from the interventricular septum. Concomitant tricuspid valve replacement using a bioprosthesis was required due to the involvement of the septal leaflet of the tricuspid valve. Although large pulmonary thromboembolism was initially suspected, a pathological examination confirmed undifferentiated cardiac sarcoma. The patient did not consent to additional neoadjuvant chemotherapy or radiation therapy. After palliative surgical management, she was discharged. Recurrence rapidly progressed and the patient died approximately 2 months after surgery. We herein present a successful palliative surgical case of large cardiac undifferentiated sarcoma originating from the intraventricular septum and involving the right ventricle to pulmonary trunk.

Left ventricular myxoma: A contractile mass causing intracavitary obstruction and severe pulmonary hypertension

Cardiac myxomas can be fatal and left ventricular (LV) myxomas with papillary muscle and mitral valve (MV) involvement are rare. The following case is that of a 55-year-old woman who developed signs and symptoms of pulmonary hypertension. Imaging revealed a contractile mass in the LV that was in continuum with the papillary muscles and affected MV function. Her clinical course, radiologic, and hemodynamic findings are discussed. Finally, her surgical extraction technique is described in addition to potential complications encountered.

Outcome and Pathological Characteristics of Primary Malignant Cardiac Tumors

The literature on malignant cardiac tumors is relatively limited because they are rare, especially among the Chinese population. We analyzed 14 patients diagnosed with malignant cardiac tumors in Fuwai Hospital and present the results of surgical treatments on the tumors. The mean age at tumor diagnosis was 47 years in a male-dominated cohort. There was a high frequency of pericardial effusion and coronary artery involvement in our group. We compared the survival times of patients who received different treatments and found that surgery improved prognosis of tumors, especially for patients who underwent orthotopic heart transplantation.

Pathobiology of cardiovascular diseases: an update

This article introduces the Second Special Issue of Cardiovascular Pathology (CVP), the official journal of the Society for Cardiovascular Pathology (SCVP). This CVP Special Issue showcases a series of commemorative review articles in celebration of the 25th anniversary of CVP originally published in 2016 and now compiled into a virtual collection with online access for the cardiovascular pathology community. This overview also provides updates on the major categories of cardiovascular diseases from the perspective of cardiovascular pathologists, highlighting publications from CVP, as well as additional important review articles and clinicopathologic references.

Multidisciplinary approach to rare primary cardiac sarcoma: a case report and review

Background

Undifferentiated pleomorphic sarcoma is a very rare and aggressive type of primary cardiac tumors. Most cardiac sarcomas result in rapid growth and quick death. According to different sources the median survival is typically 6 to 12 months. We are presenting a case of primary cardiac sarcoma with 26 months disease free survival following cytoreductive surgery and chemotherapy.

Case presentation

A 48-year-old woman with progressing symptoms of dyspnea and palpitations for over 2 months was referred to a cardiologist. With the help of echocardiography and cardiovascular magnetic resonance cardiac sarcoma was suspected. Open biopsy and cytoreductive surgery were performed, complete resection of the tumor was not possible. Histology revealed undifferentiated pleomorphic sarcoma. Seven cycles of chemotherapy with Doxorubicine and Ifosfamide were completed. Cardiovascular magnetic resonance revealed a complete response – only signs of fibrosis without any signs of tumor were visible. Follow ups with echocardiography, cardiovascular magnetic resonance and chest, abdomen and pelvic computed tomography is performed every 3 months. Twenty-six months from initial diagnosis the patient is still free of recurrence of tumor with no compromises of the quality of life.

Conclusion

Standard chemotherapy together with cytoreductive surgery can have a complete response effect in undifferentiated pleomorphic sarcoma with unusual long-term survival.

Primary Cardiac Angiosarcoma with Extensive Visceral Metastases: Utility of 18F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography in Response Assessment to Sorafenib

Primary cardiac angiosarcomas although rare neoplasms remain the most common primary malignant neoplasms affecting the heart. We discuss the sequential positron-emission tomography–computed tomography findings of a 50-year-old man who was diagnosed with the metastatic cardiac angiosarcoma at the outset and developed progressive disease despite sorafenib therapy.

Cardiac Mass: A Case of Cardiac Papillary Fibroelastoma

Cardiac papillary fibroelastoma (CPF) is one of the most common neoplasms of the cardiac valvular structures that are associated with complications such as systemic stroke, embolism, and arrhythmias. We present a case of an incidentally discovered left ventricular mass in a 75-year-old Caucasian woman.

Rare operations in pediatric heart surgery: Cardiac tumors in childhood

BACKGROUND

In this study, we present our 12-year experience in the surgical treatment of primary cardiac tumors in childhood.

METHODS

Thirteen pediatric patients (8 males, 5 females; mean age 1.3±1.9 years; range, 3 days to 6 years) who were operated for a primary cardiac tumor in our center between January 2005 and December 2017 were included in this study. The data were evaluated retrospectively based on our medical records.

RESULTS

All of the masses resected were benign. However, the most common tumor was rhabdomyoma (n=7), followed by fibroma (n=3), myxoma (n=2), and pericardial teratoma (n=1). The mortality rate was 15.4%, as two patients died in the early postoperative period. No residual mass or tumor recurrence was observed in the early and late postoperative period in the remaining patients.

CONCLUSION

Although primary cardiac tumors in childhood are usually benign, they may cause clinically significant problems depending on the localization and size of the tumor. Surgical tumor excision is often associated with good long-term outcomes.

'Cryptogenic Drop Attacks' revisited: evidence of overlap with functional neurological disorder

OBJECTIVE

In their 1973 BMJ paper 'Cryptogenic Drop Attacks', Stevens and Matthews described 40, mostly middle-aged, female patients with drop attacks of unknown cause. Although clinically common, there has been little on this topic since. We aimed to determine clinical features, comorbidity and outcome of patients with drop attacks.

METHODS

We carried out a retrospective review of patients with cryptogenic drop attacks seen consecutively by one clinician (JS) between 2006 and 2016. Demographics, phenomenology, duration and frequency of attacks, attack description and comorbid diagnoses were recorded. Patients were followed up with a notes review.

RESULTS

83 patients with cryptogenic drop attacks were predominantly female (89%, n=79), mean age 44  years. The majority (93%, n=77) could not remember the fall itself and almost half (43%, n=36) experienced prodromal dissociative symptoms. Mechanical trips or syncope preceded drop attacks, historically, in 24% (n=20) of cases. Persistent fatigue (73%, n=61), chronic pain (40%, n=33), functional limb weakness (31%,n=26) and dissociative (non-epileptic) attacks 28% (n=23) were common, with the latter usually preceding or emerging from drop attacks. At follow-up (88%, mean 38 months), 28% (n=23) had resolution of their drop attacks. Predisposing (but non-causative) disease comorbidity was found at baseline (n=12) and follow-up (n=5).

CONCLUSIONS

Cryptogenic drop attacks are associated with high frequency of comorbid functional somatic and functional neurological disorders. Patients commonly have prodromal dissociative symptoms and in some there was a clear relationship with prior or subsequent dissociative (non-epileptic) attacks. Some cryptogenic drop attacks may be best understood as phenomena on the spectrum of dissociative attacks.

Prevalence of primary cardiac tumor malignancies in retrospective studies over six decades: a systematic review and meta-analysis

The incidence of patients diagnosed with primary malignant cardiac tumors (PMCTs) has increased greatly in the past few decades. Whether this rising prevalence is due to overdiagnosis or an increased malignancy rate of primary cardiac tumors (PCTs) remains unclear. Therefore, we performed a systematic review and meta-analysis of published retrospective studies to determine whether the malignancy rate has been increasing over time. Published studies containing relevant data between 1956 and 2014 were evaluated. Two authors searched for all retrospective studies that included patients diagnosed with PCT and PMCT. Two other investigators independently extracted the data, and discrepancies were resolved by consensus. A random-effects meta-analysis model and cumulative meta-analysis model were used to evaluate the pooled prevalence and trend of dynamic change in PCT malignancies. The effects of time, study period and sample size were studied using a logit-linear regression model with robust error variance and a time variable. Thirty-eight studies involving 5,586 patients were analyzed. The pooled prevalence of PMCT among the patients diagnosed with PCT was 9.9% (95% CI, 8.4% to 11.4%) (I²=70%; P< 0.001), and this prevalence has been stable since around 2003. In the regression model, the malignancy odds ratio remained stable from 1975 onward, and no time effect was observed. Our study confirms that PMCT is uncommon, and the prevalence of PCT malignancies remained stable in the past few decades. The clinically observed increase in incidence is unlikely to reflect a true population-level increase in tumorigenesis. This result strongly suggests that the observed increase in incidence of PMCT most likely reflects increased diagnostic detection over time.

Primary Cardiac Sarcoma: 25-Year Cleveland Clinic Experience

BACKGROUND

Cardiac sarcomas are rare and have a poor prognosis. The median overall survival remains dismal and has been reported ranging from 6 months to a few years. Primary cardiac sarcoma is the most common malignant tumor comprising approximately 95% of all malignant tumors of the heart.

METHODS

We conducted a retrospective chart review in a single institution of patients diagnosed between March 1988 and April 2013. A total of 42 patients were identified. The following variables were studied: age at diagnosis, year of diagnosis, sex, stage, site of tumor involvement, tumor histology, grade, treatment modality, type of chemotherapy, and survival outcome. The overall median follow-up time was 49.5 months.

RESULTS

The most common histologic type was angiosarcoma. Overall estimated median survival (EMS) was 25 months. Tumors involving the left side of the heart and pericardium demonstrated better survival. Patients who received multimodality treatment (any combination of surgery, radiation therapy, and chemotherapy) had an EMS of 36.5 months compared with 14.1 months for patients treated with surgery, radiation therapy, or chemotherapy only (P=0.05).

CONCLUSIONS

Cardiac sarcoma is a lethal tumor with an EMS of 25 months. The tumor histology could be a possible predictor of better survival. Although selection bias may have been present, multimodality therapy (surgery, radiation therapy, and chemotherapy) was associated with improved survival.

Pericardial Masses, Cysts and Diverticula: A Comprehensive Review Using Multimodality Imaging

Pericardial masses/tumors, cysts, and diverticula are quite rare. Presentation is variable and often patients may be asymptomatic with pericardial involvement initially only detected at time of autopsy. When patients do present with symptoms they are often non-specific and often mimic other conditions of the pericardium such as pericarditis, pericardial effusion, constriction or tamponade. Therefore, echocardiography and cross-sectional imaging are essential in identifying and characterizing pericardial disease. Imaging findings vary in specificity depending on the type of tumor. The purpose of this review is to describe the role of multi-modality imaging and characteristic findings in patients with pericardial masses/tumors, cysts, and diverticula.

Usefulness of CHA2DS2-VASc Scoring Systems for Predicting Risk of Perioperative Embolism in Patients of Cardiac Myxomas Underwent Surgical Treatment

Cardiac myxomas are rare but manifested with risk of embolism and often cause unexpected symptoms or sudden death. We retrospectively collected the medical records of patients diagnosed of cardiac myxomas at the cardiac center of our university. Overall 465 patients were included in this study, patients in the embolism group had significantly higher CHA₂DS₂-VASc scores (P = 0.005). In embolic group, stroke was recorded in 110 (77.14%) patients, while embolic events in the limbs were observed in 10 (2.15%) and 9(1.93%) developed splenic infarction. Patients in embolism group had older age (P = 0.021) and higher BMI (P  <0.001) than those in non-embolism group. There was no significant difference between two groups in terms of time of mechanical ventilation (P = 0.065), ICU stay (P = 0.053), hospital stay (P = 0.071) and volume of drainage (P = 0.083), blood transfusions (P = 0.060) except that patients with embolic events had significantly higher incidence of postoperative atrial fibrillation (P = 0.032) and lower survival rate (P < 0.001). Furthermore, the CHA₂DS₂-VASc score was a significant predictor of embolism in patients with cardiac myxomas (P = 0.015; P = 0.003) and the Kaplan-Meier analysis obtained a higher rate of embolism in patients with higher stratification of CHA₂DS₂-VASc scores (P = 0.002). In conclusion, CHA₂DS₂-VASc scoring scheme was strongly predictive of stroke and embolic events in patients with cardiac myxomas.

Papillary fibroelastoma: clinical and echocardiographic features and initial approach in 54 cases

INTRODUCTION

Papillary fibroelastoma (PFE) is a benign cardiac tumor that is currently detected more often due to the technological improvements in echocardiography.

OBJECTIVES

To describe the echocardiographic features of PFE and correlate them with the clinical presentation and initial treatment.

MATERIALS AND METHODS

A prospective analysis of patients with a diagnosis of PFE was conducted between 2000 and 2015. We assessed the clinical history, symptoms at the time of diagnosis, echocardiographic features, and initial treatment.

RESULTS

Fifty-four patients with a diagnosis of PFE by echocardiography were included. The incidence was 0.038%. Mean age was 62±16 years; 50% were male. Forty-six percent of patients had symptoms at the time of diagnosis, the most frequent of which was transient ischemic accident (TIA). Embolic episodes occurred in 31% of patients, mainly to the brain. PFEs were valvular in 70.4% of cases and multiple in 13%. Mean maximum length was 1.18±0.58 cm, and 44% were mobile. PFEs >1.5 cm were most often found in the heart valves (56.8% vs 10.8%; P=.045). There was no significant relation between size, mobility, location and number of tumors, and the presence of embolism or symptoms. Most frequent treatment was oral anticoagulation in 48.6%, followed by simple tumor resection in 42.8% of cases.

CONCLUSIONS

PFE is a small tumor, predominantly valvular and benign, but entails a high incidence of cerebral embolism. The initial approach should be individualized according to clinical manifestations, comorbidities, and the experience of the surgical center.

Primary cardiac angiosarcoma: a prolonged response to surgical resection followed by concurrent chemoradiotherapy with docetaxel

Introduction

Primary cardiac cancer is a very rare disease, among which primary cardiac angiosarcoma is one of the most frequent type and is characterized by extremely poor prognosis without established optimal treatment.

Case description

Here we report a case of primary cardiac angiosarcoma with hemorrhagic pericardial effusion who achieved a durable response with tumor excision followed by concurrent chemoradiotherapy with docetaxel. A sixty year old man was presented with dyspnea and was diagnosed with primary cardiac angiosarcoma with hemorrhagic pericardial effusion. After surgical excision of primary tumor with microscopic residual disease followed by concurrent chemoradiotherapy with docetaxel, the patient showed durable response of progression free survival of 12 months.

Discussion and evaluation

This case shows benefit of concurrent chemoradiotherapy with taxane. Further investigation of aggressive multimodal treatment strategy is warranted for primary cardiac angiosarcoma with pauci-metastasis even when achievement of complete resection seems unlikely.

Surgical treatment of cardiac tumors: a 5-year experience from a single cardiac center

BACKGROUND

Cardiac tumors are rare but manifested with various clinical presentations and often cause unexpected symptoms or sudden death. The objective is to review the clinical presentation, histopathological spectrum, mortality and follow-up data of patients with cardiac tumors following surgery treatment over a period of 5 years.

METHODS

We retrospectively collected the medical records of all patients diagnosed of cardiac tumors in the period between January 2008 and December 2013 at the cardiac center of our university. Clinical histories, perioperative data, surgical findings, efficacy and follow-up data were reviewed in our study. Patients were divided into two groups according to site distribution of the tumors in the heart.

RESULTS

A total of 131 patients underwent surgical treatment of cardiac tumors were enrolled in this study, with a mean age of 51.39±16.37. The result of analysis showed that 79.47% (n=104) of the primary intracardiac tumors were benign, while primary malignant neoplasms accounted for 16.03% (n=21) of all patients, with the remainder (n=6, 4.6%) metastatic tumors transferred from other organs. Among all patients there were 2 in-hospital deaths and the survival rate in all patients at 1-year, 3-year and 5-year follow up was 83.20%, 78.62% and 66.41% respectively. Both patients with tumors in the left and right heart had similar basic characteristics except sex gender (P=0.002), BSA (P=0.045) and weight (P=0.033). Compared with patients with tumors in the right heart, patients with tumors in the left heart had significant higher CPB time (P<0.001), cross clamp time (P<0.001) and time of mechanical ventilation (P<0.001), and they also had longer ICU stay (P<0.001) but not total hospital stay (P=0.434).

CONCLUSIONS

Surgical resection represents an effective protocol in treating cardiac tumors. Data in our study of cardiac tumors on frequency and allocation were consistent with previous reports which may provide useful clinical evidence on shared data, and data revealed that patients with malignant cardiac tumors had significant lower survival both in hospital and long-term follow-up.

Rare case of entero-enteric intussusception caused by small bowel metastasis from a cardiac liposarcoma

Primary cardiac liposarcoma is exceedingly rare and its metastatic potential varies based on the actual tumor subclass. Intestinal intussusception is also an uncommon cause of abdominal pain and bowel obstruction in adults and it usually generates at a malignant lead point in this age group. We report a case of a primary cardiac dedifferentiated liposarcoma in a pregnant woman causing small bowel seeding leading to bowel intussusception.

In vitro and in vivo studies on the inhibitory effects of myocardial cell culture medium on growth of a human lung adenocarcinoma cell line, A549

BACKGROUND

Although the heart is one of the body's vital organs, with an abundant blood supply, metastasis to the heart is considered rare. In a previous study, we found that the myocardial microenvironment might contain a low molecular weight natural tumour suppressor. The present study was designed to investigate the inhibitory effect of cardiac myocyte-conditioned medium (cmcm) on the growth of A549 human lung adenocarcinoma cells in vitro and in vivo.

METHODS

An mtt assay was used to detect the inhibition ratio with respect to A549 proliferation. Human lung adenocarcinoma cells (A549 cell strain) were transplanted subcutaneously into nude mice to produce tumours. The xenograft tumour growth in mice was observed after selected drug administration.

RESULTS

After treatment with cmcm and cisplatin (Cis), A549 cell viability significantly declined (p < 0.001). The cell viability in the cmcm and Cis groups were 53.42% ± 3.45% and 58.45% ± 6.39% respectively. Growth of implanted tumour cells in vivo was significantly inhibited in the cmcm group, the group treated with recombinant human adenovirus-p53, and the Cis-treated group compared with a control group. The inhibition rates were 41.44% in the cmcm group, 41.34% in the p53 group, and 64.50% in the Cis group. Lung metastasis capacity was significantly reduced in the presence of cmcm (p < 0.05). Lung metastasis inhibition rates in mice were 56.52% in the cmcm group, 47.83% in the p53 group, and 82.61% in the Cis group. With cmcm, the lives of A549-tumour-bearing mice could be significantly prolonged without any effect on weight loss.

CONCLUSIONS

Use of cmcm has the effect of reducing A549 cell viability, tumour volume, and lung metastasis rate, while prolonging survival duration without severe toxicity.

Surgical treatment of primary cardiac valve tumor: early and late results in eight patients

Background

To report early and late outcomes of patients with the primary cardiac valve tumor undergoing surgical treatment over a 30-year period in our cardiovascular center.

Methods

From January 1980 to December 2014, a total of 211 patients with primary cardiac tumors accepted surgical treatments, of which only 8 (3.8 %) were primary cardiac valve tumor patients in our surgical center of cardiovascular.

Results

The diagnosis was identified by echocardiography preoperatively and pathological analysis postoperatively. All patients underwent intracardiac procedures with extracorporeal circulation. Intracardiac procedures included resection of tumor on leaflet in 2 patients (25 %), resection of tumor and native valvuloplasty in 2 patients (25 %), resection of neoplasm and replacement of native valve with prosthetic valve in 4 patients (50 %). One man was performed a resection of tumor on aortic noncoronary leaflet and a coronary artery bypass graft. Eight cases of primary valve tumor occured in all of four cardiac valves. The majority of valvular tumor was myxoma in 3 cases (37.5 %), followed by the papillary fibroelastomas in 2 cases (25 %). There were one rhabdomyoma (12.5 %), one lipoma (12.5 %) and one mild malignant sarcoma (12.5 %). The mitral valve was the most commonly original valve (62.5 %). There was pulmonic (12.5 %), aortic (12.5 %) and tricuspid (12.5 %) valve tumor each one patient. There was no death and recrudescence in the series. Follow-up of all patients ranged from 1 to 16 years (mean 7.06±4.24 years). There was no recrudesce and cardiac valve dysfunction. 

Conclusion

The incidence of primary valve tumor was very low. More understanding of the rare disease and widespread use of echocardiography would greatly improve the diagnosis of primary valve tumor in the early stage. Echocardiography could detect millimeters in diameter neoplasms on cardiac valve. The diagnoses were based on imaging findings and the classical triad symptoms associated with the hemodynamic abnormalities, the organ embolism and the systemic symptoms directly from tumors. The intraoperative frozen sections and postoperative pathology analysis provided accurate diagnosis and supported the treatment strategies. Early diagnosis and intervention were keys to reserve the normal original valve function. Prompt surgical resection is necessary to prevent potential critical events.

Characteristics and Survival of Malignant Cardiac Tumors: A 40-Year Analysis of >500 Patients

BACKGROUND

The aim of this study was to investigate the incidence, histopathology, demographics, and survival associated with primary malignant cardiac tumors (PMCTs).

METHODS AND RESULTS

We queried the Surveillance, Epidemiology and End Results (SEER) 18 registry from the National Cancer Institute for all PMCTs diagnosed from 1973 to 2011. We describe PMCT histopathology and incidence, comparing characteristics and survival of these patients with those of patients with extracardiac malignancies of similar histopathology. From a total of 7 384 580 cases of cancer registered in SEER, we identified 551 PMCTs (0.008%). The incidence of PMCT diagnosis is 34 cases per 100 million persons and has increased over time (25.1 in 1973-1989, 30.2 in 1990-1999, and 46.6 in 2000-2011). Most patients are female (54.1%) and white (78.6%) with median age at diagnosis of 50 years. The most common PMCTs are sarcomas (n=357, 64.8%), followed by lymphomas (n=150, 27%) and mesotheliomas (n=44, 8%). Most patients are diagnosed with tissue sample (96.8%). Although use of chemotherapy is not documented in SEER, 19% of patients received radiation and 44% had surgery. After a median follow-up of 80 months, 413 patients had died. The 1-, 3-, and 5-year survival rates were 46%, 22%, and 17% and have improved over the eras, with 1-, 3-, and 5-year survival rates of 32%, 17%, and 14% for 1973 to 1989 and 50%, 24%, and 19% for 2000 to 2011 (P=0.009). Cardiac sarcomas and mesotheliomas are the most lethal PMCTs, with 1-, 3-, 5-year survival rates of 47%, 16%, and 11% and of 51%, 26%, and 23% compared with 59%, 41%, and 34% for lymphomas, respectively (log rank test P<0.001). Patients with cardiac lymphomas and sarcomas are younger and have worse survival than patients with extracardiac disease of similar histopathology (P<0.001).

CONCLUSIONS

PMCTs are extremely rare and continue to be associated with poor prognosis. Over the past 5 decades, the incidence and survival of patients diagnosed with PMCT appear to have increased. Compared with those with extracardiac cancers of similar histopathology, patients with PMCTs are often younger and have worse survival.

Cardiac tumors: a brief commentary

Patients with cardiac tumors may present with cardiovascular related or constitutional symptoms, but more often than not a cardiac mass is discovered incidentally during an imaging examination performed for an unrelated indication. Cardiac myxoma is generally considered to be a surgical emergency. Echocardiography, including the transesophageal approach, is the most important means of diagnosis; computed tomography and magnetic resonance imaging. The clinical presentation has changed, and the management of cardiac myxoma now needs to be reviewed.

Cardiac angiosarcoma: an unexpected diagnosis

Cardiac angiosarcoma is a rare entity. The incidence through autopsy findings ranges between 0.001% and 0.03%. The disease usually presents with non-specific symptoms, although asymptomatic cases are frequent; therefore, diagnosis is unexpected and consequently delayed. The authors report the case of a middle-aged man with a recent onset cough and dyspnea. He sought medical care several times without receiving a definite diagnosis until a plain chest radiography was taken showing a mediastinal enlargement, which was the reason why he was hospitalized for clinical investigation. During the diagnostic workup, an echodopplercardiogram and a thoracic computed tomography were performed, showing a heterogeneous soft-tissue mass infiltrating the pericardium and the anterior atrial wall. Multiple and scattered pulmonary nodules were also present. A pulmonary nodule was biopsied, which revealed an angiosarcoma. The clinical features added to the radiological and histological findings permitted the diagnosis of right atrial angiosarcoma. The authors highlight the unexpected pattern in the presentation of cardiac tumors.