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

Advancements in Diagnosis and Treatment of Cardiac Sarcomas: A Comprehensive Review

OPINION STATEMENT

Cardiac sarcomas are rare, aggressive malignancies originating from various cardiac cell types, presenting significant challenges in both diagnosis and treatment. This comprehensive review explores recent advancements in diagnosis and treatment of cardiac angiosarcoma, fibrosarcoma, leiomyosarcoma, and rhabdomyosarcoma. And we briefly discuss the exceedingly rare occurrence of cardiac osteosarcoma and present our perspectives on its treatment. Development of these tumors is influenced by genetic mutations, environmental factors, and chromosomal abnormalities, necessitating a multidisciplinary approach for accurate diagnosis and management. Advanced imaging techniques, biomarkers, and immunohistochemical analysis assist in confirming the diagnosis and guiding treatment decisions. Surgical resection, adjuvant therapies, and personalized treatment strategies based on genetic profiling offer promising avenues for improving patient outcomes. Emerging therapeutic approaches, such as targeted therapies and immunotherapies, have shown promising progress in recent years. Despite these advancements, the prognosis for patient with cardiac sarcomas remains poor, highlighting the urgent need for continued research to refine treatment methods and enhance long-term survival outcomes. Ongoing efforts and clinical trials are essential for advancing the management of these rare and aggressive tumors, ultimately improving quality of life for affected patients.

Primary Cardiac Leiomyosarcoma Extending From Right Atrium to Inferior Vena Cava Without Metastasis: A Case Report

A 27-year-old female with a history of acute lymphoblastic leukemia in remission presented with chest pain, liver cirrhosis, and a thrombus in the hepatic vein on ultrasound. Further workup with computed tomography (CT) and magnetic resonance imaging (MRI) revealed a mass extending from the inferior vena cava to the right atrium, 3.4 x 3.4 x 7.0 cm in size. She underwent excision of the intracardiac mass with a full sternotomy and cardiopulmonary bypass successfully. Her postoperative course was uncomplicated. She was discharged home on postoperative day six. Subsequent histopathology confirmed high-grade leiomyosarcoma. Postoperative positron emission tomography CT showed no evidence of metastatic disease.

Intractable Ventricular Tachycardia Prior to an Overt Cardiac Tumor Mass of Metastatic Cardiac Rhabdomyosarcoma (Spindle-cell Type)

We herein report a 37-year-old man who experienced recurrence of metastatic cardiac rhabdomyosarcoma along with intractable ventricular tachycardia (VT) 7 years after resection of rhabdomyosarcoma in his right elbow. At 36 years old, he developed VT unresponsive to radiofrequency catheter ablation (RFCA). Initially, the cardiac tumor was not detected, but it gradually grew in size at the RFCA site. A surgical biopsy confirmed the diagnosis of metastatic cardiac rhabdomyosarcoma. Despite radiation therapy, cardiac tumor progression and VT instability could not be prevented. Ultimately, the patient died 27 months after the initial documentation of VT.

Malignant cardiac neoplasms and associated malignancies over 16 years in the USA

BACKGROUND

Malignant cardiac neoplasms (MCNs), both primary and metastatic, are rare with few epidemiologic studies.

METHODS

This retrospective study used the Healthcare Utilization Project/Nationwide Inpatient Sample database from 2002 to 2018 to evaluate the co-occurrences with other malignancies, and mortality of MCNs in the USA.

RESULTS

The data contained 7207 weighted discharges of MCN. Median patient age was 51.4 years, 52.29 % were male, in-hospital mortality was 10.51 %, mean cost of hospitalization was $34,280 USD. Lung, mediastinum, and airways were the most common primary cancers associated with metastatic MCN.

CONCLUSIONS

MCN are rare in the USA, however they carry a high in-hospital mortality, high morbidity, and hospital cost.

Low NT5DC2 expression predicts favorable prognosis and suppresses soft tissue sarcoma progression via ECM-receptor interaction pathway

BACKGROUND

Soft tissue sarcoma, a malignant tumor arising from mesenchymal tissues with poor prognosis. 5'-Nucleotidase Domain Containing 2 (NT5DC2) is a novel oncogene, and the precise involvement of NT5DC2 in soft tissue sarcoma were still undefined. Hence, our study aims to investigate NT5DC2 functions in soft tissue sarcoma progression.

METHODS

The tumor immune single-cell hub 2 (TISCH2) website, The Cancer Genome Atlas (TCGA) pan-cancer or sarcoma and Gene Expression Omnibus (GEO, GSE21122) databases were applied to visualize the NT5DC2 status in the sarcoma databases. The NT5DC2 protein expression in sarcoma tissues in our hospital was detected by using immunohistochemistry (IHC) and analyzed the associations between NT5DC2 expression and clinicopathological parameters. Real-time quantitative polymerase chain reaction (RT-qPCR), colony formation, 5-ethynyl-2'-deoxyuridine (EdU) assay, wound healing, transwell, flow cytometry and xenograft model were used to elucidate the effects of NT5DC2 downregulated by lentivirus in sarcoma cell.

RESULTS

The TISCH2 website detection found that NT5DC2 expression is enriched in malignant cells in sarcoma single-cell database. Furthermore, the TCGA-sarcoma database indicated that NT5DC2 expression correlates with metastasis, positive margin status, prognosis, and diagnostic value. Additionally, IHC staining showed that 40 % of soft tissue sarcoma patients present high expression of NT5DC2, and NT5DC2 upregulation is closely associated with poor prognosis. Functional verification analysis further revealed that downregulating NT5DC2 expression can suppress sarcoma progression through the ECM-receptor interaction pathway.

CONCLUSION

Low expression of NT5DC2 predicts a favorable prognosis in soft tissue sarcoma, and downregulated NT5DC2 expression can suppress sarcoma cell progression through the ECM-receptor interaction pathway.

Case report: Navigating treatment pathways for cardiac intimal sarcoma with PDGFRβ N666K mutation

In the realm of rare cardiac tumors, intimal sarcoma presents a formidable challenge, often requiring innovative treatment approaches. This case report presents a unique instance of primary intimal sarcoma in the left atrium, underscoring the critical role of genomic profiling in guiding treatment. Initial genomic testing unveiled a somatic, active mutation in PDGFRβ (PDGFRβ N666K), accompanied by MDM2 and CDK4 amplifications. This discovery directed the treatment course toward pazopanib, a PDGFRβ inhibitor, following irradiation. The patient's response was remarkable, with the therapeutic efficacy of pazopanib lasting for 16.3 months. However, the patient experienced a recurrence in the left atrium, where subsequent genomic analysis revealed the absence of the PDGFRβ N666K mutation and a significant reduction in PDGFRβ expression. This case report illustrates the complexities and evolving nature of cardiac intimal sarcoma treatment, emphasizing the potential of PDGFRβ signaling as a strategic target and highlighting the importance of adapting treatment pathways in response to genetic shifts.

Surgical resection of primary intracardiac sarcomas and outcomes: A review of case reports over 20 years

Objective

A quarter of all cardiac tumors are malignant, and most (~ 95%) are sarcomas. It is the most aggressive malignant cardiac tumor carrying the worst prognosis. Tumor involvement with the vital intracardiac structures makes it difficult for complete surgical resection. We aimed to study the role of complete surgical resection and its importance in long-term outcomes.

Methods

We analyzed published literature from 2002 to 2022 using PubMed. Cases reported adult, intracardiac sarcomas, and received surgical resections were included. We reviewed 132 published case reports, including and analyzed the following variables: demographics, clinical presentations, diagnostic imaging modality, the extent of surgical resection, pathological diagnosis, tumor location, postoperative chemo-radiation therapy, and follow-up (including re-operation, local and distant recurrence).

Results

A total of 135 patients are included from 132 articles. The mean age was 46.69 (18-86) and 76 patients were females. The main complaints were dyspnea (70%) and chest pain (32%). Performed investigations were transthoracic echocardiography (TTE) in 114/135 (84%), computer tomography (CT) scan 89/135 (66%), trans-esophageal echocardiography (TOE) 22%, and cardiac magnetic resonance imaging (MRI) 29%. The most common location was the atrium (left 46%, right 30%). Complete surgical resection was performed in 91 cases (67%), and frozen section was performed in 62 patients (43 positives). Incomplete resections were in 42 cases. Patients who underwent complete surgical resection had mean survival of 14.58 months and median of 10.5 months, compared to incomplete resection patients with 9.12 months and 6.5 months respectively.

Conclusion

Our review shows complete surgical resection results in better short- and long-term outcomes in intracardiac sarcoma patients. Furthermore, combining chemo-radiotherapy has additional benefits towards long-term survival.

A rare inflammatory myofibroblastic tumor appearing both inside and outside the heart

BACKGROUND

Inflammatory myofibroblastic tumor (IMT) is an uncommon cardiac tumor that primarily affects infants, children, and young adults. While complete surgical resection generally leads to a favorable prognosis, accurate diagnostic tests remain limited.

CASE PRESENTATION

We describe the case of a 26-year-old female who had a dual tumor inside and outside the heart and was misdiagnosed by echocardiography and MRI. We also review 71 cases of cardiac IMTs from the literature regarding their epidemiology, clinical presentation, and outcome.

CONCLUSION

Early detection of this rare disorder is essential for optimal surgical management.

Pulmonary valve spindle-cell lipoma: A case report

Primary cardiac tumours are rare and most of them are benign. Myxomas, fibroelastomas and lipomas are common in adults. Primary valvular cardiac tumours are even more rare and affect all four valves in a similar proportion. Valvular lipomas are very rare. In the pulmonary valve there is only one described. Lipomas can be spindle-cell varieties. But of these, there is only one described in a valve, and it is placed in the aortic valve. Pulmonary valve lipomas can produce obstruction to the right ventricular outflow tract as well as pulmonary valve regurgitation, or pulmonary embolism. Symptoms may be dyspnoea, angina, arrhythmias, or syncope. We aim to illustrate with this case report how we came into this very rare pathology, so we present a 54-year-old woman with a giant spindle-cell lipoma located in the anterior pulmonary leaflet and severe dyspnoea. Total resection of the tumour was performed and restoration of valve function was obtained by means of bicuspidization of the remaining pulmonary leaflets. She had a good recovery after surgery and no complication during the postoperative evolution, being discharged from hospital after 7 days from surgery, with echocardiographic control showing good biventricular function, absence of tumour or obstruction, and minimal pulmonary valve regurgitation.

Case report: Cardiac intimal sarcoma in a young child

Undifferentiated mesenchymal tumors from the intimal layer (intimal sarcomas) are rare within the ventricles and exceptional in children. A rare case of an intimal sarcoma located in the right ventricle in a young child is presented with need for urgent surgical resection due to mechanical flow obstruction. Tumor cells showed amplification of MDM2 gene and a homozygous loss of CDKN2A on 9p21. A review of the literature regarding primary cardiac malignancies and intimal sarcoma in children is provided.

Challenges in diagnosis and therapeutic options for metastatic prostate cancer to the right ventricle

Our patient presented with right-sided heart failure symptoms and found to have a large mass protruding into the heart's right ventricle. Cardiac MRI delineated the morphological and tissue characteristics of the tumour. Although 18-fluorodeoxyglucose positron emission tomography (PET) did not reveal an intracardiac mass, the lesion was well demonstrated by Fluciclovine F18 PET/CT.

A rare case of left atrial myxofibromyosarcoma

Myxofibrosarcoma is an aggressive soft tissue sarcoma, previously known as myxoid variant of malignant fibrous histiocytoma. Primary cardiac myxofibrosarcomas are the rarest forms of cardiac malignant tumors that often remain asymptomatic until metastasis occurs. In this case report, we describe a rare left atrial cardiac myxofibrosarcoma in a patient with recurrent renal cell carcinoma. We discuss the multimodality imaging approach to diagnose and evaluate cardiac masses as well as imaging characteristics to differentiate cardiac masses from thrombus.

Cardiac sarcoma: A rare case of primary cardiac sarcoma

INTRODUCTION AND IMPORTANCE

Primary cardiac sarcoma is a rare malignancy with a poor prognosis because of diagnostic delay, therapeutic difficulties, and high metastatic potential. The therapeutic approach includes surgery, chemotherapy, and radiation therapy, alone or in combination. However, there is a lack of evidence to guide the treatment.

CASE PRESENTATION

We present a case of primary cardiac sarcoma. Our patient was presented in the department of emergency medicine (ED) in our institute with shortness of breath on exertion associated with orthopnea. Based on the history and cardiovascular examination, he underwent an echocardiogram, which revealed a sizeable echogenic density in the right ventricular outflow tract. He underwent surgical resection of the cardiac mass via median sternotomy and total cardiopulmonary bypass approach. The patient was eventually diagnosed with primary cardiac sarcoma, confirmed by tissue biopsy after surgical intervention.

CLINICAL DISCUSSION

Through this report, we highlight the rarity of primary cardiac sarcomas, the importance of multidisciplinary tumor board (MDT) discussion and provide evidence of surgical excision being the treatment of choice, followed by systemic chemotherapy in selected cases.

CONCLUSION

Cardiac sarcoma is a rare but highly malignant tumor with a poor prognosis. However, early diagnosis and surgical resection of a primary cardiac sarcoma can significantly increase the patient's survival and quality of life. Therefore, physicians should keep a high suspicion of a patient with clinical features suggestive of cardiac sarcoma, and echocardiography should be the diagnostic modality of choice in such patients.

Metastatic Melanoma Extending along the Pulmonary Vein into the Left Atrium: A Rare Route of Metastasis Characterized by Transesophageal Echocardiography

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Melanoma commonly metastasizes to the heart through hematogenous spread.

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These metastases can resemble benign cardiac tumors.

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Isolated left-sided cardiac involvement is rare with metastatic melanoma.

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Metastasis can atypically take a course through the pulmonary vein.

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Multimodality imaging is useful for characterization of these intracardiac masses.

A spiral cystic fibroma originating from left ventricular fascicular muscle: a case report

Background

In adults, cardiac fibromas are fairly rare, mostly round in shape, and few cases of ventricular fibromas of other morphology have been reported.

Case presentation

We report a case of a 47-year-old male patient admitted with recurrent nocturnal paroxysmal dyspnea, diagnosed by transthoracic cardiac ultrasound, transesophageal ultrasound, and computed tomography (CT) as a left ventricular occupancy with a spiral shape resembling a conch with a fixed base and a free distal end.

Conclusion

This case reports a rare but noteworthy morphological features of the adult uncommon ventricular tumor pathological type. Furthermore, the patient had no notable postoperative issues and was followed up on for a year following surgery, with no residual tumors or arrhythmias discovered during the examination.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01616-w.

Expansive intracardiac leiomyosarcoma - a combined therapeutic approach resulting in survival with complete remission. A literature review and case report

Primary cardiac sarcomas are extremely rare and often with dismal prognosis. Only a few case series and retrospective studies regarding its biological characteristics, diagnostics, and treatment were reported. The multi-modality therapeutic strategy has been discussed in the published literature, but often with contradictory results. There is thus, no consensus on the optimal therapeutic approach to date. We present the case report of the 66-year old female endangered by a large primary leiomyosarcoma expanding in the right-sided heart chambers with imminent risk of acute obstruction of blood flow. The patient was managed by urgent surgical resection. After the histological confirmation of incomplete R1 resection, the treatment was supplemented by adjuvant CT-targeted radiotherapy, resulting in extraordinary survival with complete remission over a 24-month follow-up period. Our case report aims to demonstrate a favorable result of an individually suited complex surgical and oncological treatment to support the multidisciplinary therapeutic approach to these patients. The article is supplemented by a detailed literature review providing a theoretical background and an overview of the acquired knowledge and possible strategies.

Metastatic Carcinoma to the Right Heart: The Complementary Utility of Contrast-Enhanced Echocardiography and Cardiac Positron Emission Tomography/Computed Tomography

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Metastatic tumors are >40 times more common than primary cardiac tumors.

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Parotid gland tumors rarely metastasize to the heart.

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TTE is the initial test of choice to evaluate for cardiac metastases.

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Contrast TTE is not contraindicated in patients with advanced CKD.

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Contrast TTE can assist in differentiating benign from malignant cardiac masses.

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

Cardiac tumours are some of the rarest primary tumours, while cardiac metastasis are more common yet still relatively rare. Seventy five percent of primary cardiac tumours are benign tumours. Cardiac tumours present with a range of obstructive, embolic, arrhythmic or systemic symptoms, and in many cases may present asymptomatically. The clinical presentation depends largely on the size and location of the mass. With advances in cardiac imagining and the introduction of cardiopulmonary bypass, the diagnosis and surgical treatment of these rare tumours has improved the prognosis and outlook for benign and malignant tumours. Management depends on tumour histology, size and location as well as the clinical presentation. Conservative management is reserved for small, benign tumours that can undergo regular echocardiographic follow-up. Symptomatic benign tumours are treated with surgical resection and the results are excellent. Malignant primary cardiac tumours have a poor prognosis with high rates of relapse and a median survival of 10-24 months.

Primary mitral valve angiosarcoma: A multifaced ultra-rare tumor

Malignant primary cardiac valve tumors are extremely rare neoplasms usually remaining silent up to late advanced stages. Getting to know the various features of this latent tumor, which needs prompt intervention, can assist in the earlier diagnosis. Herein we report a 24-year-old woman with angiosarcoma that originated from the mitral valve and manifested itself through dyspnea and pulmonary edema. The case is noteworthy with respect to appealing echocardiographic images.

Cardiac angiosarcoma: A case report and review of the literature

Primary cardiac tumors are extremely rare, among which malignancies comprise about 15-25%. As the most common type of primary cardiac malignancies, angiosarcomas tend to arise in the right heart, especially right atrium. In this case report, we presented a 32-year-old female with primary cardiac angiosarcoma in the right atrial appendage detected by transesophageal echocardiography, as it is difficult to display on conventional transthoracic echocardiography.

Benign Cardiac Neoplasms in the United States: A Thirteen-Year Review

Cardiac neoplasms are uncommon tumors. For epidemiological purposes, they can be divided into benign and malignant subtypes, with the former occurring at a significantly higher rate than the latter. Due to their uncommon nature, there are few data-driven studies examining the characteristics and trends of benign cardiac neoplasms. Our retrospective HCUP-NIS data review purports to illuminate some of the trends surrounding benign cardiac neoplasms and their associated co-occurrences. The data consisted of 482,872,274 weighted discharges. There were 45,568 weighted discharges that included a benign cardiac neoplasm. Benign cardiac neoplasms were more often observed in women (64.33%), and the average age was 63.8 years. The most common cardiovascular co-occurrences in patients with benign cardiac neoplasm were atrial tachyarrhythmias (28.93%), heart failure (19.61%), and embolic events such as stroke, myocardial infarct, or pulmonary embolism (19.82%). Other co-occurrences included pulmonary hypertension (7.55%), ventricular arrhythmias (3.23%), and other EKG abnormalities (3.70%). Procedures were numerous in patients with benign cardiac neoplasms. 43% of patients with this diagnosis had some form of cardiac surgery during their hospitalization. Overall, this study found low incidence of benign cardiac neoplasms in the USA during this 13-year study period. However, in the presence of benign cardiac neoplasms, our study showed that cardiovascular co-occurrences are not uncommon and may help to illuminate this otherwise rare diagnosis.

Interactions Networks for Primary Heart Sarcomas

Personalized medicine incorporates genetic information into medical practice so as to optimize the management of chronic diseases. In rare diseases, such as heart cancer (incidence 0.0017-0.33%), this may be elusive. Ninety-five percent of the cases are due to secondary involvementwith the neoplasm originating in the lungs, breasts, kidney, blood, or skin. The clinical manifestations of heart tumors (benign or malignant) include heart failure, hypertension, and cardiac arrhythmias of varying severity, frequently resulting in blood vessel emboli, including strokes. This study aims to explain the pathophysiology and contribute to a P4 medicine model for use by cardiologists, pathologists, and oncologists. We created six gene/protein heart-related and tumor-related targets high-confidence interactomes, which unfold the main pathways that may lead to cardiac diseases (heart failure, hypertension, coronary artery disease, arrhythmias), i.e., the sympathetic nervous system, the renin-angiotensin-aldosterone axis and the endothelin pathway, and excludes others, such as the K oxidase or cytochrome P450 pathways. We concluded that heart cancer patients could be affected by beta-adrenergic blockers, ACE inhibitors, QT-prolonging antiarrhythmic drugs, antibiotics, and antipsychotics. Interactomes may elucidate unknown pathways, adding to patient/survivor wellness during/after chemo- and/or radio-therapy.

[Non-Hodgkin cardiac lymphomas]

Cardiac non-Hodgkin lymphoma (CNHL) is a rare extranodal lymphoma with a poor prognosis. Secondary cardiac lymphoma is more frequent than primary cardiac lymphoma. CNHL often involves the right side of the heart. Diagnosis of CNHL can be suggested by echocardiography and magnetic resonance imaging. Cytological examination of pericardial fluid or histological of cardiac tissue is essential. The majority of cases are diffuse B-cell lymphoma. A prompt immediate diagnosis and early treatment are essential for better outcome. Management should be individualized and the most effective treatment is chemotherapy containing anthracycline variably combined with radiotherapy. A multidisciplinary approach is essential to the successful treatment of CNHL.

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.

Cerebrovascular manifestations of tumors of the heart

Primary tumors of the heart, most commonly myxoma, are an uncommon cause of ischemic stroke and intracranial aneurysms. The tumors may occur in any age group but are most frequently detected in middle-aged persons with an atypical or cryptogenic stroke. While some patients will have a history of cardiac or constitutional symptoms, in many cases ischemic stroke will be the initial manifestation of the cardiac mass. Myxomas are the most common cardiac tumors, and valvular fibroelastoma is also a potential cardiac cause of stroke. Among patients with stroke, the most common location for a myxoma is the left atrium. Elevations of inflammatory markers provide clue for a myxoma. Cardiac imaging is the most definitive diagnostic study. Treatment centers on surgical removal of the cardiac mass may be curative.

The Current Management of Cardiac Tumours: a Comprehensive Literature Review

OBJECTIVE

To understand the current evidence and guidelines behind the appropriate management of cardiac tumours.

METHODS

A comprehensive electronic literature search has been performed in major databases - PubMed, Embase, Scopus, Ovid, and Google Scholar. All articles that discussed all different forms of cardiac tumours, their clinical presentation, diagnosis, and management methods have been critically appraised in this narrative review.

RESULTS

All relevant studies have been summarized in appropriate sections within our review. Cardiac tumours are rare but can be catastrophic and life-threatening if not identified and managed on timely manner. Utilization of all the available imaging methods can be of equivocal importance, relevant to each cardiac tumour. Surgical excision is the ultimate treatment method, however histopathological results can guide the adjunct treatment.

CONCLUSION

Early detection of cardiac tumours has significant effect on planning the method of intervention. Technological advancements and increased availability of imaging modalities have enabled earlier and more accurate detection of these tumours. Novel medical therapies, recommendations for screening, and operative techniques have all contributed to overall improving knowledge of these tumours and ultimately patient outcomes.

A rare case of multimetastatic cardiac angiosarcoma

Cardiac malignant tumors are rare entities with nonspecific clinical presentation and poor prognosis. Here, we report a case of about a 30-year-old man who was admitted for right thoracic pain. Imaging indicated a cardiac malignant tumor, and pathology confirmed the diagnosis. Our case highlights the value of multimodal imaging in the differential diagnosis of a cardiac mass.

Cardiac Tumors: JACC CardioOncology State-of-the-Art Review

Cardiac masses are rare, but remain an important component of cardio-oncology practice. These include benign tumors, malignant tumors (primary and secondary) and tumor-like conditions (e.g., thrombus, Lambl’s excrescences, and pericardial cyst). The advent of multimodality imaging has enabled identification of the etiology of cardiac masses in many cases, especially in conjunction with information from clinical settings. This paper provides a comprehensive review of the epidemiology, clinical presentation, imaging, diagnosis, management, and outcomes of cardiac masses.

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Cardiac tumors are rare and should be considered as part of the differential diagnosis of any space-occupying mass noted on cardiovascular and/or thoracic imaging modalities.

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It may be possible to get close to a diagnosis without biopsy using a structured imaging approach.

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The prognosis and treatment of each tumor is different, although early diagnosis is usually associated with a better outcome.

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.

Cardiac Tumors

Cardiac tumors (CTs) are extremely rare, with an incidence of approximately 0.02% in autopsy series. Primary tumors of the heart are far less common than metastatic tumors. CTs usually present with any possible clinical combination of heart failure, arrhythmias, or embolism. Echocardiography remains the first diagnostic approach when suspecting a CT which, on the other side, frequently appears unexpectedly during an echocardiographic examination. Yet, cardiac tomography and especially magnetic resonance imaging may offer several adjunctive opportunities in the diagnosis of CTs. Early and exact diagnosis is crucial for the following therapy and outcome of CTs.

Intracardiac metastasis from unknown uterine cervical cancer with severe thrombocytopenia

INTRODUCTION

Cardiac metastasis is relatively common in malignant neoplasms, such as lung cancers, breast cancers, melanomas, lymphomas, and leukemias. In contrast, cardiac metastasis of uterine cervical cancer, solitary metastasis to the heart, and tumors inducing severe thrombocytopenia are rare.

CASE REPORT

The present patient was a 52-year-old female who was diagnosed with a solitary cardiac tumor prior to uterine cervical cancer and presented with severe thrombocytopenia. Our case had two remarkable aspects: 1) successful treatment under the condition of severe thrombocytopenia in association with the presence of a cardiac tumor, and survival without recurrence of the carcinoma one year after surgery; and 2) a solitary cardiac metastatic tumor larger than the primary uterine cervix carcinoma.

COMMENT

we report an extremely rare case of solitary cardiac metastasis of uterine cervical cancer, which wassuccessfully treated. One year after cardiac surgery, the patient is alive without recurrence of the carcinoma.

Identification Of Actionable Genetic Targets In Primary Cardiac Sarcomas

BACKGROUND

Primary cardiac tumors are extremely rare; most are myxomas with a benign prognosis. However, primary sarcomas are highly aggressive and treatment options are limited. Radical surgery is often not feasible and conventional therapies provide only modest results. Due to the rare nature of primary cardiac tumors, there are no proper randomized studies to guide treatment. Their complexity requires alternative approaches in order to improve treatment efficacy.

METHODS

We isolated DNA from 5 primary cardiac sarcomas; the quality of DNA from 3 of them was sufficient to perform high-resolution single nucleotide polymorphism (SNP) array analysis.

RESULTS

In the present study, molecular karyotyping revealed numerous segmental chromosomal alterations and amplifications affecting actionable genes that may be involved in disease initiation and/or progression. These include chromosomal break flanking AKT2 in undifferentiated pleomorphic rhabdomyosarcoma, chromosomal break in promoter of TERT, and gain of CDK4 and amplification of MDM2 in inflammatory myofibroblastic tumor. We detected segmental break flanking MOS in high-grade myxofibrosarcoma. In addition, the high number of chromosomal aberrations in high-grade myxofibrosarcoma may cause multiple tumor-specific epitopes, supporting the study of immunotherapy treatment in this type of aggressive tumor.

CONCLUSION

Our results provide a genetic rationale that supports an alternative, personalized therapeutic management of primary cardiac sarcomas.

A right atrium metastasis of breast cancer after long-term endocrine therapy

We report a case of right atrial metastasis in a 66-year-old female patient with breast cancer. The patient presented with palpitation and dyspnea after long-term endocrine therapy. A large echo-dense mass was found in the right atrium after the examination. In order to relieve the symptoms, the patient underwent a resection of the atrial lesion, and the pathology confirmed that it was metastatic breast cancer. Next-generation sequencing (NGS) of the entire exon was taken to explore the gene expression of the metastatic lesion. Forty-eighty genes were identified with mutations, and the mutations of ATM and ESR1 were considered to be associated with the development and metastasis of breast cancer in this case.

Multimodality Imaging of a Right Atrial Cardiac Mass

Work up of a right atrial mass usually requires multimodality imaging and sometimes a biopsy to affirm histological diagnosis. We present a case of a 74-year-old woman with primary cutaneous melanoma (wildtype BRAF) of the right toe who was found to have a large heterogeneous mass in the right atrium on routine surveillance CT scan. She did not have any cardiac symptoms. Vital signs and physical examination were unremarkable. Cardiac magnetic resonance (CMR) imaging demonstrated a bilobed mass with an intramural component and a mobile blood pool component, with interposed thrombus. Three-dimensional transesophageal echocardiogram (3D-TEE) revealed the mass and its site of attachment on the lateral wall of the right atrium. Given the large size of the tumor and its potential for obstruction of tricuspid inflow, the right atrial mass was surgically resected. Pathology confirmed metastatic melanoma. The patient tolerated cardiac surgery well and was discharged shortly thereafter. In the present case, a large cardiac metastasis was discovered in the absence of clinically detectable disease elsewhere. CMR allowed a comprehensive evaluation of the location, extension, and tissue characterization of the cardiac mass. Transthoracic echocardiogram (TTE) and 3D-TEE allowed assessment of the hemodynamic consequences of this mass and aided in operative planning.

Cardiac Metastasis in a Patient with Head and Neck Cancer: A Case Report and Review of the Literature

Cardiac metastasis from a primary head and neck cancer is a rare finding. Most patients with cardiac metastases have nonspecific symptoms that may vary depending on the severity and location of the lesion. Due to the infrequency of reported cases, there are no clear guidelines for the diagnosis or management of cardiac metastasis in head and neck cancer patients. In this report, we discuss the case of a patient with a primary diagnosis of oral tongue cancer who developed a cardiac metastasis that was detected antemortem.

Evaluation of a cardiac sarcoma with CT multislice contrast-enhanced and 18FDG-PET/TC

We present the case of an adult male who arrived to our emergency room with progressive dyspnea that had been ongoing for 2 months. During the radiological investigation, we found a large intracardiac mass, which invaded the pericardium, pulmonary trunk, pulmonary arteries, and left ventricle. Studies done with the 18FDG-PET/CT scan helped us to determine the malignant nature of the mass and to suspect the diagnosis of rhabdomyosarcoma.

Hamartomas and other tumor-like malformations of the lungs and heart

Tumor-like malformative lesions are seen throughout the body, and they may be confused with true neoplasms by clinicians and pathologists alike. In the lungs, they are principally represented by hamartomas-which may contain chondroid, adipocytic, fibroblastic, and myxoid tissue, with entrapped bronchiolar epithelium-and congenital pulmonary airway malformations (CPAMs). The latter have been subdivided into 5 groups, based on their histological features, but they basically comprise proliferations of malformed bronchopulmonary tissues of different types. Type 1 lesions have a capacity for malignant transformation in a small proportion of cases. Malformative cardiac tumefactions include rhabdomyoma-like hamartomas; fibromatous hamartomas; and mesenchymal ventricular hamartomas, which contain cardiac muscle, smooth muscle, fat, vasogenic tissue, and nerves. Another intracardiac proliferation in the same general category is seen in the interatrial septum, in the region of the atrioventricular node. It comprises randomly-disposed gland-like profiles that are made up of endodermal epithelium. Originally thought to be a form of mesothelial lesion, that abnormality is now classified as an endodermal choristoma. All forms of pulmonary and cardiac malformations are only rarely symptomatic, and the necessity for surgical excision of them depends on the particular details of each case.

Primary Cardiac Lymphoma: Importance of Tissue Diagnosis

Primary cardiac lymphoma (PCL) is a rare disease entity that can present with severe cardiac and cardioembolic symptoms. We present a 79-year-old male with history of polymalgia rheumatica on chronic prednisone who presented with a two-week history of progressively worsening dyspnea, cough, and a 10 pound weight loss. Transthoracic echocardiogram (TTE) and computed tomography (CT) of the chest showed a large mediastinal mass with invasion of the pericardium. A biopsy of an abdominal soft-tissue mass confirmed the diagnosis of PCL. The patient was treated with two cycles of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) which was complicated by progressive heart failure requiring substitution of liposomal doxorubicin. The epidemiology, presentation, diagnosis, and treatment options of PCL are discussed.

Early and late results in surgical excision of primary cardiac tumors: Our single-institution experience

Background

In the present study, we present our experience for surgical excision for cardiac masses and to analyze survival characteristics of these patients.

Methods

Between January 2004 and December 2015, a total of 131 patients (88 females, 43 males; mean age 49.4±16.2 years; range, 1.2 months to 81 years) with primary cardiac tumors who underwent surgery in our center were included in this study. Demographic and other patient-related data were retrospectively reviewed from medical records of our center.

Results

All benign tumors were completely resected, whereas only palliative procedures were performed for malignant tumors. Pathology results revealed 88.5% (n=116) benign and 11.5% (n=15) malignant tumors. Tumors were most frequently located in the left atrium (76.3%, n=100), followed by the right atrium (11.5%, n=15), and the right ventricle (5.3%, n=7). Among all patients, 116 (88.5%) survived, while late mortality was seen in 15 patients (11.5%). The mean survival was 130.6±4.5 months. The latest mortality was observed at 124 months, whereby the cumulative survival rate was 79.2%. There was a statistically significant relationship between mortality and pathological characteristics of the tumor, and malignant cases had significantly higher mortality rates (p=0.002).

Conclusion

Surgical resection of primary cardiac tumors can be performed with low morbidity and mortality rates. Although survival rates in benign tumors are satisfactory, patients with malignant tumors have poor prognosis. The main clinical predic.

Evaluation and Management of Cardiac Tumors

PURPOSE OF REVIEW

Our purpose is to discuss the importance of multimodality imaging in the assessment of cardiac tumors and management. We have compiled a recent review of the scientific literature and embedded our clinical pathways and recommendations based on data and clinical experience.

RECENT FINDINGS

The use of contrast echocardiography in the assessment of cardiac masses has been shown to be helpful in distinguishing tumor from thrombus. Deformation imaging of cardiac tumors has been shown to differentiate better rhabdomyomas from fibromas in pediatric patients. Cardiac MRI (CMR) appears to be helpful in determining whether cardiac tumors are benign or malignant by identifying presence of infiltration, uptake of contrast in first pass perfusion and gadolinium enhancement. Patients with evidence of cardiac metastases by CMR show similar survival to stage IV cancer without cardiac metastases. In our institution, we use a standardized approach for the evaluation of cardiac masses, which includes multimodality imaging in the appropriate clinical context. The autotransplantation surgical technique has shown some promise in improving survival in patients with primary cardiac sarcomas. In our institution, we do not routinely recommend anticoagulation for "tumor-thrombus" in renal cell carcinoma due to risk of bleeding from primary tumor. Cardiac masses are often found incidentally, but sometimes can present with cardiovascular symptoms due to obstruction and valvular dysfunction, which may prompt imaging. It is important to determine whether the mass is a normal variant, imaging artifact, vegetation, thrombus, or tumor. Transthoracic echocardiography is ideally suited to be the initial imaging modality because of the portability, wide availability, lack of radiation, and relatively low cost. The gold standard cardiac imaging technique to distinguish tumor from thrombus is contrast enhanced CMR with prolonged inversion time. Advantages of CMR when compared to echocardiography regarding characterization of cardiac tumors are as follows: larger field of view, better spatial resolution, better tissue characterization, lack of attenuation, and ability to image at any prescribed plane. Primary and secondary cardiac tumors have particular characteristics in echocardiography and CMR. Imaging of cardiac tumors plays an important role in establishing a diagnosis and in planning management.