Primary cardiac sarcomas: Treatment strategies

Prevalence, Diagnosis, and Treatment of Cardiac Tumors: A Narrative Review

Cardiac tumors, though rare, present significant diagnostic and therapeutic challenges due to their heterogeneous nature and anatomical complexity. This narrative review synthesizes current evidence on prevalence, diagnostic modalities, and management strategies for primary and metastatic cardiac tumors. Echocardiography, cardiac MRI, and CT remain cornerstone imaging tools for differentiating tumors from non-neoplastic masses, while advances in PET/CT and tissue characterization techniques refine staging and treatment planning. Surgical resection with clear margins (R0) is critical for resectable tumors, particularly benign myxomas, though malignant tumors like sarcomas require multimodal approaches combining surgery, radiotherapy, and systemic therapies. Emerging strategies such as heart autotransplantation and staged resections offer promise for complex cases, while oligometastatic disease management highlights the role of stereotactic radiotherapy and immunotherapy. Key challenges include standardizing resection margins, optimizing neoadjuvant therapies, and addressing high recurrence rates in malignancies. Future directions emphasize integrating AI-driven imaging analysis, molecular biomarkers, and genomic profiling to personalize therapies, alongside global registries to enhance data on rare tumors. Equitable access to advanced diagnostics and multidisciplinary collaboration are essential to improve outcomes. This review underscores the need for standardized guidelines, technological innovation, and patient-centered research to address gaps in cardiac oncology.

Diagnosis and treatment of cardiac tumors

Cardiac tumors, though rare, present significant diagnostic and therapeutic challenges due to their diverse nature and potential severity. These tumors, which can be primary or metastatic, are often detected incidentally through imaging modalities such as echocardiography or CT scans. Differentiating between benign and malignant forms is crucial for guiding appropriate management strategies. This review synthesizes current diagnostic approaches and treatment modalities for cardiac tumors, with a focus on the role of imaging techniques like UCG, CT, MRI, and PET in tumor characterization. Multidisciplinary treatment plans are necessary, including surgical resection for benign tumors, chemotherapy, and radiotherapy for malignant tumors, and novel targeted therapies such as MDM2 inhibitors for selected cases. While primary malignant tumors like sarcomas and mesotheliomas exhibit rapid progression and poor prognosis, recent advances in multimodal therapy offer potential improvements in survival. The incidence of primary cardiac tumors is low, with an autopsy-reported occurrence rate of 0.02%. Benign cardiac tumors, such as myxomas and fibromas, generally have favorable outcomes with surgical resection. In contrast, primary malignant tumors like sarcomas and mesotheliomas exhibit rapid progression and poor prognosis, necessitating aggressive treatment including surgery, chemotherapy, and radiotherapy. Metastatic cardiac tumors occur in approximately 10% of cancer patients at autopsy and are managed according to the treatment plan for the primary malignancy. The management of cardiac tumors requires a multidisciplinary approach tailored to tumor type, location, and systemic effects. While benign tumors often respond well to surgical management, malignant and metastatic tumors demand more complex strategies to optimize patient outcomes.

CARDIAC TUMORS: UPDATED CLASSIFICATIONS AND MAIN CLINICO-PATHOLOGIC FINDINGS

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

Surgical Resected Cardiac Angiosarcoma in a 75-Year-Old Patient With a Mitral Valve Bioprosthesis

A 75-year-old patient with a history of mitral and aortic valve replacement surgery 7 years ago, presented with progressive dyspnea. Transesophageal echocardiogram showed a mass suggestive of bioprosthetic mitral valve thrombosis. We present the investigation process using imaging, surgical findings, nuclear medicine, and histopathology that result in the diagnosis of cardiac angiosarcoma.

Echocardiography-Guided Radiofrequency Ablation for Cardiac Tumors

Background

Patients with cardiac tumors may present challenges for surgical resection due to poor clinical condition. Echocardiography-guided transapical radiofrequency ablation for cardiac tumors (TARFACT) potentially offers a less invasive palliative therapy option.

Objectives

This study aimed to evaluate the safety and efficacy of TARFACT.

Methods

Five patients with cardiac tumors (mucinous liposarcoma, myocardial hypertrophy with inflammatory cell infiltration mass, fibrous tissue tumor hyperplasia, myocardial clear cell sarcoma, and cardiac rhabdomyoma) were included. All patients underwent TARFACT and were assessed with electrocardiogram, echocardiographic imaging, biochemical analysis, and pathological confirmation.

Results

The median follow-up for all patients was 9 (range 4-12) months. Three surviving patients were alive at their last follow-up (9, 12, and 12 months, respectively), whereas 2 patients with late-stage tumors survived 6 months and 13 months after TARFACT, respectively. After TARFACT, all patients showed significant reductions in tumor size: the mean length decreased from 6.7 ± 2.0 cm to 4.7 ± 1.8 cm (P = 0.007); and the mean width decreased from 5.0 ± 2.1 cm to 2.5 ± 0.7 cm (P = 0.041). NYHA functional class also improved: median (IQR) decreased from 3.0 (1.5) to 2.0 (1.0) (P = 0.038), Peak E-wave on echocardiography showed a mean increase from 64.4 ± 15.7 cm/s to 76.6 ± 18.6 cm/s (P = 0.008), and NT-pro BNP levels had a median (IQR) reduction from 115.7 (252.1) pg/mL to 55.0 (121.6) pg/mL (P = 0.043).

Conclusions

TARFACT is a novel palliative treatment option for cardiac tumors, reducing accessible tumors and improving clinical symptoms in a preliminary group of patients. (Cardiac Tumors Interventional [Radio Frequency/Laser Ablation] Therapy [CTIH]; NCT02815553).

A rare presentation of primary cardiac myxofibrosarcoma: Case report and literature review

BACKGROUND

Primary cardiac myxofibrosarcoma is a rare and aggressive malignancy, with the majority of approaching strategies relying on case reports. This article provides insights into its diagnosis and treatment.

CASE PRESENTATION

This paper presents the case of a 40-year-old man with sudden onset hemoptysis, leading to the diagnosis of primary cardiac myxofibrosarcoma. Treatment involved open-heart surgery to excise the left atrium tumor, followed by 6 cycles of adjuvant chemotherapy. Unfortunately, brain metastasis developed, leading to the patient's death 1 year after initial diagnosis.

CONCLUSION

Primary cardiac myxofibrosarcoma remains a clinical challenge with an unfavorable prognosis. Early diagnosis through advanced imaging is crucial, and research is needed to explore innovative treatments. This case underscores the complexities of managing this rare cardiac malignancy and highlights the necessity for ongoing investigations to enhance patient outcomes.

Primary cardiac rhabdomyosarcoma in a mitral valve involved with rheumatic disease

A 51-year-old female underwent emergency mitral valve replacement for mitral stenosis with an undetermined mass which was attached to the anterior mitral leaflet. Histopathological testing of the excised specimen confirmed the diagnosis of rheumatic mitral disease in combination with a primary rhabdomyosarcoma. Postoperative adjuvant chemotherapy with pazopanib hydrochloride was given. At 10 months of follow-up, repeated computed tomographic screening has not shown any signs of local recurrence or secondary metastases. The potential for the existence of primary rhabdomyosarcomas should be borne in mind when faced with undetermined masses on mitral leaflets, even in the presence of rheumatic disease.

Multimodality treatment of primary cardiac angiosarcoma: A systematic literature review

BACKGROUND

Primary cardiac angiosarcoma (PCA) is the most prevalent histological type of cardiac sarcoma but its rarity poses a challenge for standardizing treatment protocols. Moreover, published studies are limited by small patient numbers and lack of randomization, making it challenging to establish evidence-based treatment strategies. This systematic review aims to consolidate the heterogeneous published data and identify factors related to the treatment outcome of PCA patients.

METHODS

The PubMed and Scopus bibliographic databases were systematically searched for original articles reporting clinical, treatment and outcome data for PCA patients. Kaplan-Meier analysis was used to calculate the time to progression and survival. The Log-Rank test was used to compare progression-free and overall survival data. The Cox proportional hazards regression model was used for univariate and multivariate analysis of survival data.

RESULTS

A total of 127 studies containing data for 162 patients were analyzed. The median age of the patient cohort was 45 years, with males being 1.5 times more frequently affected than females. Tumors were primarily located on the right side of the heart, with a median size of 6 cm. Median progression-free and overall survival of 5 months and 12 months, respectively, were calculated. Age, sex, and resection margins did not have a significant impact on PCA survival, as determined by both univariate and multivariate analyses. The presence of metastases at diagnosis was associated with lower overall survival in univariate analysis, although this effect was not significant in multivariate analysis. Multimodality treatment that incorporated surgery and adjuvant chemo-radiotherapy was associated with a statistically significant survival benefit. Median overall survival increased from 6 months with surgery alone to 13 months and 27 months with adjuvant chemotherapy and chemo-radiotherapy, respectively.

CONCLUSION

Multimodality treatment including surgery and chemo-radiotherapy was found to offer the greatest survival benefit for PCA patients.

Cardiac osteosarcoma: a case report and literature review

Background

Primary cardiac tumors are rare, and malignant primary cardiac tumors are even rarer. Cardiac osteosarcoma is a very rare type of malignant primary cardiac tumor with limited reported cases. We present a case report of cardiac osteosarcoma and review its characteristics and the related literature.

Case summary

A 44-year-old female patient without a specific medical history presented with intermittent dyspnea that started 1 month prior to presentation. A heterogeneous mass was observed in the left atrium on echocardiography and a large mass was observed in the left atrium on computed tomography. Surgery was performed under the suspicion of atypical cardiac myxoma, and the tumor was successfully removed. However, postoperative histopathological examination revealed cardiac osteosarcoma. The patient underwent chemotherapy and has been well maintained without recurrence for 10 years.

Conclusion

We present a case report of the echocardiographic features and treatment strategies for cardiac osteosarcoma, an extremely rare cardiac tumor. Multimodal imaging can be helpful; however, a histological diagnosis through surgical resection is essential. Appropriate treatment and follow-up based on histological findings are necessary.

Outcomes of Full and Partial Cardiac Autotransplantation for Complex Left-Sided Heart Tumors

Background

Complex or malignant left-sided heart tumors present a challenge for resection and reconstruction. Cardiac autotransplantation was developed to address this but is a complex technique. Partial autotransplantation was developed to simplify the procedure. This study evaluates the outcomes of partial cardiac autotransplantation compared with those of full cardiac autotransplantation.

Methods

We analyzed our prospectively collected cardiac tumor database for cases between 1998 and 2022 requiring full or partial cardiac autotransplantation. The primary end points for the study were morbidities including bleeding, total blood transfusions, renal failure, prolonged ventilation (>48 hours), arrhythmias, total cardiopulmonary bypass time, total aortic clamp time, hospital length of stay, and intensive care unit length of stay. The secondary end point was operative 30-day mortality.

Results

We identified 57 consecutive cases of partial or full cardiac autotransplantation. Full autotransplantation was performed in 47 of 57 (82.5%) patients, and partial autotransplantation was performed in 10 of 57 (17.5%) patients. For full vs partial techniques, mean cardiopulmonary bypass time was 191.0 vs 147.5 minutes (P = .01), and median number of blood transfusions was 5.0 vs 2.0 units (P = .04). Mean aortic clamp time was 120.5 vs 103.0 minutes (P = .12), median length of hospital stay was 12.0 vs 8.5 days (P = .23), and intensive care unit stay was 5.0 vs 2.0 days (P = .14); renal failure (9/47 [19%] vs 0) did not differ (P = .34). There was no 30-day mortality in the partial group.

Conclusions

Partial cardiac autotransplantation represents a simplification of the full autotransplantation technique and can be performed with a reasonable operative risk.

Geographic variation in malignant cardiac tumors and their outcomes: SEER database analysis

Introduction

Primary malignant cardiac tumors (PMCTs) are rare. Geographical distribution has been demonstrated to affect cancer outcomes, making the reduction of geographical inequalities a major priority for cancer control agencies. Geographic survival disparities have not been reported previously for PMCT and the aim of this study is to compare the prevalence and the long-term survival rate with respect to the geographic location of PMCTs using the Surveillance, Epidemiology, and End Results (SEER) research plus data 17 registries between 2000 and 2019.

Methods

The SEER database was queried to identify geographic variation among PMCTs. We classified the included states into 4 geographical regions (Midwest, Northeast, South and West regions) based on the U.S. Census Bureau-designated regions and divisions. Different demographic and clinical variables were analyzed and compared between the four groups. Kaplan Meier curves and Cox regression were used for survival assessment.

Results

A total of 563 patients were included in our analysis. The median age was 53 years (inter-quartile range (IQR): 38 - 68 years) and included 26, 90, 101, and 346 patients from the Midwest, Northeast, South, and West regions respectively. Sarcoma represented 65.6% of the cases, followed by hematological tumors (26.2%), while mesothelioma accounted for 2.1%. Treatment analysis showed no significant differences between different regions. Median overall survival was 11, 21, 13, and 11 months for Midwest, Northeast, South and West regions respectively and 5-year overall survival was 22.2%, 25.4%, 14.9%, and 17.6% respectively. On multivariate Cox regression, significant independent predictors of late overall mortality among the entire cohort included age (Hazard Ratio [HR] 1.028), year of diagnosis (HR 0.967), sarcoma (HR 3.36), surgery (HR 0.63) and chemotherapy (HR 0.56).

Conclusion

Primary malignant cardiac tumors are rare and associated with poor prognosis. Sarcoma is the most common pathological type. Younger age, recent era diagnosis, surgical resection, and chemotherapy were the independent predictors of better survival. While univariate analysis revealed that patients in the South areas had a worse survival trend compared to other areas, geographic disparity in survival was nullified in multivariate analysis.