Unexplained Hemopericardium as a Presenting Feature of Primary Cardiac Angiosarcoma: A Case Report and a Review of the Diagnostic Dilemma

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.

Concomitant intravascular and extravascular obstructive shock: a case report of cardiac angiosarcoma presenting with pericardial tamponade

Atraumatic pericardial tamponade and intracardiac masses are both recognized etiologies of acute obstructive shock. Pericardial tamponade, is a cardiovascular emergency commonly considered by emergency physicians and, as a result, evaluation for this process has been incorporated into standardized point of care ultrasound algorithms for assessing hypotension. Obstructive shock secondary to intracardiac tumors is an atypical clinical presentation, and although it is evaluated by the same ultrasound imaging modality, it is generally not considered or evaluated for in the emergency department setting. The concomitant presentation of these two pathologic processes is an extremely rare oncologic emergency. Existing literature on the subject is found in a small number of case reports with nearly no prior descriptions in emergency medicine references. In the right clinical context this unique presentation should be considered and evaluated for in the emergency department via point of care ultrasound modality to help guide in the management of the resulting obstructive shock.

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.

Extensive pulmonary metastases in young boy with primary cardiac angiosarcoma: a case report

BACKGROUND

Malignant primary cardiac neoplasms are rare and primary cardiac angiosarcoma is the most common and aggressive subtype. It most commonly presents in middle-aged males and due to its non-specific clinical presentation, the diagnosis is often delayed until advanced disease is already present. Clinical presentation is determined by manifestations of local infiltration or metastatic disease and making an early diagnosis is extremely challenging.

CASE SUMMARY

A 15-year-old previously healthy boy was admitted to the emergency department with a history of pathological weight loss and functional decline. The patient was found to have a left-sided pneumothorax as well as bilateral diffusely spread pulmonary nodules on plain chest radiograph. Computed tomography chest confirmed widespread pulmonary metastases and a right atrial filling defect. Echocardiography revealed a right atrial tumour and transvenous endomyocardial biopsy of the tumour was done under fluoroscopic and echocardiographic guidance. A diagnosis of primary cardiac angiosarcoma was made. The patient demised shortly after presentation.

DISCUSSION

Primary cardiac angiosarcoma is rare and even more so in patients as young as the case described. The diagnostic process poses several challenges to the clinician, of which the obtaining of a histological sample is one. This case report demonstrates aspects both unique and typical of this rare disease. It also describes an effective option for obtaining tissue for a histological diagnosis in patients whose clinical condition may not allow biopsy under general anaesthesia.

Fast growing angiosarcoma of the right atrium after radiofrequency catheter ablation: a missed diagnosis or misdiagnosis case report

Background

Primary angiosarcomas of the right atrium are extremely rare, often resulted in missed diagnosis or misdiagnosis with routine examination tools. These malignant cardiac tumors are highly aggressive with generally poor prognosis. Surgical excision is the mainstay of treatment as it is essentially not responsive to current regimens of chemoradiotherapy.

Case presentation

Herein, we describe a patient who initially presented with paroxysmal atrial fibrillation and was subsequently treated with radiofrequency catheter ablation (RFCA). Prior to RFCA, an initial transesophageal echocardiography revealed a local thickening of the intratrial septum. Three months later, she was hospitalized with progressive dyspnea and massive pericardial effusion. A large immobile, non-pedunculated mass, occupying almost half of the right atrium was detected by transthoracic and transesophageal echocardiogram. Multimodality cardiac imaging was useful in further characterizing this mass, which was ultimately diagnosed as an angiosarcoma based upon biopsy results. The growth rate was extremely rapid following RFCA, and patient underwent surgical excision. After discharge, the angiosarcoma recurred and patient survived for 7 months from the first episode of tamponade.

Conclusions

Primary cardiac angiosarcoma of the right atrium can easily be mistaken for structural anomalies in its early stages, losing the opportunity for initiating earlier treatments to improve potential patient outcomes. The correct diagnosis of this rare case relied on the comprehensive utilization of multimodal imaging techniques including biopsy.

Primary Angiosarcoma-A Rare Cause of Right Ventricular Outflow Tract Obstruction: Case Report and Literature Review

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Cardiac angiosarcoma is most common malignant cardiac tumor.

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Diagnosis remains challenging because of its nonspecific presentation.

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As a result of its aggressive nature and late diagnosis, the prognosis remains poor.

Primary cardiac angiosarcoma: A case report

BACKGROUND

Primary cardiac angiosarcoma is rare, but it is the most aggressive type of cardiac malignant tumor. When disease is confirmed it is often late in its stage resulting in a poor prognosis.

CASE PRESENTATION

We reported a 52-year-old woman who complained of dyspnea for 2 months and dry cough for 10 days. Computed tomography (CT), F-fluorodeoxyglucose (F-FDG), positron emission tomography-computed tomography (PET-CT), and transthoracic echocardiography showed a space-occupying lesion 7 cm × 5 cm × 5 cm in the right atrium. Malignant cells can be seen in pericardial fluid by pericardiocentesis in local hospital, but not be diagnosed definitely. We conducted CT-guided biopsy of the tumor and observed the necrotic tissues. An exploratory thoracotomy was performed and histological examination confirmed angiosarcoma. Unable to be surgical excision due to infiltrating widely, the patients received chemotherapy with docetaxel for 2 cycles and the disease was progressive. Antiangiogenesis-targeted therapy was combined with chemotherapy for 3 months. Unfortunately, the tumor was still in progress. She died of respiratory failure, survived for 10 months.

CONCLUSION

It is difficult to diagnose the primary cardiac angiosarcoma in early stage. Chemotherapy and target therapy are very limited in this case. Surgery remains the preferred treatment for patients with primary cardiac angiosarcoma. More efforts should be carried out on the effective diagnosis and multimodality treatment for this malignant disease.

Echocardiographic Features of Cardiac Angiosarcomas: The Mayo Clinic Experience (1976-2013)

OBJECTIVE

Cardiac angiosarcoma is the most common primary malignant cardiac tumor. The dismal prognosis and nonspecific symptomatology underscore the need for an accurate and cost-effective approach to the identification and characterization of this rare tumor.

METHODS

Mayo Clinic tissue registry archives were queried for all histologically confirmed cases of cardiac angiosarcoma (1976-2013) with available imaging data. Echocardiograms were retrospectively reviewed.

RESULTS

Thirty-three cases of cardiac angiosarcoma were identified; of these, 17 had echocardiograms available (mean age, 46 years; six men). Transthoracic echocardiography (TTE) as the initial diagnostic test had 75% sensitivity for visualizing primary cardiac angiosarcoma (9/12 patients). Tumor extension into the pericardium was common and pericardial effusion was present in 15 patients (88%); however, pericardial fluid cytology was negative for malignancy in all tested patients (n = 15). Left ventricular ejection fraction (LVEF) was preserved in 16 patients (94%) (average LVEF, 62%). Right ventricular function was mildly reduced in two patients (12%) at initial presentation. Tricuspid valve obstruction was present in three patients (18%; mean diastolic gradient, 6.3 mmHg [range, 3-11 mmHg]).

CONCLUSION

The sensitivity of TTE as the first diagnostic imaging modality compared favorably with computed tomography. Pericardial effusion was common, but pericardial fluid cytology was negative in all patients who underwent pericardiocentesis. The absence of a stalk was a universal finding that may help distinguish angiosarcoma from benign, primarily pedunculated tumors such as myxoma and papillary fibroelastoma.

Elusive Cardiac Angiosarcoma in a Young Pregnant Female: Rare Presentation With Fatal Outcome

Heart tumors are rare occurrences. They can present diagnostic challenges and severe complications especially in pregnant women. We report a rare case of angiosarcoma (AS) cordis of the right atrium in a young healthy pregnant female. Her diagnosis remained elusive for some time until development of advanced disease symptomatology. The diagnosis was unfortunately clinched when her tumor grew to be detected by imaging modalities. An emergency cesarean section was performed delivering a healthy baby. The patient was aggressively treated with chemotherapy to no avail. She passed away 2 months after her diagnosis was established. Only few cases of the occurrence of aggressive cardiac AS and human pregnancy are documented. The course of this disastrous combination is usually marked by severe complications, difficult therapeutic options and ultimately fast demise. Physicians need to be more aware of such diagnosis and diligently try to diagnose it as early as possible.

Cardiac angiosarcoma-associated membranoproliferative glomerulonephropathy

Primary cardiac angiosarcoma is a rare cardiac tumor. The initial clinical course is often asymptomatic, and metastatic disease is present in a majority of affected patients at diagnosis. We present a patient who presented with a hemorrhagic pericardial effusion. No malignant cells were evident on cytological examination. He subsequently developed membranoproliferative glomerulonephritis requiring hemodialysis. Metastatic cardiac angiosarcoma was diagnosed 5 months later. To our knowledge, this is the first reported case of paraneoplastic membranoproliferative glomerulopathy associated with cardiac angiosarcoma.