Symposium on cardiac tumors

Clinical aspects of cardiac tumors☆

Cardiac tumors are an uncommon cause for neurologic disease, but if undiagnosed can be associated with devastating neurologic consequences. Primary cardiac tumors, both benign and neoplastic, and metastatic tumors occur. Primary cardiac tumors are more likely to be associated with neurologic embolic complications. Metastatic cardiac tumors are more likely to be associated with valvular distraction, arrhythmia, diminished cardiac output and indirect neurological dysfunction. Primary and metastatic cardiac tumors may result in cerebral metastatic disease. Atrial myxoma, a benign primary cardiac tumor, is the most common cardiac tumor associated with neurologic disease, and most commonly causes cerebral embolization and stroke. The use of thrombolytic therapy for these strokes is controversial. Additionally, delayed manifestations, including aneurysm formation and intracranial hemorrhage, are possible. Aneurysm formation has been described as occurring after removal of the primary tumor. The availability of noninvasive cardiac imaging has significantly helped decrease the neurologic morbidity of cardiac tumors and has led to frequent successful intervention.

We report a patient in whom there was right ventricular outflow tract obstruction by extended metastasis from esophageal cancer. A 65-year-old man was admitted to the hospital for evaluation of recent onset of weight loss and heart murmur. Esophagogram and endoscopy showed a 10-cm, ulcerative, infiltrative esophageal cancer. This esophageal cancer was histologically proven to be a squamous cell carcinoma. To assess the cardiac metastasis, echocardiography, magnetic resonance imaging, coronary angiography, and endomyocardial biopsy were performed. The magnetic resonance imaging, echocardiography, and right ventriculography revealed a 7-cm lobulated mass extending to the right ventricular outflow tract, right ventricle, septum, and anterior wall of the left ventricle. Interestingly, the feeding vessels of the tumor were identified by echocardiography and coronary angiography. Histologically, the cardiac tumor was proven to be have the same pathologic findings as esophageal cancer, compatible with carcinomatous metastasis. (J Am Soc Echocardiogr 2002;15:1541-4.)

The authors assessed the usefulness of the electrocardiography in patients with left atrial myxoma. The authors retrospectively reviewed the records of 15 patients with left atrial myxoma before and after tumor excision. The 12-lead electrocardiogram presented the P-wave abnormality shown by a broad P wave in lead II (PDII) and/or a deep and broad negative P terminal force in lead V1 (PTFV1). These abnormal findings were shown in the 13 patients whose tumor weight was 16 g or more. However, the other 2 patients whose tumor weight were 7 g or less did not have a prolonged PDII or an increased PTFV1. Both PDII and PTFV1 were correlated not only with the tumor size but also with the left atrial dimension and/or the left atrial pressure. These P-wave abnormalities were markedly improved or disappeared, and the left atrial dimension and pressure decreased immediately after tumor excision. The increasing size of the tumor brings about the P-wave abnormalities, which may result from enlargement of the left atrial cavity. It is suggested that while not specific the 12-lead ECG findings of PDII and PTFV1 may be useful for detecting a myxoma weighting 16 g or more, but was an insensitive technique for smaller ones.

An asymptomatic 57-year-old man had an abnormal resting electrocardiogram and a positive treadmill stress test. Cardiac catheterization with left ventriculography revealed a large left ventricular mass in the apex, but otherwise normal coronary arteries. Excisional biopsy of the mass was consistent with oat-cell carcinoma. Additional evaluation was negative for metastasis. The patient was treated with combined chemoradiotherapy and was doing well at 16 months follow-up. (Heart Lung® 2002;31:229-32.)

Three cases of right ventricular outflow tract obstruction caused by 3 distinct tumors—myxoma, sarcoma, and presumed metastatic tumor—diagnosed by transthoracic and transesophageal echocardiography are presented. The differences among these 3 types of tumors with similar clinical and echocardiographic findings are highlighted, and a review of the pertinent literature is discussed. By applying the approximate frequencies of cardiac tumors categorized by type and site, statistically, an intracavitary right ventricular outflow tract tumor is 70 to 140 times more likely to be malignant than benign; furthermore, if it is a primary cardiac tumor, it is approximately 2 times more likely to be a sarcoma than a myxoma. (J Am Soc Echocardiogr 2001;14:937-40.)