Surgical management of metastatic melanoma to the ventricle

The treatment of patients who have cardiac tumors can be challenging, because these tumors occur infrequently and in variable locations, and surgical resection is often technically difficult. We report the cases of 2 patients, each of whom underwent successful surgical excision of large melanomas that had metastasized to the right cardiac ventricle. Although the presence of widespread disease and a limited life expectancy usually prevent surgical therapy for patients who have metastatic cardiac tumors, removal of such masses greatly facilitated subsequent medical management of these 2 patients and improved their quality of life.     

Two-dimensional and three-dimensional transthoracic echocardiography in surgical planning for right atrial metastatic melanoma.

Melanoma is the most common form of cardiac metastases. Surgical excision has been shown to be an effective palliative measure. This requires detailed definition of cardiac anatomy in relation to the tumour. Two-dimensional (2D), three-dimensional (3D) transthoracic (TTE) and transoesophageal echocardiography (TEE), spiral computerised tomography (CT) and magnetic resonance imaging (MRI) have all been described in aiding surgical planning for excision of cardiac tumours. In this case report, 3D-TTE provided excellent anatomical definition for surgical planning of a large right atrial melanoma precluding the need for more invasive and expensive investigations.     

Surgical treatment of heart failure in the elderly

Heart failure (HF) in elderly patients who may benefit from surgical therapy is usually secondary to ischemic or valvular heart disease. When referring such patients for surgery, life expectancy, along with the expectations of the patient and family with regard to the surgical treatment, must be considered. The goals of cardiac surgery in this patient population are to maintain or improve cardiac function, decrease HF episodes, reduce hospital admissions, and improve functional class. Safer surgical techniques developed during the last two decades have allowed high-risk patients well into their 80s to undergo complex cardiac operations with decreasing morbidity and mortality. Successful surgical intervention often leads to a more productive and independent life for elderly patients who have HF.     

Surgical treatment of heart failure in the elderly

Heart failure (HF) in elderly patients who may benefit from surgical therapy is usually secondary to ischemic or valvular heart disease. When referring such patients for surgery, life expectancy, along with the expectations of the patient and family with regard to the surgical treatment, must be considered. The goals of cardiac surgery in this patient population are to maintain or improve cardiac function, decrease HF episodes, reduce hospital admissions,and improve functional class. Safer surgical techniques developed during the last two decades have allowed high-risk patients well into their 80s to undergo complex cardiac operations with decreasing morbidity and mortality. Successful surgical intervention often leads to a more productive and independent life for elderly patients who have HF.     

Lymph node metastasis in gastric cardiac adenocarcinoma in male patients

AIM:To reveal the clinicopathological features and risk factors for lymph node metastases in gastric cardiac adenocarcinoma of male patients.METHODS:We retrospective reviewed a total of 146male and female patients with gastric cardiac adenocarcinoma who had undergone curative gastrectomy with lymphadenectomy in the Department of Surgery,Xin Hua Hospital and Rui Jin Hospital of Shanghai Jiaotong University Medical School between November2001 and May 2012.Both the surgical procedure and extent of lymph node dissection were based on the recommendations of Japanese gastric cancer treatment guidelines.Univariate and multivariate analyses of lymph node metastases and the clinicopathological features were undertaken.RESULTS:The rate of lymph node metastases in male patients with gastric cardiac adenocarcinoma was72.1%.Univariate analysis showed an obvious correlation between lymph node metastases and tumor size,gross appearance,differentiation,pathological tumor depth,and lymphatic invasion in male patients.Multivariate logistic regression analysis revealed that tumor differentiation and pathological tumor depth were the independent risk factors for lymph node metastases in male patients.There was an obvious relationship between lymph node metastases and tumor size,gross appearance,differentiation,pathological tumor depth,lymphatic invasion at pN1and pN2,and nerve invasion at pN3in male patients.There were no significant differences in clinicopathological features or lymph node metastases between female and male patients.CONCLUSION:Tumor differentiation and tumor depth were risk factors for lymph node metastases in male patients with gastric cardiac adenocarcinoma and should be considered when choosing surgery.     

Ventricular metastasis without atrial or caval involvement: a rare presentation

Right ventricular metastases from renal cell carcinoma without inferior vena cava (IVC) or right atrium involvement are rare. We discuss a 44-year-old male who presented with a left thigh mass, which was resected and the pathology revealed an epithelial sarcoma or a possible metastasis from another organ. His preradiotherapy cardiac evaluation showed mass in the right and left ventricles, which was confirmed by transesophagial echocardiogram. Computed tomography revealed a right renal mass in addition to the ventricular masses without any involvement of IVC or the atria. The patient underwent right radical nephrectomy without complications and systemic chemotherapy with interleukin-1 for metastatic renal cell carcinoma. He is doing well and follow-up echocardiogram showed significant reduction in the size of the cardiac metastases, even without surgical resection of these tumors. Thus, our article presents this unique case of asymptomatic ventricular metastases of renal cell carcinoma without any atrial or caval involvement and provides a new insight into the management of this syndrome.     

Postcardiotomy extracorporeal life support

The need for postcardiotomy mechanical support is uncommon and likely to decline. A mixture of options is necessary to meet the diverse indications for cardiac support in a comprehensive heart failure program. Between January 1997 and December 2000, 29 adult, neonate, and infant cardiac surgical patients were supported on an extracorporeal life support system. Indications for cardiac assist included post-cardiotomy low cardiac output syndrome, and hyperacute rejection after cardiac transplantation. Data for analysis were collected prospectively. Survival on the life support system was 20/29 (69%) and 12 patients (41%) survived to discharge. The mean time to starting extracorporeal life support was longer in survivors than non-survivors. The extracorporeal life support system provides effective cardiopulmonary and end-organ support.     

Cardiac metastasis of melanoma presenting as acute aortic occlusion

Cardiac diseases are the most common cause of acute arterial emboli, however, cardiac tumors are not as frequent. Cardiac metastases from melanoma are usually silent, and rarely cause symptoms. Only a few reports are found in the literature of metastatic melanoma, causing arterial emboli. Here, we report a case of a cardiac metastasis of melanoma cancer that presented preoperative as arterial emboli. The gross appearance of the emboli already suggested the presence of a cardiac tumor. In selected patients who have a solitary intracardiac melanoma, surgical resection can provide relief from clinical symptoms and minimize potential cardiac sequelae of the tumor.     

Carcinoid heart disease

Opinion statement In patients with carcinoid heart disease, a multidisciplinary approach to patient care is required because treatment of the systemic disease and management of cardiac involvement must be considered at the same time. Somatostatin analogue use is a therapeutic cornerstone, effective in symptomatic control of the endocrine syndrome. Chemotherapy is of limited efficacy in patients with carcinoid tumors. Hepatic resection of metastases is the preferred treatment option and has been shown to result in improved outcome. It should be considered if at least 90% of the metastases in the liver are removable. Hepatic artery embolization is usually applied if a patient is not eligible for surgical debulking. Development and progression of carcinoid heart disease complicate the carcinoid syndrome and contribute to poor prognosis. In patients with severe cardiac involvement and well-controlled systemic disease, valve replacement surgery is an effective treatment modality that can relieve intractable symptoms and contribute to improved outcome.     

Surgical resection of solitary metastasis of malignant melanoma to the right atrium

Malignant melanoma has a very high tendency to metastasize to the heart. Although most cardiac metastases of melanomas are clinically silent, the lesions may present with life-threatening cardiac morbidities, including dysrhythmia, right ventricular outflow tract obstruction, myocardial dysfunction, pericardial effusion, or heart failure. In selected patients who have a solitary intracardiac melanoma, surgical resection can provide relief from clinical symptoms and minimize potential cardiac sequelae of the tumor. Because tumor embolization of cardiac melanoma has been reported, the presence of atrial metastatic melanoma can be another indication for surgery.Herein, we present the case of a 31-year-old man who had a right atrial metastatic melanoma of unknown primary origin. He underwent surgical resection of the tumor before beginning a course of chemotherapy. After 1 year, he was well and had no symptoms. We describe the clinical features of this rare presentation of melanoma.     

Extensive metastasectomy for a single lesion with cardiac invasion

Cardiac metastases are rare and considered a sign of end-stage oncologic disease. A lack of telltale clinical symptoms leads to late detection, thus usually limiting surgical options. Modern diagnostic tools such as fluorodeoxyglucose positron emission tomography, single-photon emission computed tomography, or cardiac magnetic resonance imaging could allow for timely detection and open up new therapeutic options. Highly selected oligometastatic patients may benefit from extensive surgical procedures including transmyocardial resection.     

Malignant pericardial effusion and cardiac tamponade as a late complication of endometrial carcinoma

Malignant pericardial effusion, as a complication of gynecological cancer, is a rare occurrence. A review of the literature reveals only four cases of malignant pericardial effusion from endometrial carcinoma diagnosed during life. All of them were followed by cardiac tamponade a short time after being diagnosed and were associated with extensive myometrial invasion and multiple metastases. We describe a case of malignant pericardial effusion and cardiac tamponade due to recurrence of endometrial carcinoma characterized by the long period from diagnosis to clinical evidence of pericardial involvement. The causes of long-term disease-free interval are discussed.     

Primary cardiac angiosarcoma: in a patient with a dacron aortic prosthesis

This is a report of a primary cardiac angiosarcoma in a woman who, several years earlier, had undergone repair of an aortic dissection with a Dacron graft prosthesis. Dacron prostheses have rarely been associated with neoplasia, and this, to our knowledge, is the first reported case of primary cardiac angiosarcoma in association with Dacron. Our patient presented with extensive metastases. If tumors are localized, they can be treated successfully with a combination of surgical resection, chemotherapy, and radiotherapy. Cardiac transplantation can also be beneficial, but the overall prognosis remains poor.     

Metastatic periosteal osteosarcoma causing cardiac and renal failure

The case of a 25-year-old man who had periosteal osteogenic sarcoma with intravascular metastases in unusual locations is reported. The patient presented with acute renal failure, unilateral pulmonary edema, functional mitral stenosis, and low cardiac output. After successful surgical removal of a left atrial metastasis with subsequent improvement in cardiac output, renal function improved only transiently and urinary output varied markedly. At autopsy, metastatic osteogenic sarcoma was discovered within the lumen of the abdominal aorta obstructing both renal arteries. The case is the first report of a neoplasm metastatic to the aorta causing intermittent bilateral renal arterial obstruction; it illustrates the diagnostic difficulties presented by intravascular metastatic disease.     

Metastatic synovial sarcoma of the left ventricle

A metastatic synovial sarcoma of the left ventricle is described. A 26-year-old Japanese woman underwent resection of a synovial sarcoma of the right thigh 8 years prior to admission, which was followed by multiple surgical procedures for pulmonary metastasectomy. Echocardiography demonstrated obstruction of the outflow tract of the left ventricle caused by a metastatic tumor, which was surgically resected on the day of admission. The histologic characteristics of the cardiac tumor were identical to those of the pulmonary metastases. Additional cardiac metastasectomy was performed 9 months later. She complained of dyspnea on exertion 8 months after the second cardiac metastasectomy due to recurrence in the heart. Radiotherapy with LINAC (a total dose: 50 Gy) diminished the size of the tumor temporarily. The patient died 20 months after the initial cardiac metastasectomy.     

Ablative therapies for liver metastases of digestive endocrine tumours

Hepatic metastases are frequently encountered in patients with digestive endocrine tumors and their presence plays an important role in quality of life and overall prognosis. Surgery is the treatment method of choice for hepatic metastases but this is frequently impossible due to the extent of disease. Systemic chemotherapy is offered to patients with diffuse and/or progressive liver metastases but results are disappointing especially in patients with metastases of midgut origin. In the latter patients with carcinoid syndrome, somatostatin analogs are frequently initially effective but their efficacy wanes due to disease progression and development of tachyphylaxis. Other therapeutic options in the treatment of hepatic metastases are locoregional strategies where vascular occlusion induces ischemia in these highly vascular tumors using either surgical or radiological techniques. Available methods include surgical ligation of the hepatic artery, transient hepatic ischemia or sequential hepatic arterialization. Trans-catheter arterial chemoembolization has proven effective in terms of long palliation and objective tumor responses. Other treatments aimed at regional destruction either alone or in combination with surgery include radiofrequency ablation and cryotherapy. The latter are usually important adjuncts to surgery and are usually reserved for limited disease.     

Successful surgical treatment of peritoneal dissemination of hepatocellular carcinoma

Hepatocellular carcinoma rarely disseminates intraperitoneally. When it does, it usually is considered a terminal event. The successful treatment of complications of peritoneal metastases by surgical resection in a patient with hepatocellular carcinoma is reported. A 63-year-old man with hepatocellular carcinoma in the anterior segment underwent transarterial and portal embolization followed by extended radical hepatectomy. Five years and 8 months later, he presented with an ileus that was secondary to multiple peritoneal metastases that were resected to the extent possible. Eight months later, the patient presented with a second episode of ileus and underwent another operation that included bowel resection. However, pelvic tumors that were unresectable also were present. The patient survived for another 9 months before dying with peritoneal carcinomatosis. Although surgical treatment of peritoneal dissemination of hepatocellular carcinoma is not curative, surgery may improve survival and provide a good quality of life in selected cases.     

Metastatic melanoma presenting as cardiac mass and hemobilia

We present a rare case of malignant melanoma of unknown primary origin presenting as cardiac and cholecystic masses. In this 72-year-old man, a cardiac lesion caused right ventricular outlet obstruction, and gallbladder lesions led to hemobilia. Right atrial and gallbladder metastases were resected. After 2 years of disease-free survival, the patient had recurrent skin lesions, which were treated with local resection and dacarbazine. The patient has survived for more than 5 years after initial diagnosis, with continued complete clinical remission. This case illustrates the importance of aggressive surgical resection and chemotherapy in the treatment of metastatic malignant melanoma.     

Surgical approach to liver metastasis with hepatic hilar invasion

We present a surgical procedure for liver metastases with hepatic hilar invasion, which was originally developed for hilar bile duct cancer. A 64-year-old man with 8 metastatic nodules from colon cancer and hepatic hilar invasion received this technique, and lived for more than 5 years without any restriction in his life. The authors recommend this procedure for those patients in order to preserve their quality of life.     

Concomitant atrial fibrillation ablation in patients undergoing coronary artery bypass and cardiac valve surgery

Surgical ablation of atrial fibrillation (AF) in conjunction with other cardiac surgery is now a class I guideline recommendation. Multiple studies have demonstrated that the concomitant surgical ablation of AF can be performed safely and effectively during valve and coronary artery bypass grafting (CABG) resulting in a return to sinus rhythm postoperatively and improved long‐term results. However, the surgical ablation of AF at the time of other cardiac surgery is performed less often than it should be, especially in patients undergoing CABG and aortic valve surgery. Randomized‐controlled trials designed to determine the effect of treating AF concomitantly with other cardiac surgical procedures have lacked long‐term follow up, but multiple, large observational studies have demonstrated an improved quality of life, a decrease in long‐term strokes, and improved late survival in patients who undergo AF ablation. However, the potential survival benefit of concomitant AF ablation was not addressed by either the Society of Thoracic Surgery or American Association for Thoracic Surgery guideline committees. Left atrial appendage closure is an important part of the surgical ablation of AF as it significantly reduces the long‐term risk of stroke following cardiac surgery and improves the success of AF treatment. In this study, we update the electrophysiology and surgical community on the recommended surgical techniques for AF ablation and its effect on perioperative morbidity, perioperative mortality, as well as its long‐term effects on stroke, quality of life, and survival.