Surgical treatment of cardiac myxosarcoma

A 36-year-old man suffering from exertional dyspnea was admitted to our hospital. An echocardiogram showed a left atrial tumor, which was excised via the left atrial approach. Histological examination of the surgical specimen revealed that it was a myxosarcoma. Twelve months after the surgery, the tumor recurred in the left atrium, and metastatic tumors were found in the right atrium and right ventricle. Surgery was performed once again, but examinations 5 months after the second surgery showed local recurrences and multiple metastases. Although the patient had received chemotherapy, he died 30 months after the first operation.     

Left atrial sarcoma with the initial diagnosis of myxoma

Primary tumors of the heart are rare. The majority of these tumors are benign, with myxomas located in the left atrium being the most common form. Almost all malignant tumors are sarcomas and occur preferentially in the right side of the heart. The case of a 73-year-old woman who presented with symptoms of mitral valve stenosis is reported. Echocardiography revealed a left atrial mass that was interpreted as atrial myxoma. At the operation, the tumor which was lobulated and had a smooth surface was arising from posterior wall of left atrium extending into the mitral annulus. Wide surgical excision was possible with left atrial reconstruction and mitral valve replacement. Histological and immunohistochemical studies revealed malignant undifferentiated sarcoma extending to the surface of mitral valve. Postoperative metastatic work-up showed no evidence of dissemination. The patient survived the operation without adjuvant radiation and chemotherapy and has been symptom-free over 1 year. At present, 16 months following the operation, the patient is alive with no evidence of disease.     

Calcified metastatic brain tumor--two case reports

A 29-year-old man and a 46-year-old woman presented with calcified brain metastasis from pulmonary adenocarcinoma. Both patients had a relatively benign clinical course and prolonged survival after total removal of the tumors. The male patient was still alive 2 years 3 months after surgical resection of the metastatic and primary tumors. The female patient had had brain metastasis 8 years after surgical resection of lung cancer, and survived for 3 years 3 months after removal of the brain metastasis. The MIB-1 indexes of the two cases were relatively low compared with other cases of brain metastases. Calcification and low MIB-1 index may indicate longer survival in patients with metastatic tumors if the primary tumor is controlled.     

Tumors of the heart: surgical considerations

A series of 23 cardiac tumors is reported. Six were diagnosed at autopsy; 17 tumors were surgically explored. Eleven of the 17 were myxomas within the left atrium. Eight of the 17 patients presented with congestive heart failure; peripheral and cerebral emboli were also common. The diagnosis was made preoperatively in 10 patients. Two-dimensional echocardiography was the most reliable diagnostic tool. Follow-up averages 55 months; there have been no late deaths or recurrences. The other six surgically treated tumors were: a left ventricular rhabdomyoma, a septal lipoma, a right atrial calcified endocardial mass, a right ventricular fibrosarcoma, a rhabdomyosarcoma, and a sarcoma metastatic to the pericardium and right atrium. From this series and a review of the literature, we concluded that: benign cardiac tumors can usually be excised with a low morbidity and excellent long-term results; malignant cardiac tumors have a dismal prognosis, and operation is primarily diagnostic; tumors metastatic to the heart should be operated upon only if successful palliation seems possible.     

Cerebral metastasis from a renal cell carcinoma more than 10 years after nephrectomy: report of two cases

The authors report two cases with renal cell carcinoma (RCC) metastatic to the brain more than 10 years after nephrectomy. Case 1: An eighty-six-year-old female, on whom nephrectomy had been performed 12 years before, complained of alexia. Computed tomography (CT) revealed ring enhancement in the left temporoparietal region. Total removal of the brain tumor and irradiation of 18 Gy during surgery was performed. Histological examination showed metastatic brain tumor from RCC. The postoperative course was excellent. In the postoperative examination lung metastasis was found. Case 2: A sixty-seven-year-old male, on whom nephrectomy had been performed 15 years before, presented with right hemiparesis, aphasia and convulsion. CT showed two enhanced lesions, one of which accompanied with a hematoma in the left frontal lobe. Chest X-ray showed a coin lesion in the right lower lobe. Total removal of brain tumors was performed and 18 Gy irradiation was administered during surgery. Histological study revealed RCC. However, 3 months after surgery, a new lesion was recognized in the opposite hemisphere. The long interval of latency may be attributed to the slow-growing characteristic of renal cell carcinoma and the fact that renal cell carcinoma is under the influence of host immunity. Surgical treatment is recommended for patients who develop a solitary metastatic lesion or in whom other lesions are controlled and remain in a stable condition.     

Primary osteogenic sarcoma of the heart.

The clinical course of a 17-year-old boy with primary osteogenic sarcoma of the left atrium with partial obstruction of the mitral valve and the right pulmonary veins is described. After operative removal of the tumor, echocardiography documented its rapid recurrence. Despite two subsequent open-heart operations and adjuvant chemotherapy and radiotherapy, the patient died twenty-one months after the initial symptoms. Previous reports of such tumors are reviewed, and technical difficulties of removal are discussed.     

Brain metastasis of Merkel cell carcinoma

Merkel cell carcinoma (MCC) is a rare primary cutaneous neuroendocrine tumor that is locally aggressive and has potential for metastatic spread. However, brain metastases are rare, and therapy for such tumors has never reported. The authors present a 48-year-old woman with MCC of the left elbow and a right cerebellar metastasis. After the right cerebellar mass was totally resected, radiation treatment and chemotherapy were performed. Eight cases of brain metastasis have been reported in the literature, but only 5 have been presented in sufficient detail for analysis. Therapy for brain metastases has always been palliative whole-brain irradiation and chemotherapy except for our patient, who underwent total removal of the tumor and survived for 11 months without neurological deficit. Except in the case of 1 with a particularly radiosensitive MCC, the patients with brain metastases died within 9 months after detection of the brain lesions. If possible, aggressive excision of brain metastases as well as of the primary lesion should be done.     

Intracranial hemorrhage due to brain metastasis from hepatocellular carcinoma--case report.

The authors report a case of repeated brain metastases from hepatocellular carcinoma (HCC) in a 70-year-old male, who had underwent liver segmentectomy for HCC 5 years earlier. He developed intracerebral hemorrhage in the right parietal region, which was considered to be intratumoral because the metastatic tumor was detected in the same region. Total removal of the tumor and hepatic artery embolization followed by ethanol injection for recurrent HCC were performed. One month later, a metastatic tumor was discovered in the upper vermis and was totally removed. Both metastatic brain tumors were histologically verified as Edmondson grade 2 HCC. Four months later, multiple metastases to the left frontal region and the upper vermis occurred, and he died of pneumonia. Brain metastasis from HCC is rare; nine such cases have been reported in the literature, of which eight cases developed intracranial hemorrhage as in the present case.     

Surgical technique for a cystic-type metastatic brain tumor: transformation to a solid-type tumor using hydrofiber dressing

Background

Many metastatic brain tumors have a distinct border with normal brain tissue, which facilitates tumor removal. However, residual tumor tissue may be present after surgery when metastatic brain tumors are of cystic type. We have developed a method using hydrofiber dressing to transform cystic-type into solid-type tumors.

Methods

Hydrofiber dressing is a sodium carboxymethylcellulose hydrocolloid polymer with high fluid-absorptive capacity. This material was originally used as a dressing for exudative wounds. Hydrofiber dressing was used for 8 patients with cystic-type metastatic brain tumor. Tumor removal was performed after hydrofiber dressing was inserted into the cyst cavity to transform the tumor into a solid-type tumor.

Results

Transformation of cystic-type metastatic brain tumors into smaller solid-type tumors using hydrofiber dressing facilitated en bloc resection of tumor. The dressing also absorbed residual cyst fluid and was thus also effective in preventing intraoperative dissemination of tumor cells. This approach enabled ideal en bloc resection in all patients. There were no adverse events.

Conclusions

These findings suggest hydrofiber dressing may be useful in surgery for cystic-type metastatic brain tumors.     

Intracardiac extension of malignant uterine tumors. Echocardiographic detection and successful surgical resection

The echocardiographic findings of two unusual cases of malignant uterine tumors that invaded the heart are reported. A woman previously operated on for invasive cervical carcinoma had multiple embolic phenomena and evidence of obstruction to mitral flow. An echocardiogram showed a mass in the left atrium that reached the mitral valve ring. The tumor was implanted in a pulmonary vein and was removed with no complications. Cell type indicated metastatic carcinoma of the cervix. In the second case the patient had a large abdominal mass and precordial manifestations of obstruction and regurgitation of the tricuspid valve. An echocardiogram showed that a mass emanating from the inferior vena cava filled the right atrium and part of the right ventricle. The trajectory of the tumor was followed to its origin in an ovarian vein by tomography. The entire tumor was removed and identified as endometrial stromal sarcoma. An increase in operations with or without radiation therapy for malignant tumors has augmented the frequency of metastatic invasion of the heart; intracavitary extension tends to results from embolization or propagation along great veins. This is the first report of a uterine carcinoma reaching the heart by way of the pulmonary veins and of invasion of the heart by endometrial stromal sarcoma, both with successful excision.     

Metastatic lung tumor from uterine leiomyosarcoma

We herein present 2 cases of metastatic lung tumor derived from uterine leiomyosarcoma. In the case 1, a 59-year-old woman was admitted to our hospital to examine abnormal shadow detected on chest X-ray. She had undergone hysterectomy and oophorectomy for uterine leiomyosarcoma 19 months previously. A round 3 cm mass in the right lung (S10) was seen on chest X-ray and computed tomography (CT). No other distant metastases or local recurrence were found, and the right lower lobectomy was perfomed under the clinical diagnosis of metastatic lung tumor. Postoperative pathologic examination revealed the tumor as a metastatic leiomyosarcoma. The patient recovered uneventfully, and there have been no signs of recurrence for 26 months after the pulmonary resection. In the case 2, a 58-year-old woman, who had undergone hysterectomy and oophorectomy for uterine leiomyosarcoma 7 months previously, was admitted to our hospital for further examination of pulmonary tumors on chest X-ray. Two tumors were recognized in the left lung (S8 and S10) on chest X-ray and CT. No other distant metastases or local recurrence were found, and the left lower lobectomy was performed under the clinical diagnosis of metastatic lung tumors. Pathological examinations revealed smooth muscle cells with nuclear pleomorphism and high mitotic indices. The tumors proved to be lung metastases derived from uterine leiomyosarcoma. Postoperative course was uneventful. However, brain metastasis was found 1 month after the pulmonary resection, and she underwent resection of brain metastasis. Two months after the brain metastasectomy, local recurrence of the brain tumor developed and re-resection followed by stereotactic radiotherapy was performed. Furthermore, intrapelvic recurrence was found 4 months after the pulmonary resection. Exploratory laparotomy revealed the tumor was unresectable, and she received 4 courses of chemotherapy (paclitaxel and carboplatin). For metastatic lung tumor from uterine leiomyosarcoma, surgery has been considered the best choice. However, for patients with uterine leiomyosarcoma who cannot be treated surgically because of multiple metastatic tumors or poor surgical risk chemotherapy (paclitaxel and carboplatin) or stereotactic radiotherapy can be strategies.     

Hepatocellular carcinoma with tumor thrombus extending into the right atrium: report of a successful resection with the use of cardiopulmonary bypass.

Hepatocellular carcinoma with a tumor thrombus extending into the right atrium has been considered beyond the reach of resection. These patients usually die within a short period because of pulmonary embolism, heart failure, or cancer progression. The only treatment is hepatic resection with removal of the tumor thrombus. A 38-year-old woman underwent left lobectomy with removal of the tumor thrombus with the use of cardiopulmonary bypass. The patient had an uneventful course and is doing well 15 months after surgery, without signs of recurrence. We have proved that hepatic resection with removal of a tumor thrombus extending into the right atrium can be carried out successfully. The next problem is whether the lives of these patients can be prolonged by this operation.     

Results of the surgical treatment of metastatic brain tumors

Results of surgical treatment in 85 cases with metastatic brain tumors are reviewed. The lung was the most frequent site of primary lesion and the following sites were GI tract and the breast. Adequate treatment consisted of total removal of tumor, irradiation and/or chemotherapy were carried out in 51 cases. The remaining 34 cases had an unsuccessful treatment because of their poor physical condition. Mean survival time after adequate treatment was 8.75 months in the former group and 3.06 months in the latter group. Of 51 patients (86.3%) in the former group, 44 showed improvement of the neurological signs after treatment. In the latter group, only 14 patients (41.2%) revealed neurological improvement. Total removal of tumor was carried out in 55 of 85 cases. The one-month operative mortality for all patients was 19.2%. Postoperative one-year survival rate was 12.5% in 16 cases with multiple metastases and in 36 cases with single metastasis was 25.6%. Follow-up study of 77 cases showed 31.2% of survival rate in 6 months, 18.2% in one-year and 5.2% in two-years. Only four patients survived more than 3 years after treatment. The direct causes of death in cases of total removal were attributed in recurrence of primary lesion or remote metastases to other organs. This study revealed that the prognosis of the patient with metastatic brain tumor was influenced by existence of intracranial hypertension due to brain edema or metastatic tumor itself and metastases to other organs.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case of tumor thrombus in the right atrium after multimodal treatment of testicular tumor

A case was reported concerning a successful removal of tumor thrombus extending into the right atrium through the left brachiocephalic vein and the superior vena cava. The patient was a 34-year-old man who underwent a left inguinal orchiectomy for immature teratoma of testis in June 1987. The operation was followed by another three operations for excision of lymph node metastases and five courses of cisplatin based combination chemotherapy. In December 1988, the chest CT scan film revealed filling defect in the superior vena cava and the right atrium. Thrombus was detected using echocardiography and angiography. He had no symptom, but multiple pulmonary infarcts were also detected. In February 1989, the operation was performed by means of cardio-pulmonary bypass. A soft yellowish thrombus attached to the left venous angle was removed with resection of the left brachiocephalic vein. Microscopic findings revealed that the thrombus was metastatic testicular teratoma. With further treatment after the operation, he has been disease-free for 14 months now. We conclude that in this case aggressive surgical management following chemotherapy had great value to control the disseminated testicular tumor.     

Undifferentiated pleomorphic sarcoma in the left atrium; report of a case

Primary cardiac sarcomas are rare. A 41-year-old woman complaining of dyspnea was admitted to our hospital. Echocardiography and computed tomography (CT) showed a primary cardiac tumor in the left atrium. During surgery, the tumor was noted to be arising from the anterior wall of the left atrium, under the aortic sinuses. Histological and immunohistochemical studies revealed an undifferentiated pleomorphic sarcoma. Eleven months later, echocardiography and CT showed recurrence of the cardiac sarcoma in the left atrium. The patient underwent wide resection of the left atrium and mitral valve replacement because the tumor extended to the mitral valve leaflet. The patient died 3 months after the 2nd surgery because of the 2nd recurrence of the cardiac sarcoma. Although most tumors that develop in the left atrium are benign myxomas, preoperative differential diagnosis is important. It is especially necessary to suspect a sarcoma in the case of a non-septal orgin of the mass.     

Primary osteosarcoma of heart with severe congestive heart failure.

We present a case report on a 54-year-old woman with extraskeletal osteosarcoma of the left atrium featuring severe congestive heart failure. We resected the tumor, which occupied the left atrium and had widely infiltrated the atrial wall, but the patients died of the tumor 9 months after surgery. This is to our knowledge the 32nd case of cardiac osteosarcoma ever reported.     

Metastatic fibrosarcoma of the brain: transformation from conventional to epithelioid form--case report

A 45-year-old woman presented with an extremely rare metastatic fibrosarcoma of the brain manifesting as persistent headache. She had undergone surgery for a fibrosarcoma of the soft tissue of the thigh 2 months earlier. She had a history of previous surgery and radiotherapy for this tumor. She was somnolent with papilledema and left hemiparesis. Magnetic resonance imaging of the brain revealed a right frontal lesion with mass effect and heterogeneous enhancement. Computed tomography and scintigraphy showed multiple metastatic lesions of the lung. Right frontal craniotomy was performed for gross total removal of the yellowish-white tumor. Histological examination showed signs of epithelioid transformation based on positive staining for epithelial membrane antigen compared to the primary tumor. Postoperatively the patient was alert and the left hemiparesis improved. She refused radiotherapy or chemotherapy. Follow-up computed tomography showed multiple intracranial metastases. She died 5 months after the surgery.     

Primary cardiac angiosarcoma: presenting with cardiac tamponade followed by cerebral hemorrhage with brain metastases

A 49-year-old man presented with palpitation and shortness of breath. He was seen to have a massive pleural and pericardial effusion on radiography and echocardiography. Computed tomography (CT) scanning showed that cardiac tumors arose from the right atrium with epicardial and endocardial extension. Pathology examination of samples at pericardiotomy revealed them to be angiosarcoma. Two days after the surgery, he developed left hemiparesis. CT scans showed a large cerebral hemorrhage on the right temporal lobe with midline shift by brain metastases. He died 37 days after the surgery. At autopsy, he had metastases in the brain, multiple bones, and soft tissues but no lung or left-side heart involvement. Primary cardiac angiosarcoma is rare, and mostly arises from the right side of the heart. Common metastatic sites are the lungs and liver. There are only a few reports of brain metastases. In conclusion, this is a rare report of cardiac angiosarcoma presenting with pericardial tamponade. There were rapid brain and multiple bone metastases but no lung or left-side heart lesions.     

Liposarcomatous tumor emboli to the left iliac artery growing intraluminally into the femoral artery. A report of an operative and autopsy case

A 74-year-old female patient with a past history of the locally recurrent tumor of the liposarcoma in the right thigh over 20 years ago received an emergency vascular operation to relieve severe ischemic symptoms in the left leg. The left femoral artery was pulseless and was filled with several long, translucent and cord-like tumors which resembled the hands of a cuttlefish. The tumors were easily removed except its root adhering to the left common iliac artery. A crossover femoro-femoral artery bypass was carried out. On the 24th postoperative day she died suddenly. The autopsy findings were as follows: A hen egg-sized tumor occupied almost whole space of the left atrium, and connected with the metastatic right lung tumor via the pulmonary vein. The sudden death was probably due to the abrupt obstruction of the mitral valve by the tumor in the left atrium. The residual tumor was noted in the left common iliac artery, but its adventitia was not involved. The pathohistological diagnosis of each tumor was same, well differentiated liposarcoma. The tumors which occluded the left iliofemoral artery must have originated from the tumor in the left atrium in form of the tumor embolism, lodged in the left common iliac artery, grown intraluminally into external iliac and femoral artery, and finally caused ischemia of the left leg.     

A case report of primary rhabdomyosarcoma of the heart treated with mitral valve replacement]

We report a case of rhabdomyosarcoma involving the mitral valve of a 57-year-old female. She was referred to our hospital for progressive orthopnea and edema. Chest X-ray showed marked cardiomegaly and pulmonary congestion. Echocardiogram revealed solid mass in left atrium involving the mitral valve. Emergency operation was required because of acute heart failure. At the operation, the mitral orifice was obstructed by the tumor arising from the left atrium. After partial resection of the left atrium, mitral valve replacement with a Carpentier-Edward prosthesis was performed. Subsequently microscopic examination diagnosed as rhabdomyosarcoma. She died three months after the operation of heart failure probably due to progression of the remnant of the tumor. This, to our knowledge, is the first case of mitral valve replacement for a primary rhabdomyosarcoma of the heart in Japan.