Presentation for students

1. CARDIAC
NEOPLASMS
DEPARTMENT OF CARDIAC AND VASCULAR SURGERY
MEDICAL UNIVERSITY PLOVDIV
HRISTO RAHMAN

2. CARDIAC NEOPLASMS
CLASSIFICATION
▸PRIMARY CARDIAC TUMORS
▸- BENIGN 75%;
▸- MALIGNANT 25%
▸SECONDARY CARDIAC TUMORS
▸- FROM METASTATIC SPREAD ( LYMPHOMA, BREAST, LUNG,
MELANOMA, SARCOMA );
▸- FROM DIRECT SPREAD ( OESOPHAGUS, LUNG, BREAST, THYMUS )
▸SECONDARY TUMORS FROM BOTH METASTATIC AND DIRECT SPREAD
TO THE HEART: 30 TIMES MORE COMMON THAN PRIMARY CARDIAC
TUMORS

3. CARDIAC NEOPLASMS
CLASSIFICATION
▸SUBDIAPHRAGMATIC TUMORS
▸- ORIGINATING FROM:
▸1. KIDNEYS;
▸2. UTERUS;
▸3. LIVER;
▸4. ADRENAL GLANDS.
▸SUBDIAPHRAGMATIC TUMORS MAY ALSO “INVADE” THE RIGHT
ATRIUM A VIA THE INFERIOR VENA CAVA

4. CARDIAC NEOPLASMS
▸ Renal cell carcinoma of
the right kidney
extending into the
inferior vena cava and
right atrium
▸ A. Serial axial computed
tomography images
demonstrating a large
right renal tutor and a
“filling defect” in the
inferior vena cava and
right atrium
▸ B. Excised right kidney
with tutor extension into
the inferior vena cava

5. CARDIAC NEOPLASMS
MOST FREQUENT PRIMARY BENIGN
CARDIAC TUMORS
▸ 1. MYXOMA;
▸ 2. LIPOMA:
▸ - WELL ENCAPSULATED
TUMORS THROUGHOUT THE
HEART ( ESPECIALLY RA);
▸ - COMMONLY IN OBESE,
ELDERLY, FEMALE PATIENTS;
▸ - SURGERY: USUALLY
INDICATED FOR SYMPTOMATIC
PATIENTS CAUSED BY
OBSTRUCTION TO CARDIAC
OUTFLOW

6. CARDIAC NEOPLASMS
MOST FREQUENT PRIMARY BENIGN
CARDIAC TUMORS
▸3. PAPILLARY
FIBROELASTOMA:
▸ - USUALLY OCCURS ON:
▸ * CARDIAC VALVES ( ESPECIALLY
MITRAL AND AORTIC );
▸ ** IN VENTRICLES AS MASSES
WITH FROND-LIKE PROJECTIONS.
▸ - FIBROELASTOMAS CAN BE
ASYMPTOMATIC, OBSTRUCT
FLOW OR EMBOLISE
▸ - SURGICALLY TREATED BY
RESECTION

7. CARDIAC NEOPLASMS
PAPILLARY FIBROELASTOMA

8. CARDIAC NEOPLASMS
MOST FREQUENT PRIMARY BENIGN
CARDIAC TUMORS
▸4. RHABDOMYOMA:
▸- COMMONEST BENIGN CARDIAC TUMOR
IN CHILDREN;
▸- MULTICENTRIC, PEDUNCULATED
TUMORS IN EITHER VENTRICLE CAUSING
OBSTRUCTIVE SYMPTOMS, VALVULAR
REGURGITATION OR ARRHYTHMIAS
▸5. OTHER BENIGN CARDIAC TUMORS:
▸- 5.1 FIBROMA;
▸- 5.2 HAEMANGIOMA;
▸- 5.3 TERATOMA;
▸- 5.4 NEUROFIBROMA;
▸- 5.5 LYMPHANGIOMA

9. CARDIAC NEOPLASMS
EPIDEMIOLOGY OF CARDIAC MYXOMAS
▸OCCUR WITH INCIDENCE
1:500,000, WITH 5%
FAMILIAL;
▸COMMONEST IN PATIENTS
AGED 40-60 WITH FEMALE
PREDOMINANCE (70%);
▸ACCOUNT FOR:
▸- 40% OF BENIGN CARDIAC
TUMORS IN ADULTS;
▸- 15% IN CHILDREN

10. CARDIAC NEOPLASMS
EPIDEMIOLOGY OF CARDIAC MYXOMAS
▸THE MAJORITY ARE
LOCATED IN THE LEFT
ATRIUM ( 75%)
▸USUALLY ORIGINATE FROM
THE INTERATRIAL SEPTUM
▸20% - LOCATED IN THE
RIGHT ATRIUM
▸5% - LOCATED IN THE
VENTRICLES OR ATTACHED
TO VALVES

11. CARDIAC NEOPLASMS
CARNEY’S SYNDROME
▸AUTOSOMAL DOMINANT FAMILIAL FORM OF ATRIAL MYXOMA
▸MALE PREDOMINANCE AT AN EARLIER AGE
▸NON-FAMILIAL FORM - OFTEN IN CHILDHOOD
▸COMMONLY OCCUR IN BOTH ATRIA AND ARE MULTICENTRIC
( 65% ) WITH FREQUENT RECURRENCE ( 40% )
▸ASSOCIATED WITH ADRENOCORTICAL NODULAR MASSES,
SERTOLI CELL TESTICULAR TUMOR, SPOTTY
MUCOCUTANEOUS PIGMENTATION

12. CARDIAC NEOPLASMS
PATHOLOGY OF CARDIAC MYXOMAS
▸CARDIAC MYXOMAS ARE NEOPLASMS
OF ENDOCARDIAL ORIGIN, DERIVED
FROM EITHER PLURIPOTENT
MESENCHYMAL CELLS OR
ENDOCARDIAL NERVE CELLS
▸OFTEN APPEAR AS OVOID,
PEDUNCULATED MASSES, WHICH ARE
FRIABLE, MUCOID, GRAY-WHITE IN
COLOR AND SMOOTH OR GRANULAR IN
APPEARANCE
▸HISTOLOGICAL ANALYSIS: ACID
MUCOPOLYSACCHARIDE MATRIX WITH
POLYGONAL CELLS, CAPILLARY-LIKE
STRUCTURES AND HAEMORRHAGIC
AREAS

13. CARDIAC NEOPLASMS
CLINICAL FEATURES OF CARDIAC
MYXOMAS
▸SYMPTOMS REALTED TO:
▸1. OBSTRUCTION TO BLOOD FLOW;
▸2. INTERFERENCE WITH VALVULAR FUNCTION;
▸3. SYSTEMIC EMBOLISATION;
▸4. CONSTITUTIONAL SYMPTOMS - FEVER,
WEIGHT LOSS, MALAISE, MYALGIA, ANAEMIA
▸DIASTOLIC MURMUR ( MIMICS MITRAL OR
TRICUSPID STENOSIS )
▸EARLY DIASTOLIC TUMOR “PLOP”
▸PAN-SYSTOLIC MURMUR OF MITRAL OR
TRICUSPID REGURGITATION ( WRECKING BALL
EFFECT )

14. CARDIAC NEOPLASMS
DIAGNOSTIC IMAGING MODALITIES
▸ECG - NOT SPECIFIC; EVIDENCE OF
ARRHYTHMIAS AND CONDUCTION
DISTURBANCES;
▸CHEST RADIOGRAPHY NOT SPECIFIC;
EVIDENCE OF CARDIOMEGALY;
▸ECHOCARDIOGRAPHY ( TTE & TEE ) -
MOST APPROPRIATE; EVIDENCE OF
VALVE PATHOLOGY AND FUNCTION;
▸COMPUTED TOMOGRAPHY;
▸MAGNETIC RESONANCE IMAGING

15. CARDIAC NEOPLASMS
PRINCIPLES OF SURGERY FOR PATIENTS
WITH LEFT ATRIAL MYXOMA▸MEDIAN STERNOTOMY
▸CARDIOPULMONARY BYPASS ( BICAVAL
CANNULATION AND SNARES)
▸MINIMAL CARDIAC MANIPULATION TO AVOID
TUMOR EMBOLISATION
▸THE MYXOMA IS APPROACHED VIA STANDARD
LEFT ATRIOTOMY, TRANS-SEPTAL ATRIAL
INCISION, DUBOST BI-ATRIAL INCISION
▸IDEALLY THE TUMOR IS RESECTED EN BLOC
WITH CLEAR RESECTION MARGINS
▸IF THE SEPTUM IS INVOLVED, IT MAY BE
CLOSED WITH PERICARDIAL PATCH
▸IRRIGATION OF THE ATRIAL CAVITY WITH
SALINE TO WASH AWAY ANY RESIDUAL
NEOPLASTIC CELLS
▸ASSESSMENT OF VALVULAR FUNCTION FOR
ANY “WRECKING BALL” EFFECT CAUSING
REGURGITATION

16. CARDIAC NEOPLASMS
PRINCIPLES OF SURGERY FOR PATIENTS
WITH LEFT ATRIAL MYXOMA▸MEDIAN STERNOTOMY
▸CARDIOPULMONARY BYPASS ( BICAVAL
CANNULATION AND SNARES)
▸MINIMAL CARDIAC MANIPULATION TO
AVOID TUMOR EMBOLISATION
▸THE MYXOMA IS APPROACHED VIA
TRANS-SEPTAL ATRIAL
INCISION, IDEALLY THE TUMOR IS
RESECTED EN BLOC WITH CLEAR
RESECTION MARGINS
▸IF THE SEPTUM IS INVOLVED, IT MAY BE
CLOSED WITH PERICARDIAL PATCH
▸IRRIGATION OF THE ATRIAL CAVITY WITH
SALINE TO WASH AWAY ANY RESIDUAL
NEOPLASTIC CELLS
▸ASSESSMENT OF VALVULAR FUNCTION
FOR ANY “WRECKING BALL” EFFECT
CAUSING REGURGITATION

18. CARDIAC NEOPLASMS
PRINCIPLES OF SURGERY FOR PATIENTS
WITH LEFT ATRIAL MYXOMA
▸RECURRENCE RATE < 5% DUE TO:
▸1. INADEQUATE RESECTION;
▸2. TUMOR SEEDING AT THE PRIMARY OPERATION;
▸3. MULTICENTRIC TUMORS

19. CARDIAC NEOPLASMS
MOST FREQUENT PRIMARY MALIGNANT
CARDIAC TUMORS
▸1. ANGIOSARCOMA:
▸- FREQUENTLY LOCATED IN THE ATRIA;
▸- PRESENT WITH CAVAL OR VALVULAR
OBSTRUCTION;
▸- PATIENTS USUALLY HAVE DISTANT METASTASES
AT THE TIME OF PRESENTATION
▸- POOR PROGNOSIS (
MEDIAN SURVIVAL APPROX. 6 MONTHS)

20. CARDIAC NEOPLASMS
MOST FREQUENT PRIMARY MALIGNANT
CARDIAC TUMORS
▸2. RHABDOMYOSARCOMA:
▸- MULTICENTRIC TUMORS
OCCURING IN ALL LOCATIONS
THROUGHOUT THE HEART;
▸- USUALLY TREATED BY
SURGICAL RESECTION
FOLLOWED BY ADJUVANT
CHEMOTHERAPY AND
RADIOTHERAPY;
▸- POOR PROGNOSIS
( MEDIAN SURVIVAL IS APPROX.
12 MONTHS )

21. CARDIAC NEOPLASMS
MOST FREQUENT PRIMARY MALIGNANT
CARDIAC TUMORS
▸3. OTHER PRIMARY MALIGNANT CARDIAC TUMORS:
▸- 3.1 FIBROUS HISTIOCYTOMA;
▸- 3.2 FIBROSARCOMA;
▸- 3.3 LEIOMYOSARCOMA;
▸- 3.4 LIPOSARCOMA

22. MOST SARCOMAS
ARE INCURABLE BUT
CARDIAC
TRANSPLANTATION
CAN BE CONSIDERED
FOR THOSE WITHOUT
METASTATIC SPREAD
ONCOLOGY & CARDIAC
SURGERY
CARDIAC NEOPLASMS