A case presentation of right atrial tumor and an overall review of cardiac tumors

1. CASE PRESENTATION OF
RIGHT ATRIAL TUMOR
Presenter: M5 Clerk 楊 憶

2. PATIENT PROFILE
• Name: 趙O芝
• Chart No: 2573740
• Age: 64 y/o
• Gender: Female
• Date of admission: 2020/05/24

3. PAST HISTORY
Past Medical History
1. Type 2 diabetes mellitus
2. Hypertension
3. Hyperlipidemia
4. Hepatitis
(unknown, denied HBV/HCV/alcohol,
r/o steohepatitis)

4. PAST HISTORY
Social and Personal History
1. Smoking: a few cigarettes for 30+ years,
quitted now
2. Alcohol: social
3. Betel nuts: denied
Family History: Not contributory

5. CHIEF COMPLAINT
• Worsening dyspnea on exertion on
recent days

6. PRESENT ILLNESS
• Dyspnea on exertion
• Left shoulder pain – only related to position
→ visit orthopedic OPD at 弘大H
→ CXR: no bone lesion, but lung lesions were noted
• Referred to CV OPD
→ Suggest CAG and tumor excision
months
ago
• Referred to our CS OPD
→ CT: RA tumor, suspect lipoma
→ Heart echo: RA tumor, suspect myxoma
2 wk
ago
1 wk
ago

10. CLINICAL COURSE
• Dyspnea on exertion worsened (only climbing a few
steps upstairs)
• No radiated pain or cold sweating
• Fever(-), chills(-), chest tightness/ pain(-),
cold sweating(-), abdominal pain(-)
• CAG: Insignificant coronary artery disease
→ Consult CVS for RA tumor and arrange operation
05/24
05/25

11. TENTATIVE DIAGNOSIS
1. Right atrium tumor, nature to be determined
2. Type 2 diabetes mellitus
3. Hypertension
4. Hyperlipidemia
5. Hepatitis

12. PLAN
1. Pre-op evaluation: Euroscore (0.75%)
2. Tumor excision

13. • OP day
• Complete excision of RA tumor and atrium repair
• Operation findings:
A large lipoma-like tumor about 5x2x2cm, arising from
and intermingled with RA wall, involving the appendix,
upper RA wall and proximal SVC
The remaining RA wall was repaired with an autologous
pericardial patch
• Post op SICU care
CLINICAL COURSE
05/26

16. PATHOLOGY
• Right atrial intracardiac lipoma

17. • Remove endo
• Stable condition
• No fever or dyspnea
• Transfer to CVS ward
CLINICAL COURSE
• Discharge
06/01
05/27
1
05/29

18. FINAL DIAGNOSIS
• Right atrial lipoma

19. CARDIAC TUMORS
Discussion:

20. Introduction Classification
Diagnostic
evaluation
Management
• Cardiac tumors are differenciated into primary and
secondary (metastatic)
• Prevalence of primary cardiac tumors: 0.001-0.03%
• Benign: 75%, myxoma most frequent
• Malignant: 25%, sarcomas most frequent
• Secondary tumors are 20-40x more common than
primary tumors
• 15% of patients with any form of cancer exhibit heart
metastases

21. Introduction Classification
Diagnostic
evaluation
Management
Primary Cardiac Tumors
• Benign (75%)
1. Myxoma
2. Lipoma and Lipomatous Hypertrophy of
the Interatrial Septum
3. Papillary Fibroelastoma
4. Rhabdomyoma
5. Fibroma
6. Others
• Malignant (25%)
1. Sarcomas

22. Introduction Classification
Diagnostic
evaluation
Management
Primary Benign Cardiac Tumors
1. Myxoma
§ Most frequent (25% of all cardiac tumors, >50% of
benign cardiac tumors)
§ Affects mainly women and age groups of 30-60 y/o
§ Originate in undifferentiated and totipotent
mesenchymal stem cells
§ Located in the LA(75%), RA(20%), ventricles(5%)
§ Usually has a pedicle attached to the cardiac wall
§ 35% are friable or villous, tend to present with
emboli
§ 7% of cases are familial: Carney complex
→ relapses are frequent, need close monitoring

23. Introduction Classification
Diagnostic
evaluation
Management
Primary Benign Cardiac Tumors
2-1. Lipoma
§ No sex or age predominance
§ Usually arise from the subepicardium of RA or LV
§ Often asymptomatic
§ Encapsulated, embolization is rare
§ May cause arrhythmias, conduction system
disturbances and symptoms of HF
2-2. Lipomatous Hypertrophy of the Interatrial Septum
§ Hyperplasia of adipocytes on the atrial septum
§ Unencapsulated, spares the fossa ovalis
§ Affects mainly the elderly and obese men

24. Introduction Classification
Diagnostic
evaluation
Management
Primary Benign Cardiac Tumors
3. Papillary Fibroelastoma
§ Second most frequent cardiac tumor
§ Most common valvular tumor (75%)
§ Affects mainly the elderly (age range 60±16)
§ Generally small (<1cm)
§ Located mainly in the aortic(36%), mitral(29%)
valves
§ Symptoms usually were caused by embolization,
either of the tumor itself or thrombus

25. Introduction Classification
Diagnostic
evaluation
Management
Primary Benign Cardiac Tumors
4. Rhabdomyoma
§ Most common pediatric cardiac tumor(<1 y/o)
§ Associated with tuberous sclerosis
§ Usually multiple, affects the RV and LV likewise
§ Most of them regress spontaneously after birth
5. Fibroma
§ Second most common pediatric cardiac tumor
§ Intramural, mostly located in the LV
§ Does not regress spontaneously
§ Often mistaken for hypertrophic cardiomyopathy
or apical thrombus

26. Introduction Classification
Diagnostic
evaluation
Management
Primary Benign Cardiac Tumors
6. Others
§ Angiomas, teratomas, and mesotheliomas
§ Rare (7% of cardiac tumors)
§ Affect mainly children
§ Teratomas arise within the pericardium
→may lead to constrictive pericarditis

27. Introduction Classification
Diagnostic
evaluation
Management
Primary Malignant Cardiac Tumors
1. Sarcomas
§ Affect ages from 30-50 y/o
§ Angiosarcomas are usually located in the RA
§ Other sarcomas affect the LA more frequently
§ Poor prognosis
§ Mestatses affect the lungs, brain, and bones

28. Introduction Classification
Diagnostic
evaluation
Management
Secondary (Metastatic) Cardiac Tumors
§ Arise from melanoma, lung, breast, renal cancer, or
lymphoma
§ Often affects the pericardium (55%)
→ Percardial effusion (contain cancer cells or blood
clots and fibrin)
§ Carcinoid syndrome
• Usually affects the right chambers
• Deposition of fibrous plagues
→ tricuspid and/or pulmonic valve thickening
→ subsequent regurgitation and stenosis

29. Introduction Classification Diagnostic evaluation Management

30. Introduction Classification
Diagnostic
evaluation Management
Benign primary tumors
§ Surgical resection
§ Urgency determined by:
§ Symptoms
§ Type of the tumor
Malignant primary tumors
§ Surgical resection
§ Chemotherapy
Metastatic tumors
§ Management of cardiovascular complications

31. Introduction Classification
Diagnostic
evaluation Management
1. Myxoma
§ High risk of embolic and cardiac complications
§ Immediate resection regardless of symptoms
§ Relapse 3%
§ Operative mortality <5%
2. Papillary fibroelastomas
§ Surgically removed in large (>1cm) and/or mobile
tumors
§ Small, immobile → conservative txt and f/u
§ Most authors propose surgical management even in
asymptomatic patients

32. Introduction Classification
Diagnostic
evaluation Management
3. Lipoma and lipomatous hypertrophy of interatrial septum
§ Surgically removed only in cases of serious
hemodynamic compromise
4. Rhabdomyoma
§ Regress spontaneously
§ Usually doesn’t need surgical management

33. Introduction Classification
Diagnostic
evaluation Management
Benign primary tumors
§ Surgical resection
§ Urgency determined by:
§ Symptoms
§ Type of the tumor
Malignant primary tumors
§ Surgical resection
§ Chemotherapy
Metastatic tumors
§ Management of cardiovascular complications

34. Introduction Classification
Diagnostic
evaluation Management
1. Sarcomas
§ Surgical resection
§ Poor results
§ High rates of relapse
§ Chemotherapy
§ Neoadjuvant or adjuvant
§ Non-operable or metastatic sarcomas
§ Median survival is typically 6 to 12 months
2. Lymphoma
§ Chemotherapy with/without RT

35. Introduction Classification
Diagnostic
evaluation Management
Benign primary tumors
§ Surgical resection
§ Urgency determined by:
§ Symptoms
§ Type of the tumor
Malignant primary tumors
§ Surgical resection
§ Chemotherapy
Metastatic tumors
§ Management of cardiovascular complications

36. Thank you