Cardiac Mass in a 78-Year-Old Patient With a History of Cancer: Diagnostic and Treatment Challenges

Figures

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  Fig. 1. Preoperative transthoracic echocardiogram. A) The 4-chamber view of the heart shows the tumor on the IAS projecting toward the right atrium. B) The bicaval view of the heart shows the tumor on the IAS creating a stenosis on the SVC/right atrial junction. IAS, interatrial septum; IVC, inferior vena cava; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; SVC, superior vena cava.

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  Fig. 2. Cardiac tumor. A) Surgeon's view of the tumor. B) Illustration of the operative field for orientation purposes. C) Cardiac reconstruction shows the neo–superior vena cava made of bovine pericardium and the anastomosis with the neo-atrium made of bovine pericardium. Ao, aorta; IVC, inferior vena cava; LEAD, automatic implantable cardioverter-defibrillator lead; RA, right atrium; RV, right ventricle; SVC, superior vena cava; TU, tumor. Illustration by Ismael A. Salas de Armas, MD.

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  Fig. 3. Photographs of surgical resection specimen. A) Internal view of the tumor, with the right atrial endocardium inked blue. B) External view of the tumor. Gross examination of the resected mass shows nodularity and pedunculated lesions arising from the endocardium of the right atrium. The interatrial septum was expanded. C) Cross-sections of the specimen show expansion of the interatrial septum caused by a 6.0 × 3.8 × 3.0–cm tan-brown, hemorrhagic, focally cystic, ill-defined mass in continuity with the lesions from the right atrial endocardium.

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  Fig. 4. Photomicrographs of hematoxylin and eosin–stained slides from the surgical resection specimen. A) The tumor infiltrates the interatrial septum; irregular, sieve-like, anastomosing vascular channels and solid growth are apparent (×20 magnification). B) The tumor infiltrates the myocardium (×100 magnification). C) A high-power view shows that the tumor cells are spindled, with a high nuclear-cytoplasmic ratio, intracytoplasmic lumina (with erythrocytes), nuclear pleomorphism, abundant mitoses, and apoptotic debris (×400 magnification).

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  Fig. 5. Photomicrographs. A) A low-power view of the lesion shows a spindle cell neoplasm with geographic necrosis and moderate nuclear atypia (×100 magnification). B) A high-power view of the lesion reveals a spindle cell neoplasm with frequent atypic mitosis, apoptosis, necrosis, and extravasation of red blood cells (×400 magnification). C) Immunohistochemistry staining for ERG shows diffuse and strong nuclear staining (×100 magnification). D) Immunohistochemistry staining for Ki-67 revealed more than 80% nuclear staining in the tumor cell and provided evidence of high-grade malignant cells (×100 magnification).

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  Fig. 6. Autopsy findings. A) Photographs of the heart (anterior); all elements of the reconstruction were found to be intact. B) Posterior view of the heart.

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  Fig. 7. Photomicrographs of findings from autopsy. A) Tumor emboli in the pulmonary artery (×10 magnification). B) Morphologic features are identical to the primary tumor (×400 magnification).