High-Grade Pleomorphic Sarcoma of the Left Atrium after Incomplete Resection and Adjuvant Chemotherapy

Ricardo J. Razera Amanda Mendonça de Araújo Viviane Pereira Bernardes Fernanda Miranda Moisés Leonardo Santos Mundim Rogério A. Araújo About the authors

Keywords
Cardiovascular Diseases; Neoplasms; Sarcoma/complications; Sarcoma/surgery; Heart Atria/surgery; Atrial Function; Drug Therapy

Introduction

Primary cardiac tumors are extremely rare, found in only 0.02% of all autopsies.11. Hoffmeier A, Sindermann JR, Scheld HH, Martens S. Cardiac tumors - diagnosis and surgical treatment. Dtsch Arztebl Int. 2014 Mar 21;111(12):205-11. These tumors are malignant in only 25% of the cases, 75% of which are sarcomas, frequently affecting young people with no risk factors.² The median overall survival is less than 1 year,³ ranging from 9 to 16 months,44. Oliveira GH, Al-Kindi SG, Hoimes C, Park SJ. Characteristics and survival of malignant cardiac tumors: a 40-year analysis of >500 patients. Circulation. 2015 Oct 14;132(25):2395-402.,55. Bakaeen FG, Reardon MJ, Coselli JS, Miller CC, Howell JF, Lawrie GM, et.al. Surgical outcome in 85 patients with primary cardiac tumors. Am J Sur. 2003 Dec;186(6):641-7. with rapid proliferation and deaths caused by arrhythmias, thrombosis, pulmonary embolism,66. Toufan-Tabrizi M, Parvizi R, Reshadati N, Shokouhi B. Left atrial malignant fibrous histiocytoma with right atrium invasion. Caspian J Intern Med. 2019;10(2):228-30. and, most importantly, heart failure.77. Donsbeck AV, Ranchere D, Coindre JM, Le Gall F, Cordier JF, Loire R. Primary cardiac sarcomas: an immunohistochemical and grading study with long-term follow-up of 24 cases. Histopathology. 1999 Apr;34(4):295-304. Due to its rarity, reports in the literature about the best treatment are scarce, especially in malignant tumors.¹ The aim of the present work is to report a case of an undifferentiated pleomorphic sarcoma (UPS) in the left atrium in which surgical treatment was associated with chemotherapy, with an overall and progression-free survival of neoplastic disease higher than the median described in previous manuscripts.

Case Report

A 32-year-old woman was admitted to the institution in May 2019, complaining of dyspnea upon exertion, which had lasted for 6 months and had progressively worsened, associated with sinus tachycardia, coughing, and vomiting. The patient underwent a Doppler echocardiogram, which showed a mass in the left atrium, with irregular contours, attached to the interatrial septum and involvement of the mitral valve, with an ejection fraction (Simpson) of 62%; a double mitral lesion, with significant stenosis and moderate insufficiency; as well as tricuspid valve insufficiency and moderate pulmonary hypertension. It is important to note that the mass was not an artifact, since it was viewed in more than one slice.

Symptoms were attributed mainly to pulmonary congestion, caused by the predominance of stenosis, as compared to mitral regurgitation. Right (RA) and left (LA) atria presented a slight volumetric increase, the right ventricle (RV) with a moderate increase in diameter and the left ventricle (LV) with a normal diameter. Slightly impaired biventricular function decreased to a slight degree only in the RV. The mitral valve apparatus contained a thickened anterior leaflet with reduced mobility and cupola due to the presence of tumor mass infiltration in the leaflet body, measuring approximately 18 × 21 mm in diameter, coupled with a reduced valve opening, once again justifying the diagnosis of stenosis. The Doppler images showed a moderate, eccentric reflux to the LA lateral wall and a valve area of 0.7 m2. Tricuspid valve apparatus with slightly thickened leaflets was also observed, pulled by ventricular remodeling and presenting reduced mobility. Aortic and pulmonary valves showed no major changes, and the presence of diffuse pericardial effusion showed no major hemodynamic repercussions. The patient did not undergo a transesophageal echocardiogram, nor was the pericardial fluid evaluated.

The patient underwent surgery, conducting an incomplete resection of the mass in the interatrial septum and reconstruction with bovine pericardium, leaving a residual infiltrative lesion in the mitral valve, which was considered inoperable. Thus, this surgery was considered to be palliative to relieve the symptoms and to aid in the final diagnosis. Upon macroscopy, the surgical specimen revealed fragments of solid, infiltrative, yellowish-brown, and elastic tissue neoformation, with areas of non-encapsulated hemorrhaging. Histological sections showed fragments of poorly differentiated mesenchymal tissue neoformation, with high cellularity, comprised of spindle and epithelioid cells, with nuclear pleomorphism and moderate anaplasia, dispersed in a fibrillar or myxoid stroma, with up to 12 mitoses / 10 high-magnification fields (occasional atypical mitoses) and a tumor necrosis area (less than 50% of the neoplasia volume). Upon immunohistochemistry, histopathological analysis allowed us to conclude that it was a high-grade undifferentiated pleomorphic sarcoma. Staging exams showed disease restricted to the heart, and chest computed tomography (CT) showed a mass with soft tissue density and a lobulated contour located in the left atrium, measuring 6.0 × 5.3 cm (Figure 1).

Figure 1
Computed Tomography Exam showing heart region before chemotherapy

After incomplete tumor resection (R2 surgery), the multidisciplinary team decided to start cytoreductive chemotherapy in an attempt to target the maximum response rate with subsequent reassessment for the second surgical procedure, if feasible, regarding the residual infiltrative lesions in pulmonary vessels. In this sense, the patient received three cycles of chemotherapy with ifosfamide and doxorubicin, followed by three cycles of ifosfamide alone. Doxorubicin was suspended at the end of the third cycle due to a drop in the left ventricular ejection fraction (LVEF) to 48%. The patient is currently asymptomatic, using Carvedilol, Furosemide, and Enalapril, having been prophylactically anticoagulated only during the immediate postoperative period, as advised by the assistant cardiology team. She has a regular heartbeat with two sounds and a systolic murmur in the mitral focus 3 + / 6 +. Moreover, she is normotensive (blood pressure: 110/70 mmHg), eupneic (respiratory rate: 18 breaths per minute), with a heart rate of 62 beats per minute.

The revaluation tomography (Figure 2) showed a partial reduction in mass, but the echocardiogram quantified the lesions as stable after six cycles of chemotherapy, configuring a stable cancer disease, rendering the infiltration in the mitral ring inoperable. Therefore, it was decided to maintain chemotherapy with ifosfamide to control the underlying disease. A second line of treatment has not been proposed so far due to an episode of febrile neutropenia with sepsis. Heart transplantation, in turn, was not indicated due to active neoplastic disease.

Figure 2
Computed Tomography Exam after third cycle of chemotherapy

Despite the failure to convert the residual disease into operable, the patient has been evolving in good general condition, is asymptomatic, and is maintaining a good quality of life, with 7 months of current survival. For the follow-up, although the magnetic resonance imaging exam (MRI) had been recommended, the fact that the service in question did not perform the referred exam led to the consideration of only the transthoracic echocardiogram to monitor the case. A new surgical approach is still under discussion, especially if a reduction in tumor size from second-line drugs is considered.

Discussion

Tumors of the heart and pericardial sac can be divided into primary and secondary tumors. The main histological types of primary heart tumors are myxomas, fibromyxomas, and sarcomas, which are differentiated into benign or malignant, as shown in Table 1. The main secondary tumor, in turn, comes from metastases of melanomas.88. Lima PRL, Crotti PLR. Malignant cardiac tumours. Braz J Cardiovasc Surg. 2004;19(1):64-73.

Table 1
Differences between benign and malignant primary tumors of the heart

The most common type of benign primary heart tumor is myxoma. This prevails among women of 40 and 50 years of age, and is usually located in the left atrium, close to the mitral valve leaflets.88. Lima PRL, Crotti PLR. Malignant cardiac tumours. Braz J Cardiovasc Surg. 2004;19(1):64-73.

In its morphology, the myxoma is mostly pedicled. It is able to suffer prolapse through the mitral valve and prevent the filling of the ventricle during the diastole phase.99. Rao AK. Tumores cardíacos. Rush University Medical Center; 2018 May. In microscopic histopathological analysis, myxomas may present stellate, fusiform or elongated, polygonal cells, wrapped in a myxoid stroma.1010. Butany J, Nair V, Naseemuddin A, Nair GM, Catton C, Yau T. Cardiac tumours: diagnosis and management. Lancet Oncol. 2005;6(4):219-28. In addition, it has characteristics of mesenchymal cells with intermediate filaments and narrow intracellular junctions, there are no desmosomes, and some cells may have characteristics of myofibroblasts.1010. Butany J, Nair V, Naseemuddin A, Nair GM, Catton C, Yau T. Cardiac tumours: diagnosis and management. Lancet Oncol. 2005;6(4):219-28. Macroscopically, these can reach up to 15 cm and be of different colors and consistencies, in addition to being able to present a myxoid or gelatinous structure.99. Rao AK. Tumores cardíacos. Rush University Medical Center; 2018 May.

The most frequent primary malignant tumor of the heart is the sarcoma type1111. Siontis BL, Zhao L, Leja M, McHugh JB, Shango MM, Baker LH, et.al. Primary cardiac sarcoma: a rare, aggressive malignancy with a high propensity for brain metastases. Sarcoma. 2019 Mar 10;2019:1960593. of the heart muscle, with a higher frequency between the third and fifth decade of life and with a predominant location in the right atrium.1212. Karigyo CJT, Silva FBF. Cardiac tumors: a brief review of the literature. Rev Méd Residente. 16(1):27-34. The angiosarcoma type is the most common, with a higher incidence in men, originating from mesenchymal tissue, with a broad multilobulated base, measuring between 2 and 10 cm, dark brown or blackish in color, close to the inferior vena cava, and with early metastases to the pleura, mediastinum, and lungs.1212. Karigyo CJT, Silva FBF. Cardiac tumors: a brief review of the literature. Rev Méd Residente. 16(1):27-34. The patient usually shows a clinical picture of heart failure and pericardial effusion.1212. Karigyo CJT, Silva FBF. Cardiac tumors: a brief review of the literature. Rev Méd Residente. 16(1):27-34.

Histologically, angiosarcoma can present different aspects, depending on its degree of differentiation. They may contain atypical pleomorphic endothelial cells, which form papillary structures and vascular channels in well-differentiated areas, and in areas with little differentiation have fusiform anaplastic cells.1313. Abreu GC, Gontijo MCR, Chaves MCL, Drumond JW, Marino BCA, Bernardes RC, et al. Primary cardiac angiosarcoma: case report of a rare neoplasia. J Bras Patol Med Lab. 2017;53(5):320-4. An angiosarcoma can, therefore, have both well-differentiated and undifferentiated regions.1313. Abreu GC, Gontijo MCR, Chaves MCL, Drumond JW, Marino BCA, Bernardes RC, et al. Primary cardiac angiosarcoma: case report of a rare neoplasia. J Bras Patol Med Lab. 2017;53(5):320-4.

The UPS, or malignant fibrous histiocytoma,1414. Hirano Y. Editorial: Primary cardiac malignant fibrous histiocytoma is a rare case of cardiac tumor. J Cardiol Cases. 2015 Nov;12(5):143-4. in turn, makes up to one third of all cardiac sarcomas,1515. Orlandi A, Ferlosio A, Roselli M, Chiariello L, Spagnoli LG. Cardiac sarcomas: an update. J Thorac Oncol. 2010 Sep;5(9):1483-9. and its etiology and pathogenesis are uncertain.1616. Ostrowski S, Marcinkiewicz A, Kośmider A, Jaszewski R. Sarcomas of the heart as a difficult interdisciplinary problem. Arch Med Sci. 2014 Feb 24;10(1):135-48. The age of onset varies from 14 to 80 years of age,1717. Prifti E, Ademaj F, Ikonomi M, Demiraj A. Unusual localization of a primary pleomorphic malignant fibrous histiocytoma on the mitral valve: a case report and review of the literature. J Med Case Rep. 2015 Oct 31;9:246. 47 years of age on average.1818. Okamoto K, Kato S, Katsuki S, Wada Y, Toyozumi Y, Morimatsu M, et.al. Malignant fibrous histiocytoma of the heart: case report and review of 46 cases in the literature. Intern Med. 2001 Dec;40(12):1222-6. The incidence is higher (67%) in women.1717. Prifti E, Ademaj F, Ikonomi M, Demiraj A. Unusual localization of a primary pleomorphic malignant fibrous histiocytoma on the mitral valve: a case report and review of the literature. J Med Case Rep. 2015 Oct 31;9:246. Symptoms are variable and dependent on the location and size of the tumor, but dyspnea was reported in 70% of all cases; palpitations in 45%;1717. Prifti E, Ademaj F, Ikonomi M, Demiraj A. Unusual localization of a primary pleomorphic malignant fibrous histiocytoma on the mitral valve: a case report and review of the literature. J Med Case Rep. 2015 Oct 31;9:246. chest pain in 20%;1111. Siontis BL, Zhao L, Leja M, McHugh JB, Shango MM, Baker LH, et.al. Primary cardiac sarcoma: a rare, aggressive malignancy with a high propensity for brain metastases. Sarcoma. 2019 Mar 10;2019:1960593.,1919. Isambert N, Ray-Coquard I, Italiano A, Rios M, Kerbrat P, Gauthier M, et.al. Primary cardiac sarcomas: a retrospective study of the French Sarcoma Group. Eur J Cancer. 2014 Jan;50(1):128-36. and cough, bilateral edema of the lower limbs, and hemoptysis in 8%,1919. Isambert N, Ray-Coquard I, Italiano A, Rios M, Kerbrat P, Gauthier M, et.al. Primary cardiac sarcomas: a retrospective study of the French Sarcoma Group. Eur J Cancer. 2014 Jan;50(1):128-36. with nausea and vomiting also reported.2020. Balaceanu A, Mateescu D, Diaconu C, Sarsan A. Primary malignant fibrous histiocytoma of the right ventricle. J Ultrasound Med. 2010;29(4):655–8. Pericardial effusion is a complication present mainly in metastatic tumors to the heart, which occur mainly in the pericardium, due to lymphatic dissemination, and in the right cavities, caused by hematogenous dissemination. Thus, patients with metastasis to the pericardium may present massive pericardial effusions and cardiac tamponade.88. Lima PRL, Crotti PLR. Malignant cardiac tumours. Braz J Cardiovasc Surg. 2004;19(1):64-73.

Physiologically, patients who have benign or malignant primary tumors or secondary tumors due to metastasis from another tumor, may manifest disturbances in the electrical conduction of the heart, atrial fibrillation and flutter, ventricular extrasystoles, right branch block, and, primarily, arrhythmias.1212. Karigyo CJT, Silva FBF. Cardiac tumors: a brief review of the literature. Rev Méd Residente. 16(1):27-34. In addition, they may show signs and symptoms of heart failure, requiring tests to make a differential diagnosis with other pathologies.1212. Karigyo CJT, Silva FBF. Cardiac tumors: a brief review of the literature. Rev Méd Residente. 16(1):27-34.

The best exam for an initial assessment in clinical investigation is transthoracic echocardiography.2121. Araoz PA, Eklund HE, Welch TJ, Breen JF. CT and MR imaging of primary cardiac malignancies. Radiographics. 1999;19(6):1421-34. MRI and CT demonstrate the extent of the tumor in the myocardium and the presence of metastases.2222. Eswaran P, Devadoss P, Narasimhan LS, Kannan K. Synovial sarcoma of the heart: a case report and literature review. J Can Res Ther. 2015;11(3):659. The diagnosis of sarcoma is only made after histological analysis, but there are characteristics of radiological tests to differentiate it from the myxoma, such as the non-septal connection of the mass, multiple masses, extensive connection to the left atrial wall, extension to the pulmonary vein, and semi-solid consistency.2323. Kim JT, Baek WK, Kim KH, Yoon YH, Kim DH, Lim HK. A primary cardiac sarcoma preoperatively presented as a benign left atrial myxoma. Yonsei Med J. 2003;44(3):530–3. Moreover, gastrointestinal symptoms appear more in UPS than in myxomas.1414. Hirano Y. Editorial: Primary cardiac malignant fibrous histiocytoma is a rare case of cardiac tumor. J Cardiol Cases. 2015 Nov;12(5):143-4.

In general, the prognosis of tumors in the right atrium is worse, with significantly reduced survival.1717. Prifti E, Ademaj F, Ikonomi M, Demiraj A. Unusual localization of a primary pleomorphic malignant fibrous histiocytoma on the mitral valve: a case report and review of the literature. J Med Case Rep. 2015 Oct 31;9:246.,2424. Aksu T, Gode S, Oz K, Ersoy B, Ustunısık CT, Guner Y, et al. Rapidly progressive malignant fibrous histiocytoma of right atrium: a rare case report. Braz J Cardiovasc Surg. 2019;34(3):372–6. However, this occurs in only 7% to 10% of the UPS,1111. Siontis BL, Zhao L, Leja M, McHugh JB, Shango MM, Baker LH, et.al. Primary cardiac sarcoma: a rare, aggressive malignancy with a high propensity for brain metastases. Sarcoma. 2019 Mar 10;2019:1960593.,1717. Prifti E, Ademaj F, Ikonomi M, Demiraj A. Unusual localization of a primary pleomorphic malignant fibrous histiocytoma on the mitral valve: a case report and review of the literature. J Med Case Rep. 2015 Oct 31;9:246. which have a preference for the left atrium2020. Balaceanu A, Mateescu D, Diaconu C, Sarsan A. Primary malignant fibrous histiocytoma of the right ventricle. J Ultrasound Med. 2010;29(4):655–8. in 65.5% of cases, usually in the posterior wall,1818. Okamoto K, Kato S, Katsuki S, Wada Y, Toyozumi Y, Morimatsu M, et.al. Malignant fibrous histiocytoma of the heart: case report and review of 46 cases in the literature. Intern Med. 2001 Dec;40(12):1222-6. with an invasion of the mitral valve in up to 10%.1717. Prifti E, Ademaj F, Ikonomi M, Demiraj A. Unusual localization of a primary pleomorphic malignant fibrous histiocytoma on the mitral valve: a case report and review of the literature. J Med Case Rep. 2015 Oct 31;9:246. When a malignant tumor is found in the left atrium, the UPS and leiomyosarcoma are more likely, making up 44% and 22% of the cases, respectively.1111. Siontis BL, Zhao L, Leja M, McHugh JB, Shango MM, Baker LH, et.al. Primary cardiac sarcoma: a rare, aggressive malignancy with a high propensity for brain metastases. Sarcoma. 2019 Mar 10;2019:1960593.

Surgery, the best treatment for local sarcomas,1111. Siontis BL, Zhao L, Leja M, McHugh JB, Shango MM, Baker LH, et.al. Primary cardiac sarcoma: a rare, aggressive malignancy with a high propensity for brain metastases. Sarcoma. 2019 Mar 10;2019:1960593. can relieve symptoms,2525. Saraiva J, Antunes PE, Carvalho L, Antunes MJ. Primary malignant cardiac tumors: surgical results. Rev Port Cardiol. 2016;35(4):199-204. but it is not usually curative, unlike that which happens with benign neoplasias.³ The prognosis is better when the tumor is completely removed, with an average survival of 4 years more than that of incomplete resection.26 Although complete resection with negative microscopic margins does not prevent recurrence in 2/3 of the patients, it does increase survival by 30 months, when compared to those with positive margins.2626. Li H, Xu D, Chen Z, Ding W, Hong T, Chen H, et.al. Prognostic analysis for survival after resections of localized primary cardiac sarcomas: a single-institution experience. Ann Thorac Surg. 2014;97(4):1379–85. However, the rate of complete resection is only 13%,1919. Isambert N, Ray-Coquard I, Italiano A, Rios M, Kerbrat P, Gauthier M, et.al. Primary cardiac sarcomas: a retrospective study of the French Sarcoma Group. Eur J Cancer. 2014 Jan;50(1):128-36. partly attributed to the difficulty in diagnosis.2727. Beller JP, Maddalo S, Zamuco R, Axel L, DeAnda A, Balsam LB. Right ventricular undifferentiated pleomorphic sarcoma: a case report. J Cardiol Cases. 2015;13(2):60-2. When complete resection is not practicable, more than 90% of the patients die within a year, regardless of post-surgical therapy.1515. Orlandi A, Ferlosio A, Roselli M, Chiariello L, Spagnoli LG. Cardiac sarcomas: an update. J Thorac Oncol. 2010 Sep;5(9):1483-9.

The recommendation for adjuvant treatment is not well established in the literature, and there is no consensus on the ideal time for onset or duration.2727. Beller JP, Maddalo S, Zamuco R, Axel L, DeAnda A, Balsam LB. Right ventricular undifferentiated pleomorphic sarcoma: a case report. J Cardiol Cases. 2015;13(2):60-2. There are reports of good evolution without it, even with positive margins on microscopy after resection.2727. Beller JP, Maddalo S, Zamuco R, Axel L, DeAnda A, Balsam LB. Right ventricular undifferentiated pleomorphic sarcoma: a case report. J Cardiol Cases. 2015;13(2):60-2. However, there are studies that demonstrate the advantage of multimodal treatment,2828. Akishima S, Imai A, Enomoto Y, Shigeta O. Combined treatment for a large primary cardiac sarcoma: a case report. Surg Case Rep. 2019 Dec 5;5(1):97.,2929. Randhawa JS, Budd GT, Randhawa M, Ahluwalia M, Jia X, Daw H, et. al. Primary cardiac sarcoma: 25-year Cleveland Clinic Experience. Am J Clin Oncol. 2016;39(6):593–9. although the use is limited in those cases with incomplete resection.2828. Akishima S, Imai A, Enomoto Y, Shigeta O. Combined treatment for a large primary cardiac sarcoma: a case report. Surg Case Rep. 2019 Dec 5;5(1):97.

In one cohort, patients who received chemotherapy alone, or in combination with surgery, presented better survival rates than did those who did not receive it. However, those who received chemotherapy showed better physical performance.1111. Siontis BL, Zhao L, Leja M, McHugh JB, Shango MM, Baker LH, et.al. Primary cardiac sarcoma: a rare, aggressive malignancy with a high propensity for brain metastases. Sarcoma. 2019 Mar 10;2019:1960593. Local disease control, associated with imp17,roved cardiac function, most likely leads to greater tolerance for aggressive therapies.1111. Siontis BL, Zhao L, Leja M, McHugh JB, Shango MM, Baker LH, et.al. Primary cardiac sarcoma: a rare, aggressive malignancy with a high propensity for brain metastases. Sarcoma. 2019 Mar 10;2019:1960593.

Several studies show better disease-free survival with doxorubicin without impacting overall survival.3030. Tierney JF. Adjuvant chemotherapy for localised resectable soft-tissue sarcoma of adults: meta-analysis of individual data. Sarcoma Meta-analysis Collaboration. Lancet. 1997;350(9092):1647-54. The usual administration is six cycles of ifosfamide and doxorubicin,1717. Prifti E, Ademaj F, Ikonomi M, Demiraj A. Unusual localization of a primary pleomorphic malignant fibrous histiocytoma on the mitral valve: a case report and review of the literature. J Med Case Rep. 2015 Oct 31;9:246.,2020. Balaceanu A, Mateescu D, Diaconu C, Sarsan A. Primary malignant fibrous histiocytoma of the right ventricle. J Ultrasound Med. 2010;29(4):655–8.,3131. Lennerz C, O’Connor M, Schunkert H, Deutsch MA. A case report of primary cardiac sarcoma: a diagnostic and therapeutic challenge. Eur Heart J Case Rep. 2018;2(4):143. and a better survival rate with taxanes has recently been reported.1919. Isambert N, Ray-Coquard I, Italiano A, Rios M, Kerbrat P, Gauthier M, et.al. Primary cardiac sarcomas: a retrospective study of the French Sarcoma Group. Eur J Cancer. 2014 Jan;50(1):128-36. Sarcomas are resistant to radiotherapy.3232. Gupta A. Primary cardiac sarcomas. Expert Rev Cardiovasc Ther. 2008;6(10):1295–7. However, it can be used to prevent or delay local recurrence.2626. Li H, Xu D, Chen Z, Ding W, Hong T, Chen H, et.al. Prognostic analysis for survival after resections of localized primary cardiac sarcomas: a single-institution experience. Ann Thorac Surg. 2014;97(4):1379–85.,1414. Hirano Y. Editorial: Primary cardiac malignant fibrous histiocytoma is a rare case of cardiac tumor. J Cardiol Cases. 2015 Nov;12(5):143-4. Proton beam irradiation has been successfully used.2828. Akishima S, Imai A, Enomoto Y, Shigeta O. Combined treatment for a large primary cardiac sarcoma: a case report. Surg Case Rep. 2019 Dec 5;5(1):97. Furthermore, neoadjuvant chemotherapy can increase the chance of a complete resection of the tumor, which would translate into better patient survival.3333. Saleh WKA, Ramlawi B, Shapira OM, Jabbari OA, Ravi V, Benjamin R, et. al. Improved outcomes with the evolution of a neoadjuvant chemotherapy approach to right heart sarcoma. Ann Thorac Surg. 2017;104(1):90-6.

Heart transplantation has been reported with variable results. However, this practice is hampered by the scarcity of donors, the possibility of tumor recurrence by post-transplant immunomodulation, and the exclusion of many patients for other chronic and psychosocial diseases.2727. Beller JP, Maddalo S, Zamuco R, Axel L, DeAnda A, Balsam LB. Right ventricular undifferentiated pleomorphic sarcoma: a case report. J Cardiol Cases. 2015;13(2):60-2. A promising alternative pointed out in the literature would be the genetic identification of the tumor for individualized therapeutic options, including tyrosine kinase inhibitors, monoclonal antibodies, and CKD-4 inhibitors.3333. Saleh WKA, Ramlawi B, Shapira OM, Jabbari OA, Ravi V, Benjamin R, et. al. Improved outcomes with the evolution of a neoadjuvant chemotherapy approach to right heart sarcoma. Ann Thorac Surg. 2017;104(1):90-6.

Conclusion

Cardiac UPS is rare and aggressive, and presents a poor prognosis, with an average survival of less than one year. It presents variable symptoms that depend on the location and can cause multiple complications. The most effective treatment for localized tumors is surgical resection, and adjuvant therapies are not well established in the literature. However, there is a consensus on the administration of six cycles of ifosfamide and doxorubicin, a protocol followed by our patient, who remained stable, with a short follow-up of only seven months.

  • Sources of Funding
    There were no external funding sources for this study.
  • Study Association
    This study is not associated with any thesis or dissertation work.
  • Ethics Approval and Consent to Participate
    This study was approved by the Ethics Committee of the Universidade Federal de Uberlândia under the protocol number 4.041.793. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study.

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    Prifti E, Ademaj F, Ikonomi M, Demiraj A. Unusual localization of a primary pleomorphic malignant fibrous histiocytoma on the mitral valve: a case report and review of the literature. J Med Case Rep. 2015 Oct 31;9:246.
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    Isambert N, Ray-Coquard I, Italiano A, Rios M, Kerbrat P, Gauthier M, et.al. Primary cardiac sarcomas: a retrospective study of the French Sarcoma Group. Eur J Cancer. 2014 Jan;50(1):128-36.
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Publication Dates

  • Publication in this collection
    16 Apr 2021
  • Date of issue
    2021

History

  • Received
    26 May 2020
  • Reviewed
    13 Oct 2020
  • Accepted
    08 Nov 2020
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