Surgical pathology of cardiac tumors. Two decades at an urban institution

Abstract

Background: As better diagnostic techniques and new operative approaches are developed pathologists will be called upon more often for intraoperative consultation to render a pathologic diagnosis and assess adequacy of resection.

Methods: We conducted a retrospective survey of all patients presenting to our institution from 1979 to 1999. The surgical pathology and cardiothoracic surgery databases were used to identify these patients.

Results: Of the 29 patients with primary cardiac neoplasms, 15 were male and 14 female. The mean age at surgery was 51.9 years (range, 7 months to 84 years). Twenty-six of 29 patients had a benign pathological diagnosis. The majority (20/26) of the benign tumors were myxomas. Other benign pathologic diagnoses included rhabdomyoma, fibroma, papillary fibroelastoma, localized fibrous tumor and lipoma. Three out of 29 were malignant: 1 fibrosarcoma, 1 malignant mesenchymoma, and 1 rhabdomyosarcoma. Six of the patients presented with thrombo-embolism, 8 with congestive heart failure symptoms, and three with chest discomfort. Five were asymptomatic or the neoplasm was an incidental finding. 2-D echocardiography established the diagnosis in all of the patients except one. Twenty-two of the 29 tumors were located in the atria (LA=15, RA=6, biatrial=1) and 5 in the ventricles (LV=1, RV=2, biventricular=2). Two patients in this series were referred for reresection. A median sternotomy approach was used for tumor extirpation in all patients. Three of the 29 patients have died at a mean follow-up period of 757 days (median, 118 days). There were two late deaths and one hospital (early) death in a reoperation for recurrent malignancy employing cardiac autotransplantation. One additional patient required cardiac reoperation.

Conclusions: Primary cardiac neoplasms are rare and occur less commonly than metastatic disease of the heart. Congestive heart failure symptoms and thrombo-embolism account for close to half of the presenting signs and symptoms. 2-D echocardiography remains the mainstay of detection. Distinguishing between benign and malignant, thrombus and vegetation, and extracardiac structure is usually established by the size, shape, mobility and attachment of the mass. Clinical presentation and transesophageal echocardiographic views are extremely helpful in sharpening the accuracy of the diagnosis. Since surgery is the only reliable therapy pathologists will be called upon for intraoperative consultation. The majority of the neoplasms are benign. Malignant neoplasms are difficult to excise completely and portend a grave prognosis.