You are in: eMedicine Specialties > Oncology > Carcinomas of the Lung and Other Intrathoracic Carcinomas Cardiac SarcomaArticle Last Updated: Jan 7, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: John H Raaf, MD, PhD, Professor, Department of Surgery, Case Western University John H Raaf is a member of the following medical societies: American Association for Cancer Research, American Association of Endocrine Surgeons, American College of Surgeons, American Society of Clinical Oncology, Central Surgical Association, and Society of Surgical Oncology Coauthor(s): Anastasios K Konstantakos, MD, Clinical Associate Surgeon, Brigham and Women's Hospital, Harvard University; Heather N Raaf, MD, Chief Deputy Coroner, Cuyahoga County Coroner's Office (Retired) Editors: Robert C Shepard, MD, FACP, Associate Professor of Medicine in Hematology and Oncology at University of North Carolina at Chapel Hill; Vice President of Scientific Affairs, Therapeutic Expertise, Oncology, at PRA International; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Rajalaxmi McKenna, MD, FACP, Consulting Staff, Department of Medicine, Southwest Medical Consultants, SC, Good Samaritan Hospital, Advocate Health Systems; Jules E Harris, MD, Visiting Professor of Medicine, Division of Hematology/Medical Oncology, Department of Internal Medicine, University of Arizona College of Medicine at Tucson; Consulting Staff, Arizona Cancer Center Author and Editor Disclosure Synonyms and related keywords: angiosarcoma, metastatic cardiac sarcoma, rhabdomyosarcoma, malignant schwannoma, mesothelioma, fibrosarcoma, malignant fibrous histiocytoma, heart tumor, heart sarcoma, heart malignancy, heart cancer, cancer INTRODUCTIONSection 2 of 10
  BackgroundPrimary cardiac neoplasms are rare entities,1 with an autopsy prevalence of 0.001-0.28%. The most common primary malignant tumor of the heart and pericardium is sarcoma. PathophysiologyThe diagnosis of cardiac sarcoma is often not made preoperatively or even antemortem. It is overlooked because of the rarity of the lesion and the nonspecific nature of the symptoms and signs. Tumors that originate in the epicardium or pericardium and that lead to cardiac encasement may cause chest pain, hypotension, tachycardia, and malaise. Diminished cardiac sounds and a friction rub may be heard. Cardiac tamponade (usually from a persistent and bloody pericardial effusion) may eventually cause intractable cardiac failure. Myocardial involvement may lead to refractory arrhythmias, heart block, heart failure, angina, or infarction. Endomyocardial masses cause valvular obstruction or insufficiency. Rarely, a pedunculated tumor causes an audible plop from tumor prolapse through a valve. Tumor fragments may embolize from the right side of the heart to the lungs and cause dyspnea or hemoptysis. Left-sided emboli may lead to cerebrovascular accidents, peripheral organ infarctions, seizures, and distant metastases. Local extension of tumors may cause signs and symptoms such as superior vena cava syndrome, hemoptysis, and dysphonia. Several subtypes of primary cardiac sarcoma exist (ie, angiosarcoma, rhabdomyosarcoma, mesothelioma, fibrosarcoma, malignant schwannoma), which occur in decreasing order of frequency in adults. Nearly 80% of cardiac angiosarcomas arise as mural masses in the right atrium. Typically, they completely replace the atrial wall and fill the entire cardiac chamber. They may invade adjacent structures (eg, vena cava, tricuspid valve). These tumors are both symptomatic and rapidly fatal. Extensive pericardial spread and encasement of the heart often occur. Pericardial angiosarcoma (without myocardial involvement) occurs rarely. This is the second most common primary cardiac sarcoma. It has been described in all age groups. No heart chamber is particularly favored. Diffuse pericardial spread is not often observed. A myocardial component is nearly always present; valvular interference, only occasionally. Rhabdomyosarcoma is the most common form of cardiac sarcoma in children. These tumors typically arise in the visceral or parietal pericardium and can spread to constrict the heart. They do not invade the underlying myocardium. Extensive local spread may lead to pleural, diaphragmatic, or peritoneal involvement. Grossly, the tumor is firm and white, with both nodular and sheetlike growth. No age group has a particular predilection for these tumors. Interestingly, no etiologic association of pericardial mesotheliomas to asbestos exposure exists, in contrast to the more typical primary pleural mesotheliomas. Fibrosarcoma and malignant fibrous histiocytoma These whitish lesions have a firm texture and exhibit infiltrative growth patterns. No age or cardiac chamber predilection has been noted. However, cardiac valvular involvement is found in as many as 50% of lesions. Pericardial invasion rarely occurs. This tumor is derived from peripheral nerve sheath tissue. Such tumors have a spatial association with the juxtacardiac position of the vagus nerve. Metastatic cardiac sarcoma Metastases to the heart and pericardium are 40 times more common than primary cardiac tumors. In fact, an estimated 25% of patients who die from metastatic soft tissue sarcoma have cardiac metastases. No particular gross pattern of myocardial spread exists (ie, diffuse, nodular). In children, rhabdomyosarcoma is the most common type of sarcoma that metastasizes to the heart. FrequencyUnited StatesCardiac sarcoma occurs in less than 0.2% of decedents undergoing autopsy, both nationally and internationally. InternationalFigures are the same as in the United States. Mortality/MorbidityData on patients with primary cardiac sarcomas have shown that median survival is 6 months from the time of diagnosis. SexSex predilection has not been defined for cardiac sarcoma. AgeCardiac sarcomas can occur at any age; however, children have an increased rate of cardiac rhabdomyosarcomas. CLINICALSection 3 of 10
HistoryNo typical presentation of cardiac sarcoma exists because the common symptoms and signs are nonspecific. However, patients may complain of dyspnea, chest pain, and/or generalized fatigue. Physical
CausesNo specific causes of cardiac sarcomas are known. Cytogenetic analysis of these tumors may show numerical and structural chromosomal changes. Immunohistochemical analysis has revealed, in the case of a cardiac angiosarcoma, high expression of mutated p53 gene products.2 DIFFERENTIALSSection 4 of 10
Angina Pectoris Atrial Myxoma Cardiomyopathy, Restrictive Mediastinitis Mesothelioma Pericarditis, Constrictive Other Problems to Be ConsideredBecause of the nonspecific presentation of cardiac sarcomas, the number of disease processes that should be considered in the differential diagnosis is vast (eg, bronchogenic carcinoma, congestive heart failure, atrial myxoma, pericarditis, pericardial tamponade, coronary insufficiency, mediastinitis, mesothelioma). WORKUPSection 5 of 10
Imaging Studies
Other Tests
Procedures
Histologic FindingsSpecific subtypes of cardiac sarcomas have characteristic gross and microscopic features (see Pathophysiology). TREATMENTSection 6 of 10
Surgical CareCardiac sarcoma is rarely cured, but prolonged survival or significant palliation is possible with surgical resection.4 Exploration with biopsy yields tissue for histologic diagnosis and assessment of the gross extent of the tumor.
ConsultationsCardiothoracic surgeon and/or oncologist FOLLOW-UPSection 7 of 10
Further Outpatient CareNo specific guidelines for follow-up care have been established; however, because of the low postoperative survival rate (median survival, 6 mo), pay careful attention postoperatively to the patient's cardiopulmonary status and overall physical state. PrognosisData from patients with primary cardiac sarcomas show that median survival is approximately 6 months. Histologic type does not affect prognosis. However, more than 10 mitoses per high-power field or necrosis is correlated with a poorer outcome. Longer survival is associated with left-sided lesions. MISCELLANEOUSSection 8 of 10
Medical/Legal Pitfalls
MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
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