Case report
Giant tumoral lesion in the left atrium: An uncommon case of undifferentiated cardiac sarcoma
Catarina Ferreiraa,b,
, Daniel Martinsc, Rodolfo Pereirac, Hélder Ribeiroa, Fátima Nevesc, Pedro Mateusa, Ilídio Moreiraa, Luís Vougac
Corresponding author
a Serviço de Cardiologia, Hospital de S. Pedro, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
b Centro de Investigação em Ciências da Saúde, Programa de Doutoramento em Medicina, Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal
c Serviço de Cirurgia Cardiotorácica, Hospital Eduardo Santos Silva, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
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Myocardial biopsy, after glucocorticoid and immunosuppressive therapy, showing complete resolution of eosinophilic myocarditis (B).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Sofia Correia, Alexandra Gonçalves, Vítor Araújo, João Almeida e Silva, José Manuel Pereira, Pedro Rodrigues Pereira, Manuel Pizarro, João Carlos Silva, Maria Júlia Maciel" "autores" => array:9 [ 0 => array:2 [ "nombre" => "Ana Sofia" "apellidos" => "Correia" ] 1 => array:2 [ "nombre" => "Alexandra" "apellidos" => "Gonçalves" ] 2 => array:2 [ "nombre" => "Vítor" "apellidos" => "Araújo" ] 3 => array:2 [ "nombre" => "João" "apellidos" => "Almeida e Silva" ] 4 => array:2 [ "nombre" => "José Manuel" "apellidos" => "Pereira" ] 5 => array:2 [ "nombre" => "Pedro" "apellidos" => "Rodrigues Pereira" ] 6 => array:2 [ "nombre" => "Manuel" "apellidos" => "Pizarro" ] 7 => array:2 [ "nombre" => "João Carlos" "apellidos" => "Silva" ] 8 => array:2 [ "nombre" => "Maria Júlia" "apellidos" => "Maciel" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217420491300247X?idApp=UINPBA00004E" "url" => "/21742049/0000003200000009/v1_201312060118/S217420491300247X/v1_201312060118/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Giant tumoral lesion in the left atrium: An uncommon case of undifferentiated cardiac sarcoma" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "713" "paginaFinal" => "716" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Catarina Ferreira, Daniel Martins, Rodolfo Pereira, Hélder Ribeiro, Fátima Neves, Pedro Mateus, Ilídio Moreira, Luís Vouga" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Catarina" "apellidos" => "Ferreira" "email" => array:1 [ 0 => "catferreirinha@net.sapo.pt" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Daniel" "apellidos" => "Martins" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Rodolfo" "apellidos" => "Pereira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Hélder" "apellidos" => "Ribeiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Fátima" "apellidos" => "Neves" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "Pedro" "apellidos" => "Mateus" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "Ilídio" "apellidos" => "Moreira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "Luís" "apellidos" => "Vouga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Serviço de Cardiologia, Hospital de S. Pedro, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Investigação em Ciências da Saúde, Programa de Doutoramento em Medicina, Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Serviço de Cirurgia Cardiotorácica, Hospital Eduardo Santos Silva, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 636 "Ancho" => 950 "Tamanyo" => 78567 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Two-dimensional echocardiogram in parasternal long-axis view showing a well-defined structure in the left atrium attached to the interatrial septum.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Primary malignant cardiac tumors, of which sarcomas are the most frequent, are extremely rare.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Cardiac sarcomas are of mesenchymal origin and can affect any part of the heart. The most common types are angiosarcoma, undifferentiated cardiac sarcoma (UCS), malignant fibrous histiocytoma and leiomyosarcoma.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> They can develop at any age, but are more common in the fourth decade of life, occurring with equal frequency in both sexes.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Around half are located in the left atrium (81% in the case of UCS). UCS is characterized by a lack of a specific histological pattern; it originates in fibroblasts or histoblasts, and due to its shape and location is often initially diagnosed as a probable myxoma.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Valve involvement is reported in 50% of cases. It is less likely to metastasize than other sarcomas such as angiosarcoma, and patients most frequently die of local heart disease before metastases develop. Clinical manifestations of these tumors can include heart failure, dyspnea, acute pulmonary edema, syncope, systemic embolism, constitutional symptoms and fatigue.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Diagnostic exams are those used to assess cardiac lesions in general, namely transthoracic and transesophageal echocardiography, magnetic resonance imaging (MRI) and computed tomography (CT).<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Macroscopically these tumors tend to be yellowish-white with areas of necrosis and extensive infiltration of the myocardium and cardiac structures. Histological study provides a definitive diagnosis. Microscopically they may be heterogeneous with a storiform pattern, marked pleomorphism, elevated mitotic activity, and at times foci of necrosis. Immunohistochemical analysis is crucial; epithelial, neuronal and endothelial markers are usually negative and vimentin is typically positive.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The recommended treatment is complete surgical excision whenever possible, but this is often difficult due to extensive invasion of cardiac structures or to tumor location that would require complex surgical reconstruction.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> If resection is incomplete, over 90% of patients do not survive more than a year, even with adjuvant therapy. There is no firm consensus on non-surgical treatment: some authors recommend chemotherapy, but some studies have found no benefit<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a>; while postoperative radiotherapy is an option, it is also of limited value due to its cardiotoxicity. Heart transplantation may be considered in selected patients.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The authors describe the case of a patient diagnosed with a large UCS, followed by a review of the literature, clinical characteristics and the diagnostic exams used in this very rare and little documented disease, for which there is as yet no standard treatment.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0035" class="elsevierStylePara elsevierViewall">We present the case of a 75-year-old Caucasian woman with a known history of essential hypertension and type 2 diabetes, medicated with oral antidiabetics (metformin 850 mg twice daily and vildagliptin 50 mg twice daily) and a diuretic (furosemide 20 mg daily).</p><p id="par0040" class="elsevierStylePara elsevierViewall">She had been suffering from constitutional symptoms, including losing 20 kg in weight, over the previous 12 months, and dyspnea on moderate exertion and lower limb edema in the six months before admission. She was admitted to the emergency department due to dyspnea on minimal exertion, orthopnea and paroxysmal nocturnal dyspnea. On physical examination she was tachypneic with jugular distension at 45° and moderate lower limb edema of the entire leg; she was hemodynamically and electrically stable, with oxygen saturation of 90% in room air. Cardiac auscultation revealed a grade II/VI systolic murmur at the left sternal border and a grade II/VI apical mid-diastolic murmur, and blood gas analysis was compatible with type 1 respiratory failure. The ECG showed sinus rhythm with non-specific ventricular repolarization abnormalities. The following alterations were detected by laboratory testing: normochromic normocytic anemia (hemoglobin 9.2 g/dl), C-reactive protein 3.1 mg/dl, pro-brain natriuretic peptide 7332 pg/ml and D-dimers 2 mg/ml; myocardial necrosis markers were negative. The chest X-ray revealed increased cardiothoracic index and bilateral pleural effusion. Thoracic CT angiography was then performed due to suspicion of pulmonary thromboembolism, one of the initial diagnostic hypotheses, but the exam ruled this out, showing a medium-sized bilateral pleural effusion, a large lesion in the left atrium and mediastinal nodules less than 1 cm in size.</p><p id="par0155" class="elsevierStylePara elsevierViewall">In the light of the clinical setting and the findings of initial exams, the patient was admitted for treatment and further investigation. Transthoracic and subsequently transesophageal echocardiography revealed a well-defined mass in the left atrium attached to the interatrial septum, measuring approximately 5.4<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3.2<span class="elsevierStyleHsp" style=""></span>cm and protruding into the left ventricle in diastole (<a class="elsevierStyleCrossRefs" href="#fig0005">Figures 1 and 2</a>), significantly obstructing mitral flow (peak gradient 20<span class="elsevierStyleHsp" style=""></span>mmHg and mean gradient 13<span class="elsevierStyleHsp" style=""></span>mmHg; functional area 1.0<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> by the pressure half-time method and 0.8<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> by the continuity equation). Severe tricuspid regurgitation was also observed (dilatation of the annulus to around 41<span class="elsevierStyleHsp" style=""></span>mm) and pulmonary artery systolic pressure was estimated at 100<span class="elsevierStyleHsp" style=""></span>mmHg.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">As part of surgical evaluation, cardiac catheterization was performed, which revealed only non-significant vessel wall disease in the mid anterior descending coronary artery. Given the size of the lesion and the resulting obstruction, the patient was rapidly proposed and accepted for surgery. In view of the location of the mass and the clinical setting, the initial diagnostic hypothesis was a cardiac myxoma.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Five days after admission the patient underwent surgical excision of the lesion, the interatrial septum being opened via the fossa ovale and the incision extended to the left atrium (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). A tumor was observed invading the interatrial septum and part of the left atrial roof and protruding through the mitral valve, the anterior leaflet of which it appeared also to have invaded. The mass was excised; on visual inspection it was nodular with an uneven surface, and consisted of relatively soft and elastic tissue with hemorrhagic areas, weighing around 55 g and measuring 7.4 cm × 5 cm × 3 cm (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>). On direct observation the diagnosis of myxoma appeared less likely.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">After tumor excision, severe mitral valve regurgitation was seen, with failure of central coaptation, and the valve was replaced with a biological prosthesis, removing the anterior leaflet and preserving the posterior leaflet. Inspection of the tricuspid valve and intraoperative transesophageal echocardiography revealed moderate rather than severe regurgitation and it was decided not to perform valvuloplasty.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The operation took longer and was more complex than expected and the postoperative period was complicated by a stroke on the second day manifested clinically by left hemiparesis, predominantly of the arm. Brain CT showed a partial infarction of the anterior circulation.</p><p id="par0070" class="elsevierStylePara elsevierViewall">At discharge the patient was significantly improved in neurological terms, with only residual paresis of the arm. Due to the prolonged postoperative period (one month of hospitalization) she was discharged to a continuing care unit, where she began rehabilitation. Anatomopathological study revealed cellular proliferation with marked pleomorphism, atypical mitosis and positivity for vimentin, these results being compatible with UCS. The same histopathological characteristics were found in the resected anterior mitral leaflet and in the biopsy specimen of the preserved subvalvular apparatus.</p><p id="par0075" class="elsevierStylePara elsevierViewall">After discussion of the therapeutic options, a multidisciplinary decision was taken not to proceed with chemotherapy or radiotherapy. Repeat echocardiography two months after the surgery showed no images suggestive of intracardiac masses and CT did not reveal signs of metastasization or pleural effusion. Almost six months after the operation the patient continues in a rehabilitation and physiotherapy program, with residual neurological deficits mainly in the arm, and is in NYHA class II.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">There have been few cases reported of UCS, particularly as large as the one described, which occupied practically the entire left atrium.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Due to its location and size, the mass was initially thought to be a myxoma, but visual inspection of the surgical specimen cast doubt on this diagnosis, which was ruled out by pathoanatomical study.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In this patient the tumor's clinical manifestations were essentially heart failure and constitutional symptoms. On initial observation the patient presented a large lesion and significant symptoms, and was therefore rapidly proposed for surgery.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Echocardiography is extremely useful in the assessment of any cardiac lesion, particularly of this type.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The high resolution of contrast CT also helps characterize lesions.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However, MRI is superior in several ways, especially for differential diagnosis,<span class="elsevierStyleSup">8</span> and would have been valuable in the case presented, but could not be performed promptly.</p><p id="par0100" class="elsevierStylePara elsevierViewall">With regard to adjuvant therapy, the decision was taken not to proceed with radiotherapy or chemotherapy. According to the literature (which consists of a few case reports and small series), if complete resection is impossible, over 90% of patients die within a year even with adjuvant therapy. Some studies have found that chemotherapy conferred no benefit<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>; there have been no clinical trials specifically on UCS, due to its rarity, and chemotherapy regimes are based on those for extracardiac sarcomas. Radiotherapy is also used as adjuvant therapy for incompletely resected extracardiac sarcoma, but its value in the treatment of cardiac sarcomas is limited by its cardiotoxicity, and its role in the treatment of such tumors is unclear.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The prognosis of cardiac sarcoma is generally very poor whatever treatment is used.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4,7</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In view of our patient's clinical course, the results of the histological study (showing invasion of the subvalvular apparatus) and the state of the art, and after careful weighing of risks and benefits, it was decided not to proceed with chemotherapy or radiotherapy.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0115" class="elsevierStylePara elsevierViewall">The rarity of cardiac sarcoma means that this tumor represents a challenge for diagnosis and especially the therapeutic approach to adopt.</p><p id="par0120" class="elsevierStylePara elsevierViewall">A high index of suspicion is required for timely diagnosis and treatment. Surgical excision is the only treatment that has been shown to improve symptoms and survival in selected patients. The role of adjuvant therapy remains unclear.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Further studies, particularly biomolecular and genetic, are required to improve the characterization, management and treatment of these tumors, with a view to improving their prognosis.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflict of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres296955" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec280620" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres296954" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec280619" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interest" ] 10 => array:2 [ "identificador" => "xack69456" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-11-10" "fechaAceptado" => "2012-12-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec280620" "palabras" => array:4 [ 0 => "Primary cardiac tumors" 1 => "Cardiac sarcoma" 2 => "Diagnostic techniques and procedures" 3 => "Echocardiography" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec280619" "palabras" => array:4 [ 0 => "Tumores cardíacos primários" 1 => "Sarcoma cardíaco" 2 => "Procedimentos e técnicas de diagnóstico" 3 => "Ecocardiografia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Primary cardiac tumors are rare, with an incidence ranging from 0.0001% to 0.030%; 80% are benign, while sarcomas account for 95% of malignant tumors.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The authors report the case of a 75-year-old patient with a giant mass in the left atrium. The final diagnosis was of an undifferentiated cardiac sarcoma. This tumor represents a real challenge not only for timely diagnosis, but especially the therapeutic approach to adopt.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Os tumores cardíacos primários (TCP) são muito raros, com uma incidência de 0,001 a 0,030%. Os tumores benignos são os mais frequentes, representando cerca de 80% dos TCP; os sarcomas são responsáveis por 95% dos tumores malignos.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Os autores relatam o caso de uma doente de 75 anos de idade a quem foi diagnosticada uma massa na aurícula esquerda, que impressionava pelas suas dimensões. O diagnóstico final revelou tratar-se de um sarcoma cardíaco indiferenciado. Este tumor representa um verdadeiro desafio não só no diagnóstico atempado, mas principalmente a nível da terapêutica a instituir.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ferreira C, Martins D, Pereira R, et al. Lesão tumoral gigante na aurícula esquerda: um caso incomum de sarcoma cardíaco indiferenciado. Rev Port Cardiol. 2013;32:713–716.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 636 "Ancho" => 950 "Tamanyo" => 78567 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Two-dimensional echocardiogram in parasternal long-axis view showing a well-defined structure in the left atrium attached to the interatrial septum.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 626 "Ancho" => 950 "Tamanyo" => 78657 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Two-dimensional echocardiogram in apical 3-chamber view, showing the same structure (approximately 5.4 cm × 3.2 cm), protruding into the left ventricle in diastole.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 665 "Ancho" => 950 "Tamanyo" => 171221 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Photograph taken during surgery.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 630 "Ancho" => 950 "Tamanyo" => 99984 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Photograph of the mass following excision.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac tumors" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Riberi" 1 => "V. Gariboldi" 2 => "D. Grisoli" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.pneumo.2009.12.012" "Revista" => array:6 [ "tituloSerie" => "Rev Pneumol Clin" "fecha" => "2010" "volumen" => "66" "paginaInicial" => "95" "paginaFinal" => "103" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20207301" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac sarcoma presenting as heart failure and diagnosed as recurrent myxoma by echocardiogram" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H.R. Patil" 1 => "D. Singh" 2 => "M. Hajdu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/ejechocard/jep201" "Revista" => array:5 [ "tituloSerie" => "Eur J Echocardiogr" "fecha" => "2010" "volumen" => "11" "paginaInicial" => "E12" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20008329" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac tumors: diagnosis and management" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Butany" 1 => "V. Nair" 2 => "A. Naseemuddin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1470-2045(05)70093-0" "Revista" => array:6 [ "tituloSerie" => "Lancet Oncol" "fecha" => "2005" "volumen" => "6" "paginaInicial" => "219" "paginaFinal" => "228" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15811617" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac sarcomas: an update" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Orlandi" 1 => "A. Ferlosio" 2 => "M. Roselli" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/JTO.0b013e3181e59a91" "Revista" => array:6 [ "tituloSerie" => "J Thorac Oncol" "fecha" => "2010" "volumen" => "5" "paginaInicial" => "1483" "paginaFinal" => "1489" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20651614" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Malignant tumors of the heart: a review of tumor type, diagnosis and therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. Neragi-Miandoab" 1 => "J. Kim" 2 => "G.J. Vlahakes" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Oncol (R Coll Radiol)" "fecha" => "2007" "volumen" => "19" "paginaInicial" => "748" "paginaFinal" => "756" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Therapy insight: malignant primary cardiac tumors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.J. Reardon" 1 => "J.C. Walkes" 2 => "R. Benjamin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/ncpcardio0653" "Revista" => array:6 [ "tituloSerie" => "Nat Clin Pract Cardiovasc Med" "fecha" => "2006" "volumen" => "3" "paginaInicial" => "548" "paginaFinal" => "553" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16990840" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adjuvant chemotherapy for primary cardiac sarcomas: the IGR experience" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Llombart-Cussac" 1 => "X. Pivot" 2 => "G. Contesso" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Cancer" "fecha" => "1998" "volumen" => "78" "paginaInicial" => "1624" "paginaFinal" => "1628" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9862574" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack69456" "titulo" => "Acknowledgements" "texto" => "<p id="par0150" class="elsevierStylePara elsevierViewall">We thank Dr. Fátima Neves and Dr. Couceiro, of Centro Hospitalar de Vila Nova de Gaia/Espinho, Hospital Eduardo Santos Silva.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003200000009/v1_201312060118/S2174204913001797/v1_201312060118/en/main.assets" "Apartado" => array:4 [ "identificador" => "9919" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003200000009/v1_201312060118/S2174204913001797/v1_201312060118/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913001797?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
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| 2024 November | 4 | 4 | 8 |
| 2024 October | 38 | 28 | 66 |
| 2024 September | 53 | 24 | 77 |
| 2024 August | 54 | 34 | 88 |
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| 2023 September | 28 | 19 | 47 |
| 2023 August | 32 | 20 | 52 |
| 2023 July | 40 | 14 | 54 |
| 2023 June | 46 | 13 | 59 |
| 2023 May | 60 | 29 | 89 |
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| 2023 March | 39 | 21 | 60 |
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| 2022 June | 35 | 14 | 49 |
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| 2021 July | 32 | 25 | 57 |
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| 2020 October | 23 | 13 | 36 |
| 2020 September | 43 | 6 | 49 |
| 2020 August | 12 | 9 | 21 |
| 2020 July | 35 | 6 | 41 |
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| 2020 May | 33 | 2 | 35 |
| 2020 April | 29 | 13 | 42 |
| 2020 March | 31 | 11 | 42 |
| 2020 February | 53 | 24 | 77 |
| 2020 January | 31 | 9 | 40 |
| 2019 December | 31 | 4 | 35 |
| 2019 November | 37 | 3 | 40 |
| 2019 October | 46 | 2 | 48 |
| 2019 September | 21 | 8 | 29 |
| 2019 August | 26 | 5 | 31 |
| 2019 July | 43 | 12 | 55 |
| 2019 June | 30 | 4 | 34 |
| 2019 May | 41 | 3 | 44 |
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| 2019 January | 86 | 7 | 93 |
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| 2018 November | 131 | 8 | 139 |
| 2018 October | 130 | 11 | 141 |
| 2018 September | 42 | 9 | 51 |
| 2018 August | 49 | 9 | 58 |
| 2018 July | 18 | 8 | 26 |
| 2018 June | 31 | 2 | 33 |
| 2018 May | 37 | 5 | 42 |
| 2018 April | 30 | 10 | 40 |
| 2018 March | 48 | 11 | 59 |
| 2018 February | 16 | 1 | 17 |
| 2018 January | 33 | 9 | 42 |
| 2017 December | 38 | 4 | 42 |
| 2017 November | 28 | 10 | 38 |
| 2017 October | 23 | 7 | 30 |
| 2017 September | 24 | 3 | 27 |
| 2017 August | 24 | 12 | 36 |
| 2017 July | 23 | 9 | 32 |
| 2017 June | 26 | 11 | 37 |
| 2017 May | 40 | 7 | 47 |
| 2017 April | 25 | 4 | 29 |
| 2017 March | 21 | 30 | 51 |
| 2017 February | 28 | 3 | 31 |
| 2017 January | 28 | 4 | 32 |
| 2016 December | 43 | 10 | 53 |
| 2016 November | 32 | 6 | 38 |
| 2016 October | 73 | 9 | 82 |
| 2016 September | 52 | 2 | 54 |
| 2016 August | 23 | 9 | 32 |
| 2016 July | 18 | 3 | 21 |
| 2016 June | 23 | 3 | 26 |
| 2016 May | 18 | 4 | 22 |
| 2016 April | 39 | 2 | 41 |
| 2016 March | 51 | 6 | 57 |
| 2016 February | 54 | 14 | 68 |
| 2016 January | 45 | 5 | 50 |
| 2015 December | 28 | 9 | 37 |
| 2015 November | 39 | 4 | 43 |
| 2015 October | 39 | 8 | 47 |
| 2015 September | 43 | 6 | 49 |
| 2015 August | 27 | 6 | 33 |
| 2015 July | 26 | 6 | 32 |
| 2015 June | 19 | 0 | 19 |
| 2015 May | 28 | 6 | 34 |
| 2015 April | 22 | 4 | 26 |
| 2015 March | 26 | 3 | 29 |
| 2015 February | 35 | 4 | 39 |
| 2015 January | 40 | 2 | 42 |
| 2014 December | 39 | 8 | 47 |
| 2014 November | 28 | 5 | 33 |
| 2014 October | 44 | 5 | 49 |
| 2014 September | 28 | 3 | 31 |
| 2014 August | 31 | 5 | 36 |
| 2014 July | 43 | 9 | 52 |
| 2014 June | 27 | 4 | 31 |
| 2014 May | 30 | 5 | 35 |
| 2014 April | 30 | 3 | 33 |
| 2014 March | 48 | 10 | 58 |
| 2014 February | 50 | 11 | 61 |
| 2014 January | 58 | 11 | 69 |
| 2013 December | 28 | 9 | 37 |
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