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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Primary cardiac tumors are classified as benign&#44; malignant or of uncertain behavior&#46; Myxoma is the most frequent cardiac tumor and belongs to the group of benign neoplasms&#46; Inflammatory myofibroblastic tumor &#40;IMT&#41; is considered to be of uncertain behavior&#44; tending to produce local infiltration&#44; but not frequent metastasis propagation&#44; although it can be locally aggressive&#46; Differential diagnosis is challenging due to the variability of its histopathologic myxoid and inflammatory cellular findings that are similar to myxoma and sarcoma&#46; IMT does not display the cytologic atypia and nuclear hyperchromasia which characterize sarcomas&#44; although a few mitotic figures can be found&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;2</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 66-year-old female was admitted to the hospital suffering progressive dyspnea for several months&#46; Echocardiography revealed an intracavitary left atrial tumor&#46; The report described a homogenous non-mobile mass of approximately 4 cm&#215;3 cm originating from the interatrial septum and occupying nearly the entire left atrial cavity&#46; The thoraco-abdominal computed tomography &#40;CT&#41; scan &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A&#41; confirmed the presence of a left atrial tumor extending to the right inferior pulmonary vein outlet&#46; Also&#44; a hypodense Image 7 mm in size was seen in hepatic segment VI suggesting possible focal steatosis&#46; The patient had no relevant family history&#46; Her personal history included advanced diabetic retinopathy associated with neovascular glaucoma&#44; without other relevant medical history&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Surgery was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B&#41; establishing cardiopulmonary bypass with aortic and bicaval cannulation&#46; The surgical approach was biatrial&#58; the first approach was the left atrium via the interatrial groove&#44; but direct right atrial access was required later for complete resection of the tumor and its base of implantation&#46; The tumoral implantation was found in the left atrial face of the interatrial septum in the area corresponding to the foramen ovale&#46; With a diameter estimated at 6 cm&#215;5 cm&#44; it occupied almost all the available space in the left atrium and expanded into the origin of both right pulmonary veins&#46; The tumoral implantation zone extended inferiorly to the coronary venous sinus orifice&#46; The mass displayed a mother-of-pearl appearance and elastic consistency with protuberant characteristics&#46; A clear cleavage plane was identified by a fibrous sheet which allowed a dull dissection&#44; separating the mass from the atrial wall&#44; making the suspicion of myxoma controversial and less likely&#46; Resection was completed including the base of implantation&#46; Reconstruction of the interatrial septum with a pericardial patch was necessary&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The postoperative course was marked by the need for permanent pacemaker implantation due to complete atrioventricular block&#46; Echocardiography demonstrated total absence of the atrial tumor and good biventricular function&#46; The study was extended with positron emission tomography&#44; which showed no signs of activity suggesting metastasis&#44; including the hepatic lesion seen in the preoperative thoraco-abdominal CT scan&#46; Anatomopathological study &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A&#41; led to the diagnosis of an IMT with spindle cells expressing actin&#44; calponin and CD68&#59; no atypia or mitosis was reported&#46; Tests for pS100&#44; anaplastic lymphoma kinase &#40;ALK&#41;&#44; p53&#44; immunoglobulin G4&#44; Epstein-Barr virus and calretinin were negative&#46; A few zones of spindle cells were associated with fibrohistiocytes and giant multinucleated cells&#44; some of them with mitosis&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Although postoperative echocardiographic controls were normal&#44; a CT scan in the third follow-up year revealed a contrast-enhanced mass occupying the right atrium measuring 17 mm&#215;15 mm&#215;34 mm with no infiltration to the surrounding structures&#46; There were no other relevant findings&#46; Magnetic resonance imaging was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41; to specify the mass&#39;s characteristics&#59; it was isointense in T1 and presented edema and late contrast enhancement&#44; suggesting malignant properties&#46; Although the patient remained asymptomatic&#44; after assessment by the heart tumor committee it was decided to operate due to the tumor&#39;s resectable characteristics&#46; Resternotomy was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#44; bicaval cardiopulmonary bypass was initiated and right atriotomy revealed a solid and homogeneous tumoral mass occupying the right atrial free wall extending from the superior to the inferior vena cava&#46; Its surface and interior had a mother-of-pearl appearance and no necrosis or hemorrhagic areas were observed&#46; Resection was complete although no clear boundaries were identified&#46; Reconstruction of the right atrial free wall with a heterologous pericardial patch was performed&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Postoperative echocardiography confirmed the absence of residual right atrial masses and normal ejection fraction in both ventricles&#46; However&#44; during the CT control scan three months after the second intervention&#44; a new increase in right atrial free wall density was reported&#44; suggesting tumoral recurrence&#44; with suspected pericardial infiltration&#46; Magnetic resonance confirmed this finding&#46; Surgical biopsy &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>B&#41; revealed spindle and stellate cells infiltrating cardiac muscle with marked nuclear pleomorphism without necrosis and a rate of three mitoses per 10 high-power fields&#46; Immunohistochemistry and fluorescence in situ hybridization study demonstrated MDM2 overexpression&#44; compatible with a mesenchymal neoplasm suggestive of intimal sarcoma&#46; Chemotherapy was not initiated due to the absence of changes in the immediate postoperative period on the CT scan&#44; cardiac magnetic resonance and echocardiography performed during follow-up&#44; thereby avoiding the side effects of chemotherapy that would have been administered with palliative intention&#46; The last control was a cardiac magnetic resonance in the 10th postoperative month&#46; The patient remained asymptomatic in cardiorespiratory terms&#44; without dyspnea or congestive symptoms&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Primary cardiac tumors are rare&#44; and almost 70&#37; of them are benign&#46; Myxoma&#44; the most frequent heart tumor in adults&#44; is normally found in the left atrium&#44; which makes it the first diagnostic hypothesis when a mass is encountered there&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;3</span></a> IMT is considered to be underdiagnosed&#46; It is characterized by a variety of myxoid and inflammatory findings with a mitosis rate of less than one per 10 high-power fields&#46; ALK expression is not a specific marker but is one of its characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">IMTs appear more frequently in the lungs than in the heart and usually manifest during childhood or adolescence&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> The tumor&#39;s recurrence rate has not been thoroughly studied in the literature due to its low incidence&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> It is considered to be of uncertain behavior&#44; tending to produce local infiltration&#44; but not frequent metastasis propagation&#44; although it can be locally aggressive&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;2</span></a> The natural history of IMT is benign and surgical resection is considered curative&#46; Thus&#44; surgical intervention is recommended if the mass is deemed to be susceptible to successful complete resection&#44; given its potentially fatal outcome if prolapse or embolization occurs&#46; Nevertheless&#44; close follow-up is advised due to its unpredictable subsequent behavior&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;2&#44;4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A negative finding of ALK expression in IMT is associated with aggressive behavior&#46; Cases have been reported with a higher frequency of local recurrence and distant metastasis&#46; Malignant transformation is possible in such situations&#44; when these tumors are classified as sarcomas&#46; In addition&#44; they usually present a worse response to treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5&#8211;7</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0050" class="elsevierStylePara elsevierViewall">We present a case report of a 66-year-old female in whom surgical resection of a left atrial tumor was performed&#46; Initially&#44; a cardiac myxoma was suspected given its frequency and typical left atrial location&#46; However&#44; the macroscopic characteristics&#44; microscopic findings and immunohistochemical study led to a diagnosis of IMT&#46; After three years of follow-up the patient required a second intervention due to the appearance of a new mass in the right atrium&#44; which was diagnosed as intimal sarcoma&#46; It cannot be confirmed whether the tumoral recurrence with a different diagnosis &#40;intimal sarcoma&#41; was a progression and differentiation from the primary IMT or the metachronous appearance of a spontaneous sarcoma&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Inflammatory myofibroblastic tumor is a neoplasm with uncertain behavior&#46; We describe a case in a 66-year-old female who underwent resection of a left atrial tumor suspected to be a cardiac myxoma which was subsequently diagnosed as an inflammatory myofibroblastic tumor&#46; After three years&#8217; follow-up the patient underwent a second operation to remove tumoral occurrence in the right atrium&#44; diagnosed as an intimal sarcoma&#46; It cannot be confirmed whether the tumoral recurrence with a different diagnosis &#40;intimal sarcoma&#41; was a progression from the primary tumor or the metachronous appearance of a spontaneous sarcoma&#46;</p></span>"
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Case report
Inflammatory myofibroblastic tumor: A rare entity with a complex diagnosis
Carlos Domínguez-Massaa,
Autor para correspondência
dominguez.massa@gmail.com

Corresponding author.
, Lucía Doñate-Bertolína, Óscar R. Blanco-Herreraa, Tomás Heredia-Cambraa, Manuel Pérez-Guilléna, Vicent Martínez-Cózarb, Empar Mayordomo-Arandab, Fernando Hornero-Sosa
a Department of Cardiovascular Surgery, Hospital Universitario y Politécnico La Fe, Valencia, Spain
b Department of Pathology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Primary cardiac tumors are classified as benign&#44; malignant or of uncertain behavior&#46; Myxoma is the most frequent cardiac tumor and belongs to the group of benign neoplasms&#46; Inflammatory myofibroblastic tumor &#40;IMT&#41; is considered to be of uncertain behavior&#44; tending to produce local infiltration&#44; but not frequent metastasis propagation&#44; although it can be locally aggressive&#46; Differential diagnosis is challenging due to the variability of its histopathologic myxoid and inflammatory cellular findings that are similar to myxoma and sarcoma&#46; IMT does not display the cytologic atypia and nuclear hyperchromasia which characterize sarcomas&#44; although a few mitotic figures can be found&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;2</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 66-year-old female was admitted to the hospital suffering progressive dyspnea for several months&#46; Echocardiography revealed an intracavitary left atrial tumor&#46; The report described a homogenous non-mobile mass of approximately 4 cm&#215;3 cm originating from the interatrial septum and occupying nearly the entire left atrial cavity&#46; The thoraco-abdominal computed tomography &#40;CT&#41; scan &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A&#41; confirmed the presence of a left atrial tumor extending to the right inferior pulmonary vein outlet&#46; Also&#44; a hypodense Image 7 mm in size was seen in hepatic segment VI suggesting possible focal steatosis&#46; The patient had no relevant family history&#46; Her personal history included advanced diabetic retinopathy associated with neovascular glaucoma&#44; without other relevant medical history&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Surgery was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B&#41; establishing cardiopulmonary bypass with aortic and bicaval cannulation&#46; The surgical approach was biatrial&#58; the first approach was the left atrium via the interatrial groove&#44; but direct right atrial access was required later for complete resection of the tumor and its base of implantation&#46; The tumoral implantation was found in the left atrial face of the interatrial septum in the area corresponding to the foramen ovale&#46; With a diameter estimated at 6 cm&#215;5 cm&#44; it occupied almost all the available space in the left atrium and expanded into the origin of both right pulmonary veins&#46; The tumoral implantation zone extended inferiorly to the coronary venous sinus orifice&#46; The mass displayed a mother-of-pearl appearance and elastic consistency with protuberant characteristics&#46; A clear cleavage plane was identified by a fibrous sheet which allowed a dull dissection&#44; separating the mass from the atrial wall&#44; making the suspicion of myxoma controversial and less likely&#46; Resection was completed including the base of implantation&#46; Reconstruction of the interatrial septum with a pericardial patch was necessary&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The postoperative course was marked by the need for permanent pacemaker implantation due to complete atrioventricular block&#46; Echocardiography demonstrated total absence of the atrial tumor and good biventricular function&#46; The study was extended with positron emission tomography&#44; which showed no signs of activity suggesting metastasis&#44; including the hepatic lesion seen in the preoperative thoraco-abdominal CT scan&#46; Anatomopathological study &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A&#41; led to the diagnosis of an IMT with spindle cells expressing actin&#44; calponin and CD68&#59; no atypia or mitosis was reported&#46; Tests for pS100&#44; anaplastic lymphoma kinase &#40;ALK&#41;&#44; p53&#44; immunoglobulin G4&#44; Epstein-Barr virus and calretinin were negative&#46; A few zones of spindle cells were associated with fibrohistiocytes and giant multinucleated cells&#44; some of them with mitosis&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Although postoperative echocardiographic controls were normal&#44; a CT scan in the third follow-up year revealed a contrast-enhanced mass occupying the right atrium measuring 17 mm&#215;15 mm&#215;34 mm with no infiltration to the surrounding structures&#46; There were no other relevant findings&#46; Magnetic resonance imaging was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41; to specify the mass&#39;s characteristics&#59; it was isointense in T1 and presented edema and late contrast enhancement&#44; suggesting malignant properties&#46; Although the patient remained asymptomatic&#44; after assessment by the heart tumor committee it was decided to operate due to the tumor&#39;s resectable characteristics&#46; Resternotomy was performed &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#44; bicaval cardiopulmonary bypass was initiated and right atriotomy revealed a solid and homogeneous tumoral mass occupying the right atrial free wall extending from the superior to the inferior vena cava&#46; Its surface and interior had a mother-of-pearl appearance and no necrosis or hemorrhagic areas were observed&#46; Resection was complete although no clear boundaries were identified&#46; Reconstruction of the right atrial free wall with a heterologous pericardial patch was performed&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Postoperative echocardiography confirmed the absence of residual right atrial masses and normal ejection fraction in both ventricles&#46; However&#44; during the CT control scan three months after the second intervention&#44; a new increase in right atrial free wall density was reported&#44; suggesting tumoral recurrence&#44; with suspected pericardial infiltration&#46; Magnetic resonance confirmed this finding&#46; Surgical biopsy &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>B&#41; revealed spindle and stellate cells infiltrating cardiac muscle with marked nuclear pleomorphism without necrosis and a rate of three mitoses per 10 high-power fields&#46; Immunohistochemistry and fluorescence in situ hybridization study demonstrated MDM2 overexpression&#44; compatible with a mesenchymal neoplasm suggestive of intimal sarcoma&#46; Chemotherapy was not initiated due to the absence of changes in the immediate postoperative period on the CT scan&#44; cardiac magnetic resonance and echocardiography performed during follow-up&#44; thereby avoiding the side effects of chemotherapy that would have been administered with palliative intention&#46; The last control was a cardiac magnetic resonance in the 10th postoperative month&#46; The patient remained asymptomatic in cardiorespiratory terms&#44; without dyspnea or congestive symptoms&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Primary cardiac tumors are rare&#44; and almost 70&#37; of them are benign&#46; Myxoma&#44; the most frequent heart tumor in adults&#44; is normally found in the left atrium&#44; which makes it the first diagnostic hypothesis when a mass is encountered there&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;3</span></a> IMT is considered to be underdiagnosed&#46; It is characterized by a variety of myxoid and inflammatory findings with a mitosis rate of less than one per 10 high-power fields&#46; ALK expression is not a specific marker but is one of its characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">IMTs appear more frequently in the lungs than in the heart and usually manifest during childhood or adolescence&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> The tumor&#39;s recurrence rate has not been thoroughly studied in the literature due to its low incidence&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> It is considered to be of uncertain behavior&#44; tending to produce local infiltration&#44; but not frequent metastasis propagation&#44; although it can be locally aggressive&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;2</span></a> The natural history of IMT is benign and surgical resection is considered curative&#46; Thus&#44; surgical intervention is recommended if the mass is deemed to be susceptible to successful complete resection&#44; given its potentially fatal outcome if prolapse or embolization occurs&#46; Nevertheless&#44; close follow-up is advised due to its unpredictable subsequent behavior&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#44;2&#44;4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A negative finding of ALK expression in IMT is associated with aggressive behavior&#46; Cases have been reported with a higher frequency of local recurrence and distant metastasis&#46; Malignant transformation is possible in such situations&#44; when these tumors are classified as sarcomas&#46; In addition&#44; they usually present a worse response to treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5&#8211;7</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0050" class="elsevierStylePara elsevierViewall">We present a case report of a 66-year-old female in whom surgical resection of a left atrial tumor was performed&#46; Initially&#44; a cardiac myxoma was suspected given its frequency and typical left atrial location&#46; However&#44; the macroscopic characteristics&#44; microscopic findings and immunohistochemical study led to a diagnosis of IMT&#46; After three years of follow-up the patient required a second intervention due to the appearance of a new mass in the right atrium&#44; which was diagnosed as intimal sarcoma&#46; It cannot be confirmed whether the tumoral recurrence with a different diagnosis &#40;intimal sarcoma&#41; was a progression and differentiation from the primary IMT or the metachronous appearance of a spontaneous sarcoma&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Inflammatory myofibroblastic tumor is a neoplasm with uncertain behavior&#46; We describe a case in a 66-year-old female who underwent resection of a left atrial tumor suspected to be a cardiac myxoma which was subsequently diagnosed as an inflammatory myofibroblastic tumor&#46; After three years&#8217; follow-up the patient underwent a second operation to remove tumoral occurrence in the right atrium&#44; diagnosed as an intimal sarcoma&#46; It cannot be confirmed whether the tumoral recurrence with a different diagnosis &#40;intimal sarcoma&#41; was a progression from the primary tumor or the metachronous appearance of a spontaneous sarcoma&#46;</p></span>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Microscopic image of inflammatory myofibroblastic tumor&#46; Tumor lesion of heterogeneous cellularity in a loose stroma&#44; which varies from mucoid to dense with abundant collagen&#46; It is vascularized by dilated vessels of variable caliber&#44; some thrombosed&#46; The predominant cells are lymphocytes and plasma cells&#44; polyclonal inflammatory in nature&#44; which mask the stromal cells&#46; There is no atypia or mitosis&#46; Other areas contain fibrohistiocytes and multinucleated giant cells&#44; some undergoing mitosis&#59; &#40;B&#41; microscopic image of intimal sarcoma&#46; Proliferation of elongated spindle and stellate cells that grow interconnected in long&#44; ill-defined bundles infiltrating the cardiac muscle&#46; The cells show marked nuclear pleomorphism&#44; without necrosis&#46; There are three mitoses per 10 high-power fields&#46;</p>"
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