Ann Thorac Surg 2008;86:666. doi:10.1016/j.athoracsur.2007.10.055
© 2008 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Leiomyosarcoma of the Left Ventricle
Derek D. Muehrcke, MD, FACS*,
Keith Justice, MD
Department of Cardiac Surgery, Flagler Hospital, St. Augustine, Florida
* Address correspondence to Dr Muehrcke, Flagler Hospital, Department of Cardiac Surgery, 300 Health Park Blvd, Suite 5000, St. Augustine, FL 32086 (Email: dmuehrcke{at}aol.com).
This two-dimensional echocardiographic image of the left ventricle enhanced with Definity (Bristol-Meyers Squibb, Billerica, MA) contrast demonstrates a 2.5 x 2.5 cm apical leiomyosarcoma (Fig 1). Left ventricular function was normal; however, under the area of attachment of the mass, there was slightly a decrease function. This 42-year-old black female presented with a chief complaint of tiredness, headaches, and shortness of breath. The mass was confirmed by magnetic resonance imaging, which demonstrated the mass incorporated with the underlying myocardium. A subsequent fusion positron emission tomographic scan was normal. Cardiac catheterization revealed normal coronary arteries and preserved left ventricular function.
She underwent a left apical cardiac resection and reconstruction. The left ventricle was amputated using the technique used for post myocardial infarction ventricular septal defect repairs. We used felt buttressing inside and out to ensure that the sutures would not pull out. Operative margins were negative for tumor. Final pathology revealed the mass to be a low grade (ie, grade 1 of 4) leiomyosarcoma. The neoplastic cells were positive for vimentin, muscle specific actin, smooth muscle actin, and desmins. The tumor was negative for myogenin and human melanoma black-45.
After surgical resection, the patient's constitutional symptoms abated and she made a full recovery. She was treated with adjuvant chemotherapy including Adriamycin (doxorubicin; Pharmacia, Kalamazoo, MI), Cytoxan (Cyclophosphamide; Bristol-Myers Squibb, Princeton, NJ), and dacarbazine (DTIC; Bayer Healthcare, Leverkusen, Germany). She has no evidence of recurrent disease at two years on follow-up examination and fusion positron emission tomographic scan.
The interesting aspect of our case is that not all left apical masses are thrombus. Factors making our mass more likely to a neoplasm were the fact that our patient's left ventricular function was preserved and the mass was pedunculated versus sessile. The MRI revealed the mass to blend imperceptibly into the myocardium. She had no evidence of coronary artery disease and was young. Moreover, the mass had an unusual heart shape to it which was extenuated by the Definity contrast.
