Background
Primary cardiac sarcomas are rare, aggressive types of malignancies with poor prognoses and can rarely present with thrombocytopenia. Sarcomas account for 65% of primary malignant cardiac tumours. Clinical symptoms often present with constitutional symptoms such as shortness of breath, weight loss, and fatigue. In addition, the tumour’s location determines treatment options and prognosis. Multimodal imaging facilitates the detection and assessment of cardiovascular tumours. This case study presents a rare primary right heart cardiac sarcoma presenting with thrombocytopenia.
Case summary
An 80-year-old male presented to the emergency department with complaints of worsening dyspnoea, ease of bruising, and chest pain. An extensive investigation into the cause of thrombocytopenia was performed. A transthoracic echocardiogram, computed tomography scan, and cardiac magnetic resonance (CMR) image revealed a large mass affecting the right atrium and right ventricle. Myocardial biopsy showed high-grade angiosarcoma. Due to his advanced age and intraventricular septal involvement of the mass, the multidisciplinary team decided to proceed with palliative chemotherapy.
Discussion
Many cardiac tumours remain asymptomatic, and the diagnosis is made at an advanced stage of the disease. Differential diagnoses of the intramural masses include haemangiomas, lipomas, rhabdomyomas, lymphomas, and sarcomas. Multiple treatment options should be considered to address thrombocytopenia. Tumour diagnosis and identification consist of laboratory tests and multimodal imaging. Complete surgical resection with neoadjuvant and adjuvant purposes is the mainstay of cardiac sarcoma therapy. A multidisciplinary, individualized care approach should be performed.
Primary achalasia is a progressive neurodegenerative disease. The goal of therapy is to disrupt the lower esophageal sphincter to improve emptying while avoiding reflux. Patient reported outcomes continue to be the primary measure of success of myotomy but objective measures of myotomy adequacy, GERD development, and reinterventions are also critical outcomes post treatment. A simple, tabular broad based scoring card that captures each of these testing measures can better display the changes that arise after intervention and allow for comparison.
The robotic platform has permeated esophageal surgery both in the abdominal and thoracic approaches. The most widely studied entities include achalasia, gastroesophageal reflux disease, hiatal hernia and esophageal cancer. A literature review of robotic surgeries for the management of the above mentioned disorders is presented. Data is limited to meta-analyses, case series, or small prospective trials in the different indications. One exception is a randomized controlled trial looking at outcomes in esophageal cancer being managed with a hybrid robotic versus open approach. Overall differences when comparing laparoscopic or thoracoscopic surgery to robotic are few. These differences are best highlighted in the achalasia and esophageal cancer literature. There are less intraoperative mucosal injuries in robotic Heller myotomy.A large meta analysis found a rate of 1% versus 24.5% mucosal injury rate favoring the robotic versus laparoscopic Heller myotomy methods. With respect to esophagectomy data, there is slightly less vocal cord paralysis in the robotic versus MIE data, with a P value of 0.044. However, length of stay, intraoperative bleeding and major morbidity are similar across the various indications. Robotic esophageal surgery is a safe alternative to laparoscopic/thoracoscopic techniques. Further large-scale randomized trials are needed to fully ascertain if it yields superior outcomes.
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