An Insidious Cardiac Sarcoma Presenting with Progressive Neurologic Dysfunction
A 45 year-old Caucasian woman, with no significant past medical history, developed newonset headaches. She was initially treated conservatively with rest and analgesics over the course of several months. However, her symptoms gradually worsened and began to include nonspecific mental status changes such as forgetfulness, daytime somnolence and postural imbalance. She eventually sought care at a local emergency department where her review of symptoms at the time was negative for any cardiac or respiratory involvement. Physical examination revealed no abnormal findings in the chest on auscultation. During the course of her evaluation a magnetic resonance imaging scan revealed two brain lesions, one in the right frontal lobe measuring 2×1.7 cm with extensive edema and another in the left parietal lobe measuring 0.8×0.6 cm on the axial T1-weighted images (, yellow and red arrow, respectively). She underwent a stereotactic biopsy of the right frontal lobe lesion that revealed a spindle cell sarcoma with highgrade features of necrosis, increased mitoses, and nuclear pleomorphism.\nSubsequent staging computed tomography scans of the chest, abdomen and pelvis were not able to identify a primary tumor site. However, a PET scan revealed a FDG-avid in the left atrium. Further evaluation with a transesophageal echocardiogram showed a 2.5×1.8 cm left atrial mass at the base of the posterior mitral valve leaflet with mobile fronds (, yellow circle). An MRI of the chest further demonstrated that this mass was irregular and extended into the appendage and down the anterolateral mitral annulus without interfering with mitral valve function. Shortly thereafter, she underwent stereotactic radiosurgery for the two cerebral metastases present that was later followed by an excision of the left atrial mass with a pericardial patch reconstruction of the atrium and pulmonary veins. Intraoperatively, the tumor was found to obliterate the left atrial appendage and extended into the mitral valve annulus (, yellow arrow). Unfortunately, the mass proved to be larger than radiographic imaging had predicted making the goal of achieving clear margins unattainable, as a small rim of residual tumor was left behind in the atrioventricular groove. The final pathology confirmed a 5.5×5.1×2.1 cm high grade undifferentiated cardiac sarcoma.\nDuring the subsequent month as she was recovering from her surgery, she began to have severe headaches again and an MRI of the brain revealed several new lesions. Moreover, a repeat CT of the chest also showed interval growth of the mass within the left atrium as compared to post-surgical CT studies. She underwent palliative whole brain radiation therapy but continued to experience headaches, visual disturbances, and numbness in the upper extremities. She eventually transitioned to palliative care in view of the rapid progression of disease in the brain.