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Calcified left atrial myxoma with osseous metaplasia

Sushil Kumar Singh & Tushar Goyal & Santosh Gupta &

Vivek Tewarson

Received: 24 May 2012 /Revised: 4 July 2012 /Accepted: 9 August 2012 /Published online: 7 May 2013# Indian Association of Cardiovascular-Thoracic Surgeons 2013

A 55 years old female patient presented to cardiology depart-ment with the complaints of dyspnea and palpitation since last7 days. She was in atrial fibrillation with a ventricular rate of110/minute. Her blood pressure was 90/60 mm of Hg. Amiddiastolic murmur was audible over precordium withbilateral basal crepitation.

Chest roengtogram showed cardiomegaly with bilateralobliteration of costophrenic angle. There was an ovalradiopaque mass within the cardiac shadow (Fig. 1).Echocardiography revealed enlarged left and right atriumwith severe tricuspid regurgitation. There was a largeheterogeneous sessile mass in left atrium of 5.9×4.3 cmdiameter with well-defined margin and doubtful calcifica-tion, arising from interatrial septum. Other chambers andvalves were normal.

Operation was performed through median sternotomyusing cardiopulmonary bypass and moderate hypother-mia. Aortic and bicaval cannulation with antegradecold cardioplegic arrest was done. A transseptal ap-proach through right atriotomy was used. The tumor

was firm to hard in consistency with a wide base, and,it was difficult to go towards left atrium through thisapproach.

A separate left atriotomy was done which revealed ahard, yellowish-white calcified mass of approximately6 cm diameter (Fig. 2) attached to atrial septum througha wide base. The left atrial tumor was excised togetherwith a cuff of atrial septum. The defect was closed with5/0 running prolene suture (Ethicon, Somerville, NJ,USA) using pericardial patch. All other cardiac cham-bers were free of any residual and/or additional tumor.Tricuspid valve repair was done using De Vega’sannuloplasty. Patient was discharged from the hospital on5th postoperative day. Follow up echocardiography after6 months didn’t showed any residual tumor or atrialseptal defect.

Pathological examination of excised tissue showed anencapsulated mass with smooth outer surface measuring6×6×4 cm having both cystic and solid areas, with foci ofgrayish white calcification. Microscopic examinationshowed monomorphic feature comprising of both stellateto fusiform tumor cells arranged in multiple cell layer pat-tern within the background of loose myxomatous stroma.The tumor cells were oval to round in shape having elon-gated nuclei with vesicular chromatin, and abundant eosin-ophilic cytoplasm. Interspersed within the tumor-variablesized irregular areas of osseous metaplasia were noted(Fig. 3). Upto 80 % of myxomas are localized in the leftatrium, of which 75 % involve interatrial septum. It isknown that calcification is present in 10–20 % of myxomaand appears to be more frequent when the tumor is in theright atrium rather than in the left atrium [1, 2], but heavy

S. K. Singh (*) : T. Goyal : S. Gupta :V. TewarsonCardiothoracic & Vascular Surgery Department, King George’sMedical University, Lucknow Pin-226003, Indiae-mail: doctorsushil@hotmail.com

T. Goyale-mail: drtushargoyal@gmail.com

S. Guptae-mail: santoshhari7@gmail.com

V. Tewarsone-mail: vctewarson@gmail.com

Indian J Thorac Cardiovasc Surg (April–June 2013) 29(2):155–156DOI 10.1007/s12055-013-0202-8

calcification of atrial myxoma is uncommon [3]. A calcifiedmyxoma visible in a plain chest radiograph is a rare finding[3, 4] and so is ossification or bone formation of an atrialmyxoma [1–3]. Radio opacity within cardiac shadow onchest x-ray was present in our case also. A calcified ballthrombus can present a similar appearance macroscopically,but the mass in this patient was easily distinguishablehistologically as a tumor. Very few cases of bone formationhave been reported in literature [5–8]. Our case showedosseous metaplasia on histological examination.

We consider our case a rare, because of heavily calcifiedleft atrial myxoma which was visible on chest x-ray. Inaddition osseous metaplasia was present in our case, whichis extremely rare.

References

1. Oliver GC, Missen GA. A heavily calcified right atrial myxoma.Guys Hosp Rep. 1966;115:37–63.

2. Fleming HA, Stovin PGI. Calcified right atrial mass. Report of acase and discussion of the differential diagnosis. Thorax. 1972;27:373–81.

3. Sharratt GP, Grover ML, Monro JL. Calcified left atrial myxomawith floppy mitral valve. Br Heart J. 1979;42:608–10.

4. Stewart J, Saunders NR. Left atrial myxoma with extensive calcifi-cation. Thorax. 1982;37:224–5.

5. Ishikawa T, Shimizu Y, Kimura E, Nishizawa K, Takanashi S,Kaneko K. A surgical case report of ossified left atrial myxoma.Nihon Kyobu Geka Gakkai Zasshi. 1996;44:1796–9.

6. Kugai T, Chibana M. Left atrial myxoma with extramedullaryhematopoiesis and ossification. Kyobu Geka. 2002;55:376–8.

7. Nishida T, Tomita Y, Mizobe K, Inokuchi K, Sunagawa K, Morita S.Ossifying cardiac myxoma with neovascularity. Jpn J ThoracCardiovasc Surg. 2005;53:210–2.

8. Panagiotou M, Panagopoulos ND, Ravazoula P, Kaklamanis L,Koletsis EN. Large asymptomatic left atrial myxoma with ossification:case report. J Cardiothorac Surg. 2008;3:19.

Fig. 3 Microscopic examination showed loose myxomatous stromawith stellate to fusiform tumor cells admixed with irregular osseousmetaplasia area (Hematoxylin & Eosin×200)

Fig. 1 Chest x-ray Poster anterior view showed oval radiopaque masswithin the cardiac shadow (arrow)

Fig. 2 Gross examination of excised specimen showed stone hardyellowish-white calcified mass of approximately 6 cm

156 Indian J Thorac Cardiovasc Surg (April–June 2013) 29(2):155–156