PMC3568891_01
Two-dimensional (a) and magnified three-dimensional (b) transesophageal echocardiogram (TEE) of the left atrium (LA), mitral valve, and left ventricle. A 4.4 x 3.5 cm mass (asterisk) is seen attached to the posterolateral aspect of the LA.
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fig1
Mean and peak gradients across the mitral inflow were 4 and 12 mmHg, respectively (Figure 1).
Axial (a) MRI T1- and (b) T2-weighted and (c) CT contrast enhanced imaging and 4-chamber MRI (d) first pass perfusion and (e) late gadolinium enhancement (TI = 350 ms) imaging. MRI T1- and T2-weighted black blood images demonstrate a lobulated mass (asterisk) with central signal drop-out suggestive of punctuate calcification confirmed by CT. CT imaging also suggests that this mass is contiguous with the posterior leaflet of the mitral valve. Dynamic contrast-enhanced MRI demonstrates very minimal first pass perfusion and heterogenous late enhancement consistent with surface thrombus overlying a tumour. (RA) right atrium, (LA) left atrium, (RV) right ventricle, and (LV) left ventricle.
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fig2
Cardiac CT and MRI corroborated the TEE findings (Figure 2).
Macroscopic image shows the left atrial mass attached to the posterior wall of the left atrium and the entire posterior mitral leaflet, except for its free margin.
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fig3
The mass involved the atrial wall posteriorly and the entire posterior mitral leaflet, except for its free margin (Figure 3).
Section shows sheets of densely packed spindle cells infiltrating the myocardium, as well as the overlying epicardial adipose tissue (Stain: H&E, x5).
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fig4
The tumour cells had large, pleomorphic nuclei with prominent nucleoli (Figure 4).
The tumour cells show large, pleomorphic nuclei with prominent nucleoli. An abnormal mitotic figure is identified (Stain: H&E, x40).
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fig5
Frequent abnormal mitotic figures were identified (Figure 5).
Focal areas of the tumour showed malignant cartilaginous change (a), osteoid and bone formation ((a) Stain: H&E, x10, (b) Stain: H&E, x20).
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fig6
In some areas, the tumour showed malignant cartilaginous and osteoid differentiation (Figure 6).
Immunohistochemistry profile shows mild focal positivity for S100.
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fig7
S100 (Figure 7), and negative staining for smooth muscle actin, CD117, CD34, and O13 (CD99). Staining with MDM2 and platelet-derived growth factor (PDGF) was not performed.