PMC9944787_01
Non-contrast (A) and contrast-enhanced CT (B) showed multiple rounded lesions with mild inner enhancement in the left frontal and parietal areas.
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Computed tomography showed multiple high-intensity signals with mild enhancements in the left frontal and parietal lobes (Figures 1A, B).
Cerebral MRI examination showed multiple cerebral tumors with recent hemorrhage on axial T1WI (A) and T2WI (B) and perilesional edema on FLAIR-weighted images (C). Enhanced T1WI after gadolinium showed the largest heterogeneous single-nodular enhancement lesion in frontal lobe on axial (D) and sagittal panel (E). That left dispersive presence of multiple focal regions of susceptibility-induced signal loss of variable size on axial SWI (F).
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Magnetic resonance imaging showed multiple intracranial tumors with manifestations of bleeding (Figures 2A, B). Enhanced T1WI showed enhanced lesion in frontal lobe (Figures 2D, E). FLAIR (fluid attenuated inversion recovery) and SWI (Susceptibility-weighted imaging) showed peripheral edema around the tumor sites (Figures 2C, F).
Cardiac echocardiography revealed a left atrium myxoma measuring ~ 27 x 13 millimeters (arrow).
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Overall, the results were consistent with the clinical manifestation of cavernous hemangioma (Figure 3).
Sections under microscopic examination showed circumscribed fragments of fibrocol-lagenous tissue and some ectatic vascular channels with hemorrhage (A, B, metastatic cerebral sites). Under light microscopy, myxomatous component is seen. It is characteristically composed of stellate or fusiform shaped cells surrounded by loose stroma with abundant basophil cells in-filtration (C, cardiac myxoma). Immunohistochemical stain revealed positive expression of CD34 (D).
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The surgery was successful; all four lesions were resected, and the pathological report of the specimens was consistent with pathological features of cardiac myxoma metastases (Figures 4A, B). The HE report was suggestive of a myxomatous lesion with hemorrhaging (Figure 4C), consistent with cerebral metastatic lesions (Figures 4A, B). Immunohistochemical staining showed that myxoma cells in this case highly express vascular marker CD34 (metastatic cerebral site: Figure 4D, cardiac site: Figure 8D), which is not express by myxofibrosarcoma cells.
Cerebral MRI re-examination in postoperative 8 months demonstrated cerebral lesions had increased in quantity and size, especially in occipital lobe, with peripheral enlarged edema and mild inner gadolinium enhancement in the largest lesion located in frontal lobe. Axial T1WI (A), axial T2WI (B), FLAIR (C), axial (D), sagittal (E), enhanced T1WI and axial SWI (F).
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Three new tumor sites in the occipital lobe were found on MRI (Figure 5).
These MRI performed after the second admission revealed serious edema surrounding lesions with mild midline shift, without obvious gadolinium enhancement. Axial T1WI (A), axial T2WI (B), FLAIR (C), axial (D), sagittal (E), and enhanced T1WI and axial SWI (F).
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The post-operative MRI showed that the relapsed tumor sites were entirely removed (Figure 6).
A large bilateral cerebellar hemisphere infarction was identified on multiple panel of T2-weighted (upper) and diffuse weighted image (below).
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A diffuse weighted image (DWI) identified massive bilateral cerebellar hemisphere infarction (Figure 7).
(A-C) Hematoxylin and eosin staining showing the cardiac myxoma attached to the atrial wall (A) and the enrichment of small plump spindle to ovoid tumor cells with abundant eosinophilic cytoplasm and minimal cytologic atypia (B) growing in aggregates and embedded within the myxoid stroma (C). Scale bar = 100 mum. (D, E) Immunohistochemical staining showing that myxoma cells express CD34 (D) but do not express SMA (E). Scale bar = 100 mum. (F) Immunohistochemical staining of Ki67 showing that myxoma cells are with very low proliferation index. Scale bar = 100 mum.
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In this case, the neoplasm is composed of small stellate to plump spindle cells with abundant eosinophilic cytoplasm and the stroma is myxoid (Figures 8A-C), there is no cytologic atypia nor increased mitotic figures, supporting the classical histological features of cardiac myxoma (Figures 8A-C). Immunohistochemical staining showed that myxoma cells in this case highly express vascular marker CD34 (metastatic cerebral site: Figure 4D, cardiac site: Figure 8D), which is not express by myxofibrosarcoma cells. However, these cells do not express the smooth muscle marker SMA or Desmin (Figure 8E). Proliferation index of myxoma cells in this case is very low, i.e., around 1% (Figure 8F).
Follow-up MRI revealed no signs of recurrence of tumors and gradually lessening ede-ma surrounding lesions without midline shift and obvious gadolinium enhancement. Axial (A), sagittal (B), and enhanced T1WI, FLAIR (C).
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At present, all metastatic sites are well-controlled, and there is no evidence of recurrence (Figure 9).