warfarin and Fibroma

Cardiac papillary fibroelastoma is reported to be the 2nd most common cardiac tumor following myxoma. Owing to the risk of embolism, early surgical excision is the treatment of choice. We report a case of effective anticoagulation therapy prior to surgical excision of an aortic valve papillary fibroelastoma. A 78-year-old man was admitted to our hospital because of transient cerebral ischemic attack. The symptom was relieved in a short period. Echocardiography revealed a tumor at the aortic valve. Cardiac computed tomography revealed a sea-anemone-like appearance of the tumor. Cardiac papillary fibroelastoma was suspected on close examination. The operation was postponed because of gingivitis that required draining. During 3 months awaiting the operation, he continued receiving anticoagulation therapy, which successfully prevented thromboembolism. Administration of anticoagulation therapy may be considered, unless early surgical excision can be performed.

Topics: Aged; Aortic Valve; Fibroma; Heart Neoplasms; Humans; Ischemic Attack, Transient; Male; Papillary Muscles; Warfarin

Thrombotic thrombocytopenic purpura (TTP), a complex thrombotic microangiopathy, remains an evolving enigma. A 49-year-old African-American woman presented with acute left hemiplegia, an ischemic cerebrovascular accident involving the right middle cerebral artery. Sequential appearance of thrombocytopenia and evidence of microangiopathic haemolysis led to the diagnosis of acquired idiopathic autoimmune TTP. This was managed with plasma exchange (PEX) and steroids. Early haematologic relapse within a month was managed with the addition of rituximab attaining sustained remission. The patient presented 3 years later with acute confusion and expressive aphasia due to multiple infarcts involving the left parieto-occipital cortex. Transoesophageal echocardiography demonstrated a pedunculated 6 mm mitral valvular mass consistent with a papillary fibroelastoma. Anticoagulation was instituted and the patient was continued on therapeutic oral warfarin. A haematologic relapse of TTP eventually emerged and was managed with PEX, steroids and rituximab. This vignette demonstrates several dilemmas in the clinical presentation, diagnosis and management of TTP in current day practice. Rituximab has adjuvant benefits to PEX and is being investigated as potential first-line therapy. Monitoring ADAMTS13 activity and inhibitor titre, as in our case, prove to have prognostic significance. Cardiac fibroelastomas are rare benign cardiac tumours usually arising from valvular endocardium with thromboembolic potential. One of the proposed mechanisms of origin of these masses is organizing thrombi in the setting of endocardial injury and inflammation questioning a possible link to thrombotic microangiopathy. To the best of our knowledge, this is the first report of this unique coexistence.

Topics: ADAM Proteins; ADAMTS13 Protein; Antibodies, Monoclonal, Murine-Derived; Anticoagulants; Female; Fibroma; Heart Neoplasms; Hemiplegia; Humans; Middle Aged; Mitral Valve; Plasma Exchange; Purpura, Thrombotic Thrombocytopenic; Rituximab; Steroids; Warfarin

Herein we report the clinical presentation and radiographic findings of a patient with a known history of multiple nonossifying fibromas, also known as the Jaffe-Campanacci syndrome, who presented with persistent pleuritic chest pain after a fall and was found to have a small pulmonary embolus. The presentation, pathophysiology and management of the syndrome are briefly discussed.

Topics: Angiography; Bone Neoplasms; Cafe-au-Lait Spots; Chest Pain; Female; Fibroma; Heparin; Humans; Pleurisy; Pulmonary Embolism; Syndrome; Treatment Outcome; Warfarin; Young Adult

Ten patients with large inoperable desmoid tumors in various body locations were treated with testolactone. Four tumors (40%) responded with major regressions, i.e., more than 50% reduction in volume. Eight patients received nonsteroid anti-inflammatory drugs (indomethacin, sulindac, or sulindac with warfarin and vitamin K1 [Mephyton]) for periods of 2 to 91 months. There was one major regression, one partial regression, and three instances of tumor growth arrest over periods up to 8 years. Seven patients were treated with nonsteroid anti-inflammatory drugs concurrent with or after testolactone or tamoxifen. There were five major regressions and one partial regression with extensive central necrosis of an enormous intra-abdominal tumor. The last patient has been treated for only 12 months, with no change in tumor volume. It appears that estrogens function as growth factors for desmoid tumors, and that minimization of these effects inhibits tumor growth in some, but not all, cases. In those instances where antiestrogens were not effective as single agents, the tumors usually responded to subsequent nonsteroid anti-inflammatory drug therapy. Withdrawal of estrogen may be followed by inhibition of transcription of genes that support tumor cell proliferation, and sulindac and indomethacin may augment these effects by inhibiting prostaglandin and cyclic AMP synthesis and the activity of protein kinase C. Warfarin may function as a protonophore to acidify the cytoplasm and prevent the alkalinization that is necessary to initiate DNA synthesis and cell cycle progression, again an impairment of the transcription process.

Topics: Abdominal Neoplasms; Adult; Aged; Antineoplastic Combined Chemotherapy Protocols; Female; Fibroma; Gardner Syndrome; Humans; Indomethacin; Male; Remission Induction; Sulindac; Tamoxifen; Testolactone; Time Factors; Vitamin K 1; Warfarin