Discussion
Angiofibroma is a benign, highly vascular tumor that is most commonly
found within the nasopharyngeal region in the male adolescent population
(5,6). According to the literature, angiofibroma has a heterogeneous
appearance with intermediate in T1 weighted and intermediate to high
signal intensity in T2 weighted MRI as was the case about our patient
CMR even though in another case of cardiac angiofibroma reported by Kim
et al. hyperintensity was observed in both T1 and T2 weighted sequences
(3). Furthermore, considering the profound vascular component of
angiofibroma, MRI shows intense enhancement following gadolinium
contrast administration which also came true in our patient CMR; though
we did not consider angiofibroma firstly as a diagnosis, because given
the prevalence, hemangioma as an intensely vascular tumor is more
probable than angiofibroma (1,6,7). One of the differences disclosed in
the literature between hemangioma and angiofibroma CMR is that
hemangioma exhibits faster enhancement than angiofibroma during the
infusion of the contrast agent (3). Therefore, in general, we should add
angiofibroma to our differential diagnoses besides hemangioma when we
confront a benign vascular cardiac tumor based on CMR.
In addition to CMR which is the most comprehensive imaging modality to
identify and evaluate cardiac masses, histopathologic evaluation is
crucial to confirm the diagnosis of cardiac angiofibroma (1,3).
Angiofibroma pathology consists of 2 main components: vascular and
stromal tissue; a rich network of variably sized, irregularly shaped
vessels surrounded by a low to moderately cellular stroma with thick and
thin fibrils of collagen must be observed in microscopic assessment
(4,5). Moreover, to confirm the presence of vessels and fibrosis and
essentially rule out other diagnoses like hamartoma ( which contains
smooth muscles ), IHC and trichrome staining are required. CD31 IHC
staining is utilized to indicate the presence of endothelial cells,
Desmin IHC is employed to show the existence of muscles and trichrome
staining makes fibrotic tissue blue while it makes muscles appear
reddish (3).
In view of the management of a cardiac tumor, an interdisciplinary team
comprising a cardiac surgeon, cardiologist, and oncologist is required
(1). Nonetheless, there is a paucity of information about the treatment
of cardiac angiofibroma due to its rarity, considering the benign
cardiac tumors, surgical treatment results in a favorable prognosis with
a very low recurrence rate (8); consequently, we can presume a similar
scenario for cardiac angiofibroma which has benign behavior but a
long-term follow-up warrants consideration. Finally in respect of
surgical approach, besides traditional median sternotomy (MS) which is a
gold standard treatment for PCTs and has great early and late clinical
outcomes, an emerging approach is minimally invasive (MI) surgery. It
has shown to have appreciable early and late clinical outcomes with a
low recurrence rate based on a recent systematic review (9). Although
the MS approach was used for our patient, it is recommended to consider
the MI technique in the excision of benign cardiac tumors including
cardiac angiofibroma.