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.