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Differential diagnosis of space occupying lesions in the heart * Type of lesions Prevalence § Most Common Location Pathologic Features Echo. Features CT Features MR Imaging Features Myxoma 30 % LA(83%), RA(13%), Pedunclated solitary Mobile tumor, narrow Heterogeneous, Heterogeneous, bright on subendocardial tumor (>90%) with a stalk low attenuation T2WI; heterogeneous stalk to subendothelium Lipomas 10 % enhancement Subendocardial and Very large, broad-based; Hypoechoic in the Homogeneous Homogeneous fat signal subepicaridal tumor, no no calcification, pericardial space, fat attenuation intensity (increased T1); chamber predilection hemorrhage, or necrosis echogenic in a cardiac (low attenuation) no enhancement chamber Papillary 8% fibroelastomas Rhabdomyomas ** Fibromas 6% 3% 80-90% on valvular 1cm lesion with delicate Small, mobile masses a mass on a valve leaflet or on the endocardial endocardium, aortic papillary fronds, single in attached to the valve surface on CT or MR imaging. valve most common 91% with a short pedicle Ventricles > atria multiple small (<1mm) Multiple, small, Multiple nodules, T1-isointense and lesions. in most tuberous homogeneous, hyper or hypo- T2-hyperintense relative sclerosis (50%) hyperechoic intramural attenuating to myocardium. Contrast associated. tumors. . enhancement. Interventricular septum Solitary intramural tumor Intramural, calcified Low attenuation, Isointensity on T1WI, and left ventricular free (5-cm average size) calcified dark on T2WI; No wall in > 90% Hemangioma Metastatic tumors Angiosarcomas 2% @ 8% Ventricles > atria Pericardium 90% in right atrium enhancement. Multiple tumors in 30% Hyperechoic lesions Heterogeneous at isointensity on T1WI and unenhanced CT, hyperintensity on T2WI. Contrast Inhomogeneous enhancement. enhancement at contrast *** large, heterogeneous, Nearly always multiple Pericardial effusion is microscopic nests and the most common echo broad based masses with discrete nodules. finding. tumor necrosis. Intramural mass with Echocardiography is protrusion into the cavity, excellent for initial intermediate intensity on infiltrative, frequent visualization of T1WI, clear demarcation involvement of malignant cardiac on T2WI. Contrast pericardium. # lesions *** Mosaic pattern: enhancement. Rhabdomyosarcomas 5% No chamber predilection Multiple lesions seen in # *** Homogeneous, 60%, infiltrative Isointense on T1WI, and hyperintense on T2WI. Contrast enhancement. Leiomyosarcomas Primary cardiac 1% 2% lymphomas Cardiac thrombi Vegetations 70-80% in LA, may Solitary lesion in70%, # *** Isointense on T1WI, and involve pulmonary trunk infiltrative Right side of the heart in Single lesion in 66% and Echo, CT and MR signals are not specific, and histopathologic diagnosis 69-72% multiple lesions in34%, is required. Most commonly manifest as circumscribed, nodular masses may pericardial effusion in the myocardium, often with an associated pericardial effusion. hyperintense on T2WI. Cardiac Most in LV apex or Most in atrial fibrillation, More echogenic than Most thrombi are Increased intensity on thrombi are LA appendage enlarged atrial chamber, the underlying myo- not mobile. T1WI and lower more low cardiac output state, cardium, and a contour differentiating a intensity on T2WI. No frequent and wall motion distinct from the thrombus from other contrast enhancement. than tumors abnormalities endocardial border. tissues density Incidence of Typically attached to Growing in size, either as homogeneous, mobile, CT and MRI may have a role in the diagnosis IE: 3.6~7 valve, upstream side. a sessile clump or a echogenic, irregular of endocarditis complications, especially aortic cases per highly mobile and even mass. root abscesses and aneurysms ## 100,000 pedunculated mass. patient-year Irregular shape. *: 1. Moluk Mirrasouli Ragland, and Tahir Tak. The role of echocardiography in diagnosing space-occupying lesions of the heart. Clinical Medicine & Research. 2006: volume 4, number 1: 22-32. 2. Bruce McManus and Cheng-Han Lee. Braunwald’s Heart Disease: a textbook of cardiovascular medicine. 8 th ed. Philadelphia, PA: Saunders Elseviers; 2008, 1815-1828. §: Relative frequency of primary cardiac tumors: from Feigenbaum et al. Feigenbaum’s echocardiography. 6 th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.703. **: the most common benign pediatric tumors; @: 20 times more common than primary cardiac tumors. *** : Features suggesting malignancy : 1. Wide attachment to walls of heart; 2. Destruction of cardiac chamber walls 3. Invasion of pericardium and particularly hemorrhage 4. Extension into the pulmonary arteries or veins, or vena cava metastatic spread 5. Involvement of two cardiac chambers 6. Necrosis of the mass lesion 7. Multiple lesions suggest 8. Involvement beyond the pericardium, lung or mediastinum. #: Echocardiographic examination focuses on the anatomic location and extent of the tumor involvement, the physiologic consequences of the tumor (e.g., valve regurgitation, chamber obliteration, obstruction) and associated findings (pericardial effusion, evidence of tamponade physiology) ##: CT or MR in the diagnosis of infective endocarditis has not yet been established.