Download Evaluation of Cardiac Masses

Anne-Marie Anagnostopoulos, MD
Non-Invasive Conference
April 8, 2009
EVALUATION OF
CARDIAC MASSES
Outline
 Clinical Presentation
 Echocardiographic Evaluation and Normal
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Variants
Primary Cardiac Tumors
Metastatic Disease in the Heart
Cardiac Thrombus
Summary
Presentation
 Cardiac tumors are often misdiagnosed
because they are rare
 Examples of confusion include: RHD,
endocarditis, myocarditis, pulmonary
embolism, PHTN, vasculitis
 Can present with heart failure, arrhythmia, or
embolic phenomena
Presentation
 Heart Failure: Due to obstruction of outflow
tract or cavity filling or dysfunction due to
myocardial involvement
 Arrythmias: More often occur with intramural
involvement; SVT’s with atrial masses,
PVC/VT/VF with ventricular myocardial
involvement and conduction problems with
AV node involvement
 Emboli: Right and left sided phenomena
Normal Variants on Echo
 Many benign findings on echo often
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misinterpreted as pathologic
Chiari network, Eustatian valve, Catheters,
crista terminalis
Suture line, coronary sinus, moderator band,
muscle bundles
False chords, trabeculations, Brachiocephalic
vein, pleural effusion
Other non-cardiac findings
Eustatian Valve
Chiari Network
Primary Cardiac Tumors
 The vast majority are benign – 75%
 In an autopsy series, incidence was only found to be 0.02 %
 TTE can identify masses/tumors accurately and is useful in
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follow up
CT can define myocardial infiltration, calcification and
surrounding structures
Cardiac MRI offers the best soft tissue characterization and
correlates well with pathological findings
T1 images good for soft tissue, T2 for tissue contrast and fluid
components (useful for heterogeneous masses)
Can suppress fat signals (useful for lipomas)
Gadolinium enhancement can define myocardial infiltration,
vascularity of mass, and differentiate between mass and
thrombus
Benign Primary Cardiac Tumors
Braunwald’s, 7th Edition, page 1746
Cardiac Myxomas
 75% are found in Left Atrium
 Site of attachment almost always
the limbus of the fossa ovalis
 15-20% in the right atrium, less often in right
and left ventricles
 90% are solitary, average size 5-6cm (range 115 cm)
 Average age of presentation is 50 years old
Cardiac Myxomas – Echo Features
 Mobile Tumor
 Narrow Stalk connected to fossa ovalis
 Heterogenous with hypo/hyper-echoic foci
 Lucent areas and areas of calcification
 If appearance is typical, TTE is diagnostic
 TEE and 3D echo can supplement
characterization of myxomas
Cardiac Myxoma - TTE
Cardiac Myxoma - TEE
Cardiac Myxoma- 3D echo
Cardiac Myxoma
Cardiac Myxomas – CT and MRI
Features
 Contrast enhanced CT: usually demonstrates
well defined mass with lobular contours that
does not enhance
 CMR findings of Heterogeneous mass with
heterogeneous enhancement
 Primarily isointense on T1, and hyperintense
on T2 images
Cardiac Myxomas - Treatment
 Treatment is surgical with en bloc resection
including rim of septum around base
 Recurrence in about 1-5% of cases
(incomplete resection, implantation from first
tumor etc) - therefore annual surveillance
recommended
 In the familial Carney complex (combination
of myxomas, pigmented skin lesions, and
endocrine neoplasia)– risk of recurrence 1222%
Cardiac Myxomas
Papillary
Fibroelastomas
 Benign papilloma of
endocardium
 Average age of detection is 60 years old
 Found equally in men and women
 Many are clinically silent but can result in
emboli
Papillary Fibroelastoma –
Echo Features
 90% are single, with median diameter of 8mm
 Most commonly found on downstream side of valves
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(can be confused for vegetations)
Less common locations: Papillary muscle, chordae
tendenae or atria
Irregularly shaped with delicate frond-like surface
Mobility is common and risk factor for embolization
Valvular regurgitation is rare
Controversial if they are distinct from Lambl’s
excrescences (acellular deposits covered by
endothelium on valves, often at closure margins)
Because of small size – difficult to see on CT or MRI
Papillary Fibroelastoma – TTE
Papillary Fibroelastoma - TEE
? MRI PF
CMR same patient
CMR same patient
Papillary Fibroelastoma –
Less Common Site
Papillary Fibroelastoma –
Treatment
 Most recommend resection, especially for left
sided lesions
 Risk of embolism can be up to 25% over 3
years and 6% in asymptomatic patients in
whom the fibroelastoma was found
incidentally
 Surgery can usually be valve-sparing
 Recurrences have not been reported
Papillary Fibroelastoma
Cardiac Lipomas
 Uncommon benign tumor, usually small and found on
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epicardial surface
True lipomas are rare, more often present as lipomatous
hypertrophy of the interatrial septum
Highly echogenic
Usually present in inferior and superior portions of the
septum with sparing of fossa ovalis  “dumbell-shaped”
Associated with atrial arrhythmias
No enhacement on MRI, decreased signal with fat
suppression
True lipomas  resection
Lipomatous hypertrophy  surgery only if SVC
obstructed or significant arrhythmias
Cardiac Lipoma – CMR Imaging
After fat suppression turned on:
Lipomatous Hypertrophy of
Interatrial Septum
Lipomatous Hypertrophy of
Interatrial Septum
Rhabdomyomas and Fibromas
 Most common cardiac tumor in children
 Rhabdomyomas occur within a cavity or
embedded within myocardium, usual small and
multiple; often regress on own
 Fibromas are well-demarcated, echogenic
masses that can extend into cavity and result in
obstruction and arrhythmia; often found in free
wall of LV
 On MRI rhabomyomas are hyperintense on T2,
while fibromas are hypointense on T2 and isointense after gadolinium
Rhabdomyomas and Fibromas
Cardiac Fibroma
Malignant Primary
Cardiac Tumors
Braunwald’s, 7th Edition, page 1746
Malignant Primary Cardiac
Tumors – Echo Assessment
 Much less common than metastatic disease
 Malignant tumors tend to invade/replace
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myocardial tissue with disruption of normal
anatomy
Heart can appear teathered
Associated pericardial effusion is common
Angiosarcoma often involves right atrium
Rhabdomyosarcoma can occur anywhere
Cardiac Angiosarcoma
 No consensus on
treatment
 Surgery, chemotherapy
and radiation have been
used
 Prognosis is poor – survival
about 1 year after
diagnosis
Malignant Cardiac Tumors –
CT and MRI assessment
 Angiosarcoma on CT: low attenuation,
irregular or nodular with contrast
enhacement
 Angiosarcoma on MRI: heterogeneous signal
intensity on T2 images due to blood filled
spaces in neoplasm; heterogeneous
enhancement with gadolinium; late
enhancement due to fibrosis
Angiosarcoma on MRI
T2 weighted image
Primary Cardiac Lymphoma
 Rare, especially in immunocompetent patients
 Median age of presentation is 64 years old, 3:1
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male:female
Often aggressive B-cell lymphomas associated with EBV
Typically present with right sided heart failure, fever,
arrhythmias, tamponade
Most commonly arises from Right atrium and half have
pericardial effusions (often large)
TTE only moderate sensitivity, MRI has best sensitivity;
biopsy is diagnostic
Survival approximately 1 year, with chemotherapy
treatment
Cardiac Lymphoma - TTE
Cardiac Lymphoma - TEE
Cardiac Lymphoma - TEE
Cardiac Lymphoma – CT scan
Cardiac Lymphoma - CMR
Cardiac Tumor Imaging
Braunwald’s 7th Edition
Metastatic Disease to the Heart
 Metastases can manifest in the
heart as a mass, pericardial
disease, myocardial involvement
 Tumors can spread to heart by:
direct invasion, spread through
venous system or
hematongenously
 Cardiac involvement is often
established at autopsy in
patients with otherwise widely
metastatic disease
Metastatic Disease to the Heart
Primary Malignancy
Cardiac Effect
Lung
Direct extension, effusion
Breast
Hematogenous/lymphatic spread,
effusion
Lymphoma
Lymphatic spread, variable effects
GI
Variable
Melanoma
Intracardiac and myocardial
Involvement
Renal Cell Carcinoma
IVC-RA-RV extension, can look like
thrombus
Carcinoid
Tricuspid and pulmonic valve
abnormalities
Metastatic Melanoma
 Metastasizes to myocardium or pericardium
and involves the heart 50% of the time
 Often presents as intracardiac mass
 Best visualized on TTE after contrast injection
 Differentiated from thrombus by intact apical
wall motion
Metastatic Melanoma
Metastatic Renal Cell Carcinoma
 Commonly spreads by intravascular
extension from IVC to RA
 RA mass seen on echo can be first
presentation and should be distinguished
from thrombus or other benign mass
 May need supplemental imaging with CT and
MRI
Metastatic Renal Cell Carcinoma
Metastatic Renal Cell Carcinoma
Metastatic Renal Cell Carcinoma
CMR – Renal Cell Carcinoma
CMR – Renal Cell Carcinoma
Metastasis by Direct Extension:
Lung Cancer Common
Metastatic Lymphoma
CT Scan
CMR
Metastatic Carcinoid
 Tricuspid and pulmonic valves affected by
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vasoactive substances released by carcinoid
tumors when mets present in liver
Results in valve thickening and fibrosis
On echo: the valves can be thick, retracted
and immobile
Effect on TV: severe regurgitation
Effect on PV (when involved): stenosis
Metastatic Carcinoid
Intracardiac Thrombus
 Intracardiac source of emboli account for
approximately 15-20% of strokes
 TEE is imaging modality of choice for
evaluation of intracardiac thrombus and
source of emboli (except for LV apex)
 Major sources: LA (45%), LV apex, aorta,
valve prosthesis, abnormal interatrial septum
(aneurysm)
Imaging Intracardiac Thrombus
 Transthoracic Echo with/without contrast –
best for LV thrombi associated with aneurysm
or akinesis of the apex
 TEE – best for all other locations of thrombus
 MRI – excellent way to identify thrombus;
usually identified on spin echo and
gadolinium enhanced images with delayed
enhancement
LV Thrombus – Echo Features
 Sensitivity of TTE to detect LV thrombus is 7595%
 Associated with myocardial infarction that
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results in akinesis of the apex or dilated
cardiomyopathy resulting in slow flow
May be multiple, mobile
Texture usually distinct from myocardium
Risk factors for embolism: large size, mobility,
and protrusion into LV cavity
TTE used to follow LV thrombi over time
LV Thrombus - TTE
LV Thrombus – TTE with contrast
LV thrombus
Multiple Intracardiac Thrombi
LV thrombus on CMR
LV Thrombus on Delayed
Enhancement Imaging - CMR
LA Thrombus – Echo Features
 LA appendage is most likely site
 Associated conditions: Atrial Fibrillation, mitral stenosis,
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LV failure
The LAA can be multi-lobed in up to 70% of patients
Sensitivity of TEE to detect an LA thrombus approaches
95%, with equally high specificity
TEE evaluates size, mobility, emptying velocity,
extension into LA, and interatrial aneurysm if present
Can also assess spontaneous echo contrast
LA Appendage Thrombus
LA Thrombus
Summary
 Primary Cardiac tumors are rare and usually benign
 Clinical presentation based on location and size of mass
 Echo (TTE and TEE) remains the initial imaging test
 CMR is a useful modality to further characterize
intracardiac masses (especially lipomas, angiosarcomas
and thrombi) and narrow the differential diagnosis
 Treatment usually involves surgery for tumors
References
 Braunwald’s 7th Edition
 NEJM case records
 Feigenbaum
 Uptodate
 Imaging teaching files