Cardiac Masses Flashcards
- Definition of thrombosis:
- General characteristics of a thrombus:
formation of a blood clot within intact vessels
– Begin at a site of endothelial injury, or a site of turbulence of flow, or site of blood stasis
– Point of attachment to wall
– Lines of Zahn: laminations apparent grossly +/or microscopically produced by alternating layers of platelets, fibrin, & RBCs
– May fragment and create emboli
Three primary abnormalities that lead to thrombus formation in Virchows Triad
Abnormal blood flow, hypercoagulability, endothelial injury
Risk factors for cardiac thrombi
- Abnormal blood flow = abnormal myocardial contraction from: Arrhythmia/ Dilated cardiomyopathy/ Myocardial infarction
- Hypercoagulability
- Endothelial injury from Myocarditis or endocarditis
Cardia mural thrombi attach to wall usually at site of:
decreased contraction where blood flow is turbulent (secondary to MI)
Significance of Cardiac thrombi
- In left atrium or left ventricle :
- In right atrium or right ventricle:
- In left atrium or left ventricle can embolization to various organs and decreased cardiac output
- In right atrium or right ventricle embolization to lungs and decreased cardiac output
Definition of embolus/emboli and causes
detached intravascular mass carried by blood to site distant from origin
– Thrombus (thromboembolism): most common
– Fat
– Air
– Amniotic fluid
– Tumor
Consequence of emobli
ischemic necrosis to target organ
Origin of systemic embolisms:
– Heart: atrium, ventricle, valve (80%)
• 2/3 with LV infarcts
• ¼ with dilated left atria
– Atherosclerotic plaque (abdominal aorta, carotid artery)
Systemic embolism travel in arterial circulation
– What is their destination:
***** Results in infarction of area supplied by vessel
lower legs (75%), brain (10%), intestines, kidneys, spleen, upper extremities
What is a paradoxical embolism?
• Paradoxical embolism: travels through heart defect into systemic circulation (patent foramen
ovale)
Heart tumors come from where?
Metastases – more common than primary neoplasms
– Primary sites: lung carcinoma, melanoma, lymphomas, breast carcinoma, leukemias
Clinical presentation of patients with heart tumors
dependent upon site of tumor within heart (pericardium, conduction system, ventricle)
The masses may be diffuse, mulitnodular, or a single dominant mass
5% of pts dying of cancer have mets to heart
What is true of primary neoplasms in the heart:
Most are benign!!
What is the most common cardiac tumor and where is it in the heart?
– Myxoma (90% in atria, L:R = 4:1), most common cardiac
tumor, mean age at presentation = 50 yrs
• Sessile or pedunculated (ball-valve obstruction)
Histologically what do we see in myxoma’s in the heart?
myxoma cells embedded in abundant ground substance, the tumor cells are splindled and in this amorphous substance
Syndrome associated with myxomatous cardiac tumors
Carney syndrome in 10%
Multiple cardiac/extracardiac myxomas (skin, breast, uterus), spotty pigmentation, endocrine overactivity
– Familial (AD and AR
Most common heart tumor in infants or children is:
Usually assoicated with:
Rhabdomyoma; may be hamartomas or malformations rather then neoplasms~~ these guys are BENIGN and slow growth, just in a bad place
ASsoicated with tuberous sclerosis
Clincal presentation of child with rhabdomyoma in the heart?
Gross morphology of tumor?
Clincal presentation depends on size and location; can be in either or both sides of heart; usally causes congestive sysmptoms and congestive heart fail.
Gross: see multple firm white nodules
What are these spider cells assoicated with?
Rhabdomyomas, altered muyocytes with vacuolation
– often asymptomatic, may cause ball-valve effect or arrhythmia
– form on valves, can embolize
Lipomas
Papillary fibroelastomas
Hemangiomas, lymphagiomas, glomus tumor and bacillary antiomatosis are examples of
Benign vascular malformations and neoplasms
– Kaposi sarcoma and hemangioendothelioma are examples of:
Intermediate grade vascular malformations and neoplasms
Angiosarcoma and hemagiopericytoma are examples of
Malignant vascular malformations and neoplasms
– Very common; 5-10% of benign pediatric tumors; often congenital
– Increased numbers of normal or abnormal, blood-filled vesels
Hemangiomas
Difference between capillary and cavernous hemangiomas
Capillary:Skin, subcutaneous tissue, mucous membranes, some visceral organs
–includes juvenile (strawberry)/ Adult (cherry)/ and Pyogenic granulomas
Cavernous:• Larger, dilated channels; deeper tissue; do not regress.
• Associated with von Hippel-Lindau disease
Hemangioma that grows for a few months, fades around 2 yo, then usually regresses by age 7
Juvenile “stawberry” hemiangioma… type of Capillary hemangioma
Below are two types of capillary hemangioimas, describe them
Adult (“cherry”) hemangioma –
Pyogenic granulomas –
more common with increasing age; does not regress
ulcerate and bleed; seen w/pregnancy or trauma
Larger, dilated channels; deeper tissue; do not regress.
• Associated with von Hippel-Lindau disease
Cavernous hemangiomas (think deep into the cave)
type of lymphangioma seen on neck or axilla of infants/children
• Poorly circumscribed, very large vessels devoid of blood (bc full of lymph)
• Associated with Turner syndrome
Cavernous lymphangiomas
Bacillary angiomatosis looks like a vascular lesion… but it’s not. What is it and how do you diagnosis it?
– Actually Bartonella infection in immunocompromised host
– Causes capillary proliferation (bacteria secrete HIF-1)
– Diagnosed on biopsy and/or PCR testing
clear, small nodules on the head/neck/ axilla
Simple lymphangiomas
– Composed of modified smooth muscle cells
– Small, on digits, often under nails
– Painful, easily cured by excision
Glomus tumor (glomangioma)
*Bening vascular lesion
Kaposi Sarcoma is associated or caused in what 4 ways?
Chronic, classic: indolent, see multiple, red to purple skin nodules, legs
• Eastern European or Mediterranean descent (Ashkenazi Jews)
• Lymphadenopathic, African or endemic: . African Bantu children and is aggressive
**• Transplant – associated KS; **Localized or widely metastatic, mostly internal in lymphs and viscera; not necessarily have cutaneous lesions, regresses with decreased immunosuppresion
• AIDS – associated (epidemic) KS
• 25% of AIDS patients / 40% of homosexual men, 5% of others/ Most common HIV-related malignancy
Why is KS so high in homosexual men with AIDS?
Human Herpes Virus type 8 (HHV 8): found in 95% of the lesions
– Also called KS-associated herpes virus (KSHV) and infects the endothelial cells
**Transmission not limited to sexual contact
What type of cells do we see histologically in KS?
Later stages: spindle cells predominant
*Spindle cells are believed to be of endothelial cell origin
Disease expression of KS is affected by degree of
immunosuppresion and 95% of time we see HHV 8
Tx recommendation for pts with KS that are not immunosuppressed:
– Resection/cryotherapy: if superficial and localized
– Radiation: if in limited area
– Chemotherapy: if disseminated
In pt immunocompromised, what is the tx for KS?
- Decrease immunosuppression if possible
- Add chemotherapy and/or radiation if needed
- Angiogenesis inhibitors have had success
What is Angiosarcoma, who do we see it in and where in the body?
Malignant neoplasm of endothelial cell seen in older adults
• Anywhere there are endothelial cells, but commonly:
– Skin, soft tissues, breast, liver
What are spefic associations do we see in angiosarcomas?
– Liver and arsenic, Thorotrast*, polyvinyl chloride
– Arm in patient with lymphedema, most commonly post mastectomy (often d/t disrupted lymph drainage)
– Post radiation
Describe the histology you see in angiosarcoma
well differentiated:
poorly differentiated:
Well differentiated: abundant vascular channels
▫ Less differentiated forms: solid spindle cell proliferation
Prognosis of angiosarcoma
5 year survival is 30%
Malignant variant of lymphangioma
• Occurs in the setting of chronic lymphatic
obstruction (such as post-axillary dissection
lymphedema after radical mastectomy)
Lymphangiosarcoma
