Cardiac Masses Flashcards
Many of the cardiac lesions detected are usually tumor-like lesions, with _________ representing most cases
Thrombus
20 to 40 times more common than primary cardiac tumors
Tumors due to metastatic disease
First line inaging technique used to evaluate cardiac masses
Echocardiography
imaging wherein the heard is imaged throughout the cardiac cycle, may be helpful to demonstrate movement of the mass during the cardiac cycle
restrospective ECG gating
imaging modality of choice in evaluating cardiac masses
Cardiac MRI
MRI sequence that allows for excellent localization of the mass and simultaneously allows for functional analysis
Gradient echo cine imaging
most cardiac tumors demonstrate what MRI signal characteristics
low to intermediate signal on T1W imaging and high signal on T2W imaging
Key MRI imaging sequences for evaluation of lesion vascularity and enhancement
Postcontrast T1 based perfusion and late gadolinium enhancement images
Size and number of lesions in benign cardiac mass
small, <5 cm and single
Usual location of a benign cardiac mass
left sided
Marginal characteristics of benign cardiac masses
smooth, well-defined borders, no extension through tissue planes
Pericardial involvement in benign cardiac masses
no involvement
Tissue characteristics of benign cardiac mass
homogeneous, absent to minimal early enhancement, variable delayed enhancement
size and number of lesions in malignant cardiac masses
large, >5 cm, multiple
usual location of malignant cardiac mass
right sided
margins of a malignant cardiac mass
irregular, ill-defined, direct invasion through tissue places
pericardial involvement in malignant cardiac mass
hemorrhagic pericardial effusion, pericardial invasion or multiple nodular masses
tissue characteristics of malignant cardiac mass
heterogeneous due to hemorrhage and necrosis, prominent early enhancement, variable delayed enhancement
MRI sequence perfromed and prescribed based on the location of cardiac mass
Steady state free precession cine images (SSFP)
can aid in the detection of lesions localized near or within the pericardium
myocardial tissue tagging
can help detect the presence of a noncontractile intramyocardial mass, such as rhabdomyoma, or differentiate a true mass versus asymmetric focal hypertrophic cardiomyopathy
myocardial tissue tagging
MRI technique that can distinguish a thrombus from a tumor
longer invesion recovery times (such as 600 ms)
benign lesions of endocardial origin. most common primary cardiac tumor and represent 50^ of all benign cardiac masses and 25% of all primary cardiac tumors
Myxoma
arises from undifferentiated and totipotent mesenchymal stem cell and have a gelatinous compositin described as an acid mucopolysaccharide-rich stroma. Usually occurs in 4th to 7th decade of life, and commonly in females
myxoma
cardiac tumor that may be related to carney complex
myxoma
Include hyperpigmented skin lesions, endocrinopathy, and extracardiac neoplasms such as breast fibroadenomas, melanotic schwannomas or pituitray adenomas
Carney complex
majority of myxomas occur on what chamber
left atrium; majority arising from the interatrial septum ner the fossa ovalis
embolization in atrial myxomas, are more worrisome on what chamber of involvement
left atrium
benign lesions which constitute approximately 10% of all primary cardiac tumors. Consists of encapsulated mature adipose cells which are commonly well-defined, round or oval in shape, and broad-based
Lipoma
Majority of cardiac lipomas arise from the
epicardial surface and extend outward into the pericardial space
presence of chemical shift/”India ink” artifact at the interface between the lipoma and the surrounding tissue on SSFP sequences is another characteristic finding of
lipoma
Feature that differentiates cardiac lipomas from lipomatous hypertrophy of the interatrial septum
location of the lesion within the interatrial septum with sparing of the fossa ovalis will allow differentiation of lipomatous hypertrophy from a true lipoma
benign endocardial based lesions which constitute approximately 10% of all primary cardiac tumors. They contain avascular dense connective tissue covered in a single layer of endothelium
papillary fibroelastoma
accounts for 75% of all valvular neoplasms
papillary fibroelastoma
most papillary fibroelastoma occurs where
aortic and mitral valves, usually on the aortic side of the aortic valve and atrial side of AV vales, away from the free edge of the leaflet
usually the best modality to detect and evaluate papillary fibroelastomas
echocardiography
Key MRI finding in distinguishing fibroelastoma from a vegetation, which is a main differential diagnosis for a valvular mass
presence of delated gadolinium enhancement
Aside from delayed gadolinium enhancement of fibroelastoma, what other features can differentiate it from vegetation
vegetations represent infected thrombi, there is often destruction of the associated valve with valvular or perivalvular regurgitation, which is absent with fibroelastoma
benign congenital tumors which are the most common primary tumors in infants and children
rhabdomyoma
they are hamartomas of altered enlarged cardiac myocytes which arise as small intramural nodules in the ventricular myocardium, measuring between 1 and 3 cm on average
rhabdomyoma
50% of cases of rhabdomyoma are seen in patients with ____ and are usually multiple
tuberous sclerosis
most rhabdomyomas will regress at what age
before 4 years old
this tumor can be detected on pre- or postnatal echocardiograms, seen as solid hyperechoic masses either within the ventricular myocardium or intracavitary and attached to the myocardium
rhabdomyomas
True or false: Rhabdomyomas are difficult to detect on CT, with minimal to no enhancement
true
benign fibrous hamartomas which are the second most common cardiac tumors in infants and children
fibroma
nonencapsulated fibrous tumors composed of neoplastic fibroblasts and abundant collagen. they are typically solitary, intramural tumors measuring between 2 and 7 cm
fibroma
common location for fibroma
left ventricular wall or interventricular septum
Fibroma is associated with what syndrome, which is an autosomal dominant syndrome of basal cell carcinoma, odontogenic keratocysts and other neoplasms
Gorlin syndrome (aka basal cell nevus syndrome)
true or false: 1/2 to 2/3 of the cardiac fibromas are symptomatic, with a range of symptoms including chest pain, heart failure, arrhythmias, syncope or sudden cardiac death
true
cardiac tumor that appears as well-defined, homogeneous low attenuation mass located within the left ventricular myocardium on CT. coarse calcifications are present in 15 to 20% of cases and are often located centrally
fibromas
while fibromas are avscular and will show no enhancement during perfusion imaging, they will clasically show intense enhancement with late gadolinium imaging due to
their large amount of collagen creating an expanded extracellular space for contrast to pool into
rare cardiac tumor that account for 5% to 10% of all primary benign cardiac tumors. they are composed of vascular endothelial cells and can be AV, capillary or cavernous in type
hemangioma
50% of cardiac hemangioma are of what type
AV type, which made up of dysplastic arterial and venous structures
hemangiomas can be located in any part of the heart with 75% of cases being
intramural
cardiac hemangiomas are associated with _____, which is characterized by multiple hemangiomas causing recurrent thrombocytopenia and consumptive coagulopathy
Kasabach-Merritt syndrome
Rare cardiac tumors derived from clustered neuroendocrine cells and are cloely related to pheochromocytomas
paraganglioma
Myxoma can be present in patients with the ____ trid, which is made up of extra-adrenal pheochromocytoma, GIST and pulmonary chondroma
Carney triad
paragangliomas commonly occur in what chamber
left atrial wall, in the location of the normal cardiac paraganglioma cells, typically involving either the left atrial roof or posterior wall
highly specific imaging for cardiac paragangliomas
focal cardiac abnormal uptake on iodine-123 or iodine-131 metaiodobenzylguanidine scintigraphy
germ cell tumors made up of several different types of tissue, they are commonly found in infants/children as complex multilocular, heterogeneous cystic masses growing within the pericardial sac, typically on the right side. Usually large in size and associated with a pericardial effusion
teratoma
benign abnormal collections of lymphatic vessels which are rare benign neoplasms, most commonly found in children
cardiac lymphangiomas
typically multiloculated cystic lesions within the pericardial space and may be associated with a chylous pericardial effusion
cardiac lymphangiomas
extremely rare and are composed of hypertrophied disorganized myocytes with interstitial fibrosis
cardiac hamartomas
cardiac hamartomas commonly occur at what chamber
left ventricular myocardium
most common cardiac mass found in adult population
metastatic disease
most common metastatic lesion to the heart
lung cancer, followed by hematologic malignancies, breast ca and esophageal ca
most common route of spread in cardiac metastatic disease
direct invasion or lymphatic extension to the pericardium and epicardium
malignancies that are common to spread to the heart hematogeneously and usually result in intramural involvement
melanomas, renal cell ca and sarcomas
most common findings in imaging heart for metastatic disease
pericardial involvement and/or intracavitary masses
neoplastic lesions which arise from the mesenchymal cells within the cardiac muscle. most common primary malignant tumor of the heart, accounting for 1/3 of cases and include several subtypes
sarcoma
most common differentiated cardiac sarcoma
angiosarcoma
most common primary cardiac malignancy in childhood
rhabdomyosarcoma
only cardiac sarcoma that predominately arises in the RA in the region of the right AV groove. encasement of the right coronary artery is a common finding
cardiac angiosarcoma
characteristic enhancement finding in angiosarcoma
intense enhancement within the soft tissue component of the tumor and rapid enhancement on first pass perfusion
true or false: while angiosarcomas predominate in theRA and rhabdomyosarcoma have no chamber predilection, the other histologic subtypes of cardiac sarcomas usually occur in the LA
true
cardiac lymphoma is usually of what type
non-Hodgkin B cell type
cardiac lymphoma is often related with what infection
Epstein- Barr virus
primary cardiac lymphima commonly involves what side of the heart
right side, particularly RA, with predilection for the right AV groove
unique feature of this cardiac malignancy is its tendency to extend along the epicardium, encasing adjacent structures including the coronary arteries, aortic root or pulmonary vessels
lymphoma
lymphoma may be distinguished from other cardiac tumors by what characteristic
homogeneous MRI signal throughout the lesion
most common intracardiac lesion and can involve any cardiac chamber
thrombus
thrombus is often best delineated during what phase of imaging
portal venous phase, where it appears hypodense to the normally enhancing myocardium
imaging of choice in distinguishing thrombus from tumor
CMR
acute thrombus demonstrates what signal on T1W and T2W
hyperintense
chronic thrombus will demonstrate what signal on T1W and T2W
hypointense
subacute thrombus will appear as what on T1W and T2W
hyperintense on T1W and hypointense on T2W
true or false: chronic organised thrombus may demonstrate peripheral enhancement on late gadolinium enhancement imaging due to fibrous material forming around it
true
benign process characterized by proliferation of adipose cells within the interatrial septum. occurs in 8% of population and can be associated with an increased body mass index and large amount of epicardial fat
lipomatous hypertrophy of the interatrial septum
on cross sectional imaging, it will demonstrate dumbbell-shaped fatty mass in the interatrial septum, commonly with asymmetric enlargement of its posterolateral component. dumbbell spade is created by the sparing of the fossa ovalis
lipomatous hypertrophy of the interatrial septum
normal septal thickness
less than 1 cm
lipomatous hypertrophy of interatrial septum can measure up to
2cm or greater
key feature in lipomatous hypertrophy of interatrial septum that helps in distinguishing it from other abnormalities
sparing of fossa ovalis
adherent lesions made up of platelets, fibrin and inflammatory cells that seed the valvular leaflets, usually in an area of endocardial injury
vegetations
noninfective endocarditis are rare and can be due to
nonbacterial thrombotic endocarditis seen in the setting of malignancy or Libman-Sacks endocarditis which occurs in patients with SLE
two most common normal anatomic structures that may appear as pseudomasses
crista terminalis and eustachian valve
vertically oriented smooth muscle ridge within the RA which extends from SVC to IVC. it is a normal anatomic structure which demarcates the area of embryologic fusion of primitive RA and sinus venosus
crista terminalis
normal ridge of tissue at the junction of the RA and IVC, which in utero directed blood flow from the IVC into the fossa ovalis
eustachian valve
