516 TUESDAY CARDIAC TUMORS Sharon Sudarshan Brouha, MD, MPH Assistant Clinical Professor Cardiothoracic Imaging Section Cardiothoracic Imaging Section University of California San Diego Imaging techniques Imaging techniques Cardiac and pericardial masses Cardiac and pericardial masses Cardiac tumor mimics Cardiac tumor mimics Overview Overview Prevalence of 0.002-0.3% at autopsy 75% are benign Cli i li ifi Clinical significance Cardiac physiology Embolism Arrhythmias Radiology: Volume 268: Number 1July 2013 Modality Advantages Disadvantages Echocardiography Often the first study Limited Echocardiography Often the first study Suspected mass Incidental finding Noninvasive Limited FOV Tissue characterization RV evaluation Accessible Anatomic and functional detail Large body habitus Pulmonary disease Operator dependent Cardiac CT Incidental cardiac mass Spatial resolution Tissue characterization Calcification Radiation exposure Limited temporal resolution Limited contrast Calcification Fat Enhancement Limited contrast resolution compared to MR ECG gating PET Metabolic activity Evaluation of interval change Limited anatomic detail Cardiac MR Tissue characterization Limited access Radiology: Volume 268: Number 1July 2013 No radiation exposure ECG gating Breath-holding Characteristics of cardiac t tumors Anatomic considerations >5 cm Tissue characteristics Heterogeneous signal Irregular borders Invasion Right heart involvement Hemorrhagic pericardial effusion Contrast enhancement Pericardial or pleural involvement Effusions Effusions Nodules Multiplicity Cardiac MR protocol Cardiac MR protocol St d rd Opti l Standard Optional T1 FSE thorax SSFP 2, 4 and SAX and two orthogonal planes through mass Myocardial tagging T1 DIR in optimal plane T1 DIR with fat suppression in optimal plane T2 TIR in optimal plane Early post Gd T1 DIR with TI 450-500 ms Early post Gd T1 DIR (<2 min post Perfusion Gd) LGE T1 DIR in optimal plane and SAX Cardiac Tumors Sharon S. Brouha, MD
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Cardiac Tumors - Society of Thoracic Radiology · LEFT ATRIAL MYXOMA Pericadial biopsy was normal ... Imaging manifestations Adjacent to left atrium or anterior to aorticAdjacent
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CARDIACTUMORS
Sharon Sudarshan Brouha, MD, MPHAssistant Clinical Professor
Cardiothoracic Imaging SectionCardiothoracic Imaging SectionUniversity of California San Diego
Imaging techniquesImaging techniques
Cardiac and pericardial massesCardiac and pericardial masses
Cardiac tumor mimicsCardiac tumor mimics
OverviewOverview
Prevalence of 0.002-0.3% at autopsy
75% are benign
Cli i l i ifiClinical significance�Cardiac physiologyp y gy�Embolism�Arrhythmias
Radiology: Volume 268: Number 1�July 2013
Modality Advantages Disadvantages
Echocardiography Often the first study LimitedEchocardiography Often the first study� Suspected mass� Incidental findingNoninvasive
Limited contrast resolution compared to MRECG gating
PET Metabolic activityEvaluation of interval change
Limited anatomic detail
Cardiac MR Tissue characterization Limited access
Radiology: Volume 268: Number 1�July 2013
No radiation exposure ECG gatingBreath-holding
Characteristics of cardiac ttumors
Anatomic considerations
� >5 cm
Tissue characteristics
� Heterogeneous signal� Irregular borders� Invasion� Right heart involvement
� Hemorrhagic pericardial effusion
� Contrast enhancementg� Pericardial or pleural
involvement� EffusionsEffusions� Nodules
� Multiplicity
Cardiac MR protocolCardiac MR protocol
St d rd Opti lStandard Optional
T1 FSE thorax
SSFP 2, 4 and SAX and two orthogonal planes through mass Myocardial tagging
T1 DIR in optimal plane
T1 DIR with fat suppression in optimal plane
T2 TIR in optimal plane
Early post Gd T1 DIR with TI 450-500 ms
Early post Gd T1 DIR (<2 min post Perfusiony p ( pGd)
LGE T1 DIR in optimal plane and SAX
Cardiac Tumors Sharon S. Brouha, MD
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Cardiac MR protocolCardiac MR protocol
T1 FSE thoraxT1 FSE thorax
Overview of the thoraxOverview of the thoraxIdentification of tumorBreath-hold or free breathing if necessaryg y
Cardiac MR protocolCardiac MR protocol
SSFP 2, 4 and SAXSSFP 2, 4 and SAX
Localization of massLocalization of massAnatomic detailMobility of massyFunctional significance
Cardiac MR protocolCardiac MR protocol
T1 weighted images pre and post contrastT1 weighted images pre and post contrast
Tissue characterizationTissue characterizationFat suppression for diagnosis of fatty elementsEarly Gd enhancementy� T1 of 450-500 ms post Gd renders thrombus low in signalLate Gd enhancement�Myocardial tumor infiltration with increased interstitial matrix or�Myocardial tumor infiltration with increased interstitial matrix or
scarring
Cardiac MR protocolCardiac MR protocol
T2 weighted imagesT2 weighted images
Tissue characterizationTissue characterizationEdema and liquefactive necrosis=high signalCoagulative necrosis=low signalg gHemorrhage or thrombus
Predilection for the right heartPredilection for the right heart
Multiple lesionsMultiple lesions
Nodular infiltration of myocardium
MR�Homogeneous signal� T1 and T2 isointense� Little to no enhancement on LGE images� Little to no enhancement on LGE images
70FHx: Chronic
i di l ff ipericardial effusion followed with ECHO
Presented to the ED ith bd i lED with abdominal pain
CT A/P revealed ovarian mass and
dicardiac mass
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T1 DIR T1 DIR post gad IR post gad
LEFT ATRIAL MYXOMAPericadial biopsy was normal
LEFT ATRIAL MYXOMA
MyxomaMyxoma
Occur at interatrial septum near fossa ovalisOccur at interatrial septum near fossa ovalis
Smooth, lobulated margins
Pedunculated
Symptoms� Mass effect and obstruction� Embolization� Embolization� Constitutional symptoms due to IL-6� Carney complex: skin lentigines, endocrine tumors,
fibroadenomas and melanotic schwannomasfibroadenomas and melanotic schwannomas
LocationLocation� 75% left atrium� 20% right atrium� 5% right or left ventricle
MR� T1 isointense� T2 hyperintense� Additional featuresAdditional features� Internal hemorrhage, cysts, necrosis, calcification� Mobile on cine images� Surface thrombus is low signal on LGE imagesSurface thrombus is low signal on LGE images
17MHx: Presented in 6/2012 for routine6/2012 for routine sports physical� Arrhythmia with
f t PVCfrequent PVCs
MR: mass in theMR: mass in the superolateral wall of left ventricle
Referred for surgical resection
DIR T1 FS TIR T2
DIR T2 IR post gad
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Subtotal resection of tumor with residual tumor at left main
FIBROMA
Subtotal resection of tumor with residual tumor at left main bifurcation
I t l i th t i l b tIntramural in the ventricles but multiple
MRMR
� T1 isointenseT1 isointense� T2 hyperintense� Little to no enhancementLittle to no enhancement
82FHx: Pulmonary
tartery mass
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Papillary fibroelastoma: Imaging if t timanifestations
T i ll < 1 5Typically < 1.5 cm
Cli i l iClinical presentation�Often asymptomaticOften asymptomatic�Embolization of surface thrombus/tumor�No valvular abnormality�No valvular abnormality�Surgery if symptomatic or >1cm and
left-sidedleft sided
Papillary fibroelastoma: Imaging if t timanifestations
Pedicle adherent to downstream side of valvePedicle adherent to downstream side of valve unlike vegetation
Mobile
MR
� Isointense T1� Hyperintense T2� No enhancement� No enhancement