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cardiac tumors CSN


Cardiac tumors and masses can be: 1 Vegetations 2 Thrombi 3 Pacemaker wires 4 Internal cardiac defibrillator wires 5 Swan-Ganz catheter 6 Hickman catheter (RA,RV) 7 Migrated Kimray Greenfield filter 8 Bullets
PRIMARY TUMORS Rare Metastatic more common than primary
Echo evaluation for masses: Can’t determine exact composition of masses Can tell shape, location, and mobility of mass
MYXOMA Most common primary tumor of the heart 75% of primary cardiac tumors are benign Myxomas are neoplasms that arise from endocardial tissues Surgical removal needs to occur soon after diagnosis
MYXOMAS May be part of a syndrome and present along with 2 or more of the following: 1 Skin myxomas 2 Cutaneous lentiginosis 3 Pituitary adenomas 4 Primary nodular adrenal cortical disease w/ or w/o Cushing’s syndrome
MYXOMAS Continued: 1 Testicular tumors 2 Myxoid fibroadenoma of the breast
MYXOMAS Echo appearance: - In LA or RA - Usually pedunculated w/ fibrovascular stalk - Round or oval -Smooth, well defined border - Can have hemorrhage w/in tumor (Distinguishes it from vegetation or thrombus)
SYMPTOMS FROM MYXOMA Depend on origin and size of tumor and can include: Asymptomatic Rarely sudden death from: - Acute rupture - Obstruction of cardiac valve - Embolization
SYMPTOMS FROM MYXOMA Left sided tumors: - Dyspnea - Orthopnea - Paroxysmal nocturnal dyspnea - Chest pain - Cough - Hemoptysis - Acute pulmonary edema - Syncope
SYMPTOMS FROM MYXOMA Right sided tumors: -Right heart failure -Peripheral edema -Distended jugular veins -Ascites -Hepatomegaly
Large myxomas may: -Prolapse into valve orifice -Obstruct flow -Damage valve apparatus -Symptoms may also be limited to specific body positions
LIPOMA -Neoplasm consisting of mature fat cells -Fibrolipoma -Fibrous connective tissue and fat cells -Myolipoma -Muscular tissue and fat cells
LIPOMA : -Lipomas mostly found in LV, RA, and IAS -Tumors invade subendocardial and intermyocardial tissue and can be found in pericardium -Symptoms depend on size and location -Can be 1-15 cm
Echo appearance: -Well defined -Homogeneous -Dense -Mass is within myocardium or extending from the endocardial or epicardial region
LIPOMATOUS HYPERTROPHY OF THE IAS - Collection of fat cells within the septum -Is not a true neoplasm -IAS hypertrophies except for the fossa ovalis
LIPOMATOUS HYPERTROPHY OF THE IAS:Echo appearance: -Classic dumbbell shaped -Homogeneous -Echo dense
PAPILLARY FIBROELASTOMA - Second most common cardiac tumor (10%) - Most common tumor of cardiac valves and apparatus - MV and AoV are most common location in adults -TV is most common location for children
PAPILLARY FIBROELASTOMA AKA: -Papilloma -Papillary fibroma -Papillary endocardial tumor Giant Lambl’s excrescence Papilloelastoma fibropapilloma
PAPILLARY FIBROELASTOMA Echo appearance: -Frond-like -Usually < 1 cm, but can be up to 4 cm -Attached by a simple stalk -Can arise from any endocardial surface -Highly mobile
PAPILLARY FIBROELASOMA II Echo appearance: -Hard to differentiate from veggies -Small, round, dense, highly mobile mass extending from endocardial surface -Moves rapidly as valve opens and closes
ANGIOSARCOMA Most common malignant primary cardiac tumor Hemangiosarcoma: Soft tissue tumors of the blood vessels
Lymphosarcoma: Lymphatic endothelium
ANGIOSARCOMA Most commonly affect: -Head -Face -Liver -Chest heart -Males -Seen usually in RA
ANGIOSARCOMA Symptoms: -Chest pain -Cough -Dyspnea -Can infiltrate into pericardium, rupture, and cause tamponade
ANGIOSARCOMA II Symptoms: Can obstruct blood flow in two ways: -Extrinsic compression -Consumes chamber cavity
ANGIOSARCOMA Echo Appearance: -Poorly defined mass -Regions of increased echodensity -Often found in pericardium
RHABDOMYOMA -Most common benign tumor of children -Usually under 1 year old -RV and LV are most common sites -Atrial sites are uncommon -It is associated w/ tuberous sclerosis 70-90% of cases
RHABDOMYOMA 50% of tumors cause hemodynamic obstruction Symptoms: -Arrhythmias -AV block -Pericardial effusion -Sudden death
RHABDOMYOMA Echo appearance: -Solid, echodense mass extending into LV -Sometimes intramural tumors can extend into chamber cavity -Blood flow typically impeded -Tumors can recede over time -May need surgical resection usu. w/ flow obstruction
RHABDOMYOSARCOMA -Tumors arise from striated muscle fibers that diffusely infiltrate the muscle of the heart -Most common soft tissue sarcoma in children -Second most common primary sarcoma of the heart
RHABDOMYOSARCOMA PART II -Found in multiple sites in the heart -Invades tissue adjacent to myocardial origin -Can be in pericardium and can replace valvular tissue
RHABDOMYOSARCOMA Distal metastatic sites: -Lungs -Liver -Skeleton
RHABDOMYOSARCOMA Echo Appearance: -Solid, echodense mass -Irregular borders -Multiple sites
FIBROMA -Unencapsulated -Well circumscribed -Benign tumors -Intramural origin -Usually arise from LV free wall or IVS -Can extend into chamber and cause inflow or outflow obstruction
FIBROMA Can cause: -Cardiomegaly -Arrhythmias -Outflow tract obstruction -CHF -Sudden death -Usu. From involvement of conduction system
FIBROMA Echo appearance: -Large mass within the IVS (usually) -May appear highly refractile
FIBROSARCOMA Can be RV or LV origin -½ of cases get large enough to obstruct blood flow -Can obstruct IVC or pulmonary veins -Thrombus can form when obstruction occurs -Pericardium can be involved
FIBROSARCOMA Echo Appearance: -“fish flesh” appearance -Areas of hemorrhage and necrosis -Can differentiate from fibroma because fibrosarcoma invades surrounding tissue, especially the pericardium
HEMANGIOMA Vascular tumor -Can be found in any chamber -Can be intramyocardial or intracavitary -Usually on the right side of heart -Usually discrete masses smaller than 3-4cm -Some can get large and impede blood flow
HEMANGIOMA Can spontaneously resolve -Most likely of all tumors to be accompanied by a PE -May have: -Lakes -Channels -Highly vascular
HEMANGIOMA Echo Appearance: -Single sessile mass -Nonhomogeneous -PE can help differentiate from rhabdomyoma
TERATOMA Contain all 3 germ cell layers They may contain: -Skeletal cells -Nerve cells -Connective tissue -Usually in children and in either RA, RV, and septum
TERATOMA After surgical removal, the tumor is found to have: -Teeth components -Hair components -Skeletal components
TERATOMA Echo Appearance: -Well defined mass -Varying echodensities
SECONDARY TUMORS (METASTATIC) More common than primary tumors Most common tumors to spread to the heart are: -Lung -Breast -Lymphoma -Leukemia -Malignant melanoma
METASTATIC TUMORS Survival rate of mets to heart is poor Mets is spread by: -Direct extension -Via lymphatics -Via circulatory flow
METASTATIC TUMORS Direct extension: -Lung carcinoma -Extension of ovarian or testicular cancer up venous system, along IVC, into RA
METASTATIC TUMORS Lymphatic or circulatory: -Melanoma -Lymphoma -leukemia
METASTATIC TUMORS When secondary tumors metastasize they usually spread to multiple locations in the heart Clinical manifestations of cardiac involvement centers on either pericardium, myocardium, or external cardiac compression
METASTATIC TUMORS Manifestations include: -PE (most common) -Tamponade (most common) -Tachyarrhythmias -AV block -Thromboembolism -Hemodynamic obstruction -CHF
METASTATIC TUMORS ECHO APPEARANCE -Pericardial involvement- -Mass on parietal or visceral surface W/ or w/o PE -May encircle heart and obliterate pericardial space
METASTATIC TUMORS Differential diagnosis (pericardial mass can look like): -Fibrin strands -Thickened, consolidated effusions -Thrombus formation -Radiation induced pericarditis
METASTATIC TUMORS I Tumors from endocardium and intramyocardial regions are difficult to differentiate from primary tumors
METASTATIC TUMORS II Tumors should be evaluated for effect on: -Impedance of blood flow -Valve function -Obstruction
EXTRACARDIAC MASSES Can arise from mediastinum or pleura from: -Lung cancer -Hematomas -Thymomas -Cysts -Metastases
EXTRACARDIAC MASSES Echo Appearance: -Echolucent -Echodense -Any size -Anterior to heart -Posterior to heart -Accurate diagnosis is limited
PERICARDIAL CYSTS -Most common benign tumor of the pericardium -Usually along the right costophrenic angle -May less commonly be in: -Left costophrenic angle -Upper mediastinum -Hila or left cardiac border
PERICARDIAL CYSTS Symptoms: -Patient is usually asymptomatic -Dyspnea -Tachycardia -Arrhythmias -Chest pain -Cough
PERICARDIAL CYSTS Echo Appearance: -Well circumscribed -Echolucent -Extends from pericardium -Adjacent to cardiac chamber
PERICARDIAL CYSTS Differential diagnosis: -Pericardial diverticulum -Outpouching of pericardium creating a fold that can fill with fluid -Diverticulum moves or swings with changes in body position, cysts do not
PERICARDIAL CYSTS Differential diagnosis: Differential diagnosis: -Loculated pericardial effusion -Dilated coronary sinus -Ventricular pseudoaneurysm
PERICARDIAL CYSTS Treatment: -Cysts can be drained if symptoms occur -Drained during thoracoscopy which is minimally invasive -The alternative is a thoracotomy which requires anesthesia and is not as desirable
FALSE POSITIVE CARDIAC MASSES Normal variations within the heart Congenital structures that persist and remain prominent: -Chiari network -Eustachian valve -Thebesian valve
FALSE POSITIVE CARDIAC MASSES Normal variants: -Atrial septal aneurysms -Prominent moderator band -False tendons
FALSE POSITIVE CARDIAC MASSES Manufactured objects -Pacemaker wires -Defibrillator wires -Infusion catheters
EUSTACHIAN AND THEBESIAN VALVES -Remnants of right venous valve -Help direct blood across foramen ovale to LA in fetus
Eustachian valve -Valve of IVC -Extends from inferior lateral wall of RA to posterior portion of fossa ovalis
Thebesian valve -In region of coronary sinus as it enters RA
CHIARI NETWORK (REMNANTS) -Fenestrated right venous valve -Various attachment points -Swing widely in atrium even into -TV orifice -Eustachian valve has a more restricted movement -Both appear as an echodense linear structure in US
STRUCTURES MISTAKEN FOR MASSES -RA wall with prominent trabeculations -Atrial appendage along with pectinate muscle -Moderator band
STRUCTURES MISTAKEN FOR MASSES False tendons in ventricle -Can extend from septum to lateral, anterior, or inferior -wall, or parallel along the same wall -Can appear similar to chordae Check for flow obstruction -Considered coincidental findings
MANUFACTURED OBJECTS -Easily identified -Take a good history -Course through the heart needs to be documented -Usually the object will create reverberations which will help distinguish it
Created by: 100001592513232