TUMORS
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| 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
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| PRIMARY TUMORS | Rare
Metastatic more common than primary
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| Echo evaluation for masses: | Can’t determine exact composition of masses
Can tell shape, location, and mobility of mass
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| 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
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| 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
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| MYXOMAS Continued: | 1 Testicular tumors
2 Myxoid fibroadenoma of the breast
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| 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)
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| 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
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| SYMPTOMS FROM MYXOMA Left sided tumors: | - Dyspnea
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Chest pain
- Cough
- Hemoptysis
- Acute pulmonary edema
- Syncope
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| SYMPTOMS FROM MYXOMA Right sided tumors: | -Right heart failure
-Peripheral edema
-Distended jugular veins
-Ascites
-Hepatomegaly
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| Large myxomas may: | -Prolapse into valve orifice
-Obstruct flow
-Damage valve apparatus
-Symptoms may also be limited to specific body positions
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| LIPOMA | -Neoplasm consisting of mature fat cells
-Fibrolipoma
-Fibrous connective tissue and fat cells
-Myolipoma
-Muscular tissue and fat cells
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| 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
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| Echo appearance: | -Well defined
-Homogeneous
-Dense
-Mass is within myocardium or extending from the endocardial or epicardial region
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| LIPOMATOUS HYPERTROPHY OF THE IAS | - Collection of fat cells within the septum
-Is not a true neoplasm
-IAS hypertrophies except for the fossa ovalis
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| LIPOMATOUS HYPERTROPHY OF THE IAS:Echo appearance: | -Classic dumbbell shaped
-Homogeneous
-Echo dense
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| 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
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| PAPILLARY FIBROELASTOMA | AKA:
-Papilloma
-Papillary fibroma
-Papillary endocardial tumor
Giant Lambl’s excrescence
Papilloelastoma
fibropapilloma
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| 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
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| 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
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| ANGIOSARCOMA Most common malignant primary cardiac tumor Hemangiosarcoma: | Soft tissue tumors of the blood vessels
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| Lymphosarcoma: | Lymphatic endothelium
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| ANGIOSARCOMA Most commonly affect: | -Head
-Face
-Liver
-Chest heart
-Males
-Seen usually in RA
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| ANGIOSARCOMA Symptoms: | -Chest pain
-Cough
-Dyspnea
-Can infiltrate into pericardium, rupture, and cause tamponade
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| ANGIOSARCOMA II Symptoms: Can obstruct blood flow in two ways: | -Extrinsic compression
-Consumes chamber cavity
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| ANGIOSARCOMA Echo Appearance: | -Poorly defined mass
-Regions of increased echodensity
-Often found in pericardium
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| 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
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| RHABDOMYOMA 50% of tumors cause hemodynamic obstruction Symptoms: | -Arrhythmias
-AV block
-Pericardial effusion
-Sudden death
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| 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
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| 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
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| 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
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| RHABDOMYOSARCOMA Distal metastatic sites: | -Lungs
-Liver
-Skeleton
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| RHABDOMYOSARCOMA Echo Appearance: | -Solid, echodense mass
-Irregular borders
-Multiple sites
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| 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
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| FIBROMA Can cause: | -Cardiomegaly
-Arrhythmias
-Outflow tract obstruction
-CHF
-Sudden death
-Usu. From involvement of conduction system
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| FIBROMA Echo appearance: | -Large mass within the IVS (usually)
-May appear highly refractile
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| 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
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| FIBROSARCOMA Echo Appearance: | -“fish flesh” appearance
-Areas of hemorrhage and necrosis
-Can differentiate from fibroma because fibrosarcoma invades surrounding tissue, especially the pericardium
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| 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
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| HEMANGIOMA Can spontaneously resolve | -Most likely of all tumors to be accompanied by a PE
-May have:
-Lakes
-Channels
-Highly vascular
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| HEMANGIOMA Echo Appearance: | -Single sessile mass
-Nonhomogeneous
-PE can help differentiate from rhabdomyoma
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| 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
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| TERATOMA After surgical removal, the tumor is found to have: | -Teeth components
-Hair components
-Skeletal components
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| TERATOMA Echo Appearance: | -Well defined mass
-Varying echodensities
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| SECONDARY TUMORS (METASTATIC) More common than primary tumors Most common tumors to spread to the heart are: | -Lung
-Breast
-Lymphoma
-Leukemia
-Malignant melanoma
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| METASTATIC TUMORS Survival rate of mets to heart is poor Mets is spread by: | -Direct extension
-Via lymphatics
-Via circulatory flow
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| METASTATIC TUMORS Direct extension: | -Lung carcinoma
-Extension of ovarian or testicular cancer up venous system, along IVC, into RA
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| METASTATIC TUMORS Lymphatic or circulatory: | -Melanoma
-Lymphoma
-leukemia
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| 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
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| METASTATIC TUMORS Manifestations include: | -PE (most common)
-Tamponade (most common)
-Tachyarrhythmias
-AV block
-Thromboembolism
-Hemodynamic obstruction
-CHF
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| METASTATIC TUMORS ECHO APPEARANCE | -Pericardial involvement-
-Mass on parietal or visceral surface
W/ or w/o PE
-May encircle heart and obliterate pericardial space
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| METASTATIC TUMORS Differential diagnosis (pericardial mass can look like): | -Fibrin strands
-Thickened, consolidated effusions
-Thrombus formation
-Radiation induced pericarditis
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| METASTATIC TUMORS I | Tumors from endocardium and intramyocardial regions are difficult to differentiate from primary tumors
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| METASTATIC TUMORS II | Tumors should be evaluated for effect on:
-Impedance of blood flow
-Valve function
-Obstruction
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| EXTRACARDIAC MASSES Can arise from mediastinum or pleura from: | -Lung cancer
-Hematomas
-Thymomas
-Cysts
-Metastases
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| EXTRACARDIAC MASSES Echo Appearance: | -Echolucent
-Echodense
-Any size
-Anterior to heart
-Posterior to heart
-Accurate diagnosis is limited
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| 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
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| PERICARDIAL CYSTS Symptoms: | -Patient is usually asymptomatic
-Dyspnea
-Tachycardia
-Arrhythmias
-Chest pain
-Cough
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| PERICARDIAL CYSTS Echo Appearance: | -Well circumscribed
-Echolucent
-Extends from pericardium
-Adjacent to cardiac chamber
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| 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
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| PERICARDIAL CYSTS Differential diagnosis: | Differential diagnosis:
-Loculated pericardial effusion
-Dilated coronary sinus
-Ventricular pseudoaneurysm
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| 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
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| FALSE POSITIVE CARDIAC MASSES Normal variations within the heart Congenital structures that persist and remain prominent: | -Chiari network
-Eustachian valve
-Thebesian valve
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| FALSE POSITIVE CARDIAC MASSES Normal variants: | -Atrial septal aneurysms
-Prominent moderator band
-False tendons
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| FALSE POSITIVE CARDIAC MASSES Manufactured objects | -Pacemaker wires
-Defibrillator wires
-Infusion catheters
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| EUSTACHIAN AND THEBESIAN VALVES | -Remnants of right venous valve
-Help direct blood across foramen ovale to LA in fetus
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| Eustachian valve | -Valve of IVC
-Extends from inferior lateral wall of RA to posterior portion of fossa ovalis
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| Thebesian valve | -In region of coronary sinus as it enters RA
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| 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
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| STRUCTURES MISTAKEN FOR MASSES | -RA wall with prominent trabeculations
-Atrial appendage along with pectinate muscle
-Moderator band
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| 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
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| 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
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