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cardiac tumors CSN
TUMORS
| Question | Answer |
|---|---|
| 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 |
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