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CT and MR Imaging of Cardiac Tumors

CT and MR Imaging of Cardiac Tumors. B.Zandi Professor of Radiology. Objectives . To review the Spectrum of CT and MRI findings for a variety of cardiac neoplasms . The role of CT and MRI in : The Diagnosis of Cardiac Tumors To DD Benign from Malignant Masses. the use of

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CT and MR Imaging of Cardiac Tumors

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  1. CT and MR Imaging ofCardiac Tumors B.Zandi Professor of Radiology

  2. Objectives • To review the Spectrum of CT and MRI findings for a variety of cardiac neoplasms. • The role of CT and MRI in : • The Diagnosis of Cardiac Tumors • To DD Benign from Malignant Masses. • the use of • MDCT in providing Anatomical Information • MRI for Tissue Characterization of Cardiac Masses.

  3. Cardiac tumors • Prevalence of 0.002-0.3% at Autopsy • 1. Primary Cardiac Neoplasms • (Benign and malignant) • 2. Metastatic • approximately 30 times more Prevalent than primary

  4. Imaging Modalities • Trans-thoracic Echocardiography • Trans-esophageal Echocardiography • Multi-detector CT Scanning (MDCT) • Magnetic resonance imaging (MRI)

  5. Imaging Modalities • Trans-thoracic Echocardiography : • Most Widely Used imaging modality • The Best Imaging modality to depict Small Masses (Valves ) • Limitations : Visualization of Extra-Cardiac Extension • TEE : less limitation of acoustic window than thoracic mode, • The Airways and lungs can be obstacles for imaging of the Aortic arch, Pulmonary Arteries and Veins

  6. Imaging Modalities • MRI : • The Modality of Choice to evaluate Cardiac Tumors. • High Contrast Resolution and MPR allow : • a Specific Diagnosis • Optimal Evaluation of Myocardial infiltration, • Pericardial involvement • and Extra-Cardiac Extension.

  7. Imaging Modalities • MDCT Scan : • MDCT Recently, has been Increasingly Utilized for Cardiac Imaging. • Short Image Acquisition Time compared to MRI ( an advantage in Cardiac Imaging ) • ECG Gating MDCT either by Scanning or Reconstructing Raw Data at the point of the Least Cardiac Motion. • CT has better Soft Tissue Contrast Resolution than Echo • definitively characterize Fat and Calcifications • Wide field-of-view helps : • to assess the Extent of a Cardiac Malignancy • and to detect Metastatic Lesions

  8. Table 1. Primary Benign Tumors and Cysts of Heart andPericardium in 533 cases • Myxoma 130 (24.2) • Lipoma 45 (8.4) • Papillary Fibroelastoma 42 (7.9) • Rhabdomyoma 36 (6.8) • Fibroma 17 (3.2) • Hemangioma 15 (2.8) • Teratoma 14 (2.6) • Mesotheloma of AV node 12 (2.3) • Granular cell tumor 3 • Neurofibroma 3 • Lymphangioma 3 • Subtotal 319 (59.8 • Pericardial Cyst 82 (15.4) • Bronchogenic Cyst 7 (1.3) • Subtotal  89 (16.7)

  9. Myxomas • the Most Common Benign Tumor (4th-7th decades) • LOCATION : • Inter-atrial Septum at fossaovalis LA (Most Common ) • 75%LA ( typically, in the Inter-atrial Septum ) • 20% in RA , • rarely in the Ventricles. • Typical Morphologic Characteristics : Gelatinous, attached to stalk, Calcification , Hemorrhage or Necrosis; Common

  10. Imaging Characteristics • Echo Features : Mobile tumor, Narrow stalk • CT Features : Well-defined Spherical or Ovoid Intra-Cavitary Mass with Heterogeneous, low attenuation, Typically Lobular Contours • IV-CT : Heterogeneous (Hemorrhage, Necrosis, Cyst formation, Fibrosis or Calcification) • MR Imaging Features : • Heterogeneous (before contrast) • Heterogeneous Enhancement (after contrast) • areas of Low signal intensity within the tumor (due to Calcification orHemosiderin ). • T2W : Markedly High Signal

  11. LV Myxoma in 38-year-old female.A. Mass (arrow) in LA. B. Mass (arrow) extends into LV during diastolic phase through mitral valve. MPR MDCT 4-chamber view

  12. LA Myxoma in 65-year-old male. • A. shows LA mass attached to inter-atrial septum by broad pedicle • Strong Enhancement in part of mass with foci of Calcification • B. Gross specimen : Multicolor Soft Tissue Mass ( mixture of Hemorrhage, Necrosis, Cyst formation and Fibrosis ) MPR MDCT

  13. RV Myxoma in 30-year-old female. • A. Isointense mass occupying RVOT • B. High Signal Intensity in most parts of mass • C. Hyperenhancement of mass • D. Yellow Soft Tissue Mass with narrow base of attachment to RV. MRI-TIR MRI- Gd-DIR MRI-DIR

  14. short-axis view systole • RV myxoma in a 55-year-old man. • a mass prolapsing into the main PA .

  15. Lipomas • The Second Most Common Benign Cardiac Tumors in adults. • Age : Variabale • Associated Syndromes : Tuberous Sclerosis (few cases) • Location : Pericardial Space or any Cardiac Chamber • Typical Morphologic Characteristics : Very large, Broad-based; no Calcification, Hemorrhage, or Necrosis • Echo : Usually Hypoechoic in the Pericardial Space, Echogenic in a cardiac Chamber • Specific CT and MR imaging Characteristics. • CT : Homogeneous, low-attenuation mass • MRI : Homogeneous High Signal intensity on the T1/T2 • that decreases with the use of Fat-Sat sequences. • do not show Contrast enhancement

  16. RA lipoma in 62-year-old female. • A. Homogeneously low-attenuated mass with pedicle (arrow) attached to free wall of RA • B. Gross specimen : shows fatty nature of mass. ECG-g MDCT

  17. RA lipoma in a 72- year-old man. • A . large mass (M) arising from the postero-lateral wall of the RA • B . Circumscribed, broad-based mass , High Signal fills most of the RA. • C . Smooth lipoma filling the RA. apical 4ch view T1W MR Intra-operative photograph

  18. Lipomatous Hypertrophy of the inter-atrial septum /35-year-old woman with AF . • sparing the adjacent FossaOvalis, favouring the diagnosis of lipomatous hypertrophy rather than lipoma. 4ch, T2 BB T1 BB delayed 10 min fat-suppressed, T2

  19. Fatty infiltration of the inter-atrial septum in a 69-year-old, mildly obese woman with palpitations, dyspnea, and an atrial tachyarrhythmia. • wedge-shaped fatty thickening of the inter-atrial septum (arrows). • extension of fatty tissue into the RV (arrowhead).

  20. Papillary Fibroelastomas • Are Benign Endocardial Papillomas • Age : Middle-age • Typical Morphologic Characteristics : Small (<1.5 cm) frond- like, narrow stalk mass attached to the Moving Valves ; Calcification rare, no Hemorrhage or Necrosis • Location : Cardiac Valves • 75% of all Cardiac Valvular tumors . • Echo : small masses with “Shimmering” edges • CT and MR Features : Usually not seen • MRI : Typically a mass on a Valve Leaflet or on the Endocardial surface • Cine MR : Turbulence in the blood flow.

  21. Papillary Fibroelastoma of AO Valve in 60-year-old female. • A : abnormal Thickening of AO Valve (arrow). • B, C : small mass (arrows) attached to Aortic Valve ( moving according to valvular motion ). • D : slightly high signal intensity of small mass (arrow). ECG-gated MDCT cine MR Oblique TIR MR

  22. Rhabdomyomas • the Most Common Cardiac Tumors in Infancy and Childhood, • Associated Syndromes : Tuberous Sclerosis in up to 50% of cases • Mostly Asymptomatic and generally regress spontaneously. • Location : Typically in the Myocardium of Ventricles, and multiple lesions up to 90% of cases. • MRI : • T1W ; Isointense to marginally Hyperintense • T2W ; Hyperintense

  23. Cardiac Rhabdomyoma in Newborn with TuberousSclerosis. • A. Nodules in Caudate Nuclei and Frontal Lobes • B. Iso-Intense mass in Septum and anterior wall of LV. • C. Mild Enhancement Gd-E T1W Sagittal T1W SE MR Axial Gd-E T1W SE MR

  24. Fibroma of the LV in a 32-year-old F, with recurrent syncope and runs of V Tach. • (a,b,c) a well-defined, low-signal mass within the anterior wall of the LV. • (d) uniform enhancement and a thin rim of surrounding compressed myocardium. T1 T2 * SSFP (WB) Delayed10 min

  25. Table 1. Primary Malignant Tumors and Cysts of Heart and Pericardium in533 cases • Malignant • Angiosarcoma 39 (7.3) • Rhabdomyosarcoma 26 (4.9) • Mesothelioma 19 (3.6) • Fibrosarcoma 14 (2.6) • Malignant Lymphoma 7 (1.3) • ExtraskeletalOsteosarcoma 5 • Neurogenic Sarcoma 4 • Malignant Teratoma 1 • Thymoma 1 • Leiomyosarcoma 1 • Liposarcoma Synovial Sarcoma 1 • Subtotal 125 (23.5)

  26. Angiosarcomas • The Most Common Cardiac Sarcomas (37%) • Location : RA and involves the Pericardium. • Presentation : Rt-sided Heart Failure or Tamponade • Late Presentation (often Metastases at the time of diagnosis, particularly to the Lung ) • Invasive behavior ( Pericardial or Pleural Effusion ).

  27. Angiosarcomas • CT : a Low-Density Irregular or Nodular Mass in the RA • Specific MR feature: (on T1/T2 ) a Heterogeneous Papillary Appearance , with and Nodular areas of High Signal interspersed within areas of Intermediate Signal • Enhancement : Linear along the Vascular Spaces as a “Sunray”

  28. Angiosarcoma of RA in 48- year-old male. • A. large mass at the free wall of RA.(irregular and nodular contour and strong contrast enhancement). • B. mostly Isointense mass in RA. • C. Heterogeneously Hyperintense mass . • D. Heterogeneous Hyper-enhancement /areas of no enhancement (Intra-tumoral Thrombosis). . ECG-gated MDCT DIR MR TIR MR Gd-E DIR MR

  29. T2W DIR FSE T1W DIR FSE • Primary Cardiac Angiosarcoma in a 55-year-old man with Weight loss, Dyspnea, and Peripheral Edema. • A. a large, Heterogeneous, Isointense mass completely obliterates the RA. (areas of low and High signal , (due to hemorrhage , necrosis ). 4Ch SSFP GdE T1W DIR FSE

  30. The influence of different MR Sequences Primary Cardiac Angiosarcoma T1WSE echo-planar T2W DIR fast SE T2W DIR Fat-Supp • Primary cardiac angiosarcoma in a 25-year old woman : • with leg swelling, abdominal pain, bloating, and dyspnea. • A. a large Heterogeneous mass at the RA free wall. predominantly isointense , some areas of High-Signal (localized hemorrhage) • B,C. large, Hyperintense, Water- rich mass, left pl eff

  31. Other Cardiac Sarcomas • Including : • Undifferentiated Sarcomas • Malignant Fibrous Histiocytomas (MFHs) • Leiomyosarcomas • Osteosarcomas • Lymphosarcomas • Myxosarcomas • Neurogenic Sarcomas • Synovial Sarcomas • Neurofibrosarcomas • Kaposi’s Sarcomas • Although most Angiosarcomas occur in the RA, the other sarcomas affect the LA more frequently, (an important differentiating feature)

  32. Rhabdomyosarcoma • is the CommonestChildhood Primary Cardiac Malignancy • two distinct Histological Types: • Embryonal types, occur in Children and Adults • Pleomorphic , Much Less Frequent and occur in Adulthood • Location : No Specific Chamber • Valves involvement , ismore likely than any other Primary Cardiac Sarcoma • Multiple sites of involvement

  33. Rhabdomyosarcoma • The presentation: Depends on the area of involvement, • but as the other Cardiac Sarcomas, CHF is common. • MRI : • T1W Iso-intense to myocardium • Homogeneous Gd-enhancement • Some areas of low Signal Intensity (Central Necrosis).

  34. Rhabdomyosarcoma in 22 year old • A,D. MDCT+IV : LA mas Extending through the septum to the RA • B,C. T1 SE 6 months after resection , Recurrence at the septum and pericardial involvement MDCT+IV T1 SE T1 SE T1 SE

  35. Fibrosarcoma • CT 4 Chamber Involvement • T1W 1 year later after therapy

  36. Primary Cardiac Lymphomas • Extremely Rare, ( incidence of 0.15 to 1% ) • Most Common Type : Diffuse Large B cell • Mostly : Solid Infiltrative Tumors in one or multiple chambers of the heart. • Mimicking Classic HCM(massive infiltration of the myocardium )

  37. Primary Cardiac Lymphomas • CT : • as Hypo- or Iso-attenuated Infiltration • Enhancement : Heterogeneous • MRI : • T1W ; Isointense • T2W ; Heterogeneously Hyperintense • Gd-E ; Heterogeneous Enhancement

  38. Primary Cardiac Lymphoma (diffuse large B-cell type) in 73-year-old male. • A. Homogeneous infiltration at RA wall and inter-atrial septum. • Pericardial effusion; (Pericardial invasion ?) • B. Diffuse Infiltrative Mass in RA • Homogeneous Enhancement (distinguishes it from pericardial eff) Enh-MDCT Gd-E DIR MR

  39. Primary cardiac lymphoma : different patterns of cardiac involvement. • (a) A 35-year-old man with AIDS presented with dyspnoea. • a large, solid mass filling the LA isointense with myocardium. • (b) A 42-year-old F, no history of immunosuppression /with cardiac failure. • Diffuse soft-tissue mass filling the pericardial space and the free wall of the RA and LV SSFP (WB) T1 BB

  40. Secondary Cardiac Lymphoma , bilateral Adrenal, renal and intera and retroperitoneal involvement.

  41. Metastatic Involvement • Much More Common than Primary Tumors, Ratio of 30:1 • Cardiac mets occur in 11% of cases of malignancies • Most Frequent Malignancies to the heart : • Lung , Breast, Melanomas and Lymphomas • The Most Common site : Epicardium • Spreading means : • 1. mainly the MediastinalLymphatics to the Epicardial Surface • 2. Hematogenously through the : • Coronary arteries, or less commonly IVC • 3. Direct Extension ( Thymic , Bronchial, Breast and Esophagus )

  42. Metastatic Involvement • Commonly Coincidence Hematogenous Mets in other organs (Lungs). • Trans-Venous tumor spread : • into the RA through the SVC (lung ) or IVC (kidney or liver) • into the LA via the Pulmonary Veins. • DD of Metastases from Thrombus : • Enhancement Patterns after IV Gd-E: (HetergenousEnh) • IR Time 400-500msec

  43. Intracardiac Metastases ( 20-year-old, Seminoma ; with dyspnoea and chest pain. • MDCT : Several large low attenuation masses within the RV. • the changes in both lungs, caused by multiple tumouremboli.

  44. Hematogenous Cardiac Metastases from HCC • A ,B . Marked Diffuse Thickening of RV free wall (arrows). • C, D. HCC Characteristic pattern of early enhancement and wash out MDCT Gd-e DIR MR Arterial (C) and delayed (D) CT

  45. Direct Venous Extension of a left-sided RCC • LRV and IVC are filled by a isointensemass extending into the RA Nonenhanced T1W SE echo-planar

  46. Tumorlike Lesions • Thrombus is The commonest Mimic of a cardiac Neoplasms • Most likely to be located posteriorly in the LA,( AF , or severe LV Dysfunction) • It can also be found in the right side of the heart

  47. Tumor-like Lesions (Thrombus) • MR Characteristics : Variable depending on the age of the thrombus. • Acute thrombus : Bright on both T1 and T2 • Subacute thrombus : Bright on T1, and Low-Signal areas on T2 (the Paramagnetic effects of Methemoglobin ) • Chronic organized thrombus : T1/T2; Low Signal (Water depletion , with or without calcification ) • Gd-E ; Useful for DD thrombus from tumors ( Thrombus doesn't enhance) • Long Inversion time (400 msec) • Note : Organized Thrombus may show some surface Enhancement) • DD : Slow or Static Flow / Flows through the imaging plane

  48. Vertical, long axis (2-ch) delayed 10 min ,long IR time(500 ms) • Intracardiac Thrombus. • (a) A 64-year-old man with a past history of anterior wall myocardial infarction. • non-enhanced mass (arrows) and an overlying (high signal) full thickness MI. • (b) A 55-year-old man with a prior history of anterior myocardial infarction. • a low-attenuation mass within the LV delayed- 10 min + 500mSec IR

  49. Flow artefact within the RV as a low attenuation filling defect ‘‘pseudotumour’’ IVC inflow SSFP

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