Computed Tomography of Cardiac Pseudotumors and Neoplasms

Cardiac Masses Discovered by Echocardiogram; What to Do Next?

Cardiac tumors are rare conditions, typically diagnosed on autopsy, but with the advancement of imaging techniques they are now encountered more frequently in clinical practice. Echocardiography is often the initial method of investigation for cardiac masses and provides a quick and valuable springboard for their characterization. While some cardiac masses can be readily identified by echocardiography alone, several require incorporation of multiple data points to reach diagnostic certainty. Herein, we will provide an overview of the main clinical, diagnostic, and therapeutic characteristics of cardiac masses within the framework of their location.

Cardiac Tumors: Diagnosis, Prognosis, and Treatment

Purpose of Review

Cardiac masses frequently present significant diagnostic and therapeutic clinical challenges and encompass a broad set of lesions that can be either neoplastic or non-neoplastic. We sought to provide an overview of cardiac tumors using a cardiac chamber prevalence approach and providing epidemiology, imaging, histopathology, diagnostic workup, treatment, and prognoses of cardiac tumors.

Recent Findings

Cardiac tumors are rare but remain an important component of cardio-oncology practice. Over the past decade, the advances in imaging techniques have enabled a noninvasive diagnosis in many cases. Indeed, imaging modalities such as cardiac magnetic resonance, computed tomography, and positron emission tomography are important tools for diagnosing and characterizing the lesions. Although an epidemiological and multimodality imaging approach is useful, the definite diagnosis requires histologic examination in challenging scenarios, and histopathological characterization remains the diagnostic gold standard.

Summary

A comprehensive clinical and multimodality imaging evaluation of cardiac tumors is fundamental to obtain a proper differential diagnosis, but histopathology is necessary to reach the final diagnosis and subsequent clinical management.

Mediastinal Masses: 18F-FDG-PET/CT Features Based on the International Thymic Malignancy Interest Group Classification

Imaging plays a key role in the management of mediastinal masses. In an effort to standardize the analysis of the mediastinum, the International Thymic Malignancy Interest Group (ITMIG) has proposed a three compartments-based diagnostic classification, intended for clinicians and radiologists. Several articles have documented its usefulness to guide the diagnosis using cross-sectional imaging. Similarly, fluorine-18-radiolabeled fluorodeoxyglucose positron emission tomography combined to computed tomography (¹⁸F-FDG-PET/CT) can be useful in this setting, either as a first-line diagnostic technique, or in addition to cross-sectional imaging. In this article, which is thought as an aid for nuclear medicine physicians and radiologists, we aim to present, based on the ITMIG classification, the main mediastinal pathologies that can be observed with ¹⁸F-FDG-PET/CT, and the additional diagnostic value that can be expected from this technique. For this purpose, we segmented the mediastinum according to the ITMIG classification, and reviewed the available literature for each of the corresponding organs and/or disease. Given the importance of the clinical context for the interpretation of PET imaging, we presented each of the diseases according to: (1) their suggestive clinical context; (2) the suggestive features on nonenhanced CT (which is the standard in PET imaging); and (3) the typical ¹⁸F-FDG characteristics. The purpose of this article is to depict the main features of the most common mediastinal diseases that can be encountered with ¹⁸F-FDG-PET/CT, and to highlight its diagnostic value in this setting, alone or in combination with other imaging modalities.

Surgical results and pathological analysis of cardiac fibroma in the adolescent and the adult

BACKGROUNDS

Disparities may exist between the adolescent and the adult patients with cardiac fibromas in the symptoms, surgical outcomes, and pathological characteristics. The aim of this study was to compare short and midterm surgical outcomes of cardiac fibromas and to compare the biomarker expressions of tumor tissue samples between the adult and the adolescent.

METHODS

Consecutive patients with the diagnosis of cardiac fibroma were admitted and received surgeries. Primary outcomes included in-hospital mortality, low cardiac output, and readmission due to heart failure. The expression of PCNA and Ki67, two widely adopted indicators of cell proliferation, were evaluated in tissue samples.

RESULTS

A total of five adolescent patients and five adult patients diagnosed as cardiac fibroma were admitted and given surgeries. When compare with the adults, the adolescent patients were more likely to present symptoms on admission (P = .048). Postoperative low cardiac output syndrome was significantly higher in the adolescents than in the adults (80.0% vs 0.0, P = .048). The tumor volume relative to ventricular end diastolic diameter had good discriminative ability for low cardiac output (c statistics: 0.96). Pathologically, the percentage of PCNA-positive cell nuclei was significantly higher in the adolescents than in the adults (36.04% ± 10.54% vs 4.15% ± 3.93%, P = .001). However, there were no Ki67-positive nuclei in the 10 cases.

CONCLUSIONS

In the current study, we found that postoperative low cardiac output was more likely to occur in the adolescent patients than in the adult patients. When compared with the adult patients, significantly more PCNA-positive nuclei were observed in the adolescents.

Atrial thrombi or cardiac tumours? The image-challenge of intracardiac masses: a case report

BACKGROUND

Cardiac masses (CM) encompass a broad set of lesions that can be either neoplastic or non-neoplastic. A stepwise diagnostic strategy through multimodality imaging evaluation is the cornerstone for the appropriate approach.

CASE SUMMARY

We report the case of an 83-year-old man presenting at the emergency department for acute heart failure showing bilateral atrial masses without unequivocal aetiological aspects at several imaging techniques, emphasizing the critical aspects in the differential diagnosis.

DISCUSSION

In the complex field of CM, a proper differential diagnosis is very important in order to start the appropriate treatment; however, sometimes it could be challenging despite a multimodality imaging approach, therefore still requiring histologic examination.

In-situ recurrence of the primary cardiac dedifferentiated liposarcoma: To resect or not?

Dedifferentiated liposarcoma (DDLPS) is a rare type of neoplasm which can originally rise in cardiac chamber. Owing to the recurrence and distant metastasis, the prognosis of the primary malignant cardiac tumor is extremely poor and remains a challenge for cardiac surgeons. Here, we report a patient with an intracavitary mass which was diagnosed as DDLPS by postoperative pathological examinations, experienced repeated in-situ recurrence of the malignant cardiac tumor.

Primary cardiac dedifferentiated liposarcoma in a middle-aged female: a case report

BACKGROUND

Primary malignant cardiac tumors are extremely rare and can present with the same nonspecific characteristics as benign primary cardiac tumors. We herein describe a middle-aged female with an intracavitary, irregular atrial mass who experienced partial surgical resection. The atrial mass which was recognized as myxoma before surgery was finally diagnosed as dedifferentiated liposarcoma (DDLPS) by postoperative pathological examination.

CASE PRESENTATION

The patient, a 61-year-old female, presented to the emergency room because of progressive chest congestion and shortage of liberties for 6 months and orthopnoea and paroxysmal nocturnal dyspnea for 3 days. The laboratory examinations confirmed no abnormalities. The thoracic computed tomography (CT) scan showed massive hydropericardium, pleural effusion and left atrium occupying lesion. The transesophageal echocardiography (TEE) confirmed an intracavitary and irregular left atrial mass, limiting the mitral valve inflow and pulmonary venous blood reflux. The positron emission tomography/computed tomography (PET/CT) revealed high grade fluorodeoxyglucose uptake only in the intracavitary mass which near the mitral valve. According to operative exploration, the intracavitary mass had invaded the mitral annulus and posterior wall of left ventricle which cannot be resected completely, we did merely partial surgical resection to relieve the patient's symptoms. Postoperative immunohistochemical stain confirmed the diagnosis of DDLPS. The patient was transferred to the oncology department for further therapy. Unfortunately, the patient was detected with brain metastasis 1 month later and died within 5 months after the surgery.

CONCLUSIONS

Primary cardiac DDLPS is an extremely rare histological subtype of undifferentiated pleomorphic sarcomas which present the same nonspecific characteristics as benign primary cardiac tumors. Even though surgical resection combined with chemotherapy or radiotherapy remains the mainstream treatment strategy, the prognosis of cardiac malignancy is poor with high mortality. Novel management strategies need to be further explored.

Symptomatic Aortic Valve Mass - Cardiac Work-Up Challenges and Role of Computed Tomography Angiography: A Case Report

Cardiac papillary fibroelastoma are rare, benign cardiac tumors that may lead to lethal complications from embolization or valvular dysfunction if left untreated. When working up symptomatic tumors with concomitant angina, traditional diagnostic studies such as cardiac catheterization may predispose the patient to embolic complications if the mass is located in the path of the catheter. Newer, non-invasive diagnostic testing, such as cardiac magnetic resonance imaging or dynamic computed tomography angiography, may be considered in lieu of invasive approaches to avoid potentially devastating complications. We herein present a case report of a 77-year-old female with a symptomatic aortic valve tumor and describe our diagnostic strategy and management.

Significant incidental cardiac disease on thoracic CT: what the general radiologist needs to know

Objective

Incidental cardiac findings are often found on chest CT studies, some of which may be clinically significant. The objective of this pictorial review is to illustrate and describe the appearances and management of the most frequently encountered significant cardiac findings on non-electrocardiographically gated thoracic CT. Most radiologists will interpret multidetector chest CT and should be aware of the imaging appearances, significance, and the appropriate next management steps, when incidental significant cardiac disease is encountered on thoracic CT.

Conclusion

This article reviews significant incidental cardiac findings which may be encountered on chest CT studies. After completing this review, the reader should not only be familiar with recognizing clinically significant cardiac findings seen on thoracic CT examinations but also have the confidence to direct their further management.

Cardiac melanoma: Retrospective review of a rare disease at the Mayo clinic (1988-2015)

BACKGROUND

Melanoma metastasizing to the heart (cardiac melanoma) is a rare entity that has been described only in autopsy studies or isolated pre-mortem case reports. We aim to better characterize cardiac melanoma, and describe its presenting features, imaging findings, and disease course with a case series collected over nearly 30years.

METHODS

We performed a retrospective review of all patients diagnosed with cardiac melanoma at the Mayo Clinic from 1988 to 2015. Qualitative analysis was performed on patient demographics, clinical history, and imaging modalities.

RESULTS

11 patients (7 male, median age 63years) were identified with cardiac melanoma. Shortness of breath (64%) was the most common presenting symptom. Transthoracic echocardiography (TTE) was utilized in the assessment of all patients though it failed to identify 20% of masses that were seen on fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) or cardiac magnetic resonance (CMR). The majority of masses were located within the cardiac chambers (46% right atrium, 18% right ventricle, 18% left atrium), and 36% appeared mobile on TTE. Patients lived for a median of 68months (interquartile range [IQR] 14-143months) after the initial diagnosis of primary melanoma, and only 12months (IQR 2-150months) after diagnosis of cardiac melanoma.

CONCLUSION

Echocardiography can generally identify most cases of cardiac melanoma, though it misses one-fifth of masses seen on FDG PET/CT or CMR. Cardiac melanoma is associated with a poor prognosis.

Pathology, imaging, and treatment of cardiac tumours

Cardiac tumours are a rare, but often devastating, clinical diagnosis. They encompass a broad set of lesions that include both neoplastic and non-neoplastic conditions. Cardiac tumours are often diagnosed incidentally during work-up for other conditions, or during ultrasound, CT, or MRI scans for unusual or nonspecific symptoms. In the past decade, important changes have been made in the nomenclature and the recommendations for diagnosis of cardiac tumours, as highlighted by the WHO's 2015 revision of the classification of cardiac tumours. Moreover, important advances in molecular genetics and therapeutics offer new approaches for the diagnosis and treatment of affected patients. In this Review, we provide an overview of the clinical, pathological, and imaging characteristics of all types of cardiac masses, including both benign and malignant primary cardiac neoplasms.

[Evaluation of cardiac tumors by multidetector computed tomography and magnetic resonance imaging]

Cardiac tumors, are a rare pathology (0.002-0.3%) in all age groups, however, they have a clinic importance, due the affected organ. They are classified in primary (benign or malignant) and secondary (metastasis) types. Among primary type, mixoma, is the most common benign tumor, and sarcoma represents most of the malignant injuries. Cardiac metastasis are more frequent than primary tumors. Clinic effects of cardiac tumors are unspecific and vary according their location, size and agresivity. The use of Multidetector Computed Tomography (MDCT) and Magnetic Resonance Imaging (MRI) assist on the location, sizing, anatomical relationships and the compromise of adyacents structures, besides, MRI is useful for tissue characterization of the tumor. Due to the previous reasons, studies based on noninvasive cardiovascular imaging, have an important role on the characterization of these lesions and the differential diagnosis among them.

Korean guidelines for the appropriate use of cardiac CT

The development of cardiac CT has provided a non-invasive alternative to echocardiography, exercise electrocardiogram, and invasive angiography and cardiac CT continues to develop at an exponential speed even now. The appropriate use of cardiac CT may lead to improvements in the medical performances of physicians and can reduce medical costs which eventually contribute to better public health. However, until now, there has been no guideline regarding the appropriate use of cardiac CT in Korea. We intend to provide guidelines for the appropriate use of cardiac CT in heart diseases based on scientific data. The purpose of this guideline is to assist clinicians and other health professionals in the use of cardiac CT for diagnosis and treatment of heart diseases, especially in patients at high risk or suspected of heart disease.

Cardiac CT angiography beyond the coronary arteries: what radiologists need to know and why they need to know it

OBJECTIVE

With current state-of-the-art CT combining fast scanning times and high spatial resolution, anatomy beyond the coronary arteries is well visualized and may lead to discovery of abnormalities. The purpose of this article is to provide a strategy for radiologists to recognize important extracoronary cardiac CT angiography (CTA) findings.

CONCLUSION

A systemic approach to cardiac CTA by anatomic location and attention to key CT features are critical to identify and properly characterize important extracoronary cardiac abnormalities.

CT and MR imaging of the aortic valve: radiologic-pathologic correlation

Valvular disease is estimated to account for as many as 20% of cardiac surgical procedures performed in the United States. It may be congenital in origin or secondary to another disease process. One congenital anomaly, bicuspid aortic valve, is associated with increased incidence of stenosis, regurgitation, endocarditis, and aneurysmal dilatation of the aorta. A bicuspid valve has two cusps instead of the normal three; resultant fusion or poor excursion of the valve leaflets may lead to aortic stenosis, the presence of which is signaled by dephasing jets on magnetic resonance (MR) images. Surgery is generally recommended for patients with severe stenosis who are symptomatic or who have significant ventricular dysfunction; transcatheter aortic valve implantation (TAVI) is an emerging therapeutic option for patients who are not eligible for surgical treatment. Computed tomography (CT) is an essential component of preoperative planning for TAVI; it is used to determine the aortic root dimensions, severity of peripheral vascular disease, and status of the coronary arteries. Aortic regurgitation, which is caused by incompetent closure of the aortic valve, likewise leads to the appearance of jets on MR images. The severity of regurgitation is graded on the basis of valvular morphologic parameters; qualitative assessment of dephasing jets at Doppler ultrasonography; or measurements of the regurgitant fraction, volume, and orifice area. Mild regurgitation is managed conservatively, whereas severe or symptomatic regurgitation usually leads to valve replacement surgery, especially in the presence of substantial left ventricular enlargement or dysfunction. Bacterial endocarditis, although less common than aortic stenosis and regurgitation, is associated with substantial morbidity and mortality. Electrocardiographically gated CT reliably demonstrates infectious vegetations and benign excrescences of 1 cm or more on the valve surface, allowing the assessment of any embolic complications.

Atrial masses post cardiac transplantation: diagnostic and treatment dilemmas

Atrial masses postcardiac transplant are not well reported and their diagnosis and treatment can be challenging. In the asymptomatic patient, differentiating thrombus from cardiac tumor can sometimes be difficult and the use of multiple imaging modalities is recommended. Accurate diagnosis is imperative to inform a treatment plan that balances the benefits and risks of a medical versus surgical approach. We present three cases of atrial masses postcardiac transplant to illustrate this clinical dilemma.

Surgery for Primary Cardiac Tumors in Children

Background—

To evaluate indications and results of surgery for primary cardiac tumors in children.

Methods and Results—

Eighty-nine patients aged ≤18 years undergoing surgery for cardiac tumor between 1990 and 2005 from 16 centers were included retrospectively (M/F=41/48; median age 4.3 months, range 1 day to 18 years). Sixty-three patients (68.5%) presented with symptoms. Surgery consisted of complete resection in 62 (69.7%) patients, partial resection in 21 (23.6%), and cardiac transplant in 4 (4.5%). Most frequent histotypes (93.2%) were benign (rhabdomyoma, myxoma, teratoma, fibroma, and hemangioma). Postoperative complications occurred in 29.9%. Early and late mortality were 4.5% each (mean follow-up, 6.3±4.4 years); major adverse events occurred in 28.2% of the patients; 90.7% of patients are in New York Heart Association class I. There were no statistically significant differences in survival, postoperative complications, or adverse events after complete and partial resection in benign tumors other than myxomas. Cardiac transplant was associated significantly with higher mortality rate ( P= 0.006). Overall mortality was associated to malignancy ( P =0.0008), and adverse events during follow-up ( P =0.005).

Conclusions—

Surgery for primary cardiac tumors in children has good early and long-term outcomes, with low recurrence rate. Rhabdomyomas are the most frequent surgical histotypes. Malignant tumors negatively affect early and late survival. Heart transplant is indicated when conservative surgery is not feasible. Lack of recurrence after partial resection of benign cardiac tumors indicates that a less risky tumor debulking is effective for a subset of histotypes such as rhabdomyomas and fibromas.

Cardiac Tumors

Cardiac neoplasms and other mass-forming lesions are not commonly encountered in surgical pathology practice. Fortunately, for the most part, these fall into a small group of well characterized and readily-recognized entities, although they are not without diagnostic dilemmas. A brief and practical synopsis of cardiac tumors is presented in this section with attention to more frequently encountered and clinically significant diagnostic challenges as well as pertinent clinical associations and prognostic information.

[Spontaneous hematoma of the atrial wall]

The clinical signs of heart masses tend to be nonspecific, generally depending more on their repercussions on heart function caused by their location rather than on their type. Imaging techniques make it possible to limit the differential diagnosis of heart masses based on their location, morphology, and characteristics of echogenicity, density, or intensity, depending on the technique used to study them. We present the case of a woman with squeezing mid chest pain irradiating to her shoulder and positive cardiac markers in whom a left atrial mass was identified at echocardiography. This finding was confirmed at chest CT. The signs at chest CT were compatible with a mural hematoma and this diagnosis was confirmed after intraoperative biopsy.

Cardiac CT of non-shunt pathology of the interatrial septum

The development and anatomy of the interatrial septum is complex. With the increasing use of cardiac CT and its precise delineation of the anatomy, it is important for the cardiac imager to become familiar with the normal anatomic structures that compose the interatrial septum and their variants. Furthermore, it is important to recognize pathologic processes occurring in this region other than atrial septal defects and potential imaging pitfalls. This pictorial essay provides a detailed review of these topics with emphasis in CT appearance and related technical aspects.