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CT and MR Imaging of Cardiac Tumors

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Presentation on theme: "CT and MR Imaging of Cardiac Tumors"— Presentation transcript:

1 CT and MR Imaging of Cardiac 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 and Pericardium in 533 cases
Myxoma (24.2) Lipoma (8.4) Papillary Fibroelastoma (7.9) Rhabdomyoma (6.8) Fibroma (3.2) Hemangioma (2.8) Teratoma (2.6) Mesotheloma of AV node (2.3) Granular cell tumor Neurofibroma Lymphangioma Subtotal (59.8 Pericardial Cyst (15.4) Bronchogenic Cyst (1.3) Subtotal  (16.7)

9 Myxomas the Most Common Benign Tumor (4th-7th decades) LOCATION :
Inter-atrial Septum at fossa ovalis 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 or Hemosiderin ). T2W : Markedly High Signal

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

12 LA Myxoma in 65-year-old male.
MPR MDCT 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 )

13 RV Myxoma in 30-year-old female. A. Isointense mass occupying RVOT
MRI-TIR MRI- Gd-DIR MRI-DIR 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.

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.
ECG-g MDCT 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.

17 Intra-operative photograph
apical 4ch view T1W MR Intra-operative photograph 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.

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

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 ECG-gated MDCT cine MR Oblique TIR MR 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).

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

24 T1 T2 * SSFP (WB) Delayed10 min
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.

25 Table 1. Primary Malignant Tumors and Cysts of Heart and Pericardium in533 cases
Angiosarcoma (7.3) Rhabdomyosarcoma (4.9) Mesothelioma (3.6) Fibrosarcoma (2.6) Malignant Lymphoma (1.3) Extraskeletal Osteosarcoma Neurogenic Sarcoma Malignant Teratoma Thymoma Leiomyosarcoma Liposarcoma Synovial Sarcoma Subtotal (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”

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).

29 T2W DIR FSE T1W DIR FSE 4Ch SSFP GdE 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 ).

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 Commonest Childhood 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 , is more 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 T1 SE T1 SE T1 SE Rhabdomyosarcoma in 22 year old
MDCT+IV T1 SE T1 SE T1 SE 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

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 Enh-MDCT Gd-E DIR MR 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)

39 Primary cardiac lymphoma : different patterns of cardiac involvement.
SSFP (WB) T1 BB (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

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 Mediastinal Lymphatics 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: (Hetergenous Enh) IR Time msec

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 tumour emboli.

44 Hematogenous Cardiac Metastases from HCC
MDCT Gd-e DIR MR Arterial (C) and delayed (D) CT 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

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


47 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

48 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

49 Intracardiac Thrombus.
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

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

51 Thrombus different locations

52 a smoothly marginated mass indenting the RV free wall.
Axial SSFP Coronal Gd-E First pass RCA Aneurysm. a smoothly marginated mass indenting the RV free wall.

53 CONCLUSION CT and MRI may be useful in the DD of Benign/Malignant cardiac masses. CT is useful for the evaluation of Ca and Fat content within a mass The High Spatial Resolution of MDCT is beneficial to define Small Lesions MDCT is useful in the Staging of Malignant Tumors. The Excellent Contrast Resolution of MRI allows Characterization of Fibromas and Hemangiomas. Homogeneity of a mass due to compact cellularity may be characteristic of a Lymphoma. Acquisition of Post-Contrast Sequences enables better depiction of tumor Vascularity and can be used to define Tumor Borders. MRI has an important role in DD Thrombi from Cardiac Tumors. MDCT and MRI might help determine Resectability of a Tumor and allow planning for reconstruction of the cardiac chambers.

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