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CT AND MR IMAGING OF CARDIAC TUMORS B.Zandi Professor of Radiology.

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Presentation on theme: "CT AND MR IMAGING OF CARDIAC TUMORS B.Zandi Professor of Radiology."— 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 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 (4 th -7 th 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 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-DIR MRI-TIRMRI- Gd-DIR

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

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 Fossa Ovalis, favouring the diagnosis of lipomatous hypertrophy rather than lipoma. 4ch, T2 BB T1 BB fat-suppressed, T2delayed 10 min

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 Tuberous Sclerosis.  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 MRAxial 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. T1T2 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)  Extraskeletal Osteosarcoma 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  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 ). T1W DIR FSE T2W DIR FSE GdE T1W DIR FSE 4Ch SSFP

30  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 T1WSE echo-planarT2W DIR fast SET2W DIR Fat-Supp The influence of different MR Sequences Primary Cardiac Angiosarcoma

31 Other Cardiac Sarcomas  Including :  Undifferentiated Sarcomas  Malignant Fibrous Histiocytomas (MFHs)  Leiomyosarcomas  Osteosarcomas  Lymphosarcomas  Myxosarcomas  Neurogenic Sarcomas  Synovial Sarcomas  Neurofibrosarcomas  Kaposi’s Sarcomas o 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  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

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

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 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 tumour emboli.

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 isointense mass extending into the RA Nonenhanced T1W SE echo-planar


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.  (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 Vertical, long axis (2-ch) delayed 10 min,long IR time(500 ms)

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

51  Thrombus different locations

52  RCA Aneurysm.  a smoothly marginated mass indenting the RV free wall. Axial SSFPCoronal Gd-E First pass T

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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