Presentation on theme: "CT and MR Imaging of Cardiac Tumors"— Presentation transcript:
1 CT and MR Imaging of Cardiac Tumors B.ZandiProfessor of Radiology
2 ObjectivesTo 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 TumorsTo DD Benign from Malignant Masses.the use ofMDCT in providing Anatomical InformationMRI 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. Metastaticapproximately 30 times more Prevalent than primary
5 Imaging Modalities Trans-thoracic Echocardiography : Most Widely Used imaging modalityThe Best Imaging modality to depict Small Masses (Valves )Limitations : Visualization of Extra-Cardiac ExtensionTEE : 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 DiagnosisOptimal Evaluation of Myocardial infiltration,Pericardial involvementand 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 Echodefinitively characterize Fat and CalcificationsWide field-of-view helps :to assess the Extent of a Cardiac Malignancyand 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 tumorNeurofibromaLymphangiomaSubtotal (59.8Pericardial 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 stalkCT Features : Well-defined Spherical or Ovoid Intra-Cavitary Mass with Heterogeneous, low attenuation, Typically Lobular ContoursIV-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 viewLV 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 MDCTLA Myxoma in 65-year-old male.A. shows LA mass attached to inter-atrial septum by broad pedicleStrong Enhancement in part of mass with foci of CalcificationB. 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-TIRMRI- Gd-DIRMRI-DIRRV Myxoma in 30-year-old female.A. Isointense mass occupying RVOTB. High Signal Intensity in most parts of massC. Hyperenhancement of massD. 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 : VariabaleAssociated Syndromes : Tuberous Sclerosis (few cases)Location : Pericardial Space or any Cardiac ChamberTypical Morphologic Characteristics : Very large, Broad-based; no Calcification, Hemorrhage, or NecrosisEcho : Usually Hypoechoic in the Pericardial Space, Echogenic in a cardiac ChamberSpecific CT and MR imaging Characteristics.CT : Homogeneous, low-attenuation massMRI : Homogeneous High Signal intensity on the T1/T2that decreases with the use of Fat-Sat sequences.do not show Contrast enhancement
16 RA lipoma in 62-year-old female. ECG-g MDCTRA lipoma in 62-year-old female.A. Homogeneously low-attenuated mass with pedicle (arrow) attached to free wall of RAB. Gross specimen : shows fatty nature of mass.
17 Intra-operative photograph apical 4ch viewT1W MRIntra-operative photographRA lipoma in a 72- year-old man.A . large mass (M) arising from the postero-lateral wall of the RAB . Circumscribed, broad-based mass , High Signal fills most of the RA.C . Smooth lipoma filling the RA.
18 4ch, T2 BBT1 BBdelayed 10 minfat-suppressed, T2Lipomatous 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 PapillomasAge : Middle-ageTypical Morphologic Characteristics : Small (<1.5 cm) frond- like, narrow stalk mass attached to the Moving Valves ; Calcification rare, no Hemorrhage or NecrosisLocation : Cardiac Valves75% of all Cardiac Valvular tumors .Echo : small masses with “Shimmering” edgesCT and MR Features : Usually not seenMRI : Typically a mass on a Valve Leaflet or on the Endocardial surfaceCine MR : Turbulence in the blood flow.
21 ECG-gated MDCTcine MROblique TIR MRPapillary 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 casesMostly 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 HyperintenseT2W ; Hyperintense
23 Cardiac Rhabdomyoma in Newborn with Tuberous Sclerosis. Gd-E T1WSagittal T1W SE MRAxial Gd-E T1W SE MRCardiac Rhabdomyoma in Newborn with Tuberous Sclerosis.A. Nodules in Caudate Nuclei and Frontal LobesB. 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 OsteosarcomaNeurogenic SarcomaMalignant TeratomaThymomaLeiomyosarcomaLiposarcoma Synovial SarcomaSubtotal (23.5)
26 Angiosarcomas The Most Common Cardiac Sarcomas (37%) Location : RA and involves the Pericardium.Presentation : Rt-sided Heart Failure or TamponadeLate 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 SignalEnhancement : Linear along the Vascular Spaces as a “Sunray”
28 . ECG-gated MDCT DIR MR TIR MR Gd-E DIR MR 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 FSET1W DIR FSE4Ch SSFPGdE T1W DIR FSEPrimary 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-planarT2W DIR fast SET2W DIR Fat-SuppPrimary 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 SarcomasMalignant Fibrous Histiocytomas (MFHs)LeiomyosarcomasOsteosarcomasLymphosarcomasMyxosarcomasNeurogenic SarcomasSynovial SarcomasNeurofibrosarcomasKaposi’s SarcomasAlthough 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 AdultsPleomorphic , Much Less Frequent and occur in AdulthoodLocation : No Specific ChamberValves involvement , is more likely than any other Primary Cardiac SarcomaMultiple 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 myocardiumHomogeneous Gd-enhancementSome areas of low Signal Intensity (Central Necrosis).
34 T1 SE T1 SE T1 SE Rhabdomyosarcoma in 22 year old MDCT+IVT1 SET1 SET1 SERhabdomyosarcoma in 22 year oldA,D. MDCT+IV : LA mas Extending through the septum to the RAB,C. T1 SE 6 months after resection , Recurrence at the septum and pericardial involvement
35 FibrosarcomaCT 4 Chamber InvolvementT1W 1 year later after therapy
36 Primary Cardiac Lymphomas Extremely Rare, ( incidence of 0.15 to 1% )Most Common Type : Diffuse Large B cellMostly : Solid Infiltrative Tumors in one or multiple chambers of the heart.Mimicking Classic HCM (massive infiltration of the myocardium )
38 Enh-MDCTGd-E DIR MRPrimary 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 RAHomogeneous 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 30:1Cardiac mets occur in 11% of cases of malignanciesMost Frequent Malignancies to the heart :Lung , Breast, Melanomas and LymphomasThe Most Common site : EpicardiumSpreading means :1. mainly the Mediastinal Lymphatics to the Epicardial Surface2. Hematogenously through the :Coronary arteries, or less commonly IVC3. 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 MDCTGd-e DIR MRArterial (C) and delayed (D) CTHematogenous Cardiac Metastases from HCCA ,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-planarDirect Venous Extension of a left-sided RCCLRV and IVC are filled by a isointense mass extending into the RA
47 Tumorlike LesionsThrombus is The commonest Mimic of a cardiac NeoplasmsMost 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 T2Subacute 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 LVdelayed- 10 min + 500mSec IR
50 SSFPFlow artefact within the RV as a low attenuation filling defect ‘‘pseudotumour’’ IVC inflow
52 a smoothly marginated mass indenting the RV free wall. Axial SSFPCoronal Gd-E First passRCA Aneurysm.a smoothly marginated mass indenting the RV free wall.
53 CONCLUSIONCT 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 massThe High Spatial Resolution of MDCT is beneficial to define Small LesionsMDCT 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.