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Chapter 13: THE ECHOCARDIOGRAM CARDIAC TUMORS

Although diagnosed infrequently, cardiac tumors often are included in the differential diagnosis of cardiac problems because of their protean clinical manifestations. Cardiac tumors may be intracavitary or intramural, and the location determines their echocardiographic appearance. Intracavitary tumors appear as sessile or mobile echo densities attached to the mural endocardium while intramural tumors appear as localized thickening of the LV wall.672 The pericardium also may be involved with cardiac tumors, with or without the presence of concomitant effusion (Chap. 77).

Myxomas

Myxomas are the most common primary cardiac tumors, accounting for about 25 percent of all such lesions.673-675 Myxomas can occur in any cardiac chamber, but 75 percent are found in the LA.675 On 2D imaging, myxomas usually appear as gelatinous, speckled, sometimes globular masses with frond-like projections (Figs. 13-132 and 13-133). Tissue heterogeneity is common, but calcification is rare.673 Although they may be sessile, myxomas are usually attached to the endocardial surface by a pedicle. Typically, they are attached to the interatrial septum, but they can originate from the posterior or anterior atrial wall, the appendage, or even the cardiac valves.676,677 Large tumors are almost always mobile to some degree, and a sizable left atrial mass that appears fixed in position is therefore less likely to be a myxoma. Large left atrial myxomas may move back and forth into the mitral valve annulus during the cardiac cycle, entering the orifice in diastole and the left atrium in systole. Accordingly, Doppler interrogation may demonstrate either obstruction of flow, valvular regurgitation, or both.678,679 Most myxomas are visible on TTE, but TEE is superior for the delineation of tumor attachments and detection of small myxomas.680 Since approximately 5 percent of myxomas are biatrial, careful evaluation of the RA is mandatory.675

Coronary Artery Position Tee

Figure 13-132: Apical four-chamber image of a left atrial myxoma which is attached to the interatrial septum and prolapses through the mitral valve. LA = left atrium; RA = right atrium; RV = right ventricle; LV = left ventricle. (From Blanchard DG, DeMaria AN. Cardiac and extracardiac masses: Echocardiographic evaluation. In: Skorton DJ, Schelbert HR, Wolf GL, Brundage BH, eds. Marcus' Cardiac Imaging, 2d ed. Philadelphia: Saunders, 1996:452-480, with permission.)

Figure 13-132: Apical four-chamber image of a left atrial myxoma which is attached to the interatrial septum and prolapses through the mitral valve. LA = left atrium; RA = right atrium; RV = right ventricle; LV = left ventricle. (From Blanchard DG, DeMaria AN. Cardiac and extracardiac masses: Echocardiographic evaluation. In: Skorton DJ, Schelbert HR, Wolf GL, Brundage BH, eds. Marcus' Cardiac Imaging, 2d ed. Philadelphia: Saunders, 1996:452-480, with permission.)

Additional Primary Tumors Benign

Rhabdomyomas are rare cardiac tumors associated with tuberous sclerosis.681,682 There is a strong tendency for multiple tumors to occur within an affected heart (90 percent of cases).681,683 Fibromas are found most often in children and affect the left ventricle most frequently. The tumor may grow within the myocardium rather than expanding into a cardiac chamber.684,685 Papillary fibroelastomas are usually quite small in size (less than 1 cm in diameter) and often grow on cardiac valves or chordae. These rare tumors typically have multiple small fronds that tend to embolize.625,686,687 Echocardiographic differentiation from vegetations can be difficult (Chap. 77).

Malignant

Primary malignant cardiac tumors are quite rare and confer a very poor prognosis. Angiosarcoma is the most common and occurs most often in the right atrium. Rhabdomyosarcoma is an additional primary cardiac malignancy.688 Echocardiography can be useful in monitoring response to therapy, but its diagnostic utility is limited, as most findings are nonspecific.

Metastatic and Secondary Tumors of the Heart and Pericardium

Metastatic tumors to the pericardium and heart occur 20 to 40 times more often than primary cardiac tumors (Fig. 13-134).689 Tumors that commonly involve the heart and pericardium include breast and lung carcinoma, melanoma, and lymphoma. Involvement may be secondary to hematogenous, lymphatic, or contiguous spread. Tumors such as hepatoma and renal carcinoma can also extend to the heart via the venae cavae.690 In these cases, tumor is often visible in the inferior vena cava and RA. Metastatic disease affects the pericardium more frequently than the heart itself, and pericardial effusion is the most common echocardiographic manifestation in patients with cardiac metastases.689,691,692 Intracavitary and pericardial masses are easily visualized with 2D imaging, although intramural tumors are sometimes difficult to image. Echocardiographic findings are nonspecific, and metastatic tumors may be mistaken for primary cardiac neoplasms, vegetations, thrombi, or even prominent muscular trabeculations (Chap. 77).

Echinococcal Cyst Heart

Figure 13-134: Modified subcostal image showing a metastatic tumor on the epicardium (arrows) and a malignant pericardial effusion. RV = right ventricle; LV = left ventricle. (From Blanchard DG, DeMaria AN. Cardiac and extracardiac masses: Echocardiographic evaluation. In: Skorton DJ, Schelbert HR, Wolf GL, Brundage BH, eds. Marcus' Cardiac Imaging, 2d ed. Philadelphia: Saunders; 1996:452-480, with permission.)

Additional Cardiac Masses

The heart is rarely involved in echinococcal disease (<2 percent of cases), but intracardiac or intrapericardial rupture of a cyst can lead to anaphylaxis and cardiac tamponade, respectively.6" Echocardiographic detection of a multiseptated cyst in the left ventricle or interventricular septum suggests cardiac echinococcal disease.694

Simple pericardial cysts usually occur in the right costophrenic angle (posterior to the right atrium) and have a benign prognosis. The structures are nonseptated and fluid-filled; they do not compress the cardiac chambers.695

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