Final Exam Cardiac Masses and Tumors Flashcards
(85 cards)
1
Q
Name 10 things that a cardiac mass/tumor could be
A
- V egetations
- T umors (benign/malignant , primary/secondary)
- Thrombi
- N ormal variants
- P acemaker wires
- Internal cardiac defibrill ator wires
- S wan-Ganz catheter
- H ickman catheter (RA, RV)
- Migrated Kimray Greenfield filter
- Bullets
2
Q
Primary tumors are common True or False
A
False
Primary tumors are rare!
3
Q
Phew! What percentage of primary tumors are benign?
A
75%
4
Q
The most prevalent type of benign primary tumor is a
A
myxoma @ 27%
5
Q
The most prevalent type of malignant primary tumor is a
A
angiosarcoma @ 9%
6
Q
The most prevalent type of cyst (primary tumor) is
A
pericardial @ 18%
7
Q
When it comes to primary tumors there are (4) subcategorical classifications
A
benign, malignant, cysts, metastatic or non primary
8
Q
these are TWENTY TIMES more common than primary tumors
A
NONPRIMARY TUMORS!
9
Q
What are (5) ways that nonprimary tumors can affect the heart?
A
- NEAR: direct spread from adjacent malignant tissue (breast, lung)
- FAR: spread from distant dz in lymphatic system (lymphoma, melanoma)
- “PAN” cardiac - is that a word? Invasion of all layers of heart walls (pericardium, epicardium, myocardium, endocardium)
- Bio hazard!!! LOL biologically active substances being produced (ie carcinoid heart dz)
- Treatment, toxic side fx on heart (ex therapy from chemo, radiation therapy)
10
Q
Could you explain what a myxoma is?
A
neoplasm that arises from endocardial tissues
11
Q
associations of myxoma (6)
A
skin myxoma
cutaneous lentignosis
pituitary adenomas
primary nodular adrenal cortical dz w/ or w/out Cushings
Testicular tumors
Myxoid fibroadenoma of breast
12
Q
possible clinical presentation of a myxoma?
A
fever, malaise, clinically evident embolic events, mv obstruction symptoms
13
Q
When thinking of myxoma symptoms (right side vs left side) think of the plumbing…
A
Left-sided tumors:
- Dyspnea
- Orthopnea
- Paroxysmal nocturnal dyspnea - Chest pain
- Cough
- Hemoptysis
- Acute pulmonary edema
- Syncope
- Right-sided tumors:
- Right heart failure
- Peripheral edema
- Distended jugular veins - Ascites
- Hepatomegaly
14
Q
On auscultation, a prolapsing myxoma across the MV annulus could cause this sound:
A
a tumor “plop”
15
Q
It is IMPORTANT for US to do the following when evaluating a tumor (3)
A
- where is it ATTACHED?
- are the leaflets INVOLVED?
- does he have FRIENDS? (multiple masses)
16
Q
A lipoma is what classification of tumor? Define what it is and their general appearance on echo.
A
A lipoma is a benign primary tumor.
It is a neoplasm consisting of mature fat cells, commonly found in KIDS.
Is hyper-reflective on echo.
17
Q
Where can lipomas be found? what determines symptoms?
A
LV, RA, and IAS
*size and location determine symptoms
18
Q
Range of size for a lipoma?
A
1-15 centimeters!!!!!
19
Q
What is a lipomatous hypertrophy of the IAS? Something is “not true” about this pathology.
A
It is an excessive collection of adipose tissue in IAS… n0t AcTuAl HyPeRtR0pHy… just proliferation of fat cells.
It is NOT a TRUE neoplasm.
It is benign.
Usually incidental finding.
IAS hypertrophies except for fossa ovalis.
20
Q
lipomatous hypertrophy is usually associated with
A
-increasing age and obesity
-asymptomatic
-supraventricular arrhythmias
21
Q
papillary fibroelastoma has many names… (6) listed here. What is one that doesn’t even have the root word in it?
A
Giant lambl’s excrescence!
aka
papilloma
papillary fibroma
papillary endocardial tumor
papilloelastoma
fibropapiloma
22
Q
What is the 2nd most common primary tumor and what are its common locations…? Can it appear in children and adults?
A
papillary fibroelastoma
MV and AoV most common location in adults
In children… most common on TV
Valvular or nonvalvular sites
embolic events more common when tumor is mobile/attached to stalk
More discreet shape / don’t tend to cause regurg/stenosis/valve disruption like veggies do
23
Q
Lambl’s excrescence can be mistaken for a
A
papillary fibroelastoma
NOT TO BE CONFUSED WITH GIANT LAMBL’S EXCRESCENCE (which is aka papillary fibroelastoma)
24
Q
Nothing really remarkable to discuss about malignant primary tumors (general). They are common/rare? Where could they be found and what are symptoms?
A
Rare
Incidental finding possibility
Could be present with TAMPONADE
Nonspecific symptoms: fever, malaise
25
What is the most common MALIGNANT primary tumor?
Angiosarcoma
26
Could you describe what an angiosarcoma is?
It is a soft tissue tumor of the blood vessel
27
A lymphosarcoma is a slight variation on an
angiosarcoma. It is an angiosarcoma but taking place in the lymphatic endothelium.
28
Where do angiosarcomas most commonly affect? What are symptoms?
head, face, liver, chest - heart, males, usually in RA...
Symptoms are: Chest pain
* Cough
* Dyspnea
* Can infiltrate into pericardium, rupture, and cause tamponade * Can obstruct blood flow in 2 ways:
- 1. Extrinsic compression
- 2. Consumes chamber cavity (intrinsic)
29
angiosarcomas can infiltrate what, causing what. They can also obstruct _____ in ___ ways.
* Can infiltrate into pericardium, rupture, and cause tamponade
* Can obstruct blood flow in 2 ways:
- 1. Extrinsic compression
- 2. Consumes chamber cavity (intrinsic)
30
What is the most common benign tumor of children?
Rhabdomyoma (kids have "rhabbits")
usually under 1 yo
31
Most common sites of rhabdomyomas?
RV and LV are most common sites (atrial uncommon)
Little rhabbit that hops between the ventricles… LOL
32
Rhadomyoma associated with what in up to 90% of cases????????
tuberous sclerosis
33
Half of these tumors cause hemodynamic obstruction!!!
rhabdomyomas
ALSO *fibrosarcomas*
34
Symptoms of rhabdomyomas
* Arrhythmias
* AVblock
* Pericardial effusion
* Sudden death (usu from arrthymial issue)
Good bunnies can kill you!
35
most common soft tissue sarcoma in children... this tumor arises from what
*kids can also have EVIL rhabbits*
RHABDOMYOSARCOMA
Tumors arise from striated muscle fibers that diffusely infiltrate the muscle of the heart
36
The second most common primary malignant tumor of the heart... (also most common sarcoma for kids)?
RHABDOMYOSARCOMA
37
Where can be rhabdomyosarcomas be found?
- Found in multiple sites in the heart
- Invades tissue adjacent to myocardial origin
- Can be in pericardium and can replace valvular tissue - Distal metastatic sites:
* Lungs
* Liver
* Skeleton
Think of a skeleton rabbit**
Think.. invade and replace
38
differences between fibroma and fibrosarcoma
FIBROMA
- Unencapsulated
- Well circumscribed
- Benign tumors
- Intramural origin
- Usually arise from LV free wall or IVS
- Can extend into chamber and cause inflow or outflow obstruction
MAJOR TAKEAWAYS... BENIGN AND INTRAMURAL
FIBROSARCOMA
- Can be RV/LV origin
- 50% or half (1/2) of cases get large enough to obstruct blood flow - Can obstruct IVC or pulmonary veins
- Thrombus can form when obstruction occurs
- Pericardium can be involved
MAJOR TAKEAWAYS: Ventricular origin, can lead to thrombus, Pericardium involvement
39
Fibroma can cause
- Cardiomegaly
- Arrhythmias
- Outflow tract obstruction - CHF
- Sudden death
* Usually from involvement of conduction system
(Because of location of these tumors, INTRAMURAL - u can deduce)
40
*I am the Most likely of ALL tumors to cause a PERICARDIAL EFFUSION
Hemangioma
41
Hemangioma... could you describe some key points about me? I can be quite mysterious.
- Vascular tumor
- Can be found in any chamber
- Can be intramyocardial or intracavitary
- Usually on RIGHT side of heart
- Usually discrete masses smaller than 3 cm
- Some can get large and impede blood flow
- Can spontaneously resolve
- Most likely of all tumors to be accompanied by a PE (Pericardial Effusion)\ - May have:
* Lakes
* Channels
* Highly vascular
The highly vascular nature of tumor… is that why it os most common with PE
Think… “Hemangioma Lake”
42
Teratoma. What am I made of and where am I usually found?
Contain all 3 germ cell layers. May contain skeletal/nerve/connective tissue.
Usu in children and in either RA, RV, and septum
43
Secondary tumors aka _______. We are more common than _________.
aka METASTATIC
more common than PRIMARY tumors
44
Most common tumors to spread to the heart are
secondary (metastatic tumors) found @
- lung
- breast
- lymphoma
- leukemia
- malignant melanoma
45
Mets is spread in a few different ways:
- Mets is spread by:
- Direct extension:
* Lung carcinoma
* Extension of ovarian or testicular cancer up venous system, along IVC, into RA
- Lymphatic or circulatory:
* Melanoma * Lymphoma * Leukemia
46
When secondary tumors metastasize they usu do what
spread to multiple locations in heart
47
Describe clinical manifestations of metastatic tumors (7) what is the most common manifestation?
* Clinical manifestations of cardiac involvement centers on either pericardium, myocardium, or
external cardiac compression
* Manifestations include:
* PE( most common) pericardial effusion * Tamponade (most common)
* Tachyarrhythmias
* AVblock
* Thromboembolism
* Hemodynamic obstruction * CHF
48
Describe some differentials for metastatic tumors? (4)
- fibrin strands
- thickened, consolidated effusions
- thrombus formation
- radiation induced pericarditis
49
Extracardiac masses can arise from ______ due to ______.
Can arise from mediastinum or pleura from
* Lung cancer
* Hematomas
* Thymomas (thyroid)
* Cysts
* Metastasis
50
Can you name the most common benign tumor of the pericardium?
Percardial cyst
51
Most common benign tumor the pericardium... where am I usu located and where might I also be located?
pericardial cyst
-
- - Usually along the right costophrenic angle
- May less commonly be in:
* Left costophrenic angle
* Upper mediastinum
* Hila or left cardiac border
52
Could you name some symptoms of pericardial cysts?
* Usually asymptomatic
* Dyspnea
* Tachycardia * Arrhythmias * Chest pain
* Cough
Think: compression... its a cyst pushing on the pericardium.. what could happen?
53
There are a few differentials for pericardial cysts... could you name them?
- pericardial diverticulum
* Outpouching of pericardium creating a fold that can fill with fluid
* Diverticulum moves or swing with changes in body position, cysts do not - Located pericardial effusion
- Dilated coronary sinus
- Ventricular pseudoaneurysm
54
What is the treatment for a pericardial cyst?
* Cysts can be drained if symptoms occur
* Drained during thorascopy which is minimally invasive
* Alternative is a thoracotomy which requires anesthesia and is not as desirable
55
We are normal variants within the heart that can be confused with a cardiac mass. They call us:
False Positive Cardiac Masses
Can be congenital or normal structures that PERSIST or are PROMINENT such as:
- chiari network
- eustachian valve
- thebesian valve
- pectinate muscle
- muscular ridge
- prominent moderator band
- false tendons
- manufactured objects (pacemaker, defibrillator wires, infusion catheters)
56
Could you describe and talk about the eustachian valve
* Help direct blood across foramen ovals to LA in fetus
* Valve of IVC
* Extend from inferior lateral wall of RA to posterior portion of fossa ovals * Usually regresses during childhood
* Usually vestigial and small, size and shape - can vary considerable in adults * If seen is usually an incidental finding
- May be:
* Absent
* Present as thin ridge
* Crescent fold of tissue coming from anterior rim of IVC
* May be rigid or slightly mobile
* Can be elongated and mobile, projecting several cm into the RA
57
could you talk about the chiari network
* Embryologic remnant from incomplete resorption of the rt sinus venous valve that
persists
* Lace-like strands or fenestrated membrane with variable attachments to
- Crista terminali
- Thebesian valve
- Upper region of RA
- IAS
- “Floor” of RA in the region of the opening of the coronary sinus
* Rarely associated with: - Thrombus formation - Embolus entrapment - Arrhythmias
- Tumor development
- Catheter entrapment
- Infection
- Entanglement of atrial septal occlude device
58
Difference with chiari network in comparison to eustachian valve (5)
* Chiari is more extensive than EV (more into the RA)
* Attaches to 2 or more regions
* Fenestrated or net-like (spaghetti)
* No clinical significance
* Important to differentiate from RA mass just like EV (eustachian valve)
59
Could you talk about the thebesian valve? it is remnants of what?
*Thebesian valve
* Remnants of right venous valve * Thebesian valve
- In region of coronary sinus as it enters RA
60
Could you talk about pectinate muscle?
*Pectinate muscle
* Course along endocardial surfaces of both atria and appendages
* Usu only seen on TEE
* When prominent they protrude into LAA lumen and mimic thrombus * May differentiate from thrombus by:
- Lack of mobility independent of atrial wall (move with it) - Small and linear
- Usu have multiple, parallel ridge like appearance:
* Ie teeth of comb
****caution, when you end up assisting in a TEE don't be a dumbass and assume that there is a thrombus, know that it could very well be pectinate muscle
61
Could you talk about the muscular ridge?
*Muscular ridge
* Muscular ridge between LAA and LUPV
* Ridge is composed of cardiac muscle with endocardial tissue covering it * If prominent, can resemble mass mistaken of tumor or thrombus
* Often has “matchstick” or “Q-tip” appearance
62
Could you talk about some more structures mistaken for masses?
- False tendons or ectopic chordae
- RA wall with prominent trabeculations
- Atrial appendage along with pectinate muscle
- Muscular ridge
- Moderator band
- Caseous calcification of the mitral valve annulus - False tendons in ventricle
* Can extend from septum to lateral, anterior, or inferior wall, or parallel along the same wall * Can appear similar to chordae
* Check for flow obstruction
* Considered coincidental finding
63
# "Toothpaste"
What is caseous MAC?
- Caseous calcification of the mitral valve annulus
- Rare variant of MAC
- There is central liquefaction necrosis of the MAC - Incidental finding
## Footnote
CMAC is composed of a liquefied mixture of calcium, cholesterol, and fatty acids, which explains the central echolucency on transthoracic echocardiography/transesophageal echocardiography and the central hypodensity in CT imaging (6); it is therefore also known as a “toothpaste-like” tumor among surgeons because of its similar consistency
https://www.sciencedirect.com/science/article/pii/S266608492031192X
64
With manufactured objects, identifying can be easier with this giveaway
- Usually the object will create reverberations which will help distinguish it
( Easily identified, Take a good history, Course through the heart needs to be documented)
65
Definitive diagnoses can be made with a
biopsy
A "bio-tome" is used to harvest the tissue
66
Echo appearance of myxoma
Usually pedunculate with fibrovascular stalk. 75% in LA. 18% in RA. Round/oval. Smooth, well defined border. Can have hemorrhage within tumor (distinguishes it from veggie or thrombus)
peduncle is like a barnacle....stalk that attaches to something
67
Echo appearance of lipoma
Well defined, homogeneous, dense, mass is within myocardium or extending from endocardial or epicardial region
68
Echo appearance of lipomatous hypertrophy of IAS
Classic dumbbell shape, homogenous, echo dense, septal thickness usually 15-20mm, cephalic portion usually thicker than caudal portion. Fat accumulation often extends to atrial wall and occasionally the IVS
think..."dumbell shape" is STRONG... aka hypertrophy... when a muscle hypertrophies it is getting stronger... need dumbell's to get stronger... LOL
69
Echo appearance of TV fatty infiltrate
Tends to be triangular in shape. Base of anterior TV leaflet comes off apex of triangular “mass”
70
Echo appearance of papillary fibroelastoma
Frond-like (gives it a shimmering appearance on echo). Usually <1cm, can be up to 4cm. Attached by simple stalk. Can arise from any endocardial surface. Highly mobile. Hard to differentiate from veggies. More often found on downstream side of valve (unlike veggies) - Lv side of MV and Ao side of AoV. Small, round, dense, highly mobil mass extending from endocardial surface. Moves rapidly as valve opens and closes. In some cases thrombus can superimpose on tumor and cause embolic events. BEST SEEN WITH TEE. Differential: could be Lambl’s excrescence (more wispy/ fibrolinear)
this is the with 6 freaking different names.... just think.... it's got so many names for it and all this info about it. must be important!
71
Echo appearance of angiosarcoma
Poorly defined mass. Regions of increase echo density. Often found in pericardium.
72
Echo appearance of rhabdomyoma
Solid, echodense mass extending into LV
Sometimes intramural tumors can extend into chamber cavity. Blood flow typically impeded. Tumors can recede over time. May need surgical resection usu w/ flow obstruction
72
Echo appearance of rhabdomyosarcoma
Solid, echo dense mass, irregular borders, multiple sites
73
echo appearance of fibroma
Large mass within the IVS (usu). May appear highly refactile or hyper-reflective (so dense. It’s attenuating sound beam - shadowing
74
echo appearance of fibrosarcoma
“Fish flesh” appearance. Areas of hemorrhage and necrosis. Can differentiate from fibroma because fibrosarcoma invades surrounding tissue, especially the pericardium
75
echo appearance of hemangioma
Single sessile mass. Nonhomogeneous. PE (pericardium effusion) can help differentiate from rhabdomyoma. With contrast hemangiomas will actually take up contrast on echo evaluation
76
echo appearance of teratoma
Well defined mass. Varying echodensities
77
echo appearance of metastatic tumors and differentials
Pericardial involvement. Mass on parietal or visceral surface. With or without pericardial effusion. May encircle heart and obliterate pericardial space. Differential: fibrin strands, thickened, consolidated effusions, thrombus formation, radiation induced pericarditis
78
echo appearance of extracardiac masses
Echolucent, echodense, any size, anterior or posterior to heart, accurate diagnosis is limited
79
echo appearance of pericardial cysts
Well circumscribed, echolucent, extends from pericardium, adjacent to cardiac chamber. Differential: pericardial diverticulum (out pouching of pericardium creating a fold that can fill with fluid, diverticulum moves/swings with changes in body positions, cysts do not)
80
echo appearance of chiari network
Long, thin, sometimes curvilinear, highly mobile, variable insertion sites
81
echo appearance of pectinate muscle
Lack of mobility independent of atrial wall (move with it). Small and linear. Usu have multiple, parallel ridge like appearance
82
echo appearance of muscular ridge
If prominent, can resemble mass mistaken of tumor or thrombus. Often has “matchstick” or “Q-tip” appearance
83
echo appearance of caseous MAC
Large, round echo dense mass in periannular region with clear, central, echolucent zone. Absence of shadowing differentiates it from classic MAC. May be mistaken for myocardial abscess or tumor
84
PE can help differentiate this from a rhabdomyoma
hemangioma
