Cardiac Masses

7/30/2019 Cardiac Masses

1/77

CARDIAC MASSES

Nick Tehrani, MD


2/77

Outline

General

Primary Cardiac tumorsBenign

Malignant

Secondary Cardiac TumorsBenign

Malignant

Q U I Z TIME


3/77

General

Neoplasia of the heartor pericardiumis more likely to be:

Secondary, than

Primary


4/77

General

Primary tumors


5/77

GeneralPresentation:

Embolization

SystemicPulmonary (less common)

Obstruction

Arrhythmia

TamponadeDirect compression of coronary artery

Intramyocardial

Conduction disturbances

Global dysfunction due to infiltration


6/77

What is this?


7/77

Potential Pitfalls

Reverberation artifactChange depthand gain

Hiatal hernia

Fills the Rt. Or Lt. AtriumDrink Pepsi


8/77

Normal Anatomic Variants

Crista terminalis

Normal anatomic ridgeEustatian valve

Attaches to the anterior lip of the IVC

Post transplant suture lines

All kinds of funny masses

Intraoperative inversion of the Lt atrialappendage


9/77

Anatomy

Crista

Eustatian V.


10/77

What is this?


11/77

Outline

General



12/77

Primary Cardiac Tumors

BenignMyxoma

Papillary fibroelastoma

Fibroma

Lipoma

Rhabdomyomas


13/77

BenignPrimary Cardiac Tumors

The most common primary cardiactumor in the Age > 35

75% in the Lt. Atrium near fossa ovalis

15% Rt. Atrium

5-10% Lt. Ventricle

5% multiple sites Will discuss further

Myxomas:


14/77

Benign Primary Cardiac Tumors

Grossly

Typically pedunculated

Gelatinous consistency

Friable

Histologically

Copious mucopolysaccharide stroma

Scattered solitary or clustered polygonal

cells.

Myxomas:


15/77

Left atrial Myxoma


16/77


Extra cardiac manifestations suggestive ofCollagen Vascular dz:

Fever

ESR elevation

Anemia

Thrombocythemia

Circulating autoantibodies

Myxomas:


17/77


Etiology of immunologic manifestations

? ? ?

? Tumor necrosisAnitimyocardial antibody titers declinepost resection

Myxomas:


18/77


High propensity for embolization

Surgical results excellent

Decision to operate:

Lt. versus Rt. Sided tumor

Sx.

Age

Co morbidities

Managementof Myxomas:


19/77


Familial pattern of Myxomas with

autosomal dominant featuresAge < 30

Bad actor

Any guesses?

Carney Complex


20/77


Carney Complex:

Multiple lentigines and blue nevi

Peripheral myxoid tumors (cutaneous myxoma,myxoid mamary fibroadenoma)

Psamommatous melanotic schwannoma

Endocrine over activity (Cushings syndrome,pituitary adenomas, testicular Sertoli celltumors)

Multiple recurrent cardiac masses


21/77


Carney Complex:

Genes located on chromosomes

2p

17q2

Family members should be screenedwhen an index case is identified


22/77


Benign

Myxoma



23/77


The most common valvular tumor,followed by

Sarcoma

MelanomaPresent in all age groups, but mostcommonly in Age>60

Papillary Fibroelastoma:(aka Papilloma)


24/77


Small tumors (


25/77


Adults Aortic valve

Children Tricuspid valveRarely on endocardial surfaces

Symptomatic only in the aortic position (otherthan embolic Sx)

Ostial occlusion angina, sudden death

Rarely valvular dysfunction

Source of embolization in up to 30% of

patients

Papillary Fibroelastoma:


26/77


Surgical resection is not uniformly necessary

Anticoagulation may be sufficient in manypatients

Surgery indicated for

Embolic eventsOstial occlusionTopol Textbook of Cardiovascular Medicine

All fibroelastomas, any size, any age are to be

resected Seward, ACC 2000

Management ofPapillary Fibroelastoma


27/77


Benign

Myxoma


Fibroma


28/77


Encapsulated, solitary tumors

Frequently in the septal myocardium

Often encroach on the conductionsystem as they grow

Fibromas:


29/77


With septal involvement V.Fib is oftenthe first presentation

Indications for surgical resection:

Mechanical problems due to sizeArrhythmogenic nidus

Resection of septal fibromas is notalways possible

Fibromas:


30/77


Lipomas:

Affect both myocardium andpericardium

Can reach several centimeters in size


31/77


Rhabdomyoma:

Most common tumor of the heart forAge < 30 yo

Almost exclusively in children

Associated with tuberous sclerosis

Regression of tumor in infancy hasbeen reported


32/77

Outline

GeneralPrimary Cardiac tumors

Benign

Malignant


33/77

Malignant Primary Cardiac Tumors

AngiosarcomasRhabdomyosarcomas

Mesotheliomas

LymphomaIntrapericardial Pheochromocytomas


34/77


Most common primary malignancy of the heart

Malignant cells that form vascular channels

Most commonly affect the

Rt. HeartRt. Atrium

PericardiumHemorrhagic effusion

Thrombus

Angiosarcomas:


35/77


Diffuse, irregularly shaped

Mean survival one year

Successful Rx with Chemo and XRTfollowed by transplant reported

Angiosarcomas:


36/77


Most commonly seen in adults

No chamber selectivity

No pericardial involvement

Multiple sites of cardiac involvement is

commonPoor prognosis

Limited success with resection andadjuvant Rx.

Rhabdomyosarcomas:


37/77

Undifferentiated Sarcoma


38/77


Diffuse pericardial tumor

Involve both parietal and visceralpericardium

Superficially invade the myocardium

Rarely invade the cardiac chambers

Mesotheliomas:


39/77


Sx of pericarditis or tamponade

Poor prognosis

XTR or chemo only offer temporaryimprovement

Mesotheliomas:


40/77


Lymphoma:Heart and pericardium are the onlyaffected organs

No predilection for any particular site


41/77


Soft, fleshy, highly vascular

Anatomic location

AV groove

Atrium

Interatrial septumCoronary, Pulmonary, Aorticopulmonaryregions

Generally very difficult to resect

Intrapericardial Pheochromocytomas:


42/77


Generalizations:

Pulmonary vein mass Malignancy

Lateral wall of the LA Malignancy

Atrial septum Myxoma


43/77

Outline

General

Primary Cardiac tumors

Benign

Malignant

Secondary Cardiac Tumors

Malignant


44/77

MalignantSecondary Cardiac Tumors

Incidenceof Solid Tumors involving the heart:

LungBreast

Soft tissue sarcomas

Renal carcinomaMelanoma

Leukemia and Lymphomas also common culprits


45/77


46/77

What is this?


47/77

MalignantSecondary Cardiac Tumors

IVC tumors in General

Renal carcinoma

80% 5 year survival for surgicalresection of tumors migrating up

the IVCHepatoma

Ovarian CA


48/77

Outline

General


Malignant

Secondary Cardiac TumorsMalignant

Benign


49/77

BenignSecondary Cardiac Tumors

Hints:

IVC tumor

Long stringy appearance

Seen many years post hysterectomy

LEIOMYOMATOSIS


50/77

BenignSecondary Cardiac Tumors

Akin to FibroidsControlled by hormone suppression

Can degenerate into very low gradesarcoma

Histologically, similar structures arepresent in the venous channels of the

uterus

Leiomyomatosis:


51/77

HIVand cardiac tumorsKaposis sarcoma can involve themyocardium or pericardium

Non-Hodgkin's lymphoma

Can present as primary cardiaclymphoma

When involving the heart usuallydiffusely infiltrative

Variable results with chemo and XRT


52/77

Another Benign Secondary

CardiacTumor


53/77

How about this one?


54/77

APICAL MASSES

Differential Dx for Apical Masses

Thrombus

Leoflers

Endomyocardial fibrosis (seen intropics)

NL Wall Motion


55/77

Outline

General

Primary Cardiac tumors

Benign

Malignant

Secondary Cardiac Tumors

Malignant

Benign

Surgical Options


56/77

Surgical Options


Rare entity,


57/77

Surgical Options

If surgical resection is contemplated,thorough metastatic evaluation is necessary:

CT

Head

Chest

AbdBone scan if indicated

Bone marrow Bx if indicated


58/77

Surgical Options

Total of 28 patients have undergoneorthotopic heart transplantation for

inoperable primary cardiac tumors:

7 had benign histology

Mean survival of 46 months21 had malignant histology

Mean survival 12 months


59/77

SurgicalOptions

OF the 7 with benign histology

Fibroma 5 patients

Rhabdomyoma 1

Pheochromocytoma 1

Survival range: 8 to 105 months

Survival mean: 46 months

No patients had recurrence of tumor

Two deaths due to rejection


60/77

Surgical Options

OFthe 21 with malignant histologySarcoma 15

Malignant fibrohistiocytoma 3Lymphoma 3

14/21 died between 1 and 36 months(mean 12 months)

13/14 died of recurrent mets

1/14 cause of death unknown

7 others; follow up 6 66 months

one had recurrence malignancy


61/77

Surgical Options

OHT is promising for patientswith unresectable benign

neoplasias


62/77

Surgical Options

Malignant primary cardiac neoplasms

not routinely considered for OHT dueto:

Concern for tumor recurrence

Immunosuppression stimulation oftumor growth


63/77

SurgicalOptions

Patients with Primary malignant neoplasiasneed to be assessed on a case by case basis

due to:Limited experience

Heterogeneous nature of the malignancies

Yet to be defined, role of:Adjuvant chemo

10/21 had received chemo

XRT


64/77

Q U I Z TIME


65/77

Any Guesses??


66/77

The answer Is

Ruptured Papillary Muscle Abcess

Inflamatory tissue


67/77

Any Guesses??


68/77

The answer Is

Non-specific Inflamatory Tissue


69/77

What is this?


70/77

PE in Transit across PFO


71/77

What is this?


72/77

Hiatal Hernia


73/77

What is this?


74/77

Mediastinal Lymph node


75/77


76/77

Myxoma with recent thrombosis


77/77

What do you really see here?

Cardiac Masses

Documents

Transcript of Cardiac Masses