Assessment of cardiac masses: magnetic resonance imaging versus transthoracic echocardiography/Kardiyak kitleleri degerlendirmede manyetik rezonans ve transtorasik ekokardiyografinin karsilaslirimasi.
Objective: The purpose of this study is to compare the role of magnetic resonance imaging (MRI) with transthoracic echocardiography (TTE) for characterization of cardiac masses.
Methods: Twenty-three patients were examined with a 1.5T MRI Scanner and TTE for the evaluation of suspected intracardiac masses. MRI examinations were performed with a protocol of steady cine imaging, HASTE and 3D IR-FLASH sequence after administration of gadolinium chelate. All patients were examined with MRI within a period of 1-2 weeks after TTE.
Results: According to the results of MRI, 15 patients underwent cardiac surgery. All of the operated patients were proven to have cardiac tumors with no false positive diagnosis on MRI. In 3 of 8 unoperated patients who were diagnosed to have cardiac tumors on TTE, cardiac thrombi were identified on MRI. Two patients with Eustachian valve in the right atrium on MRI were misinterpreted as having cardiac masses on TTE. In one patient with known renal cancer, metastases were diagnosed within the myocardium on MRI. TTE demonstrated a mass in the left atrium in one patient with a history of myxoma operation, whereas MRI was able to show the paracardiac extension of the mass into pulmonary veins and lung metastases, which are indicators of malignant transformation. In one patient, a mediastinal mass compressing the left atrium on MRI was misinterpreted as an intracavitary lesion with TTE.
Conclusion: Contrast enhanced MRI is a noninvasive method superior to TTE in diagnosis, differentiation, and detection of extension of cardiac masses. (Anadolu Kardiyol Derg 2010; 10:69-74)
Keywords: Transthoracic echocardiography, cardiac tumor, thrombus, pulmonary vein, magnetic resonance imaging, diagnostic value of tests
Amac: Bu calicmanm amaci kardiyak kitleleri karakterize etmede transtorasik ekokardiyografi (TTE) ve manyetik rezonans (MR) tetkiklerini karsjlastirmaktir.
Yontemler: Kardiyak kitle Seuphesi olan 23 hasta TTE ve takiben 1.5 Tesla MR cihazi ile incelendi. Manyetik rezonans tetkiki steady cine incelemesi, HASTE, gadolinium verilmesini takiben 3D FLASH IR sekanslari ile gerceklestirildi. Transtorasik ekokardiyografiyi takiben 1-2 nafta icerisinde tum hastalara MR tetkiki uygulandi.
Bulgular: Manyetik rezonans incelemesi sonuclanna gore 15 hasta opere edildi. Tum opere hastalarda kardiyak tumor saptandi ve MR incelemesine ait yalanci pozitif bulgu tespit edilmedi. Opere edilmeyen 8 hastanm 3'une TTE'de kardiyak tumor tanisi konurken MR incelemesinde lezyonlarm trombus olduklan belirlendi. iki hastada da ekokardiyografide sag atriyumda kitle tarif edilirken lezyonlarm MR incelemesinde ostaki kapakcigi oldugu izlendi. Renal hucreli kanser oykusu olan bir hastada ise miyokardiyal metastazlar MR tetkiki ile goruldu. Miksoma hikayesi olan bir hastada sol atriyumda kitle saptanirken MR incelemesinde kitlenin malign transformasyona icaret eden pulmoner venlere parakardiyak uzanimi ve akciger metastazlan tespit edildi. Bir hastada ise TTE'de izlenen sol atriyum kitlesinin sol atriyuma basi yapan mediastinal kitle oldugu goruldu.
Sonuc: Kontrastli MR incelemesi kardiyak kitlelerin tani, karakterizasyonu ve uzanimlarimn saptanmasinda TTE'ye gore ustun noninvazif goruntuleme yontemidir. (Anadolu Kardiyol Derg 2010; 10:69-74)
Anahtar kelimeler: Transtorasik ekokardiyografi, kardiyak tumor, trombus, pulmoner ven, manyetik rezonans goruntuleme, testlerin tanisal degeri
Primary cardiac tumors are rare, with an incidence of 0.0010.003% in autopsy series (1, 2). Benign cardiac tumors are most common, accounting for 80% of all primary cardiac tumors. The most frequent benign cardiac neoplasm is myxoma, followed by lipoma, papillary fibroelastoma and hemangioma (3).
Transthoracic echocardiography (TTE) is the primary modality for imaging of cardiac tumors with high sensitivity and specificity (4). Two-dimensional (2D) echocardiography detects tumor sizes and exact localization, whereas Doppler technique is used to measure the flow of blood through heart chambers and assess hemodynamic effects of cardiac tumors such as valvular stenosis, insufficiency and blood flow value changes. Obesity, narrow rib spaces, and pulmonary diseases (emphysema or chronic obstructive pulmonary disease) limit the ability to obtain satisfactory images of heart chambers (2, 5, 6).
Magnetic resonance imaging (MRI) shows the localization of cardiac masses and also provides information on the extension of tumor within cardiac chambers and outside the heart, due to its wide field of view; including the pericardium, great vessels, adjacent mediastinal and pulmonary structures (1). Gated--cineloop images show the pathophysiological effects of cardiac tumors on cardiac valves (5). Additionally, MRI permits increased specificity for the evaluation of tissue characteristics such as hemorrhage, calcification, cystic necrosis, which commonly present in the stroma of these tumors and helps to differentiate them from thrombi. Beyond tumor characterization, MRI confirms the diagnosis through the addition of contrast material, which helps to distinguish the tumor from the myocardium, thrombi and blood flow artifacts (5, 7).
In this study, TTE and MRI were compared in terms of the localization, characterization and extension of cardiac tumors.
Twenty-three patients (12 men, 11 women; age range 7-81 years, median 58.8 years) who were diagnosed with cardiac tumor on TTE were enrolled in this study. Local ethical committee approval and informed consent were obtained. These patients were studied by cardiac gated MRI within a week of TTE for the comparison of two modalities. Records of all patients were reviewed retrospectively. Patients were referred to our institution because of symptoms including arrhythmia, angina pectoris, pulmonary embolism, arthralgia, weight loss and anemia.
Twelve patients were examined with 1.5 Tesla System MR Scanner (Philips Intera Achieva; Philips Medical Systems, Netherlands) with cardiac gated steady-state precession sequence (TR/TE/flip angle-3,5/1,7/60) with slice thickness of 8 mm. Eleven patients were examined with 1.5 Tesla scanner (Magnetom Sonata; Siemens Medical Solutions, Erlangen, Germany) with a protocol of steady-state precession sequence cine imaging (true FISR TR 3 ms, TE 1.5 ms, FA 65 degrees) in standard shortand long-axis orientation, HASTE (half Fourier acquisition single shot turbo spin-echo; TR/TE/FA 700/23ms/160 degrees) and 3D IR-FLASH sequence with fat suppression (TR 4 ms, TE 1.5 ms, FA 10 degrees; TI 300 ms) after administration of gadolinium chelate. Contrast-enhanced imaging was performed after administration of 0.2 mmol/kg gadolonium diethylene triamine pentaacetic acid (Magnevist; Schering, Berlin, Germany) with a flow rate of 2 mL/ sec. The studies were electrocardiographically gated and all patients in this study were in sinus rhythm during examination.
Echocardiographic examination was performed in all study patients by using a commercially available system (Acuson Sequa S12 Machine with a 3-Mhz transducer, Siemens, Mountain View, CA, USA). Measurements were made during normal breathing at the end of expiration. Echocardiographic measurements were obtained on the basis of the standards of the American Society of Echocardiography. The localization and extension of cardiac tumors were noted and the sizes of tumors were measured.
Statistical analysis was performed with NCCS 2007 &PASS 2008 Statistical Software (Utah, USA) using Mc Nemar test and Cohen Kappa test for comparison of the results of echocardiography and MRI findings with final diagnosis. The p values were regarded as significant when <0.05.
Cardiac masses cause various symptoms related to their size, localization and extension. Patients describe obstructive cardiac symptoms, constitutional symptoms or embolic events.
In our study, the most common clinical presentation was arrhythmia (ventricular tachycardia in one patient, atrial fibrillation in one patient, and atrial arrhythmia in seven patients). Nine patients with angina pectoris and two patients with a prior history of pulmonary embolism were found to have cardiac tumors on TTE. One patient with cardiac tumor presented with arthralgia, weight loss and anemia. Cardiac masses were also detected during routine follow-up examinations in one patient with renal cell cancer and in another one with aplastic anemia and paroxysmal nocturnal hemoglobinuria (Fig. 1a, b).
On both TTE and MRI, mass lesions were detected in the right atrium in 10 patients, in the left atrium in 2 patients and in the right ventricle in 1 patient. Tumors were found to be attached to the mitral valve in 5 patients, to the aortic valve in 2 patients and within the left ventricular myocardium in 1 patient (Fig. 2-5). MRI proved to supply diagnostic information in 2 patients with suboptimal echocardiography. TTE misdiagnosed thrombi in 3 patients and anatomic variations such as Eustachian valve in 2 patients as cardiac tumors. In one patient with known renal cancer, metastases were diagnosed within the myocardium on MRI, but not on TTE. A 46-year-old woman with a prior surgical history for myxoma of the left atrium demonstrated a huge mass (7x5 cm) in the left atrium on TTE. MRI showed extension to lateral and superior atrial walls as well as to pulmonary veins, thus causing occlusion, all of which were indicators of malignant transformation of the previously operated myxoma. One patient diagnosed with an intracavitary mass in the left atrium on TTE was shown to have an extracardiac tumor in the mediastinum with compression of the left atrium on MRI (Fig. 6). Table 1 summarizes TTE, MRI findings and final diagnoses of all patients.
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Comparison of results of echocardiography and MRI in terms of the diagnosis of cardiac tumors demonstrated that the diagnostic value of MRI was significantly higher than of transthoracic echocardiography (65.2% by echocardiography, Mc-Nemar test: 0.008 and 100% by MRI Mc-Nemar test: 1.000; Cohen Kappa: 1.000).
In this study, results of MRI correlated with the pathological findings in all of the operated 15 patients. Transthoracic echocardiography depicted cardiac masses, whereas MRI was able to characterize the tumors, including even suspicious masses and could differentiate thrombi as well as anatomic variations. In our study, transthoracic echocardiography misinterpreted a Eustachian valve as cardiac mass in one patient and was not able to differentiate thrombi from cardiac masses in 3 patients. Also in a patient with hemangiopericytoma located in the anterior mediastinum the mass was misinterpreted as tumor in the left atrium on TTE. Malignant transformation of atrial myxoma after operation in one patient was identified by MRI by demonstrating extension of the tumor to the lateral and superior walls of the left atrium and occlusive involvement of pulmonary veins.
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2D echocardiography is a routine diagnostic method and plays a significant role in the detection of cardiac tumors, with a sensitivity and specificity of 90% and 95% respectively (8,9). The sensitivity of 2D echocardiography is related to localization, size and sonographic acoustic properties of tumors (8). Shyu et al. (10) reported that TTE may incorrectly identify the fat accumulation on tricuspid valve, hypertrophic moderator band, artifacts around mitral annulus as cardiac masses. Left atrial appendage is difficult to evaluate adequately with echocardiography but it may be better assessed by MRI. Fusion of Eustachian valve may also be misinterpreted as a cardiac mass on TTE (8).
Myxomas are the most common primary cardiac neoplasms, comprising about half of cardiac tumors. Cardiac myxomas typically arise from the interatrial septum from a narrow base of attachment (11). The surface of myxomas is often covered with thrombi, causing a 20-45% incidence of systemic embolus (12).
MRI of myxomas provides the assessment in terms of size, localization and point of attachment of the tumor in multiple planes, thus helps in planning of surgery. Myxomas often have a similar signal intensity relative to the myocardium on T1 -weighted images and high signal intensity on T2-weighted images; however, various intensity patterns have also been described (13). Myxomas were the most frequent tumors in the current study. MRI characteristics were apparently adequate to diagnose the type of tumors in all cases.
Lipomas are the second most frequent benign cardiac tumors after myxomas. Cardiac lipomas are distributed throughout the heart in endocardial, myocardial, epicardial locations; although the majority appear to be subepicardial. At MRI, lipomas have homogeneous increased signal intensity on T1-weighted images that decreases with fat-saturated sequences (13).
Thrombi do not have a specific signal intensity on spin echo MR sequences (11). They usually tend to have a low signal intensity on Tl--and T2-weighted images compared to most cardiac tumors which depict high signal intensity on T2-weighted images (4). Hyperacute thrombi show intermediate signal intensity which limit tumor differentiation (14). Thrombi may be differentiated from myxomas since they do not show contrast enhancement (15). In our study all thrombi were interpreted as mass lesions on echocardiography, however on MRI examination diagnoses were relevant as the lesions did not enhance after contrast administration.
Sarcomas are the second most common primary cardiac tumors after myxomas and are encountered in adults with a mean age of 40 years (5). The most common type of sarcomas are angiosarcomas, frequently involving the right atrium. Other sarcoma types are undifferentiated sarcomas, malignant fibrous histiocytoma and leiomyosarcoma affecting the left atrium (4). These tumors are diagnosed on MRI as heterogeneous invasive masses with hemorrhage, necrosis, valvular destruction, extracardiac invasion and metastases.
Another cardiac tumor type causing embolic events is papillary elastoma accounting for 75% of valvular tumors. Papillary fibroelastomas occur in elderly patients (age range 60 [+ or -] 16 years) and reach sizes of 9 [+ or -] 4 mm over the cardiac valves (16, 17). Embolic events may not originate from the tumor itself but from thrombi accumulating on the tumor mass (2).
Excluding myxomas, a lesion in the right side of the heart is always suspicious of malignancy. Metastases via transvenous invasion are 20-40 times more common than primary malignant cardiac tumors (14). Beyond hematogeneous spread, lymphatic or direct continuous extension to the myocardium or pericardium may also occur. Melanoma has the highest frequency of metastases to the heart of any neoplasm followed by malignant germ cell tumor, leukemia, lymphoma, cancer of the lung and the various sarcomas (18).
Arrhythmia is the most frequent complaint caused by metastatic tumors and suggests involvement of the myocardium, just as it was the case for our patient with renal cell carcinoma.
Lymphomas have a very high frequency of metastases to the heart. Nearly 25% of patients with disseminated lymphoma have cardiac metastases, while primary cardiac lymphoma is very rare.
Typically lymphomas infiltrate the myocardium and pericardium. At MRI they are isointense relative to the myocardium on T1 weighted images and isointense-heterogeneously hyperintense on T2-weighted images; they demonstrate heterogeneous enhancement after administration of gadolinium contrast material (5).
In infants and children, rhabdomyomas should be considered when myocardium thickening is observed. These tumors have a similar signal intensity relative to normal myocardium on T1- and T2-weighted images (5). Spontaneous regression of rhabdomyomas has been reported in 60-100 cases under age 4 (19-21). Cardiac fibromas are the most common benign primary cardiac tumors after rhabdomyoma. Because of their dense, fibrous nature, fibromas appear as isointense or hypointense masses on T1 -weighted images and homogeneous, hypointense on T2-weighted images (22).
The first diagnostic tool for cardiac masses is TTE, which is an efficient method to show the localization, size, extension, hemodynamic effects and vascularization of cardiac tumors. Differentiation of cardiac tumors from thrombi on echocardiography is not always possible (23). MRI provides diagnosis of tumors and their types and also differentiates thrombi. Rarely, mediastinal masses may also be misdiagnosed as cardiac tumors due to external compression of cardiac walls. MRI provided more information compared to echocardiography concerning multiplanar and non-invasive evaluation of cardiac masses, together with their extension to mediastinal structures (24-27).
There are some limitations of this study. Cardiac MRI can depict false-negative or false-positive findings without prior knowledge of the echocardiography results. Respiratory artifacts and frequent arrhythmias result in a lower quality of image. Our study revealed that MRI of cardiac tumors helps us to classify the type of tumors. However, this study has limited number of patients and should be evaluated with larger clinical trials.
In conclusion, although the diagnosis of cardiac tumors relies on transthoracic echocardiography, MRI provides significant data for the diagnosis of cardiac tumors with its superior structural definition as well as its ability to delineate tumor extent and its relationship to adjacent organs. Contrast-enhanced dynamic imaging further supports the diagnosis.
Conflict of interest: None declared
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Burcu Narin, Alper Arman , Deniz Arslan, Masum Simsek, Ahmet Narin 
Department of Radiology, Haydarpasa Numune Education and Research Hospital, Istanbul
 Department of Radiology, Euromed Visualization Center, Istanbul
 Department of Cardiology, Dr. Siyami Ersek Education and Research Hospital, Istanbul, Turkey
Address for Correspondence/Yazrcma Adresi: Burcu Narin MD, Haydarpaca Numune Education and Research Hospital, Department of Radiology, Istanbul, Turkey
Phone: +90 216 542 20 20 E-mail: email@example.com
Accepted/Kabul Tarihi: 09.12.2009
Table 1. Transthoracic echocardiography and MRI findings with final diagnosis of patients Patients Echocardiographic findings MRI findings 1 * Myocardial mass in left Myocardial mass, 2.3x1.9 ventricular apicolateral cm. wall; 1.9x1.8 cm Isointense relative to myocardium on T1 ve T2 weighted images, high homogeneous contrast enhancement 2,3 * Right atrial mass, 1 cm Right atrial mass, 1 cm Hyperintense on T1 weighted images, not easily visible on T2 weighted images and reduction of signal intensity on fat suppressed T1 images, no contrast enhancement 4,5,6 Right atrial mass connected Right atrial mass, 1 cm, to right atrium inferior located at the inferior wall, 1 cm right atrium wall extending to lateral wall Isointense to myocardium on T1 and T2 weighted images, isointense to myocardium after contrast administration 7-10 * Right atrial mass with Right atrial mass, 1 cm, narrow stalk to interatrial connected to interatrial septum, 1 cm septum with thin pedincule Hypointense on T1 and hyperintense on T2 weighted images, contrast enhancement of tumor and pedincule 11 Left atrial mass, arising Left atrial mass, 7 x4.5x5 from lateral wall of left cm, connected to atrium, 7.5 x 4 x 5 cm interatrial septum with extension to lateral and superior wall and to pulmonary veins leading to occlusion. Heterogeneous signal intensity on T1 and T2 weighted images with heterogeneous contrast enhancement Additionally pulmonary metastases were detected 12 * Left ventricular mass Left ventricular mass, 1 arising from the right cm, connected to aortic aortic cusp by a short valve Isointense relative pedicle, 1 cm to myocardium on T1 and hyperintense on T2 weighted images, heterogeneous contrast enhancement 13-17 * Mass arising from mitral Left atrial mass attached valve, 1 cm to mitral valve, 1 cm Hypointense on T1 and hyperintense on T2 weighted images with heterogeneous contrast enhancement 18 * Left ventricular mass Left ventricular mass, 1 arising from aortic valve, cm, broad based, arising 1 cm from aortic valve Hypointense on T1 and hyperintense on T2 weighted images with heterogeneous contrast enhancement 19 Myocardial mass, arising Myocardial mass of left from apicolateral wall of ventricular wall, 4x3 cm LV, 4x3 cm Isointense relative to myocardium on TI ve T2 weighted images, high homogeneous contrast enhancement Moreover lung and bone metastases were identified. 20 Suspect of right atrial and Right atrial and right right ventricular mass ventricular mass attached around tricuspid valve to tricuspid valve Isointense relative to myocardium on T1 and T2 weighted images, no contrast enhancement 21 Suspect of left atrial mass Left atrial mass, 1 cm Hypointense to myocardium on T1 and T2 weighted images, no contrast enhancement 22 Right atrial mass in right Right atrial mass, 3x2.5 cm atrium appendix, 3.2x2.5 cm Isointense to myocardium on T1 and T2 weighted images, no contrast enhancement 23 * Left atrial mass, 3.2x4 cm Mass in anterior mediastinum with external compression to left atrium, 3x4 cm Isointense to myocardium on T1 and hyperintense on T2 weighted images, peripheric contrast enhancement with central necrosis Patients Final Diagnosis 1 * Rhabdomyoma 2,3 * Lipoma 4,5,6 Eustachian valve 7-10 * Myxoma 11 Myxoma with malignant transformation 12 * Aortic valve papillary fibroelastoma 13-17 * Papillary fibroelastoma 18 * Papillary fibroelastoma 19 Metastases 20 Thrombus 21 Thrombus 22 Thrombus 23 * Hemangiopericytoma MR--magnetic resonance Asterisk (*) indicates operated and pathologically proven cases
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|Title Annotation:||Original Investigation/Ozgun Arastirma|
|Author:||Narin, Burcu; Arman, Alper; Arslan, Deniz; Simsek, Masum; Narin, Ahmet|
|Publication:||The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)|
|Date:||Feb 1, 2010|
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