Cardiac Masses: Assessment

Cardiac

Masses:

Assessment

by MR

Imaging

Received August 15, 1988; accepted after

revi-sion October 12, 1988.

Presented at the annual meeting of the American

Roentgen Ray Society, San Francisco, May 1988.

Department of Diagnostic Radiology, Mayo

Clinic and Foundation, Rochester, MN 55905.

Ad-dress reprint requests to A. L. Ehman.

2Divis of Cardiology and Internal Medicine,

Mayo Clinic and Foundation, Rochester, MN 55905.

AJR 152:469-473, March 1989

0361 -803x/89/1 523-469

© American Roentgen Ray Society

The purpose of this study was to assess the role of MR imaging for evaluating suspected cardiac tumors or paracardiac masses involving the heart. Sixty-one patients with clinical or radiologic evidence of cardiac masses were imaged with ECG-gated MR at 1.5 T (22 patients) or 0.15 T (39 patients). Fifty-one patients had echocardiography previously. Among the tissue diagnoses were myxoma (six); fibroma, rhabdomyoma, plasma cell granuloma, lipomatous hypertrophy of the atrial septum, mesothelioma, and thymoma (two each); and leiomyosarcoma, lymphoma, metastatic carcinold, melanoma, malignant fibrous histiocytoma, hemangiopericytoma, and lung spindle cell sarcoma (one each). MR imaging demonstrated masses in 50 patients (82%); they were centered

in the heart in 32, pencardial in nine, and juxtacardiac in nine. MR imaging provided

diagnostic information that affected clinical management or surgical planning in 53 patients (87%), including 11 (18%) in whom cardiac mass was excluded by MR.

The ability to provide a global view of cardiac anatomy and other unique capabilities

of MR imaging give the procedure an important role in the diagnosis and preoperative

assessment of cardiac masses.

At present, echocardiography is the most important noninvasive technique for imaging the heart [1 -7]. Generally, it is the initial imaging procedure used.

Never-theless, certain of the inherent advantages of MR imaging suggest that the technique has an important role in cardiac imaging [2, 8, 9]. These include the ability to provide high contrast between flowing blood and soft tissue and to allow imaging of the heart in any plane [2, 7-9].

The objective of this study was to assess the role of MR imaging for evaluation

of patients with cardiac tumors and to determine how MR imaging can contribute

to their management.

Materials and Methods

Between September 1983 and May 1987, 61 patients with suspected cardiac masses

seen at the Mayo Clinic were examined with MR imaging. The 32 male and 29 female patients

were 3 months to 82 years old (mean, 51 years). Insome cases, patients had MR because

a cardiac tumor was suspected on the basis of the history and physical examination, but in

the great majority, MR was performed to confirm and evaluate masses initially recognized by CT or two-dimensionalechocardiography. Two-dimensionalechocardiography was performed

in 51 patients; CT was performed in 25. In three patients, two with myxomas and one with

metastatic melanoma, the lesion was detected during coronary angiography and

ventnculog-raphy. Forty-three patients had chest radiographs, of which 14 showed a cardiac mass or

mass adjacent to the heart. In many patients, two or more imaging procedures had been

performed before referralforMA imaging.

Cardiac MR imaging was performed in the 61 patients with the spin-echo technique and

cardiac gating. Twenty-two patients were imaged on a 1 .5-T Signa machine (General Electric,

Milwaukee, WI) with a TE of 20-25 msec, a TA that was ECG-gated to every beat, a section

thickness of 0.5-1.0 cm, 256 views, two signal averages, a field of view of 32-48 cm, and

the spatial presaturation technique [10]. Thirty-nine patients were imaged on a0.1 5-T Picker

Fig. 1.-Cardiac mass. MR image (TE = 35

msec) showslarge mass involving left ventricular

wall, which contains Innumerable tortuous vessels (arrow). This appearance was considered diag-nostic of arterlovenous malformation.

Fig. 2.-Unresectable pericardlal meso- Fig. 3.-Juxtacardiac mass. MR image (TE =

thelloma. MR image (TE =35 msec) shows per- 25 ms.c) shows mass is pericardlal fat. Note

Icardlal mesothelloma with extensive involve- that fat isseparated from heart by thin,

hypoln-ment of right atrial and ventricular walls (white tense line representing pericardium (arrow). arrow) and hepatic metastases (black arrows).

470 LUND ET AL. AJR:152, March 1989

machine (Picker, Cleveland, OH) with a TE of 30-40 msec, a TA that

was ECG-gated to every beat, a section thickness of 0.5-1 .0 cm,

1 28 views, four signal averages, and a 40-cm field of view. The

examinations were tailored to the particular clinical question in each

case on the basis of the prior clinical, laboratory, and imaging results.

Transaxial sections were obtained in all examinations, followed by

sagittal (16 examinations), coronal (1 3 examinations), or both (32

examinations) planes as indicated.

The initial interpretation of the MR studies was performed by one of three radiologists with full knowledge of the patients’ clinical and

prior imaging findings. The examinations were reevaluated by two

radiologists. Available at this second evaluation was information

compiled about each patient’s clinical presentation, initial diagnostic

workup, surgical procedure, clinical outcome, and follow-up when

possible. To assess the impact of the MA examination on patient

management, we reviewed the notes in the patient’s record to

determine the diagnosis before and after the MA examination.

Spe-cific information sought was as follows: (1) Did the MA examination

alter management by confirming or excluding a mass? (2) Did MA

imaging substantially contribute to the decision-making process by

further defining anatomy and tumor extent? (3) Did MA influence the

decision to operate on the patient and/or the surgical approach? (4)

Did MA obviate further clinical workup?

Results

Eleven (18%) of the 61 patients had normal MR examina-tions. In 10 of the ii, a mass suspected by echocardiography was excluded by MR. A suspected cardiac mass in one of these patients was shown to be a prominent fusion of the thebesian and eustachian valves. In the eleventh patient, a mass or absent pericardium had been suggested on

echo-cardiography, but MR showed a normal pericardium and

excluded a mass. One-year follow-up echocardiographic ex-aminations in two patients and MR examination in one of these were both negative. The other nine patients have not had follow-up studies.

MR studies were positive in 50 (82%) of the 61 patients.

Thirty-two had myocardial or intraluminal masses (Fig. 1); nine

masses were pericardial (Fig. 2), with or without myocardial involvement. Nine masses were adjacent to the heart without involvement of either the pericardium or myocardium (Fig. 3).

Tissue diagnoses included benign and malignant lesions, both primary and metastatic, and thrombus, both bland and tumorous. Lipomatous hypertrophy of the atrial septum in two patients was clearly shown on MR. Three patients had mural thrombi and two had tumor thrombus due to hyperne-phroma extension. The tumorous thrombi were easily identi-fled but the mural thrombi were difficult to differentiate from intraluminal flow artifacts. Of the remaining 25 cardiac masses, 10 were malignant and 1 5 benign. Eight of the malignant cardiac masses were metastatic, including mela-noma, carcinoid, and malignant fibrous histiocytoma. The two primary malignant cardiac masses were leiomyosarcoma and non-Hodgkin lymphoma. The 1 5 benign cardiac masses in-cluded six myxomas (Fig. 4). One of the benign primary cardiac masses was a fibroma (Fig. 5). Two patients with tuberous sclerosis had cardiac rhabdomyomata. The nine lesions in the pericardial group included two benign lesions (both were radiation-induced pericardial thickening) and seven malignant lesions including pericardial mesothelioma and met-astatic lymphoma, osteogenic sarcoma, and hemangiopericy-toma. Masses adjacent to the heart and pericardium included one malignant mass, a lung spindle cell sarcoma, and eight benign lesions, including two thymomas and pericardial fat.

Pericardial involvement by tumor was correctly identified or excluded in all 10 patients in whom surgical confirmation was available. Tumor involvement of the pericardium in four pa-tients by melanoma, fibrosarcoma, hepatocellular carcinoma, and lymphoma was correctly determined by MR. Echocar-diography did not detect pericardial involvement in any of the three patients examined, and CT correctly evaluated the pericardium only in two of three patients examined. All

Fig. 4.-A and B, Typical atrlal myxoma (TE = 25msec). Sagittal (A) and coronal (B) views show Fig. 5.-Benign cardiac mass. MR Image (TE =

bibbed atrlal myxoma (arrows) centered ininteratrlal septum and extending Into both atria. 24 msec) of primary cardiac flbroma involving left

ventricular free wall (arrow).

Fig. 6.-MR demonstration of no pericardial

In-volvement by this lung mass altered the surgical

approach.

A, CTimage shows 4-cm mass adjacent to left

ventricle (arrow). There isa suggestion of perlcar-dial Involvement by mass, but artifact makes

ac-curate assessment difficult.

B, Axial MR Image (TE = 25 msec) at level similar to CT scan clearly showsnormal, thin,

low-intensity perlcardial line (arrow).

niques correctly evaluated pericardial involvement by scar tissue caused by radiation therapy, but only MR showed no pericardial involvement in four other patients. The pericardium in one patient with partial absence of the pericardium due to prior surgical resection of adherent plasma cell granuloma was correctly evaluated by MR but was not imaged by either

echocardiography or CT.

Information provided by MR imaging contributed to a

deci-sion against surgery in 26 patients. Eleven of these patients

had negative examinations and eight had a benign process, such as occurred in the two patients with lipomatous hyper-trophy of the atrial septum. The role of MR imaging was easiest to document in the seven patients who were shown to have unresectable tumors. MR clearly showed unresecta-bility due to the extent of myocardial involvement in a patient with pericardial mesothelioma metastatic to the liver (Fig. 2).

MR provided guidance for planning surgery in 25 patients. In two patients, a thoracotomy rather than a median ster-notomy was performed on the basis of information obtained from the MR examination. One of these patients was found

to have a left lung mass on a chest film. Echocardiography suggested that the mass was cystic. CT examination sug-gested pericardial involvement (Fig. 6A). On MR, the mass had internal inhomogeneity, which is characteristic of soft tissue but not of fat or fluid. There was no transpericardial involvement (Fig. 6B). On the basis of these findings, a

thoracotomy rather than a median sternotomy was

per-formed. Surgery revealed a primary lung spindle cell sarcoma with no pericardial involvement.

Discussion

In ECG-gated MR imaging, the TR interval cannot be cho-sen freely but is determined by the RR interval of the patient’s ECG. The typical TR and TE values on spin-echo ECG-gated MR imaging fall into the category of partial-saturation spin-echo sequences. Such sequences tend not to differentiate

between various nonfatty soft tissues. Nevertheless, the

com-bination of intensity characteristics, morphologic information, and clinical data allowed a correct diagnosis to be made in several cases. Qualitative tissue characterization was

Fig. 7.-A and B, Hepatocellular carcinoma. Sagittal (A) and coronal (B) MR images (TE = 35 Fig. 8.-Focal pericardial invasion by

fibrosar-msec) show absence of low-intensity pencardial line along diaphragmatic border (arrows) indicative coma. MR image (TE = 35 msec) shows focal

oftranspericardial involvement. absence of low-intensity pericardial line lateral to

right atrium (arrow) due to invasion by fibrosar-coma at this site.

A B

472 LUND ET AL. AJR:152, March 1989

Fig. 9.-Recurrent osteogenic sarcoma.

A, Recurrent osteogenic sarcoma (asterisk) of

sternum. CT shows ossified tumor well but does

not clearly show perlcardial involvement

B,MR image(TE = 25msec), while not depicting

calcification in recurrent osteogenic sarcoma as

well as CT does, clearly shows focal absence of low-intensity pericardial line (arrow) indicative of tumor invasion.

ble with fatty lesions and those containing large vascular structures. Relative tissue-intensity characteristics have been shown to allow a degree of specificity in the MR diagnosis of some cardiac lesions, such as lipomatous hypertrophy of the atnal septum [4, 1 1], fibroma [1 2], thrombus [12-15], myxoma [12, 16], and pericardial cyst or fat pad [12, 17, 18]. As others have noted, the primary contribution of MR imaging in these cases was not its ability to obtain a tissue diagnosis, but rather its ability to delineate the anatomic extent and to aid in treatment planning [12, 13, 19].

Several authors have pointed to a role for MR imaging in evaluating possible cardiac masses suggested by echocar-diography [20]. In our series, cardiac masses were excluded in 11 cases within this clinical setting. Demonstration of prominent fusion of the thebesian and eustachian valves in one patient and exclusion of a cardiac mass in the other 10 patients were sufficient evidence to end further workup. Ten of the 11 patients were initially examined by echocardiogra-phy. Eight of these patients were strikingly similar in that

echocardiography had suggested the presence of a mass in the region of the left atrial appendage, an area that has been shown to be difficult to evaluate adequately with

echocar-diography [21]. Our experience subsequent to this study has

indicated that the area of the superior portion of the atrial septum is a similar problematic region that is well assessed by MR imaging. Transesophageal echocardiography can spe-cifically address the limitations of transthoracic echocardiog-raphy in these regions as well [22].

MR findings influenced surgical planning and patient man-agement by excluding or confirming the presence of a cardiac mass. Surgical planning was aided by the ability of MR to clearly show the location and extent of tumor and the pres-ence of transpencardial involvement.

The normal pericardium usually is depicted on MR images as a thin band of low intensity [7, 8, 14, 17, 23]. Pericardial fluid normally is not present in sufficient quantity to allow this appearance to be attributed to a flow phenomenon. It has been stated that this hypointense line is due to the relatively

low spin density of the fibrous component of the pericardium [8, 23].

The low spin-echo intensity of the pericardium is explained partly by the presence of a phase discontinuity artifact [13,

24-26]. The shearing action between the visceral and parietal

pericardium results in a large local velocity gradient causing

a reduction in signal intensity from the volume elements spanning the pericardium. Focal absence of the low-intensity

pericardial line implies that no shearing motion is present

across the pericardium at that point. Such lack of shearing

motion can be caused by transpericardial tumor invasion or

inflammatory adhesions. This sign assisted reliable MR im-aging diagnosis of pericardial involvement in some cases of

hepatocellular carcinoma (Fig. 7), mediaStinal fibrosarcoma

(Fig. 8), and recurrent osteogenic sarcoma of the sternum (Fig. 9), which were confirmed at surgery.

It appears that, while echocardiography will continue to be the primary imaging technique for detecting Cardiac masses, MR imaging can play a significant complementary role. The most compelling indication for MR imaging is preoperative assessment of patients with known cardiac masses. In our series, it helped to determine whether to operate and aided

surgical planning.

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