Cardiac tumors differential diagnosis: Difference between revisions

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{{Cardiac tumors}}
{{Cardiac tumors}}
{{CMG}} {{AE}} {{HK}}


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==Overview==
Cardiac tumors present as a cardiac mass on imaging. Different types of cardiac tumors such as myxomas, rhabdomyomas, fibroelastomas, cardiac fibromas, cardiac hemangiomas, cardiac lipomas, paragangiomas and atrioventricular nodal tumors are classified as benign tumors of the heart. These can be differentiated based on age of presentation, location, morphological features on echocardiography and MRI findings. Malignant tumors of the heart include rhabdomyosarcoma, angiosarcoma, fibrosarcoma and lymphoma. Malignant cardiac tumors also have varying morphological features and MRI findings, which may aid in differentiating these tumors.
==Differential Diagnosis of Cardiac Mass==
Cardiac tumors present as a cardiac mass on imaging. The following are the differentials of cardiac mass:<ref name="pmid27600455">{{cite journal |vauthors=Mankad R, Herrmann J |title=Cardiac tumors: echo assessment |journal=Echo Res Pract |volume=3 |issue=4 |pages=R65–R77 |date=December 2016 |pmid=27600455 |pmc=5292983 |doi=10.1530/ERP-16-0035 |url=}}</ref><ref name="pmid22283202">{{cite journal |vauthors=Zaragoza-Macias E, Zaragosa-Macias E, Chen MA, Gill EA |title=Real time three-dimensional echocardiography evaluation of intracardiac masses |journal=Echocardiography |volume=29 |issue=2 |pages=207–19 |date=February 2012 |pmid=22283202 |doi=10.1111/j.1540-8175.2011.01627.x |url=}}</ref><ref name="pmid7062746">{{cite journal |vauthors=Larrieu AJ, Jamieson WR, Tyers GF, Burr LH, Munro AI, Miyagishima RT, Gerein AN, Allen P |title=Primary cardiac tumors: experience with 25 cases |journal=J. Thorac. Cardiovasc. Surg. |volume=83 |issue=3 |pages=339–48 |date=March 1982 |pmid=7062746 |doi= |url=}}</ref><ref name="pmid2237900">{{cite journal |vauthors=Molina JE, Edwards JE, Ward HB |title=Primary cardiac tumors: experience at the University of Minnesota |journal=Thorac Cardiovasc Surg |volume=38 Suppl 2 |issue= |pages=183–91 |date=August 1990 |pmid=2237900 |doi=10.1055/s-2007-1014064 |url=}}</ref><ref name="pmid1434856">{{cite journal |vauthors=Tazelaar HD, Locke TJ, McGregor CG |title=Pathology of surgically excised primary cardiac tumors |journal=Mayo Clin. Proc. |volume=67 |issue=10 |pages=957–65 |date=October 1992 |pmid=1434856 |doi= |url=}}</ref><ref name="pmid14728061">{{cite journal |vauthors=Sarjeant JM, Butany J, Cusimano RJ |title=Cancer of the heart: epidemiology and management of primary tumors and metastases |journal=Am J Cardiovasc Drugs |volume=3 |issue=6 |pages=407–21 |date=2003 |pmid=14728061 |doi=10.2165/00129784-200303060-00004 |url=}}</ref><ref name="pmid7382545">{{cite journal |vauthors=St John Sutton MG, Mercier LA, Giuliani ER, Lie JT |title=Atrial myxomas: a review of clinical experience in 40 patients |journal=Mayo Clin. Proc. |volume=55 |issue=6 |pages=371–6 |date=June 1980 |pmid=7382545 |doi= |url=}}</ref><ref name="pmid11388092">{{cite journal |vauthors=Pinede L, Duhaut P, Loire R |title=Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases |journal=Medicine (Baltimore) |volume=80 |issue=3 |pages=159–72 |date=May 2001 |pmid=11388092 |doi= |url=}}</ref><ref name="pmid7477198">{{cite journal |vauthors=Reynen K |title=Cardiac myxomas |journal=N. Engl. J. Med. |volume=333 |issue=24 |pages=1610–7 |date=December 1995 |pmid=7477198 |doi=10.1056/NEJM199512143332407 |url=}}</ref><ref name="pmid24642215">{{cite journal |vauthors=Javed A, Zalawadiya S, Kovach J, Afonso L |title=Aortic valve myxoma at the extreme age: a review of literature |journal=BMJ Case Rep |volume=2014 |issue= |pages= |date=March 2014 |pmid=24642215 |pmc=3962858 |doi=10.1136/bcr-2013-202689 |url=}}</ref><ref name="pmid17698701">{{cite journal |vauthors=Lee VH, Connolly HM, Brown RD |title=Central nervous system manifestations of cardiac myxoma |journal=Arch. Neurol. |volume=64 |issue=8 |pages=1115–20 |date=August 2007 |pmid=17698701 |doi=10.1001/archneur.64.8.1115 |url=}}</ref><ref name="pmid4010501">{{cite journal |vauthors=Carney JA, Gordon H, Carpenter PC, Shenoy BV, Go VL |title=The complex of myxomas, spotty pigmentation, and endocrine overactivity |journal=Medicine (Baltimore) |volume=64 |issue=4 |pages=270–83 |date=July 1985 |pmid=4010501 |doi= |url=}}</ref><ref name="pmid10028128">{{cite journal |vauthors=McAllister HA, Hall RJ, Cooley DA |title=Tumors of the heart and pericardium |journal=Curr Probl Cardiol |volume=24 |issue=2 |pages=57–116 |date=February 1999 |pmid=10028128 |doi= |url=}}</ref><ref name="pmid9283541">{{cite journal |vauthors=Klarich KW, Enriquez-Sarano M, Gura GM, Edwards WD, Tajik AJ, Seward JB |title=Papillary fibroelastoma: echocardiographic characteristics for diagnosis and pathologic correlation |journal=J. Am. Coll. Cardiol. |volume=30 |issue=3 |pages=784–90 |date=September 1997 |pmid=9283541 |doi= |url=}}</ref><ref name="pmid26046736">{{cite journal |vauthors=Tamin SS, Maleszewski JJ, Scott CG, Khan SK, Edwards WD, Bruce CJ, Oh JK, Pellikka PA, Klarich KW |title=Prognostic and Bioepidemiologic Implications of Papillary Fibroelastomas |journal=J. Am. Coll. Cardiol. |volume=65 |issue=22 |pages=2420–9 |date=June 2015 |pmid=26046736 |doi=10.1016/j.jacc.2015.03.569 |url=}}</ref><ref name="pmid12947356">{{cite journal |vauthors=Gowda RM, Khan IA, Nair CK, Mehta NJ, Vasavada BC, Sacchi TJ |title=Cardiac papillary fibroelastoma: a comprehensive analysis of 725 cases |journal=Am. Heart J. |volume=146 |issue=3 |pages=404–10 |date=September 2003 |pmid=12947356 |doi=10.1016/S0002-8703(03)00249-7 |url=}}</ref><ref name="pmid9424072">{{cite journal |vauthors=Beghetti M, Gow RM, Haney I, Mawson J, Williams WG, Freedom RM |title=Pediatric primary benign cardiac tumors: a 15-year review |journal=Am. Heart J. |volume=134 |issue=6 |pages=1107–14 |date=December 1997 |pmid=9424072 |doi= |url=}}</ref><ref name="pmid2239731">{{cite journal |vauthors=Smythe JF, Dyck JD, Smallhorn JF, Freedom RM |title=Natural history of cardiac rhabdomyoma in infancy and childhood |journal=Am. J. Cardiol. |volume=66 |issue=17 |pages=1247–9 |date=November 1990 |pmid=2239731 |doi= |url=}}</ref><ref name="pmid7979700">{{cite journal |vauthors=Jacobs JP, Konstantakos AK, Holland FW, Herskowitz K, Ferrer PL, Perryman RA |title=Surgical treatment for cardiac rhabdomyomas in children |journal=Ann. Thorac. Surg. |volume=58 |issue=5 |pages=1552–5 |date=November 1994 |pmid=7979700 |doi= |url=}}</ref><ref name="pmid18824772">{{cite journal |vauthors=Elbardissi AW, Dearani JA, Daly RC, Mullany CJ, Orszulak TA, Puga FJ, Schaff HV |title=Survival after resection of primary cardiac tumors: a 48-year experience |journal=Circulation |volume=118 |issue=14 Suppl |pages=S7–15 |date=September 2008 |pmid=18824772 |doi=10.1161/CIRCULATIONAHA.107.783126 |url=}}</ref><ref name="pmid8049952">{{cite journal |vauthors=Basu S, Folliguet T, Anselmo M, Greengart A, Sabado M, Cunningham JN, Jacobowitz IJ |title=Lipomatous hypertrophy of the interatrial septum |journal=Cardiovasc Surg |volume=2 |issue=2 |pages=229–31 |date=April 1994 |pmid=8049952 |doi= |url=}}</ref><ref name="pmid18428209">{{cite journal |vauthors=Simpson L, Kumar SK, Okuno SH, Schaff HV, Porrata LF, Buckner JC, Moynihan TJ |title=Malignant primary cardiac tumors: review of a single institution experience |journal=Cancer |volume=112 |issue=11 |pages=2440–6 |date=June 2008 |pmid=18428209 |doi=10.1002/cncr.23459 |url=}}</ref><ref name="pmid10807431">{{cite journal |vauthors=Vander Salm TJ |title=Unusual primary tumors of the heart |journal=Semin. Thorac. Cardiovasc. Surg. |volume=12 |issue=2 |pages=89–100 |date=April 2000 |pmid=10807431 |doi= |url=}}</ref><ref name="pmid1008078">{{cite journal |vauthors=Petersen CD, Robinson WA, Kurnick JE |title=Involvement of the heart and pericardium in the malignant lymphomas |journal=Am. J. Med. Sci. |volume=272 |issue=2 |pages=161–5 |date=1976 |pmid=1008078 |doi= |url=}}</ref><ref name="pmid16595790">{{cite journal |vauthors=Ragland MM, Tak T |title=The role of echocardiography in diagnosing space-occupying lesions of the heart |journal=Clin Med Res |volume=4 |issue=1 |pages=22–32 |date=March 2006 |pmid=16595790 |pmc=1447535 |doi= |url=}}</ref><ref name="pmid20227122">{{cite journal |vauthors=Miguel CE, Bestetti RB |title=Primary cardiac lymphoma |journal=Int. J. Cardiol. |volume=149 |issue=3 |pages=358–63 |date=June 2011 |pmid=20227122 |doi=10.1016/j.ijcard.2010.02.016 |url=}}</ref><ref name="pmid10903697">{{cite journal |vauthors=Grebenc ML, Rosado de Christenson ML, Burke AP, Green CE, Galvin JR |title=Primary cardiac and pericardial neoplasms: radiologic-pathologic correlation |journal=Radiographics |volume=20 |issue=4 |pages=1073–103; quiz 1110–1, 1112 |date=2000 |pmid=10903697 |doi=10.1148/radiographics.20.4.g00jl081073 |url=}}</ref><ref name="pmid9869763">{{cite journal |vauthors=Grinda JM, Couetil JP, Chauvaud S, D'Attellis N, Berrebi A, Fabiani JN, Deloche A, Carpentier A |title=Cardiac valve papillary fibroelastoma: surgical excision for revealed or potential embolization |journal=J. Thorac. Cardiovasc. Surg. |volume=117 |issue=1 |pages=106–10 |date=January 1999 |pmid=9869763 |doi= |url=}}</ref><ref name="pmid8466239">{{cite journal |vauthors=Webb DW, Thomas RD, Osborne JP |title=Cardiac rhabdomyomas and their association with tuberous sclerosis |journal=Arch. Dis. Child. |volume=68 |issue=3 |pages=367–70 |date=March 1993 |pmid=8466239 |pmc=1793857 |doi= |url=}}</ref><ref name="pmid19493870">{{cite journal |vauthors=Yoshitake I, Hata M, Sezai A, Niino T, Unosawa S, Shimura K, Kasamaki Y, Minami K |title=Cardiac angiosarcoma with cardiac tamponade diagnosed as a ruptured aneurysm of the sinus valsalva |journal=Jpn. J. Clin. Oncol. |volume=39 |issue=9 |pages=612–5 |date=September 2009 |pmid=19493870 |doi=10.1093/jjco/hyp044 |url=}}</ref><ref name="pmid20939891">{{cite journal |vauthors=Parissis H, Akbar MT, Young V |title=Primary leiomyosarcoma of the right atrium: a case report and literature update |journal=J Cardiothorac Surg |volume=5 |issue= |pages=80 |date=October 2010 |pmid=20939891 |pmc=2964688 |doi=10.1186/1749-8090-5-80 |url=}}</ref><ref name="pmid15383848">{{cite journal |vauthors=Gulati G, Sharma S, Kothari SS, Juneja R, Saxena A, Talwar KK |title=Comparison of echo and MRI in the imaging evaluation of intracardiac masses |journal=Cardiovasc Intervent Radiol |volume=27 |issue=5 |pages=459–69 |date=2004 |pmid=15383848 |doi=10.1007/s00270-004-0123-4 |url=}}</ref><ref name="pmid20150010">{{cite journal |vauthors=Narin B, Arman A, Arslan D, Simşek M, Narin A |title=Assessment of cardiac masses: magnetic resonance imaging versus transthoracic echocardiography |journal=Anadolu Kardiyol Derg |volume=10 |issue=1 |pages=69–74 |date=February 2010 |pmid=20150010 |doi= |url=}}</ref><ref name="urlacademic.oup.com">{{cite web |url=https://academic.oup.com/ehjcimaging/article/8/6/487/2398147 |title=academic.oup.com |format= |work= |accessdate=}}</ref><ref name="pmid26486106">{{cite journal |vauthors=Ismail I, Al-Khafaji K, Mutyala M, Aggarwal S, Cotter W, Hakim H, Khosla S, Arora R |title=Cardiac lipoma |journal=J Community Hosp Intern Med Perspect |volume=5 |issue=5 |pages=28449 |date=2015 |pmid=26486106 |pmc=4612478 |doi=10.3402/jchimp.v5.28449 |url=}}</ref><ref name="pmid28088193">{{cite journal |vauthors=D'Souza J, Shah R, Abbass A, Burt JR, Goud A, Dahagam C |title=Invasive Cardiac Lipoma: a case report and review of literature |journal=BMC Cardiovasc Disord |volume=17 |issue=1 |pages=28 |date=January 2017 |pmid=28088193 |pmc=5237479 |doi=10.1186/s12872-016-0465-2 |url=}}</ref><ref name="YadavBaquero2014">{{cite journal|last1=Yadav|first1=Pradeep K.|last2=Baquero|first2=Giselle A.|last3=Malysz|first3=Jozef|last4=Kelleman|first4=John|last5=Gilchrist|first5=Ian C.|title=Cardiac Paraganglioma|journal=Circulation: Cardiovascular Interventions|volume=7|issue=6|year=2014|pages=851–856|issn=1941-7640|doi=10.1161/CIRCINTERVENTIONS.114.001856}}</ref><ref name="pmid20069088">{{cite journal |vauthors=Tahir M, Noor SJ, Herle A, Downing S |title=Right atrial paraganglioma: a rare primary cardiac neoplasm as a cause of chest pain |journal=Tex Heart Inst J |volume=36 |issue=6 |pages=594–7 |date=2009 |pmid=20069088 |pmc=2801953 |doi= |url=}}</ref><ref name="pmid89769312">{{cite journal |vauthors=Hamilton BH, Francis IR, Gross BH, Korobkin M, Shapiro B, Shulkin BL, Deeb CM, Orringer MB |title=Intrapericardial paragangliomas (pheochromocytomas): imaging features |journal=AJR Am J Roentgenol |volume=168 |issue=1 |pages=109–13 |date=January 1997 |pmid=8976931 |doi=10.2214/ajr.168.1.8976931 |url=}}</ref><ref name="ShihMcCullough1993">{{cite journal|last1=Shih|first1=Wei-Jen|last2=McCullough|first2=Scott|last3=Smith|first3=Mary|title=Diagnostic imagings for primary cardiac fibrosarcoma|journal=International Journal of Cardiology|volume=39|issue=2|year=1993|pages=157–161|issn=01675273|doi=10.1016/0167-5273(93)90028-F}}</ref><ref name="pmid9832064">{{cite journal |vauthors=Arai T, Kurashima C, Wada S, Chida K, Ohkawa S |title=Histological evidence for cell proliferation activity in cystic tumor (endodermal heterotopia) of the atrioventricular node |journal=Pathol. 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{| class="wikitable"
|+
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Site of Tumor
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Malignant Potential
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Type of Tumor
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Tissue of Origin
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Age of Presentation
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Location
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |Morphology
! colspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" + |Signs and Symptoms
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" + |MRI Findings
|-
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Systemic Manifestations
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Cardiac Manifestations
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Embolic Manifestations
|-
| rowspan="13" style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Primary Cardiac Tumor'''
| rowspan="9" |'''Primary Benign'''
|'''[[Myxoma]]'''
|
* [[Mesenchymal]]
|
* Between third to sixth decade of life
|
* [[Left atrium]] (75%)
* [[Right atrium]] (15-20%)
* Arise from border of [[fossa ovalis]]
|
* 1-15 cm in diameter
* Pedunculated
* Polypoid
* Smooth and lobulated
* Villous and pappillary appearance associated with [[embolization]]
|
* Constitutional symptoms
* [[Carney complex]]:
** Spotty skin pigmentation
** [[Endocrine tumors|Endocrinal tumors]] such as [[Sertoli Cell Tumor|sertoli testicular tumors]], [[pituitary adenomas]], [[Thyroid tumor|thyroid tumors]]
** [[Schwannoma]]
* NAME syndrome:
** [[Nevi]]
** [[Atrial myxoma]]
** Myxoid neurofibroma
** Ephelides
* LAMB syndrome:
** [[Lentigo]] (small brown patches on the [[skin]])
** [[Atrial myxoma]]
** [[Nevi|Blue nevi]]
|
* [[Dyspnea]]
* [[Mitral regurgitation]] (LA)
* [[Right heart failure]] (RA)
* [[Cardiomegaly]]
|
* [[Pulmonary hypertension]] and [[pulmonary emboli]] (RA)
|
* Oval mobile left [[atrial]] lesion
* Heterogenous enhancement
* Attachment to [[fossa ovalis]]
|-
|'''Rhabdomyoma'''
|
* Striated Muscle
|
* Majority (80%) in [[infants]] (<12 months)
* Most common cardiac mass in childhood
* 50-70% of all [[pediatric]] [[tumors]]
|
* [[Ventricles]]
* [[Interventricular septum]]
|
* 1-3 cm in size
* Yellow-gray color
* Firm
* Circumscribed lobulated
* Majority multiple if associated with [[tuberous sclerosis]] (of those with no association, 50% are single)
|
* Associated with [[tuberous sclerosis]]:
** [[Developmental delay]]
** Renal tumors ([[Angiomyolipoma|angiomyolipomas]]'')''
** [[Phakomatoses|Phakomas]] (white retinal spots)
** Hypomelanic macules (ash leaf spots)
** Ungal fibromas
** Facial [[Angiofibroma|angiofibromas]]
** [[Headache]]
** [[Blurred vision]]
** [[Cardiac arrhythmia|Arrhythmias]]
** [[Benign]] [[Brain tumor|brain tumors]] ([[Cerebral cortex|cortical]] tubers, [[Subependymal zone|subependymal]] nodules)
|
* Outflow obstruction (both [[Ventricle|right and left ventricles]])
* [[Cardiac arrhythmia|Arrhythmias]] (ventricular pre-excitation, [[Wolff-Parkinson-White syndrome|Wolff-Parkinson White syndrome]])
* Spontaneous regression in young cases (< 4 years); seldom regress in adult cases
|
* [[Pulmonary embolism]]
* [[Ischemic stroke]]
|
* Multiple masses isointense to [[muscle tissue]] on T1 images
* Hyperintense on T2 images
|-
|'''[[Fibroma]]'''
|
* [[Fibrous]]
|
* Children (1/3rd in infants)
|
* [[Ventricles]]
* [[Interventricular septum|Ventricular septum]] >[[Left ventricular|Left ventricular free wall]] > [[Right ventricle]] > [[Atria]]
* Central [[calcification]]
|
* Solitary
|
* [[Asymptomatic]]
* [[Cyanosis]]
|
* Atypical [[chest pain]]
* [[Heart failure]]
* [[Cardiomegaly]]
* Biventricular hypertrophy
* [[Atrioventricular block|Atrioventricular nodal block]]
|
* [[Pulmonary embolism]]
* [[Ischemic stroke]]
|
* Solitary mass
* Low intensity on T2 weighted image
|-
|'''Fibroelastoma'''
|
* Valvular [[endocardium]]
|
|
* Valvular [[endocardium]] (Adults-[[Aortic valve|Aortic]], children-[[Tricuspid valve|Tricuspid]])
* [[Ventricular]] surface of [[aortic]] and [[pulmonary valves]] and [[atrial]] surface of [[atrioventricular valves]]
|
* < 1 cm in diameter
* Solitary
* Papillary
* Flower-like appearance with multiple attachments to valve
* Short pedicle
*
|
* [[Asymptomatic]]
* Association with [[hypertrophic obstructive cardiomyopathy]] ([[Hypertrophic cardiomyopathy|HOCM]])
|
* [[Subacute bacterial endocarditis]]
|
* [[Pulmonary embolism]]
|
* T1 and T2 weighted images show uniform intermediate signal intensity similar to [[myocardium]]
* Homogeneous late gadolinium contrast enhancement
|-
|'''[[Hemangioma]]'''
|
* [[Vascular]]
|
* < 1 year to 70 years
* < 2 % of primary cardiac tumors
|
* [[Ventricle|Right Ventricle]]
* [[Left ventricle]]
* Right atrium
* Small percentage in [[interatrial septum]] and [[left atrium]]
|
* Polypoid
* Encapsulated
|
* [[Cyanosis]]
* [[Kasabach-Merritt syndrome]] (giant hemangiomas):
** [[Thrombosis]]
** [[Thrombocytopenia]]
** [[Coagulopathy]]
|
* [[Pericardial effusions]]
* [[CHF]]
* [[Arrhythmias]]
|
* [[Pulmonary embolism]]
* [[Ischemic stroke]]
|
* Intermediate density on T1 images
* Hypointense on T2 images
* Multicystic enhancing lesion
* Involvement of [[epicardium]] or [[pericardium]]
|-
|'''[[Lipoma]]'''
|
* [[Adipose]]
|
* Between fourth to sixth decade of life
|
* [[Left ventricle]] (most commonly subendocardium)
* [[Right atrium]]
|
* Sessile and small (specially [[subendocardial]] that protrude into [[cardiac]] chambers)
* Broad pedicle
* Growth into [[pericardial space]]
|
* [[Asymptomatic]]
|
* [[Dyspnea]]
* Local compression (subepicardial)
* [[Arrhythmia]]
|
* [[Ischemic stroke]]
|
* [[Epicardial]] or intramural lesion
* High intensity on T1 weighted image
* Drop out on [[fat]] saturation images
|-
|'''[[Paraganglioma]]'''
|
* [[Nervous system|Nervous]] ([[chromaffin cells]] of the [[sympathetic ganglia]])
|
* Average age of presentation is 11-13 years


*
|
* [[Left atrium]] (under the aorta and the [[pulmonary artery]])
* [[Interatrial septum]]
* [[Left ventricle]]
* [[Right ventricular outflow tract]]
|
* 3-8 cm
* Well-defined
* Broad base
* Encapsulated
* Heterogeneous
* Hypervascular
|
* Majority [[asymptomatic]]
* May present with [[symptoms]] of [[catecholamine]] excess:
** [[Tachycardia]]
** [[Hypertension]]
** [[Palpitations]]
** [[Fever]]
** [[Diaphoresis]]
* Positive for [[chromogranin]] and [[synaptophysin]]
* Association with [[succinate dehydrogenase]] ([[Succinate dehydrogenase|SDH]]) [[mutation]]
|
* [[Dyspnea]]
* [[Valvular]] obstruction ([[murmurs]])
* [[Acute coronary syndromes|Acute coronary syndrome]] ([[Angina|anginal pain]])
|
* Enascement of [[coronary arteries]] by [[tumor]]
|
* Well defined lesion arising from [[Atrial|atrial walls]] or [[Interatrial septum|septum]]
* Bright on T2 weighted imaging
|-
|'''Atrioventricular Node Tumor'''
|
* [[Endoderm|Endodermal]]
|
* Average age of diagnosis is 38 years
* Female to male ratio 3:1
|
* [[Triangle of Koch]] in the [[AV node|AV nodal]] region of the [[atrial septum]]
|
* 2 mm to 2 cm
* Multiple
* Cystic
* Thickening of the [[atrial septum]]
|
* Most common [[Cardiac tumors|cardiac tumor]] leading to sudden death
* [[Emery-Dreifuss muscular dystrophy]]
* Midline developmental defects along the central vertical body axis:
** [[Thyroglossal cyst|Thyroglossal duct cysts]]
** Cysts in the [[ovaries]], [[breasts]]
** [[Ventricular septal defect]]
** [[Encephalocele]]
* Positive for:
** [[Cytokeratin]] CAM5.2
** [[Cytokeratin]] AE1/AE3
** [[Cytokeratin]] 34βE12
** [[Cytokeratin]] 5/6 (CK5/6)
** [[Cytokeratin]] 7 (CK7)
** Epithelial membrane antigen (EMA)
** [[Carcinoembryonic antigen]] ([[CEA]])
** [[CA 19-9|Carbohydrate antigen]] (CA)19.9, p63, [[bcl2]], [[Galectin-3|galectin 3]]
|
* [[Palpitations]]
* [[Dyspnea]]
* [[Chest pain]]
* [[Dizziness|Diziness]]
* [[Syncope]]
* [[Complete heart block]]
* Partial [[Atrioventricular block|AV block]]
* [[Paroxysmal atrial tachycardia]]
* Spontaneous intermittent pre-excitation
|
* [[Myocardial infarction]]
* [[Ischemic stroke]]
|
* Hypointense [[Cardiac mass causes|cardiac mass]] on standard imaging
* Hyperintensity on late gadolinium enhancement (LGE) images with heterogeneous contrast enhancement
|-
|'''Lipomatous hypertrophy of the interatrial septum'''
|
* [[Adipose]]
|
* > 60 years
|
* Limbus of the [[fossa ovalis]] (sparing [[fossa ovalis]] membrane)
|
* > 2 cm
* [[Interatrial septum]] maybe upto 7 cm in thickness
|
* Mostly [[asymptomatic]]
* May present with obstructive symptoms such as [[syncope]] in rare cases of extension into [[superior vena cava]]
* Associated with:
** Increased age
** [[Obesity]]
** [[Cardiac arrhythmia|Arrhythmias]]
|
* [[Palpitations]]
* [[Dyspnea]]
* [[Fatigue]]
|<nowiki>-</nowiki>
|
* Diffuse or nodular thickening of [[atrial]] walls
* Hyperintense to normal [[myocardium]]
* Hypointense to [[pericardial]] and posterior [[mediastinal]] fat
|-
| rowspan="4" |'''Primary Malignant'''
|'''[[Fibrosarcoma]]'''
|
* [[Fibrous]]
|
* 20 to 80 years
|
* Left sided ([[atrial]] mostly)
|
* Sessile or pedunculated protruding masses in [[ventricular]] cavities
* Soft
* Lobulated
* Gelatinous
|
* [[Fever]]
* [[Fatigue]]
* [[Malaise]]
* [[Weight loss]]
* Cytoplasmatic positivity for a-SMA
|
* [[CHF]]
* [[Pericardial]] infiltration ([[Pericardial effusion|effusions]])
|
* [[Pulmonary embolism]]
* [[Ischemic stroke]]
* [[Metastasis]]
|
* Heterogenous or isointense to [[myocardium]] on T1 weighted images
|-
|'''[[Angiosarcoma]]'''
|
* [[Vascular]]
|
* 30 to 50 years
|
* [[Right atrium]]
|
* Broad-based
* Internal [[hemorrhage]]
|
* [[Fever]]
* [[Fatigue]]
* [[Weight loss]]
* [[Congestion]]
* [[Superior vena cava syndrome]]
* Embolic stroke
* Endothelial marker D2-40
|
* [[Dyspnea]]
* [[Congestive heart failure|CHF]]
* [[Pericardial effusions]]
* [[Cardiac tamponade]]
|
* [[Pulmonary embolism]]
* [[Ischemic stroke]]
* [[Metastasis]]
|
* Arterial phase enhancement
|-
|'''[[Rhabdomyosarcoma]]'''
|
* [[Mesenchymal]]
|
* Most common primary [[sarcoma]] of children
* Average age of presentation is 20 years
|
* Left sided ([[atrial]] mostly)
|
* Multiple
* Three types:
** Embryonic
** Pleomorphic
** Alveolar
|
* [[Fever]]
* [[Fatigue]]
* [[Weight loss]]
* [[Metastasize]] to [[lung]] and [[lymph nodes]]
|
* [[CHF]]
* [[Arrhythmias]]
|
* [[Pulmonary embolism]]
* [[Ischemic stroke]]
* [[Metastasis]]
|
* Intermediate-to-hypointensity compared with [[muscle]] on T1 images
* Hyperintense on T2-weighted imaging with heterogeneous contrast enhancement
|-
|'''[[Lymphoma]]'''
|
* [[Lymphoid]]
|
* 10 to 90 years
* Males > females
|
* Right sided mostly
|
* Majority solitary (1/3rd multiple)
|
* Associations:
** [[Immunosupression|Chronic immunosupression]]
** [[Epstein Barr virus]]
** [[HIV]]
** [[Diffuse large B cell lymphoma]]
|
* May involve [[epicardium]] and [[pericardium]]
|
* [[Pulmonary embolism]]
* [[Ischemic stroke]]
* [[Metastasis]]
|
* Hypointense on T1-weighted images and hyperintense on T2-weighted images
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |'''Secondary Cardiac Tumor'''
|'''Metastastatic Malignant'''
|'''[[Metastasis]]'''
|
* [[Skin]] ([[Melanoma]])
* [[Lung carcinoma]]
* [[Lymph]] ([[leukemia]] and [[lymphoma]])
* [[Breast carcinoma]]
* [[Smooth muscle]] ([[Esophageal carcinoma]])
|
* Any age
|
* [[Tumors]] [[metastasizing]] via hematogenous route present as multiple intramyocardial masses:
** [[Melanoma]]
** [[Leukemia]]
** [[Sarcoma]]
* [[Tumors]] [[metastasizing]] via venous system as right sided mass:
** [[Renal cell carcinoma]]
** [[Hepatocellular carcinoma]]
* [[Lung]] tumor [[Metastasize|metastasizes]] to [[left atrium]]
|
* Multiple
*
|
* [[Fever]]
* [[Fatigue]]
* [[Weight loss]]
* [[Dysphagia]]
* [[Lymphadenopathy]]
* [[Night sweats]]
|
* [[Pericardial effusions]]
* [[Dyspnea]]
* [[Arrhythmia]]
* Outflow obstruction
|
* [[Pulmonary embolism]]
* [[Ischemic stroke]]
* [[Metastasis]]
|
* Hyperintense relative to myocardium
* Cardiac mass displaces [[Epicardial fat pad|epicardial fat]] and [[pericardial effusion]] away from [[heart]]
|}
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Revision as of 02:23, 18 January 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]

Overview

Cardiac tumors present as a cardiac mass on imaging. Different types of cardiac tumors such as myxomas, rhabdomyomas, fibroelastomas, cardiac fibromas, cardiac hemangiomas, cardiac lipomas, paragangiomas and atrioventricular nodal tumors are classified as benign tumors of the heart. These can be differentiated based on age of presentation, location, morphological features on echocardiography and MRI findings. Malignant tumors of the heart include rhabdomyosarcoma, angiosarcoma, fibrosarcoma and lymphoma. Malignant cardiac tumors also have varying morphological features and MRI findings, which may aid in differentiating these tumors.

Differential Diagnosis of Cardiac Mass

Cardiac tumors present as a cardiac mass on imaging. The following are the differentials of cardiac mass:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47]

Site of Tumor Malignant Potential Type of Tumor Tissue of Origin Age of Presentation Location Morphology Signs and Symptoms MRI Findings
Systemic Manifestations Cardiac Manifestations Embolic Manifestations
Primary Cardiac Tumor Primary Benign Myxoma
  • Between third to sixth decade of life
  • 1-15 cm in diameter
  • Pedunculated
  • Polypoid
  • Smooth and lobulated
  • Villous and pappillary appearance associated with embolization
Rhabdomyoma
  • Striated Muscle
  • 1-3 cm in size
  • Yellow-gray color
  • Firm
  • Circumscribed lobulated
  • Majority multiple if associated with tuberous sclerosis (of those with no association, 50% are single)
  • Multiple masses isointense to muscle tissue on T1 images
  • Hyperintense on T2 images
Fibroma
  • Children (1/3rd in infants)
  • Solitary
  • Solitary mass
  • Low intensity on T2 weighted image
Fibroelastoma
  • < 1 cm in diameter
  • Solitary
  • Papillary
  • Flower-like appearance with multiple attachments to valve
  • Short pedicle
  • T1 and T2 weighted images show uniform intermediate signal intensity similar to myocardium
  • Homogeneous late gadolinium contrast enhancement
Hemangioma
  • < 1 year to 70 years
  • < 2 % of primary cardiac tumors
  • Polypoid
  • Encapsulated
  • Intermediate density on T1 images
  • Hypointense on T2 images
  • Multicystic enhancing lesion
  • Involvement of epicardium or pericardium
Lipoma
  • Between fourth to sixth decade of life
  • Epicardial or intramural lesion
  • High intensity on T1 weighted image
  • Drop out on fat saturation images
Paraganglioma
  • Average age of presentation is 11-13 years
  • 3-8 cm
  • Well-defined
  • Broad base
  • Encapsulated
  • Heterogeneous
  • Hypervascular
Atrioventricular Node Tumor
  • Average age of diagnosis is 38 years
  • Female to male ratio 3:1
  • Hypointense cardiac mass on standard imaging
  • Hyperintensity on late gadolinium enhancement (LGE) images with heterogeneous contrast enhancement
Lipomatous hypertrophy of the interatrial septum
  • > 60 years
 -
Primary Malignant Fibrosarcoma
  • 20 to 80 years
  • Sessile or pedunculated protruding masses in ventricular cavities
  • Soft
  • Lobulated
  • Gelatinous
  • Heterogenous or isointense to myocardium on T1 weighted images
Angiosarcoma
  • 30 to 50 years
  • Arterial phase enhancement
Rhabdomyosarcoma
  • Most common primary sarcoma of children
  • Average age of presentation is 20 years
  • Multiple
  • Three types:
    • Embryonic
    • Pleomorphic
    • Alveolar
  • Intermediate-to-hypointensity compared with muscle on T1 images
  • Hyperintense on T2-weighted imaging with heterogeneous contrast enhancement
Lymphoma
  • 10 to 90 years
  • Males > females
  • Right sided mostly
  • Majority solitary (1/3rd multiple)
  • Hypointense on T1-weighted images and hyperintense on T2-weighted images
Secondary Cardiac Tumor Metastastatic Malignant Metastasis
  • Any age
  • Multiple

References

  1. ↑ Mankad R, Herrmann J (December 2016). "Cardiac tumors: echo assessment". Echo Res Pract. 3 (4): R65–R77. doi:10.1530/ERP-16-0035. PMC 5292983. PMID 27600455.
  2. ↑ Zaragoza-Macias E, Zaragosa-Macias E, Chen MA, Gill EA (February 2012). "Real time three-dimensional echocardiography evaluation of intracardiac masses". Echocardiography. 29 (2): 207–19. doi:10.1111/j.1540-8175.2011.01627.x. PMID 22283202.
  3. ↑ Larrieu AJ, Jamieson WR, Tyers GF, Burr LH, Munro AI, Miyagishima RT, Gerein AN, Allen P (March 1982). "Primary cardiac tumors: experience with 25 cases". J. Thorac. Cardiovasc. Surg. 83 (3): 339–48. PMID 7062746.
  4. ↑ Molina JE, Edwards JE, Ward HB (August 1990). "Primary cardiac tumors: experience at the University of Minnesota". Thorac Cardiovasc Surg. 38 Suppl 2: 183–91. doi:10.1055/s-2007-1014064. PMID 2237900.
  5. ↑ Tazelaar HD, Locke TJ, McGregor CG (October 1992). "Pathology of surgically excised primary cardiac tumors". Mayo Clin. Proc. 67 (10): 957–65. PMID 1434856.
  6. ↑ Sarjeant JM, Butany J, Cusimano RJ (2003). "Cancer of the heart: epidemiology and management of primary tumors and metastases". Am J Cardiovasc Drugs. 3 (6): 407–21. doi:10.2165/00129784-200303060-00004. PMID 14728061.
  7. ↑ St John Sutton MG, Mercier LA, Giuliani ER, Lie JT (June 1980). "Atrial myxomas: a review of clinical experience in 40 patients". Mayo Clin. Proc. 55 (6): 371–6. PMID 7382545.
  8. ↑ Pinede L, Duhaut P, Loire R (May 2001). "Clinical presentation of left atrial cardiac myxoma. A series of 112 consecutive cases". Medicine (Baltimore). 80 (3): 159–72. PMID 11388092.
  9. ↑ Reynen K (December 1995). "Cardiac myxomas". N. Engl. J. Med. 333 (24): 1610–7. doi:10.1056/NEJM199512143332407. PMID 7477198.
  10. ↑ Javed A, Zalawadiya S, Kovach J, Afonso L (March 2014). "Aortic valve myxoma at the extreme age: a review of literature". BMJ Case Rep. 2014. doi:10.1136/bcr-2013-202689. PMC 3962858. PMID 24642215.
  11. ↑ Lee VH, Connolly HM, Brown RD (August 2007). "Central nervous system manifestations of cardiac myxoma". Arch. Neurol. 64 (8): 1115–20. doi:10.1001/archneur.64.8.1115. PMID 17698701.
  12. ↑ Carney JA, Gordon H, Carpenter PC, Shenoy BV, Go VL (July 1985). "The complex of myxomas, spotty pigmentation, and endocrine overactivity". Medicine (Baltimore). 64 (4): 270–83. PMID 4010501.
  13. ↑ McAllister HA, Hall RJ, Cooley DA (February 1999). "Tumors of the heart and pericardium". Curr Probl Cardiol. 24 (2): 57–116. PMID 10028128.
  14. ↑ Klarich KW, Enriquez-Sarano M, Gura GM, Edwards WD, Tajik AJ, Seward JB (September 1997). "Papillary fibroelastoma: echocardiographic characteristics for diagnosis and pathologic correlation". J. Am. Coll. Cardiol. 30 (3): 784–90. PMID 9283541.
  15. ↑ Tamin SS, Maleszewski JJ, Scott CG, Khan SK, Edwards WD, Bruce CJ, Oh JK, Pellikka PA, Klarich KW (June 2015). "Prognostic and Bioepidemiologic Implications of Papillary Fibroelastomas". J. Am. Coll. Cardiol. 65 (22): 2420–9. doi:10.1016/j.jacc.2015.03.569. PMID 26046736.
  16. ↑ Gowda RM, Khan IA, Nair CK, Mehta NJ, Vasavada BC, Sacchi TJ (September 2003). "Cardiac papillary fibroelastoma: a comprehensive analysis of 725 cases". Am. Heart J. 146 (3): 404–10. doi:10.1016/S0002-8703(03)00249-7. PMID 12947356.
  17. ↑ Beghetti M, Gow RM, Haney I, Mawson J, Williams WG, Freedom RM (December 1997). "Pediatric primary benign cardiac tumors: a 15-year review". Am. Heart J. 134 (6): 1107–14. PMID 9424072.
  18. ↑ Smythe JF, Dyck JD, Smallhorn JF, Freedom RM (November 1990). "Natural history of cardiac rhabdomyoma in infancy and childhood". Am. J. Cardiol. 66 (17): 1247–9. PMID 2239731.
  19. ↑ Jacobs JP, Konstantakos AK, Holland FW, Herskowitz K, Ferrer PL, Perryman RA (November 1994). "Surgical treatment for cardiac rhabdomyomas in children". Ann. Thorac. Surg. 58 (5): 1552–5. PMID 7979700.
  20. ↑ Elbardissi AW, Dearani JA, Daly RC, Mullany CJ, Orszulak TA, Puga FJ, Schaff HV (September 2008). "Survival after resection of primary cardiac tumors: a 48-year experience". Circulation. 118 (14 Suppl): S7–15. doi:10.1161/CIRCULATIONAHA.107.783126. PMID 18824772.
  21. ↑ Basu S, Folliguet T, Anselmo M, Greengart A, Sabado M, Cunningham JN, Jacobowitz IJ (April 1994). "Lipomatous hypertrophy of the interatrial septum". Cardiovasc Surg. 2 (2): 229–31. PMID 8049952.
  22. ↑ Simpson L, Kumar SK, Okuno SH, Schaff HV, Porrata LF, Buckner JC, Moynihan TJ (June 2008). "Malignant primary cardiac tumors: review of a single institution experience". Cancer. 112 (11): 2440–6. doi:10.1002/cncr.23459. PMID 18428209.
  23. ↑ Vander Salm TJ (April 2000). "Unusual primary tumors of the heart". Semin. Thorac. Cardiovasc. Surg. 12 (2): 89–100. PMID 10807431.
  24. ↑ Petersen CD, Robinson WA, Kurnick JE (1976). "Involvement of the heart and pericardium in the malignant lymphomas". Am. J. Med. Sci. 272 (2): 161–5. PMID 1008078.
  25. ↑ Ragland MM, Tak T (March 2006). "The role of echocardiography in diagnosing space-occupying lesions of the heart". Clin Med Res. 4 (1): 22–32. PMC 1447535. PMID 16595790.
  26. ↑ Miguel CE, Bestetti RB (June 2011). "Primary cardiac lymphoma". Int. J. Cardiol. 149 (3): 358–63. doi:10.1016/j.ijcard.2010.02.016. PMID 20227122.
  27. ↑ Grebenc ML, Rosado de Christenson ML, Burke AP, Green CE, Galvin JR (2000). "Primary cardiac and pericardial neoplasms: radiologic-pathologic correlation". Radiographics. 20 (4): 1073–103, quiz 1110–1, 1112. doi:10.1148/radiographics.20.4.g00jl081073. PMID 10903697.
  28. ↑ Grinda JM, Couetil JP, Chauvaud S, D'Attellis N, Berrebi A, Fabiani JN, Deloche A, Carpentier A (January 1999). "Cardiac valve papillary fibroelastoma: surgical excision for revealed or potential embolization". J. Thorac. Cardiovasc. Surg. 117 (1): 106–10. PMID 9869763.
  29. ↑ Webb DW, Thomas RD, Osborne JP (March 1993). "Cardiac rhabdomyomas and their association with tuberous sclerosis". Arch. Dis. Child. 68 (3): 367–70. PMC 1793857. PMID 8466239.
  30. ↑ Yoshitake I, Hata M, Sezai A, Niino T, Unosawa S, Shimura K, Kasamaki Y, Minami K (September 2009). "Cardiac angiosarcoma with cardiac tamponade diagnosed as a ruptured aneurysm of the sinus valsalva". Jpn. J. Clin. Oncol. 39 (9): 612–5. doi:10.1093/jjco/hyp044. PMID 19493870.
  31. ↑ Parissis H, Akbar MT, Young V (October 2010). "Primary leiomyosarcoma of the right atrium: a case report and literature update". J Cardiothorac Surg. 5: 80. doi:10.1186/1749-8090-5-80. PMC 2964688. PMID 20939891.
  32. ↑ Gulati G, Sharma S, Kothari SS, Juneja R, Saxena A, Talwar KK (2004). "Comparison of echo and MRI in the imaging evaluation of intracardiac masses". Cardiovasc Intervent Radiol. 27 (5): 459–69. doi:10.1007/s00270-004-0123-4. PMID 15383848.
  33. ↑ Narin B, Arman A, Arslan D, Simşek M, Narin A (February 2010). "Assessment of cardiac masses: magnetic resonance imaging versus transthoracic echocardiography". Anadolu Kardiyol Derg. 10 (1): 69–74. PMID 20150010.
  34. ↑ "academic.oup.com".
  35. ↑ Ismail I, Al-Khafaji K, Mutyala M, Aggarwal S, Cotter W, Hakim H, Khosla S, Arora R (2015). "Cardiac lipoma". J Community Hosp Intern Med Perspect. 5 (5): 28449. doi:10.3402/jchimp.v5.28449. PMC 4612478. PMID 26486106.
  36. ↑ D'Souza J, Shah R, Abbass A, Burt JR, Goud A, Dahagam C (January 2017). "Invasive Cardiac Lipoma: a case report and review of literature". BMC Cardiovasc Disord. 17 (1): 28. doi:10.1186/s12872-016-0465-2. PMC 5237479. PMID 28088193.
  37. ↑ Yadav, Pradeep K.; Baquero, Giselle A.; Malysz, Jozef; Kelleman, John; Gilchrist, Ian C. (2014). "Cardiac Paraganglioma". Circulation: Cardiovascular Interventions. 7 (6): 851–856. doi:10.1161/CIRCINTERVENTIONS.114.001856. ISSN 1941-7640.
  38. ↑ Tahir M, Noor SJ, Herle A, Downing S (2009). "Right atrial paraganglioma: a rare primary cardiac neoplasm as a cause of chest pain". Tex Heart Inst J. 36 (6): 594–7. PMC 2801953. PMID 20069088.
  39. ↑ Hamilton BH, Francis IR, Gross BH, Korobkin M, Shapiro B, Shulkin BL, Deeb CM, Orringer MB (January 1997). "Intrapericardial paragangliomas (pheochromocytomas): imaging features". AJR Am J Roentgenol. 168 (1): 109–13. doi:10.2214/ajr.168.1.8976931. PMID 8976931.
  40. ↑ Shih, Wei-Jen; McCullough, Scott; Smith, Mary (1993). "Diagnostic imagings for primary cardiac fibrosarcoma". International Journal of Cardiology. 39 (2): 157–161. doi:10.1016/0167-5273(93)90028-F. ISSN 0167-5273.
  41. ↑ Arai T, Kurashima C, Wada S, Chida K, Ohkawa S (November 1998). "Histological evidence for cell proliferation activity in cystic tumor (endodermal heterotopia) of the atrioventricular node". Pathol. Int. 48 (11): 917–23. PMID 9832064.
  42. ↑ Wolf PL, Bing R (November 1965). "The smallest tumor which causes sudden death". JAMA. 194 (6): 674–5. PMID 5897246.
  43. ↑ Burke AP, Anderson PG, Virmani R, James TN, Herrera GA, Ceballos R (October 1990). "Tumor of the atrioventricular nodal region. A clinical and immunohistochemical study". Arch. Pathol. Lab. Med. 114 (10): 1057–62. PMID 2222148.
  44. ↑ Burke A, Tavora F (April 2016). "The 2015 WHO Classification of Tumors of the Heart and Pericardium". J Thorac Oncol. 11 (4): 441–52. doi:10.1016/j.jtho.2015.11.009. PMID 26725181.
  45. ↑ Tran, Thao T; Starnes, Vaughn; Wang, Xuedong; Getzen, James; Ross, Brian D (2009). "Cardiovascular magnetics resonance diagnosis of cystic tumor of the atrioventricular node". Journal of Cardiovascular Magnetic Resonance. 11 (1): 13. doi:10.1186/1532-429X-11-13. ISSN 1532-429X.
  46. ↑ Tatli, Servet; O'Gara, Patrick Thomas; Lambert, Jarvis; Kwong, Raymond; Byrne, John Gerald; Yucel, E. Kent (2004). "MRI of Atypical Lipomatous Hypertrophy of the Interatrial Septum". American Journal of Roentgenology. 182 (3): 598–600. doi:10.2214/ajr.182.3.1820598. ISSN 0361-803X.
  47. ↑ Saboo, Sachin S.; Krajewski, Katherine M.; Zukotynski, Katherine; Howard, Stephanie; Jagannathan, Jyothi P.; Hornick, Jason L.; Ramaiya, Nikhil (2012). "Imaging Features of Primary and Secondary Adult Rhabdomyosarcoma". American Journal of Roentgenology. 199 (6): W694–W703. doi:10.2214/AJR.11.8213. ISSN 0361-803X.

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