MR Imaging of Primary Cardiac and Pericardiac Tumors 1

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1 Journl of the Koren Rdiologicl Society, 1995 : 32(2) : MR Imging of Primry Crdic nd Pericrdic Tumors 1 Myung Kwn Lim, M.D., Je Hyung Prk, M.D., Jin Wook Chung, M.D., Ji Hye Kim, M.D., Yeon Hyun Choe, M.D.2, Mn Chung Hn, M.D. Purpose: To evlute chrcteristic MR findings of primry crdic nd pericrdictumors. Mterils nd Methods: There were myxoms (n= 기, mlignnt Iymphom (n=1 ).Iipom (n=1). nd pericrdic mesothelioms (n=2). We nlyzed loction, size, shpe, signl intensity, contrst enhncement, nd ssocited findings of djcent structures such s pericrdic nd pleurl effusion, nd medistinl Iymph node enlrgement. Results: Loctions of the myxoms were left trium in four cses, left ventricle in one, right trium in one, nd right ventricle in one. Men dimeter ws 3.5 cm (rnge, 2-7cm). They were polypoid or loulted in shpe, nd ttched to intertril or interventriculr septum in ll cses except in right tril myxom which ws ttched to lterl wll. Their peduncles were demonstrted in three left tril myxoms. The signl intensities were iso or slightly high on T1- weighted imges nd high on T2-weighted imges. Pleurl nd pericrdil effusions were shown in thethree cses. Mlignnt Iymphom ws mnifested s lrge mss in right ventricle infiltrting to right trium, interventriculr septum, right prtrchel nd retrocrdic re. It hd slightly high intensity in oth T1- nd T2-weighted imges with strong contrst enhncement nd ssocited with oth pericrdic nd pleurl effusion. Lipom ws polypoid in shpe nd ttched to lterl wll of left ventricle with right T1 nd high T2 signl intensity. Pericrdic mesotheliom ws mnifested s pericrdic nd tril mss with diffuse irregulr uneven thickening of pericrdium which hd iso signl on T1- nd high T2-weighted imges with moderte contrst enhncement. Conculsion: MR imging is very useful method in demonstrtion of the 10- ction, extent, tissue chrcteristics of the mss, nd reltionship with its djcent structures in evlution of crdic nd pericrdic tumors. Index Words : Hert, MR Hert, neoplsms Primry crdic tumor of the hert is rre, nd onethird of it is mlignnt(1, 2). At present time, echocrdiogrphy is the most importnt non - invsive techhnique for imging of hert, nd generlly it is n initil imging procedure(1, 3-6). ECG - gted MR imging hs een known to provide high - qulity imges of the hert nd to e useful in the detection of crdic 1 Deprtment 01 Rdiol ogy, Seoul Ntionl Uni versity Co li ege 01 Medicine 20eprtment 01 Rdiology, SmSung Medicl Center Received Octoer 1 0,1994; Accepted Jnury9, 1995 Surported y grnt No Irom the Seoul Ntionl University Hospi tl Reserch Fund Address repr int requ ests to : Myung Kwn Lim, M.O., Oeprtment 01 Rdiology, Seoul Ntionl University Hospitl, 28 Yongon.dong Chongno.gu, Seoul , Kore. Te l Fx x m tumors, thromi, nd pericrdic msses(7, 8). This report is to descrie the chrcteristic findings of MRI in 11 ptients with surgiclly nd pthologiclly proven primry cl"dic nd pericrdic tumors. MATERIALS nd METHODS MR imge of 11 ptients with surgiclly nd pth logiclly proven primry crdic nd pericrdic tumors were reviewed retrospectively. Six mle nd 5 femle ptients, rnging in ge from 27 to 64 yers were exmined. AII studies were done with 0.5T superconductive ECG - gted MR imger (Supertech 5000, GoldStr, Seoul, Kore). Imging ws done in the trnsverse plne in ll 11

2 Journ l of the Koren Rdiologicl Society, 1995 ; 32(2) : ptiens, with dditionl imging in coronl in 8 ptients nd sgittl plne in 7 ptients. Multisection imging ws performed to hve seven or fifteen sections per imging sequences. The spin-echo technique ws used with repetition time (TR) equl to RR intervl of the ECG nd echo dely time (TE) of 30 msec. The section thickness ws mm nd sequentil imges were contiguous. We nlized the tumors in terms of loction of the mss, size or extent, shpe, signl intensity with heterogeneity, nd degree of contrst enhncement. We lso reviewed reltionship of the tumor to surrounding structure such s pleurl effusion, medistinl Iymph node enlrgement, pericrdil effusion. Signl intensity ws compred with crdic muscles nd shpe of the mss ws clssified s exophytic, infiltertive, nd polypoid. RESULTS There were 11 ptients with primry crdic nd pericrdic tumors including 7 myxoms, mlignnt Iymphom, lipom, nd two pericrdic mesothelioms. AII were operted nd pthologiclly proven. Myxoms were t left trium in four (Fig. 1), nd left ventricle, right trium, nd right ventriclein one cse, respectively. Men dimeter ws 3.5 cm with rnge of 2-7 cm. They were p 이 yp 이 d or loultedin shpe, nd tttched to intertril or interventriculr septum in li cses except in right tril myxom which ws ttched to lterl wl l. The peduncle ws demonstrted in three left tril myxoms. The signl intensity ws iso or slightly high on T1 - weighted imges nd high on T2 - weighted imges. Pleurl effusion ws shown in 3 cses nd pericrdil effusion ws in 2 cses. There ws no medistinllymph node enlrgement. Mlignnt Iymphom ws represented with lrge right ventriculr mss infilterted to right trium nd interventriculr septum, nd extended to medistinum, tht is, right prtrchel nd retrocrdic re (Fig. 2). Its signl intensity ws homogeneous nd slightly high on oth T1 - nd T2 - weighted imges with strong contrst enhncement. There ws ilterl pleurl effusion nd miniml pericrdil effusion. No Fig. 1. Myxom in left trium.. Left ventri cle is enlrged nd there is pol ypoid mss with heterogeneous iso-signl intensity on T1 -weighted imge (T1WIl within left trium. It is tttched to intertril septum (rrows). Pericrdil effusion is noted (1 ong rrows), c. Contrst enhnced xil() nd sgittl (c) imges show little enhncement d. On T2WI, this mss shows heterogeneous high signl intensity e. Grdient echo dynmic imge shows this mss s fillin g defect in left trium c m e

3 Myung Kwn Li m, et l: MR Imging of Primry Crdic nd Pericrdic Tumors medistinllymph node enlrgement ws shown. Lipom ws polypoid in shpe nd tttched to lterl wll nd pex of left ventricle(fig. 3) with high signl intensity on T1 - nd T2 - weighted imge. No contrst enhncement ws done. No rection with surrounding structure ws shown In one pericrdic mesotheliom, it ws menifested s diffuse irregulr uneven pericrdil thickening nd prtilly infilterted to right ventricle, left trium nd right lung(fig. 4). It hd iso signl intensity on T1 weighted imge nd high T2 signl intensity with moderte contrst enhncement. In nother pericrdic mesotheliom, diffuse even pericrdil wll thickening ws seen with encsement of the ort nd pulmonry rtery. The signl intensity ws identicl with the other one DISCUSSION Primry tumors of hert nd pericrdium re found in less thn 0.1 % of utopsy series nd re two to three times more often enign thn mlignnt (3, 4, 7). Metststic neoplsms involving the hert re times more frequent thn primry tumors (9, 1 이. Left tril myxom comprises 50% 01 the enign crdic tumors in dults, while rhdomyom, firom, nd myxom Fig. 2. Lymphom. There is soft tissue mss in right ventriculr free wll with extension into left ventricle (white rrow) nd interventriculr septum (smll white rrows). On T1 WI, it shows high signl intensity. There re pericrdil effusion (lck rrows) nd pleurl effusion (rrow heds). Contrst enhnced coronl scn shows heterogeneous mild enhncemment of the mss with tumorl infiltertion to the diphrgmtic surfce (rrows) Fig. 3. Li pom. There is well-demrcted polypoid mss in left ventriculr pex nd lterl wll with very high signl intensity on T1 WI.. On T2WI, this mss shows slight high signl intensity τ

4 Journl of the Koren Rdiologicl Society, 1995: 32(2) : Fig. 4. Pericrdic mesotheliom c,. There is diffuse uneven pericrdil thickening especilly in right pericrdium nd infiltertion into right trium,ieft trium nd right lung. This mss shows iso signl intensity on T1 WI(), nd high signl intensity on T2WI() c. Sgittl T1 WI shows homogeneous pericrdil thicken ing. τ1 ιre mostcommon in infnts nd children (4-6). In spite of modern dignostic methods, crdic tumors still present dignostic chllenge. These tumors my remin symptomtic for periods of time, nd present with nonspecific symptoms such s chest pin, unexplined hert fil t:j re, emoliztion, sign of inflow r outflow ostruction, loss of weight, hert murmurs, nonspecific ECG chnges, vrition in hert size, nd pericrdil effusion. If crdic tumor is suspected from history nd physicl exmintion, the first dignostic tool should e echocrdiogrphy, which is n efficient nd noninvsive method. In cses positive for crdic tumor the following re of specil clinicl interest : locliztion, size, infiltertion of crdic structures, hemodynmic effects, vsculriztion, consistency, nd histologic clssifiction. If, in spite of negtive echocrdiogrphic findings, crdic tumor is still suspected cliniclly, dditionl dignostic work- up is mndtory. The following methods cn e used: conventionl or ultrfst CT with nd without contrst enhncement, MR imging with nd without prmgnetic gents such s gdolinium diethylenetrimine pentcette (Gd - DTPA), ngiogrphy, endomyocrdil iopsy, nd direct surgicl procedures (5, 11-14). MR nd echocrdiogrphy shre the dvntge of direct imging of the crdic msses, wheres ngiogrphy relies on indirect evidence such s filling defects, focl wll thickening, or distortion. The ility of MR to pertorm sgittl nd coronl imging s well s the expnding cpility to otin imges in the plne of the short xis of the hert enles MR to define the ntomic loction nd extent of mss lesions precisely. Additionlly, MR imging, with its wide field of view, cn lso define ny extrcrdic portions of the mss. A reltive disdvntge of CT compred with MR imging is tht dignostic yield of the former depends to lrge extent on the proper timing of the injection of n dequte mount of ionized contrst meteril with scn quisition t the vrious ntomicl levels. The reltive disdvntges of echocrdiogrphy re its 1 imittion in oese ptients nd those with ostructive lung disese, nd much smller field of view thn MR imging. However, 2D echocrdiogrphy hs the dvntges of thinner tomogrphic sections nd limitless imging plnes(3, 15). MR imging, which provides two - dimensionl cross - sectionl imges ofthe crdic chmers, is n ccurte method for detecting crdic tumors. Rpidly flowing lood, which emits little or no signl, ppers lck within the chmers of the hert. This enles the excellent seprtion of lood - filled chmers from the soft tissue tht mkes up the wll of the chmer. Intrcrdic tumors re identifile within the chmers of the hert without contrst enhncement, s used with CT. MR imging lso llows direct imging in multiple plnes- sgittl, coronl, nd trnsxil. M 비 tiple plne imging ssists in determining the reltionship of the tumor to vrious crdic structures. The imges re lso otined without ionizing rdition. In ECG - gted MR imging, the TR intervl cnnot e

5 Myung Kwn Li m, et l : MR Imging of Primry Crdic nd Pericrdic Tumors chosen freely ut is determined y the RR intervl of the ptient s ECG. The typicl TR nd TE vlues on spin - echo EEG - gted MR imging fll into the ctegory of prtil-sturtion spin -echo sequences. Such sequences tend not to differentite etween vrious nonftty soft tissues. Nevertheless, the comintion of intensity chrcteristics, morphologic informtion, nd clinicl dt llowed correct dignosis to e mde in severl cses. Qulittive tissue chrcteriztion ws possile with ftty lesions nd those contining lrge vsculr structures. Reltive tissue - intensity chrcteristics hve een shown to llow degree of specificity in the MR dignosis of some crdic lesions, such s lipomtous hypertrophy of the tril septum, firom, thromus, myxom, nd pericrdil cyst or ft pd (1, 4). In our study, specific dignosis were possile in myxom, lipom nd Iymphom with tissue - intensity chrcteristics nd in pericrdic mesothelioms with morphologic informtion. Tht is, heterogeneous intermedite or slightly high signl on T1 weighted imge nd high signl on T2 - weighted imge is seen in crdic myxom(15-17), infiltertive high signl intensity lesions on T1 - nd T2 - wighted imges in Iymphom, very high signl mss on T1 - weighted imge nd slight high signl intensity on T2WI in lipom(11, 18-20). Also, irregulr diffuse uneven thickening of pericrdium is reltively specific morphologicl chrteristics in pericrdil mesotheliom. But, s others hve noted, the primry contriution of MR imging in these cses ws not its ility to otin tissue dignosis, ut rther its ility to delinete the ntomic extent nd to id in tretment plnning (4, 21, 22). In conclusion, MR imges re useful method in demonstrtion of the loction, extent, tissue chrcteristics, nd reltionship with its djcent structures in evlution of crdic nd pericrdic tumors. REFERENCES 1. Pietro DA. Prisi AF. Intrcrdic msses : tumors. vegettions. thromi. nd loreign odies. Med clin North Am 1980 ; Kim EE. Wllce S. Aello R. et l. Mlignnt crdic li- rous histiocytoms nd ngiosrcoms: MR letures. J Comput AssistTomogr1989 ; 13 : Winkler M. 에 ggins CB. Suspected intrcrdic msses: evlution with MR imging. Rdiology 1987 ; 165: Lund JT. Ehmn RL. Julsrud PR. Sink LJ. Tjik AJ. Crdic msses: ssessment y MR imging. AJR : Rienmuller R. Ll oret JL. Tiling R. et l. MR imging 01 peditric crdic tumors previously dignosed y echocrdiogrphy. J Comput Assist Tomogr 1989 ; 13 : Bouton S. Yng A. McClindle BW. Kidd L. McVeigh ER. Zerhouni EA. Dillerentition 01 tumor Irom vile myocrdium using crdic tgging with MR imging. J Comput AssistTomogr1991 ; Gomes AS. Lois JF. Child JS. Brown K. Btr P. Crdic tumors nd thromus:evlution with MR imging. AJR 1987 ; Boxer RA. LCorte MA. Singh S. et l. Dignosis 01 crdic tumors in inlnts y mgnetic resomnce imging. Am JCrdi 이 1985 ; 56 : Brkos JA. Brown JJ. Higgins CB. MR imging 01 secondry crdic nd prcrdic lesions. AJR 1989 ; 153 : Lee R. Fisher MR. MR imging 01 crdic metstsis Irom ml i g nnt lirous histiocytom. J Comput Assist Tomogr 1989; Conces DJ. Vix VA. Trver RD. Dignosis 01 myocrdillipom y using CT. AJR 1989; 153 : McAdms HP. Scheler PS. Ghed VN. Leukemic inliltertes 01 the hert: CT lindings. J Comput Assist Tomogr 1989; Korokin M. Csno VA. Intrcvl nd intrcrdic extension 01. mlignnt thymom :CT dignosis. J Comput Assist Tomogr 1989 ; 1 3 : Gross BH. Glzer GM. Frncis IR. CT 01 intrcdic nd intrpericrdil msses AJR 1983 ; 140 : Conces DJ. Vix VA. Kltte EC. Gted MR imging 01 left tril myxoms. Rdiology 1985; 156 : Michel AS. Mikhel MA. Christ M. Myxom 01 the hert presenting with recurrent episodes 01 hemmorhgic cerrerl inlrction : MR lindings. J Comput Assist Tomogr 1989 ; Mrkel ML. Wller BF. Armstrong WF. Crdic myxom: re. view. Medicine 1987 ; 66 ; Kpln KR. Rilkin MD. MR dignosis 01 lipomtous inliltertion 01 the intertril septum. AJR 1989 ; 153: King SJ. Smllhorn JF. Burrows PE. Epicrdil lipom: imging lindings. AJR 1993; 160 : Applegte PM. Tjik AJ. Ehmn RL. Julsrud PR. Miller FA Two-dimensionl echocrdiogrphic nd mgnetic resonnce imging oservtions in mssive I ipomtous hypertrophy 01 the tril septum. Am J Crdio/1987 ; 59: Conti VR. Sydjri R. Ampro EG. Prgngliom 01 the hert : the vlue 01 mgnetic resonnce imging in the preopertive evlution. Chest : Fisher MR. Higgins CB. Andereck W. MR imging 01 n intrpericrdic pheochromocytom. J Comput Assis

6 Journl of the Koren Rdiologicl Society, 1995 : 32(2) : 대한방사선의학회지 1995: 32(2) : 원발성심장및심막종양의자기공명영상 I I 서울대학교의과대학방사선과학교실 2 삼성의료원방사선과 임명관 박재형 정진욱 김지혜 최연현 2 한만청 목적 : 원발성심장및심막종앙의특징적인자기영상소견을알아보고자하였다. 대상및방법 :7예의점액종, 악성림프종, 지방종각 1 예, 심막중피종 2예등총 11 예의종양이대상이었으며, 자기공명영 상소견에서종괴의위치와크기, 모앙, 신호강도와초영증강정도를분석하였고심막혹은늑막삼출이나종격동림프질의비 후등동반된소견들을분석하였다. 결 과 : 점액종의위치는좌심방이 4 예로가장많았고그외좌심실과우심방, 우심실이각각 1 예씩이었다. 평균크기는 3.5cm(2-7 cm 범위 ) 였다. 모앙은폴립앙이거나분엽모앙이었고외측벽에붙어있었던 1 예의우심방의종괴를제외하면 모두에서심방중격혹은심실중격에붙어있었다. 종괴경 (peduncle) 은 3예의좌심방점액종에서보였다. 신호강도는 Tl 강조 영상에서는심장근육에비해같거나약간높고 T2 강조영상에서는높은신호강도를나타내었다. 심막삼출과늑막삼출이각 각 3 예에서보였다. 악성림프종은커다란우심실의종괴로나타났으며우심방과심실중격, 우측기관주위와심장후방공간 을광범위하게침범하고있었다. Tl 및 T2 강조영상에서모두약간높은신호강도를보였으며강하게조영증강이되었고심 막및는막삼출이동반되었다. 지방종은폴립앙으로좌심실의외측벽에붙어있었다. 특징적으로 Tl 강조영상에서매우높은 신호강도를 T2 강조영상에서도높은신호강도를나타내었다. 심막중피종은우측심막과앙측심방의종괴로나타났으며심 막의전반적인불규칙적인비후소견을보였다. Tl 강조영상에서는주위근육과비슷한신호강도를 T2 강조영상에서는높은 신호강도를나타냈으며중등도로조영증강되었다. 결 론 : 자기공멸영상은여러신호강도와여러단면영상으로심장및심막종괴를평가함에있어, 그위치나크기, 조직학 적특성및주위조직간의관계를보는데매우유용할것으로생각된다. 않