.ノaJm4Mqmhomcjch'1αg伽8 1 8 : 2 0 牛 2 0 6 , 2 0 0 3 L i p p i n c o t t W i l l i a m s & W i l k i n s , I n c . , P h i l a d e l p h i a CardiacHemangiomaoftheLeftAtrialAppendage: CTandMRFindings HidekazuOshima,MD*,MasakiHara,MD*,TaroKono,MD*,YutaShibamoto,MD*, AkiraMishima,MD↑,andSachieAkita,MDネ S u m m a r y : C a r d i a c h e m a n g i o m a s a r c r a r e , b e n i g n p n m a r y c a r d i a c n e o p l a s m s , W e describetheCTandMRimagingfindingsofacardiachemangiomaansingfmmthe m y o c a r d i u m o f t h e l e f t a t r i a l a p p e n d a g e a n d p r o t r u d i n g i n t o t h e p e r i c a r d i a l c a v i t y 、 T h e t u m o r d i s p l a y e d h o m o g e n o u s d e n s i t y o n C T , h e t e r o g e n e o u s s i g n a l i n t e n s i t y o n M R , a n d i n h o m o g e n e o u s e n h a n c e m e n t a f i e r i n t r a v e n o u s c o m a s t a d m i n i s t r a t i o n , T h e h e m a n g i o m a i n t h i s c a s e w a s d i f f i c u l t t o d i f f e r c n t i a t e f r o m o t h e r m y o c a l d i a l o r a p e n c a r dialtumor・ K e y W 0 r d s : h e m a n g i o m a , h e a r t , n e o p l a s m s , c o m p u t e d t o m o g r a p h y , m a g n e t i c r e s o nancelmagmg Cardiachemangiomaisarare,benigntumorofvasc u l a r o r i g i n t h a t a c c o u n t s f b r a p p r o x i m a t e l y 5 1 0 % o f mentandleftpleuralefhlsionwereobservedonchest r a d i o g r a p h y , a n d s h e w a s r e f e l T e d t o o u r h o s p i t a l f b r b e n i g n p r i m a l y c a r d i a c t u m o r s . ’ D u e t o i t s r a r i t y , t h e filrtherevaluation、 r a d i o l o g i c c h a r a c t e r i s t i c s o f c a r d i a c h e m a n g i o m a s h a v e n o t y e t b e e n w e n d o c u m e n t e d ・ W e e n c o u n t e r e d a p a t i e n t w i t h a c a r d i a c h e m a n g i o m a a r i s i n g f i r o m t h e m y o c a r d i u m o f t h e l e f t a t r i a l a p p e n d a g e a n d p r o t r u d i n g i n t o t h e p e r i c a r d i a l c a v i t y ・ W e h e r e i n d e s c r i b e i t s C T a n d M R f i n d ‐ m a r g i n a t e d , h o m o g e n o u s , l o w d e n s i t y m a s s w i t h o u t c a l ‐ c i f i c a t i o n a d j a c e n t a n d t o t h e l e f t o f t h e l e f t a t l i u m ・ L e f t p l e u r a l e f f u s i o n w a s p r e s e n t ( F i g . 1 A ) . C o n t r a s t ‐ UnenhancedCTshoweda4、5×3.6cmwell‐ enhancedCTshowedhomogenousenhancementofthe mass(Fig.1B).MRshowedinhomogeneouslowsignal i n t e n s i t y o n T 1 w e i g h t e d i m a g e s ( F i g . 2 A ) , m i x e d i n t e r ‐ m e d i a t e a n d l o w s i g l a l i n t e n s i t y o n T 2 w e i g h t e d i m a g e s ( F i g . 2 B ) , a n d i n h o m o g e n e o u s e n h a n c e m e n t a f t e r a d m i n ‐ mgs. CASEREPORT A 7 0 y e a r o l d w o m a n w a s f b u n d t o h a v e c a r d i a c e n ‐ l a r g e m e n t o n r o u t i n e s c r e e n i n g c h e s t r a d i o g r a p h y a t a n ‐ o t h e r h o s p i t a L P e r i c a r d i a l e f f U s i o n w a s d e t e c t e d b y e c h o ‐ c a r d i o g r a p h y b u t t h e e t i o l o g y w a s u 、 C l e a r ・ P a l l i a t i v e p e r i c a r d i o t o m y w a s p e I f b r m e d t o p r e v e n t c a r d i a c t a m ‐ p o n a d e 、 F o r s e v e r a l m o n t h s , t h e p a t i e n t , s c l i n i c a l c o n d i ‐ tlonremainedstable,Sixmonthslater,cardiacenlarge‐ i s t r a t i o n o f G d D T P A ( F i g . 2 C ) . S u r g i c a l e x p l o r a t i o n r e v e a l e d t h a t t h e m a s s a r o s e f r o m t h e m y o c a r d i u m o f t h e l e f t a t r i a l a p p e n d a g e , p r o t r u d e d intothepericardialcavity,andwascoveredwith t h i c k e n e d p e r i c a r d i u m , T h e l e f t p l e u r a l e f f U s i o n w a s h e m o r r h a g i c , P a t h o l o g i c a l l y , a d i a g n o s i s o f m i x e d c a p i l l a r y a n d c a v e m o u s h e m a n g i o m a w a s c o n f i I m e d ( F i g . 3 ) . F m m t h e D e p a r t m e n t s o f * R a d i o l o g y , 十 C a I d i o v a s c u l a r S u r g e I y , a n d * I n t e m a l M e d i c i m e a n d P a t h o p h y s i o l o g y , a l l a t N a g o y a C i t y U n i v e r s i t y G r a d u a t e S c h o o l o f M e d i c a l S c i e n c e s , 1 K a w a s u m i , M i z u h o c h o , M i ‐ z u h o k u , N a g o y a 4 6 7 8 6 0 1 , J a p a n ・ A d d r c s s c o r T e s p o n d e n c e a n d r e p r i n t r e q u e s t s t o H i d e k a z u O s h i m a , MD,DepartmentofQuantumRadiology,NagoyaCityUniversity DISCUSSION Cardiachemangiomasarerarebenigntumorsofthe h e a r t t h a t c a n a f f e c t p a t i e n t s o f a l l a g e g r o u p s ・ T h e s e l e s i o n s m a y i n v o l v e t h e e n d o c a r d i u m , m y o c a r d i u m , o r e p i c a r d i u m a n d h a v e b e e n d e s c r i b e d i n a l l c h a m b e r s GradwweSchoolofMedicalSciences,lKawasumi,Mizuho-cho, Mizuho-ku,Nagoya467-8601,Japan・E-mail:eaaa2420@mb・ infbwebnejp 204 』 _ c上z7戒acHg"2α"gio"zaqノノW2eL蛾A"α/A”e"ぬge:CTα"dMRF加成"g‘s 毒覇壷毒百二F岸一一一=−−lF 205 ー 一 N 蝿 j u g為F=ー A 両 知 oH D弓が勺q咳マーーマーママ1 −=唾圭 可 戸 リ 型 ー軸 ヘ r 、 』 f 』 ii︲ 『 ■ ! i l .‐、 哩 一 」 総 i 、 自 画 髄 │ $ i 、 ■ FF冠 I 』 r…‘ 己 ワ , 〃 上 ■ 『 四 … f H 可 ロミ4詞憲垂▼ 為 hrI 『 聡 厩 ■ △ 巳一rdFQ■Q 司 謹 雪 ' 9 = Z 邑 壷 E1hA 。 台■ 棚 C 型 YCE 一 画 G U R E 1 . A ・ U n e n h a n c e d c h e s t C T , A h o m o g e n o u s m a s s w i t h o u t c m l c i f i c a t i o n l o c a t e d a d j a c e n t a n d [ o t h e l e f t o f [ h e l e f t a t I i u m ( a l T o w ) . L e f I p l e u r a l e f l U s i o n i s p r e s e n t ・ P e r i c a r d i a l e f n I s i o I 1 a n d a t h i c k e n e d p e r i c a r d i u m a r e s e e n ( a r r o w h e a d ) . B ・ C o n t r a s t e n h a n c e d c h e s t C T 、 H o m o g e n o u s enhancemen[ofthetumorisshown,Athickenedpericardiumshowsenhancement. i n c l u d i n g w i t h i n t h e p e r i c a r d i u m 2 C a r d i a c h e m a n g i o m a s a r e c l a s s i f i e d a s c a v e m o u s , c a p i l l a I y , o r a r t e l i o v e n o u s ・ TheCTandMRfindingsofcardiachemangiomas h a v e b e e n d e s c r i b e d i n o n l y a f e w c a s e s , 3 − 6 G r e b e n c e t tumorwasalsoincludedinthedifferentialdiagnosisdue tothelocationofthemass、However,solitaryfibrous tumorsshowlowsignalintensityonbothT1-andT2‐ w e i g h t e d i m a g e s , w h i c h r e f l e c t s t h e p r o p e r t i e s o f t h e a l 4 f o u n d t h a t c a r d i a c h e m a n g i o m a s h a v e a h e t e r o g e - f i b r o u s t i s s u e w i t h i n t h e t u m o r 、 8 A l t h o u g h m y x o m a a n d neousdensityonunellhancedCT,a、。,inmostcases, i n t e n s e l y e n h a n c e o n C T p e r f O r m e d a f t e r i n t r a v e n o u s p a p i l l a r y e l a s t o f i b r o m a a r e c o m m o n c a r d i a c n e o p l a s m s , t h e s e t u m o r s p r e s e n t a s e n d o c a r d i a l m a s s e s , P r i m a r y c a r ‐ c o n t r a s t a d m i n i s t r a t i o n , S i m i l a r t o h e p a t i c h e m a n g i o m a s , t h e s e t u m o r s t y p i c a l l y d e m o n s t r a t e i n t e r m e d i a t e s i g n a l intensityonTl-weightedimagesandhighsignalinten‐ d i a c m a l i g n a n t t u m o r s s u c h a s a n g i o s a r c o m a s a n d r h a b d o m y o s a r c o m a s t e n d t o h e m o r r h a g e a n d i n v o l v e t h e s u r ‐ s i t y o n T 2 w e i g h t e d M R i m a g e s 、 4 1 n a d d i t i o n , c a r d i a c hemangiomashavebeenreportedtohavecalcifications onCTandflowvoidsonMR、3 r o u n d i n g s t r u c t u r e s ・ Surgicalresectionisthe11・eatmentofchoicefor symptomaticlesionsorwhenthediagnosishasnot beenconfirmed・Spontaneousregressionofacardiac h e m a n g i o m a , h o w e v e r , h a s b e e n d e s c r i b e d i n o n e c a s e . , T h e r e f b r e , s u r g i c a l i n t e r v e n t i o n c a n b e a v o i d e d , p a r t i c u ‐ l a r l y i n c a s e s w i t h e x L e n s i v e b u t a s y m p t o m a t i c h e m a n ‐ Inourpatient,wemadeapreoperativediagnosisthat themasscouldbeofpericardialoriginsuchasavascular neoplasmorsolitaryfibroustumorofthepericardium・ Thedifferentialdiagnosisofawell-circumscribedcar- g i o m a s 、 4 I n p a t i e n t s w i t h c a r d i a c o r p e r i c a r d i a l h e m a n - diachemangiomaincludesaparaganglioma,Paragang l i o m a s u s u a l l y s h o w m a r k e d l y h i g h s i g l 1 a l i n t e n s i t y o n b e e n r e p o r t e d , ' 0 , 1 1 O u r p a t i e n t , s h e m o r r h a g i c p l e u r a l T 2 w e i g h t e d M R i m a g e s 、 7 I n o u r c a s e , a s o l i t a r y f i b r o u s gioma,thedevelopmentofcardiactamponadehas efftIsionmayhavebeencausedbybleedingfromthe JCI《maIq/”o“CiC〃"αgiノZg,VbI・ノ8,/Vo.3,2003 OSノzi"Taelfaノ 206 c a r d i a c h e m a n g i o m a t h r o u g h t h e f e n e s t r a t i o n o f t h e p e r i ‐ cardium・ Insummary,wedescribedlheCTandMRfindings ofacardiachemangiomaoftheleftatrialappendage. FIGURE3.Highpowerphotomicrograph,Therearecavemousves‐ s e l s a n d s m a l l e r c a p i l l a r y c h a n n e l s d i a g n o s t i c o f a h e m a n g i o m a 、 H e ‐ m o t o x y l i n e o s i n s t a m : o r i g i n a l m a g n i f i c a t i o n × 1 0 0 . I n o u r p a t i e n t 、 i t w a s d i f f i c u l t t o d i f f e r e n t i a t e t h e h e m ‐ a n g i o m a f i ・ o m o t h e r m y o c a r d i a l o r a p r i m a r y p e r i c a r d i a l mmoI.. REFEREN図蕊 LBurkeA,VinnaniR・Tumorsoftheheartandgreatvessels・I、: A r j a s q / 、 、 ” C l ・ P α 油 o ノ o 幻 ' 、 3 r d s e r i e s , 盆 S c 1 6 . W a s h i n g t o n , D C : A r m e d F o r c e s l n s t i m l e o f P a l h o l o g y ; 1 9 9 6 . 2.SobermanMS,PlauIhWH,WinnKJ,etaLHemangiomaofthe r i g h t v c n t r i C l e c a u s i n g o u t f l o w l r a c t o b s t r u c t i o 、 . 』 刀 I o m c C a ノ 戯 0 ‐ v a s c S z " 苫 . 1 9 8 8 ; 9 6 : 3 0 7 3 0 9 . 3.KempJL,KesslerRM,RaizadaV,etaLCasereporLMRandCT a p p e a r a n c e o f c a r d i a c h e m a n g i o m a ・ J C C " I ノ フ ゙ z 〃 A ” 師 T o " Z o g 7 . 。 1996;20:482-483. 4.GrebencML,RosadodeChlistensonML,BurkeAP,etaLPrimaエy 《ロ c a r d i a c a n d p e r i c a r d i a l n e o p l a s m s : r a d i o l o g i c p a t h o l o g i c c o 丘 e l a ‐ t i o n ・ R a d i o 8 m p ノ z i c s 、 2 0 0 0 ; 2 0 : 1 0 7 3 1 1 0 3 . 5.BravermanRM,LipshultzSE,McCartenKM,etaLPediatriccase o f t h e d a y , C a r d i a c h c m a n g i o m a , R a d i o g ノ ” 〃 “ . 1 9 9 1 ; 1 1 : 9 3 2 9 3 4 . 6.FukuzawaS,YamamotoT,ShimadaK,etaLHemangiomaofthe l e f t v e n l r i c u l a r c a v i t y : p r e s u m p l i v e d i a g n o s i s b y m a g n e t i c r e s o ‐ n a n c c i m a g i n g . H “ ノ ・ I V E s S e l S ・ ’ 9 9 3 ; 8 : 2 1 1 − 2 1 4 . 7.AraozPA,MulvaghSL,TazelaarHD・etaLCTandMRimaging o f b e n i g n p r i m a r y c a r d i a c n e o p l a s m s w i t h e c h o c a r d i o g r a p h i c c o r ‐ r e l a t i o n ・ R a d i o 8 m p h i c s 、 2 0 0 0 ; 2 0 : 1 3 0 3 1 3 1 9 . 8 . F e l r e U j G R , C h i l e s C , C h o p l i n R H , e t a l ・ L o c a l i z e d b e n i g n f i b r o u s m m o r s o f t h e p l e u r a 、 A J R A ノ 打 J R o g " I 8 e ノ z o / 、 1 9 9 7 ; 1 6 9 : 6 8 3 6 8 6 . 9.PalmerTE,TreschDD,BonchekLI・Spontaneousresolutionofa l a r g e , c a v e m o u s h c m a n g i o m a o f t h e h e a r t . A ノ 〃 J C a ノ . 。 わ / 、 1 9 8 6 ; 58:184-185. FIGURE2.A.AxialT1-weigh[ed(TR775/TE20)image、Themass s h o w s i n h o m o g e n e o u s l o w s i g I m a l i n t e n s i t y ( a I T o w ) . B , A x i a l T 2 ‐ w e i g h t e d ( r R 3 , 8 7 6 / T E l 3 2 ) i m a g e 、 T h e m a s s s h o w s m i x e d i n t e l m e ‐ d i a t e a n d l o w s i g n a l i n t e n s i t y . C ・ A x i a l T l w e i 2 h t e d ( T R 7 7 5 / T E 2 0 ) i m a g e a f [ e r l V a d m i n i s t r a t i o n o f 2 a d o l i n i u m − D T P A ・ T h e m a s s s h o w s - iI1homogeneousenhancemem. 必u"Iα/qf7ソIomcicルノ1α9mg,Vbノ.ノ8,ノVo,3,20“ 1 0 . H a n g l e r H B , V o r d e r w i n k l e r K P , F e n d R e l a l 、 I n t r a m u r a l r i 2 h t a I r i a l m y o c a r d i a l h e m 3 n c i o m a t r e a t e d b y e m e r g e n c y s u r g e r y . & " ・ ー 、 ノ C a 7 ・ d i o 1 A o r z z c S I " 9 . 1 9 9 7 ; 1 1 : 7 8 2 7 8 4 . 1 1 . S t o u p e l E , P r i m o G , K a h n R J 、 e t a l ・ C a r d i a c l a m p o n a d e w n h r e n a l failureduetohemangiomaoftheheart・AC、α㎡oI.1979:34: 345−351.
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