The International Journal of Cardiovascular Imaging (2007) 23:655–658 DOI 10.1007/s10554-005-9051-x
Ó Springer 2006
Case Report
Multiple cardiac lipomas and pericardial lipomatosis: Multidedector-row computer tomography findings Hatice Tuba Sanal, Murat Kocaog˘lu, Du¨zgu¨n Yildirim & Fatih Ors Department of Radiology, Gu¨lhane Military Medical Academy, Ankara, Turkey Received 4 October 2005; accepted in revised form 1 November 2005
Key words: Cardiac lipoma, MDCT, pericardial lipomatosis
Abstract Being rare tumors of the heart, cardiac lipomas are usually discovered incidentally during non-cardiacrelated examinations of the chest. Although they are reported to be typically solitary, multiplicity has been described in tuberosclerosis patients. Here we reported the multidedector-row computer tomography (MDCT) findings of a nontuberosclerosis case with multiple cardiac lipomas along with pericardial lipomatosis, who presented with symptoms of left heart failure after a histerectomy surgery but otherwise healthy before that operation.
Introduction Cardiac lipomas are uncommon, usually asymptomatic benign primary tumors of the heart that may incidentally be discovered during non-cardiacrelated examinations of the chest [1, 2]. Although they are typically solitary, multiplicity has been described in tuberosclerosis patients [1]. We reported the multidedector-row computer tomography (MDCT) findings of a nontuberosclerosis case with multiple cardiac lipomas along with pericardial lipomatosis, who presented with symptoms of left heart failure after a histerectomy surgery but otherwise healthy before that operation. Case report A 49-year-old woman who was totally histerectomized 2 days ago, admitted to our institution with the complaints of chest pain and dyspnea. She
had a normal pulse rate and a regular rhythm. Her blood pressure was 120/70 mmHg and body temperature measured from axilla was 37.8 °C. No murmur or thrill was present. The biochemical study and electrocardiography showed no alterations. Chest radiography showed a moderate cardiac enlargement and bilaterally costodiaphragmatic sinuses obliteration indicating pleural effusion. Echocardiography revealed a tumor mass in the right atrial wall filling most of the atrial cavity. On suspicion for pulmonary embolism because of the chest pain displayed after the history of an operation, MDCT was performed. Sixteen channel MDCT (with bolus tracking method, 160.75 collimation, 1 mm slice thickness, 0.5 mm increment, 0.5 mm reconstruction interval, 0.5 sec rotation time and 0.9 pitch) of the chest performed after the injection of iodinated contrast media, revealed a large, sessile, non-enhancing ovoid mass, measuring 4.5 3.5 cm in the right atrial
656 wall with a density similar to that of fat ( )160 HU). In the vicinity of this mass, there were few more, minute lesions with the same imaging features. There was also pericardial lipomatosis covering the anterior walls of both ventricles and extending to the arc of aorta anteriorly and atrioventricular sinuses bilaterally. There was pleural effusion bilaterally with the compressive athelectasis of the neighbouring lung fields. The patient underwent cardiac surgery for resection of the right atrial masses. As it is informed from the epicrisis, at surgery the right atrium was opened. A large broad pedicled fatty mass was found arising from the right atrial wall. The base of the tumour was dissected and the tumour was resected easily. The defect in the inferior surface of the right atrium was repaired with suture Histopathologic examination was compatible with lipomas (Figure 1).
Discussion Lipomas are rarely encountered tumors of the heart which account for 8.4% of a previously reported study that comprised 533 primary tumors of the heart and pericardium [1, 2]. Cardiac lipomas are encapsulated true neoplasms, composed of mature adipose tissue [3]. Lipomas can originate in subendocard, subepicard or myocard with an incidence of 50, 25 and 25%, respectively [1, 4]. The most common sites for lipomas are reported to be right atrium, left ventricle and interatrial septum [5]. These are typically solitary tumors but multiple lipomas have been described in patients with tuberosclerosis [1]. Although our case was not a tuberosclerosis, there were lipomas more than one in the atrial wall. To our knowledge, multiple cardiac lipomas in a nontuberosclerosis person have not been mentioned in the English-language literature before. There was also an increase in pericardial fatty tissue covering the anterior walls of both ventricles and extending to the arc of aorta anteriorly and atrioventricular sinuses bilaterally. Most cardiac lipomas are asymptomatic and discovered incidentally during a non-cardiac examination [6]. In rare instances, depending on their size, location and mobility lipomas can
display symptoms [7]. Symptoms such as (i) alteration of ventricular function, cardiac insufficiency, congestive heart failure secondary to mass effect of large lipomas, (ii) valvular obstruction or insufficiency, (iii) ventricular dysrhytmies with intramyocardial lipomas, (iv) obstruction of intracardiac blood flow with dimensionally great lipomas, (v) systemic or pulmonary embolism, (vi) angina, syncope and sudden death are all mentioned in the literature [4, 7–10]. In our case, the constrictive effect of the extensive pericardial fatty accumulation is postulated to be the cause of pleural effusion secondary to left heart failure. The histerectomy operation put a burden on to the heart and pericardial lipomatosis exerted a constrictive effect causing effusion. In our opinion, lipomas in the right atrium have minor role in the display because after the cardiac surgery patient improved, only after the addition of anticongestive medical therapy. With MDCT, in different imaging planes, the exact site and extension of lipomas can be detected on the basis of their densities similar to that of fat attenuation (0 HU) [2, 4]. Liposarcoma can be excluded in the differential diagnosis of lipomas because even a well-differentiated liposarcoma has a higher CT HU number [4]. This is the first case of multiple cardiac lipomas along with pericardial lipomatosis presented with MDCT findings. With MDCT, postprocessing of the raw data with a three-dimensional (3D) volume rendering technique and two-dimensional (2D) multiplanar reformatted images generate high quality vascular maps. Images taken in a short time with MDCT opposite to MRI’s, is the advantage that should be taken into consideration when the general condition of the patient is not suitable for long periods of imaging. Cardiac MRI, with its large field of view, perfect contrast and spatial resolution, and multiplanar imaging capabilities, is also well suited for the diagnosis and evaluation of cardiac lipomata. It makes not only possible to precisely localize the tumor in relationship to cardiac chambers but also show involvement of myocardium, pericardium, valve, or adjacent structures [1]. With MRI ionizing radiation and iodinated contrast medium is not
657
Figure 1. (a, b) Axial MDCT after contrast media injection shows a dimensionally great lipoma in the right atrial wall with neighbouring tiny ones. Pericardial lipomatosis is also seen covering the anterior walls of both ventricles and extending to the atrioventricular sinuses bilaterally. There is pleural effusion bilaterally with compressive athelectasis.
used. The disadvantages of MRI include contraindications, like, implanted defibrillators and pacemakers, ferromagnetic aneurysm clips and the requirement of a stable cardiac rhythm for ECGtriggered sequences. In our patient, MR imaging was not possible because of dyspnea that is worsened in decubitus position; besides MDCT revealed lesion characteristics and its extent with no supplementary need for MRI.
Although long-term prognosis for asymptomatic lipomas is good, fatal courses have been described for untreated symptomatic lipomas [10]. Treatment of myocardial lipomatous lesions is generally conservative, particularly if they have infiltrated the conduction system, His bundles, making resection impossible [6]. In the literature, a case with pericardial lipomatosis treated by pericardiectomy is reported [11].
658 In conclusion, lipomas of the heart which can be multiple, can be diagnosed by MDCT in different planes with their typical imaging properties i.e, site, homogenous low density and nonenhancement. Lipomas of the heart can stay asymptomatic for years until a burden like operation deteriorates the function of the heart and general condition of the patient. The necessity of cardiac surgery for extirpation of the tumor should be scrutinized once more because the lipoma itself may not be throughly responsible for the disease scenario displayed. The patient may improve simply by medical treatment like in our case.
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Address for correspondence: Hatice Tuba Sanal, Department of Radiology, Gu¨lhane Military Medical Academy, Tellikaya sok. O¨rnek Apt. 9/9, Ankara, Ic¸cebeci, 06590, Turkey E-mail:
[email protected]
