Quick Fire Cases
Mihir Shah, MD
Resident Physician
Temple University Hospital
Mihir Shah, MD
Resident Physician
Temple University Hospital
Joel Novograd, MD
Resident Physician
Temple University Hospital
Aruna Padmanabhan, MD
Attending Physician
Temple University Hospital
Chandra Dass, MD
Professor of Radiology
Lewis Katz School of Medicine at Temple University
Pravin Patil, MD
Attending Cardiologist
Temple University Hospital
37 year old male presented with paresthesia in the perineal region associated with constipation and urinary retention for three weeks. He denied a history of chest pain, dyspnea, or palpitations. On admission, CT abdomen/pelvis was unrevealing. Given symptoms, MR pelvis and lumbar spine were obtained, revealing several bone enhancing lesions. Subsequent bone biopsy from one of the rib lesions resulted with spindle cells, consistent with a low grade vascular neoplasm without obvious features of angiosarcoma. Further radiological correlation was recommended.
Diagnostic Techniques and Their Most Important Findings:
A CT chest was obtained which reportedly showed a 5 cm mass along the right anterolateral aspect of the heart. A TTE was used to further characterize the mass however no mass was visualized. Cardiac MR was then ordered to further evaluate structure and morphology. CMR demonstrated cardiac mass in right atrial appendage. Axial b-SSFP Cine demonstrated the intra-cavitary nature and deformation of the right atrial appendage. Triple inversion recovery black-blood imaging demonstrated enhancement of the mass and adjacent pericardial structures. In first-pass perfusion imaging there was early gadolinium enhancement, then delayed enhancement of the mass was observed with areas of necrosis and adherent thrombi (Figure 1). Subsequent FDG PET/CT demonstrated uptake in cardiac mass (SUV 11.4), multiple rib lesions (SUV 8.7,14.3), and pre-sacral mass (SUV 14). CT Guided biopsy of pre-sacral mass with final diagnosis of well-differentiated spindle cell angiosarcoma of the bone.
Learning Points from this Case:
This case demonstrates the utility of a multimodal approach to aid in the characterization and diagnosis of undifferentiated cardiac masses. The initial CT chest and subsequent transthoracic echo were of little diagnostic utility. Utilization of cardiac MR allowed for further definition of the intracardiac nature of the lesion. It highlights the value of cross-modality correlation for cardiac masses, ultimately CMR and FDG PET correlation proved most valuable. Although the final diagnosis was ultimately pathological and extracardiac, the characterization of an intracardiac right atrial lesion reminds us of the broad differential diagnosis and the possibility of metastatic right atrial appendage angiosarcoma.
