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Tumor Mimics
Eva Kusmirek, MD; John D. Grizzard, MD; Kathryn M. Olsen, MD
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KEY FACTS

  • Terminology

    • Imaging

      TERMINOLOGY

      • Synonyms

        • Pseudomasses
      • Definitions

        • Entities that appear as masses on initial imaging (usually echo) but often are either normal structures or clinically insignificant variant lesions; usually resolved with cross-sectional imaging (CT or MR)
          • Normal cardiac variants
            • Crista terminalis
              • Normal fibromuscular ridge indenting right atrium (RA)
              • Demarcates site of fusion of embryologic primitive RA with sinus venosus
            • Eustachian valve
              • Variably prominent ridge of tissue at junction of inferior vena cava (IVC) with RA
              • Directs blood flow toward foramen ovale in fetal life
              • When prominent, can be mistaken for mass on echo
            • Other congenital remnants of valve of sinus venosus in RA
              • Thebesian valve: At junction of coronary sinus with RA
              • Chiari network: Net-like structure though to be variant of eustachian valve but much more mobile
            • Taenia sagittalis
              • Most prominent pectinate muscle in RA
              • Remnant of septum spurium
            • Coumadin (warfarin) ridge
              • Band-like structure in left atrium (LA), between left superior pulmonary vein and left atrial appendage (LAA)
              • Described as Q-tip sign on transesophageal echocardiography (TEE)
              • Mistaken for thrombus or mass in echocardiography
          • Intracardiac benign abnormalities
            • Lipomatous hypertrophy of interatrial septum (LHIAS)
              • Hyperplasia of normal fat cells often contiguous with epicardial fat
              • Fat infiltrates interatrial septum and expands it to diameter > 2 cm but spares fossa ovalis, creating dumbbell shape
              • May be hot on FDG PET due to composition of brown fat, which is FDG avid
            • Mitral annular calcification (MAC)
              • Calcification of fibrous annulus of mitral valve usually occurs as degenerative change
              • Occurs earlier and is more extensive in renal failure
              • May appear mass-like in some cases, especially if caseous MAC
            • Sinus of Valsalva aneurysm
              • Abnormal enlargement of single sinus, usually right (~ 80%)
              • Usually congenital in origin, less commonly due to endocarditis
            • Membranous septal aneurysm associated with ventricular septal defect (VSD)
              • Redundant septal tissue arising adjacent to membranous VSD that may appear mass-like
              • May partially occlude VSD
            • Hypertrophic cardiomyopathy (asymmetric variant)
          • Extracardiac lesions: Less common causes of confusion on imaging
            • Hiatal hernia
            • Complex/loculated pericardial effusion or prominent pericardial fat
          • Thrombus
            • Actually mass, not pseudomass, but not neoplasm

      IMAGING

      • General Features

        • MR Findings

          • CT Findings

            • Imaging Recommendations

              DIFFERENTIAL DIAGNOSIS

                PATHOLOGY

                • Staging, Grading, & Classification

                  CLINICAL ISSUES

                  • Presentation

                    DIAGNOSTIC CHECKLIST

                    • Consider

                      • Image Interpretation Pearls

                        Selected References

                        1. Tumma R et al: Evaluation of cardiac masses by CMR-strengths and pitfalls: a tertiary center experience. Int J Cardiovasc Imaging. 32(6):913-20, 2016
                        2. Terpenning S et al: Imaging pitfalls, normal anatomy, and anatomical variants that can simulate disease on cardiac imaging as demonstrated on multidetector computed tomography. Acta Radiol Short Rep. 4(1):2047981614562443, 2015
                        3. Anavekar NS et al: Computed tomography of cardiac pseudotumors and neoplasms. Radiol Clin North Am. 48(4):799-816, 2010
                        4. Weinsaft JW et al: Detection of left ventricular thrombus by delayed-enhancement cardiovascular magnetic resonance prevalence and markers in patients with systolic dysfunction. J Am Coll Cardiol. 52(2):148-57, 2008
                        5. Salanitri JC et al: Cardiac lipoma and lipomatous hypertrophy of the interatrial septum: cardiac magnetic resonance imaging findings. J Comput Assist Tomogr. 28(6):852-6, 2004
                        6. Meier RA et al: MRI of right atrial pseudomass: is it really a diagnostic problem? J Comput Assist Tomogr. 18(3):398-401, 1994
                        7. Mirowitz SA et al: Fibromuscular elements of the right atrium: pseudomass at MR imaging. Radiology. 182(1):231-3, 1992
                        Related Anatomy
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                        Related Differential Diagnoses
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                        References
                        Tables

                        Tables

                        KEY FACTS

                        • Terminology

                          • Imaging

                            TERMINOLOGY

                            • Synonyms

                              • Pseudomasses
                            • Definitions

                              • Entities that appear as masses on initial imaging (usually echo) but often are either normal structures or clinically insignificant variant lesions; usually resolved with cross-sectional imaging (CT or MR)
                                • Normal cardiac variants
                                  • Crista terminalis
                                    • Normal fibromuscular ridge indenting right atrium (RA)
                                    • Demarcates site of fusion of embryologic primitive RA with sinus venosus
                                  • Eustachian valve
                                    • Variably prominent ridge of tissue at junction of inferior vena cava (IVC) with RA
                                    • Directs blood flow toward foramen ovale in fetal life
                                    • When prominent, can be mistaken for mass on echo
                                  • Other congenital remnants of valve of sinus venosus in RA
                                    • Thebesian valve: At junction of coronary sinus with RA
                                    • Chiari network: Net-like structure though to be variant of eustachian valve but much more mobile
                                  • Taenia sagittalis
                                    • Most prominent pectinate muscle in RA
                                    • Remnant of septum spurium
                                  • Coumadin (warfarin) ridge
                                    • Band-like structure in left atrium (LA), between left superior pulmonary vein and left atrial appendage (LAA)
                                    • Described as Q-tip sign on transesophageal echocardiography (TEE)
                                    • Mistaken for thrombus or mass in echocardiography
                                • Intracardiac benign abnormalities
                                  • Lipomatous hypertrophy of interatrial septum (LHIAS)
                                    • Hyperplasia of normal fat cells often contiguous with epicardial fat
                                    • Fat infiltrates interatrial septum and expands it to diameter > 2 cm but spares fossa ovalis, creating dumbbell shape
                                    • May be hot on FDG PET due to composition of brown fat, which is FDG avid
                                  • Mitral annular calcification (MAC)
                                    • Calcification of fibrous annulus of mitral valve usually occurs as degenerative change
                                    • Occurs earlier and is more extensive in renal failure
                                    • May appear mass-like in some cases, especially if caseous MAC
                                  • Sinus of Valsalva aneurysm
                                    • Abnormal enlargement of single sinus, usually right (~ 80%)
                                    • Usually congenital in origin, less commonly due to endocarditis
                                  • Membranous septal aneurysm associated with ventricular septal defect (VSD)
                                    • Redundant septal tissue arising adjacent to membranous VSD that may appear mass-like
                                    • May partially occlude VSD
                                  • Hypertrophic cardiomyopathy (asymmetric variant)
                                • Extracardiac lesions: Less common causes of confusion on imaging
                                  • Hiatal hernia
                                  • Complex/loculated pericardial effusion or prominent pericardial fat
                                • Thrombus
                                  • Actually mass, not pseudomass, but not neoplasm

                            IMAGING

                            • General Features

                              • MR Findings

                                • CT Findings

                                  • Imaging Recommendations

                                    DIFFERENTIAL DIAGNOSIS

                                      PATHOLOGY

                                      • Staging, Grading, & Classification

                                        CLINICAL ISSUES

                                        • Presentation

                                          DIAGNOSTIC CHECKLIST

                                          • Consider

                                            • Image Interpretation Pearls

                                              Selected References

                                              1. Tumma R et al: Evaluation of cardiac masses by CMR-strengths and pitfalls: a tertiary center experience. Int J Cardiovasc Imaging. 32(6):913-20, 2016
                                              2. Terpenning S et al: Imaging pitfalls, normal anatomy, and anatomical variants that can simulate disease on cardiac imaging as demonstrated on multidetector computed tomography. Acta Radiol Short Rep. 4(1):2047981614562443, 2015
                                              3. Anavekar NS et al: Computed tomography of cardiac pseudotumors and neoplasms. Radiol Clin North Am. 48(4):799-816, 2010
                                              4. Weinsaft JW et al: Detection of left ventricular thrombus by delayed-enhancement cardiovascular magnetic resonance prevalence and markers in patients with systolic dysfunction. J Am Coll Cardiol. 52(2):148-57, 2008
                                              5. Salanitri JC et al: Cardiac lipoma and lipomatous hypertrophy of the interatrial septum: cardiac magnetic resonance imaging findings. J Comput Assist Tomogr. 28(6):852-6, 2004
                                              6. Meier RA et al: MRI of right atrial pseudomass: is it really a diagnostic problem? J Comput Assist Tomogr. 18(3):398-401, 1994
                                              7. Mirowitz SA et al: Fibromuscular elements of the right atrium: pseudomass at MR imaging. Radiology. 182(1):231-3, 1992