Unni Krishnan Sorry Jithesh, my brain does not work without a history, so could you provide a clinical context please?
Jithesh Kizhakkevalappil A middle aged lady presented with Dyspnoea ,Facial puffiness and engorged neck veins... All features suggestive of SVC...On examination she had few enlarged cervical and axillary LNEs......Chest X ray shows right side plueral effusion only, will later upload(I cant find it on my computer)
Unni Krishnan: Jithesh, I will give you my raw interpretation and then you can polish this.
Firstly I struggled to assess the level, but seeing that there is the tip of the scapula on the right, it has to be lower thoracic, I assume.
Secondly, for a guy with a hammer... you know, so I focused on the heart after a cursory glance at the b/l effusion (Rt > Lt). My first thought was that given this is a contrast study, there is not much dye in the RA. Now is this just the plane of the scan (i.e., too near the diaphragm?), but then, the level of the slice seems to go through the upper pulmonary veins. Also the plane is at the base of the heart, not the apex, almost like a parasternal short axis view (echo) with the aortic root in the middle and the right heart wrapping around it. If this is the case, then the RA is definitely full of something and the 'something' seems to arise from the atrial septum.
If so, then is this lymphomatous infiltration, given the LNE? I guess it could also be a direct spread from the abdomen like carcinoid, RCC etc.
Feel free to shoot me down if I am barking up the wrong tree. I see the world through a catheter most of the time, so I apologise for my scotomatous view.
Did she also have pedal oedema? My hypothesis would only fit if she has pedal oedema.
Purushothaman Kuzhikkathukandiyil Unni, If the RA was filled with lymphomatous infilteration and as you said infilterating from abd. through IVC.( Whatever, ) why there is no pedal odema abdominal distention. From jithesh description the neck veins only distended. ................I agree the density of the right pleural and RA is same, ............. RA infliteration ,,,,will it be this uniform....?
Prakash Iyer my DD..1, atrial myxoma..enhancing mass.. 2. tumor thrombus...3,mets...
Purushothaman Kuzhikkathukandiyil Prakash , if you consider the right atrial uniform shadow , as invasion , .......lymphoma is the first possibility ....where we can explain all other findings.Why i am a bit suspicious is , by the time RA is this much filled why there is only upper part congestion only and wil it not compromise the cardiac out put ....
Prakash Iyer Sir..1. pericardial effusion seen seperating pericardium from mass. so lymphoma can be consisdered lower down...
Prakash Iyer now it is not lymphoma also for the other reason which u have mentioned in the later part ..also sir it will be difficult to explain effusion in that case..
Prakash Iyer mets will be a good bet...
Prakash Iyer i have seen 2 cases of carcinoma breast with right atrial mets,,and one thymic mets with similar features
Praveen Ayyappan Nair b/l pl.eff+pericardial eff in middle aged female+ LNE+SVCO; D/D are lymphoma, bronchogenic ca ,tuberculosis,mets, LAM rarely.
Unni Krishnan Sir, as I said in my post, my diagnosis will only work if there is pedal oedema. I think it is infiltrative because the 'mass' is the same density as the atrial septum. Regarding myxoma, I am not sure how common they are in the RA, also they are not usually so sessile.
Unni Krishnan Also the atrial septum appears thickened
Purushothaman Kuzhikkathukandiyil Prakash , please clear my doubt. The density of right sided pleural , and right atrial is same and we consider the right atrial shadow is some infilteration, and we find it difficult to explain. My doubt is in contrast CT , it can be explained as two phases. right sided and left sided appearing with two densities. and right atrial shadow is normal blood ...( ie no invasion there
Prakash Iyer Sir i have tried colouring and put it as a new post ..
Dileep Raman one comment about the densities. the RA is close to the contrast in the left system. This can give some artifact.
Unni Krishnan
Purushu Sir, two things:
1. Welcome back - I felt a little lost without your posts over the last few days, strange as it may sound, sitting 3000 miles away!
2. Regarding the contrast issue, if that were the case, then the RV should not light up with contrast either. Here you can see the RV inflow and outflow/MPA areas filled with contrast (or so I believe, Prakash is the expert and he will correct me) which means the RA should also have contrast.
The phasic contrast distribution as far as I understand is relevant for the vascular phases rather than the cardiac phase, i.e., different timings to look for PE vs aortic dissection. For the Rt vs Lt cardiac chambers, I guess it does not make such a difference (although you would want a more delayed scan for CTCA compared to CTPA).
Purushothaman Kuzhikkathukandiyil yes i agree Unni, especially , The fact that there is difference between RA and RV can not be explained , which is evident here
Sandhya Ramesh ct chest with contrast mediastinal window..b/l effusion>> on rt, with shift of med to lft and with mediastinal mass with vascular invasion nd?pericardial effsn/med encystment..rt pleura shows thickng also?lymphoma..? germ cell tumor
Paramez Ayyappath
saw it now- shall continue from sandhya's view- as there is shift of med- a primary endo bronchial lesion in rt side is excluded in most of the times (though its hard to comment with a single view and without a lung window) ...See More
Unni Krishnan Jithesh, enlighten us please...
Jithesh Kizhakkevalappil
This patient had features of SVCO, She had cervical nodular lesion and small right axillary LNE. Lymphoma was the obvious first clinical dd... Attempt to biopsy the cervical "node" showed that it was only a thrombosed venous segment...No other node to biopsy and CT thorax showed a nearly fully filled RA lesion(Can any one enlighten me how the blood was flowing through the heart when RA is fully filed with an obstructive mass,Through PFO?)...Radiologist gave a dd of Lyphoma/Atrial myxoma and cardiologist who did ECHO suspected Atrial myxoma... thoracotomy with mediastinal LNE biopsy confirmed High grade lymphoma....Steroids in the chemo regimen caused the RA mass to lyse in a few days time....What is the actual component of this RA mass in Lymphoma....Clumps of malignant lymphoid cells,?thrombus? (I have no clue please enlighten)...heart does not have a lymphatic system so is this mass formed from blood or invading the RA from outside....?
Unni Krishnan
I did not think of myxoma first because of the fact that I have only known of myxomas to occur in the RA very very rarely. Also the rest of the story does not fit.
When we say the RA is filled, we should accept the limitation of the imaging tool. The RA would have enlarged significantly and there would be enough of a path for blood to track alongside the tumour. The flow is not predominantyl through a PFO for the following reasons:
1. The patient is not cyanotic
2. It will be difficult for blood to go through a PFO when the tumour is arising from and involving the IAS
3. There is contrast in the RV and PA on this slice, it can only get there if it flows through the TV
The RA mass would be comprised of the same things that comprise the lymphoma elsewhere. There may well be overlying thrombus.
Infiltration by lmphoma is usually intramural. So it must be haematogenous spread, I would have thought. Sanjay/Anoop - any suggestions?
Also, for completion sake, did the patient have pedal oedema?
Paramez Ayyappath was a PET CT done before chemo? can MRI of any benefit in cardiac imaging?
Unni Krishnan CMR can tell you the plane of the tumour and the consistency (sold/vacoulated etc) and vascularity/enhancement (Gad). However, in this case, I am not sure it would have added much beyond what a CT and TOE would tell us. When things are less obvious, it helps more, in my opinion.
Purushothaman Kuzhikkathukandiyil Unni ......There was a case report from CMC.about five years back. Dr.Naraynadas ,,,,,,,That was a mass in RV which was proved to be NHL in a case ,i think a boy of 12 years. ( i did n t see that case, but read in our Indian pediatric journal
Prakash Iyer I agree with unni on imaging limitations...MRI would not benefit more...Anyhow it was good discussion..NHL in RA...sir that is an eyeopener for me...
Unni Krishnan Sorry Jithesh, my brain does not work without a history, so could you provide a clinical context please?
Jithesh Kizhakkevalappil A middle aged lady presented with Dyspnoea ,Facial puffiness and engorged neck veins... All features suggestive of SVC...On examination she had few enlarged cervical and axillary LNEs......Chest X ray shows right side plueral effusion only, will later upload(I cant find it on my computer)
Unni Krishnan: Jithesh, I will give you my raw interpretation and then you can polish this.
Firstly I struggled to assess the level, but seeing that there is the tip of the scapula on the right, it has to be lower thoracic, I assume.
Secondly, for a guy with a hammer... you know, so I focused on the heart after a cursory glance at the b/l effusion (Rt > Lt). My first thought was that given this is a contrast study, there is not much dye in the RA. Now is this just the plane of the scan (i.e., too near the diaphragm?), but then, the level of the slice seems to go through the upper pulmonary veins. Also the plane is at the base of the heart, not the apex, almost like a parasternal short axis view (echo) with the aortic root in the middle and the right heart wrapping around it. If this is the case, then the RA is definitely full of something and the 'something' seems to arise from the atrial septum.
If so, then is this lymphomatous infiltration, given the LNE? I guess it could also be a direct spread from the abdomen like carcinoid, RCC etc.
Feel free to shoot me down if I am barking up the wrong tree. I see the world through a catheter most of the time, so I apologise for my scotomatous view.
Did she also have pedal oedema? My hypothesis would only fit if she has pedal oedema.
Purushothaman Kuzhikkathukandiyil Unni, If the RA was filled with lymphomatous infilteration and as you said infilterating from abd. through IVC.( Whatever, ) why there is no pedal odema abdominal distention. From jithesh description the neck veins only distended. ................I agree the density of the right pleural and RA is same, ............. RA infliteration ,,,,will it be this uniform....?
Prakash Iyer my DD..1, atrial myxoma..enhancing mass.. 2. tumor thrombus...3,mets...
Purushothaman Kuzhikkathukandiyil Prakash , if you consider the right atrial uniform shadow , as invasion , .......lymphoma is the first possibility ....where we can explain all other findings.Why i am a bit suspicious is , by the time RA is this much filled why there is only upper part congestion only and wil it not compromise the cardiac out put ....
Prakash Iyer Sir..1. pericardial effusion seen seperating pericardium from mass. so lymphoma can be consisdered lower down...
Prakash Iyer now it is not lymphoma also for the other reason which u have mentioned in the later part ..also sir it will be difficult to explain effusion in that case..
Prakash Iyer mets will be a good bet...
Prakash Iyer i have seen 2 cases of carcinoma breast with right atrial mets,,and one thymic mets with similar features
Praveen Ayyappan Nair b/l pl.eff+pericardial eff in middle aged female+ LNE+SVCO; D/D are lymphoma, bronchogenic ca ,tuberculosis,mets, LAM rarely.
Unni Krishnan Sir, as I said in my post, my diagnosis will only work if there is pedal oedema. I think it is infiltrative because the 'mass' is the same density as the atrial septum. Regarding myxoma, I am not sure how common they are in the RA, also they are not usually so sessile.
Unni Krishnan Also the atrial septum appears thickened
Purushothaman Kuzhikkathukandiyil Prakash , please clear my doubt. The density of right sided pleural , and right atrial is same and we consider the right atrial shadow is some infilteration, and we find it difficult to explain. My doubt is in contrast CT , it can be explained as two phases. right sided and left sided appearing with two densities. and right atrial shadow is normal blood ...( ie no invasion there
Prakash Iyer Sir i have tried colouring and put it as a new post ..
Dileep Raman one comment about the densities. the RA is close to the contrast in the left system. This can give some artifact.
Unni Krishnan
Purushu Sir, two things:
1. Welcome back - I felt a little lost without your posts over the last few days, strange as it may sound, sitting 3000 miles away!
2. Regarding the contrast issue, if that were the case, then the RV should not light up with contrast either. Here you can see the RV inflow and outflow/MPA areas filled with contrast (or so I believe, Prakash is the expert and he will correct me) which means the RA should also have contrast.
The phasic contrast distribution as far as I understand is relevant for the vascular phases rather than the cardiac phase, i.e., different timings to look for PE vs aortic dissection. For the Rt vs Lt cardiac chambers, I guess it does not make such a difference (although you would want a more delayed scan for CTCA compared to CTPA).
Purushothaman Kuzhikkathukandiyil yes i agree Unni, especially , The fact that there is difference between RA and RV can not be explained , which is evident here
Sandhya Ramesh ct chest with contrast mediastinal window..b/l effusion>> on rt, with shift of med to lft and with mediastinal mass with vascular invasion nd?pericardial effsn/med encystment..rt pleura shows thickng also?lymphoma..? germ cell tumor
Paramez Ayyappath
saw it now- shall continue from sandhya's view- as there is shift of med- a primary endo bronchial lesion in rt side is excluded in most of the times (though its hard to comment with a single view and without a lung window) ...See More
Unni Krishnan Jithesh, enlighten us please...
Jithesh Kizhakkevalappil
This patient had features of SVCO, She had cervical nodular lesion and small right axillary LNE. Lymphoma was the obvious first clinical dd... Attempt to biopsy the cervical "node" showed that it was only a thrombosed venous segment...No other node to biopsy and CT thorax showed a nearly fully filled RA lesion(Can any one enlighten me how the blood was flowing through the heart when RA is fully filed with an obstructive mass,Through PFO?)...Radiologist gave a dd of Lyphoma/Atrial myxoma and cardiologist who did ECHO suspected Atrial myxoma... thoracotomy with mediastinal LNE biopsy confirmed High grade lymphoma....Steroids in the chemo regimen caused the RA mass to lyse in a few days time....What is the actual component of this RA mass in Lymphoma....Clumps of malignant lymphoid cells,?thrombus? (I have no clue please enlighten)...heart does not have a lymphatic system so is this mass formed from blood or invading the RA from outside....?
Unni Krishnan
I did not think of myxoma first because of the fact that I have only known of myxomas to occur in the RA very very rarely. Also the rest of the story does not fit.
When we say the RA is filled, we should accept the limitation of the imaging tool. The RA would have enlarged significantly and there would be enough of a path for blood to track alongside the tumour. The flow is not predominantyl through a PFO for the following reasons:
1. The patient is not cyanotic
2. It will be difficult for blood to go through a PFO when the tumour is arising from and involving the IAS
3. There is contrast in the RV and PA on this slice, it can only get there if it flows through the TV
The RA mass would be comprised of the same things that comprise the lymphoma elsewhere. There may well be overlying thrombus.
Infiltration by lmphoma is usually intramural. So it must be haematogenous spread, I would have thought. Sanjay/Anoop - any suggestions?
Also, for completion sake, did the patient have pedal oedema?
Paramez Ayyappath was a PET CT done before chemo? can MRI of any benefit in cardiac imaging?
Unni Krishnan CMR can tell you the plane of the tumour and the consistency (sold/vacoulated etc) and vascularity/enhancement (Gad). However, in this case, I am not sure it would have added much beyond what a CT and TOE would tell us. When things are less obvious, it helps more, in my opinion.
Purushothaman Kuzhikkathukandiyil Unni ......There was a case report from CMC.about five years back. Dr.Naraynadas ,,,,,,,That was a mass in RV which was proved to be NHL in a case ,i think a boy of 12 years. ( i did n t see that case, but read in our Indian pediatric journal
Prakash Iyer I agree with unni on imaging limitations...MRI would not benefit more...Anyhow it was good discussion..NHL in RA...sir that is an eyeopener for me...
Purushothaman Kuzhikkathukandiyil http://www.indianpediatrics.net/may2001/may-543-545.htm prakash that was in an issue 2001 IP
Indian Pediatrics - Editorial
www.indianpediatrics.net