Echocardiographic features of pheochromocytoma of the heart

Evaluation and Management of Cardiac Tumors

PURPOSE OF REVIEW

Our purpose is to discuss the importance of multimodality imaging in the assessment of cardiac tumors and management. We have compiled a recent review of the scientific literature and embedded our clinical pathways and recommendations based on data and clinical experience.

RECENT FINDINGS

The use of contrast echocardiography in the assessment of cardiac masses has been shown to be helpful in distinguishing tumor from thrombus. Deformation imaging of cardiac tumors has been shown to differentiate better rhabdomyomas from fibromas in pediatric patients. Cardiac MRI (CMR) appears to be helpful in determining whether cardiac tumors are benign or malignant by identifying presence of infiltration, uptake of contrast in first pass perfusion and gadolinium enhancement. Patients with evidence of cardiac metastases by CMR show similar survival to stage IV cancer without cardiac metastases. In our institution, we use a standardized approach for the evaluation of cardiac masses, which includes multimodality imaging in the appropriate clinical context. The autotransplantation surgical technique has shown some promise in improving survival in patients with primary cardiac sarcomas. In our institution, we do not routinely recommend anticoagulation for "tumor-thrombus" in renal cell carcinoma due to risk of bleeding from primary tumor. Cardiac masses are often found incidentally, but sometimes can present with cardiovascular symptoms due to obstruction and valvular dysfunction, which may prompt imaging. It is important to determine whether the mass is a normal variant, imaging artifact, vegetation, thrombus, or tumor. Transthoracic echocardiography is ideally suited to be the initial imaging modality because of the portability, wide availability, lack of radiation, and relatively low cost. The gold standard cardiac imaging technique to distinguish tumor from thrombus is contrast enhanced CMR with prolonged inversion time. Advantages of CMR when compared to echocardiography regarding characterization of cardiac tumors are as follows: larger field of view, better spatial resolution, better tissue characterization, lack of attenuation, and ability to image at any prescribed plane. Primary and secondary cardiac tumors have particular characteristics in echocardiography and CMR. Imaging of cardiac tumors plays an important role in establishing a diagnosis and in planning management.

Echocardiographic Guidance for Surgical Excision of the Intracardiac Component of a Pheochromocytoma

Pheochromocytomas are rare neuroendocrine tumors, with published incidence of 2 to 8 cases per million patients per year. The extension of these tumors into the vena cava and right atrium is rarely seen. Transesophageal echocardiography may be invaluable to delineate tumor extent and characteristics, which in turn may provide a useful tool to guide intraoperative surgical approach to these uncommon masses. In the case presented in this article, we describe the role of transesophageal echocardiography in guiding a safe and complete, excision of an invasive pheochromocytoma without embolization of tumor components.

Perioperative Management of Pheochromocytoma

Pheochromocytomas are rare neuroendocrine tumors that produce and store catecholamines. Without adequate preparation, the release of excessive amounts of catecholamines, especially during anesthetic induction or during surgical removal, can produce life-threatening cardiovascular complications. This review focuses on the perioperative management of pheochromocytoma/paragangliomas, initially summarizing the clinical aspects of the disease and then highlighting the current evidence available for preoperative, intraoperative, and postoperative anesthetic management.

Pheochromocytoma resection: Current concepts in anesthetic management

Pheochromocytoma represents very significant challenges to the anesthetist, especially when undiagnosed. These chromaffin tissue tumors are not uncommon in anesthetic practice and have varied manifestations. The perioperative management of these tumors has improved remarkably over the years, in conjunction with the evolution of surgical techniques (open laparotomy to laparoscopic techniques and now to robotic approaches in the present day). This review attempts to comprehensively address the intraoperative and postoperative issues in the management of these challenging tumors with an emphasis on hemodynamic monitoring and anesthetic technique.

Transthoracic echocardiographic features of cardiac pheochromocytoma: a single-institution experience

BACKGROUND

Cardiac pheochromocytoma is extremely rare. Previous papers usually are reports of a single case. Transthoracic echocardiography (TTE) offers a useful option, but the features of cardiac pheochromocytoma on TTE have not been favorably reported. In this study, the findings of cardiac pheochromocytoma on TTE in nine cases were presented.

METHODS

TTE images (especially two-dimensional ultrasound) of nine patients with cardiac pheochromocytomas were analyzed retrospectively and compared with the findings from surgery.

RESULTS

Among the nine patients with cardiac pheochromocytomas identified in Peking Union Medical College Hospital (PUMCH) clinical and echocardiographic database, TTE identified one cardiac tumor in seven cases (77.8%), two cardiac tumors in one case (11.1%), and a false-negative result in another (11.1%). Cardiac pheochromocytomas were usually located on the base of the heart, near the origin of great arteries. The tumors were usually round or ovoid, ranging from 1.4 cm to 7.7 cm in diameter, with homogeneous and moderate echoes and low activity. They could press or invade surrounding cardiac structures and influence hemodynamics. In this study the majority of cardiac pheochromocytoma seemed marginated and appeared to be encapsulated on TTE. Apical four-chamber view and parasternal short-axis view of the aortic valve were most effective in identifying cardiac pheochromocytomas. The findings on TTE were similar to those from surgical procedures.

CONCLUSION

Cardiac pheochromocytomas presented characteristic TTE appearances in aspect of location, size, texture, and shape of tumors. Understanding of these characteristics on TTE can help correctly recognize this extremely rare disease.