Two Cases of Calcified Amorphous Tumor Mimicking Mitral Valve Vegetation
2012; Lippincott Williams & Wilkins; Volume: 125; Issue: 10 Linguagem: Inglês
10.1161/circulationaha.111.072793
ISSN1524-4539
AutoresMikiko Fujiwara, Hiroyuki Watanabe, Takako Iino, Yusuke Kobukai, Kazuyuki Ishibashi, Hiroshi Yamamoto, Kenji Iino, Fumio Yamamoto, Hiroshi Ito,
Tópico(s)Eosinophilic Disorders and Syndromes
ResumoHomeCirculationVol. 125, No. 10Two Cases of Calcified Amorphous Tumor Mimicking Mitral Valve Vegetation Free AccessBrief ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessBrief ReportPDF/EPUBTwo Cases of Calcified Amorphous Tumor Mimicking Mitral Valve Vegetation Mikiko Fujiwara, MD, Hiroyuki Watanabe, MD, PhD, Takako Iino, MD, PhD, Yusuke Kobukai, MD, PhD, Kazuyuki Ishibashi, MD, PhD, Hiroshi Yamamoto, MD, PhD, Kenji Iino, MD, PhD, Fumio Yamamoto, MD, PhD and Hiroshi Ito, MD, PhD Mikiko FujiwaraMikiko Fujiwara From the Departments of Cardiovascular and Respiratory Medicine (M.F., H.W., T.I., Y.K., K. Iino, H.I.), and Cardiovascular Surgery (K. Ishibashi, H.Y., F.Y.), Akita University Graduate School of Medicine, Akita, Japan. , Hiroyuki WatanabeHiroyuki Watanabe From the Departments of Cardiovascular and Respiratory Medicine (M.F., H.W., T.I., Y.K., K. Iino, H.I.), and Cardiovascular Surgery (K. Ishibashi, H.Y., F.Y.), Akita University Graduate School of Medicine, Akita, Japan. , Takako IinoTakako Iino From the Departments of Cardiovascular and Respiratory Medicine (M.F., H.W., T.I., Y.K., K. Iino, H.I.), and Cardiovascular Surgery (K. Ishibashi, H.Y., F.Y.), Akita University Graduate School of Medicine, Akita, Japan. , Yusuke KobukaiYusuke Kobukai From the Departments of Cardiovascular and Respiratory Medicine (M.F., H.W., T.I., Y.K., K. Iino, H.I.), and Cardiovascular Surgery (K. Ishibashi, H.Y., F.Y.), Akita University Graduate School of Medicine, Akita, Japan. , Kazuyuki IshibashiKazuyuki Ishibashi From the Departments of Cardiovascular and Respiratory Medicine (M.F., H.W., T.I., Y.K., K. Iino, H.I.), and Cardiovascular Surgery (K. Ishibashi, H.Y., F.Y.), Akita University Graduate School of Medicine, Akita, Japan. , Hiroshi YamamotoHiroshi Yamamoto From the Departments of Cardiovascular and Respiratory Medicine (M.F., H.W., T.I., Y.K., K. Iino, H.I.), and Cardiovascular Surgery (K. Ishibashi, H.Y., F.Y.), Akita University Graduate School of Medicine, Akita, Japan. , Kenji IinoKenji Iino From the Departments of Cardiovascular and Respiratory Medicine (M.F., H.W., T.I., Y.K., K. Iino, H.I.), and Cardiovascular Surgery (K. Ishibashi, H.Y., F.Y.), Akita University Graduate School of Medicine, Akita, Japan. , Fumio YamamotoFumio Yamamoto From the Departments of Cardiovascular and Respiratory Medicine (M.F., H.W., T.I., Y.K., K. Iino, H.I.), and Cardiovascular Surgery (K. Ishibashi, H.Y., F.Y.), Akita University Graduate School of Medicine, Akita, Japan. and Hiroshi ItoHiroshi Ito From the Departments of Cardiovascular and Respiratory Medicine (M.F., H.W., T.I., Y.K., K. Iino, H.I.), and Cardiovascular Surgery (K. Ishibashi, H.Y., F.Y.), Akita University Graduate School of Medicine, Akita, Japan. Originally published13 Mar 2012https://doi.org/10.1161/CIRCULATIONAHA.111.072793Circulation. 2012;125:e432–e434The term cardiac calcified amorphous tumor (CAT) was coined in 1997 by Reynolds et al,1 who described 11 cases with nonneoplastic cardiac masses characterized by a pedicle and diffuse calcification. Additionally, CAT could originate in any of the 4 chambers. Once the mass is excised, its unique histological features such as the presence of calcified nodules in an amorphous background of fibrin with degeneration and focal inflammation allow an accurate diagnosis of cardiac CAT. However, in cases when CAT has arisen close to the cardiac valves and is mobile, it is not always easy to distinguish between CAT and mitral valve vegetation preoperatively. Here, we report 2 cases of CAT arising from mitral annular calcification (MAC) and propose imaging features that can be used to distinguish CAT from mitral valve vegetation.Case 1. A 58-year-old man with end-stage renal disease secondary to diabetic nephropathy was referred to our hospital. He had been maintained on hemodialysis for the past 4 years. Transthoracic echocardiography revealed 2 cardiac tumors adherent to the posterior MAC (Figure 1A). One was a highly mobile, spindle-shaped tumor attached to the atrial side. Notably, transesophageal echocardiography showed the revolving movement of the tumor, which was moving in a circular manner in the left atrial and ventricular cavity (Figure 1B and Movie I in the online-only Data Supplement). The other was an immobile, round tumor with partial echolucency attached to the ventricular side. Mild mitral regurgitation was noted but was not associated with the original site of the tumor. Because of the high risk of embolization, the patient underwent surgical resection and mitral valvuloplasty, and the clinical course was uneventful. The putty-like liquefaction was sucked from the immobile tumor, compatible with liquefactive necrosis.Download figureDownload PowerPointFigure 1. Transthoracic echocardiogram of the apical view in case 1 (A) shows 2 echogenic masses (arrowhead and arrow) attached to the posterior mitral annulus with severe calcification. The immobile, round tumor (arrowhead) contained echolucency at the center of the head. The spindle-shaped tumor (arrow) was highly mobile. Two-dimensional transesophageal echocardiogram (B) demonstrates the spindle-shaped tumor arising from mitral annular calcification and the revolving movement among the left atrial (LA) and left ventricular (LV) cavity.Case 2. A 65-year-old man with chronic glomerulonephritis who had received hemodialysis for 8 years was admitted to our hospital because a mobile club-shaped tumor was found on transthoracic echocardiography. The tumor was attached to the ventricular and anteromedial side of the MAC (Figure 2A and Movie II in the online-only Data Supplement). Transesophageal echocardiography showed the revolving movement of the tumor in the left ventricular tract regardless of the mild mitral regurgitation jet (Figure 2B and 2C). Moreover, 3-dimensional transesophageal echocardiography revealed that the original site of the tumor was not associated with the mitral regurgitation jet (Movie III in the online-only Data Supplement). Surgical resection was performed successfully.Download figureDownload PowerPointFigure 2. Transthoracic echocardiogram (A) and 2-dimensional transesophageal echocardiogram (B) in case 2 shows the mobile club-shaped mass (arrow) attached to the ventricular side of mitral annular calcification and moving in a circular manner in left ventricular outflow tract. Three-dimensional transesophageal echocardiogram (C) also shows the revolving movement of the tumor (arrow) regardless of the mitral regurgitation jet. Ao indicates aorta; AV, aortic valve; LA, left atrium; LV, left ventricle; and MV, mitral valve.In both cases, histological examination revealed nodular calcification encapsulated in amorphous material, including dense fibrin, chronic inflammation, and blood capillaries, which confirmed the diagnosis of CAT (Figures 3 and 4).Download figureDownload PowerPointFigure 3. High-powered histological view of the mobile spindle-shaped tumor in case 1 shows deposits of calcium with surrounding amorphous fibrin material and chronic inflammation (magnification ×200).Download figureDownload PowerPointFigure 4. Macroscopic appearance in case 2 (A) indicates yellowish color and partially calcified resected tumor (7×2 mm in size). Microscopic views of the tumor shows nodular calcification covered with dense fibrin and hyperplasia of blood capillary (B; magnification ×100; C, ×200).Four cases of MAC-related CAT, including our cases, have been reported to date.2,3 All patients suffered from end-stage renal disease, and the CATs were highly mobile and apparently mimicked valve vegetation. Although MAC-related CAT is considered to be a subgroup of CAT, these features are not common in CATs originating from other sites. Mitral annulus involvement in end-stage renal disease patients is most commonly manifested as MAC. Recently, liquefactive necrosis (also known as annular caseous calcification) within a zone of MAC is increasingly recognized as a variant of MAC. Indeed, the immobile tumor in case 1 was identified as liquefactive necrosis. Similarly, mobile CAT arising from the mitral annulus may also be an atypical variant of MAC. However, the specific features of MAC-related CAT are not well documented. Preoperatively, mobile MAC-related CAT represents a diagnostic challenge. Our patients were asymptomatic and afebrile, and both were suffering from end-stage renal disease. No remarkable inflammatory changes were detected on routine blood examination. In addition to this clinical background, the continuity with MAC, the lack of association with valve leaflets and regurgitation jet, and the revolving movement among the left atrial and ventricular cavities, constituting a unique echocardiographic appearance, are characteristic features that distinguish these lesions from valve vegetation. Unlike other modalities of cardiac imaging, echocardiography can evaluate rapid motion with ease. The observed echocardiographic appearance of the revolving movement has not been reported previously and represents valuable information for the diagnosis of MAC-related CAT.DisclosuresNone.FootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.111.072793/-/DC1.Correspondence to Hiroyuki Watanabe, Department of Cardiovascular and Respiratory Medicine, Akita University Graduate School of Medicine, Hondoh 1-1-1, Akita 010-8543, Japan. E-mail [email protected]med.akita-u.ac.jpReferences1. Reynolds C, Tazelaar HD, Edwards WD. Calcified amorphous tumor of the heart (cardiac CAT). Hum Pathol. 1997; 28: 601– 606. CrossrefMedlineGoogle Scholar2. Inamdar V, Wanat FE, Nanda NC, Pothineni KR, Burri MV, Kimmler S. Amorphous calcific tumor of the mitral annulus echocardiographically mimicking a vegetation. Echocardiography. 2008; 25: 537– 539. CrossrefMedlineGoogle Scholar3. Kubota H, Fujioka Y, Yoshino H, Koji H, Yoshihara K, Tonari K, Endo H, Tsuchiya H, Mera H, Soga Y, Taniai S, Sakata K, Sudo K. Cardiac swinging calcified amorphous tumors in end-stage renal failure patients. Ann Thorac Surg. 2010; 90: 1692– 1694. CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Ushioda R, Shirasaka T, Kikuchi S, Kamiya H and Kanamori T (2022) Calcified amorphous tumor located on a severely calcified mitral annulus in a patient with normal renal function, Journal of Surgical Case Reports, 10.1093/jscr/rjab608, 2022:1, Online publication date: 1-Jan-2022. ÇINAR T, ÇİÇEK V and ORHAN A (2022) Cardiac Calcified Amorphous Tumor Presenting with Thromboembolism in a Patient Under Apixaban Treatment, Bezmialem Science, 10.14235/bas.galenos.2020.3944, 10:1, (104-105), Online publication date: 26-Jan-2022. Harada T, Sasaki H and Ishitoya H (2020) A Calcified Amorphous Tumor from the Aortic Valve to the Tricuspid Valve with Aortic Valve Stenosis大動脈弁狭窄症を伴い,大動脈弁から三尖弁にかけて連続する腫瘤形成をきたした calcified amorphous tumor の1例, Japanese Journal of Cardiovascular Surgery, 10.4326/jjcvs.49.58, 49:2, (58-61), Online publication date: 15-Mar-2020. Chetrit M, Hassan O, Ho N, Collier P and Rodriguez L (2020) The "MAC" Attack: When Mitral Annular Calcification Goes Rogue! A Case Series of Mobile Mitral Annular Calcifications, CASE, 10.1016/j.case.2020.07.004, 4:5, (467-472), Online publication date: 1-Oct-2020. Yamanaka T, Fukatsu T, Uchimuro T and Takanashi S (2020) Cardiac calcified amorphous tumour associated with multiple myeloma, BMJ Case Reports, 10.1136/bcr-2019-233679, 13:4, (e233679), Online publication date: 1-Apr-2020. Koyama Y, Tsujimoto S and Yamamoto M (2020) Calcified amorphous tumor in the aortic valve identified by computed tomography, The Journal of Thoracic and Cardiovascular Surgery, 10.1016/j.jtcvs.2019.04.094, 159:3, (e161-e163), Online publication date: 1-Mar-2020. Sawada N, Nakao T, Daimon M, Nawata K, Tanaka M and Komuro I (2019) Multiple calcified amorphous tumors in a patient with end-stage renal disease, Journal of Echocardiography, 10.1007/s12574-019-00416-1, 18:2, (125-126), Online publication date: 1-Jun-2020. Kinugasa Y, Teshima H, Inoue Y, Tai R, Sato M, Ikebuchi M and Irie H (2019) A Calcified Amorphous Tumor Causing Mitral Valve Perforation and Ruptured Chordae Tendineae僧帽弁穿孔,腱索断裂を引き起こしたと考えられた calcified amorphous tumor の1例, Japanese Journal of Cardiovascular Surgery, 10.4326/jjcvs.48.259, 48:4, (259-262), Online publication date: 15-Jul-2019. Nagao Y, Nakajima M, Hirahara T, Wada K, Terasaki T, Nagamine M and Ando Y (2018) Calcified Cerebral Embolism Due to a Calcified Amorphous Tumor, Journal of Stroke and Cerebrovascular Diseases, 10.1016/j.jstrokecerebrovasdis.2018.01.025, 27:7, (e115-e116), Online publication date: 1-Jul-2018. Curl E and Riemer E (2018) Caseous calcification of the mitral annulus: case report and brief review, European Heart Journal - Case Reports, 10.1093/ehjcr/yty124, 2:4, Online publication date: 1-Dec-2018. Aizawa Y, Nakai T, Saito Y, Monno K, Morikawa T, Kogawa R, Hatta T, Tamaki T, Kato M, Arimoto M, Osaka S, Sunagawa K, Tang X, Tanaka M, Hao H and Hirayama A (2018) Calcified Amorphous Tumor-Induced Acute Cerebral Infarction, International Heart Journal, 10.1536/ihj.17-020, 59:1, (240-242), . Kasai M, Osako M, Tanino T and Maeshima A (2018) A Calcified Amorphous Tumor Originating in the Aortic Valve Cusp, The Annals of Thoracic Surgery, 10.1016/j.athoracsur.2018.01.050, 105:6, (e235-e237), Online publication date: 1-Jun-2018. Yoshimura S, Kawano H, Minami T, Tsuneto A, Nakata T, Koga S, Ikeda S, Hayashi T and Maemura K (2017) Cardiac Calcified Amorphous Tumors in a Patient with Hemodialysis for Diabetic Nephropathy, Internal Medicine, 10.2169/internalmedicine.9057-17, 56:22, (3057-3060), . Watanabe H, Shimbo M and Ito H (2017) A Cardiac Calcified Amorphous Tumor Associated with End-stage Renal Disease: An Emerging Disease Concept, Internal Medicine, 10.2169/internalmedicine.9348-17, 56:22, (2967-2968), . Singu T, Inatomi Y, Yonehara T and Ando Y (2017) Calcified Amorphous Tumor Causing Shower Embolism to the Brain: A Case Report with Serial Echocardiographic and Neuroradiologic Images and a Review of the Literature, Journal of Stroke and Cerebrovascular Diseases, 10.1016/j.jstrokecerebrovasdis.2017.02.019, 26:5, (e85-e89), Online publication date: 1-May-2017. Sadeghpour A, Alizadehasl A, Nojoomizadeh L, Pouraliakbar H and Bayati P (2017) A Mitral Annular Calcification–Related Calcified Amorphous Tumor in End-Stage Renal Disease, CASE, 10.1016/j.case.2017.02.004, 1:3, (96-98), Online publication date: 1-Jun-2017. Tao K and Shigehisa Y (2017) Suddenly Appearing Swinging Calcified Amorphous Tumor in the Left Ventricular Outflow Tract in a Patient with End-Stage Renal Failure, Japanese Journal of Cardiovascular Surgery, 10.4326/jjcvs.46.226, 46:5, (226-230), . Nakamaru R, Oe H, Iwakura K, Masai T and Fujii K (2017) Calcified amorphous tumor of the heart with mitral annular calcification: a case report, Journal of Medical Case Reports, 10.1186/s13256-017-1337-9, 11:1, Online publication date: 1-Dec-2017. Seo H, Fujii H, Aoyama T and Sasako Y (2015) Cardiac calcified amorphous tumor in a hemodialysis patient, Asian Cardiovascular and Thoracic Annals, 10.1177/0218492315574795, 24:5, (461-463), Online publication date: 1-Jun-2016. Maybrook R, Afzal M, Parashar S, Deibert B, Chivington M, Walker J, Dawn B and Parashara D (2015) Intrinsic and Extrinsic Cardiac Pseudotumors: Echocardiographic Evaluation and Review of the Literature, Echocardiography, 10.1111/echo.13089, 33:1, (117-132), Online publication date: 1-Jan-2016. Matsukuma S, Eishi K, Tanigawa K, Miura T, Matsumaru I, Hisatomi K and Tsuneto A (2016) Swinging Calcified Amorphous Tumors With Related Mitral Annular Calcification, The Annals of Thoracic Surgery, 10.1016/j.athoracsur.2015.09.019, 101:4, (e103-e105), Online publication date: 1-Apr-2016. Khan N, Khan M and Chardon G (2016) Metastatic Calcinosis of Aortic Valve Secondary to Renal Failure Mimicking Infective Endocarditis, Case Reports in Cardiology, 10.1155/2016/3916507, 2016, (1-3), . Torii Y, Yamada H, Matsukuma S, Nishio S, Kusunose K, Abe M and Sata M (2016) Left Ventricular Lipomatous Hamartoma Mimicking a Calcified Amorphous Tumor, Circulation, 10.1161/CIRCULATIONAHA.115.019252, 133:8, Online publication date: 23-Feb-2016. HONDA S, KAWASAKI T, YAMANO M, SATO Y, HARIMOTO K, MIKI S, KAMITANI T and HIRAI Y (2016) A case of calcified amorphous tumor with caseous calcification of the mitral annulus, Choonpa Igaku, 10.3179/jjmu.JJMU.A.60, 43:4, (577-580), . Saito K, Doi M, Karikusa M, Sakata K, Sasaguri H and Toru S (2016) Cerebral infarction in right pons during the course of mobile mitral annular calcification-related calcified amorphous tumor during a long time hemodialysis, Rinsho Shinkeigaku, 10.5692/clinicalneurol.cn-000895, 56:8, (580-583), . Teoh J and Steeds R (2015) Cardiac calcified amorphous tumour, Echo Research & Practice, 10.1530/ERP-14-0072, 2:1, (I9-I10), Online publication date: 1-Mar-2015. Tanaka A, Mizuno M, Suzuki Y, Oshima H, Sakata F, Ishikawa H, Tsukushi S and Ito Y (2015) Calcified Amorphous Tumor in the Left Atrium in a Patient on Long-term Peritoneal Dialysis, Internal Medicine, 10.2169/internalmedicine.54.2967, 54:5, (481-485), . Kinoshita M, Okayama H, Kawamura G, Shigematsu T, Takahashi T, Miyoshi T, Higaki A, Hara K, Kawata Y, Hiasa G, Yamada T, Kazatani Y and Hayashi Y (2015) A calcified amorphous tumor that developed on both sides of the atrioventricular valve annulus, Journal of Echocardiography, 10.1007/s12574-015-0267-z, 13:4, (148-150), Online publication date: 1-Dec-2015. de Hemptinne Q, de Cannière D, Vandenbossche J and Unger P (2015) Cardiac calcified amorphous tumor: A systematic review of the literature, IJC Heart & Vasculature, 10.1016/j.ijcha.2015.01.012, 7, (1-5), Online publication date: 1-Jun-2015. Nakashima Y, Terauchi Y, Noguchi T, Tanioka K, Kubo T, Yamasaki N and Kitaoka H (2015) A case of cardiac calcified amorphous tumor (cardiac CAT) causing acute embolism in right common iliac artery, Journal of Cardiology Cases, 10.1016/j.jccase.2014.10.012, 11:3, (81-84), Online publication date: 1-Mar-2015. Masuda S, Motoyoshi N, Ito K, Hayatsu Y, Akiyama M, Kawamoto S and Saiki Y (2015) Surgical removal of calcified amorphous tumor localized to mitral valve leaflet without mitral annular calcification, Surgical Case Reports, 10.1186/s40792-015-0040-6, 1:1, Online publication date: 1-Dec-2015. de Hemptinne Q, Bar J, de Canniere D and Unger P (2015) Swinging cardiac calcified amorphous tumour arising from a calcified mitral annulus in a patient with normal renal function, Case Reports, 10.1136/bcr-2014-207401, 2015:jan07 1, (bcr2014207401-bcr2014207401), Online publication date: 7-Jan-2015. Mohamedali B, Tatooles A and Zelinger A (2014) Calcified Amorphous Tumor of the Left Ventricular Outflow Tract, The Annals of Thoracic Surgery, 10.1016/j.athoracsur.2013.06.115, 97:3, (1053-1055), Online publication date: 1-Mar-2014. Kawata T, Konishi H, Amano A and Daida H (2012) Wavering calcified amorphous tumour of the heart in a haemodialysis patient, Interactive CardioVascular and Thoracic Surgery, 10.1093/icvts/ivs430, 16:2, (219-220), Online publication date: 1-Feb-2013., Online publication date: 1-Feb-2013. Jin T and Moussa E (2016) Caseous calcification of the mitral valve annulus Radiopaedia.org, 10.53347/rID-47717 March 13, 2012Vol 125, Issue 10 Advertisement Article InformationMetrics © 2012 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.111.072793PMID: 22412095 Originally publishedMarch 13, 2012 PDF download Advertisement SubjectsDevelopmental Biology
Referência(s)