Chest ACCP Member Benefits
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Guest Access | Sign In via User Name/Password
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via ISI Web of Science (3)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kuester, L. B.
Right arrow Articles by Aquino, S. L.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kuester, L. B.
Right arrow Articles by Aquino, S. L.
(Chest. 2005;128:3888-3893.)
© 2005 American College of Chest Physicians

Lipomatous Hypertrophy of the Interatrial Septum*

Prevalence and Features on Fusion 18F Fluorodeoxyglucose Positron Emission Tomography/CT

Landon B. Kuester; Alan J. Fischman, MD, PhD; Chieh-Min Fan, MD; Elkan F. Halpern, PhD and Suzanne L. Aquino, MD

* From the Department of Radiology, Massachusetts General Hospital, Boston, MA.

Correspondence to: Suzanne L. Aquino, MD, Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114; e-mail: saquino{at}partners.org


   Abstract
TOP
 Abstract
Introduction
 Methods and Materials
 Results
 Discussion
 Conclusion
 References
 
Objective: To determine the prevalence of lipomatous hypertrophy of the interatrial septum (LHIS) on CT and its metabolic pattern on 18F fluorodeoxyglucose (FDG)-positron emission tomography (PET).

Method and materials: Eight hundred two CT PET scans were reviewed. Patients were included if the interatrial septum was ≥ 1 cm and excluded if there was evidence of malignancy in the adjacent lung, hilum, or mediastinum. CT scans were fused with PET scans, and the mean standardized uptake value (SUV) was calculated over the LHIS, chest wall (CW) fat, and mediastinal blood pool. CT scans were reviewed for presence of excessive fat in the mediastinum, pericardial, peridiaphragmatic, peritoneal, and retroperitoneal regions and for the presence of emphysema. Medical records were reviewed for body mass index (BMI) and history of arrhythmia.

Results: Twenty-three of 802 patients (2.8%) had LHIS on CT (9 women and 14 men); average age was 75.6 years (range, 58 to 95 years). Average BMI of 17 patients (± SD) was 31 ± 4.9 (range, 22.1 to 39.9). Mean CT values were as follows: thickening of LHIS, 1.47 ± 0.35 cm (range, 1.07 to 2.25 cm); LHIS, – 79.6 + 24.5 Hounsfield unit (HU) [range, – 11 to – 121 HU]. LHIS was dumbbell shaped in 18 patients. Mean SUVs were as follows: LHIS, 1.84 ± 0.10 (range, 0.48 to 3.48); CW fat, 0.36 + 0.37 (range, 0.04 to 1.98); blood pool, 1.74 + 0.51 (range, 0.25 to 2.71). The SUV of LHIS was greater than the SUV of CW wall fat in all patients (p < 0.0001). There was significant correlation between SUV and thickness of the LHIS on CT (p < 0.0001, r = 0.883). Those with dumbbell-shaped LHIS (p < 0.003) and presence of emphysema (p < 0.0377) had greater LHIS mean SUV.

Conclusion: The SUV of LHIS was greater than the SUV of CW fat in all patients. LHIS with greater thickness or dumbbell shape had greater FDG uptake. These findings on CT and PET are important to recognize in order to avoid false-positive FDG-PET interpretations.

Key Words: cardiac neoplasm • 18F fluorodeoxyglucose • image processing, computer-assisted • positron emission tomography • tomography, helical computed


   Introduction
TOP
 Abstract
 Introduction
Methods and Materials
 Results
 Discussion
 Conclusion
 References
 
First described by Prior in 1964,1 lipomatous hypertrophy of the interatrial septum (LHIS) is characterized by excessive deposition of fatty tissue in the interatrial septum.234 The reported prevalence of LHIS varies. Autopsy reports256 have found a prevalence of approximately 1%, whereas studies27 using echocardiography report a much higher prevalence of 2 to 8%. LHIS is a benign disorder that typically occurs in the elderly and obese.8 The prevalence of arrhythmias in these patients has been reported to be as high as 40%,24 and the condition has been associated with sudden death.25910

Recently, Fan et al11 described the presence of increased 18F fluorodeoxyglucose (FDG) uptake in the region of the LHIS on FDG-positron emission tomography (PET); however, there is no information on the prevalence and patterns of LHIS on FDG-PET when correlated to CT. This pattern of FDG uptake is important to recognize especially in patients with malignancy in order to avoid the false interpretation of metastatic mediastinal disease. The purposes of the current study were as follows: (1) to determine the prevalence of LHIS in serial CT PET scans of patients undergoing imaging for cancer staging or evaluation of lung nodules, and (2) to evaluate the pattern of FDG uptake in order to better characterize this relatively benign cardiac disorder and improve its detection and distinction from neoplasia.


   Methods and Materials
TOP
 Abstract
 Introduction
 Methods and Materials
Results
 Discussion
 Conclusion
 References
 
Patient Population
This study was approved by our Human Research Committee, and patient consent was waived. A retrospective review of dual CT PET scans of 802 patients acquired over an 8-month interval was performed. Indications for PET included evaluation of a single pulmonary nodule, or staging and restaging of cancers from lung, breast, GI tract, melanoma, and lymphoma. Patients were included in the study group if there was CT evidence of fat thickening, ≥ 1 cm, in the interatrial septum on axial images (Fig 1 ). Patients were excluded if they had evidence of tumor at the right hilum, adjacent right lung, or mediastinal lymphadenopathy. A medical record review was performed for each patient to tabulate recent body weight and height for body mass index (BMI) and standardized uptake value (SUV) calculation and to identify individuals with a history of cardiac arrhythmia.



View larger version (52K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1.. An 84-year-old man who underwent dual PET/CT for colon cancer staging. Left: CT scan shows LHIS that measures 1.1 cm. Right: CT image at level of fossa ovalis demonstrates the characteristic dumbbell shape (between arrows) caused by sparing of the fossa ovalis.

 
Image Acquisition
Dual FDG-PET studies were performed (REVEAL-XV1 Scanner; CTI Molecular Imaging; Knoxville, TN). Image spatial resolution of this device is 4.6 mm, full width, half maximum with a slice thickness of 3.5 mm. The patients fasted for at least 6 h before scanning, and blood glucose levels were measured just before injection of FDG. Approximately 15 mCi of FDG was administered IV as a bolus, and static emission images were obtained 60 min later. Transmission CT scans was obtained on the same patient group (REVEAL-XV1/ SOMATON Sensation 16; Siemens; Schaumburg, IL) at 5-mm slice thickness. Image reconstruction was performed with Fourier rebining and attenuation-weighted ordered subsets-expectation maximization. A subsequent diagnostic CT scan was obtained during same scanning session (REVEAL-XV1/SOMATON Sensation 16 scanner with IV contrast; 100 mL of ioxilan 300 mg/mL at an injection rate of 2mL/s) at 2-mm slices. The dose, time of injection, and the body weight were used to calculate mean SUVs.

Image Interpretation
The CT scans were reviewed on mediastinal (window width, 350 Hounsfield unit [HU]; window level, 40 HU) and lung (window width, 1,500 HU; window level, – 600 HU) settings on a picture archiving and communication system monitor. Measurement of LHIS was recorded at the widest dimension of the interatrial septum. Evidence of excessive fat in the mediastinum, pericardial, peridiaphragmatic, peritoneal, and retroperitoneal regions, and the presence of pulmonary emphysema were also recorded. Additionally, evidence of the dumbbell shape of LHIS was evaluated on axial CT at the level of the fossa ovalis (Fig 1).

The CT and FDG-PET data sets were fused and reviewed on a workstation (REVEAL-MVS; Mirada Solutions; Oxford, UK). For each fused study, the LHIS was localized on the CT images, and mean regional SUV was calculated from the corresponding PET images. Additional mean SUVs were calculated over the chest wall (CW) fat and the mediastinal blood pool at the region of the main pulmonary artery. CT/PET images were also reviewed for the presence of increased FDG uptake in other regions of fat in the neck, thorax, or abdomen that would suggest brown adipose tissue (BAT)12

Statistical Analysis
A paired t test was performed to compare mean LHIS SUV with mean SUV of the CW. Student t test was used to compare mean SUVs for the groups defined by the presence of emphysema, LHIS dumbbell shape, tapering LHIS, and excess body fat deposition. Pearson correlation coefficients were calculated for the relationship between SUV and each of LHIS thickness, LHIS HU, history of arrhythmia, and BMI.


   Results
TOP
 Abstract
 Introduction
 Methods and Materials
 Results
Discussion
 Conclusion
 References
 
Twenty-three of 802 patients (2.8%) had CT evidence of LHIS. Nine patients were women, and 14 were men (average age, 75.6 years; range, 58 to 95 years). The mean CT values of the 23 patients were as follows: thickening of LHIS: 1.47 ± 0.35 cm (range, 1.07 to 2.25 cm); HU measurement at LHIS, – 79.6 ± 24.5 HU (range, – 11 to – 121 HU) [Table 1 ]. The LHIS was bilobed/dumbbell shaped in 18 of the 23 patients (78%). The average BMI (± SD) of 17 patients was 31 ± 4.9 (range, 22.1 to 39.9). Five of 23 patients (22%) had a history of cardiac arrhythmia, four of which were atrial in origin. Fifteen of 23 patients (68%) had pulmonary emphysema.


View this table:
[in this window]
[in a new window]

  		Table 1.. Average CT and PET Values for 23 Patients With LHIS

 
Excessive fat deposits were found in the mediastinum of 9 of 23 patients (39%), in the peridiaphragmatic region of 4 of 23 patients (17%), in the retroperitoneum of 8 of 23 patients (35%), and in the peritoneum of 6 of 23 patients (26%). None of the 23 patients had increased BAT distributed in the neck, thorax, or abdomen on FDG-PET. Mean SUVs of the 23 patients with LHIS were as follows (Table 1): mean SUV at LHIS, 1.84 ± 0.10 (range, 0.48 to 3.48); CW fat, 0.36 ± 0.37 (range, 0.04 to 1.98); blood pool, 1.74 ± 0.51 (range, 0.25 to 2.71).

The mean SUV of LHIS was greater than the mean SUV of CW fat in all 23 patients (p < 0.0001) [Fig 2 ]. Nine patients had mean LHIS SUV greater than mean blood pool SUV. In this group, mean LHIS SUV was 2.85 ± 0.90 and mean LHIS width on CT was 1.748 ± 0.30 cm. Fourteen of 23 patients had mean LHIS SUV less than mean blood pool SUV. The mean SUV of this group was 1.73 ± 0.71, and the mean width on CT was 1.26 ± 0.18 cm.



View larger version (113K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 2.. A 90-year-old women who underwent dual FDG-PET CT scan for melanoma staging. Top left, A: CT scan shows dumbbell-shaped LHIS at the level of the fossa ovalis. Top right, B: Fused PET/CT scan at same slice shows increased FDG uptake at the LHIS (SUV, 3.11 ± 0.02). Bottom left, C: PET image from a dual PET/CT shows increased FDG uptake at LHIS (SUV, 0.82) [straight arrow] is greater than FDG uptake chest wall fat (SUV, 0.31) [curved arrow]. Bottom right, D: Lung windows of CT image show pulmonary emphysema. Those patients with emphysema had greater SUVs than those without (p < 0.0377).

 
Significant correlations were found between mean SUV and thickness of the LHIS on CT (p < 0.0001; r = 0.883). The average SUV of those patients with dumbbell shape LHIS was significantly different from those without (p < 0.003) [Fig 2], and the average SUV of those patients with LHIS and pulmonary emphysema was significantly different from those without (p < 0.0377). There was no significant difference between those patients with and without excess fat in the mediastinum, diaphragm, or abdomen or arrhythmia and LHIS. No correlation was found between mean LHIS SUV and BMI.


   Discussion
TOP
 Abstract
 Introduction
 Methods and Materials
 Results
 Discussion
Conclusion
 References
 
LHIS has been referred to as "lipomatous hamartoma,"13 "cardiac and paracardiac masses,"7 and "massive fatty deposits."5 Since it was first described by Prior1 > 40 years ago, > 200 cases have been documented.2 The reported prevalence of LHIS has varied from 1 to 8%.2567 The thickness of septal fatty deposits in LHIS also vary in the literature; ranging from < 1 to < 2 cm.2514 The characteristic fatty deposit of LHIS most often occurs anterior or superior to the fossa ovalis.

The histologic features of LHIS have been described by Page,8 who analyzed the septal fat accumulation patterns in 50 randomly selected hearts and compared them to 10 selected cases of extreme fatty enlargement of the interatrial septum. Page8 found that septal fat accumulation increases with patient age and is associated with epicardial fat deposits, and with increased epicardial fat in obese individuals (BMI > 30). LHIS can be distinguished by an unencapsulated excessive deposit of "mass-like" fatty tissue in the interatrial septum. Histologic findings have indicated that this fatty deposition is comprised of mature fat with varying quantities of fetal (brown) fat, inflammation, and fibrosis, and entrapment of myocardial fibers with cytologic atypia.58

Our results show a 2.8% prevalence of LHIS, which is greater than previously reported autopsy prevalence of 1%,256 but similar to a CT prevalence of 2.2% reported by Heyer et al.2 LHIS has been identified by echocardiograms,21415 CT, and MRI.416 The first report of LHIS by CT was in 1982 by Isner et al.16 More recently, Heyer et al2 described the pattern of LHIS on multidetector CT.

LHIS has a characteristic dumbbell shape that is caused by sparing of the fossa ovalis, which is relatively narrowed. We found this dumbbell shape in 18 of 23 patients = 78.2%. There was significant correlation between intensity of FDG uptake in LHIS and the presence of this dumbbell shape. The prevalence of the dumbbell shape in our study is lower than in previous reports. Meaney et al14 reported the dumbbell shape in all their patients with LHIS. Heyer et al2 reported a 92.9% prevalence of bilobed shape in patients with LHIS. These authors indicated that they were able to improve the detection of the dumbbell configuration by three-dimensional reconstruction, which was not performed in our study. In addition, this discrepancy may be a reflection of a lower inclusion threshold for LHIS in our study. We used a lower cutoff threshold of 1 cm on CT for inclusion as opposed to the study by Heyer et al,2 which used a threshold of ≥ 2 cm. The overall mean LHIS thickness of the 23 patients in our study was 1.47 ± 0.35 cm (range, 1.07 to 2.25 cm). Only two patients had LHIS that measured ≥ 2 cm; both had a dumbbell-shaped LHIS. Overall, 18 of our patients had this anatomic configuration, with a range in maximum width of 1.1 to 2.3 cm. The five patients without the dumbbell configuration had LHIS thickness ranging from 1.1 to 1.5 cm.

Heyer et al2 reported that 75% of their patients with LHIS had an increase in epicardial and/or mediastinal fat. Only 9 of 23 patients (39%) in our group had excess fat in epicardial and/or mediastinal regions. Additionally, we found that 4 of 23 patients (17%) had excess fat in the peridiaphragmatic region, 8 of 23 patients (35%) had excess fat in the retroperitoneum, and 6 of 23 patients (26%) had excess fat in peritoneum. Sixty-eight percent of our patients with LHIS had pulmonary emphysema on CT, and a significant correlation between FDG SUV and LHIS (p < 0.0377) was detected. These findings are in agreement with Heyer et al,2 who also described a higher frequency of emphysema in patients with LHIS of 64%.

A recent study by Fan et al11 first described an increase in FDG uptake in LHIS. Prior pathology studies58 of LHIS have demonstrated that these regions of fat hypertrophy contain fetal fat or brown fat, which demonstrates increased FDG uptake on PET.12 Recent studies121718 have shown that increased tracer uptake occurs in the cervical, thoracic, and occasionally abdominal fat of approximately 14% of patients studied by FDG-PET. This has been attributed to BAT; however, there have been no histopathologic human studies to confirm this.

Our results are in keeping with the report by Fan et al.11 When we measured the mean SUV of LHIS fat compared to the mean SUV of fat in the CW, we found the average SUV of LHIS to be 1.84 ± 0.10, which was significantly greater than CW fat in all patients studied (overall mean CW SUV was 0.36 ± 0.37, p < 0.0001). This may be a reflection of the concentration of brown fat that is known to accumulate in LHIS and displays increased FDG uptake. None of the patients in our study had any uptake in the CW, paraspinal, or retroperitoneal regions to suggest coexisting BAT. In keeping with this pattern of uptake, we found a significant trend in the correlation between the nine patients whose mean LHIS SUV was greater than their mean blood pool SUV. In this group, the SUV was 2.85 ± 0.90, and average thickness of LHIS on CT was greatest in this group at 1.48 ± 0.30 cm. Thirteen patients had a mean LHIS less than mean blood pool SUV; LHIS SUV was 1.73 ± 0.71, and CT thickness was 1.26 ± 0.18 cm. Again, this correlation between size and SUV (p < 0.0001) may also be a reflection of a greater concentration of brown fat in larger LHIS lesions.

We also detected significant correlations between SUV and dumbbell shape and SUV and pulmonary emphysema. In contrast to previous reports,28 we did not detect significant correlations between SUV and BMI or the presence of excess fat in the mediastinum, diaphragm, or abdomen.

The differentiation of LHIS from other cardiac neoplasms, primary or metastatic, with conventional imaging techniques can be difficult but should be in the differential diagnosis of abnormal uptake in the region of the right heart. Cardiac metastases that can occur in any of the cardiac chambers19 are more common than primary neoplasms. None of our patients had evidence for metastatic disease in the mediastinum at or near the heart. In addition, most patients had been followed up, which confirmed the stability of the LHIS on cross-sectional imaging. The most common primary cardiac neoplasm is the atrial myxoma,1920 which is a solitary neoplasm frequently arising at the fossa ovalis in the left atrium. Other neoplasms that may occur in the heart include liposarcoma, rhabdomyoma, and fibroma, which are most often seen in children, and cardiac lipoma, which unlike LHIS, is frequently encapsulated.8 Fusion imaging of PET and CT can clarify the localization of FDG uptake in these masses as well as demonstrate the presence of fat deposits in the region of the LHIS.

Knowledge of the frequency and features of LHIS on CT and FDG-PET is important in the primary staging of patients with malignancy. In patients with lung cancer, the false interpretation of FDG uptake in LHIS as metastatic disease would stage a patient as having mediastinal disease. This false interpretation, in a patient who otherwise had absent or local nodal involvement, would mean that the patient would not receive appropriate curative therapy. In addition, identification of this anomaly on PET but failure to recognize its relatively benign nature may lead to unnecessary cardiac imaging or possibly interventional procedures such as angiography, biopsy, or surgical resection.


   Conclusion
TOP
 Abstract
 Introduction
 Methods and Materials
 Results
 Discussion
 Conclusion
References
 
It is important to recognize the patterns and prevalence of LHIS on PET and CT. It is clear how LHIS, a benign disorder, can potentially mimic malignancy. False interpretation of increased FDG uptake would result in inappropriate staging and potentially inappropriate treatment. With a knowledge of the patterns and frequency of incidental LHIS on CT and PET, clinicians can appropriately detect LHIS and distinguish it from neoplasia.


   Footnotes
 
Abbreviations: BAT = brown adipose tissue; BMI = body mass index; CW = chest wall; FDG = 18F fluorodeoxyglucos; HU = Hounsfield unit; LHIS = lipomatous hypertrophy of the interatrial septum; PET = positron emission tomography; SUV = standardized uptake value

Received for publication May 5, 2005. Accepted for publication June 4, 2005.


   References
TOP
 Abstract
 Introduction
 Methods and Materials
 Results
 Discussion
 Conclusion
 References
 

  1. Prior, JT (1964) Lipomatous hypertrophy of cardiac interatrial septum: a lesion resembling hibernoma, lipoblastomatosis and infiltrating lipoma. Arch Pathol 78,11-15[ISI][Medline]
  2. Heyer, CM, Kagel, T, Lemburg, SP, et al Lipomatous hypertrophy of the interatrial septum: a prospective study of incidence, imaging findings, and clinical symptoms. Chest 2003;124,2068-2073[Abstract/Free Full Text]
  3. Burke, AP, Litovsky, S, Virmani, R Lipomatous hypertrophy of the atrial septum presenting as a right atrial mass. Am J Surg Pathol 1996;20,678-685[CrossRef][ISI][Medline]
  4. Shirani, J, Roberts, WC Clinical, electrocardiographic and morphologic features of massive fatty deposits ("lipomatous hypertrophy") in the atrial septum. J Am Coll Cardiol 1993;22,226-238[Abstract]
  5. Gay, JD, Guileyardo, JM, Townsend-Parchman, JK, et al Clinical and morphologic features of lipomatous hypertrophy ("massive fatty deposits") of the interatrial septum. Am J Forensic Med Pathol 1996;17,43-48[CrossRef][ISI][Medline]
  6. Reyes, CV, Jablokow, VR Lipomatous hypertrophy of the cardiac interatrial septum: a report of 38 cases and review of the literature. Am J Clin Pathol 1979;72,785-788[ISI][Medline]
  7. Wann, LS, Sampson, C, Liu, Y Cardiac and paracardiac masses: complementary role of echocardiography and magnetic resonance imaging. Echocardiography 1998;15,139-146[ISI][Medline]
  8. Page, DL Lipomatous hypertrophy of the cardiac interatrial septum: its development and probable clinical significance. Hum Pathol 1970;1,151-163[Medline]
  9. Hutter, AM, Jr, Page, DL Atrial arrhythmias and lipomatous hypertrophy of the cardiac interatrial septum. Am Heart J 1971;82,16-21[CrossRef][ISI][Medline]
  10. Colucci, W, Schoen, F, Braunwald, E Primary tumors of the heart. Braunwald, E eds. Heart disease Fifth Ed. 1997,1464-1477 WB Saunders. Philadelphia, PA::
  11. Fan, CM, Fischman, AJ, Kwek, BH, et al Lipomatous hypertrophy of the interatrial septum: increased uptake on FDG PET. AJR Am J Roentgenol 2005;184,339-342[Abstract/Free Full Text]
  12. Weber, WA Brown adipose tissue and nuclear medicine imaging. J Nucl Med 2004;45,1101-1103[Free Full Text]
  13. Inoue, T, Mohri, N, Nagahara, T, et al A case report of "lipomatous hypertrophy of the cardiac interatrial septum," with a proposal for a new term, lipomatous hamartoma of the cardiac atrial septum." Acta Pathol Jpn 1988;38,1583-1589[Medline]
  14. Meaney, JF, Kazerooni, EA, Jamadar, DA, et al CT appearance of lipomatous hypertrophy of the interatrial septum. AJR Am J Roentgenol 1997;168,1081-1084[Abstract/Free Full Text]
  15. Pochis, WT, Saeian, K, Sagar, KB Usefulness of transesophageal echocardiography in diagnosing lipomatous hypertrophy of the atrial septum with comparison to transthoracic echocardiography. Am J Cardiol 1992;70,396-398[CrossRef][ISI][Medline]
  16. Isner, JM, Swan, CS, II, Mikus, JP, et al Lipomatous hypertrophy of the interatrial septum: in vivo diagnosis. Circulation 1982;66,470-473[Abstract/Free Full Text]
  17. Bar-Shalom, R, Gaitini, D, Keidar, Z, et al Non-malignant FDG uptake in infradiaphragmatic adipose tissue: a new site of physiological tracer biodistribution characterised by PET/CT. Eur J Nucl Med Mol Imaging 2004;31,1105-1113[ISI][Medline]
  18. Cohade, C, Osman, M, Pannu, HK, et al Uptake in supraclavicular area fat ("USA-Fat"): description on 18F-FDG PET/CT. J Nucl Med 2003;44,170-176[Abstract/Free Full Text]
  19. Novick, R, Dobell, A Tumors of the Heart. Baue, E eds. Thoracic and cardiovascular surgery 1991,1989-2002 Appleton and Lange. East Norwalk, CT:
  20. McAllister, HJ, Fenoglio, JJ Tumors of the cardiovascular system. Atlas of tumor pathology 1978 Armed Forces Institute of Pathology. Washington, DC:




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via ISI Web of Science (3)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kuester, L. B.
Right arrow Articles by Aquino, S. L.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kuester, L. B.
Right arrow Articles by Aquino, S. L.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS