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title: "Cardiac Mass"
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docid: "fa1f894a-4619-4657-b99b-a967a3e4e871"
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authors:
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- key: "df804626-c042-4296-96e3-836a6da50fd6"
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value: "Gregory Kicska, MD, PhD"
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breadcrumbs:
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-
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name: "Cardiac"
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slug: "cardiac"
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treeNodeId: "fa90100b-619c-430e-8074-b5b9789bab39"
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-
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name: "Differential Diagnosis"
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slug: "differential-diagnosis"
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treeNodeId: "952326a0-b3ea-4a21-aa7a-d796cc9325ed"
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-
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name: "Cardiac Mass"
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slug: "cardiac-mass"
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treeNodeId: null
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category: "Cardiac"
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documentVersionId: "de88549a-e500-4b4c-8157-a415679d7913"
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imageCount: 15
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lastUpdated: "03/17/22"
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pageDescription: "Cardiac Mass"
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pageKeywords: "Cardiac, Differential Diagnosis, Cardiac Mass"
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pageTitle: "Cardiac Mass | STATdx"
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enhancedTitle: "Cardiac Mass"
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type: "DDX"
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breadcrumbs:
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- "Cardiac"
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- "Differential Diagnosis"
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- "Cardiac Mass"
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---
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# ESSENTIAL INFORMATION
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- ## Key Differential Diagnosis Issues
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- Clinical impact is most affected by determination of possible malignancy
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- Etiology of cardiac masses often cannot be distinguished with imaging
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- Mass prevalence, coupled with ancillary findings and clinical history, is best tool in generating focused differential
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- Thrombus is most common cardiac mass
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- Thrombus usually is associated with causes of flow disturbance (atrial fibrillation, ventricular aneurysm, cardiomyopathy, etc.)
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- Malignant:benign ratio = 60:1
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- Metastasis:primary cardiac tumor ratio = 40:1
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- Primary benign:primary malignant ratio = 3:1
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- Primary cardiac neoplasm prevalence reported at 1 per 3,000 to 100,000 in autopsy series
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- Malignant vs. benign
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- Heterogeneous MR signal is nonspecific and can be seen in benign or malignant neoplasms
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- Most lesions are T2 hyperintense and T1 isointense to myocardium
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- Malignant tumors more often have moderate to strong enhancement than benign masses
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- Multichamber involvement or extension into adjacent structures suggest malignant mass
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- Myxomas (benign) are usually heterogeneous
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- Pleural or pericardial effusion suggests primary cardiac malignancy or metastasis
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- In absence of effusion, primary malignancy is less common and metastasis is very uncommon
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- Right heart mass suggests metastasis
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- ## Helpful Clues for Common Diagnoses
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- **Thrombus**
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- MR signal characteristics vary based on age of thrombus
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- Chronic thrombus: T1 and T2 hypointense
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- Acute thrombus: T1 and T2 hyperintense
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- Thrombus will not enhance on postcontrast images; best determined on subtraction postcontrast images
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- Enhancement with vessel expansion suggests tumor thrombus
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- Thrombus will remain dark on delayed enhancement images using long inversion time (500 ms) due to T2* shortening
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- Signal intensity will decrease when employing gradient echo sequences vs. spin echo due to T2* shortening
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- Commonly occur adjacent to area of heart wall hypokinesis or wall thinning
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- Commonly occur in atrial appendages
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- Associated with history of myocardial infarction or atrial fibrillation
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- Polypoid thrombi more likely to embolize than smooth peripheral thrombi
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- **Cardiac Metastases**
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- In adults, most commonly lung, breast, lymphoma, esophagus, and melanoma primary
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- In children, most commonly leukemia, lymphoma, neuroblastoma, Wilms, hepatoblastoma, and sarcoma
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- ~ 90% are clinically silent
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- Autopsy series of cancer patients showed prevalence of ~ 7%
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- Imaging features are variable; diagnosis suggested by history of above malignancies
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- ## Helpful Clues for Less Common Diagnoses
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- **Myxoma**
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- Frequency: LA vs. RA ~ 4:1; bilateral (4%), RV (8%)
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- 10% of cases due to autosomal dominant inheritance
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- ~ 50% will prolapse across AV valve
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- Many cases cause pseudo-mitral valve disease
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- ~ 15% with calcification, more commonly seen in RA myxomas
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- Lobulated:smooth contour ratio ~ 3:1
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- **Sinus of Valsalva**
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- ## Helpful Clues for Rare Diagnoses
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- **Sarcoma**
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- Most patients are symptomatic, complaining of dyspnea at time of diagnosis
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- Most patients present with metastasis
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- Angiosarcoma most common pathology at 33%
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- Angiosarcoma most commonly in right atrium
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- Other sarcoma histologies preferentially intracavitary in left atrium
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- Commonly occur between 3rd and 5th decades
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- Lesion morphology is variable ranging from infiltrative to endocardial
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- Intense heterogeneous contrast enhancement
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- Heterogeneous, mostly intermediate T1 signal and heterogeneous, mostly high T2 signal
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- **Rhabdomyoma**
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- Most common benign tumor in pediatric population
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- High T2 signal and intermediate T1 signal
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- Multiple lesions are often present
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- Myocardial/intramural location
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- 50% of patients have coexistent tuberous sclerosis
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- **Fibroma**
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- 2nd most common benign tumor in pediatric population
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- Focal bulge, most commonly in ventricular wall, extending toward cardiac lumen
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- Involved myocardium is hypokinetic
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- Myocardial/intramural location
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- Solitary
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- Calcification common
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- T1 iso- or hyperintense compared to myocardium
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- T2 hypointense compared to myocardium
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- MR and CT contrast enhancement similar to myocardium or nodular peripheral enhancement
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- Present in 10-15% of patients with Gorlin syndrome
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- Autosomal dominant disease with propensity to develop multiple neoplasms, such as basal cell cancers and medulloblastomas
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- **Hemangioma**
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- Patients usually asymptomatic
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- Heterogeneous attenuation on unenhanced CT
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- Hyperenhancement on enhanced CT
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- T1 isointense compared to myocardium
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- T2 hyperintense compared to myocardium
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- Isointense to blood pool on balanced steady-state free precession
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- **Lipoma**
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- Macroscopic fat with capsule
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- Multiple lipomas seen in tuberous sclerosis
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## Images
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### Selected Images
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**Thrombus**
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*Axial CECT shows a nonenhancing filling defect in the left ventricular apex <img src='img/arrows/BS.png'/> with adjacent calcifications <img src='img/arrows/WS.png'/> and wall thinning. This patient had a prior LAD territory myocardial infarct and apical hypokinesis.*
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**Thrombus**
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*Axial CECT shows a nonenhancing filling defect in the left ventricular apex <img src='img/arrows/BS.png'/> with adjacent calcifications <img src='img/arrows/WS.png'/> and wall thinning. This patient had a prior LAD territory myocardial infarct and apical hypokinesis.*
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**Thrombus**
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*Axial CECT shows a well-marginated filling defect in the left atrial appendage <img src='img/arrows/WS.png'/> in a patient with atrial fibrillation. Atrial appendages are common locations for thrombi.*
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**Thrombus**
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*Filling defect <img src='img/arrows/WS.png'/> is seen in the inferior right atrium in a young patient with testicular cancer. Although any malignancy can metastasize to the heart, this is not commonly reported for this histology. This intracardiac mass resolved after anticoagulation.*
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**Thrombus**
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*Four-chamber delayed-phase CECT using an inversion time of 500 ms in the same patient shows low signal of the filling defect <img src='img/arrows/WS.png'/> at the level of the coronary sinus.*
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**Cardiac Metastases**
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*Frontal radiograph in a patient with known metastatic melanoma shows deviation of the left heart border <img src='img/arrows/BS.png'/> (new compared to 1 month prior). Further imaging showed cardiac metastasis.*
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**Cardiac Metastases**
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*Axial CECT in the same patient with metastatic melanoma shows diffuse hepatic metastasis and expansion of the anterior wall of the left ventricle <img src='img/arrows/WS.png'/>. Note heterogeneous contrast attenuation.*
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**Cardiac Metastases**
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*Axial CECT shows a heterogeneous mass in right and left atrium <img src='img/arrows/WS.png'/>. Although sparing of the fossa ovalis <img src='img/arrows/BC.png'/> suggests lipomatous hypertrophy of intraatrial septum, heterogeneous enhancement, soft tissue attenuation, and involvement of both atria indicate malignancy.*
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**Cardiac Metastases**
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*Short-axis T1 C+ MR shows an enhancing mass <img src='img/arrows/WS.png'/> in the left atrium, which represented metastatic B-cell lymphoma.*
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**Myxoma**
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*Four-chamber bright-blood MR shows filling defect in LA <img src='img/arrows/WS.png'/>. Mass was mobile and appeared tethered to intraatrial septum, presumably by a thin stalk.*
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**Sarcoma**
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*Four-chamber black-blood MR without (left) and with (right) fat suppression shows lipomatous hypertrophy of intraatrial septum <img src='img/arrows/WS.png'/>. Note sparing of fossa ovalis <img src='img/arrows/WO.png'/> and near-complete loss of signal with fat suppression <img src='img/arrows/WC.png'/>. This is benign but may be confused with a cardiac mass.*
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**Sarcoma**
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*Axial CECT shows a heterogeneous, enhancing mass filling the right atrium <img src='img/arrows/WS.png'/> with extension into the pericardium and obliteration of the epicardial fat <img src='img/arrows/WC.png'/>. There was no pericardial effusion. Pathology revealed an angiosarcoma.*
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**Sarcoma**
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*Axial C+ MR in the same patient shows heterogeneous contrast enhancement <img src='img/arrows/WS.png'/>. The right atrium is the most common location for cardiac angiosarcoma.*
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**Sarcoma**
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*Axial CECT shows left posterior atrial wall thickening with a lobulated contour <img src='img/arrows/WS.png'/>. The mass has a broad attachment base. Resection demonstrated a leiomyosarcoma.*
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**Hemangioma**
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*Axial T2 black-blood MR shows a high-signal right atrial mass <img src='img/arrows/WS.png'/>. Note the heterogeneous enhancement following IV contrast administration. Surgical removal revealed hemangioma.*
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### Additional Images
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**Cardiac Metastases**
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*Axial CECT shows filling defect in SVC <img src='img/arrows/WS.png'/>, which was suspected to be thrombus. Multiple other filling defects were present in the right atrium (not shown). Right skin lesion <img src='img/arrows/WO.png'/> is noted, and biopsy showed large B-cell lymphoma. SVC mass was later proven to be a tumor.*
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