---
title: "Cardiac Mass"
docid: "fa1f894a-4619-4657-b99b-a967a3e4e871"
authors:
- key: "df804626-c042-4296-96e3-836a6da50fd6"
value: "Gregory Kicska, MD, PhD"
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name: "Cardiac"
slug: "cardiac"
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name: "Differential Diagnosis"
slug: "differential-diagnosis"
treeNodeId: "952326a0-b3ea-4a21-aa7a-d796cc9325ed"
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name: "Cardiac Mass"
slug: "cardiac-mass"
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category: "Cardiac"
documentVersionId: "de88549a-e500-4b4c-8157-a415679d7913"
imageCount: 15
lastUpdated: "03/17/22"
pageDescription: "Cardiac Mass"
pageKeywords: "Cardiac, Differential Diagnosis, Cardiac Mass"
pageTitle: "Cardiac Mass | STATdx"
enhancedTitle: "Cardiac Mass"
type: "DDX"
breadcrumbs:
- "Cardiac"
- "Differential Diagnosis"
- "Cardiac Mass"
---
# ESSENTIAL INFORMATION
- ## Key Differential Diagnosis Issues
- Clinical impact is most affected by determination of possible malignancy
- Etiology of cardiac masses often cannot be distinguished with imaging
- Mass prevalence, coupled with ancillary findings and clinical history, is best tool in generating focused differential
- Thrombus is most common cardiac mass
- Thrombus usually is associated with causes of flow disturbance (atrial fibrillation, ventricular aneurysm, cardiomyopathy, etc.)
- Malignant:benign ratio = 60:1
- Metastasis:primary cardiac tumor ratio = 40:1
- Primary benign:primary malignant ratio = 3:1
- Primary cardiac neoplasm prevalence reported at 1 per 3,000 to 100,000 in autopsy series
- Malignant vs. benign
- Heterogeneous MR signal is nonspecific and can be seen in benign or malignant neoplasms
- Most lesions are T2 hyperintense and T1 isointense to myocardium
- Malignant tumors more often have moderate to strong enhancement than benign masses
- Multichamber involvement or extension into adjacent structures suggest malignant mass
- Myxomas (benign) are usually heterogeneous
- Pleural or pericardial effusion suggests primary cardiac malignancy or metastasis
- In absence of effusion, primary malignancy is less common and metastasis is very uncommon
- Right heart mass suggests metastasis
- ## Helpful Clues for Common Diagnoses
- **Thrombus**
- MR signal characteristics vary based on age of thrombus
- Chronic thrombus: T1 and T2 hypointense
- Acute thrombus: T1 and T2 hyperintense
- Thrombus will not enhance on postcontrast images; best determined on subtraction postcontrast images
- Enhancement with vessel expansion suggests tumor thrombus
- Thrombus will remain dark on delayed enhancement images using long inversion time (500 ms) due to T2* shortening
- Signal intensity will decrease when employing gradient echo sequences vs. spin echo due to T2* shortening
- Commonly occur adjacent to area of heart wall hypokinesis or wall thinning
- Commonly occur in atrial appendages
- Associated with history of myocardial infarction or atrial fibrillation
- Polypoid thrombi more likely to embolize than smooth peripheral thrombi
- **Cardiac Metastases**
- In adults, most commonly lung, breast, lymphoma, esophagus, and melanoma primary
- In children, most commonly leukemia, lymphoma, neuroblastoma, Wilms, hepatoblastoma, and sarcoma
- ~ 90% are clinically silent
- Autopsy series of cancer patients showed prevalence of ~ 7%
- Imaging features are variable; diagnosis suggested by history of above malignancies
- ## Helpful Clues for Less Common Diagnoses
- **Myxoma**
- Frequency: LA vs. RA ~ 4:1; bilateral (4%), RV (8%)
- 10% of cases due to autosomal dominant inheritance
- ~ 50% will prolapse across AV valve
- Many cases cause pseudo-mitral valve disease
- ~ 15% with calcification, more commonly seen in RA myxomas
- Lobulated:smooth contour ratio ~ 3:1
- **Sinus of Valsalva**
- ## Helpful Clues for Rare Diagnoses
- **Sarcoma**
- Most patients are symptomatic, complaining of dyspnea at time of diagnosis
- Most patients present with metastasis
- Angiosarcoma most common pathology at 33%
- Angiosarcoma most commonly in right atrium
- Other sarcoma histologies preferentially intracavitary in left atrium
- Commonly occur between 3rd and 5th decades
- Lesion morphology is variable ranging from infiltrative to endocardial
- Intense heterogeneous contrast enhancement
- Heterogeneous, mostly intermediate T1 signal and heterogeneous, mostly high T2 signal
- **Rhabdomyoma**
- Most common benign tumor in pediatric population
- High T2 signal and intermediate T1 signal
- Multiple lesions are often present
- Myocardial/intramural location
- 50% of patients have coexistent tuberous sclerosis
- **Fibroma**
- 2nd most common benign tumor in pediatric population
- Focal bulge, most commonly in ventricular wall, extending toward cardiac lumen
- Involved myocardium is hypokinetic
- Myocardial/intramural location
- Solitary
- Calcification common
- T1 iso- or hyperintense compared to myocardium
- T2 hypointense compared to myocardium
- MR and CT contrast enhancement similar to myocardium or nodular peripheral enhancement
- Present in 10-15% of patients with Gorlin syndrome
- Autosomal dominant disease with propensity to develop multiple neoplasms, such as basal cell cancers and medulloblastomas
- **Hemangioma**
- Patients usually asymptomatic
- Heterogeneous attenuation on unenhanced CT
- Hyperenhancement on enhanced CT
- T1 isointense compared to myocardium
- T2 hyperintense compared to myocardium
- Isointense to blood pool on balanced steady-state free precession
- **Lipoma**
- Macroscopic fat with capsule
- Multiple lipomas seen in tuberous sclerosis
## Images
### Selected Images
with adjacent calcifications 
and wall thinning. This patient had a prior LAD territory myocardial infarct and apical hypokinesis.](images/app.statdx.com_image_thumbnail_4afa8491-c1f8-4f03-b531-948dd8436d71_annotated_true_size_900_quality_90_65b929a1ae83a54c9b7be50908b8265b25bdca4d.jpg)
**Thrombus**
*Axial CECT shows a nonenhancing filling defect in the left ventricular apex with adjacent calcifications and wall thinning. This patient had a prior LAD territory myocardial infarct and apical hypokinesis.*
**Thrombus**
*Axial CECT shows a nonenhancing filling defect in the left ventricular apex with adjacent calcifications and wall thinning. This patient had a prior LAD territory myocardial infarct and apical hypokinesis.*
**Thrombus**
*Axial CECT shows a well-marginated filling defect in the left atrial appendage in a patient with atrial fibrillation. Atrial appendages are common locations for thrombi.*
**Thrombus**
*Filling defect 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.*
**Thrombus**
*Four-chamber delayed-phase CECT using an inversion time of 500 ms in the same patient shows low signal of the filling defect at the level of the coronary sinus.*
**Cardiac Metastases**
*Frontal radiograph in a patient with known metastatic melanoma shows deviation of the left heart border (new compared to 1 month prior). Further imaging showed cardiac metastasis.*
**Cardiac Metastases**
*Axial CECT in the same patient with metastatic melanoma shows diffuse hepatic metastasis and expansion of the anterior wall of the left ventricle . Note heterogeneous contrast attenuation.*
suggests lipomatous hypertrophy of intraatrial septum, heterogeneous enhancement, soft tissue attenuation, and involvement of both atria indicate malignancy.](images/app.statdx.com_image_thumbnail_2eef8a34-30ee-4bf0-9d61-0d8393042c00_annotated_true_size_900_quality_90_82711a6e44ad8330926b5df7bd963f7029956017.jpg)
**Cardiac Metastases**
*Axial CECT shows a heterogeneous mass in right and left atrium . Although sparing of the fossa ovalis suggests lipomatous hypertrophy of intraatrial septum, heterogeneous enhancement, soft tissue attenuation, and involvement of both atria indicate malignancy.*
**Cardiac Metastases**
*Short-axis T1 C+ MR shows an enhancing mass in the left atrium, which represented metastatic B-cell lymphoma.*
**Myxoma**
*Four-chamber bright-blood MR shows filling defect in LA . Mass was mobile and appeared tethered to intraatrial septum, presumably by a thin stalk.*
and near-complete loss of signal with fat suppression 
. This is benign but may be confused with a cardiac mass.](f8757954-1f0d-4416-b68e-0e3545421f08)
**Sarcoma**
*Four-chamber black-blood MR without (left) and with (right) fat suppression shows lipomatous hypertrophy of intraatrial septum . Note sparing of fossa ovalis and near-complete loss of signal with fat suppression . This is benign but may be confused with a cardiac mass.*
**Sarcoma**
*Axial CECT shows a heterogeneous, enhancing mass filling the right atrium with extension into the pericardium and obliteration of the epicardial fat . There was no pericardial effusion. Pathology revealed an angiosarcoma.*
**Sarcoma**
*Axial C+ MR in the same patient shows heterogeneous contrast enhancement . The right atrium is the most common location for cardiac angiosarcoma.*
**Sarcoma**
*Axial CECT shows left posterior atrial wall thickening with a lobulated contour . The mass has a broad attachment base. Resection demonstrated a leiomyosarcoma.*
**Hemangioma**
*Axial T2 black-blood MR shows a high-signal right atrial mass . Note the heterogeneous enhancement following IV contrast administration. Surgical removal revealed hemangioma.*
### Additional Images
**Cardiac Metastases**
*Axial CECT shows filling defect in SVC , which was suspected to be thrombus. Multiple other filling defects were present in the right atrium (not shown). Right skin lesion is noted, and biopsy showed large B-cell lymphoma. SVC mass was later proven to be a tumor.*