statdx/docs_md/articles/cardiac-mass_fa1f894a-4619-4657-b99b-a967a3e4e871.md

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Cardiac Mass	fa1f894a-4619-4657-b99b-a967a3e4e871	key value df804626-c042-4296-96e3-836a6da50fd6 Gregory Kicska, MD, PhD	name slug treeNodeId Cardiac cardiac fa90100b-619c-430e-8074-b5b9789bab39 name slug treeNodeId Differential Diagnosis differential-diagnosis 952326a0-b3ea-4a21-aa7a-d796cc9325ed name slug treeNodeId Cardiac Mass cardiac-mass null	Cardiac	de88549a-e500-4b4c-8157-a415679d7913	15	03/17/22	Cardiac Mass	Cardiac, Differential Diagnosis, Cardiac Mass	Cardiac Mass | STATdx	Cardiac Mass	DDX	Cardiac Differential Diagnosis Cardiac Mass

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title: "Cardiac Mass" docid: "fa1f894a-4619-4657-b99b-a967a3e4e871" authors:

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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

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.

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.

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.