204 lines
16 KiB
Markdown
204 lines
16 KiB
Markdown
---
|
|
title: "Cardiac Mass"
|
|
docid: "fa1f894a-4619-4657-b99b-a967a3e4e871"
|
|
authors:
|
|
- key: "df804626-c042-4296-96e3-836a6da50fd6"
|
|
value: "Gregory Kicska, MD, PhD"
|
|
breadcrumbs:
|
|
-
|
|
name: "Cardiac"
|
|
slug: "cardiac"
|
|
treeNodeId: "fa90100b-619c-430e-8074-b5b9789bab39"
|
|
-
|
|
name: "Differential Diagnosis"
|
|
slug: "differential-diagnosis"
|
|
treeNodeId: "952326a0-b3ea-4a21-aa7a-d796cc9325ed"
|
|
-
|
|
name: "Cardiac Mass"
|
|
slug: "cardiac-mass"
|
|
treeNodeId: null
|
|
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
|
|
|
|
|
|
**Thrombus**
|
|
*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.*
|
|
|
|
|
|
**Thrombus**
|
|
*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.*
|
|
|
|
|
|
**Thrombus**
|
|
*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.*
|
|
|
|
|
|
**Thrombus**
|
|
*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.*
|
|
|
|
|
|
**Thrombus**
|
|
*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.*
|
|
|
|
|
|
**Cardiac Metastases**
|
|
*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.*
|
|
|
|
|
|
**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 <img src='img/arrows/WS.png'/>. Note heterogeneous contrast attenuation.*
|
|
|
|
|
|
**Cardiac Metastases**
|
|
*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.*
|
|
|
|
|
|
**Cardiac Metastases**
|
|
*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.*
|
|
|
|
|
|
**Myxoma**
|
|
*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.*
|
|
|
|
|
|
**Sarcoma**
|
|
*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.*
|
|
|
|
|
|
**Sarcoma**
|
|
*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.*
|
|
|
|
|
|
**Sarcoma**
|
|
*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.*
|
|
|
|
|
|
**Sarcoma**
|
|
*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.*
|
|
|
|
|
|
**Hemangioma**
|
|
*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.*
|
|
|
|
|
|
### Additional Images
|
|
|
|
|
|
**Cardiac Metastases**
|
|
*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.*
|
|
|