CT and MR imaging findings of benign cardiac tumors

MRI and CT Appearances in Various Cardiac Tumours

While primary cardiac malignancies are infrequent, the heart often serves as a site for metastases. Myxomas are recognized as among the most prevalent primary benign tumours globally, while sarcomas represent the most common malignant primary tumours. The diverse range of potential clinical presentations depends on factors such as location, size, and the aggressiveness of the disease. The majority of diagnoses rely on medical imaging, making it crucial to familiarize oneself with their distinctive characteristics. When a cardiac mass is suspected, MRI of the heart has emerged as the preferred diagnostic method, surpassing previous techniques. CT is a valuable tool for assessing cardiac morphology and improving electrocardiography gating by providing enhanced details. This article conducts a comprehensive review of the MRI and CT characteristics of both primary and secondary cardiac malignancies, emphasizing crucial distinctions and common diagnostic pitfalls. Despite their rarity, cardiac masses continue to hold significance in the realm of cardio-oncology. Furthermore, this article explores conditions such as thrombus, Lambl's excrescences, and pericardial cysts, which can mimic tumours. Multimodal imaging has played a pivotal role in identifying the origin of cardiac masses in numerous cases, particularly when combined with the clinical context. This article offers an in-depth examination of the frequency, clinical indicators, imaging, diagnostic procedures, available treatments, and prognoses related to cardiac masses.

Cardiac Masses and Pseudomasses: An Overview about Diagnostic Imaging and Clinical Background

A cardiac lesion detected at ultrasonography might turn out to be a normal structure, a benign tumor or rarely a malignancy, and lesion characterization is very important to appropriately manage the lesion itself. The exact relationship of the mass with coronary arteries and the knowledge of possible concomitant coronary artery disease are necessary preoperative information. Moreover, the increasingly performed coronary CT angiography to evaluate non-invasively coronary artery disease leads to a rising number of incidental findings. Therefore, CT and MRI are frequently performed imaging modalities when echocardiography is deemed insufficient to evaluate a lesion. A brief comprehensive overview about diagnostic radiological imaging and the clinical background of cardiac masses and pseudomasses is reported.

Tissue characterization of benign cardiac tumors by cardiac magnetic resonance imaging, a review of core imaging protocol and benign cardiac tumors

Generally, cardiac masses are initially suspected on routine echocardiography. Cardiac magnetic resonance (CMR) imaging is further performed to differentiate tumors from pseudo-tumors and to characterize the cardiac masses based on their appearance on T1/T2-weighted images, detection of perfusion and demonstration of gadolinium-based contrast agent uptake on early and late gadolinium enhancement images. Further evaluation of cardiac masses by CMR is critical because unnecessary surgery can be avoided by better tissue characterization. Different cardiac tissues have different T1 and T2 relaxation times, principally owing to different internal biochemical environments surrounding the protons. In CMR, the signal intensity from a particular tissue depends on its T1 and T2 relaxation times and its proton density. CMR uses this principle to differentiate between various tissue types by weighting images based on their T1 or T2 relaxation times. Generally, tumor cells are larger, edematous, and have associated inflammatory reactions. Higher free water content of the neoplastic cells and other changes in tissue composition lead to prolonged T1/T2 relaxation times and thus an inherent contrast between tumors and normal tissue exists. Overall, these biochemical changes create an environment where different cardiac masses produce different signal intensity on their T1- weighted and T2- weighted images that help to discriminate between them. In this review article, we have provided a detailed description of the core CMR imaging protocol for evaluation of cardiac masses. We have also discussed the basic features of benign cardiac tumors as well as the role of CMR in evaluation and further tissue characterization of these tumors.

Common benign primary pediatric cardiac tumors: a primer for radiologists

Cardiac tumors are neoplasms arising from or located in the heart or the pericardium. Although rare, primary cardiac tumors in children require an accurate and timely diagnosis. Most pediatric primary cardiac tumors are benign (around 90%). Echocardiography is the first imaging modality used due to its availability, noninvasiveness, inexpensiveness, and absence of ionizing radiation. Computed tomography (CT) and magnetic resonance imaging (MRI) offer better soft tissue visualization as well as better visualization of extracardiac structures. A great advantage of MRI is the possibility of measuring cardiac function and blood flow, which can be important for obstructing cardiac tumors. In this article, we will offer a brief review of clinical, echocardiographic, CT, and MRI features of cardiac rhabdomyomas, fibromas, teratomas, and lipomas providing their differential diagnosis.

The challenge in diagnosing cardiac tumors to avoid unnecessary cardiac surgery

Cardiac magnetic resonance in cardiac mass: Cardiac magnetic resonance (CMR) should be considered in the evaluation of patients with cardiac mass. Especially, when the diagnosis is not certain, CMR could provide paramount information that could be helpful for the decision on cardiac surgery.

Cardiac magnetic resonance imaging of primary cardiac tumors

Cardiac magnetic resonance (CMR) offers superior advantages in cardiac imaging due to supplying a greater field of view, excellent soft-tissue imaging, and multiplanar imaging capabilities. CMR imaging can evaluate the characteristics of cardiac tumors by visualizing the relationship between the tumor and surrounding tissues, and plays a vital role in assisting the formulation of the surgical plan, the assessment of tumor progression, and the monitoring of postoperative tumor recurrence and metastasis. In this review, we present the clinical manifestations and imaging features of different cardiac tumors. The superior performance of CMR in preoperative diagnosis, surgical treatment, and postoperative follow-up of patients with heart tumors are also highlighted.

Incidental cardiac aspergillomas in an immunocompromised woman

We report a case of 3 autopsy proven incidental cardiac aspergillomas, a rare and yet deadly manifestation caused by Aspergillus. A 48-year-old Caucasian woman affected by a large B-cell lymphoma was referred to our institute for a whole-body fluorine-18 fluorodeoxyglucose positron emission tomography/contrast-enhanced computed tomography restaging examination, which demonstrated 3 intracardiac masses. The patient was hospitalized, and both a transthoracic echocardiogram and a cardiac magnetic resonance imaging examination were performed. None of the imaging modalities provided a definitive diagnosis. A positive serum galactomannan assay allowed for the initiation of antifungal therapy, but, nevertheless, the patient died a few days later. This case highlights the need to consider cardiac aspergilloma in the differential diagnosis of cardiac masses, especially in immunocompromised patients. Though noninvasive imaging modalities and cardiac magnetic resonance imaging, in particular, help determine the nature of a cardiac lesion, cardiac aspergilloma shows no distinctive radiological features. A high degree of clinical suspicion is therefore key to achieving a timely diagnosis. Histopathological examination with microbiological confirmation remains the diagnostic gold standard.

Outcomes of Patients with Cardiac Myxoma: A Retrospective Multicentre Study

Background:

We present a 15-year follow-up of patients with Cardiac Myxoma (CM) who underwent tumour resection.

Patients and Methods:

Between 2001 and 2016, 38 patients with CM were operated on. We retrospectively reviewed, their clinical presentations. We also analysed the echocardiographic, electrocardiographic and pathology reports.

Results:

No mortality was seen after surgery. The mean age of the patients was 41.7±7.8 years and the female/male ratio was 22/16. Two patients with CM were children. The main symptoms of left atrial CM were dyspnoea on exertion, chest pain and congestive heart failure. Tricuspid valve pathology, and leg oedema were the main symptoms in patients with right atrial CM combined with right heart failure. CM as a cause of nephrotic syndrome was detected in 2 patients. In 5 asymptomatic patients (13.1%), CM was detected incidentally. We detected a pericardial invasion by the tumour in 1 patient. We performed secondary surgery because of tumour recurrence in 2 patients. Overall, survival for patients after surgical excision was 96.4±1.6% at 1 year, 91.7±2.4% at 5 years, 87.6±2.6% at 10 years and 85±1.9% at 15 years.

Conclusion:

The symptoms of CM may include congestive heart failure or nephrotic syndrome. Because CM may be associated with serious cardiac symptoms, tumour excision should be performed immediately after diagnosis. The use of right anterior thoracotomy for CM resection is a safe surgical approach.

Intracardiac extension of intravenous leiomyoma, a rare phenomenon: A case report

Leiomyoma of uterine origin is a common histologically benign neoplasm in women; however, growth intravenously with intracardiac extension is a rare phenomenon. This is a diagnostic challenge that can present with varied clinical manifestations and multiple differential diagnosis. This is a case of a 45-year-old female patient with chest heaviness and an intracardiac mass on 2-dimensional (2D) echocardiogram. Previous history of hysterectomy was likewise noted. Imaging workup, including 2D echocardiogram and contrast-enhanced chest and abdomen computed tomography scans, was performed which demonstrated a large, heterogeneous, elongated filling defect in the right atrium and right ventricle extending to the inferior vena cava, left renal vein, and left gonadal vein. The diagnosis was made after resection of the tumor in a single-stage operation. The histopathologic and immunoprofile of the resected tumor were consistent with leiomyoma. The use of multiple imaging modalities such as 2D echocardiogram and computed tomography are essential in the investigation of the intracaval masses with intracardiac extension. Although intravenous leiomyoma with intracardiac extension is a rare phenomenon, radiologists and clinicians alike should be mindful of this differential diagnosis.

Clot in Lung, Clot in Heart: A Case Report of Tumor-Like Thrombus in Right Atrium

Tumor-like formation of thrombus in the right atrial cavity is rare. It may be mistaken for a myxoma. The exact pathophysiology of an isolated thrombus in the heart is still unclear. Management to prevent complications such as pulmonary thromboembolism depends on the clinical judgment of a cardiologist. This report describes a 76-year-old woman with right atrial thrombus causing subsequent pulmonary thromboembolism in right lung. She initially presented to us with pulmonary embolism, and later, an incidental finding of a mass in her right atrium revealed an association of thrombus in heart with thrombus in lung. The challenging management was to resect this thrombus which was fixed to atrial septum, and a trial of anticoagulation did not resolve it. Exact management of such incidental findings in right heart cavities is not well established. Some cases may benefit from resection of such formed fixed thrombus.

Left ventricular outflow tract obstruction due to a left ventricular myxoma that was misidentified as an accessory mitral valve tissue

We report obstruction of the left ventricle outflow tract (LVOT) caused by cardiac myxoma that was misidentified as an accessory mitral valve tissue preoperatively. A 65-year-old woman presented with chest discomfort that persisted for 7 days. Transthoracic echocardiography (TTE) revealed a mobile, low-echogenic, balloon-shaped mass attached to the anterior mitral valve leaflet and papillary muscle, which was suspected to be an accessory mitral valve tissue. Because the mass caused LVOT obstruction and it could result in hemodynamic instability, emergency operation was performed. Intraoperative transesophageal echocardiography (TEE) was performed, and the mass had irregular margins and was pedunculated, with a stalk originating from the left ventricle (LV) wall and extending to the lateral chordae of the mitral valve. The surgeon excised the mass filled with the myxomatous mass, which was yellowish and gelatinous and had a stiff stalk, and histopathologic diagnosis confirmed a myxoma. Although mitral valve or LV myxomas are rare, TEE is a useful tool for distinguishing a myxoma from other intracardiac masses, such as vegetation or an accessory mitral valve tissue.

Point-of-Care Ultrasound Diagnosis of a Catheter-Associated Atrial Thrombus

BACKGROUND

Emergency physicians can utilize point-of-care thoracic ultrasound to aid in the diagnosis of a variety of cardiovascular and respiratory complaints.

CASE REPORT

An emergency physician utilized point-of-care cardiac ultrasound to identify catheter-associated atrial thrombi in a hemodialysis patient presenting with dyspnea. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Based on this case, point-of-care ultrasound can be utilized in patients with central venous catheters, to identify intracardiac thrombi as the cause of dyspnea, thereby facilitating appropriate consultation and treatment.

Cardiac tumors: leiomyosarcoma - a case report

We present a case report of a 60-year-old woman with a long history of leiomyosarcoma in different locations. She was admitted to the clinic due to a left ventricular tumor diagnosed in ECHO examination. The patient was qualified for radical tumor resection. The early postoperative period was complicated due to low cardiac output syndrome and bradyarrhythmia requiring temporary cardiac pacing. Optimized pharmacological therapy resulted in a gradual reduction of symptoms and a clinical improvement of congestive heart failure (NYHA III - NYHA II). Due to the radical nature of the surgery, the patient was not referred for supplementary treatment. The follow-up currently exceeds 12 months - no new metastases have been found. This case provides an example of how to diagnose and treat heart tumors.

MRI assessment of cardiac tumours: part 1, multiparametric imaging protocols and spectrum of appearances of histologically benign lesions

Cardiac magnetic resonance imaging (MRI) is the reference standard technique for assessment and characterization of a suspected cardiac tumour. It provides an unrestricted field of view, high temporal resolution and non-invasive tissue characterization based on multi-parametric assessment of the chemical micro-environment. MRI exploits differences in hydrogen proton density in conjunction with T1 and T2 relaxation properties of different tissues to help differentiation normal from abnormal and benign from malignant lesions. In this article we review specific cardiac MRI techniques, tumour protocol design and the appearance of the spectrum of histologically benign tumours.

Treating cardiac myxomas: a 16-year Chinese single-center study

AIMS

Currently, myxoma is the most common type of primary cardiac tumor diagnosed. This article describes the experience over the past 16 years with cases of cardiac myxoma in Chinese patients and elucidated the differences between solid and papillary myxomas.

METHODS

The clinical details of 68 patients with cardiac myxomas who underwent surgery between January 1996 and January 2012 at our center were retrospectively analyzed.

RESULTS

The left atrium was the primary tumor site in 88% of the patients included in this study. The most common implant site was the interatrial septum (69%), especially for patients with solid tumors. Common clinical symptoms included dyspnea and palpitation, whereas embolic events occurred in 12 patients. Myxoma resection involved a midline sternotomy utilizing cardiopulmonary bypass. According to pathological classification, solid myxomas were present in 28 patients (47%), whereas papillary myxomas were detected in 40 patients (53%). In the solid group, arrhythmias and a larger tumor volume were more common. Correspondingly, in 97.4  ±  2.5% of cases, secondary surgery was not needed after 10 years. Overall, the actuarial survival for patients undergoing surgical excision of myxoma was 98.4  ±  1.6% at 5 years and 96.0  ±  2.8% at 10 years.

CONCLUSION

Solid myxomas were associated with more arrhythmias, a larger tumor volume, implantation in the interatrial septum, and a need for concomitant surgery compared with papillary myxomas. Further studies should determine whether serum or histological markers could be routinely used in combination with echocardiograms, MRI and computed tomography for the predictions of recurrent myxomas during annual follow-up examinations.

MR imaging of cardiac tumors and masses: a review of methods and clinical applications

Cardiac masses are usually first detected at echocardiography. In their further evaluation, cardiac magnetic resonance (MR) imaging has become a highly valuable technique. MR imaging offers incremental value owing to its larger field of view, superior tissue contrast, versatility in image planes, and unique ability to enable discrimination of different tissue characteristics, such as water and fat content, which give rise to particular signal patterns with T1- and T2-weighted techniques. With contrast material-enhanced MR imaging, additional tissue properties such as vascularity and fibrosis can be demonstrated. MR imaging can therefore contribute to the diagnosis of a cardiac mass as well as be used to detail its relationship to other cardiac and extracardiac structures. These assessments are important to plan therapy, such as surgical intervention. In addition, serial MR studies can be used to monitor tumor regression after surgery or chemotherapy. Primary cardiac tumors are very rare; metastases and pseudotumors (eg, thrombus) are much more common. This article provides an overview of cardiac masses and reviews the optimal MR imaging techniques for their assessment.

Cardiac tumors in a tertiary care cancer hospital: clinical features, echocardiographic findings, treatment and outcomes

Cardiac tumors are a rare entity, comprised of tumors with diverse histology and natural history. We report the clinical characteristics, echocardiograhic findings, therapy and outcome of 59 patients with primary and metastatic cardiac tumors. Our institutional echocardiogram data base from 1993 through 2005 was reviewed to identify patients diagnosed with intra-cardiac tumor. A total of 59 patients with cardiac tumors were identified and included in the study. The patients' characteristics, presenting symptoms, diagnostic tests, location, histology of the tumor, treatment and the one year survival rate of this population was collected from the medical records. Of the 59 cardiac tumor cases, 16 (27%) were primary cardiac tumors and 43 (73%) were secondary cardiac tumors. The most common primary tumor was sarcoma affecting 13 (81%) of the 16 cases. Of these, 5 patients were angiosarcoma, 5 unclassified sarcoma, one myxoid sarcoma and 2 malignant fibrous histiocytoma. The mean age at presentation was 41.1 years, and the most common location was right atrium affecting 6 cases (37.5%). The most common symptom of dyspnea was present in 10 (62.5%) cases. Eleven (25.6%) of the 43 secondary cardiac tumors were metastasis from renal cell carcinoma. The mean age at presentation was 55.4 years. Right atrium was the most frequent location affecting 18 (42%) of the 43 patients. The most common presenting symptom was dyspnea in 15 (35%) cases. For both primary and secondary tumors, dyspnea was the most common symptom and right atrium was most frequently involved. Sarcoma was the most common primary cardiac tumor while metastasis from renal cell carcinoma was the most common secondary tumor.

Left atrial mass with stalk: thrombus or myxoma?

A 63-year-old female was presented to emergency room with an abdominal pain. The patient had moderate mitral valve stenosis and atrial fibrillation. Abdominal computed tomography revealed right renal infarction. Transthoracic echocardiography showed a large mobile mass in the left atrium. Transesophageal two-and three-dimensional echocardiography showed a large mobile ovoid mass with a narrow stalk attached to the left atrial septum. It was thought to be a myxoma rather than thrombus. Anticoagulation with heparin was continued. When the operation was performed, there was no mass in the left atrium. It must be a thrombus and melt away.

Cardiac tumors: optimal cardiac MR sequences and spectrum of imaging appearances

OBJECTIVE

This article reviews the optimal cardiac MRI sequences for and the spectrum of imaging appearances of cardiac tumors.

CONCLUSION

Recent technologic advances in cardiac MRI have resulted in the rapid acquisition of images of the heart with high spatial and temporal resolution and excellent myocardial tissue characterization. Cardiac MRI provides optimal assessment of the location, functional characteristics, and soft-tissue features of cardiac tumors, allowing accurate differentiation of benign and malignant lesions.

Benign cardiac tumours: cardiac CT and MRI imaging appearances

Primary benign cardiac tumours are rarely found in clinical practice and are generally evaluated with echocardiography. However, with the increasing usage of helical multislice CT, the initial detection and evaluation of these masses may be made by the radiologist during routine daily practice for other indications. The echocardiographic, CT and cardiac MRI appearances of various benign cardiac tumours and masses are described and illustrated in this review.

Atrial myxomas and thrombi: comparison of imaging features on CT

OBJECTIVE

The purpose of our study was to compare the imaging features of atrial myxomas and thrombi using CT and to assess the accuracy of CT for determining the origin of myxomas in comparison with surgical findings.

MATERIALS AND METHODS

From July 2006 until June 2008, 23 patients (15 women, eight men; mean age, 63 +/- 14 years) with atrial myxomas (n = 13) and thrombi (n = 11) who underwent dual-source CT coronary angiography were included in this retrospective study. Two independent and blinded readers evaluated quantitative (CT attenuation and size) and qualitative (location, origin, shape, mobility, prolapse, and calcifications) parameters at CT. The shape and origin of myxomas were compared with the findings at surgery.

RESULTS

No significant differences regarding the CT attenuation of myxomas in comparison with thrombi were found (43 +/- 14 HU vs 57 +/- 30 HU; p = 0.23). Myxomas were significantly larger than thrombi (33 +/- 16 mm vs 21 +/- 7 mm; p < 0.05). The lesions were found equally in the left and right atria (p = 0.11). The origin (p < 0.001), shape (p < 0.05), mobility (p < 0.01), and occurrence of prolapse (p < 0.01) differed significantly between the lesions. Calcifications did not differ between the lesions (p = 0.2). In comparison with surgery, the origin of myxomas was correctly evaluated by CT in 11 of 13 patients (fossa ovalis, n = 5; interatrial septum, n = 4; and lateral atrial wall, n = 2), whereas CT misclassified the origin of two myxomas (posterior and lateral wall left atria at CT vs fossa ovalis at surgery).

CONCLUSION

Atrial myxomas and thrombi can be differentiated by their distinguishing features of size, origin, shape, mobility, and prolapse. CT is accurate in determining the origin of myxomas but may fail in some cases.

Cardiac MRI is Complementary to Echocardiography in the Assessment of Cardiac Masses

Despite the fact that the incidence of cardiac tumors is low, the prompt evaluation and adequate intervention of these is highly important. Although most tumors of the heart are considered histologically benign, there are significant risks associated with these "benign" tumors. These are associated with significant morbidity and mortality due to obstruction of blood flow, alterations of conduction, propagation of arrhythmias, and thromboembolism, depending on their size, location, and nature. With the advent of noninvasive imaging modalities--traditionally echocardiography; but more recently using cross-sectional imaging with cardiac computed tomography and magnetic resonance imaging--cardiac tumors can be optimally assessed providing a greater opportunity for curative treatments by cardiothoracic surgery.

Magnetic Resonance Imaging of Pericardial Disease and Cardiac Masses

MRI is known to be a superior modality for evaluating pericardial disease and masses because of its unmatched capacity for tissue characterization and high spatial resolution. New real-time sequences now complement the standard morphologic imaging of the pericardium with dynamic image acquisitions that also can provide hemodynamic information indicative of constriction. In the evaluation of masses, recently developed rapid imaging sequences have shortened examination times and improved lesion characterization. The full spectrum of pericardial disease and cardiac masses is reviewed, and the role of MRI explored.

Cardiac pseudosarcomatous fibromyxoid tumor: a review of the literature

A cardiac pseudosarcomatous fibromyxoid tumor (PFT) is described in a previously healthy 35-year-old man, together with a review of the literature. Pseudosarcomatous fibromyxoid tumor is within the spectrum of inflammatory (myofibroblastic) pseudotumors. It has previously been described predominantly within the genitourinary tract and respiratory tract. Inflammatory pseudotumor is rare as a cardiac tumor, and cardiac PFT is not previously reported. No recurrence or metastatic disease has been reported after resection of PFTs elsewhere in the body, and this tumor seems to have a benign clinical course.

Left atrial myxoma diagnosed and characterized by cardiac magnetic resonance imaging

A 71 year old man was referred for MRI investigation of the heart. He had a history of progressive dyspnea. Due to his echocardiographical findings and the known history of permanent atrial fibrillation, his cardiologist suspected atrial thrombi. MRI investigation of the heart showed a left atrial mass pedunculated at the atrial septum which showed signal enhancement after intravenous administration of gadolinium-DTPA. Left atrial myxoma was suspected. The patient underwent surgery with resection of the tumor and patch-occlusion of the atrial septum. Histology confirmed a polypoid cardial myxoma.