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Learning Modules ❯ Cardiac

CT of Cardiac Masses: Pearls and Pitfalls

Elliot K. Fishman M.D.
Johns Hopkins Hospital

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Approach to Differential Diagnosis of Cardiac Masses

Is there a cardiac mass present?
Anatomic location?
- Intracavitary mass
- Mass extension along great vessels
- Pericardial mass
- Valvular mass
Specific tissue characteristics?
Relevant clinical history?

Intracavitary Mass Differential Diagnosis

Thrombus
Primary benign neoplasms
- Myxoma, lipoma, rhabdomyoma, fibroma
Primary malignant neoplasms
- Angiosarcoma, other sarcomas, lymphoma
Metastatic neoplasms

Cardiac Tumors: Factoids

Primary tumors are rare and metastases to the heart are more common (20-40x more common)
75% of primary cardiac tumors are benign (most commonly myxoma)
25% of primary cardiac tumors are malignant (most commonly sarcomas)

“Primary cardiac neoplasms occur at an incidence of 30 per 100,000 people per year. Approximately 80% of primary cardiac tumors are benign. The World Health Organization has classified neoplasms of the heart into either benign tumors and tumorlike lesions such as myxoma, malignant lesions such as angiosarcoma, and pericardial tumors such as solitary fibrous tumors. In patients older than 16 years, the most common primary cardiac neoplasms are myxomas, lipomatous tumors, and papillary fibroelastomas. In patients younger than 16 years, the most common tumors are rhabdomyomas, teratomas, fibromas, and myxomas.”
Cardiac Neoplasms Radiologic-Pathologic Correlation
John P. Lichtenberger III et al.
Radiol Clin N Am 59 (2021) 231–242

”The most common presenting symptom of a cardiac tumor is dyspnea, but the manifestations of a neoplasm will depend on the location of the lesion and size. Even benign cardiac tumors may cause obstruction of blood flow, decreased cardiac output, arrhythmia, or heart failure, which can be fatal. In addition, systemic manifestations such as fatigue, anorexia, and fever may also be seen.”
Cardiac Neoplasms Radiologic-Pathologic Correlation
John P. Lichtenberger III et al.
Radiol Clin N Am 59 (2021) 231–242

Cardiac Tumor: Clinical Presentation

Systemic: constitutional (fever, arthralgias, weight loss, fatigue) and paraneoplastic syndromes (PCTs).
Cardiac: mass effect interfering with myocardial function or blood flow, resultant arrhythmias, interference with heart valves causing regurgitation, or pericardial effusion with or without tamponade. Typical symptoms include dyspnea, chest discomfort, pre-syncope, or syncope.
Embolic: pulmonary and/or systemic thromboembolic phenomenon from the tumor.

Cardiac Tumors: JACC CardioOncology State-of-the-Art Review.”
Tyebally, Sara et al.
JACC. CardioOncology vol. 2,2 293-311. 16 Jun. 2020,

Cardiac Masses on CT: Key Findings

size
quantity
location (cardiac chamber, pericardial involvement, extracardiac structures)
morphology (attachment, margin appearance, infiltration)
tissue characteristics (calcification, fat attenuation, vascularity)
clinical correlation (known malignancy or infection, presence of a catheter, associated syndromes)

Cardiac Masses on Cardiac CT: A Review
David Kassop et al.
Curr Cardiovasc Imaging Rep (2014) 7:9281

Cardiac Myxoma: Facts

Myxoma is the most common primary cardiac tumor, accounting for 25-50 % of cases.
typically affects middle-aged adults, 30-60 years of age, with a higher prevalence in women.
majority (60-75 %) of cases are located in the left atrium attached to the fossa ovalis by a thin stalk, though less common locations include the right atrium (15-20 %), inferior vena cava, ventricles, and the valve leaflets

Cardiac Myxomas: Facts

Cardiac myxomas are the most common PCT and are believed to be derived from mesenchymal cell precursors.
They form intracavitary masses, which are most commonly found in the left atrium attached by a stalk to the fossa ovalis, but may be seen in the right atrium in children. Other anatomical origins include the atrial free wall and mitral valve leaflets; however, these are less likely.
Association with Carney complex (a multiple neoplasia and lentiginosis syndrome) is well established in 7% of patients found to have a cardiac myxoma on presentation.
Mean age at diagnosis is 50 years, and approximately 70% occur in women.

“On cardiac CT, approximately two-thirds of myxomas are ovoid with a smooth or lobular shape, with the remainder villous in appearance. When visualized on non-contrast CT, they typically appear hypodense, consistent with blood, and may demonstrate calcifications more often in the right atrial location. On contrast-enhanced cardiac CT, myxomas appear as intracavitary filling defects with heterogeneous con- trast enhancement, though the intensity may be variable depending on their chronicity and whether necrosis or hemorrhage is present.”
Cardiac Masses on Cardiac CT: A Review
David Kassop et al.
Curr Cardiovasc Imaging Rep (2014) 7:9281

Cardiac myxomas: Facts

On cardiac CT, myxomas often manifest as a low-attenuation intracavitary mass with a smooth or slightly villous surface.
Calcification is seen in approximately 14% of patients and is more commonly associated in right-sided lesions.
Arterial-phase contrast enhancement is usually not present , but heterogeneous enhancement is recognized on studies performed with a longer time delay.

”Although they can be located in any chamber, most myxomas are located within the left atrium and originate at the interatrial septum. These lesions may have an irregular border, a pedunculated morphology, and be mobile. The size of the tumor is related to the degree of mobility and the potential that the lesion can obstruct the atrioventricular valve.”
Cardiac Neoplasms Radiologic-Pathologic Correlation
John P. Lichtenberger III et al.
Radiol Clin N Am 59 (2021) 231–242

” Although computed tomography (CT) is not the preferred method to characterize the tumor, typical findings on a contrast-enhanced CT include a spherical or ovoid mass that is lower in attenuation than surrounding myocardium.”
Cardiac Neoplasms Radiologic-Pathologic Correlation
John P. Lichtenberger III et al.
Radiol Clin N Am 59 (2021) 231–242

Atrial Myxoma: Clinical presentation