Cardiac tumours-Radiology

1. Imaging of
Cardiac Tumors
dr amol
gulhane
DNB
Resident

2. •Prevalence of 0.002-0.3%
• About 75 percent of all primary cardiac tumors -
benign neoplasms.
•Remaining 25 percent of primary cardiac tumors -
malignant neoplasms-metastatic MC
Metastatic involvement of the heart is 30 times more
prevalent than primary cardiac tumors.

3. Presurgical assessment of malignant cardiac tumors
with the use of MDCT and MRI allow determination of
the resectability of tumors and planning for the
reconstruction of cardiac chambers.
Echocardiography is the best imaging modality
to depict small masses that arise from the
cardiac valves.

4. Visualization of extracardiac extension is suboptimal with the
use of transthoracic echocardiography for the evaluation of
malignant cardiac masses.
TEE overcomes the limited acoustic window of the
transthoracic mode, the airways and lungs can be obstacles
for imaging of the aortic arch, pulmonary arteries and some
systemic and pulmonary veins

5. MRI is presently the modality of choice to evaluate cardiac tumors.
High contrast resolution and multiplanar capability allow a specific
diagnosis and optimal evaluation of myocardial infiltration,
pericardial involvement and extracardiac extension.
The use of ECG-gated MDCT has better soft tissue contrast than
echocardiography and can definitively characterize fatty content
and calcifications.

7. Relative incidence of benign heart tumors
% of Group
TUMOR Adults Children Infants
Myxoma
Lipoma
Papillary fibroelastoma
Rhabdomyoma
Fibroma
Hemangioma
Teratoma
Mesothelioma of AV node
Granular cell tumor
Neurofibroma
Lymphangioma
Hamartoma
46
21
16
2
3
5
1
3
1
1
1
0
15
0
0
46
15
5
13
4
0
1
0
1
0
0
0
65
12
4
18
2
0
0
0
0

8. BENIGN TUMORS
Myxomas
Myxomas are the most common benign tumor found in adults(4th -7th
decades).
classic triad of symptoms - cardiac obstructive symptoms related to
the obstruction of blood flow , embolic events, and constitutional
symptoms such as fever, malaise and weight loss.
It ocurs in the middle age, 40-70 years, and has an
association with pituitary adenoma, testicular tumours and
Cushing's disease.

9. • Majority sporadic; some are familial
(autosomal dominant transmission) or part
of a syndrome
1. Carney complex – spotty skin pigmentation,
myxomas, endocrine overactivity,
schwannomas
2. NAME syndrome – nevi, atrial myxoma,
myxoid neurofibroma, ephelides
3. LAMB syndrome – lentigines, atrial myxoma,
blue nevi

10. Sporadic Familial or Syndrome Myxoma
• Solitary
• More common
• Usually located in left atria
• Arise from inter-atrial septum
in vicinity of fossa ovalis
• May also occur in the
ventricles or multiple locations
• Younger individual
• Often multiple location
• Less common (10%)
• Autosomal dominant pattern
of transmission
• Associated with freckling, non-
cardiac tumors, endocrine
neoplasms
• Recurrent after surgery

11. Thromboembolic events-- left-sided myxomas 
brain, kidney, spleen and extremities
right-sided myxomas lung .
75% of myxomas == left atrium, in the interatrial
septum in the region of the fossa ovalis;
20% of myxomas == right atrium, rarely found in
the ventricles.

12. The plain film appearances can vary from a normal examination
to an enlarged heart with selective left atrial and left atria
appendage enlargement
Some mxyoma tend to Calcify with associated movement
detected on fluoroscopy.
Non Contrast-enhanced CT -- a well-defined spherical or ovoid
intracavitary mass, which typically has lobular contours.
Tumor attenuation is lower than that of the unopacified blood.

13. On intravenous contrast it appears as a mass of
low attenuation surrounded by enhancing
intracardiac blood.
Heterogeneity is a common feature of myxomas
-reflects hemorrhage, necrosis, cyst formation,
fibrosis or calcification.

14. MRI
MRI appearances are heterogeneous, reflecting the non-uniformity of
these masses. They are typically spherical or ovoid masses which may
be sessile or pedunculated
T1 : tend to be low to intermediate signal, but areas of haemorrhage
may be high
T2 :  hyperintense
can be variable due to heterogeneity in tumour componants
; e.g calcific components, hemosiderin > low signal ; myxomatous
components > high signal
GE (gradient echo) : may show blooming of calcific components
T1 C+ (Gd) : shows enhancement (important discriminator from a
thrombus)

15. Imaging findings:
A transthoracic echocardiographic study, subcostal 4 chamber view
shows a mobile mass in the right atrium . The mass is highly
echogenic and appears to protrude through the tricuspid valve into the
right ventricle The interatrial septum appears normal
MDCT confirms the presence of a large RA mass .On the axial MDCT
images a large lobulated tumor mass is seen in the right atrium.

16. Cardiac magnetic resonance (CMR) shows a mass with a broad-based
attachment to the inter-atrial septum at the floor of the fossa ovalis. The mass
has high signal intensity on T2-weighted spin echo images , persisting on fat
suppression imaging, excluding a lipoma or liposarcoma.
Signal intensity doubled on first-pass perfusion, excluding thrombus.
Delayed enhancement imaging revealed patchy hyperenhancement suggestive
of cystic cavitation, features all strongly suggestive of a myxoma.

17. Myxoma.
A, Axial contrast-enhanced CT scan shows a soft
tissue mass (Myxoma)
arising from the interatrial septum.

18. Right ventricular myxoma in 30-year-old female.
A. Sagittal double inversion-recovery MR image demonstrates isointense mass
(arrow) occupying right ventricular outflow tract.
B. Sagittal triple inversion-recovery image demonstrates bright signal intensity in
most parts of mass (arrow).
C. Postcontrast double inversion-recovery image demonstrates hyperenhancement
of mass (arrow).

19. Lipomas
Second most common benign cardiac tumors
encountered in adults
Cardiac lipomas are usually solitary
and may occur in the myocardial tissue, usually
in a subepicardial location.
CT shows cardiac lipomas as homogeneous,
low-attenuation masses either in a cardiac
chamber or in the pericardial space

20. • If subepicardial
 Compression of the heart
 Pericardial effusion
• If subendocardial
 With intracavitary extension, may
produce symptoms characteristic of their
location
• Most common chambers affected: LV, RA,
IAS

21. MR  homogeneous increased signal intensity
seen on the T1- and T2-weighted ; suppressed
on fat saturated sequences.
As with soft-tissue lipomas, cardiac lipomas do
not show enhancement with the administration
of a contrast material.

22. Right atrial lipoma
A. MDCT image shows homogeneously
low-attenuated mass with pedicle (arrow)
attached to free wall of right atrium

23. High-signal-intensity mass
(L) in the lateral wall of the
right atrium. High signal
intensity on T1 imaging is
strongly suggestive of fatty
tissue and identifies this
mass as a lipoma.

24. Papillary Fibroelastomas
rare lesion, usually affecting older adults
Benign endocardial papillomas that mainly affect the cardiac
valves and account for approximately 75% of all cardiac
valvular tumors
It is composed of multiple papillary fronds, which predispose
it to form thrombi.
Because of the risk of lethal
embolization to the coronary or cerebral circulation, surgical
resection is the treatment of choice.

25. Papillary fibroelastomas are usually not observed on CT
or MR images as they are small (< 1.5 cm in diameter)
and are attached to the moving valves .
MR imaging typically demonstrates the presence of a
mass on a valve leaflet or on the endocardial surface .
These tumors can create turbulence in the blood flow,
which might be demonstrated with the use of cine MR
imaging

26. Papillary fibroelastoma of aortic valve in 60-year-
old female
A. ECG-gated multidetector CT image
demonstrates abnormal thickening of aortic valve
(arrow).
B, C. Oblique cine MR images demonstrates small mass (arrows) attached to aortic
valve that was moving according to valvular motion.
D. Oblique transverse triple inversion-recovery MR image demonstrates slightly high
signal intensity of small mass (arrow).

27. Rhabdomyomas
most common cardiac tumors in infancy and childhood
often associated with tuberous sclerosis in up to 50% of
cases
Most patients are asymptomatic, and rhabdomyomas
generally regress spontaneously.
tumors originate within the myocardium, typically in the
ventricles, and multiple lesions present in up to 90% of
cases

28. Echocardiography is usually used for evaluation
of these tumors.
On noncontrast-enhanced CT scans,
rhabdomyomas are typically denser than the adjacent
myocardium
and may have areas of fat density.
Enhances on contrast CT.
MR isointense to marginally hyperintense as
compared with the myocardium on T1-weighted
images and hyperintense on T2-weighted images

29. Cardiac rhabdomyoma in newborn with tuberous sclerosis
B. Sagittal T1-weighted spin echo MR image shows isointense mass (arrows) in
septum and anterior wall of left ventricle.
C. Transverse gadolinium-enhanced T1-weighted spin echo MR image shows
mild enhancement of mass (arrows).

30. Fibromas
mainly affect infants and children, second most common tumors found
in this age group
Grossly, the lesions are solid tumors that arise within the myocardium
and can grow to a size that obliterates the cavity.
CT homogeneous masses with soft-tissue attenuation, may be either
sharply marginated or infiltrative. Calcification is often observed.
MRhomogeneously isointense to hypointense relative to the
myocardium on T1- and T2-weighted images due to a dense, fibrous
nature. For the same reason, these tumors often show delayed
enhancement on gadolinium-enhanced study

31. Left ventricular fibroma
A. ECG-gated multidetector CT image shows
myocardial thickening (arrows) and spotty
calcification (arrowhead) in lateral wall of left
ventricle.
B. Transverse double inversion-recovery MR
image shows hypointense mass (arrows) in
myocardium of left ventricle.
C. Transverse triple inversion-recovery MR
image also shows hypointense mass (arrows)
in myocardium of left ventricle.
D. Delayed MR image with suppression of normal myocardial signal 10 minutes
after administration of gadolinium demonstrates hyperenhancement of mass

32. Hemangiomas
benign vascular tumors
5-10% of benign tumors
Cardiac hemangiomas are heterogeneous on precontrast CT images
and show intense contrast enhancement
As with hepatic hemangiomas, these tumors typically show
intermediate signal intensity on T1-weighted images and
hyperintense on the T2-weighted images

33. Cavernous hemangioma of left atrial appendage
A. Transverse double inversionrecovery MR image
shows intermediate signal intensity mass (arrows) in
left atrial appendage.
B. Transverse triple inversion-recovery MR image
shows hyperintense mass (arrows) with smooth
margin.
C. Coronal gadolinium-enhanced double inversion-
recovery MR image shows strong enhancement of
lesion (arrows).

34. PRIMARY MALIGNANCIES
Angiosarcomas
most common cardiac sarcomas
Adults. M>F
the tumors tend to occur in the right atrium and involve the
pericardium.
usually cause right-sided heart failure or tamponade
Presentation is late, and there is often the presence of metastases at
the time of diagnosis, particularly to the lung.
Invasive behavior is a feature of malignant lesions with pericardial or
pleural effusion.

35. CT low-attenuation mass in the right atrium, might be irregular or
nodular
Heterogenous enhancement
Cardiac sarcomas  heterogeneous signal intensity on MR images ,
with blood-filled spaces within the neoplasm seen on T2 as high signal
intensity
A papillary appearance can be observed as a specific MR feature of an
angiosarcoma, with a nodular area of high signal intensity interspersed
within areas of intermediate signal intensity seen on T1- and T2-
weighted images
In cases with diffuse pericardial infiltration, linear enhancement along
the vascular spaces seen ( "sunray" appearance )

36. D. Gadolinium-enhanced double inversion-recovery MR image shows
heterogeneous hyperenhancement of mass. Within mass, some portions (arrows)
have no enhancement, representing intratumoral thrombosis.
Angiosarcoma of right atrium in 48-year-old male.
A. ECG-gated multidetector CT image shows large mass
(arrows) in free wall of right atrium. Mass shows irregular
and nodular contour and strong contrast enhancement.
B. Transverse double inversion-recovery MR image
demonstrates mostly isointense mass (arrows) in right
atrium. C. Transverse triple inversion-recovery MR
image demonstrates presence of heterogeneously
hyperintense mass (arrows).

37. Other Cardiac Sarcomas
angiosarcomas  most common cardiac sarcomas,
undifferentiated sarcomas
malignant fibrous histiocytomas (MFHs),
Leiomyosarcomas
Osteosarcomas
Lymphosarcomas
myxosarcomas,
neurogenic sarcomas
synovial sarcomas
neurofibrosarcomas
Kaposi's sarcomas can affect the heart.
Angiosarcomas -- right atrium
other sarcomas-- left atrium

38. MFHs  left atrium , attached to the posterior wall
MFH -- nonspecific signal intensity MRI
A MFH arises from the posterior wall of the left atrium and can extend
into the pulmonary veins
Myxoma does not extent to PV
MFH

39. Malignant fibrous histiocytoma in 57-year-old female.
A. Transverse double inversion-recovery MR image
shows large isointense mass (arrows) arising from
posterior wall of left atrium that extends into mitral
valve.
B. Transverse triple inversion-recovery MR image
shows hyperintense mass (arrows) with irregular
contour.
C. Gadolinium-enhanced double inversion-recovery
MR image shows heterogeneous hyperenhancement
of mass (arrows).
D. MDCT reformatted image shows that mitral valve (arrow) is abutting mass
.

40. Primary cardiac osteosarcomas
usually arise from the posterior wall of the
left atrium near the pulmonary veins.
metastatic osteosarcomas,usually involve the right
atrium.
May calcify and may be confused with calcifi ed myxoma.
OSlocation in the posterior wall of the left atrium
myxomas septal location

41. Noncontrast and contrast-enhanced computed tomograms of
heart, showing partially calcified mass

42. Lymphoma
Up to 25% of patients with lymphoma have cardiac involvement
at autopsy
Primary cardiac lymphoma (lymphoma limited to the heart and/or
pericardium) is very rare.
Primary cardiac lymphoma is usually a B-cell lymphoma.
most common locationright heart, usually the right atrium
Associated pericardial effusion is common

43. Primary cardiac lymphoma
Contrast-enhanced CT shows a lobulated mass
within the right heart at the level of the tricuspid valve. The mass
extends into the right atrial and right ventricular cavities

44. MR image shows a tumoral mass of a
cardiac lymphoma that affects the anterior
right atrial and ventricular wall and spreads
to the pericardium at the heart's apex.

45. Secondary Cardiac Tumors
Metastatic cardiac involvement is much more common
than primary cardiac neoplasms,
2ry occur most frequently in patients with pleural
mesothelioma , melanoma ,lung adenocarcinoma ,
undifferentiated carcinomas , lung squamous cell
carcinoma and breast carcinoma
Direct extension of tumor is the most
common route and typically occurs
in lung and breast cancers.

46. Symptoms due to pericardial involvement.
RCC, adrenal carcinoma, HCC, and uterine leiomyosarcoma may
involve
the heart by extension through the IVC.
Thyroid carcinoma
may extend into the heart through the SVC.
Lung cancer
may also spread along the pulmonary veins to involve the
left atrium.

47. Both lymphangitic and hematogenous
route
Leukemia and lymphoma are
the most common tumors to cause cardiac
metastases by the lymphangitic route, in
which case mediastinal nodes are
invariably involved.

48. Lesions That Mimic Cardiac Tumors
Thrombus
Thrombus within the heart may mimic a cardiac mass.
In the atria, thrombus usually involves the appendages
In the ventricle, thrombus usually occurs over an area of
hypokinesis such as a myocardial infarction or within a
ventricular aneurysm.

49. Lipomatous Hypertrophy of the Interatrial
Septum
Fat may be detected in the AV grooves and the interatrial
septum.
Normally, fat in the interatrial septum measures
less than 1 cm anterior and posterior to the fossa ovalis.
LHIS results in increased fat deposition in the interatrial
septum.
This may mimic an atrial tumor on an echocardiogram
Typically, the lesion is dumbbell-shaped
because of the sparing of the region of the fossa ovalis

50. CT and MRI are able to accurately
depict the fatty nature of the lesion
Pathologically, the lesion is not a true encapsulated
Lipoma . fetal or brown fat intermixed with myocardial cells.
Treatment is directed at controlling the
arrhythmia, if present.

51. Normal Anatomic Structures
Normal anatomic structures that may be mistaken for a
mass include
a prominent moderator band in the right ventricle,

53. The crista terminalis is a vertically
orientated smooth muscle ridge extending
from the SVC to the IVC.
its size and shape can be variable and it
may protrude into the RA, it may be
mistaken as an intracardiac mass or
thrombus.
Prominent crista terminalis

54. prominent crista
terminalis in the
right atrium

55. The RAA has a triangular or pyramidal
shape with a wide base opening and rough
trabeculation of pectinate muscles.
The pectinate muscle in the RAA may be
misinterpreted as a mass or thrombus.
the pectinate muscle have parallel course
on imaging

56. Prominent pectinate muscle in rt atrium

57. Most malignant tumors are likely to be
treated with radiation or chemotherapy
Most beingn cardiac tumours are usually treated surgically