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← Section V · Cardiac Masses, Pericardial Disease, Contrast and New Applications
V.B

Cardiac Tumors and Masses

20 cards

Notes

Approach to a cardiac mass

Three broad categories:

  1. Thrombus (most common overall).
  2. Vegetation (see II.D).
  3. Tumor - primary (rare) vs metastatic (30× more common than primary).

Cardiac tumors (primary)

Benign

  • Myxoma (most common primary cardiac tumor in adults, 50 %):
    • Usually in the LA, attached to the interatrial septum at the fossa ovalis by a stalk.
    • Mobile, gelatinous; may prolapse across the mitral valve → obstruction ("tumor plop").
    • Carney complex: familial (autosomal dominant) syndrome of multiple myxomas + skin pigmentation + endocrine tumors.
  • Papillary fibroelastoma: usually on aortic valve (downstream aspect), small, pedunculated, "sea anemone" appearance. Second most common primary cardiac tumor in adults. High embolic risk.
  • Rhabdomyoma: most common primary cardiac tumor in children. Associated with tuberous sclerosis. Multiple, echogenic, ventricular. Often regress spontaneously.
  • Fibroma: single, ventricular, may calcify. Congenital. May cause arrhythmias.
  • Lipoma: encapsulated fat, benign; distinct from lipomatous hypertrophy of the atrial septum.

Malignant primary

  • Angiosarcoma: most common primary malignant cardiac tumor in adults. Typically RA, often infiltrating the free wall.
  • Rhabdomyosarcoma, other sarcomas - rare.

Metastatic tumors

  • 30× more common than primary tumors.
  • Most common: lung, breast, melanoma, lymphoma, leukemia.
  • Melanoma has the highest per-tumor propensity for cardiac metastasis.
  • Renal cell carcinoma and hepatocellular carcinoma: may extend up the IVC into the RA (tumor thrombus).
  • Carcinoid: right-heart valvular disease from serotonin-secreting hepatic metastases.

Common mimics of a cardiac mass

  • Left atrium: Coumadin (Q-tip) ridge, right lower PV, pectinate muscle, SEC.
  • Right atrium: Eustachian valve, Chiari network, crista terminalis, Thebesian valve.
  • Left ventricle: prominent trabeculation, false tendon (linear muscle band across the LV cavity).
  • Right ventricle: moderator band (crosses the RV cavity at the mid-apical level).
  • Aortic valve: nodule of Arantius (at the center of each cusp free edge), Lambl's excrescence (thin strand on closure line).
  • Mitral valve: redundant chordae, MAC.

Thrombus

  • LA / LAA: AF, mitral stenosis, low CO. Best seen on TEE.
  • LV apex: after large anterior MI with apical akinesis; also in DCM, apical HCM. Contrast improves detection.
  • RV: rare.
  • RA / IVC: catheter- or lead-related, tumor thrombus, in transit from lower-extremity DVT.

Malignancy-related mimics

  • Lipomatous hypertrophy of the atrial septum: dumbbell-shaped fatty infiltration sparing the fossa ovalis. Benign.
  • Metastatic pericardial disease: nodular pericardial thickening + effusion; may cause tamponade.

Antiphospholipid syndrome

  • Large valvular masses (mobile or broad-based, heterogeneous echogenicity).
  • Sometimes multiple "kissing" lesions.
  • Tissue destruction is USUALLY absent (its presence → superimposed IE).

Behçet's disease

  • Cardiac involvement rare.
  • Pericarditis is the most common finding.
  • May have MR/AR, endomyocardial fibrosis, intracardiac thrombi.

Cards

  • basicV.B-001
    What is the most common primary cardiac tumor in adults, its typical location, and its attachment?
    → Atrial myxoma (~50% of primary cardiac tumors). Usually in the LEFT ATRIUM, attached by a stalk to the interatrial septum at the fossa ovalis. Mobile, gelatinous; may prolapse across the mitral valve in diastole causing obstruction and a classic 'tumor plop' sound.
  • basicV.B-002
    What is Carney complex?
    → Autosomal-dominant syndrome of multiple cardiac and cutaneous myxomas + skin pigmentation (lentigines, blue nevi) + endocrine tumors (Cushing syndrome, acromegaly). Suspect in patients with recurrent, multiple, or non-atrial myxomas.
  • basicV.B-003
    What is the second most common benign cardiac tumor in adults and its typical location?
    → Papillary fibroelastoma. Usually on the aortic valve (downstream aspect) or mitral valve. Small, pedunculated, 'sea anemone' appearance. High embolic risk despite small size.
  • basicV.B-004
    What is the most common primary cardiac tumor in children and its important association?
    → Rhabdomyoma. Associated with tuberous sclerosis complex. Usually multiple, echogenic, ventricular. Often regress spontaneously over years.
  • basicV.B-005
    What is the most common primary MALIGNANT cardiac tumor in adults?
    → Angiosarcoma. Typically involves the RIGHT ATRIUM and infiltrates the free wall. Poor prognosis.
  • basicV.B-006
    Which primary cancer has the HIGHEST per-tumor propensity for cardiac metastasis?
    → Melanoma. However, the most COMMON cardiac metastases overall (by absolute number) are from lung, breast, and lymphoma because of their high incidence.
  • basicV.B-007
    Which cancers may extend as tumor thrombus up the IVC into the right atrium?
    → Renal cell carcinoma and hepatocellular carcinoma. Also adrenocortical carcinoma. Echo shows a mass in the IVC/RA that may prolapse into the RV.
  • basicV.B-008
    Describe lipomatous hypertrophy of the atrial septum.
    → Non-encapsulated fatty infiltration of the interatrial septum with a characteristic DUMBBELL shape sparing the fossa ovalis. Benign — should not be biopsied. Can be very echogenic.
  • basicV.B-009
    Name three normal structures in the LEFT atrium that can be mistaken for a mass.
    → Coumadin ridge (Q-tip / warfarin ridge, between LAA and left upper PV), pectinate muscles (in LAA), spontaneous echo contrast (SEC).
  • basicV.B-010
    Name three normal structures in the RIGHT atrium that can be mistaken for a mass.
    → Eustachian valve (IVC valve), Chiari network (fenestrated web-like remnant of right valve of sinus venosus), crista terminalis (ridge separating trabeculated from smooth-walled RA), Thebesian valve (CS valve).
  • basicV.B-011
    Which fibroelastoma is at highest embolic risk despite small size?
    → Aortic valve papillary fibroelastoma. Surgical excision indicated even for small lesions in patients at risk of embolic stroke.
  • basicV.B-012
    What tumor should be suspected in an adult with a mass in the RA and constitutional symptoms?
    → Angiosarcoma (most common primary malignant cardiac tumor). Also consider metastasis or lymphoma.
  • basicV.B-013
    Fibroma vs rhabdomyoma — key differences?
    → Fibroma: typically single, ventricular, may calcify, congenital, may cause arrhythmias — DOES NOT regress. Rhabdomyoma: typically multiple, ventricular, associated with tuberous sclerosis — TENDS TO REGRESS spontaneously in childhood.
  • basicV.B-014
    How do 'kissing lesions' on the mitral valve suggest antiphospholipid syndrome vs infective endocarditis?
    → APS: large valvular masses, sometimes mirrored 'kissing' lesions, without leaflet destruction. IE: usually leaflet destruction (perforation, chordal rupture, aneurysm formation). Tissue destruction in an otherwise APS-like appearance suggests superimposed IE.
  • basicV.B-015
    How does a papillary fibroelastoma differ from a myxoma in typical location and behavior?
    → Fibroelastoma: SMALL, pedunculated, 'sea anemone' appearance; usually on aortic valve (downstream aspect) — HIGH embolic risk. Myxoma: LARGER, gelatinous, usually LA attached to interatrial septum at fossa ovalis by stalk; may cause obstructive symptoms.
  • basicV.B-016
    Where do most cardiac metastases from renal cell carcinoma originate?
    → Direct extension via the IVC into the RA (tumor thrombus). Renal cell carcinoma has a unique tendency for intravenous extension. Also hepatocellular carcinoma and adrenal cortical carcinoma may do this.
  • basicV.B-017
    Which chamber and tumor type is characteristic of angiosarcoma?
    → Angiosarcoma typically involves the RIGHT ATRIUM and infiltrates the free wall. Rapid progression, poor prognosis; often presents with hemorrhagic pericardial effusion.
  • basicV.B-018
    How does cardiac lymphoma most commonly present on echo?
    → Right-heart infiltrative masses (often multiple), pericardial effusion, and infiltration of atrioventricular grooves. Rapidly progressive but often responsive to chemotherapy. Consider in HIV/AIDS or immunocompromised patients.
  • basicV.B-019
    What is the RV moderator band?
    → A normal muscular band that crosses the RV cavity from the mid-septum to the anterior free wall. Contains the right bundle branch. NOT a tumor — commonly mistaken for one.
  • basicV.B-020
    What is a false tendon of the LV?
    → A thin linear muscular or fibrous band crossing the LV cavity (typically apex to base). Normal variant found in up to 50% of hearts. NOT pathologic; often mistaken for thrombus or noncompaction.