CT and MR imaging findings of malignant cardiac tumors

https://doi.org/10.1067/j.cpradiol.2004.10.003Get rights and content

This article reviews CT and MRI features of malignant cardiac and pericardial tumors, most of which originate from the lung, breast, melanoma, leukemia, or lymphoma through lymphatic, hematogenous, transvenous, and direct pathways. Although echocardiography establishes the diagnosis in most cases, CT and MRI provide additional physical, spatial, and functional information that further aids the evaluation of metastases. For instance, CT provides superior resolution for detecting calcification or fat, while MRI with its direct multiplanar ability more completely characterizes the heart, pericardium, mediastinum, and lungs. MRI also helps elucidate the pathophysiological effects of these tumors on cardiac function through gated cine-loop sequences. Beyond tumor characterization, both modalities can help confirm diagnosis through the addition of contrast, which helps distinguish tumor from myocardium, thrombus, and blood flow artifact. Ultimately, MRI best facilitates surgical planning and posttreatment follow-up in large part because of its unparalleled ability to locate and delimit these tumors.

Section snippets

Metastases

Due to their proximity to the heart, most metastases originate in the lung or breast and less often from melanoma, lymphoma, and leukemia.1, 2, 3, 4 They typically occur as late manifestations of the primary tumor at a time when diffuse involvement of other organs already has occurred.5 Accordingly, patients may present with myriad signs and symptoms, such as chest pain, dyspnea, and arrhythmias, stemming from causes like pericardial extension, venous invasion, and myocardial infiltration.6, 7,

Sarcomas

Of the malignant primary cardiac tumors, sarcomas outnumber all others and typically affect middle-aged adults.18 Such soft-tissue malignant tumors usually arise in the left atrium, affect cardiac valves, and manifest various forms from endocardial/myocardial myxomatous masses to widespread infiltrative lesions.19 Heterogeneous enhancement often coupled with diffuse dissemination distinguishes their appearance on MRI (Fig 13).20

Angiosarcomas

The most prevalent of the cardiac sarcomas, angiosarcomas predominantly affect the right atrium of men aged 20 to 50 years old.21, 22 These highly vascular tumors exhibit hemorrhagic, necrotic foci with anastomosing vessels delineated by sheets of endothelial cells. As a result, when angiosarcomas invade the pericardium, hemorrhagic effusion often ensues, sometimes leading to cardiac tamponade.21 Other consequences include tumor emboli that obstruct pulmonary vessels, precipitating progressive,

Rhabdomyosarcomas

In terms of frequency, rhabdomyosarcomas rank first in children, surpassing even nonsarcomas as the most common malignant tumors in this age group.29 Like angiosarcomas, these striated-muscle tumors disproportionately affect males and involve the myocardium but only rarely infiltrate the pericardium diffusely or extend beyond it.30, 31 They may involve any chamber or cardiac valve with a frequency unsurpassed by other sarcomas.32 As with other cardiac neoplasms, clinical presentation is varied

Fibrosarcomas

Comprising 5% of all primary cardiac tumors, fibrosarcomas consist primarily of malignant fibroblasts that equally affect both sides of the heart.37, 38 Classified as nodular or infiltrative, these rare malignant mesenchymal tumors may obliterate entire chambers and extend into or even arise primarily from the pericardium.17, 37 As with leiomyosarcomas and osteosarcomas, left-sided involvement more commonly occurs.18 Consequently, signs and symptoms of congestive heart failure predominate.39

Lymphomas

Similar to other immune-cell-based tumors, cardiac lymphomas often affect immunocompromised patients, especially middle-aged men.42, 43 Such tumors, which consist predominantly of B cells, primarily originate in the heart and pericardium.31, 44 In most cases, multiple masses invade multiple chambers, particularly those on the right side, in addition to the pericardium, which often harbors concomitant effusion.45 Furthermore, they rarely exhibit necrosis or valvular involvement, unlike their

Hemangiopericytoma

An abnormal proliferation of perivascular endothelial cells, the pericytes of Zimmerman, distinguishes hem-angiopericytomas, which are extremely rare vascular sarcomas that even more rarely involves the heart.47 They preferentially affect women without chamber predilection.48, 49 T1WI and T2WI typically demonstrate heterogeneous, high signal (Fig 18).48

Conclusion

Unlike their benign counterparts, malignant cardiac and pericardial tumors predominantly originate more from without than from within. They both rely, however, on echocardiography to provide preliminary diagnostic information and CT and MRI for the most complete characterization, which is provided in part by their superior tissue resolution and tumor demarcation.

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