This document provides an overview of cardiac masses and tumors. It begins with a differential diagnosis of cardiac masses, distinguishing non-neoplastic structures like the Eustachian valve from tumors. Primary tumors arising in the heart are then discussed, including myxomas, fibroelastomas, and lipomas. Secondary tumors that metastasize to the heart are also covered. The document concludes by outlining various ways cancer can affect the heart, such as through direct compression, infiltration, valvular involvement, or late indirect effects.

1. Cardiac Masses and
Tumors
Oleh : dr. Indra Jabbar Aziz
Pembimbing : dr. Anna Fuji Rahimah, Sp.JP(K)

2. Differential Diagnosis
of A mass : Non-
neoplastic Structures
01
Tumors Involving the
Heart and
Pericardium
02
Effect of Cancer on
the Heart
03
Table of Contents

3. Differential Diagnosis of A mass : Non-
neoplastic Structures
01

4. Normal
Structures/Variants
Simulating Tumors
01-A

5. Intracardiac
The Eustachain Valve
Also known as the valve of the
inferior vena cava (IVC) is a ridge
of tissue that extens from the entry
of the IVC to the interartrial septum.
It can remain prominetn in adults

6. Eustachian Valve

7. Eustachian Valve

8. Intracardiac
The Chiari Network
Similarly an embryonic remnant
of the sinus venosus, which
extends from and is continuous with
the Eustachian valve. It persists in 2
3% of normal adults (confirmed by
autopsy), and appears on
ultrasound as a lacy weblike or
fenestrated membranous
echogenic mass with a
characteristic chaotic, undulating
motion independent from that of
the tricuspid valve and right heart

9. Chiari network

10. The Chiari Network

11. Intracardiac
Annular Calcification
Particularly of the mitral
apparatus, and fat deposition,
often seen around the tricuspid
annulus and interatrial septum
(interatrial septal lipomatous
hypertrophy can also simulate
intracardiac masses. Calcific
deposits tend to be very
echobright and irregular,
whereas fat usually appears
as a less echodense,
homogenous mass with

12. Lipomatous Hypertrophy

13. Intracardiac
Myxomatous Mitral
Valves
When severely thickened, have been
mistaken for tumors. Within the left atrial
appendage, pectinate muscles appear as
small multiple pyramidal structures with
their bases continuous with the
myocardial wall. Unlike masses and
thrombi, the pectinate muscles are not
independently mobile from appendage
contractions. Small short linear
echodensities known as “Lambl’s
excrescences” are often noted at the tips
of the aortic valve leaflets, on both the left
ventricular outflow tract and aortic side, as
well as on the mitral apparatus in patients
older than 50 yr old.

14. Lambl’s excrescences

15. Intracardiac
Prominent Left Ventricle
Trabeculation
False tendons, aberrant muscle bands or
bridges, and subaortic membranes
should be distinguished from tumors.
Delineation of the origins and insertions of
these structures, a cylindrical or linear
morphology, and the presence of thickening
during systole can aid in the differential
diagnosis.

16. False Tendon

17. Extracardiac
Epicardial Fat Pad
a discrete “soft” or deformable mildly
granular echogenic mass lying adjacent
to pericardium, typically anterior to the
right heart and/or adjacent to the
atrioventricular groove. A useful clue for
distinguishing pericardial fat is the
identification of the echolucent cylindrical
lumen of the coronary artery running within
it.

18. Extracardiac
Pleural Effusion and Ascites
Occasionally confused with pericardial
effusions. Proper identification should avoid
the occasional misdiagnosis of echogenic
collapsed lung segments, fibrin, or thrombus
within the pleural or abdominal cavities,
which can appear similar to tumor masses

19. Pleural Effusions

20. Thrombus
01-B

21. Thrombus
Thrombi can form in the left atrial body and appendage,
particularly in patients with atrial fibrillation, mitral stenosis, or
hypercoagulable states. The thrombi vary tremendously in size,
shape, and appearance. The differentiation of a thrombus
from a tumor may be difficult if predisposing factors for
thrombus are not present. In cases of trauma or mediastinal
surgery, coagulated blood and fibrin may appear in the pericardial
and pleural space as gelatinous or coalescing echogenic masses

22. Thrombus

23. Thrombus

24. Thrombus

25. Vegetation
01-C

26. Vegetation
Discrete mobile masses that are attached to valves are more
likely to be vegetations, especially if clinical and laboratory signs of
endocarditis are present, and symptoms of valvular regurgitation
are of recent onset. Myxomatous mitral valves should also be
distinguished from vegetation and tumors

27. Vegetation

28. Artifact
01-D

29. Artifact
Artifacts resembling an echogenic mass can be caused by
reflections from the pericardium, valves, and foreign objects (e.g.,
catheters, pacemaker wires). Because of the way echo images are
processed, artifacts often appear either halfway or whole multiples
of distance from the reflecting object to the transducer, and do not
move independently of heart motion. A useful way to distinguish
an artifact is to examine the blood flow around the putative
mass with color Doppler, which should respect the borders of a
true mass but will appear to pass through an artifact

30. Artifact

31. Artifact
On transesophageal echocardiography, the normal tissue
infolding between the left atrial appendage and left upper
pulmonary vein can cause an acoustic artifact which has
occasionally been mistaken for a thrombus, hence the nickname
“warfarin ridge”

32. Warfarin Ridge

33. Tumors Involving the Heart and Pericardium
02

35. Primary Tumors
02-A

36. Primary Tumor
• Primary Tumors arising in the heart are rare
• Only 25% are malignant
• 90% detected incidentally
• Some may cause symptoms by embolization or obstruction of
cardiac inflow or output
• Atrial tumor are more often intra-cavitary
• Ventricular tumors are frequently intramural

37. Atrial Myxoma
• Cardiac myxoma is the most common cardiac tumor,
accounting for 20–50% of all cases
• There may be a female predominance, and familial syndromes
with myxoma as a phenotypic trait (e.g., Carney syndrome)
exist
• Approximately 75% of myxomas occur in the left atrium
• Complete surgical excision is usually the cure

38. Atrial Myxoma

39. Atrial Myxoma

40. Papillary
Fibroelatomas
• Next most common benign tumors
• Consist primarily of dense connective tissue elements
• Most frequently in elderly patients
• Arise from the valvular endocardium on either side of the heart
• Small (<0.2–1.0 cm) mobile pedunculated echo masses which
can be variably filamentous, frond-like, or oval in shape
• They are characteristically attached to valve leaflets, with a
predisposition mainly for the aortic valve

41. Papillary Fibroelastomas

42. Cardiac Lipomas
• Benign tumors that have been described throughout the heart,
typically in a subepicardial or subendocardial location
• They often appear more echodense and fixed than
myxomas, and are often clinically silent
• It is important to distinguish this entity from lipomatous
hypertrophy, which is an accumulation of excess fat in the
interatrial septum, sparing the fossa ovalis, giving a
characteristic “dumbbell” shape to this structure

43. Cardiac Lipoma

44. Primary Tumor
Pericaridial cysts
Benign fluid-filled tumors of the parietal pericardium, which are
occasionally detected on chest X-ray and usually occur at the
cardiophrenic
borders
Rhabdomyomas
Most common primary cardiac
tumor in pediatric pupulation, may
regress in childhood

45. Primary Tumor
Malignant sarcomas
• The various subtypes (angiosarcomas,
rhabdomyosarcomas, lymphosarcomas) have been
reported at all ages
• Angiosarcomas tend to occur in the right heart, and
rhabdomyosarcomas can arise in more than one area
of the heart
• However, there are no clear distinguishing
echocardiographic features; all share common
characteristics of rapid invasive growth and metastasis,
with frequent extension to the pericardium and a poor
prognosis.

46. Secondary Tumors
02-B

47. Secondary Tumors
• Tumors that are metastatic to the heart are 20–40 times
more common than primary tumors
• Almost any type of cancer, with the exception of brain
tumors, can spread to the heart and pericardium
• Carcinomas arising from the breast and lung are the most
common
• Malignancies that are at high risk for metastasizing to the
heart are melanoma (up to 64% of cases) and the leukemias
and lymphomas (up to 46% have been observed to
metastasize to the heart)

48. Melanoma Metastase

49. Secondary Tumors
• Metastatic spread frequently occurs by either direct extension
to the pericardium, or via lymphangitic or hematogenous
spread.
• Renal cell carcinoma, Wilms’ tumor, and hepatocellular
carcinoma can invade the right atrium by encroaching up the
IVC
• Bronchogenic neoplasms can enter the left atrium via the
pulmonary veins
• The involvement of pericardium or invasion of the tumor from
either the cardiac free walls (as opposed to septum) or
contiguous great vessels may be a clue to the secondary nature
of these tumors

51. Effect of Cancer on the Heart
03

52. Mass Effect: Extracardiac
Compression or
Intracavitary Obstruction
01
Direct Infiltration of
the Myocardium
02
Valvular Involvement
03
Late and/or Indirect
Effects
04
Effect of Cancer on the Heart

55. Thank You