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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Evidence of tumors elsewhere in the body, especially melanoma, bronchogenic carcinoma, breast cancer, lymphoma, and leukemia

  • Positive imaging study for characteristic cardiac masses

  • Positive biopsy, usually of the primary tumor or metastases in other organs

GENERAL CONSIDERATIONS

  • Metastatic tumors are the most common type of cardiac tumors

  • Bronchogenic and breast cancers spread to the heart by direct extension and usually involve the pericardium

  • Lymphoma and leukemia reach the heart by hematogenous spread and usually involve the myocardium

  • Malignant melanoma is an unusual tumor but has a predilection for cardiac involvement

  • Endocardial metastases most often occur with renal cell carcinoma and adenocarcinoma from abdominal organs

  • Renal cell carcinoma can extend from the renal vein up the inferior vena cava and appear in the right atrium

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Symptoms and signs of the primary tumor usually predominate

  • The most common cardiac presentation is pericardial tamponade due to tumor involvement of the pericardium

  • Patients with myocardial and endocardial metastases may present with signs of heart failure due to ventricular dysfunction

  • Chest pain and arrhythmias are common

PHYSICAL EXAM FINDINGS

  • Findings related to the primary tumor predominate

  • Evidence of pericardial involvement with a pericardial friction rub or signs of tamponade such as elevated jugular venous pressure and pulsus paradoxus

  • Findings of heart failure may occur

DIFFERENTIAL DIAGNOSIS

  • Primary cardiac tumors: metastatic tumors are 30 times more common

  • Thrombus: renal cell carcinoma may grow up the inferior vena cava and mimic thrombus in the right atrium

  • Vegetations; flail or prolapsing cardiac valves

  • Pericardial cysts

  • Giant aneurysm of the coronary artery

  • Diaphragmatic hernia can mimic left atrial mass on transthoracic echocardiography

  • Lipomatous infiltration

  • Normal anatomic variants:

    • – Chiari network

    • – Eustachian valve

    • – Septum spurium

    • – Thebesian valve

    • – Left superior pulmonary vein

    • – Atrial septal aneurysm

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Characteristic findings of neoplasia, such as anemia

ELECTROCARDIOGRAPHY

  • Findings depend on the structures involved

    • – Loss of myocardium may appear as infarction-like Q waves

    • – Pericarditis can result in classic diffuse ST elevation

    • – The most common finding is nonspecific ST-T–wave abnormalities

IMAGING STUDIES

  • Echocardiography is not particularly good at defining myocardial involvement

    • – Visualization of pericardial metastases is limited, although it can readily detect pericardial fluid and tamponade

  • CT and MRI are superior for defining myocardial, pericardial, and paracardiac tumors

    • – MRI can characterize tissue, especially fat, which is valuable for distinguishing lipomatous infiltration from tumors

    • 18F-Fluorodeoxyglucose positron emission tomography (PET) can be used to detect distant metastases

    • – Integrating PET with MRI can help differentiate tumors from other masses

    • – PET/CT in particular can differentiate ...

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