History and physical examination of different cardiac masses





Key points





  • Primary cardiac tumors (PCTs) are extremely rare that may be symptomatic or found incidentally.



  • The signs and symptoms of cardiac tumors generally are determined by the location of the tumor in the heart and not by its histopathology.



  • Cardiac myxoma is the most common benign heart tumor.



  • The tumor plop sound is one of the classic and characteristic auscultation findings of cardiac myxoma. The other physical examination findings in cardiac tumors include prominent A wave with elevation of JVP; loud S1, S3, S4; and diastolic rumble.



  • Malignant tumors are extremely rare and represent only 5% to 6% of PCTs. The most common are sarcomas.



  • Cardiac metastases are 20–40 times more common than PCTs.



  • Melanomas have the greatest propensity for cardiac involvement, and also carcinomas of the thorax, including breast, lung, and esophageal, are the most common carcinomas that metastasize to the heart.



Primary cardiac tumors (PCTs) are very rare . As an example, in one series of over 12,000 autopsies, only seven were identified with an incidence of less than 0.1% . Cardiac tumors may be symptomatic or found incidentally. In symptomatic patients, a mass can virtually always be detected by echocardiography, magnetic resonance imaging, and/or computed tomography. Because symptoms may mimic other cardiac conditions, the clinical challenge is to consider the possibility of a cardiac tumor so that the appropriate diagnostic test(s) can be conducted.


Fig. 1.1


Primary benign and malignant cardiac masses.




Clinical manifestations


The signs and symptoms of cardiac tumors generally are determined by the location of the tumor in the heart and not by its histopathology .


Mechanisms of symptom production


Cardiac tumors may cause symptoms through different mechanisms:




  • Embolization which is usually systemic but can be pulmonic. Aortic valve and left atrial tumors were associated with greatest risk of embolization .



  • Obstruction of the circulation through the heart or heart valves, producing symptoms of heart failure. Interference with the heart valves, causing regurgitation.



  • Direct invasion of the myocardium, resulting in impaired left ventricular function, arrhythmias, heart block, or pericardial effusion with or without tamponade.



  • Invasion of the adjacent lung may cause pulmonary symptoms and may mimic bronchogenic carcinoma. Constitutional or systemic symptoms.



  • Left atrial tumors may release tumor fragments or thrombi into the systemic circulation and lead to neurological complications.



Physical examination of cardiac tumors




Table 1.2

Physical examination findings of cardiac tumors.





































Findings Comments
Neck Prominent A wave with elevation of JVP
Heart Loud S1 Prolapsing of atrial tumor into the mitral valve orifice results in delay in closure of mitral valve producing
Delay in P2 Intensity of which depends on the absence or presence of pulmonary hypertension
Tumor plop Trial tumor striking against the endocardial wall may produce an early diastolic sound
S3 and S4 In some cases S3 and S4 may also be present
Murmur Diastolic atrial rumble Obstruction of mitral valve by the atrial tumor
Systolic murmur at cardiac apex Damaging of the mitral valves leading to mitral regurgitation
Diastolic rumble Obstruction of the tricuspid valve and a holosystolic murmur due to tricuspid regurgitation in right atrial tumors

Fig. 1.3


(A) Single second heart sound followed by a tumor plop. (B) Phonocardiogram showing tumor plop sound recognized as a high pitched sound after second heart sound ( arrow ).



Fig. 1.4


(A) A 72-year-old man with primary cardiac lymphoma (diffuse large B-cell) with marked jugular venous distention. External jugular vein marked by an arrow (B). CT scan of the chest at the level of the heart. A tumor within the right atrium adhering to the interatrial septum. A pericardial effusion is visible.



Fig. 1.5


Differential diagnosis of cardiac masses according to the site of mass.



Fig. 1.6


Benign and malignant cardiac tumor characteristics.




Histology of benign cardiac tumors




Table 1.7

Histology of benign cardiac tumors.




























Tumors Histopathology References
Myxoma Spindle or stellate cells, pseudovascular structure, myxoid matrix, hemorrhage, dystrophic calcification can be present
Lipoma Mature adipocytes, occasionally with entrapped myocytes at the periphery
Fibroma Fibroblasts and collagen bundles, some elastic fibers, calcification is a common finding
Rhabdomyoma Spider cell (vacuolated enlarged cardiac myocyte with clear cytoplasm due to abundant glycogen)
Papillary fibroelastoma Endocardium-coated fronds with an avascular collagenous core containing mucopolysaccharide and elastin


Most PCTs are benign and include myxomas, rhabdomyomas, papillary fibroelastomas, fibromas, hemangiomas, lipomas, and leiomyomas. Myxoma is the most common pathological subtype . Nonmyxoma subtypes, which mostly occur in children and adolescents, are less reported . Benign tumors have favorable prognosis with a 30-day mortality of only 1% . They are generally more common in older women , and according to their size and location, benign PCTs manifest with a wide array of symptoms. However, 13.3%–27.7% of cases occur in asymptomatic individuals and are detected incidentally .


Fig. 1.8


Left atrial myxoma in a 64-year-old man who presented with embolic events. (A) Large mobile mass ( white arrow ) seen on transthoracic echocardiography attached to the interatrial septum. (B) Low-attenuated, well-circumscribed mass with a smooth surface ( black arrow ) seen on cardiac computed tomography (CT). (C) Heterogeneous uptake in left atrial mass ( white arrow ) on late gadolinium imaging on cardiac magnetic resonance (CMR).




Cardiac myxomas are the most common PCT and be derived from mesenchymal cell precursors . They form intracavitary masses, which are most commonly found in the left atrium attached by a stalk to the fossa ovalis and also may be seen in the right atrium in children . Myxomas are morphologically divided into two groups: polypoid and papillary. The former, when large, may present with obstructive symptoms with a “tumor plop” being occasionally heard on auscultation. In contrast, papillary myxoma causes embolic events. In both variants, constitutional symptoms like fatigue, fever, and weight loss have also been reported. Calcification is seen in approximately 14% of patients and is more commonly associated in right-sided lesions .



Table 1.9

Myxoma signs and symptoms.




























Symptoms Incidence (%)
Dvsonea on exertion > 75
Paroxysmal dyspnea − 25
Fever − 50
Weight loss − 25
Severe dizziness/syncope − 20
Sudden death − 15
Hemoptysis − 15

Fig. 1.10


Multimodality images demonstrating left ventricular infiltrating lipoma. (A) The X-ray indicated an enlarged heart. (B) The mass in the left ventricle (LV) by echocardiography in parasternal long-axis view. (C) The masses at the intracardiac and extracardiac site of LV in apex four-chamber view. Ao indicates aorta; LA, left atrial; M, mass; RA, right atrial; and RV, right ventricle.

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Nov 10, 2024 | Posted by in CARDIOLOGY | Comments Off on History and physical examination of different cardiac masses

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