(Radiographics. 2001;21:439-449.)
© RSNA, 2001
Metastatic Involvement of the Heart and Pericardium: CT and MR Imaging1
Caroline Chiles, MD,
Pamela K. Woodard, MD,
Fernando R. Gutierrez, MD and
Kerry M. Link, MD
1 From the Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157 (C.C., K.M.L.); and the Department of Radiology, Mallinckrodt Institute of Radiology, St Louis, Mo (P.K.W., F.R.G.). Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received April 7, 2000; revision requested May 30 and received July 28; accepted August 3. Supported by the RSNA Research and Education Foundation. Address correspondence to C.C. (e-mail: cchiles@wfubmc.edu).
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Abstract
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Metastases to the heart and pericardium are much more common than primary cardiac tumors and are generally associated with a poor prognosis. Tumors that are most likely to involve the heart and pericardium include cancers of the lung and breast, melanoma, and lymphoma. Tumor may involve the heart and pericardium by one of four pathways: retrograde lymphatic extension, hematogenous spread, direct contiguous extension, or transvenous extension. Metastatic involvement of the heart and pericardium may go unrecognized until autopsy. Impairment of cardiac function occurs in approximately 30% of patients and is usually attributable to pericardial effusion. The clinical presentation includes shortness of breath, which may be out of proportion to radiographic findings in patients with pericardial effusion or may be the result of associated pleural effusion. Patients may also present with cough, anterior thoracic pain, pleuritic chest pain, or peripheral edema. The differential diagnosis of pericardial effusion in a patient with known malignancy includes malignant pericardial effusion, radiation-induced pericarditis, drug-induced pericarditis, and idiopathic pericarditis. Any disease process that causes thickening or nodularity of the pericardium or myocardium or masses within the cardiac chambers can mimic metastatic disease.
Index Terms: Heart, neoplasms, 50.33 • Lung neoplasms, 50.33, 55.33, 60.32 • Lymphoma, 50.33, 55.33, 99.34 • Pericardium, abnormalities, 55.33 Pericardium, fluid, 55.821
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LEARNING OBJECTIVES
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After reading this article and taking the test, the reader will be able to:
- List the tumors most likely to involve the heart and pericardium.
- Describe the four pathways of tumor spread to the heart and pericardium.
- Recognize metastatic involvement of the heart and pericardium on CT and MR images.
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Introduction
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Metastases to the heart and pericardium are much more common than primary cardiac tumors and are generally associated with a poor prognosis (1,2). Metastases to the heart were found in 1.23% of 12,485 consecutive autopsies, compared with a 0.056% prevalence of primary cardiac tumors (1). In autopsies at which a malignant neoplasm was diagnosed, cardiac metastases were found in 9.7%–10.7% of cases (3–5).
Noncardiac tumors may invade the heart and pericardium by means of lymphatic or hematogenous dissemination, local extension, or a transvenous route. Tumors that are most likely to involve the heart and pericardium include cancers of the lung and breast, melanoma, and lymphoma (4,5). Metastases to the heart and pericardium can manifest as a lung mass or mediastinal mass with direct invasion of the adjacent heart, as a central mass extending into the left atrium via the pulmonary veins, as pericardial effusion and nodularity, or as myocardial nodules. In a patient who has received radiation therapy, the pericardium may appear thickened and nodular, mimicking metastatic disease.
Whereas echocardiography is the method of imaging most frequently used to examine the heart and pericardium noninvasively, magnetic resonance (MR) imaging and computed tomography (CT) offer advantages when metastatic disease is in question. Both imaging modalities provide a large field of view, which allows evaluation of disease throughout the thorax. Of particular importance is assessment of the lung tissue and pleura surrounding the mediastinum and of vessels entering the heart. In addition, MR imaging, unlike ultrasonography or CT, offers excellent contrast resolution, which allows differentiation between tumor and myocardium. The distinction between tumor, thrombus, or blood flow artifact can be made more readily with MR imaging than with CT. Signal intensities at MR imaging may also help tissue characterization in some cases (6). Most cardiac tumors are of low signal intensity on T1-weighted images and are brighter on T2-weighted images (7). Most malignant disease enhances after administration of contrast material (8,9).
In this article, we present the appearances of metastatic involvement of the heart and pericardium and of processes that mimic metastatic involvement on CT and MR images. Specific topics discussed are statistics, clinical presentation, pathways of spread, pericardial effusion, primary tumors, and mimics.
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Statistics
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Metastases to the heart and pericardium are discovered at autopsy in 10%–12% of all patients with malignancies (4,5). The underlying malignancy is most often carcinoma of the lung, in part because of the proximity to the heart and in part because of the prevalence of this tumor (10). Autopsy shows that bronchogenic carcinoma is the primary tumor in 36% of patients with cardiac metastases; nonsolid primary malignancies (eg, leukemia, lymphoma, and Kaposi sarcoma) account for 20%; carcinoma of the breast accounts for 7%; and carcinoma of the esophagus is the primary tumor in 6% (5). In patients with cardiac metastases from carcinoma of the lung, the fact that the pericardium and epicardium are most commonly involved suggests regional lymphatic invasion. Myocardial metastases, which are less frequent, are usually associated with melanoma or lymphoma and are suggestive of hematogenous invasion (11).
During the past several decades, the primary sites and cell types of cardiac metastases have been modified by chemotherapy, by longer survival times in patients with cancer, by the increasing prevalence of bronchogenic carcinoma, and by the acquired immunodeficiency syndrome (5). Lung cancer is now the most common primary tumor, and adenocarcinoma is the most frequent cell type (5). In earlier series, breast cancer and melanoma were as common as lung cancer (3). Deaths can be attributed to cardiac tumor invasion in about one-third of patients with cardiac or pericardial metastases, in whom death is the result of cardiac tamponade, congestive heart failure, coronary artery invasion, or sinoatrial node invasion (11).
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Clinical Presentation
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Metastatic involvement of the heart and pericardium may go unrecognized until autopsy. Impairment of cardiac function occurs in approximately 30% of patients and is usually attributable to pericardial effusion (10). The clinical presentation includes shortness of breath, which may be out of proportion to radiographic findings in patients with pericardial effusion or may be the result of associated pleural effusion (12). Patients may also present with cough, anterior thoracic pain, pleuritic chest pain, or peripheral edema.
Arrhythmia in patients with cardiac metastases is usually the result of concomitant factors such as hypoxemia, altered electrolyte concentrations, or anemia; however, arrhythmia can be secondary to tumor involving autonomic fibers or coronary arteries. Arrhythmia is the most prevalent manifestation of myocardial involvement by metastatic tumors (13). The sudden occurrence of an arrhythmia in a patient with a known malignancy suggests the possibility of metastatic involvement of the myocardium. The type of arrhythmia produced depends on the size of the tumor and its location relative to the conduction system of the heart.
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Pathways of Spread
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Tumor may involve the heart and pericardium by one of four pathways: retrograde lymphatic extension, hematogenous spread, direct contiguous extension, or transvenous extension (14). The predominant route is retrograde spread through lymphatic channels in the mediastinum to the heart, producing small tumor implants on the epicardial surface of the heart (15). The visceral pericardium contains most of the lymphatic channels that drain the pericardial space. These channels come together in a single narrow area at the root of the aorta. The lymphatic drainage of the heart is obstructed rather easily by tumors in this region, resulting in pericardial effusion (Fig 1).
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Figure 1. Lymphatic spread of tumor in a 43-year-old man with lymphoma. Contrast material-enhanced axial CT scan shows a large pericardial effusion (P), which could result from extension of the tumor in the right hemithorax across the pericardium or from obstruction of the pericardial lymphatic vessels.
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Other tumors, such as melanoma, usually spread hematogenously and often produce tumor implants in the myocardium (Fig 2). Hematogenous metastases to the myocardium and epicardium occur via the coronary arteries or, less commonly, by implantation of cancer fragments carried through the vena cava (16). The microcirculations of the lungs and liver filter most cancerous cells so that only a small number eventually reach the coronary arteries. Therefore, hematogenous metastases in the heart and pericardium are usually accompanied by evidence of hematogenous metastases in other organs (Fig 3). In particular, pulmonary metastases are usually present.
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Figure 2a. Hematogenous spread in a patient with metastatic melanoma. (a) Axial T1-weighted spin-echo MR image (repetition time msec/echo time msec = 833/11) shows melanoma metastatic to the heart. The brightness of lesions within the left ventricular myocardium (arrow) is attributable to melanin. (b) Axial T2-weighted spin-echo MR image (2,535/80) shows lesions within the left ventricular myocardium (arrow), which remain bright. (Courtesy of Vincent McDermott, MD, Bons Secours Hospital, Cork, Ireland.)
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Figure 2b. Hematogenous spread in a patient with metastatic melanoma. (a) Axial T1-weighted spin-echo MR image (repetition time msec/echo time msec = 833/11) shows melanoma metastatic to the heart. The brightness of lesions within the left ventricular myocardium (arrow) is attributable to melanin. (b) Axial T2-weighted spin-echo MR image (2,535/80) shows lesions within the left ventricular myocardium (arrow), which remain bright. (Courtesy of Vincent McDermott, MD, Bons Secours Hospital, Cork, Ireland.)
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Figure 3. Hematogenous spread of tumor in a 56-year-old woman with widely metastatic pancreatic carcinoma. Contrast-enhanced axial CT scan shows hepatic metastases and a metastasis to the interventricular septum (arrow), a combination that suggests hematogenous spread.
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Direct extension of tumors into the heart and pericardium typically occurs in patients with large bronchogenic carcinomas (Figs 4, 5) but may also occur in patients with esophageal carcinoma, breast carcinoma that erodes through the chest wall, or mediastinal lymphoma (1,17). In these cases, it can be difficult to determine whether the cardiac involvement is the result of lymphatic obstruction or direct invasion.
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Figure 4a. Direct invasion in a patient with sarcoma. (a) Contrast-enhanced axial CT scan shows compression of the superior vena cava and right pulmonary artery by a sarcoma (S) of the right lung. (b) Contrast-enhanced axial CT scan shows that the sarcoma extends into the left atrium (arrow) via the right superior pulmonary vein.
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Figure 4b. Direct invasion in a patient with sarcoma. (a) Contrast-enhanced axial CT scan shows compression of the superior vena cava and right pulmonary artery by a sarcoma (S) of the right lung. (b) Contrast-enhanced axial CT scan shows that the sarcoma extends into the left atrium (arrow) via the right superior pulmonary vein.
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Figure 5. Direct extension in a 65-year-old woman with bronchogenic carcinoma. Contrast-enhanced axial CT scan shows a large bronchogenic carcinoma (C) of the left lung that involves the heart and pericardium.
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The transvenous route of tumor spread relies on extension of tumor thrombus into the right atrium via the superior or inferior vena cava (IVC) or extension into the left atrium via the pulmonary veins. This mechanism provides the means for spread of tumors from the kidney or liver (IVC) (Fig 6) and some lung cancers (superior vena cava, pulmonary veins) (14). The transvenous route of tumor extension is most common in patients with renal cell carcinoma; in these patients, tumor thrombus may spread into the right atrium via the IVC (Fig 7).
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Figure 7a. Metastatic renal cell carcinoma in a 75-year-old man. (a) Coronal doubleinversion-recovery MR image (43.49/1,364) shows a metastatic tumor (T) within the IVC and right atrium, which represents transvenous extension from renal cell carcinoma. (b) Axial double-inversion-recovery MR image (43.49/1,364) shows a filling defect (arrow) at the junction of the IVC and right atrium, a finding consistent with tumor. The tumor within the right atrium was successfully resected via a median sternotomy approach. Nephrectomy was performed via an abdominal incision.
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Figure 7b. Metastatic renal cell carcinoma in a 75-year-old man. (a) Coronal doubleinversion-recovery MR image (43.49/1,364) shows a metastatic tumor (T) within the IVC and right atrium, which represents transvenous extension from renal cell carcinoma. (b) Axial double-inversion-recovery MR image (43.49/1,364) shows a filling defect (arrow) at the junction of the IVC and right atrium, a finding consistent with tumor. The tumor within the right atrium was successfully resected via a median sternotomy approach. Nephrectomy was performed via an abdominal incision.
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Pericardial Effusion
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In a patient with a malignant tumor and pericardial effusion, the differential diagnosis includes not only malignant pericardial disease but also benign idiopathic, drug-induced, or radiation-induced pericarditis. The diagnosis of malignant pericardial effusion is made by means of pericardiocentesis, pericardioscopy, or both (18). Results of cytologic studies are positive in 80%–90% of patients with malignant pericardial effusions (19). A malignant pericardial effusion is associated with decreased survival, but therapeutic options include creation of a pericardial window (subxiphoid pericardiostomy), pericardial sclerosis through a small-bore catheter (Fig 8) (20), and radiation therapy.
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Figure 8. Placement of a small-bore catheter into the pericardium for drainage of a pericardial effusion or administration of a sclerosing agent. Contrast-enhanced axial CT scan shows a pericardial effusion (P) and bilateral pleural effusions. Slight thickening and enhancement of the visceral (arrow) and parietal layers of the pericardium can be seen.
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Pericardial metastases occur late in the course of a neoplasm, usually as recurrent disease. Rarely, a malignant pericardial effusion is the first sign of a neoplasm. Lung cancer, the most frequent source of neoplastic pericardial disease, accounts for about one-third of cases. In addition, autopsies show that approximately one-third of patients who had lung cancer also had metastatic involvement of the pericardium. Breast cancer is the second most common cause of malignant pericardial effusions (15). Approximately one in four patients with malignant pericardial effusions has breast cancer, and autopsy findings indicate that of all patients with breast cancer, approximately one in four had malignant pericardial effusion. Hematologic malignancies such as leukemia, Hodgkin disease, and non-Hodgkin lymphoma make up the third largest group (15% of cases).
In a review of 31 patients with cancer and pericardial disease (21), the diagnoses included malignant pericardial disease (58%), benign idiopathic pericarditis (32%), and radiation-induced pericarditis (10%). Overlap was observed in the clinical presentations of these three groups of patients. Patients with malignant pericardial disease had cough, facial swelling, and pericardial tamponade. In patients with idiopathic pericardial disease, clinical signs and symptoms were fever and pericardial friction rub, whereas in patients with radiation-induced pericarditis the symptoms were more likely to include pericardial tamponade, cough, or both. When pericardial fluid develops rapidly, the amount necessary for tamponade may be as little as 250 mL.
Although doxorubicin (Adriamycin; Pharmacia & Upjohn, Kalamazoo, Mich) is best known for its cardiac toxicity, an acute myopericarditis can occur within the first month of administration (15). These patients may present with acute pericarditis with effusion and tamponade. Cyclophosphamide (Cytoxan; Bristol-Myers Oncology, Princeton, NJ) also has toxic effects on both the myocardium and pericardium.
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Primary Tumors
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Bronchogenic Carcinoma
Bronchogenic carcinoma may involve the heart and pericardium by direct extension (Fig 5) or by a combination of lymphatic and hematogenous dissemination (22). Involvement of the heart and pericardium is found at autopsy in 17%–31% of patients who had bronchogenic carcinoma (5,22,23). Metastases to the heart or pericardium represent M1 or stage IV disease in the American Thoracic Society’s TNM staging system for bronchogenic carcinoma. Direct extension of tumor into the heart, pericardium, or great vessels represents T4 or stage IIIB (unresectable) disease.
The pericardium was the only site of metastases in 20% of 65 patients with lung cancer and pericardial metastases (12). At autopsy, the appearance of the pericardium ranged from firm nodules of various sizes to fibrotic adhesions. In this population, treatment of the pericardial metastases with radiation therapy led to prolonged survival (22.5 weeks from primary diagnosis vs 17.5 weeks in the untreated group).
Although local invasion of the heart indicates stage T4 disease, some surgeons have resected tumors that invaded the great vessels or left atrium (24,25). Indeed, the symptoms and prognoses of patients with T4 tumors vary according to the region that is invaded (eg, trachea, esophagus, vertebrae, superior vena cava, aorta, left atrium). Fukuse et al (25) reported a median survival time of 10 months after complete resection of tumors invading the left atrium, whereas Tsuchiya et al (24) reported extended survival times (22% at 5 years) in patients with non–small-cell carcinoma after complete resection of tumors invading the left atrium.
Intrapericardial extension of tumor and invasion of the left atrium should be suspected when CT or MR imaging demonstrates obliteration of the superior pulmonary vein (Figs 9, 10) (26). Intrapericardial extension was found at surgery in each of 10 patients whose CT scans showed obliteration of the superior pulmonary vein (26). Obliteration of the inferior pulmonary vein was seen in nine patients, and intrapericardial extension occurred in four.
Breast Cancer
Pericardial effusion and thickening are frequently seen on CT scans of patients with breast cancer. The differential diagnosis includes malignant pericardial effusion, inflammation and fibrosis occurring as a result of radiation therapy, drug-induced pericarditis, infection, hypothyroidism, autoimmune disorders, and idiopathic causes. Enhancement of the pericardium or pericardial nodularity suggests malignant involvement, but pericardiocentesis is required for definitive diagnosis.
Lymphoma
Involvement of the heart and pericardium is usually a late manifestation of lymphoma; the median time of onset is 20 months after initial diagnosis (17). Often, the diagnosis is not made until autopsy, at which time cardiac involvement is found in 16% of patients with Hodgkin disease and 18% of patients with non-Hodgkin lymphoma. Metastases are usually focal, firm nodules that may be found in the walls of all cardiac chambers and in the pericardium (Fig 11) (27). A significant pericardial effusion has been reported in 50% of patients with pericardial tumor (17). However, pericardial effusion is not a reliable sign of pericardial involvement by lymphoma, since effusion may be present in patients with or without pericardial tumor. In patients who have lymphoma and evidence of pericardial disease, possible causes include tumor involvement, radiation therapy, drug-induced pericarditis, and infection (27).
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Figure 11a. T-cell lymphoblastic lymphoma in a 32-year-old woman. (a) Contrast-enhanced axial CT scan shows pleural (arrowhead) and pericardial (arrows) tumors in the left hemithorax. (b) Cardiac-gated axial T1-weighted MR image (612/25) obtained 3 weeks after a shows the response of the tumor (arrows) to radiation therapy.
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Figure 11b. T-cell lymphoblastic lymphoma in a 32-year-old woman. (a) Contrast-enhanced axial CT scan shows pleural (arrowhead) and pericardial (arrows) tumors in the left hemithorax. (b) Cardiac-gated axial T1-weighted MR image (612/25) obtained 3 weeks after a shows the response of the tumor (arrows) to radiation therapy.
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Melanoma
The highest percentage of cardiac metastases has been found in patients with melanoma. Glancy and Roberts (28) reported a prevalence of 64% in a study of 70 autopsy cases in 1968. Other researchers report frequencies of 46%–71% (5,23). The cardiac and pericardial metastases in patients with melanoma are accompanied by metastases to many other organs. The multifocal distribution of the cardiac metastases and their more frequent location in the myocardium suggest hematogenous dissemination of the tumor (Figs 2, 12) (28). Unlike other tumors, melanoma appears bright on T1-weighted images, an effect attributed to paramagnetic metals bound by melanin (29–31).
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Figure 12. Metastatic melanoma in a 30-year-old woman. Contrast-enhanced axial CT scan shows a large filling defect (M) within the right atrium, as well as a mass (m) within the left lower lobe of the lung. Both represented metastases, likely hematogenous in origin.
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Mesothelioma
Wadler et al (32) reviewed the electrocardiograms and echocardiograms of 64 patients with biopsy-proved malignant mesothelioma. Autopsy reports were available in 19 cases. Results of electrocardiography were abnormal in 55 of 64 patients (86%); 60% had arrhythmia, and 37% had conduction abnormalities. The echocardiograms revealed that 13 patients had pericardial effusions and two had pericardial thickening. Cardiac invasion was present at autopsy in 14 of 19 patients (74%); more than one-half had invasion of the pericardium (Fig 13), and more than one-fourth had invasion of the myocardium.
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Figure 13. Mesothelioma in a 65-year-old man. Contrast-enhanced axial CT scan shows pericardial thickening (arrows), nodularity, and effusion (P), consistent with extension of mesothelioma from the pleura of the right hemithorax.
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Renal Cell Carcinoma
Renal cell carcinoma involves the IVC in 4%–10% of cases and can extend into the right atrium (33). Extension of tumor thrombus into the IVC occurs more commonly with right-sided than with left-sided renal cell carcinoma (34). The four levels of tumor thrombus affect surgical treatment of these patients. Level 1 involves tumor thrombus at the entry of the renal vein or within the IVC less than 2 cm from the confluence of the renal vein and IVC. Level 2 thrombus extends beyond the 2-cm point but remains caudal to the hepatic veins. Level 3 thrombus involves the intrahepatic IVC. Level 4 thrombus extends above the diaphragm or into the right atrium (34). Resection of tumor thrombus in the right atrium requires cardiopulmonary bypass after median sternotomy, as well as a transabdominal incision.
Intraluminal tumor thrombus must be differentiated from flow artifacts that occur when nonenhanced venous blood from the lower extremities mixes with contrast material. The flow-sensitive sequences of MR imaging make it superior to CT in this analysis. In addition, gadolinium-enhanced MR images may allow distinction between intraluminal tumor and thrombus by showing enhancement and neovascularity in a tumor.
Osteosarcoma
Osteogenic sarcoma involving the heart is unique in that the metastases contain bone. In patients with osteogenic sarcoma, the calcific areas of increased opacity may be visible on chest radiographs but are better demonstrated on CT scans as high-attenuation lesions (Fig 14) (35). On MR images, these calcifications are unlikely to be visible because calcium appears as a signal void. Seibert et al (35) reviewed autopsy results from 20 patients who had osteosarcoma and found that four had metastases to the heart. Metastases to the heart occur with approximately 15% of all sarcomas (23).
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Figure 14. Metastatic osteosarcoma in a 17-year-old girl. Nonenhanced axial CT scan shows calcification (arrows) within cardiac metastases, a unique feature of osteosarcoma. The metastases progressed rapidly.
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Mimics
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Any disease process that causes thickening or nodularity of the pericardium or myocardium or masses within the cardiac chambers can mimic metastatic disease. A pericardial effusion in a patient with a known malignancy can be the result of therapy, including both radiation therapy and chemotherapy. Other pericardial effusions are assumed to be idiopathic, since no malignant cells are discovered by means of pericardiocentesis. Infections of the pericardium can produce both nodularity and thickening of the pericardium, which may enhance with contrast material administration, as well as pericardial effusion.
Thrombus within the cardiac chambers can mimic a primary tumor or metastatic disease (Fig 15). Unfortunately, on MR images the signal intensity of thrombus varies according to its age, and relatively fresh thrombus, like tumor, may be bright on T2-weighted images. Administration of gadolinium contrast agents may help differentiate between tumor and bland thrombus, since tumor is more likely to enhance (9). Benign tumors, such as fibromas, can also mimic metastatic disease. Again, certain MR imaging characteristics may help differentiate between benign and malignant lesions. For example, unlike most malignant tumors or metastatic disease, fibromas have characteristically low signal intensity on T2-weighted images and often show no enhancement or heterogeneous enhancement due to poor vascularization of the tumor (7,8,36). Abnormalities of the pericardium, myocardium, or cardiac chambers that are demonstrated with one imaging modality (eg, echocardiography or CT) may require further study with MR imaging to distinguish metastatic disease from its mimics.
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Figure 15a. Possible metastatic breast carcinoma in a 65-year-old woman 6 years after left mastectomy for breast cancer. (a) Contrast-enhanced axial CT scan shows a mass (arrow) within the right ventricle. Additional masses were visible on contiguous axial CT scans. (b) Gadolinium-enhanced fat-suppressed cardiac-gated axial T1-weighted spin-echo MR image (689/14) shows lack of enhancement of the mass (arrow), which is more consistent with a thrombus than with metastases. (c) Cardiac-gated short-axis double-inversion-recovery MR image (1,304/41.8; 463-msec inversion time) shows multiple filling defects (arrows) within the right ventricle.
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Figure 15b. Possible metastatic breast carcinoma in a 65-year-old woman 6 years after left mastectomy for breast cancer. (a) Contrast-enhanced axial CT scan shows a mass (arrow) within the right ventricle. Additional masses were visible on contiguous axial CT scans. (b) Gadolinium-enhanced fat-suppressed cardiac-gated axial T1-weighted spin-echo MR image (689/14) shows lack of enhancement of the mass (arrow), which is more consistent with a thrombus than with metastases. (c) Cardiac-gated short-axis double-inversion-recovery MR image (1,304/41.8; 463-msec inversion time) shows multiple filling defects (arrows) within the right ventricle.
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Figure 15c. Possible metastatic breast carcinoma in a 65-year-old woman 6 years after left mastectomy for breast cancer. (a) Contrast-enhanced axial CT scan shows a mass (arrow) within the right ventricle. Additional masses were visible on contiguous axial CT scans. (b) Gadolinium-enhanced fat-suppressed cardiac-gated axial T1-weighted spin-echo MR image (689/14) shows lack of enhancement of the mass (arrow), which is more consistent with a thrombus than with metastases. (c) Cardiac-gated short-axis double-inversion-recovery MR image (1,304/41.8; 463-msec inversion time) shows multiple filling defects (arrows) within the right ventricle.
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Conclusions
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Metastases to the heart occur late in the course of malignant disease. The patient typically has metastatic disease at other sites (usually pulmonary metastases are present). Cardiac or pericardial locations are rarely the first sites of malignant disease. Because of the prevalence of carcinomas of the lung and breast and their proximity to the heart, cardiac metastases from these tumors are common. Neoplasms with the highest frequency of cardiac and pericardial metastases include melanoma, leukemia, and lymphoma. The differential diagnosis of pericardial effusion in a patient with known malignancy includes malignant pericardial effusion, radiation-induced pericarditis, drug-induced pericarditis, and idiopathic pericarditis.
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Footnotes
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Abbreviation: IVC = inferior vena cava
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References
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-
Lam KY, Dickens P, Chan ACL. Tumors of the heart: a 20-year experience with a review of 12,485 consecutive autopsies. Arch Pathol Lab Med 1993; 117:1027-1031.[Medline]
-
Mukai K, Shinkai T, Tominaga K, Shimosato Y. The incidence of secondary tumors of the heart and pericardium: a 10-year study. Jpn J Clin Oncol 1988; 18:195-201.[Abstract/Free Full Text]
-
Nakayama R, Yoneyama T, Takatani O, Kimura K. A study of metastatic tumors to the heart, pericardium and great vessels. Jpn Heart J 1966; 7:227-234.[Medline]
-
Abraham KP, Reddy V, Gattuso P. Neoplasms metastatic to the heart: review of 3314 consecutive autopsies. Am J Cardiovasc Pathol 1990; 3:195-198.[Medline]
-
Klatt EC, Heitz DR. Cardiac metastases. Cancer 1990; 65:1456-1459.[Medline]
-
Winkler M, Higgins CB. Suspected intracardiac masses: evaluation with MR imaging. Radiology 1987; 165:117-122.[Abstract/Free Full Text]
-
Fujita N, Caputo GR, Higgins CB. Diagnosis and characterization of intracardiac masses by magnetic resonance imaging. Am J Cardiac Imaging 1994; 8:69-80.[Medline]
-
Funari M, Fujita N, Peck WW, Higgins CB. Cardiac tumors: assessment with Gd-DTPA enhanced MR imaging. J Comput Assist Tomogr 1991; 15:953-958.[Medline]
-
Higgins CB. Acquired heart disease. In: Higgins CB, Hricak H, Helms CA, eds. Magnetic resonance imaging of the body. Philadelphia, Pa: Lippincott-Raven, 1997; 409-460.
-
Thurber DL, Edwards JE, Achor RWP. Secondary malignant tumors of the pericardium. Circulation 1962; 26:228-241.[Abstract/Free Full Text]
-
MacGee W. Metastatic and invasive tumours involving the heart in a geriatric population: a necropsy study. Virchows Arch A Pathol Anat Histopathol 1991; 419:183-189.[Medline]
-
Quraishi MA, Costanzi JJ, Hokanson J. The natural history of lung cancer with pericardial metastases. Cancer 1983; 51:740-742.[Medline]
-
Waller BF, Gering L, Branyas NA, Slack JD. Anatomy, histology, and pathology of the cardiac conduction system: part IV. Clin Cardiol 1993; 16:507-511.[Medline]
-
Schoen FJ, Berger BM, Guerina NG. Cardiac effects of noncardiac neoplasms. Cardiol Clin 1984; 2:657-670.[Medline]
-
Hancock EW. Neoplastic pericardial disease. Cardiol Clin 1990; 8:673-682.[Medline]
-
Weiss L. An analysis of the incidence of myocardial metastasis from solid cancers. Br Heart J 1992; 68:501-504.[Abstract/Free Full Text]
-
Petersen CD, Robinson WA, Kurnick JE. Involvement of the heart and pericardium in the malignant lymphomas. Am J Med Sci 1976; 272:161-165.[Medline]
-
Millaire A, Wurtz A, De Groote P, Saudemont A, Chambon A, Ducloux G. Malignant pericardial effusions: usefulness of pericardioscopy. Am Heart J 1992; 124:1030-1034.[Medline]
-
Meyers DG, Bouska DJ. Diagnostic usefulness of pericardial fluid cytology. Chest 1989; 95:1142-1143.[Abstract/Free Full Text]
-
Maher EA, Shepherd FA, Todd TJ. Pericardial sclerosis as the primary management of malignant pericardial effusion and cardiac tamponade. J Thorac Cardiovasc Surg 1996; 112:637-643.[Abstract/Free Full Text]
-
Posner MR, Cohen GI, Skarin AT. Pericardial disease in patients with cancer: the differentiation of malignant from idiopathic and radiation-induced pericarditis. Am J Med 1981; 71:407-413.[Medline]
-
Tamura A, Matsubara O, Yoshimura N, Kasuga T, Akagawa S, Aoki N. Cardiac metastasis of lung cancer: a study of metastatic pathways and clinical manifestations. Cancer 1992; 70:437-442.[Medline]
-
Roberts WC. Primary and secondary neoplasms of the heart. Am J Cardiol 1997; 80:671-682.[Medline]
-
Tsuchiya R, Asamura H, Kondo H, Goya T, Naruke T. Extended resection of the left atrium, great vessels, or both for lung cancer. Ann Thorac Surg 1994; 57:960-965.[Abstract]
-
Fukuse T, Wada H, Hitomi S. Extended operation for non-small cell lung cancer invading great vessels and left atrium. Eur J Cardiothorac Surg 1997; 11:664-669.[Abstract]
-
Choe DH, Lee JH, Lee BH, et al. Obliteration of the pulmonary vein in lung cancer: significance in assessing local extent with CT. J Comput Assist Tomogr 1998; 22:587-591.[Medline]
-
Roberts WC, Glancy DL, DeVita VT, Jr. Heart in malignant lymphoma (Hodgkin’s disease, lymphosarcoma, reticulum cell sarcoma and mycosis fungoides): a study of 196 autopsy cases. Am J Cardiol 1968; 22:85-107.[Medline]
-
Glancy DL, Roberts WC. The heart in malignant melanoma: a study of 70 autopsy cases. Am J Cardiol 1968; 21:555-571.[Medline]
-
Enochs WS, Petherick P, Bogdanova A, Mohr U, Weissleder R. Paramagnetic metal scavenging by melanin: MR imaging. Radiology 1997; 204:417-423.[Abstract/Free Full Text]
-
Yoshioka H, Itai Y, Niitsu M, et al. Intramuscular metastasis from malignant melanoma: MR findings. Skeletal Radiol 1999; 28:714-716.[Medline]
-
Mousseaux E, Meunier P, Azancott S, Dubayle P, Gaux JC. Cardiac metastatic melanoma investigated by magnetic resonance imaging. Magn Reson Imaging 1998; 16:91-95.[Medline]
-
Wadler S, Chahinian P, Slater W, Goldman M, Mendelson D, Holland JF. Cardiac abnormalities in patients with diffuse malignant pleural mesothelioma. Cancer 1986; 58:2744-2750.[Medline]
-
Kearney GP, Waters WB, Klein LA, Richie JP, Gittes RF. Results of inferior vena cava resection for renal cell carcinoma. J Urol 1981; 125:769-773.[Medline]
-
Oto A, Herts BR, Remer EM, Novick AC. Inferior vena cava tumor thrombus in renal cell carcinoma: staging by MR imaging and impact on surgical treatment. AJR Am J Roentgenol 1998; 171:1619- 1624.[Free Full Text]
-
Seibert KA, Rettenmier CW, Waller BF, Battle WE, Levine AS, Roberts WC. Osteogenic sarcoma metastatic to the heart. Am J Med 1982; 73:136-141.[Medline]
-
Hoffman U, Globits S, Frank H. Cardiac and paracardiac masses. Eur Heart J 1998; 19:553-563.[Free Full Text]
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Abstract
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