C a r d i o p u l m o n a r y I m a g i n g • R ev i ew

O’Donnell et al.
MRI of Cardiac Tumors

Cardiopulmonary Imaging
Review
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Cardiac Tumors: Optimal Cardiac

MR Sequences and Spectrum of
Imaging Appearances
David H. O’Donnell1 OBJECTIVE. This article reviews the optimal cardiac MRI sequences for and the spec-
Suhny Abbara2,3 trum of imaging appearances of cardiac tumors.
Vithaya Chaithiraphan2 CONCLUSION. Recent technologic advances in cardiac MRI have resulted in the rapid
Kibar Yared2,3 acquisition of images of the heart with high spatial and temporal resolution and excellent
Ronan P. Killeen1 myocardial tissue characterization. Cardiac MRI provides optimal assessment of the location,
functional characteristics, and soft-tissue features of cardiac tumors, allowing accurate dif-
Ricardo C. Cury 2,3,4
ferentiation of benign and malignant lesions.
Jonathan D. Dodd1,2,3
O’Donnell DH, Abbara S, Chaithiraphan V, et al.

R
ecent technologic advances have
allowed cardiac MRI to enter
mainstream imaging practice for
many disease entities [1, 2]. The
development of increasing magnet strengths
and surface coil channels, rapid k-space sam-
pling and postprocessing techniques, and so-
phisticated myocardial soft-tissue character-
ization sequences have made cardiac MRI a
Keywords: heart diagnosis, heart neoplasms, MRI,
neoplasm metastasis
powerful tool in the workup of many complex
cardiac conditions [3]. Cardiac tumors are one
DOI:10.2214/AJR.08.1895 such entity that has become highly suited to the
application of cardiac MRI [4, 5]. Their overall
Received October 3, 2008; accepted after revision
frequency—both primary and metastatic—
January 24, 2009.
occurs with an estimated prevalence of 0.002–
1
Cardiac CT and MRI Program, Department of Radiology 0.3% at autopsy and 0.15% in echocardio-
and Cardiology, St. Vincent’s University Hospital, Elm graphic series [6]. Cardiac neoplasms may be
Park, Dublin 4, Ireland. Address correspondence to categorized into primary and secondary tu-
J. D. Dodd.
mors. The incidence of all primary cardiac tu-
2 mors is estimated from unselected autopsy re-
Cardiac MR-PET-CT Program, CIMIT (Center for
Integration of Medicine & Innovative Technology), ports to be between 0.002% and 0.19% [7].
Boston, MA. Myxomas are the most common benign prima-
3 ry cardiac tumors found in all surgical reports.
Department of Radiology, Massachusetts General
Hospital and Harvard Medical School, Boston, MA. Primary benign tumors have a good prognosis
and a relatively low mortality rate from surgery
4
Baptist Hospitals and Baptist (Miami) Cardiac & (≈ 1%) [8]. Clinical symptoms are typically re-
Vascular Institute, Miami, FL. lated to the size and location of the cardiac tu-
CME
mor, which may alter cardiac hemodynamics,
This article is available for CME credit. cause embolization, or trigger cardiac arrhyth-
See www.arrs.org for more information. mias [9]. Interleukin-6 secretion has been
strongly implicated in causing many of the sys-
AJR 2009; 193:377–387 temic symptoms and signs [10].
0361–803X/09/1932–377
Approximately 25% of primary cardiac tu-
mors are malignant [5, 11]. They may be clini-
© American Roentgen Ray Society cally challenging to diagnose because of non-
specific symptoms and are usually at an
advanced stage when detected [12]. With so-
phisticated cardiac MRI, early detection and
management of these tumors is improving, al-
though cure is rare because of tumor inopera-
bility and high recurrence rates [13]. Angiosar-
comas and undifferentiated sarcomas are the
two most common primary malignant cardiac
tumors. Other cardiac malignancies include
rhabdomyosarcoma, osteosarcoma, leiomyosar-
coma, fibrosarcoma, liposarcoma, and cardiac
lymphoma. Metastases are much more common
than primary cardiac tumors in the adult popula-
tion [13]. Autopsy studies in patients with a
known primary cancer reveal a prevalence of
cardiac metastases of 9.7–10.7%.
Transthoracic echocardiography is the
mainstay imaging technique for cardiac tumor
detection [6]. Although generally robust, it
carries several well-described limitations, in-
cluding operator dependence, restricted field
of view (especially in patients with a large
body habitus), and occasional limited imag-
ing of the right heart chambers. Trans­
esophageal echocardiography improves im-
age quality considerably but is more invasive
and carries a restricted field of view, with
limited views of the aortic arch, inferior vena
cava, and left ventricular apex. Recent devel-
opments in 3D imaging have further en-
hanced its role in the evaluation of cardiac
masses [14]. More recently, cardiac MDCT
has been developed, primarily as a tool for the
evaluation of the coronary arteries [15]. Sev-
eral CT technologic advances—submillimeter

AJR:193, August 2009 377

 O’Donnell et al.

detector arrays, increased rows of detectors,
half-scan postprocessing algorithms, ECG
gating—have resulted in improved imaging of
cardiac structures, including cardiac masses
[16]. Current limitations of the technique in-
clude a significant radiation dose (8–14 mSv),
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Benign Versus Malignant Cardiac
Tumors: Useful Differentiating
Features
Certain cardiac MRI features allow dif-
ferentiation between benign and malignant
cardiac masses (Table 1). These include bor-
able size, sometimes almost filling an entire
chamber [17]. As a general rule, most cardi-
ac tumors involving the right atrial wall
should be considered suspicious for malig-
nancy; the right atrial wall is an uncommon
location for benign tumors [11]. Large foci of

and lower temporal resolution compared with
echocardiography and cardiac MRI. Neither
echocardiography nor MDCT has as good
soft-tissue contrast resolution as cardiac MRI.
Thus, several consensus statements now in-
clude cardiac MRI as a primary imaging tech-
nique in the workup of cardiac tumors [1, 4].
In this article, we describe the optimal
cardiac MRI protocols and provide detailed
descriptions of each sequence that allow the
most favorable characterization of cardiac
tumors. We also illustrate the spectrum of
cardiac MRI appearances of the most com-
mon benign and malignant cardiac tumors.
der, size, location, calcification, and peri-
cardial effusion. The border of most benign
cardiac tumors is smooth and well-defined,
with no irregularity or infiltration [5]. Malig-
nant cardiac tumors tend to have more lobu-
lar, ill-defined, and invasive borders, and
may be identified invading the myocardium,
pericardium, and adjacent extracardiac struc-
tures [11]. Some benign tumors (myxomas)
have a thin pedicle attaching their border to
the myocardium, whereas malignant tumors
are usually broad-based [17]. Most benign
tumors are small in comparison with malig-
nant tumors, which are usually of consider-
calcification are a characteristic hallmark of
cardiac osteosarcoma. Some benign tumors
(myxomas, fibromas) may contain small foci
of calcification. A pericardial effusion in the
presence of a cardiac mass should be consid-
ered suspicious for malignancy.
Differentiating Cardiac Tumors
From Thrombus
A common differential diagnosis for cardi-
ac tumors is intracardiac thrombus. The de-
tection of thrombus is important to avoid em-
bolic events and to provide a basis for
anticoagulation. Echocardiography has been

TABLE 1: Cardiac MRI Findings of Cardiac Tumors

Imaging Sequence
T1-Weighted
Before / After
Steady-State Fat Contrast Delayed
Tumor Morphology Most Common Location Free Precession T2-Weighted Saturation Administration Enhancement
Benign
Myxoma Lobular, pedicle Left atrium, intracavitary, Usually mobile High No change Isointense / High
interatrial septum moderate (heterogeneous)
(heterogeneous)
Lipoma Smooth Any chamber. intra­- May be mobile Low Signal dropout High / minimal None
myocardial or intracavitary
Papillary Smooth, pedicle Valvular Usually mobile High No change Isointense / high High
fibroelastoma
Fibroma Smooth, calcification, Ventricles, intramyocardial Intramyocardial Low No change Isointense / Intense
broad base minimal
Rhabdomyoma Smooth, broad base Ventricles, intramyocardial Intramyocardial High No change Isointense / High
moderate
Hemangioma Lobular, broad base Any chamber, intracavitary Usually mobile High No change Isointense / None
intense
Malignant
Angiosarcoma Lobular, broad base Right atrium Intramyocardial Heterogeneous No change Isointense / Heterogeneous
heterogeneous
Undifferentiated Lobular, broad base Left atrium Intramyocardial, Isointense No change Low —
sarcoma involves valves
Leiomyosarcoma Lobular, broad base Left atrium, posterior wall Intramyocardial High No change Isointense / high —
Fibrosarcoma Lobular, broad base Left atrium, pericardium Intramyocardial — No change Isointense / — —
Liposarcoma Lobular, broad base Left or right atrium, Intramyocardial — Signal dropout Isointense / — —
pericardium
Osteosarcoma Lobular, calcification Left atrium Intramyocardial High No change Isointense / — —
Lymphoma Lobular, pericardial Right atrium Intramyocardial High No change Isointense / High
effusion variable
Metastases Smooth, lobular Variable, pericardial effusion Intramyocardial High No change Low High
Note—Dash (—) indicates not documented.

378 AJR:193, August 2009

 MRI of Cardiac Tumors

the mainstay for thrombus detection, but its
prevalence varies considerably among echo-
cardiographic studies because of modest im-
age reproducibility and poorer spatial and
soft-tissue resolution than cardiac MRI [18,
19]. Contrast-enhanced cardiac MRI allows
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cine cardiac MRI in 4.7% (37 patients; p <
0.005). Delayed enhanced cardiac MRI also
proved to be an excellent reference standard,
providing 100% detection among five patients
with thrombus verified by pathology. A fur-
ther advantage is the detection of myocardial
One: Scout images in the axial, coronal,
and sagittal planes are acquired. The sagittal
scout image in particular is underused and is
a useful opportunity to ensure the heart is
positioned at the center of the surface coil.
Two: Fast spin-echo (FSE) axial slices

differentiation between thrombus and sur-
rounding myocardium because thrombus is
avascular and hence is characterized by an ab-
sence of contrast uptake. Rarely, large chronic
thrombi may enhance peripherally, and these
cases can be diagnostically challenging [20].
Barkhausen et al. [21] studied the use of
contrast-enhanced cardiac MRI for the detec-
tion of cardiac thrombus. In 24 patients with
known or suspected thrombus, a 2D breath-
hold recovery turbo FLASH sequence was
performed immediately after gadolinium in-
jection, which detected 15 thrombi compared
with only 12 by echocardiography. Thrombi
appeared as low-signal-intensity filling de-
fects in the cavity. Delayed enhanced cardiac
MRI sequences also allow useful differentia-
tion between tumor and thrombus [22]. Wein-
saft et al. [23] recently used delayed enhanced
cardiac MRI sequences for the detection of
cardiac thrombus in 784 consecutive at-risk
patients with systolic dysfunction [23]. De-
layed enhanced cardiac MRI detected throm-
bus in 7% (n = 55) of patients compared with
scars, which are an independent risk factor for
thrombus. Thus, delayed enhanced sequences
on cardiac MRI appear to be most useful for
thrombus detection.
Basic Cardiac MRI Protocols for
Assessment of Cardiac Masses
The cardiac MRI protocol used in tumor
imaging should be specifically tailored to the
mass. In our experience, it is important that
the radiologist be available to review the ini-
tial images; otherwise, generic image proto-
cols and image planes may be applied that
may not optimally depict or characterize the
mass. Many cardiac MRI sequences are
available, but all protocols follow a basic set
of generic sequences [24]. The basic proto-
col for cardiac tumors attempts to depict the
location, size, and extent of the mass. The
following section outlines the general basic
set of sequences for cardiac MRI tumor eval-
uation. We have used technical parameters
derived from a Magnetom Avanto 1.5-T
scanner (Siemens Medical Solutions).
(TR/TE, 1,000/27; flip angle, 160°; average
number of slices, 16–20; slice thickness,
8.0–10.0 mm; gap, 20%) are acquired. This
sequence usually requires two breath-holds
to complete the entire thorax. This is a par-
ticularly useful sequence in tumor evaluation
because it allows early localization of the tu-
mor, and subsequent sequences may be tar-
geted to the tumor (Fig. 1A).
Three: A two-chamber steady-state free pre-
cession (SSFP) sequence is acquired along a
plane passing between the center of the mitral–
tricuspid annulus and the apex of the left and
right ventricles, depending on the location of
the tumor (40/1.1; flip angle, 60°; slice thick-
ness, 6–8 mm; gap, 20%; matrix, 256 × 128).
This sequence usually requires a breath-hold of
8–12 seconds, and usually two parallel slices
are acquired. Parallel imaging can be used to
shorten the breath-hold (Fig. 1B and Fig. S1,
cardiac MRI, available at www.ajronline.org).
Four: Based on the preceding two se-
quences, a four-chamber SSFP sequence is
acquired along an image plane passing

Fig. 1—Examples of sequences used for cardiac tumor assessment on cardiac MRI.
A, 62-year-old man with progressive dyspnea. Axial fast spin-echo image quickly allows identification of mass
(arrow), enabling subsequent sequences to be targeted to left atrium in this case. Left atrial myxoma was
proven at surgery.
B, 43-year-old woman with previously resected cutaneous malignant melanoma. Two-chamber (left), four-
chamber (middle), short-axis (right) steady-state free precession images. Tumor (arrows) is accurately located
using all three image planes. Presumed diagnosis is malignant melanoma metastases. (See also Fig. S1, cine
images, in supplemental data at www.ajronline.org.)
(Fig. 1 continues on next page)
A

AJR:193, August 2009 379

 O’Donnell et al.

Eight: Delayed enhanced images are ac-

quired 7–10 minutes after contrast injection
(Fig. 1E). Most centers use a bolus of 20 mL of
0.1mmol/kg of gadolinium injected via an arm
vein, either as a hand injection or by infusion
pump. This should be followed by a saline bo-
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lus chaser of 20 mL. Certain vendors offer a

scout T1-weighted TI sequence (24/1.1; flip an-
gle, 50°; one slice repeated 41 times; slice
thickness, 8.0 mm), which allows the optimal
TI to be identified. This is then followed by the
formal delayed enhanced sequence, which is a
segmented, 2D double-inversion gradient-echo
sequence (700/3.4; trigger pulse, 2; flip angle,
C D 25°; average number of slices, 8–12; slice
thickness, 6–8 mm; gap, 20%). The TI will
vary from patient to patient and must be identi-
fied on an individual basis. If the myocardium
has a “train track” appearance, then the T1 is
usually too early; if it has a confluent gray
appearance, then it is too late. The normal TI
is generally approximately 300 milliseconds,
depending on the cardiac output and the time
after contrast injection. The TI is adjusted as
the scan progresses to allow contrast washout
of the normal myocardium; the nulling time
will change as this is happening. Increasing
the time by 10 milliseconds every 1–3 slices is
E F usually sufficient. Incorrect times on T1-
Fig. 1 (continued)—Examples of sequences used for cardiac tumor assessment on cardiac MRI. weighted sequences will result in improperly
C, 42-year-old woman with chest pain and palpitations. Four-chamber T2-weighted image shows high signal in nulled myocardium. If the TI is too high, the
extensive right ventricular free wall mass (arrows). Cardiac lymphoma was proven at biopsy. (See also Figs. S1 tumor may not be apparent in the gray myo-
and S2, cine images, in supplemental data at www.ajronline.org.)
D and E, 47-year-old woman with progressive dyspnea. Axial T1-weighted images before (D) and after (E)
cardium. This sequence evolved primarily for
administration of gadolinium show heterogeneous enhancement of right atrial mass (arrows). Right atrial the detection of myocardial infarction and
myxoma was proven at surgery. has only relatively recently been applied to
F, 43-year-old woman with previously resected cutaneous malignant melanoma (same patient as in B). Short- the imaging of cardiac masses [25, 26]. Thus,
axis delayed enhanced sequence shows enhancement (arrow) of tumor.
for several tumors, there are no documented
through the center of the left ventricular cav- Six: T2-weighted triple-inversion recov- appearances on delayed enhanced sequences
ity and the right ventricular costophrenic an- ery images to assess for edema or necrosis (Table 1). In the original pathophysiologic
gle using similar technical parameters to the in the mass are acquired. These are breath- model of acute myocardial infarction, cellu-
two-chamber sequence (Fig. 1C and Fig. S2, hold sequences with generally 3–6 slices lar breakdown was considered an important
cardiac MRI, at www.ajronline.org). through the mass to assess for high signal mechanism whereby gadolinium (normally
Five: A short-axis sequence of SSFP ac- (2,000/65; repletion time of two R-R inter- an extracellular contrast agent) could enter
quisitions is acquired along an image plane vals; inversion time (TI), 150 milliseconds; cells to become intracellular, resulting in an
perpendicular to the interventricular septum, section thickness, 8–10 mm; matrix, 256 × increased concentration in the necrotic myo-
passing through both ventricles, and some- 256; echo-train length, 20–32 (Fig. 1C). cardium [27]. In other conditions such as
times the atria, using similar technical pa- Seven: T1-weighted FSE sequence be- acute myocarditis, increased tissue edema re-
rameters to the two-chamber sequence. Two- fore and approximately 15 seconds after the sulting in increased extracellular space allows
chamber, four-chamber, and short-axis stack IV injection of 0.1 mmol/kg to acquire 5–8 gadolinium to pool extracellularly, thus in-
SSFP sequences should be targeted specifi- identical transverse sections encompassing creasing its concentration in edematous myo-
cally to encompass the tumor mass. Slice the mass (1,000/25; repletion time of one cardium [28]. A combination of both factors
thickness and gap can be reduced (5- to R-R interval, 8-mm section thickness, 256 × probably accounts for the delayed enhance-
6-mm slice thickness, 0% slice gap) to ob- 256 matrix (Figs. 1D and 1E). An addition- ment on cardiac MRI seen in cardiac tumors
tain high-spatial-resolution images of the tu- al T1-weighted FSE saturation section across because they often have elements of necrosis
mor. These sequences are particularly useful the superior vena cava (SVC) and the inferior and fibrosis. It is likely that local myocardial
for evaluating tumors that are mobile, such vena cava (IVC) is often useful to reduce the hyperemia in response to the tumor also al-
as atrial myxomas (Fig. 1B and Fig. S1, cine signal from slowly flowing blood, although lows an increased delivery of contrast agent,
CT, at www.ajronline.org). this does increase the time required. similar to other acute myocardial conditions.

380 AJR:193, August 2009


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Fig. 2—58-year-old man with breathlessness. T2-
weighted image shows heterogeneous high signal
intensity in right atrial mass (arrow). Atrial myxoma
was proven at surgery. (See also Fig. S2, cine image,
in supplemental data at www.ajronline.org.)
Benign Cardiac Tumors
Cardiac Myxoma
Myxomas account for 25–50% of all pri-
mary cardiac tumors [29]. They usually oc-
cur in the third to sixth decade of life. The
size varies from 1 to 15 cm. The most com-
mon locations are the left atrium (60–75%),
the right atrium (20–28%) and, rarely, in
both atria or ventricles [29]. Typically, myx-
omas arise near the fossa ovalis of the inter-
atrial septum, although some arise from atri-
al free walls and, rarely, from atrioventricular
valve leaflets. Their contours are generally
round or oval, sometimes lobulated with a
smooth surface and a narrow pedicle. How-
ever, a frondlike appearance and broad-based
features have been reported. Myxomas are
highly mobile and frequently protrude into
the respective atrioventricular valve during
diastole, potentially causing obstruction.
Systemic or pulmonary embolization may be
encountered, depending on the location of
the myxoma [5]. Hemorrhage, fibrosis, and
calcification are frequently identified in the
Fig. 4—42-year-old man with tuberous sclerosis.
A, Four-chamber spin-echo image before fat
saturation shows intermediate signal mass (straight
arrow) in lateral wall of left ventricle having similar
signal to epicardial fat (curved arrow).
B, Four-chamber fat-saturated image shows
marked signal dropout (straight arrow), confirming
fat-containing lesion (curved arrow) consistent
with lipoma.
AJR:193, August 2009
MRI of Cardiac Tumors
Fig. 3—62-year-old woman with palpitations. Four-
chamber steady-state free precession image shows
dumbbell-shaped thickening of interatrial septum
consistent with lipomatous hypertrophy (arrow).
tumor [30]. Recurrence after resection has
been reported, especially in the familial type
[30]. Most cases are sporadic, but if multiple
tumors are present they may be part of a syn-
drome known as Carney’s triad [31]. This au-
tosomal dominant syndrome consists of mul-
tiple cardiac myxomas, a variety of pig­mented
skin lesions such as blue nevi, extracardiac
tumors including pituitary adenomas, breast
fibroadenomas, and melanotic schwanno-
mas. Patients with Carney’s triad are usually
younger than patients with sporadic myxo-
mas, are more likely to have myxomas out-
side the left atrium, and experience recur-
rence after resection.
On cardiac MR images, myxomas typical-
ly have a heterogeneous appearance with in-
termediate signal intensity on T1-weighted
and higher signal intensity on T2-weighted
FSE sequences (Table 1) (Figs. 1D and 2, and
Fig. S2, cine CT, at www.ajronline.org) [32].
They may show high signal intensity if there
are areas of subacute or chronic hemorrhage
in the tumors. Cine SSFP sequences are use-
A B
ful to assess the mobility of the tumors and
their attachment. Attachment may be impos-
sible to identify in very large masses that oc-
cupy the entire cavity. Myxomas show mod-
erate heterogeneous enhancement after
gad­o­linium injection [33].
Lipoma and Lipomatous Hypertrophy of the
Interatrial Septum
The two most common fat-containing le-
sions in the heart are cardiac lipomas and li-
pomatous hypertrophy of the interatrial sep-
tum. True cardiac lipomas are encapsulated,
contain neoplastic fat cells, and occur at a
young age. Lipomas constitute 8–12% of pri-
mary cardiac tumors. Half of lipomas arise
from the subendocardial layer and are rela-
tively small, whereas the other half are from
either subepicardial or mid-myocardial layers
[7]. If the tumor is large enough, it may cause
symptoms from disturbed cardiac hemody-
namics; there have been reports of sudden
death from compressive effects on either the
coronary circulation or the cardiac nerve con-
duction system [34].
Lipomatous hypertrophy of the interatrial
septum is often found in older and overweight
patients [35] (Fig. 3). Unlike true lipomas,
they are not capsulated and contain lipoblasts
and mature fat cells. Because of the presence
of brown fat, this entity may show increased
radiotracer uptake on PET/CT scans [36]. The
bilobed, dumbbell-shaped fatty mass must be
greater than 20 mm in thickness and charac-
teristically spares the fossa ovalis [34]. The
lesion is rarely associated with symptoms al-
though atrial arrhythmias are reported [37].
Lipomas usually have a homogeneous sig-
nal on cardiac MR images (Table 1 and Fig. 4).
They have the same signal intensity as fat tis-
sue—that is, high intensity on T1 and lower in-
tensity T2-weighted FSE images. An invalu-
able sequence if this type of tumor is suspected
is pre- and post-fat-saturated T1-weighted FSE
381

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A B
sequences, in which signal dropout is identi-
fied in the mass on the fat-saturation sequence,
confirming a fat-containing lesion.
Papillary Fibroelastoma
Cardiac papillary fibroelastomas arise
from endocardium, 80% of which are found
on aortic or mitral valves [5]. Histopatholog-
ic features are of a papillary growth covered
by a single layer of hypertrophied endo-
thelium. The stroma is composed of a central
dense amorphous fibrous core with an outer
layer of loose connective tissue. Autopsy se-
ries report the incidence of cardiac papillary
fibroelastomas to be 2–33%, making them
the second most common primary benign
cardiac tumor. From one comprehensive re-
view, tumor size varied from 2 to 70 mm,
with a mean diameter of approximately 10
mm [38]. Clinical presentations usually re-
sult from systemic embolization of the tumor
or thrombi on the tumor surface [39]. Inci-
dental detection is also common because
many patients are asymptomatic. Most cases
are diagnosed by echocardiography, and car-
diac MRI is rarely needed except in atypical
or inconclusive cases [40]. Surgical removal
A B
382
O’Donnell et al.
is recommended in symptomatic patients
and in asymptomatic patients with mobile,
left-sided tumors [35].
On cardiac MR images, papillary fi-
broelastoma typically appears as a small,
round, homogeneous mass, sometimes with
a small pedicle attached, usually to valvular
structures (Table 1 and Fig. 5). Signal inten-
sity is intermediate on T1- and hyperintense
on T2-weighted FSE images. Fat-saturation
sequences differentiate fibroelastomas from
lipomas; the former do not show any signal
dropout. Although lipomas are reported on
valves, they rarely occur in this location [41].
Cine SSFP cardiac MRI may show a highly
mobile, hypointense mass with turbulent
flow signal surrounding it.
Cardiac Fibroma
Cardiac fibromas are the second most com-
mon congenital tumor; they are usually de-
tected in infants and children and occasional-
ly in young adults. Cardiac fibromas have a
rare association with polyposis syndromes
such as familial adenomatous polyposis and
Gardner’s syndrome [42]. Typically, cardiac
fibromas arise from the inter­ventricular sep-
Fig. 5—38-year-old man with atypical chest pain.
A, Axial oblique T1-weighted image shows
intermediate signal lesion (arrow) arising from left
coronary cusp.
B, Axial oblique T1-weighted fat-saturation image
shows no signal dropout of mass (arrow), thus
excluding lipoma; note that lipomas rarely occur
on valves. Papillary fibroelastoma was proven at
surgery.
tum and affect the left ventricle more often
than the right [43]. Those associated with
polyposis syndromes appear to occur more
commonly in the atria. Pathologic features are
similar to those of fibromas found elsewhere
in the body. Patients may present with heart
failure, chest pain, arrhythmia, and sudden
cardiac arrest. Because of the risk of sudden
death, surgical removal is recommended, even
in asymptomatic patients [32, 38].
Morphologic features include typically sol-
itary, well-defined masses in the myocardium,
usually involving the interventricular septum,
often with central calcification, which helps
differentiate them from rhabdomyomas. MRI
findings of the tumor are characteristic, with
inhomogeneous isointense or slightly hyper-
intense signal on T1-weighted and hypo-
intense signal on T2-weighted FSE images
compared with myocardium [32] (Table 1). A
disadvantage of cardiac MRI over CT is its in-
ability to directly visualize calcium, which
may be represented by low signal areas in the
tumor. If doubt exists about the nature of these
tumors, cardiac MDCT may elucidate the fea-
tures. There is slight or no enhancement with
gadolinium injection compared with sur-
Fig. 6—32-year-old woman with history of familial
adenomatous polyposis (FAP) coli and metastatic
mesenteric desmoid tumor.
A, Short-axis oblique steady-state free precession
image shows nodular mass (arrow) arising from floor
of right atrium adjacent to eustachian ridge.
B, Sagittal oblique delayed enhanced image shows
no evidence of enhancement (arrow). Diagnosis was
presumed cardiac fibroma in association with FAP.
AJR:193, August 2009
 MRI of Cardiac Tumors
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A B C
Fig. 7—63-year-old man with chest pain. (See also Fig. S3, cine image, in supplemental data at www.ajronline.org.)
A, Axial T1-weighted image shows right atrial wall thickening (arrow).
B, Six months later, repeat axial T1-weighted image shows increase in size of discrete mass (arrow) and invasion through right atrial wall.
C, Axial T1-weighted image after gadolinium administration shows marked enhancement consistent with vascular tumor (arrow). Angiosarcoma was proven at biopsy.

rounding myocardium because of the mini-
mal vascular supply or cardiac fibromas (Fig.
6). After gadolinium administration, T1-
weighted images may show central hypo-
intense areas with a well-demarcated iso-
intense surrounding shell [44].
Rhabdomyoma
Rhabdomyomas are the most common
primary cardiac tumors in children; they are
usually diagnosed in neonates [45]. Typical
findings include a single or multiple masses
arising in the ventricular myocardium. Al-
though many cases are sporadic, rhabdomyo-
mas have a strong association with tuberous
sclerosis, which should be considered if mul-
tiple tumors are present. Up to 50% of index
tuberous sclerosis cases will manifest this
cardiac tumor. Most cardiac rhabdomyomas
regress spontaneously, and surgery is there-
fore not routinely required unless patients
develop significant symptoms from severe
arrhythmias or heart failure [46].
Echocardiography is usually adequate for
making the diagnosis, but cardiac MRI is
useful in atypical presentations or when sur-
gical removal is planned. Rhabdomyomas
typically have a solid and homogeneous ap-
pearance that may be hypointense to myo-
cardium on T1-weighted and slightly hyper-
intense on T2-weighted FSE images [47].
They typically show minimal or no en-
hancement with gadolinium (Table 1).
ple locations. On cardiac MRI, hemangiomas
have isointense or increased intensity on T1-
weighted FSE images because of slow blood
flow, and they are hyperintense on T2-weight-
ed FSE images (Table 1). After gadolinium
administration, images typically show intense
enhancement because of the vascular nature
of these tumors but the findings may be het-
erogeneous because of calcification and fi-
brous septa. A variant of hemangiomas, cav-
ernous hemangiomas, have very slow flow
and may not show significant enhancement.
Other Benign Tumors
Cardiac paragangliomas are extremely rare
tumors arising from cardiac paraganglial
(chromaffin) cells [48]. Patients may experi-
ence symptoms of pheochromocytoma because
tumors may secrete active cate­cholamines. IV
leiomyomatosis is a rare benign tumor of the
smooth muscle that may extend into the right
side of the heart via the IVC [49].
Primary Malignant Tumors of
the Heart
Angiosarcoma
Angiosarcomas are the most common car-
diac sarcomas in surgical studies [9]. They
occur more commonly in middle-aged men
and almost exclusively arise in the right atri-
um. They frequently show pericardial in-
volvement. Other cardiac sarcomas occur
mainly in the left side of the heart and are of-
ten mistaken for left atrial myxoma.
There are two main morphologic types. The
first is a well-defined mass protruding into the
chamber, usually the right atrium, and sparing
the interatrial septum (Fig. 7 and Fig. S3, cine
CT, at www.ajronline.org). The second is a
more diffusely infiltrative mass extending into

Cardiac Hemangioma
Cardiac hemangiomas represent 5–10% of
primary benign cardiac tumors [47] and may
originate from endocardium, myocardium, or
epicardium. They are usually found in the
ventricles, although they may occur in multi-
Fig. 8—48-year-old woman with chest pain. Four-
chamber T1-weighted image shows aggressive, large
infiltrating mass (arrow) invading right atrium and
epicardial and pericardial spaces. Angiosarcoma was
proven at biopsy.
Fig. 9—63-year-old man with dyspnea. Two-chamber
T2-weighted image shows mass in left atrium
(arrow) that is isointense to myocardium. Poorly
differentiated sarcoma was proven at biopsy.

AJR:193, August 2009 383


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A B
the right ventricle and invading through the
pericardium with pericardial thickening or
hemorrhagic effusion [50] (Fig. 8). Because of
the location of angiosarcomas, patients often
present with right-sided heart failure or tam-
ponade. Prognosis is poor because metastases
have usually occurred at the time of diagnosis
(66–89%). Because of the propensity of an-
giosarcomas for necrosis and hemorrhage,
they typically have heterogeneous signal on
cardiac MR images [11] (Table 1). On T1-
weighted FSE sequences, tumors are typically
low-signal, and T2-weighted FSE images typi-
cally show increased signal and central areas
of hyperintensity, consistent with hemorrhage
and necrosis, and areas of moderate signal in-
tensity in more peripheral regions [51]. Be-
cause of their high vascularity, strong signal
enhancement is seen after the administration
of IV gadolinium.
Undifferentiated Sarcoma
Most undifferentiated sarcomas are found in
the left atrium [9] (Fig. 9). They may appear as
a discrete mass or irregular and infiltrative with
necrosis and hemorrhage. On cardiac MR im-
ages, tumors usually appear isointense com-
pared with myocardium on FSE images [11]
(Table 1). In recent reports, the prevalence has
been found to account for approximately 24%
of primary cardiac malignancies [45]. Undif-
ferentiated sarcomas have a similarly poor
prognosis as angiosarcomas in adults.
Leiomyosarcoma
Leiomyosarcomas represent about 8% of
cardiac sarcomas. They usually affect pa-
tients during the fourth decade. The most
common site of the tumor is the posterior
wall of the left atrium, and invasion of the
pulmonary veins is frequently seen [52] (Fig.
10). They are usually sessile, lobulated, ir-
regular masses and may be multiple in 30%
384
O’Donnell et al.
of cases. Some may originate from the IVC,
which can cause the symptoms of right-sided
heart failure. MRI findings are nonspecific,
with tumors showing intermediate signal on
T1-weighted and increased signal intensity
on T2-weighted FSE images [53] (Table 1).
Fibrosarcoma
These rare tumors represent about 5% of
cardiac sarcomas in surgical series. Like os-
teosarcoma and leiomyosarcoma, fibrosarco-
ma tends to occur in the left atrium and usu-
ally manifests as congestive heart failure.
Prognosis is also similar to other cardiac sar-
comas. MRI findings are nonspecific, with a
heterogeneous signal intensity on T1-weight-
ed FSE images [11] (Table 1).
Liposarcoma
Primary cardiac liposarcoma is extremely
rare, accounting for fewer than 1% of cardiac
sarcomas [54]. It may occur in any cardiac
chamber and may show pericardial and valve
involvement. Primary cardiac liposarcomas
are generally large, with areas of necrosis
and hemorrhage. Liposarcomas may have lit-
tle or no macroscopic fat and do not resemble
benign lipomas. They appear as masses with
heterogeneous high signal intensity on T1-
weighted FSE images and show mild gado-
linium enhancement [55] (Table 1).
Extraskeletal Cardiac Osteosarcoma
Cardiac osteosarcomas make up about
3–9% of primary malignant cardiac tumors
[11]. They commonly present with pulmonary
congestion because they are usually centered
in the left atrium, unlike metastatic cardiac
osteosarcoma (Fig. 11). They commonly con-
tain large foci of calcification, which is their
most distinguishing noninvasive imaging fea-
ture (Table 1). This may be more difficult to
appreciate on cardiac MRI than CT, which
Fig. 10—48-year-old man with dyspnea.
A, Four-chamber steady-state free precession
image shows lobulated mass (arrow) arising from
left inferior pulmonary vein. Note involvement of left
inferior pulmonary vein orifice (arrowheads) by mass.
B, Four-chamber T1-weighted image after gadolinium
administration shows enhancement of mass (arrow),
excluding acute thrombus. Diagnosis was presumed
leiomyosarcoma.
can provide complementary information if
intratumoral calcification is suspected. Other
useful features include a broad base of attach-
ment and aggressive invasion of local vascular
structures such as the pulmonary veins. Histo-
logically, they may be predominantly osteo-
blastic or may have chondroblastic or fibro-
blastic features in addition. All subtypes have
a poor prognosis.
Primary Cardiac Lymphoma
Cardiac involvement of disseminated non-
Hodgkin’s lymphoma is much more common
than primary cardiac lymphoma. Almost all
primary cardiac lymphomas are aggressive
B-cell lymphomas, most commonly occur-
ring in immunocompromised patients. Early
diagnosis and prompt treatment with chemo-
therapy may improve prognosis [56]. The tu-
mors usually arise from the right side of the
heart, often the right atrium, and are accom-
panied by a large pericardial effusion. Occa-
sionally, a pericardial effusion may be the
only finding on MRI. Generally, tumors are
large at presentation, with either diffuse in-
filtration of the right ventricle or multiple
nodules. They may appear isointense or
hypointense relative to myocardium on both
T1- and T2-weighted FSE sequences and
show heterogeneous enhancement after ad-
ministration of gadolinium [57, 58] (Table 1,
Fig. 12, and Fig. S4, cine CT, at www.ajron-
line.org). The FSE axial images of the thorax
should be evaluated carefully to identify me-
diastinal lymph nodes that may be amenable
to percutaneous or mediastinoscopic biopsy.
Delayed enhanced sequences after chemo-
therapy may show severe scarring of the
right ventricular myocardium. Patients with
this disorder should be monitored with te-
lemetry while they are undergoing initial
treatment because such extensive scarring
can act as an arrhythmogenic substrate.
AJR:193, August 2009
 MRI of Cardiac Tumors

Cardiac Metastasis metastasize to the heart include tumors of the

Metastases are much more common in the
adult population than primary cardiac tumors
[13]. Most patients with cardiac metastases
have no cardiac symptoms, and their diagno-
sis is generally made postmortem. Rarely, car-
Downloaded from www.ajronline.org by 201.87.129.122 on 07/17/23 from IP address 201.87.129.122. Copyright ARRS. For personal use only; all rights reserved
breast, kidney, and esophagus, as well as lym-
phoma, leukemia, and melanoma.
Myocardial metastases are often associat-
ed with melanoma and lymphoma and are
suggestive of hematogenous spread. Renal

Fig. 11—54-year-old-man with extraskeletal cardiac
osteosarcoma. Four-chamber steady-state free
precession image shows nodule thickening of floor
of left atrium (arrows). Nodules were isointense with
myocardium. Patient had multiple pulmonary nodules,
biopsy of which showed metastatic osteosarcoma.
diac metastasis presents as the first clinical
feature of malignancy. Cardiac metastasis
may occur via one of four pathways: direct in-
vasion, lymphatic extension, hematogenous
spread, or transvenous extension [59].
Malignant pericardial effusion is the most
common manifestation of metastasis, most
likely through lymphatic spread or direct in-
vasion from adjacent tissues (e.g., lungs,
breasts, and lymph nodes). The most common
metastases to the heart and pericardium are
from lung cancer because of their proximity
and the high prevalence of lung cancer itself
[59]. The other common primary tumors that
cell carcinoma may spread via IVC tumor
thrombus into the right atrium. Obliteration
of a pulmonary vein may be a clue to intra­
cardiac extension of bronchogenic carcino-
ma. Because metastases are rarely limited to
the heart, evidence of a primary malignancy
and metastases elsewhere strongly support
the diagnosis of myocardial metastasis.
Most metastases show low signal intensity
compared with myocardium on T1-weighted
and high signal intensity on T2-weighted FSE
images, with the exception of melanoma,
which appears bright on T1-weighted FSE im-
ages because of the paramagnetic effects of

A B C

D E
Fig. 12—54-year-old woman with chest pain, dyspnea, and palpitations. (See also Fig. S4, cine image, in supplemental data at www.ajronline.org.)
A, Four-chamber T1-weighted image shows extensive lobulated masses infiltrating right atrium, left ventricle, and right ventricle (arrows).
B, Four-chamber T1-weighted image after gadolinium shows enhancement of masses (arrows), consistent with tumor.
C, Short-axis steady-state free precession image shows extent of right atrium and infiltration of right atrioventricular groove (arrows). Note associated malignant
pericardial effusion.
D, Short-axis T2-weighted image shows high signal in mass (arrows) that is characteristic of tumor. Cardiac lymphoma was proven at biopsy.
E, Short-axis delayed enhanced sequence after first cycle of chemotherapy shows extensive scarring of right ventricular free wall (straight arrows). Note some small
foci of viable myocardium (curved arrow). During treatment, patient required multiple emergency cardioversions for ventricular tachycardia and fibrillation, probably
originating from scarred right ventricular wall.

AJR:193, August 2009 385

 O’Donnell et al.
Downloaded from www.ajronline.org by 201.87.129.122 on 07/17/23 from IP address 201.87.129.122. Copyright ARRS. For personal use only; all rights reserved

A B C
Fig. 13—Cardiac metastases. (See also Fig. S5, cine image, in supplemental data at www.ajronline.org.)
A, 61-year-old-man with right hilar non–small cell lung cancer. Four-chamber steady-state free precession image shows early invasion of right atrium (curved arrow) by
right hilar mass (straight arrow).
B, 67-year-old man with previously resected laryngeal carcinoma. Four-chamber T1-weighted fast spin-echo image shows marked infiltration of right atrium myocardium
(arrows) from hematogenous metastases.
C, Four-chamber T1-weighted gadolinium-enhanced image in same patient as in B shows enhancement in mass (arrows) consistent with vascular metastases.

melanin (Table 1, Figs. 1 and 13, and Fig. S5,
cardiac MRI, at www.ajronline.org). Almost
all malignant lesions will show identifiable
enhancement after gadolinium injection.
Conclusion
Recent technology advances have led to car-
diac MRI entering the practice of mainstream
cardiac imaging. It has become a particularly
valuable tool in the workup of suspected car-
diac tumors. These tumors are rare but, when
present, can have devastating implications for
patients, altering cardiac hemodynamics and
acting as embolic or arrhythmia substrates.
Some may be frankly malignant. Although
echocardiography is the mainstay for tumor
detection, optimal tumor characterization may
be achieved with cardiac MRI, which provides
an unrestricted field of view and superior soft-
tissue depiction without ionizing radiation.
Several cardiac MRI features have been de-
scribed that are useful in differentiating be-
nign from malignant tumors. Cardiac MRI is
also accurate in differentiating tumor from
cardiac thrombus. Although many cardiac
MRI sequences exist, all follow a basic generic
protocol, and, if followed correctly, allow opti-
mum characterization of the anatomy and tis-
sue features of cardiac tumors and enable ac-
curate assessment of their functional impact.
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