Cardiac tumors: diagnosis and management

The first step towards the diagnosis of cardiac neoplasia is made when the clinician considers the diagnosis. While the classically described signs and symptoms of left-atrial myxomas are noteworthy, the vast majority of patients present with symptomatology that is less specific--either of a constitutional nature, or related to right- or left-sided congestion. Likewise, the physical examination may rarely disclose classic auscultatory signs, but is more likely to confirm the presence of the right- or left-sided congestion inferred from history. Peripheral, embolic, or vasculitis lesions should raise suspicion of the diagnosis. Nevertheless, the majority of patients will be diagnosed by the unexpected detection of a tumor at the time of echocardiography. Transthoracic echocardiography remains the procedure of choice in screening for cardiac neoplasia. It has excellent sensitivity for intracavitary and endocardial lesions. Myocardial lesions are also well imaged. Pericardial lesions, with or without extension into contiguous structures, are poorly visualized and, here, magnetic resonance imaging is unquestionably the superior investigative approach. Further, a limited degree of tissue characterization is possible with the latter technology. Transesophageal echocardiography is ideally suited for the examination of suspected tumors involving the atria, interatrial septum, superior vena cava, atrioventricular valves and, to a lesser extent, the ventricles. These three imaging modalities clearly complement one another and the choice of application will depend upon factors including the patient's transthoracic echogenicity, the availability of magnetic resonance imaging or transesophageal echocardiography, cost, and the physical status of the patient.