Our Approach to Screening and Follow-Up in Cardiac Tumours and Intracardiac Masses

As echocardiography (imaging of the heart with ultrasound) has become far more widespread, so has the frequency with which we encounter a completely unexpected finding: a mass inside the heart that should not be there. This finding can seriously worry both the patient and, at times, the doctor who sees it for the first time. I will address the types of intracardiac masses, how we use the various imaging methods, and the details of surgical treatment in separate articles; in this article I focus directly on the part of the subject that is most useful in daily practice, namely whom we screen, when, and how we follow them up.

What Does a Mass Inside the Heart Mean?

The heart is like a pump that works without stopping; normally it contains only blood and valves. When an unexpected piece of tissue is noticed in this “clean” space, we need to clarify what it is and how dangerous it is. These masses usually present as a benign tumour arising from the heart’s own cells, very rarely as a malignant mass that has spread to the heart from another organ, or simply as clotted blood (thrombus). The encouraging point is that almost all masses detected inside the heart are benign.

Why Are Screening and Early Detection So Important?

There are three main reasons why we take an intracardiac mass seriously. First, as the mass grows it can obstruct blood flow within the heart, much as an object falling into a water pipe slows the flow. Second, small pieces breaking off the surface of the mass can travel with the bloodstream to the brain, the lungs or other organs and cause sudden blockages (embolism). In some patients the first symptom may be a stroke or a sudden circulatory disturbance. Third, some masses can give the impression of a general systemic illness with fever, weight loss and fatigue, and the diagnosis may be delayed. When these three risks (obstruction, embolism, general symptoms) are considered together, we prefer to follow a planned screening and follow-up strategy in intracardiac masses rather than a “wait-and-see” approach.

For Whom Do We Recommend Screening and Close Follow-Up?

We recommend screening with echocardiography, or follow-up at more frequent intervals, in the following situations:

• Those with a family history of cardiac tumour (particularly myxoma), especially in families where a genetic predisposition syndrome such as Carney complex is known
• Those who have had an unexplained stroke or systemic embolic event at a young age
• Those with heart failure, palpitations or a fainting (syncope) episode of unclear cause
• Those in whom imaging performed for another reason (for example during lung or breast screening) raises the suspicion of an incidental shadow or mass in the heart
• Patients who have previously been operated on for an intracardiac mass (with respect to recurrence)

How Do We Make the Diagnosis and How Do We Monitor?

The first step is almost always transthoracic echocardiography (the standard heart ultrasound performed over the chest); it is quick, painless and quite successful at detecting the great majority of intracardiac masses. In suspicious or borderline cases we move to transoesophageal echocardiography (TEE), performed through the oesophagus; because this method lets us look at the heart from much closer, we can see even masses of millimetre size. When we want to characterise the tissue of the mass in more detail, cardiac magnetic resonance imaging (MR) or computed tomography (BT) comes into play; these examinations give us important clues as to whether the mass is benign or suspicious.

In known small, low-risk masses for which a surgical decision has not yet been made, we repeat echocardiography at set intervals to monitor the growth rate and any change in shape. In masses removed surgically, however much the pathology result shows them to be benign, we recommend continuing control echocardiography at regular intervals for many years; because recurrence can be seen even in some types of benign mass.

Intracardiac Masses Are Generally the Following

Myxoma: This is the most common primary (heart-originating) cardiac tumour in adults; it is mostly located in the left atrium and is generally benign, but because of the risk of obstruction and embolism it must be taken seriously once detected. Papillary fibroelastoma: A benign mass, usually located on the heart valves, that is small but carries a potential for embolism. Intracardiac thrombus (clot): Although it is not a true tumour, it can be confused with a tumour on imaging; it usually develops in patients whose cardiac function is weak or who have a rhythm disorder, and its treatment starts with blood thinners. Metastatic (spread) masses: These arise from the spread of a cancer in another organ to the heart, and their management is planned together with the underlying cancer, by a multidisciplinary team.

When Is a Surgical Evaluation Needed?

In situations where the mass causes obstruction, leads to an embolic event, or shows malignant features on imaging, we refer the patient for surgical evaluation without losing time. I will address in detail in a separate article how this treatment decision is carried out and which minimally invasive or endoscopic techniques are used; the most important point to know here is that in the appropriate patient, surgery is usually curative (completely healing), is performed almost entirely with minimally invasive methods, and the results are quite favourable.

Frequently Asked Questions

A mass was found in my heart, does this necessarily mean cancer? No. The great majority of intracardiac masses are benign. However, every mass must be clarified with imaging and, if necessary, tissue diagnosis.

Does myxoma recur? Yes, although rarely; this is why we recommend regular follow-up with echocardiography for many years after surgery.

There is a family history of cardiac tumour, should I be screened too? Especially if there is a history of myxoma in more than one family member at a young age, a genetic predisposition (such as Carney complex) should be investigated and screening echocardiography should be recommended for family members.

Does a small, incidentally detected mass require immediate surgery? Not always. In masses that are small in size, immobile and appear low-risk, we may prefer close follow-up first; the decision is shaped by the characteristics of the mass and the patient’s clinical picture.

In Summary

Although a mass detected inside the heart is worrying at first for both patient and doctor, it is most often a situation that can be managed safely with the right screening and follow-up strategy. Our approach is to classify the type and risk of the mass correctly, to choose the appropriate imaging method, and, when necessary, to remove these masses using minimally invasive and endoscopic cardiac surgery techniques.

If a mass was suspected in your heart during a routine check, or if there is a family history of cardiac tumour, you can book an appointment for a detailed echocardiographic assessment.

References

1. Reynen K. Cardiac Myxomas. N Engl J Med. 1995;333(24):1610-1617.
2. Griborio-Guzman AG, Aseyev OI, Shah H, Sadreddini M. Cardiac Myxomas: Clinical Presentation, Diagnosis and Management. Heart. 2022;108(11):827-833.
3. Lam KY, Dickens P, Chan AC. Tumors of the Heart: A 20-Year Experience with a Review of 12,485 Consecutive Autopsies. Arch Pathol Lab Med. 1993;117(10):1027-1031.
4. Maleszewski JJ, Larsen BT, Kip NS, et al. PRKAR1A in the Development of Cardiac Myxoma: A Study of 110 Cases Including Isolated and Syndromic Tumors. Am J Surg Pathol. 2014;38(8):1079-1087.