Atrial Myxoma Workup

  • Author: Gyanendra K Sharma, MD, FACC, FASE; Chief Editor: Park W Willis IV, MD   more...
 
Updated: Aug 30, 2011
 

Laboratory Studies

Lab studies are nonspecific and nondiagnostic. If present, abnormalities may include the following:

  • Elevated erythrocyte sedimentation rate (ESR) and elevated C-reactive protein and serum gamma globulin levels
  • Leukocytosis
  • Anemia may be normochromic or hypochromic. Hemolytic anemia may occur because of the mechanical destruction of erythrocytes by the tumor.
  • Serum interleukin-6 levels may be raised and can be used as a marker of recurrence.
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Imaging Studies

  • Chest radiography
    • Abnormal cardiac silhouette, mimicking mitral stenosis
    • Unusual intracardiac tumor calcification
    • Pulmonary edema
  • Echocardiography
    • Although transesophageal echocardiography is more sensitive, 2-dimensional echocardiography is usually adequate for diagnosis.
    • Tumor location, size, attachment, and mobility can be assessed with this technique.
    • Because tumors may be in multiple locations, all 4 chambers should be visualized.
    • An atrial myxoma must be differentiated from a left atrial thrombus. The thrombus is usually situated in the posterior portion of the atrium and has a layered appearance. Presence of a stalk and mobility favors atrial myxoma.
    • Doppler echocardiography can show the hemodynamic consequences of atrial myxoma. The findings are consistent with mitral stenosis or regurgitation.
  • Transesophageal echocardiography
    • Better specificity and 100% sensitivity compared to transthoracic echocardiography
    • Good resolution of both atria and the atrial septum
    • Better visualization of anatomic details of the tumor and stalk
    • Reveals smaller (1-3 mm in diameter) vegetations or tumors
    • Visualizes atrial appendages
    • Detects shunting
    • Advisable for myxoma syndrome - Multiple less common sitesTransesophageal echocardiography. Transesophageal echocardiography.
  • MRI
    • MRI provides useful information about size, shape, and surface characteristics on T1-weighted images. Cine MR gradient echo (GRE) images can demonstrate the mobility of a tumor. Point of attachment is best visualized by MRI with a postsurgical correlation of 83%. In a small series, MRI was superior to CT scan, which showed only 30% correlation for the site of attachment.
    • Information about tissue composition can be used to differentiate a tumor and a thrombus.
  • CT scan
    • CT scan can be used to differentiate the characteristics of the myxoma from intracardiac thrombus. Myxomas are larger than a thrombus and have typical site of origin, shape, mobility, and occurrence of prolapse.[15]
    • Degree of attenuation or presence of calcification is not useful to differentiate atrial myxoma from a thrombus.
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Other Tests

  • If petechiae are present, a skin biopsy may reveal the presence of elongated or spindle-shaped, myxomatous, endothelial-like cells with round or oval nuclei and prominent nucleoli.
  • Electrocardiography may show left atrial enlargement, atrial fibrillation, atrial flutter, or conduction disturbances.
  • In suspected cases of Carney complex, molecular genetic testing for PRKAR1A should be performed to confirm the diagnosis. The family members of the PRKAR1A -positive patients should undergo genetic screening and evaluation for cardiac and extracardiac manifestations of the disease.[16]
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Procedures

Cardiac catheterization

  • Preoperative cardiac catheterization and angiography may be of value to evaluate for neovascularization.[3]
  • Cardiac catheterization is usually performed to exclude coexistent coronary artery disease in patients older than 40 years.
  • Atrial myxoma appears as an intracardiac filling defect on angiography. This was the pre-echocardiography method of diagnosis. With current imaging modalities, there is no need for angiography.
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Histologic Findings

Histologic studies are characterized by the presence of lipidic cells embedded in a vascular myxoid stroma.

  • The cells are polygonal to stellate in shape with scant eosinophilic cytoplasm.
  • Tumor necrosis is present in approximately 8% of patients; calcification is present in 10-20%.
  • A variable degree of hemorrhage may be present, and mitoses are typically absent.
  • In a series of 37 cases, 74% of tumors showed immunohistochemical expression of interleukin-6 while 17% had abnormal DNA content.[17]
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Contributor Information and Disclosures
Author

Gyanendra K Sharma, MD, FACC, FASE  Professor, Department of Medicine, Section of Cardiology, Medical College of Georgia, Georgia Health Sciences University

Gyanendra K Sharma, MD, FACC, FASE is a member of the following medical societies: American College of Cardiology, American Heart Association, American Society of Echocardiography, Society for Cardiovascular Magnetic Resonance, and Society of Cardiovascular Computed Tomography

Disclosure: Nothing to disclose.

Specialty Editor Board

Robert E Fowles, MD  Clinical Professor of Medicine, University of Utah College of Medicine; Consulting Staff, Intermountain Medical Center and LDS Hospital; Director and Consulting Staff, Department of Cardiology, Salt Lake Clinic

Robert E Fowles, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, and American Heart Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Steven J Compton, MD, FACC, FACP  Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals

Steven J Compton, MD, FACC, FACP is a member of the following medical societies: Alaska State Medical Association, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, and Heart Rhythm Society

Disclosure: Nothing to disclose.

Amer Suleman, MD  Private Practice

Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Chief Editor

Park W Willis IV, MD  Sarah Graham Distinguished Professor of Medicine and Pediatrics, University of North Carolina at Chapel Hill School of Medicine

Park W Willis IV, MD is a member of the following medical societies: American Society of Echocardiography

Disclosure: Nothing to disclose.

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Apical 4-chamber view.
Transesophageal echocardiography.
 
 
 
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