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Multimodality imaging for diagnosis of cardiac masses


Key Points

  • Cardiac tumors are being rare, but form an important component of cardio-oncology practice in which diagnosis and management are vital.

  • Tumors encompass a broad set of lesions and/or masses that can be categorized as neoplastic or nonneoplastic.

  • Neoplastic lesions can be further classified into primary and secondary tumors (i.e., metastasis to the heart).

  • Up to 90% of primary neoplastic tumors are benign and may originate from the pericardium or myocardium.

  • Compared with primary cardiac tumors, secondary cardiac tumors are 22–132 times more common and are by definition malignant.

  • Transthoracic echocardiography is an appropriate initial imaging modality due to its wide availability and lack of radiation. Echocardiography (TTE and TEE) is a useful technique to diagnose intracardiac and extracardiac masses. Shape, size, location, and ultrasound features of the scanned mass can lead to correct diagnosis of the lesions (consist of thrombi, vegetation and benign masses, and malignant neoplasms).

  • Cardiac magnetic resonance is the reference modality for the differentiation and characterization of cardiac masses. CMR is the most robust noninvasive imaging technique for cardiac masses. It provides a large field of view, multiplanar imaging along any axis, and high temporal and spatial resolution. Its tissue characterization capabilities are outstanding, even without intravenous contrast material, and CMR is the best of the noninvasive imaging techniques in this regard

  • Multidetector CT has established a role in imaging cardiac tumors, due to its fast acquisition time, its high spatial resolution, and its incomparable ability to evaluate calcification.

  • Positron emission tomography (PET) offers an accurate evaluation of the metabolic activity of tumors using fluorodeoxyglucose ( 18 F-FDG). FDG-PET is helpful for staging malignancies while also revealing potential myocardial and pericardial involvement.

Cardiac masses may represent a spectrum of disorders from normal intracardiac structures to malignant processes.

The primary goal of noninvasive cardiac imaging modalities is to determine between benign and malignant diseases, in order to direct appropriate patient management.

Using four factors including age, location, epidemiologic likelihood, and tissue characterization, it is possible to determine the etiology of cardiac mass ( Figs. 2.1 and 2.2 ) .

Fig. 2.1
The most typical locations of where different subtypes of cardiac masses are found. However, many cardiac tumours can occur in any chamber .

Fig. 2.2
Diagnostic approach when a cardiac mass is first identified. 3D , 3-dimensional; CT , computed tomography; TEE , transesophageal echocardiography; UEA , ultrasound-enhancing agent.

Multimodality imaging tools of choice for evaluating cardiac masses include echocardiography, cardiac magnetic resonance (CMR), cardiac computed tomography (CCT), and nuclear imaging .

The majority of patients with cardiac masses will come to attention following an echocardiogram.

The following paragraphs will describe these techniques and their advantages and limitations ( Table 2.3 ) .

Table 2.3
Multimodality imaging assessment of cardiac and paracardiac masses.
Echocardiography Cardiac magnetic resonance Computed tomography Positron emission tomography
Advantage Promptly available, no ionizing radiation, low cost, portable No ionizing radiation, high contrast resolution, high temporal resolution, multiplanar imaging reconstruction, large field of view Fast acquisition time, high spatial and temporal resolution, best modality for imaging of calcified lesion, multiplanar image reconstruction, evaluation of thoracic structures High sensitivity of tumor detection, serial physiologic quantitative assessment of whole tumor mass
Disadvantage Limited acoustic windows, operator dependent, limited tissue characterization Long acquisition time, claustrophobia, contraindication in those with implanted magnetic devices Ionizing radiation, iodinated contrast Limited availability, limited spatial resolution, ionizing radiation

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