Evaluation and Management of Cardiac Tumors
- 720 Downloads
Purpose of review
Our purpose is to discuss the importance of multimodality imaging in the assessment of cardiac tumors and management. We have compiled a recent review of the scientific literature and embedded our clinical pathways and recommendations based on data and clinical experience.
The use of contrast echocardiography in the assessment of cardiac masses has been shown to be helpful in distinguishing tumor from thrombus. Deformation imaging of cardiac tumors has been shown to differentiate better rhabdomyomas from fibromas in pediatric patients. Cardiac MRI (CMR) appears to be helpful in determining whether cardiac tumors are benign or malignant by identifying presence of infiltration, uptake of contrast in first pass perfusion and gadolinium enhancement. Patients with evidence of cardiac metastases by CMR show similar survival to stage IV cancer without cardiac metastases. In our institution, we use a standardized approach for the evaluation of cardiac masses, which includes multimodality imaging in the appropriate clinical context. The autotransplantation surgical technique has shown some promise in improving survival in patients with primary cardiac sarcomas. In our institution, we do not routinely recommend anticoagulation for “tumor-thrombus” in renal cell carcinoma due to risk of bleeding from primary tumor.
Cardiac masses are often found incidentally, but sometimes can present with cardiovascular symptoms due to obstruction and valvular dysfunction, which may prompt imaging. It is important to determine whether the mass is a normal variant, imaging artifact, vegetation, thrombus, or tumor. Transthoracic echocardiography is ideally suited to be the initial imaging modality because of the portability, wide availability, lack of radiation, and relatively low cost. The gold standard cardiac imaging technique to distinguish tumor from thrombus is contrast enhanced CMR with prolonged inversion time. Advantages of CMR when compared to echocardiography regarding characterization of cardiac tumors are as follows: larger field of view, better spatial resolution, better tissue characterization, lack of attenuation, and ability to image at any prescribed plane. Primary and secondary cardiac tumors have particular characteristics in echocardiography and CMR. Imaging of cardiac tumors plays an important role in establishing a diagnosis and in planning management.
KeywordsCardio-oncology Cardiac tumors Cardiac MRI CMR Tissue characterization Primary cardiac tumors Secondary cardiac tumors Echocardiography Late gadolinium enhancement Papillary fibroelastoma Lymphoma Sarcoma Cardiac autotransplantation
Compliance with Ethical Standards
Conflict of Interest
Nicolas Palaskas, Kara Thompson, Ali M. Agha, Saamir Hassan, Cezar Iliescu, Peter Kim, Jean B. Durand, and Juan C. Lopez-Mattei each declare no potential conflicts of interest. Gregory Gladish reports speaker honoraria from Bristol Myers Squibb.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 25.Barroso AS, et al. Pericardial mesothelioma presenting as a suspected ST-elevation myocardial infarction. Rev Port Cardiol. 2017;36(4):307.e1–5.Google Scholar
- 31.Hendel RC, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Cardiol. 2006;48(7):1475–97.CrossRefPubMedGoogle Scholar
- 37.•• Pazos-Lopez P, et al. Value of CMR for the differential diagnosis of cardiac masses. JACC Cardiovasc Imaging. 2014;7(9):896–905. Very important study that validates the usefulness of CMR in the evaluation of cardiac masses. Describes the features of malignant and benign tumors in CMRCrossRefPubMedGoogle Scholar
- 40.•• Pun, S.C., et al.. Pattern and prognostic implications of cardiac metastases among patients with advanced systemic cancer assessed with cardiac magnetic resonance imaging. J Am Heart Assoc. 2016. 5(5). Important study that emphasize the role of CMR in diagnosing metastatic disease and its relation with staging cancer patients in certain clinical scenarios.Google Scholar
- 41.• Lopez-Mattei, J. Chapter 9. Evaluation of a Cardiac Mass, in MD Anderson Practices in Onco-cardiology, Editor: Edward T.H. Yeh, M.D., F.A.C.C. 2016. p 29–30. This is a summary of our standardized approach of cardiac masses evaluation.Google Scholar
- 44.Colucci WS, Schoen FJ, Braunwald E. Primary tumors of the heart. In: Braunwald E, editor. Heart disease: a textbook of cardiovascular medicine. Philadelphia: W.B. Saunders Company; 1997. p. 1464–77.Google Scholar
- 45.Blackmon SH, Reardon MJ. Cardiac neoplasms. In: Cohn LH, editor. Cardiac surgery in the adult. New York: McGraw-Hill Medical; 2012.Google Scholar
- 70.Wood, C.G., Anticoagulation for renal IVC tumor thrombus, Thompson KA, editor. 2013.Google Scholar