JACC: CARDIOVASCULAR IMAGING

VOL. 7, NO. 9, 2014

ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

ISSN 1936-878X/$36.00

PUBLISHED BY ELSEVIER INC.

http://dx.doi.org/10.1016/j.jcmg.2014.05.009

Value of CMR for the Differential Diagnosis of Cardiac Masses Pablo Pazos-López, MD,*y Eduardo Pozo, MD,* Maria E. Siqueira, MD,* Inés García-Lunar, MD,*y Matthew Cham, MD,* Adam Jacobi, MD,* Frank Macaluso, BS,* Valentín Fuster, MD, PHD,*y Jagat Narula, MD, PHD,* Javier Sanz, MD*

JACC: CARDIOVASCULAR IMAGING CME CME Editor: Ragavendra R. Baliga, MD

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should: 1) recognize the additive value of cardiac MRI for the differential diagnosis of cardiac masses; 2) recall cardiac MRI specific

Accreditation and Designation Statement The American College of Cardiology Foundation (ACCF) is accredited by

features that are valuable to differentiate a thrombus from a tumor; and 3) recall cardiac MRI specific features that may be helpful to differentiate a benign from malignant neoplasm.

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From *The Zena and Michael A. Wiener Cardiovascular Institute/Marie-Josée and Henry R. Kravis Center for Cardiovascular Health, Mount Sinai Hospital, New York, New York; and the yCentro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain. Dr. Narula has received research support in the form of an equipment grant to the institution from Philips Healthcare. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Dr. Nathaniel Reichek has served as Guest Editor for this paper. Manuscript received April 1, 2014; revised manuscript received May 12, 2014, accepted May 13, 2014.

Pazos-López et al.

JACC: CARDIOVASCULAR IMAGING, VOL. 7, NO. 9, 2014 SEPTEMBER 2014:896–905

CMR for Cardiac Masses

Value of CMR for the Differential Diagnosis of Cardiac Masses ABSTRACT OBJECTIVES The goal of this study was to evaluate the diagnostic value of CMR features for the differential diagnosis of cardiac masses. BACKGROUND Differentiation of cardiac tumors and thrombi and differentiation of benign from malignant cardiac neoplasms is often challenging but important in clinical practice. Studies assessing the value of cardiac magnetic resonance (CMR) in this regard are scarce. METHODS We reviewed the CMR scans of patients with a definite cardiac thrombus or tumor. Mass characteristics on cine, T1-weighted turbo spin echo (T1w-TSE) and T2-weighted turbo spin echo (T2w-TSE), contrast first-pass perfusion (FPP), post-contrast inversion time (TI) scout, and late gadolinium enhancement (LGE) sequences were analyzed. RESULTS There were 84 thrombi, 17 benign tumors, and 25 malignant tumors in 116 patients. Morphologically, thrombi were smaller (median area 1.6 vs. 8.5 cm2; p < 0.0001), more homogeneous (99% vs. 46%; p < 0.0001), and less mobile (13% vs. 33%; p ¼ 0.007) than tumors. Hyperintensity compared with normal myocardium on T2w-TSE, FPP, and LGE were more common in tumors than in thrombi (85% vs. 42%, 70% vs. 4%, and 71% vs. 5%, respectively; all p < 0.0001). A pattern of hyperintensity/isointensity (compared with normal myocardium) with short TI and hypointensity with long TI was very frequent in thrombi (94%), rare in tumors (2%), and had the highest accuracy (95%) for the differentiation of both entities. Regarding the characterization of neoplastic masses, malignant tumors were larger (median area 11.9 vs. 6.3 cm2; p ¼ 0.006) and more frequently exhibited FPP (84% vs. 47%; p ¼ 0.03) and LGE (92% vs. 41%; p ¼ 0.001). The ability of CMR features to distinguish benign from malignant neoplasms was moderate, with LGE showing the highest accuracy (79%). CONCLUSIONS CMR features demonstrated excellent accuracy for the differentiation of cardiac thrombi from tumors and can be helpful for the distinction of benign versus malignant neoplasms. (J Am Coll Cardiol Img 2014;7:896–905) © 2014 by the American College of Cardiology Foundation.

A

lthough cardiac tumors are rare entities (esti-

dependent, offers poor tissue characterization, and

mated prevalence at autopsy of 0.02% to

has acoustic window restrictions in a subset of pa-

2.3%, and 0.15% in echocardiographic series)

tients. Transesophageal and 3-dimensional echocar-

(1), their morbidity and mortality rates are high (2).

diography may overcome some of these limitations

Surgical removal is the treatment option in most

(11,12). Computed tomography is also useful for the

cases, although satisfactory results occur only in

evaluation of tumors and thrombi (13), although at

benign types (3). Thrombi have a higher prevalence,

the expense of radiation exposure. As opposed to

ranging between 3% and 25% (4) and 2% and 50%

these modalities, cardiac magnetic resonance (CMR)

(5–7) in patients with atrial fibrillation and left ven-

has excellent contrast resolution that allows for su-

tricular systolic dysfunction, respectively, and justify

perior soft tissue characterization. The combined

anticoagulation to prevent embolic events (8,9).

evaluation of morphology, composition, and perfu-

Hence, proper differentiation among these entities

sion makes CMR a useful tool in the assessment of

remains imperative because both prognosis and ther-

cardiac masses (14–18). However, studies testing the

apeutic approach vary substantially.

accuracy of CMR in this regard are scarce and have

echocardiography

relatively small sample sizes (19–22). The aim of the

is the most common imaging technique used for

present study was to determine the ability of CMR

cardiac mass evaluation (10), but it is operator

features of cardiac masses to differentiate thrombus

Transthoracic

2-dimensional

897

898

Pazos-López et al.

JACC: CARDIOVASCULAR IMAGING, VOL. 7, NO. 9, 2014 SEPTEMBER 2014:896–905

CMR for Cardiac Masses

ABBREVIATIONS

from tumor and benign from malignant

(noninfiltrating lesion attached to the left aspect of

AND ACRONYMS

neoplasms in a larger population.

the fossa ovalis), septal lipomatosis (located in the interatrial septum with evident signal intensity

CMR = cardiac magnetic

METHODS

resonance

reduction on a fat saturation black-blood sequence), or cyst (well circumscribed, spherical or ovoid

FPP = first-pass perfusion LGE = late gadolinium enhancement

We retrospectively reviewed consecutive

shape, and high signal intensity on a T2-weighted

CMR examinations performed in patients

sequence); and 3) had a pathological diagnosis.

with a definite mass in the heart (including

T1w-TSE = T1-weighted turbo

aortic

and

pulmonary

roots)

Tumors were classified as malignant or benign on

spin echo

the

from

the basis of histology when available or otherwise on imaging characteristics different from the factors

T2w-TSE = T2-weighted turbo

January 2005 to March 2013 at Mount Sinai

spin echo

Hospital, New York. Definite thrombus was

tested in the study: infiltrating neoplasms were

TI = inversion time

defined as a noninfiltrating structure that

considered malignant, whereas noninfiltrating tu-

fulfilled any of the following classic criteria: 1) adja-

mors with typical features of myxoma, septal lip-

cent to an akinetic myocardial segment (often

omatosis, or cyst were classified as benign (Online

infarcted) or central venous catheter (without clinical

Figure 1). Clinical charts were reviewed for de-

signs or symptoms of infection); 2) located in the

mographic and medical data collection. In patients

atrial appendage in patients with documented atrial

undergoing surgery or biopsy, macroscopic and his-

fibrillation; 3) a significant size reduction occurred

tological findings were also recorded.

with anticoagulation therapy and confirmed on follow-up imaging; and 4) pathological confirmation.

CARDIAC

MAGNETIC

RESONANCE. CMR

studies

were performed on a 1.5-T (82%; Magnetom Sonata or Magnetom Avanto, Siemens Medical Solutions,

SEE PAGE 906

Erlangen, Germany) or a 3.0-T (18%; Ingenuity,

A mass was considered a definite tumor when it

Philips Healthcare, Best, the Netherlands) magnets

did not meet any of the aforementioned criteria and

by using dedicated phased-array surface coils as

fulfilled any of the following: 1) was infiltrative

receivers. Sequences were acquired during end-

(defined as ill-defined borders from normal myocar-

expiratory breath holds with electrocardiographic

dium and/or invasion of multiple cardiac or extra-

or pulse gating. Our typical protocol includes cine

cardiac structures); 2) had typical features of myxoma

and black-blood imaging before contrast, followed

T A B L E 1 Baseline Patient Characteristics

Male Age, yrs

Thrombus (n ¼ 77)

Tumor (n ¼ 39)

p Value

Benign Tumor (n ¼ 16)

Malignant Tumor (n ¼ 23)

52/77 (68)

17/39 (44)

0.013

4/16 (25)

13/23 (57)

58  15

60  15

0.85

60  11

61  18

0.9 0.13

p Value

0.051

77  17

79  16

0.61

83  15

75  16

10/75 (13)

3/39 (8)

0.37

2/16 (13)

1/23 (4)

0.58

82  28

94  37

0.39

79  57

97  35

0.54

Hypertension

44/77 (57)

18/38 (47)

0.32

9/15 (60)

9/23 (39)

0.21

Hyperlipidemia

38/77 (49)

13/38 (34)

0.12

8/15 (53)

5/23 (22)

0.045

Diabetes

23/77 (30)

9/38 (24)

0.49

5/15 (33)

4/23 (17)

0.44

Smoking history

23/77 (30)

12/38 (32)

0.85

3/15 (20)

9/23 (39)

0.29

Family history of CAD

14/77 (18)

5/38 (13)

Previous MI

45/76 (59)

1/39 (3)

Weight, kg Atrial fibrillation GFR, ml/min/1.73 m2

Previous stroke or embolic event Previous coronary revascularization History of malignancy

0.5