Imaging

Cardiac Tumors

Preliminary Diagnosis: Cardiac tumors

I. What imaging technique is first-line for this diagnosis?

Cardiac MRI with administration of IV contrast is the first-line imaging technique for optimal characterization and definition of cardiac masses already visualized by 2D echocardiography.

II. Describe the advantages and disadvantages of this technique for diagnosis of cardiac tumors.

Advantages

  • High sensitivity for detecting intracardiac thrombus

  • Ability to distinguish between benign and malignant cardiac tumors

  • Helps determine the extent of myocardial and pericardial invasion

  • Does not require the use of ionizing radiation

  • Can help with surgical planning as MRI can sometimes identify the attachment point of the tumor.

Disadvantages

  • Requires prolonged supine positioning and repeated breath-holds

  • Requires the use of IV contrast which carries associated risks

  • More costly than other imaging techniques

  • Non-enhanced images reduce the ability to distinguish thrombus from tumor.

III. What are the contraindications for the first-line imaging technique?

  • Renal impairment because of need for gadolinum

  • Patients with pacemakers or other non-MR-compatible, inplanted devices

IV. What alternative imaging techniques are available?

  • Transesophageal 2D echo (TEE) or real-time 3-D echo

  • Gated cardiac CT

  • Cardiac PET/CT

  • For patients with renal impairment, pacemakers or other non-MR-compatible devices, gated cardiac CT may be used to better characterize the cardiac mass.

V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of cardiac tumors.

Echocardiography

Advantages

  • Excellent availability and noninvasiveness

  • Absence of contrast material or radiation exposure

  • Able to make dynamic assessment of the mass/tumor

  • 3D echo improves the capabilities of 2D echo to determine size, composition, and relationship to other structures.

Disadvantages

  • Limited in obese/overweight patients

  • Very operator dependent

  • Limited in its assessment of cardiac and extracardiac structures

  • TEE is a more invasive technique.

Gated cardiac CT

Advantages

  • Provides a global assessment of the chest, especially important if metastatic disease is suspected

  • Better tolerated in patients with breathing difficulties, who are unable to repeatedly hold their breath, and/or who cannot tolerate prolonged supine position

  • Great for tissue characterization (calcifications)

  • Better tolerance for obese patients, claustrophobic patients, or patients with pacemakers

Disadvantages

  • Requires the use of iodinated contrast agent

  • Limited utility if contrast not used

  • Requires exposure to ionizing radiation

Cardiac PET/CT

Advantages

  • Excellent for visualizing and detecting metastatic lesions or sites of extracardiac disease

Disadvantages

  • Expensive, sometimes inaccessible

  • Normal FDG cardiac uptake may obscure small myocardial or pericardial lesions.

  • May have uptake of benign lipomatous hypertrophy of septum, producing false positive results

VI. What are the contraindications for the alternative imaging techniques?

Ultrasound

  • There are no major contraindications to ultrasound.

Gated CT

  • Pregnant patients, especially during the first and second trimesters

PET/CT

  • Pregnant patients, especially during the first and second trimesters

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