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.

  • High sensitivity for detecting intracardiac thrombus

  • Ability to distinguish between benign and malignant cardiac tumors

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  • 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.

  • 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.

  • 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.

  • 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
  • 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

  • Requires the use of iodinated contrast agent

  • Limited utility if contrast not used

  • Requires exposure to ionizing radiation

Cardiac PET/CT
  • Excellent for visualizing and detecting metastatic lesions or sites of extracardiac disease

  • 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?

  • There are no major contraindications to ultrasound.

Gated CT
  • Pregnant patients, especially during the first and second trimesters

  • Pregnant patients, especially during the first and second trimesters