Multimodality cardiac imaging for the management of cardiac masses

Cardiac masses are rare but can have significant health consequences. They can be categorized as non-neoplastic, benign neoplastic, primary malignant, or secondary malignant (metastatic) masses. Primary cardiac neoplasms are extremely rare, while secondary malignant masses are more common. Accurate imaging is crucial for diagnosing and managing cardiac masses, as direct biopsy is invasive and challenging. Echocardiography is often the first-line imaging test due to its widespread availability, however, can lack of specificity especially due to possible limited echocardiographic window. Further, tissue properties cannot be depicted in echocardiography and therefore cardiac magnetic resonance (CMR) imaging is the preferred method. CMR provides a comprehensive assessment of cardiac structures, function, tissue characteristics, and possible hemodynamic consequences by cardiac masses. While CMR is highly accurate in identifying thrombus, lipoma, cysts, location of a mass, its extent and neighboring structures, the differentiation of certain malignant from benign tumors can be difficult. In such cases, metabolic information obtained through fluorodeoxyglucose-positron emission tomography (FDG-PET) can offer additional diagnostic insights.1 In fact, in the recent study by Aghayev et al.2 the diagnostic accuracy of CMR and FDG-PET and the combination of both modalities were assessed in 72 cases with regard to the ability to differentiate between benign and malignant cardiac masses. The results showed that CMR and FDG-PET had a high accuracy in differentiating between benign and malignant masses. CMR features exhibited a higher sensitivity (98%), whereas FDG uptake (with a maximum standardized uptake value/blood pool ratio of ≥ 3.0) demonstrated a high specificity (88%). When multiparametric CMR features and FDG uptake were combined, the sensitivity for diagnosing malignant masses was 85%, and the specificity was 88%. Therefore, CMR and FDG-PET inherit the ability to independently diagnose benign and malignant cardiac masses; and combining these imaging modalities can even provide complementary value in specific cases.2 …