Differentiation of malignant and benign cardiac tumors using 18F-FDG PET/CT

Diagnosis and staging of cardiac masses: additional value of CMR with 18F-FDG-PET compared to CMR with CECT

PURPOSE

Characterization of malignant cardiac masses is usually performed with cardiac magnetic resonance (CMR) and staging with whole-body contrast-enhanced computed tomography (CECT). In this study, our objective was to evaluate the role of 18Fluor-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) with CMR for both characterization and staging of cardiac masses.

METHODS

Patients with cardiac masses who underwent CMR, CECT, and 18F-FDG-PET were retrospectively identified. For the characterization of cardiac masses, we calculated the respective performances of CMR alone, 18F-FDG-PET alone, and the combination of 18F-FDG-PET and CMR. For staging, we compared head-to-head the respective performances of 18F-FDG-PET and CECT. Histology served as gold standard for malignancy, and response to anticoagulation for thrombus.

RESULTS

In a total of 28 patients (median age 60.5 years, 60.7% women), CMR accurately distinguished malignant from benign masses with sensitivity (Se) of 86.7%, specificity (Sp) of 100%, positive predictive value (PPV) of 100%, negative predictive value (NPV) of 86.7%, and accuracy of 92.9%. 18F-FDG-PET demonstrated 93.3% Se, 84.6% Sp, 87.5% PPV, 91.7% NPV, and 89.3% accuracy. Combining CMR with 18F-FDG-PET allowed to benefit from the high sensitivity of 18F-FDG-PET (92.9%) and the excellent specificity of CMR (100%) for malignant diseases. For staging, 18F-FDG-PET outperformed CECT on per-patient (66.7% vs 55.6% correct diagnosis, respectively), per-organ (10 vs 7 organs, respectively), and per-lesion basis (> 29 vs > 25 lesions, respectively).

CONCLUSION

Combining 18F-FDG-PET with CMR improved the characterization of cardiac masses compared to each modality alone. Additionally, the diagnostic performance of 18F-FDG-PET was better than CECT for staging. This study suggests that the combination of CMR and 18F-FDG-PET is the most effective for the characterization of cardiac masses and the staging of these lesions.

Role of 18F-FDG PET/CT imaging in cardiac and pericardial masses

BACKGROUND

Considering the few reported cardiac masses, PET/CT in the imaging workup of cardiac masses is not well established. This retrospective study analyzed the role of 18F-FDG PET/CT imaging in cardiac/pericardial masses.

METHODS AND RESULTS

Fifty-nine patients with newly diagnosed cardiac/pericardial masses who underwent PET/CT and transthoracic echocardiography (TTE) were recruited. Echocardiographic and PET/CT characteristics were evaluated for predictive value in differentiating malignant and non-malignant lesions using histologic confirmation as the gold standard. The McNemar test was used to test the differences in sensitivity between PET/CT and TTE. 18F-FDG PET/CT had higher sensitivity in determining the malignancy of cardiac/pericardial masses compared to TTE (sensitivity, 96.6% vs 72.4%, P = .039). However, when pericardial masses were excluded from the analysis, the difference in sensitivity between the two was not statistically significant (sensitivity, 95.6% vs 78.3%, P = .219). 18F-FDG PET/CT identified two malignant pericardial masses missed on TTE, changed the diagnostic orientation of TTE in 15 patients, and found seven patients with extracardiac lesions in 29 malignant patients.

CONCLUSIONS

PET/CT was an effective additional image modality in patients with suspected malignant cardiac mass for further confirmation and to screen for potential metastasis.

Primary and secondary cardiac tumors: clinical presentation, diagnosis, surgical treatment, and results

Cardiac tumours are some of the rarest primary tumours, while cardiac metastasis are more common yet still relatively rare. Seventy five percent of primary cardiac tumours are benign tumours. Cardiac tumours present with a range of obstructive, embolic, arrhythmic or systemic symptoms, and in many cases may present asymptomatically. The clinical presentation depends largely on the size and location of the mass. With advances in cardiac imagining and the introduction of cardiopulmonary bypass, the diagnosis and surgical treatment of these rare tumours has improved the prognosis and outlook for benign and malignant tumours. Management depends on tumour histology, size and location as well as the clinical presentation. Conservative management is reserved for small, benign tumours that can undergo regular echocardiographic follow-up. Symptomatic benign tumours are treated with surgical resection and the results are excellent. Malignant primary cardiac tumours have a poor prognosis with high rates of relapse and a median survival of 10-24 months.

Cardiac angiosarcoma: A case report and review of the literature

Primary cardiac tumors are extremely rare, among which malignancies comprise about 15-25%. As the most common type of primary cardiac malignancies, angiosarcomas tend to arise in the right heart, especially right atrium. In this case report, we presented a 32-year-old female with primary cardiac angiosarcoma in the right atrial appendage detected by transesophageal echocardiography, as it is difficult to display on conventional transthoracic echocardiography.

A case of cardiac angiosarcoma and pulmonary tuberculosis; diagnostic challenges and review of literature

Background

Patient symptoms and primary investigational methods may be misleading at some points in patient management and can consume a lot of time. Sarcomas are rare malignancies and contribute 1% of all cancers of adult.

Case Presentation

A rare case of primary cardiac angiosarcoma is presented, who was first treated because of lung tuberculosis and then with only slight improvement in symptoms, further investigations were done showing right ventricular enlargement and pericardial effusion. Eventually, after ruling out pulmonary embolism and constrictive pericarditis, investigations lead to the diagnosis of primary cardiac angiosarcoma. The patient went under surgery to remove the tumor but he still had residual mass left, leading to chemotherapy and then radiotherapy. Although the tumor has a poor prognosis, our patient has managed to survive a year by now and is doing good for 6 months after radiotherapy.

Conclusion

The case describes the importance of having in mind different differential diagnosis in managing patients and the role of multi-modality imaging in guiding diagnosis and treatment.

Assessment of cardiac tumors by 18F-FDG PET/CT imaging: Histological correlation and clinical outcomes

BACKGROUND

To evaluate the diagnostic value of 18F-FDG PET/CT in distinguishing benign versus malignant cardiac tumors as well as to assess its prognostic value.

METHODS

We analyzed 38 patients with cardiac tumors who underwent 18F-FDG PET/CT and followed for median 8.5 ± 12.5 months. SUVmax and TBRmax (maximum tumor-to-background ratio) by receiver-operating characteristic (ROC) curve analysis were used to obtain threshold for the diagnosis of malignancy as defined by histology (n = 38). Survival was assessed and correlated with the dignity of the lesions and PET parameters.

RESULTS

Optimal cut-off values indicating malignancy were as follows: SUVmax = 3.44, with 100% sensitivity and 92.9% specificity, and TBRmax = 1.55, with 95.8% sensitivity and 92.9% specificity. A significant difference of 18F-FDG uptake was observed between primary benign (n = 14, SUVmax = 2.35 ± 1.31, TBRmax = 1.05 ± 0.50) compared to primary malignant cardiac tumors (n = 11, SUVmax = 8.90 ± 4.23, TBRmax = 3.82 ± 1.44) as well as cardiac metastases and lymphoma (n = 13, SUVmax = 14.37 ± 8.05, TBRmax = 6.19 ±  3.38) (all P < .001). Survival rate was significantly lower in patients with malignant as compared to benign cardiac tumors (P < .05). Regression analysis revealed that the lesion dignity determined by the cut-off value of SUVmax was an independent predictor for death in patients with cardiac tumors (P < .05).

CONCLUSION

18F-FDG uptake in cardiac tumors can differentiate between benign and malignant cardiac tumors and predicts survival.

Atypical metastatic lung cancer of the right ventricle on FDG PET/CT

Although primary cardiac tumours are extremely uncommon, secondary tumours or cardiac metastasis are not. We present a 68-year-old gentleman with squamous cell carcinoma of the right lower lobe with bony metastasis to the right clavicle who was treated with radiotherapy to the lung and clavicle as well as combination immunotherapy (Pembrolizumab) and chemotherapy (Carboplatin/Paclitaxel). Despite completing the above treatment regime, ¹⁸F-FDG PET/CT scan showed progression with two new sites of metastasis including a focus in the lateral wall of the right ventricle which correlate to a soft tissue density mass on CT as well as a FDG avid mass in the left masseter. Identification of cardiac lesions with ¹⁸F-FDG PET/CT maybe challenging with routine preparation due high physiological FDG uptake in the myocardium and significant variability, nevertheless, focal FDG uptake in the heart should be carefully assessed for the possibility of cardiac metastasis.

Cardiac haemangioma treated with surgical resection involving reconstruction of the right ventricle

A right ventricular cardiac tumour was incidentally detected in a 50-year-old woman during medical check-up. Transthoracic echocardiography, computed tomography and magnetic resonance imaging revealed that the right ventricular tumour was widely attached to the free wall of the right ventricle and extended to the right ventricular outflow tract. The tumour was excised surgically, and the postoperative course was uneventful. Histological examination revealed that the tumour was a cardiac haemangioma.

Incremental Value of FDG-PET in the Evaluation of Cardiac Masses

PURPOSE OF REVIEW

This study aims to review the various roles and evidence underlying the use of fluorodeoxyglucose (FDG) PET/CT and PET/MR for the assessment of cardiac masses.

RECENT FINDINGS

The role of FDG-PET for the evaluation of cardiac masses continues to evolve. Studies have shown that FDG-PET is particularly well-suited for differentiating malignant from benign cardiac lesions based on their metabolic activity. Furthermore, FDG-PET is uniquely positioned to investigate patients with cardiac mass as most malignant cardiac lesions are metastasis. Finally, FDG-PET enables staging of patients with primary malignant cardiac tumor, identification of potential biopsy site, and planning of radiotherapy. FDG-PET is a complementary tool for the evaluation of patients with cardiac mass and can help differentiate benign from malignant lesions, as well as provide whole-body staging.

Series of myocardial FDG uptake requiring considerations of myocardial abnormalities in FDG-PET/CT

Distinct from cardiac PET performed with preparation to control physiological FDG uptake in the myocardium, standard FDG-PET/CT performed with 4-6 h of fasting will show variation in myocardial FDG uptake. For this reason, important signs of myocardial and pericardial abnormality revealed by myocardial FDG uptake tend to be overlooked. However, recognition of possible underlying disease will support further patient management to avoid complications due to the disease. This review demonstrates the mechanism of FDG uptake in the myocardium, discusses the factors affecting uptake, and provides notable image findings that may suggest underlying disease.

Efficacy of Nivolumab Plus Ipilimumab in a Patient With Renal Cell Carcinoma Concomitant With Cardiac Metastasis: A Case Report

BACKGROUND/AIM

Patients with metastatic renal cell carcinoma (RCC) with cardiac metastasis have had poor outcomes in the era of molecular targeted therapy. There are few reported outcomes for patients with cardiac metastasis of RCC treated with immune checkpoint inhibitors (ICIs).

CASE REPORT

A 32-year-old female presented with metastatic RCC (unclassified type) with contralateral renal and cardiac metastases, as well as renal hilar lymph node metastases (cT4N2M1). An ¹⁸F-fluorodeoxyglucose (FDG) positron-emission tomography (PET) computed tomographic (CT) scan was useful in diagnosing cardiac metastasis. Nivolumab plus ipilimumab achieved prominent shrinkage of almost all tumors except for one cardiac tumor. FDG-PET/CT scan also revealed the marked attenuation of FDG uptake in each tumor. In addition, a needle biopsy of the remaining primary renal tumor was pathologically observed to have no viable cancer cells.

CONCLUSION

This successful case suggests that ICIs might provide a better outcome even for patients with cardiac metastasis of RCC, and that FDG-PET/CT scan might be useful for therapeutic assessment, as well as diagnosis.

Primary Atrial Undifferentiated Sarcoma Found on FDG PET/CT Mimicking Cardiac Myxoma

A 52-year-old man had shortness of breath and chest discomfort for 2 months. Chest CT and MRI showed a mass in the left atrium attached to the mitral annulus without obvious enhancement. Initial diagnosis was suspected of myxoma. Preoperative FDG PET/CT demonstrated the corresponding lesion with abnormal FDG uptake, indicating a malignancy. Finally, histopathologic examination revealed primary undifferentiated sarcoma.

Impact of 18F-fluorodeoxyglucose Positron Emission Tomography computed Tomography Imaging in a Case of Pericardial Cavernous Hemangioma

Hemangiomas are extremely rare tumors of the heart that may present with pericardial effusion, dyspnea, chest discomfort, palpitations, or syncope. Few published reports have highlighted the utility of ¹⁸F-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸F-FDG PET-CT) in the evaluation of cardiac lesions. We report a case demonstrating the utility of ¹⁸F-FDG PET-CT in a young man who presented with gross pericardial effusion and suspicion of metastatic carcinoma on fluid cytology.

18F-FDG PET/MRI in adult sarcomas

Aim

This mini-review aims to summarize the main findings on PET/MRI in patients with sarcomas.

Materials and methods

A literature search was carried out on MEDLINE databases, such as PubMed, Scopus, Web of Science and Google Scholar, using the search terms “PET”, “positron emission tomography”, “PET/MRI”, “positron emission tomography/magnetic resonance imaging”, and “sarcoma”. No restrictions (i.e. language, age, type of manuscript, or the like) were applied to the search strategy. Abstracts, reviews, letters to editors, and editorials were excluded.

Results

Eight studies were ultimately included. From 2013 to 2019, a total of 154 adult patients with sarcomas underwent 18F-fluorodeoxyglucose (18F-FDG) PET/MRI. Of these patients, 129 had soft tissue sarcomas (STS), 5 had bone sarcomas, and 20 had cardiac masses. Thirty-two patients had PET/MRI for early-stage disease, 45 for recurrences, and 57 for the assessment of response to treatment. For staging purposes, the studies suggest that PET/MRI can significantly improve the delineation of surgical margins. At restaging, PET/MRI can also detect sarcoma recurrences more accurately than conventional imaging.

Conclusions

18F-FDG PET/MRI has promising indications in patients with sarcomas, from disease staging to the assessment of response to treatment. Further studies are warranted to confirm these results, especially in subgroups with specific histopathological features.

Role of cardiovascular magnetic resonance in an adolescent with a giant intrapericardial mass

A 14 -year-old boy presented with chest pain and breathlessness. Echocardiography showed a large pericardial effusion with cardiac tamponade features and suspicion of cardiac mass. Cardiovascular magnetic resonance demonstrated a large, well-defined pericardial mass, suggesting atypical large coronary fistula with pericardial haematoma or primary cardiac/pericardial tumour such as angiosarcoma. Histology confirmed a mixed-type vascular malformation. Sirolimus therapy was initiated.

The Current Management of Cardiac Tumours: a Comprehensive Literature Review

OBJECTIVE

To understand the current evidence and guidelines behind the appropriate management of cardiac tumours.

METHODS

A comprehensive electronic literature search has been performed in major databases - PubMed, Embase, Scopus, Ovid, and Google Scholar. All articles that discussed all different forms of cardiac tumours, their clinical presentation, diagnosis, and management methods have been critically appraised in this narrative review.

RESULTS

All relevant studies have been summarized in appropriate sections within our review. Cardiac tumours are rare but can be catastrophic and life-threatening if not identified and managed on timely manner. Utilization of all the available imaging methods can be of equivocal importance, relevant to each cardiac tumour. Surgical excision is the ultimate treatment method, however histopathological results can guide the adjunct treatment.

CONCLUSION

Early detection of cardiac tumours has significant effect on planning the method of intervention. Technological advancements and increased availability of imaging modalities have enabled earlier and more accurate detection of these tumours. Novel medical therapies, recommendations for screening, and operative techniques have all contributed to overall improving knowledge of these tumours and ultimately patient outcomes.

Primary Cardiac Intimal Sarcoma Visualized on 2-[18F]FDG PET/CT

Primary cardiac tumors are extremely rare, with an incidence of 0.001-0.03%. Twenty-five percent of these tumors are malignant, with sarcomas accounting for approximately 95%. Cardiac intimal sarcoma is the least reported subtype of primary cardiac sarcoma. These endocardial mesenchymal tumors most often arise from great arterial vessels, and are rarely located in the heart. They often present with an aggressive clinical course and have a poor prognosis, with surgical resection with achievement of free margins being the mainstay of treatment. This emphasizes the importance of an early, correct diagnosis and timely intervention. We report a 60-year-old Caucasian male with several former cardiac surgical procedures due to congenital aortic stenosis, presenting with functional mitral stenosis/insufficiency and left ventricular outflow tract obstruction (LVOTO) due to massive masses in the left ventricle and atrium of the heart. Hybrid imaging with 2-deoxy-2-[¹⁸F]fluoro-D-glucose positron emission tomography/computed tomography (2-[¹⁸F]FDG PET/CT) was performed prior to surgery to characterize the intracardiac masses and estimate tumor burden, as well as to identify a potential extracardiac primary malignancy.

Positron emission tomography/MRI for cardiac diseases assessment

Functional imaging tools have emerged in the last few decades and are increasingly used to assess the function of the human heart in vivo. Positron emission tomography (PET) is used to evaluate myocardial metabolism and blood flow. Magnetic resonance imaging (MRI) is an essential tool for morphological and functional evaluation of the heart. In cardiology, PET is successfully combined with CT for hybrid cardiac imaging. The effective integration of two imaging modalities allows simultaneous data acquisition combining functional, structural and molecular imaging. After PET/CT has been successfully accepted for clinical practices, hybrid PET/MRI is launched. This review elaborates the current evidence of PET/MRI in cardiovascular imaging and its expected clinical applications for a comprehensive assessment of cardiovascular diseases while highlighting the advantages and limitations of this hybrid imaging approach.

Late Gadolinium Enhancement Cardiac Magnetic Resonance Tissue Characterization for Cancer-Associated Cardiac Masses: Metabolic and Prognostic Manifestations in Relation to Whole-Body Positron Emission Tomography

Background

Cardiac magnetic resonance (CMR) differentiates neoplasm from thrombus via contrast enhancement; positron emission tomography (PET) assesses metabolism. The relationship between CMR contrast enhancement and metabolism on PET is unknown.

Methods and Results

The population included 121 cancer patients undergoing CMR and ¹⁸F‐fluorodeoxyglucose (¹⁸F‐FDG)–PET, including 66 with cardiac masses and cancer‐matched controls. Cardiac mass etiology (neoplasm, thrombus) on CMR was defined by late gadolinium enhancement; PET was read blinded to CMR for diagnostic performance, then colocalized to measure FDG avidity. Of CMR‐evidenced thrombi (all nonenhancing), none were detected by PET. For neoplasm, PET yielded reasonable sensitivity (70–83%) and specificity (75–88%). Lesions undetected by PET were more likely to be highly mobile (P=0.001) despite similar size (P=0.33). Among nonmobile neoplasms, PET sensitivity varied in relation to extent of CMR‐evidenced avascularity; detection of diffusely enhancing or mixed lesions was higher versus predominantly avascular neoplasms (87% versus 63%). Colocalized analyses demonstrated 2‐ to 4‐fold higher FDG uptake in neoplasm versus thrombus (P<0.001); FDG uptake decreased stepwise when neoplasms were partitioned based on extent of avascularity on late gadolinium enhancement CMR (P≤0.001). Among patients with neoplasm, signal‐to‐noise ratio on late gadolinium enhancement CMR moderately correlated with standardized uptake values on PET (r=0.42–0.49, P<0.05). Mortality was higher among patients with CMR‐evidenced neoplasm versus controls (hazard ratio: 1.99 [95% CI, 1.1–3.6]; P=0.03) despite nonsignificant differences when partitioned via FDG avidity (hazard ratio: 1.56 [95% CI, 0.85–2.74]; P=0.16). Among FDG‐positive neoplasms detected concordantly with CMR, mortality risk versus cancer‐matched controls was equivalently increased (hazard ratio: 2.12 [95% CI, 1.01–4.44]; P=0.047).

Conclusions

CMR contrast enhancement provides a criterion for neoplasm that parallels FDG‐evidenced metabolic activity and stratifies prognosis. Extent of tissue avascularity on late gadolinium enhancement CMR affects cardiac mass identification by FDG‐PET.

Mediastinal Masses: 18F-FDG-PET/CT Features Based on the International Thymic Malignancy Interest Group Classification

Imaging plays a key role in the management of mediastinal masses. In an effort to standardize the analysis of the mediastinum, the International Thymic Malignancy Interest Group (ITMIG) has proposed a three compartments-based diagnostic classification, intended for clinicians and radiologists. Several articles have documented its usefulness to guide the diagnosis using cross-sectional imaging. Similarly, fluorine-18-radiolabeled fluorodeoxyglucose positron emission tomography combined to computed tomography (¹⁸F-FDG-PET/CT) can be useful in this setting, either as a first-line diagnostic technique, or in addition to cross-sectional imaging. In this article, which is thought as an aid for nuclear medicine physicians and radiologists, we aim to present, based on the ITMIG classification, the main mediastinal pathologies that can be observed with ¹⁸F-FDG-PET/CT, and the additional diagnostic value that can be expected from this technique. For this purpose, we segmented the mediastinum according to the ITMIG classification, and reviewed the available literature for each of the corresponding organs and/or disease. Given the importance of the clinical context for the interpretation of PET imaging, we presented each of the diseases according to: (1) their suggestive clinical context; (2) the suggestive features on nonenhanced CT (which is the standard in PET imaging); and (3) the typical ¹⁸F-FDG characteristics. The purpose of this article is to depict the main features of the most common mediastinal diseases that can be encountered with ¹⁸F-FDG-PET/CT, and to highlight its diagnostic value in this setting, alone or in combination with other imaging modalities.

Combined PET/CT with thoracic contrast-enhanced CT in assessment of primary cardiac tumors in adult patients

Background

¹⁸F-FDG PET/CT is a key molecular imaging modality to noninvasively assess and differentiate benign and malignant cardiac tumors. However, few benign cardiac tumors can be characterized by increased ¹⁸F-FDG uptake, which makes differential diagnosis difficult. This study sought to retrospectively evaluate whether combined ¹⁸F-FDG PET/CT with thoracic contrast-enhanced CT (CECT) helps in assessing primary cardiac tumors in adult patients, compared with CECT or PET/CT alone.

Methods

Forty-six consecutive patients who were diagnosed as primary cardiac tumors were enrolled. All patients underwent ¹⁸F-FDG PET/CT followed by thoracic CECT before biopsy or surgery. Visual qualitative interpretation and quantitative analysis were performed, and diagnostic performance was evaluated.

Results

More than half (16/29) of benign tumors exhibited with mild ¹⁸F-FDG uptake. There were significant differences in ¹⁸F-FDG uptake and the degree of absolute enhancement between benign and malignant tumors (P < 0.001). The combination of two modalities improved the specificity from 79 to 93%, the positive predictive value from 73 to 89%, and the accuracy of diagnosis from 85 to 93%. There were significant differences between PET/CT alone or thoracic CECT alone and combined modalities (P = 0.034 and P = 0.026, respectively). The combination with the optimal SUVmax cutoff value generated 94% sensitivity, 100% specificity, 97% negative predictive values, 100% positive predictive values, and 98% accuracy rates.

Conclusions

Combining ¹⁸F-FDG PET/C with thoracic CECT significantly improved specificity and accuracy compared to CECT or PET/CT alone in detecting tumors. This combination of diagnostic imaging is effective in differentiating malignant from benign masses.

Positron emission tomography imaging in cardiovascular disease

Positron emission tomography (PET) imaging is useful in cardiovascular disease across several areas, from assessment of myocardial perfusion and viability, to highlighting atherosclerotic plaque activity and measuring the extent of cardiac innervation in heart failure. Other important roles of PET have emerged in prosthetic valve endocarditis, implanted device infection, infiltrative cardiomyopathies, aortic stenosis and cardio-oncology. Advances in scanner technology, including hybrid PET/MRI and total body PET imaging, as well as the development of novel PET tracers and cardiac-specific postprocessing techniques using artificial intelligence will undoubtedly continue to progress the field.

A rare case of multimetastatic cardiac angiosarcoma

Cardiac malignant tumors are rare entities with nonspecific clinical presentation and poor prognosis. Here, we report a case of about a 30-year-old man who was admitted for right thoracic pain. Imaging indicated a cardiac malignant tumor, and pathology confirmed the diagnosis. Our case highlights the value of multimodal imaging in the differential diagnosis of a cardiac mass.

Diagnostic Accuracy of Cardiac Computed Tomography and 18-F Fluorodeoxyglucose Positron Emission Tomography in Cardiac Masses

OBJECTIVES

This study sought to assess the diagnostic accuracy of cardiac computed tomography (CT) and ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) with positron emission tomography/computed tomography (PET/CT) in defining the nature of cardiac masses.

BACKGROUND

The diagnostic accuracy of cardiac CT and ¹⁸F-FDG PET/CT in identifying the nature of cardiac masses has been analyzed to date only in small samples.

METHODS

Of 223 patients with echocardiographically diagnosed cardiac masses, a cohort of 60 cases who underwent cardiac CT and ¹⁸F-FDG PET/CT was selected. All masses had histological confirmation, except for a minority of thrombotic formations. For each mass, 8 morphological CT signs, standardized uptake value (SUV_max, SUV_mean), metabolic tumor volume, and total lesion glycolysis in ¹⁸F-FDG PET were used as diagnostic markers.

RESULTS

Irregular tumor margins, pericardial effusion, invasion, solid nature, mass diameter, CT contrast uptake, and pre-contrast characteristics were strongly associated with the malignant nature of masses. The coexistence of at least 5 CT signs perfectly identified malignant masses, whereas the detection of 3 or 4 CT signs did not accurately discriminate the masses' nature. The mean SUV_max, SUV_mean, metabolic tumor volume, and total lesion glycolysis values were significantly higher in malignant than in benign masses. The diagnostic accuracy of SUV, metabolic tumor volume, and total lesion glycolysis ¹⁸F-FDG PET/CT parameters was excellent in detecting malignant masses. Among patients with 3 or 4 pathological CT signs, the presence of at least 1 abnormal ¹⁸F-FDG PET/CT parameter significantly increased the identification of malignancies.

CONCLUSIONS

Cardiac CT is a powerful tool to diagnose cardiac masses as the number of abnormal signs was found to correlate with the lesions' nature. Similarly, ¹⁸F-FDG PET/CT accurately identified malignant masses and contributed with additional valuable information in diagnostic uncertainties after cardiac CT. These imaging tools should be performed in specific clinical settings such as involvement of great vessels or for disease-staging purposes.

Cardiac Tumors: JACC CardioOncology State-of-the-Art Review

Cardiac masses are rare, but remain an important component of cardio-oncology practice. These include benign tumors, malignant tumors (primary and secondary) and tumor-like conditions (e.g., thrombus, Lambl’s excrescences, and pericardial cyst). The advent of multimodality imaging has enabled identification of the etiology of cardiac masses in many cases, especially in conjunction with information from clinical settings. This paper provides a comprehensive review of the epidemiology, clinical presentation, imaging, diagnosis, management, and outcomes of cardiac masses.

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Cardiac tumors are rare and should be considered as part of the differential diagnosis of any space-occupying mass noted on cardiovascular and/or thoracic imaging modalities.

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It may be possible to get close to a diagnosis without biopsy using a structured imaging approach.

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The prognosis and treatment of each tumor is different, although early diagnosis is usually associated with a better outcome.

The role of cardiac imaging in the management of non-ischemic cardiovascular diseases in human immunodeficiency virus infection

Infection with human immunodeficiency virus (HIV) has become the pandemic of the new century. About 36.9 million people are living with HIV worldwide. The introduction of antiretroviral therapy in 1996 has dramatically changed the global landscape of HIV care, resulting in significantly improved survival and changing HIV to a chronic disease. With near-normal life expectancy, contemporary cardiac care faces multiple challenges of cardiovascular diseases, disorders specific to HIV/AIDS, and those related to aging and higher prevalence of traditional risk factors. Non-ischemic cardiovascular diseases are major components of cardiovascular morbidity and mortality in HIV/AIDS. Non-invasive cardiac imaging plays a pivotal role in the management of these diseases. This review summarizes the non-ischemic presentation of the HIV cardiovascular spectrum focusing on the role of cardiac imaging in the management of these disorders.

Incidental discovery of right ventricular lipoma in a young female associated with ventricular hyperexcitability: An imaging multimodality approach

BACKGROUND

Cardiac lipomas are rare benign tumors commonly found in the right atrium or left ventricle. Patients are usually asymptomatic, and clinical presentation depends on location and adjacent structures impairment. Right ventricle lipomas are scarce in the literature. Moreover, the previous published cases were reported in over 18-year-old patients.

CASE SUMMARY

We report a giant right ventricle lipoma discovered incidentally in a 17-year-old female while performing preoperative work-up. The diagnosis was confirmed by histopathological examination, and a conservative approach was performed.

CONCLUSION

Multimodal cardiac imaging and histopathological examination are required for a definitive diagnosis. The therapeutic approach depends on clinical presentation.

Primary Cardiac Lymphoma Manifesting as an Atrioventricular Block in a Renal Transplantation Recipient

Our report illustrates an atrioventricular block due to primary cardiac lymphoma attached to the right atrial septum that was rapidly reversible by surgical debulking and effective chemotherapy without the need for a permanent pacemaker. (Level of Difficulty: Beginner.)

Cardiac Tumors

Cardiac tumors (CTs) are extremely rare, with an incidence of approximately 0.02% in autopsy series. Primary tumors of the heart are far less common than metastatic tumors. CTs usually present with any possible clinical combination of heart failure, arrhythmias, or embolism. Echocardiography remains the first diagnostic approach when suspecting a CT which, on the other side, frequently appears unexpectedly during an echocardiographic examination. Yet, cardiac tomography and especially magnetic resonance imaging may offer several adjunctive opportunities in the diagnosis of CTs. Early and exact diagnosis is crucial for the following therapy and outcome of CTs.

Current clinical management of primary cardiac sarcoma

Introduction: Primary cardiac tumors are exceedingly rare, with approximately 75% representing benign lesions. Sarcoma represents the most common primary cardiac malignancy, with a wide range of sarcoma histologies represented. Symptoms at diagnosis vary based on tumor location. Multidisciplinary treatment including chemotherapy, surgery, and occasionally radiation is often warranted. Despite aggressive treatment, the overall prognosis for primary cardiac sarcoma (PCS) remains poor with a median survival of approximately 1 year.Areas covered: A PubMed search for the key terms; 'cardiac sarcoma', 'primary cardiac sarcoma', and 'treatment' were conducted. Abstracts were reviewed for reports on presentation, treatments, and outcomes in PCS. Available data was limited to single-institution series, most of which were retrospective. Patterns of symptoms at diagnosis varied with tumor location (right vs. left vs. pericardium). Multimodality therapy, including chemotherapy and surgical resection was most commonly reported. Completely negative margin (R0) resection has the greatest impact on overall survival.Expert opinion: Given the rarity of PCS, patients should be referred to a high-volume sarcoma center for multidisciplinary evaluation. Neoadjuvant chemotherapy should be considered to aid in surgical resection. Due to the propensity for brain metastases in cardiac tumors, brain MRI at the time of diagnosis should be considered.

Role of Imaging for Suspected Cardiac Thrombus

PURPOSE OF REVIEW

Cardiac thrombus formation is a frequent complication of a variety of prevalent diseases. Embolism of cardiac thrombus has the potential to result in significant morbidity and mortality from cerebrovascular and peripheral vascular events.

RECENT FINDINGS

Echocardiography is the most commonly used imaging modality for diagnosing intracardiac thrombus. However, technological advances in computed tomography and magnetic resonance imaging have allowed newer noninvasive modalities to evolve into robust tools for the clinical evaluation of patients suspected of disease. Complimentary use of these imaging techniques is crucial in the diagnosis of cardiac thrombus and initiation of anticoagulation therapy.

Pulmonary embolism as the initial manifestation of right atrial myxoma: A case report and review of the literature

RATIONALE

Pulmonary embolisms (PEs) are caused by emboli, which mostly originate from deep venous thrombi that travel to and suddenly block the pulmonary arteries. The emboli are usually thrombi, and right atrial myxoma emboli are rare.

PATIENT CONCERNS

A 55-year-old man presented with shortness of breath and syncope. We proceeded with computed tomography pulmonary angiography (CTPA) and transthoracic echocardiogram (TTE), the results of which suggested that the diagnosis was a right atrial mass.

DIAGNOSIS

A definitive diagnosis compatible with a right atrial myxoma (RAM) with tumoral pulmonary emboli after surgical excision was made.

INTERVENTION

Right atrial and pulmonary artery embolectomy.

OUTCOMES

The patient followed an uneventful course during the 6 years of follow-up after surgery. According to a review of the literature, RAMs are often not diagnosed in a timely manner or even go completely undiagnosed. TTE, transesophageal echocardiography (TEE), CT, magnetic resonance imaging (MRI), and positron emission tomography/computed tomography may be helpful in the preoperative diagnosis. Surgical removal of the masses from the atrium and pulmonary arteries was relatively uneventful.

LESSONS

RAMs should be considered unlikely reasons for fatal pulmonary embolisms.