Multimodality Imaging for Cardiac Mass Diagnosis: Key Insights from JACC CardioOncology 2024

Cardiac masses are a complex clinical scenario, including benign tumors, malignant tumors (primary and secondary), and pseudotumors (tumorlike masses).

Accurate histologic identification is crucial for guiding treatment, but it’s challenging. While biopsy is the traditional gold standard, its invasiveness and risks limit its use. Noninvasive multimodality imaging is emerging as an alternative, though standardized protocols and evidence are lacking.

Echocardiography is usually the initial imaging modality. Real-time three-dimensional echocardiography (RT3DE) enhances assessment by capturing the entire mass, accurately evaluating volume, attachments, and relationships with nearby structures.

Cardiac magnetic resonance (CMR) is the reference standard for noninvasive assessment, except for small valvular masses and calcified lesions. It helps identify pseudotumors, reduce further testing, and detect malignant masses and, sometimes, specific histotypes.

Computed tomography (CT) can complement or replace CMR. Cardiac CT aids in presurgical planning, identifying surgical planes, tailoring resection, and ruling out coronary artery disease. Chest, abdominal, and pelvic (CAP) CT helps locate extracardiac malignancies, assess invasion or infiltration, and stage malignant lesions.

8F-fluorodeoxyglucose positron emission tomography (FDG PET) is a third-level imaging technique used when CT and CMR are inconclusive. It evaluates metabolic activity and stages malignant cardiac masses.

This review emphasizes the current role of multimodality imaging in diagnosing and managing cardiac masses and suggests future directions for its applications.

In clinical practice, multimodality imaging is crucial for managing cardiac masses by meeting key diagnostic objectives: a) detecting and localizing mass; b) identifying anatomical variants; c) differentiating tumors from pseudotumors; d) detecting malignancy; e) staging and guiding treatment; f) presurgical planning; and g) aiding in histology determination.

Local resources and expertise influence the diagnostic approach. Awareness of multimodality imaging benefits, particularly in complex cases, is important. However, not every patient needs all available techniques.

Clinicians should understand each modality’s strengths and weaknesses to select the most appropriate and cost-effective combination for the patient. A multidisciplinary team approach optimizes multimodality imaging use and provides the best care, while recognizing when to refer to third-level centers if resources are limited.

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