Multimodality Imaging in the Diagnostic Work-Up of Patients With Cardiac Masses: JACC: CardioOncology State-of-the-Art Review

Abstract

Cardiac masses encompass a diverse range of benign and malignant tumors as well as pseudotumors. Accurate histologic identification is essential for guiding appropriate treatment, yet the diagnostic process remains challenging. Although biopsy is traditionally the diagnostic gold standard, its invasive nature and associated risks limit its application. A noninvasive multimodality imaging approach has recently emerged as an alternative, but standardized protocols and supporting evidence are still lacking. Echocardiography is typically the initial imaging modality, with cardiac magnetic resonance recognized as the noninvasive diagnostic gold standard. Cardiac computed tomography provides complementary data to aid in diagnosis and management, while positron emission tomography serves as a third-level imaging option. This state-of-the-art review highlights the role of current multimodality imaging techniques in diagnosing and managing cardiac masses and explores future directions for their applications.

Keywords: cardiac computed tomography; cardiac magnetic resonance; cardiac mass; echocardiography; multimodality imaging; positron emission tomography.

Graphical abstract

Figure 1

Overview of Imaging Modalities in the Diagnostic Work-Up of Cardiac Masses The strengths and weaknesses of each imaging modality in diagnosing cardiac masses are outlined. ∗Transthoracic echocardiography (TTE) may not be necessary for all patients if a cardiac mass is already found on cardiac magnetic resonance (CMR) or computed tomography (CT). ¹⁸F-FDG = ¹⁸F-fluorodeoxyglucose; CAD = coronary artery disease; CCT = cardiac computed tomography; CM = cardiac mass; DEM = diagnostic echocardiographic mass; EKG = electrocardiographic; HR = heart rate; LV = left ventricular; MTV = metabolic tumor volume; PET = positron emission tomography; pts = patients; SUVmax = maximum standardized uptake value; TEE = transesophageal echocardiography; TLG = total lesion glycolysis.

Figure 2

Latest Advances in Multimodality Imaging for Cardiac Masses (A,B) Atrial myxoma shown in real-time 3-dimensional echocardiography. (C) Melanoma metastasis in the posterior basal wall of the left ventricle, with mild contrast uptake observed on contrast echocardiography. (D) Right ventricle melanoma metastasis, with mild heterogeneous contrast uptake on contrast echocardiography. (E,F) Parametric mapping of a patient with an atrial myxoma, showing reduced T1 relaxation time (≈830 ms) and increased T2 relaxation time (≈130 ms). (G) Example of atrial involvement in Erdheim-Chester disease (ECD) on spectral CT. The cardiac mass shows a lower atomic number (“Z-effective” = 5-8) compared with the right and left myocardium (“Z-effective” = 8-11). (H) B-cell lymphoma localized in the atrium, seen with CMR-PET fusion imaging (SUVmax = 7). In this patient, both CMR and cardiac CT were inconclusive in characterizing the cardiac mass. The gray arrows indicate the cardiac mass. Echo = echocardiography; ECV = extracellular volume; RT3D = real-time 3-dimensional echocardiography; other abbreviations as in Figure 1.

Figure 3

Diagnostic Accuracy of Multimodality Imaging in Characterizing Cardiac Masses The ability of various imaging modalities to detect and localize cardiac masses, differentiate them from anatomical variants and pseudotumors, predict malignancy, assist with staging and treatment planning, and guide presurgical planning is depicted. Green circles indicate where the technique is useful in clinical cases, while red crosses highlight aspects for which that imaging method is less effective. Abbreviations as in Figure 1.

Central Illustration

Red Flags for Malignancy in Cardiac Masses Identified Through Multimodality Imaging This illustration summarizes key imaging findings across different modalities, highlighting 2 diagnostic scenarios for patients with suspected benign or malignant cardiac masses. ∗When clinically indicated. CMR = cardiac magnetic resonance; CT = computed tomography; EGE = early gadolinium enhancement; Echo = echocardiography; LGE = late gadolinium enhancement; PET = positron emission tomography.