[18F]FDG PET imaging in the differentiation of cardiac masses: an updated systematic review and dual Meta-Analysis of diagnostic performance and parameter variability

Abstract

Introduction: Cardiac masses (CMs) encompass a heterogeneous group of benign, malignant, and pseudotumoural lesions, posing diagnostic challenges due to their rarity and varied aetiologies. Given the limitations of conventional imaging modalities in differentiating benign from malignant masses, [¹⁸F]FDG PET/CT has emerged as a promising technique by providing metabolic information. This systematic review and meta-analysis aimed to evaluate the diagnostic performance of [¹⁸F]FDG PET/CT in characterising CMs and assess semi-quantitative parameters' role in distinguishing malignant from benign lesions.

Methods: A systematic review and meta-analysis were conducted, including studies evaluating the diagnostic accuracy of [¹⁸F]FDG PET/CT in CMs. Sensitivity and specificity were pooled using a random-effects model, and a secondary analysis examined differences in SUVmax between malignant and benign lesions.

Results: Fifteen studies enrolling 1114 patients met inclusion criteria. The pooled sensitivity and specificity of [¹⁸F]FDG PET/CT in detecting malignant CMs were 89.2% (95% CI: 85-92%) and 82.8% (95% CI: 78-87%), respectively. Malignant lesions exhibited significantly higher SUVmax values (range: 5.6-14.3) than benign masses (range: 1.1-5.3, p < 0.001). PET/CT proved particularly effective in cases with inconclusive findings from echocardiography, cardiac magnetic resonance, or CT, contributing to biopsy guidance and treatment planning.

Conclusions: [¹⁸F]FDG PET/CT demonstrates robust diagnostic accuracy in differentiating benign from malignant cardiac masses, with SUVmax as a valuable malignancy marker. Its integration into multimodal imaging strategies enhances diagnostic certainty and optimises patient management. Despite these advantages, standardised imaging protocols and further multicentre prospective studies are warranted to refine its clinical application and validate its prognostic potential.

Keywords: Cardiac masses; Diagnostic accuracy; Meta-analysis; Oncology; [18F]FDG PET/CT.

Fig. 1

Flow diagram of the study selection process

Fig. 2

A graphical overview of the quality assessment performed employing the QUADAS-2 tool. The reviewers categorised the studies included in the systematic review based on their level of bias or applicability issues for specific topics stated on the ordinate axis. The abscissa represents the percentage of studies. According to the graph, about 40% of included studies present a risk of bias in the “index test” domain due to the absence of a clear statement about patient preparation before the PET exam, an essential step toward making a precise and reproducible study

Fig. 3

SROC curve of index test’s diagnostic accuracy

Fig. 4

Pooled sensitivity and specificity of the index test in assessing CMs malignancies and relative forest plots. Legend: 95% C.I.: 95% confidence interval; TP: true positive; TN: true negative; FP: false positive; FN: false negative

Fig. 5

The index test’s negative and positive likelihood ratios and odds ratio with relative forest plots. Legend: 95% C.I.: 95% confidence interval; TP: true positive; TN: true negative; FP: false positive; FN: false negative

Fig. 6

Forest plot of the mean difference analysis. Legend: 95% C.I.: 95% confidence interval

Fig. 7

Proposed a diagnostic algorithm for optimal non-invasive assessment of CMs within a multimodal approach