For heart tumors, CMR proves powerful in predicting mortality

Chetan Shenoy calls imaging a “one-stop-shop” for evaluating patients with suspected heart disease.

In patients with suspected cardiac tumors, cardiovascular magnetic resonance (CMR) imaging can provide an accurate diagnosis and guide clinical management, according to new multicenter data. In addition, CMR results can independently predict long-term mortality greater than traditional risk factors.

“Our results show that CMR should be the imaging modality of choice for evaluating patients with suspected heart tumors, and physicians can use it as the only imaging test for virtually all patients – a ‘one stop shop’ unique “- which provides accurate diagnostic and prognostic data,” senior author Chetan Shenoy, MBBS, MS (University of Minnesota Medical Center, Minneapolis), told TCTMD in an email.

Clinicians can now confidently make patient decisions based on a CMR diagnosis, he continued. “Patients without a mass or pseudomass can be reassured, patients with a thrombus can be anticoagulated, patients with a benign tumor can undergo surgery to remove it or can be monitored over time (depending on the nature of the tumor). tumor, location, etc.), and those with a malignant tumor may be treated with biopsy (to find out the specific subtype of malignancy), surgery, chemotherapy, radiation therapy, or palliation only.

Commenting on the study for TCTMD, Jiwon Kim, MD (NewYork-Presbyterian / Weill Cornell Medical Center, New York, NY), said “The general message that this article consistently highlights is that MRI is very powerful diagnostically and prognostically useful. “ The results show “validation of the CMR technique in the evaluation of patients with suspected heart masses in a real context ”, she added.

Once considered a niche imaging modality, CMR has become more widely available in recent years for tumor assessment in the United States, Kim explained. Some issues regarding pre-authorization and reimbursement remain, but expertise has grown and safer contrast agents have allowed more patients to be imaged with CMR.

CMR results

For the study, published online last week ahead of print in the European Journal of the Heart, Shenoy and his colleagues included 903 patients (median age 60 years; 46% male) from four US centers who were referred to RMC for suspected cardiac tumor between 2003 and 2014. There was a high prevalence of risk factors. cardiac, including 59% of patients with hypertension. , 40% who were smokers and 27% with CAD. About a third (32%) had a known extracardiac malignancy. Most (78%) had undergone echocardiography before being referred to CMR, while 25% had undergone CT. All patients were scanned on 1.5 or 3T scanners (Siemens) with a standardized protocol as defined by the Society for Cardiovascular Magnetic Resonance, and images interpreted by experienced CMR physicians.

CMR diagnosed 25% of the patients as having no mass (any structure that could have been mistaken for a mass in previous imaging), while 16% had pseudomass (protruding normal structure, variant of a normal structure or pathology without mass), 16% thrombus, 17% benign tumor and 23% malignant tumor. Patients diagnosed with CMR malignancy had the highest prevalence of extracardiac malignancy, and over a quarter (26%) had no known cancer at the time of CMR.

Over a median of 4.9 years, the diagnosis of RMC was accurate in 98.4% of patients. Among the 376 patients who died, those diagnosed with thrombus (36%) and malignancy (73%) had the highest estimated cumulative death rates, while the rates were roughly similar (and lower) in patients with pseudomass (26%), benign tumor (17%) and no lump (22%).

Independent predictors of mortality on the Cox proportional hazards regression analysis included older age (HR 1.09 per 5-year increase; 95% CI 1.04-1.13), smoking (HR 1 , 37; 95% CI 1.11-1.69), reduced LVEF on CMR (HR 1.05 by 5% decrease; 95% CI 1.01-1.10), extracardiac malignancy ( HR 2.32; 95% CI 1.81-2.97), thrombus (HR 1.46 vs no mass; 95% CI 1.00-2.11) or malignant tumor (HR 3.31 vs no mass; 95% CI 2.40-4.57). In addition, a CMR diagnosis of malignancy predicted mortality, regardless of previous known cancer.

Finally, the addition of the CMR diagnosis was found to add additional value to a model based solely on clinical variables (P

Guidance document required

“We knew from small studies that RMC worked well for this purpose, but we were amazed at how effective it was in a large, real-world multi-center environment,” said Shenoy. “When we conducted the study, we were also struck by the fact that many patients were referred for suspected heart tumor as part of a known cancer outside the heart, but ended up with a variety results in the heart. “

Prior to this study, it was not known whether a mass could be ignored based solely on CMR, he explained. The researchers are providing the algorithm they use to make diagnoses – something that was not previously available – and Shenoy said he hopes it will be “useful for CMR trainees and practicing CMR doctors” .

In addition, he said he would like to see their findings “serve as evidence for stronger recommendations in future consensus documents and guidelines on this topic.”

Kim agreed that societal focus is lacking in this space, especially as advances in echocardiography have made it possible to identify more masses and pseudomasses. “I think having a document or consensus statement could be useful for clinicians to better understand the tools that currently exist to improve our diagnostic and prognostic capacity, to examine the strengths and weaknesses of existing modalities and to help determine when we choose one modality over another, “she said, adding that she expects such a publication soon.

Going forward, Shenoy called for more research with new CMR techniques such as T1 and T2 mapping. “However, we don’t anticipate that they will add much value just because our data shows that CMR works very well even without the new techniques and that there is little room for further improvements,” he said. he declares.

Kim added that it would be useful to dig further “to determine if the mortality was due to the heart tumor itself.” But also, she said, looking at T1 and T2 mapping techniques could “provide additional tissue characterization, and I think studying the value of these techniques in heart masses could be very interesting.”

About Hector Hedgepeth

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