Magnetic Resonance Imaging in the Study of Cardiac Masses: A Case Series.

Cardiac masses are currently studied using multimodality imaging. For diagnosis, different imaging techniques that can provide complementary information are used. Cardiac magnetic resonance imaging (MRI) has become a fundamental tool for this type of pathology owing to its ability to provide tissue characterization, spatial accuracy, and the anatomic relationships of the different structures. This study presents a series of four clinical cases with an initial diagnosis of a cardiac mass. All cases were evaluated at a single center, and patients were aged 57 to 72 years. An etiological study was conducted on all patients using different imaging techniques, including MRI. This study describes the diagnostic and therapeutic procedures of the four cases, which included two intracardiac metastases and two benign tumors. Cardiac MRI was decisive in the diagnostic process, determining the clinical decision-making in all four cases. Cardiac MRI has emerged as a pivotal technique in the diagnosis of cardiac masses. It can provide a highly accurate histological diagnosis without the need for invasive techniques.

Prognostic Implication of Direct Cardiac Invasion from Lung Cancer in Non-Operatively Treated Patients Based on Lung Computed Tomography Imaging.

BACKGROUND: Lung cancer with direct cardiac invasion (LCCI+) exerts a significant influence on the survival of patients. There is a paucity of comparative research into the prognosis of advanced lung cancer with and without direct cardiac invasion. METHOD: In this study, 50 LCCI+ patients and 50 sex-, age-, and TNM stage-matched patients without direct cardiac invasion (LCCI-) were retrospectively analysed. LCCI+ was defined as lung cancer directly invading the heart by penetrating mediastinum or extending into the atrium via the pulmonary vein. The study endpoint was all-cause death. In this study, the survival time was defined as the time from the first detection of direct cardiac invasion to the end of the event. RESULTS: During a median follow-up period of 31 months, all-cause death occurred in 44 patients (88.0%) in the LCCI+ group and in 36 patients (72.0%) in the LCCI- group; the overall survival (OS) time among patients in the LCCI+ group was significantly lower compared with those in the LCCI- group (5.0 [interquartile range (IQR), 2.0-12.0] vs 13.8 [IQR, 4.0-18.4] mo; p<0.001); the OS rate in the LCCI+ group was significantly lower compared with patients in the LCCI- group (log-rank, p=0.0002). Multivariate Cox regression analysis showed that direct cardiac invasion was an independent predictor of survival in patients with advanced lung cancer (hazard ratio, 2.255; 95% confidence interval, 1.443-3.524). Further analysis indicated that in patients with small cell lung cancer, the survival rate between the LCCI+ group and LCCI- group was insignificant (log-rank, p=0.075; survival time: 4.0 [IQR, 2.0-11.5] vs 11.5 [IQR, 5.0-18.3] mo); in patients with non-small cell lung cancer (NSCLC), the survival rate in the LCCI+ group was lower than that of the LCCI- group (log-rank, p=0.01; survival time: 6.0 [IQR, 3.0-13.3] vs 16.3 [IQR, 10.4-27.2] mo). CONCLUSIONS: Direct cardiac invasion from lung cancer was an independent prognostic factor for survival time in patients with lung cancer. Patients with direct cardiac invasion by NSCLC have a poorer clinical outcome than those without direct cardiac invasion. A careful preoperative evaluation is mandatory and appropriate management of cardiac involvement should be considered in the treatment of NSCLC.

Cardiac Metastases in Patients with Neuroendocrine Tumours: Clinical Features, Therapy Outcomes, and Prognostic Implications.

BACKGROUND: Cardiac metastases (CM) from neuroendocrine tumours (NET) are rare; however, with the introduction of new molecular imaging modalities, such as 68Ga-DOTATATE PET-CT for NET diagnosis and re-staging, they are now identified more frequently. This study presents a single-institution experience on the NET CM characteristics, management, and prognostic implications. METHODS: Between January 1998 and January 2020, 25 NET patients with CM were treated in our unit. A retrospective review of electronic records was performed. Overall survival (OS) was assessed by the Kaplan-Meier method. Cox regression models were used to evaluate the association of various clinical variables with OS. RESULTS: The median age in the NET CM cohort was 64 years, with small intestine being the most common primary (84%). Nearly half of the patients suffered either from shortness of breath (48%) or had palpitations (12%). Peptide receptor radionuclide therapy (PRRT) was applied in more than half of the patients (64%), who had an improved trend for a longer median OS compared to those patients who did not receive PRRT (76.0 vs. 14.0 months, p = 0.196). The multivariate analysis demonstrated that concomitant skeletal or pancreatic metastases, as well as N-terminal pro-B-type natriuretic peptide (NT pro-BNP) >2 × upper limit of normal (ULN), were independent poor prognosticators. CONCLUSIONS: Clinical features of NET CM ranged from asymptomatic patients to heart failure. Concomitant bone or pancreatic metastases and NT pro-BNP levels >2 ULN predicted shorter survival time. PRRT serves as a feasible therapy with promising survival benefits; however, more data are needed.

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.

Prognostic utility of differential tissue characterization of cardiac neoplasm and thrombus via late gadolinium enhancement cardiovascular magnetic resonance among patients with advanced systemic cancer.

BACKGROUND: Late gadolinium enhancement (LGE-) cardiovascular magnetic resonance (CMR) is well-validated for cardiac mass (CMASS) tissue characterization to differentiate neoplasm (CNEO) from thrombus (CTHR): Prognostic implications of CMASS subtypes among systemic cancer patients are unknown. METHODS: CMASS + patients and controls (CMASS -) matched for cancer diagnosis and stage underwent a standardized CMR protocol, including LGE-CMR (IR-GRE) for tissue characterization and balanced steady state free precession cine-CMR (SSFP) for cardiac structure/function. CMASS subtypes (CNEO, CTHR) were respectively defined by presence or absence of enhancement on LGE-CMR; lesions were quantified for tissue properties (contrast-to-noise ratio (CNR); signal-to-noise ratio (SNR) and size. Clinical follow-up was performed to evaluate prognosis in relation to CMASS etiology. RESULTS: The study population comprised 126 patients with systemic neoplasms referred for CMR, of whom 50% (n = 63) had CMASS + (CNEO = 32%, CTHR = 18%). Cancer etiology differed between CNEO (sarcoma = 20%, lung = 18%) and CTHR (lymphoma = 30%, GI = 26%); cardiac function (left ventricular ejection fraction: 63 ± 9 vs. 62 ± 10%; p = 0.51∣ right ventricular ejection fraction: 53 ± 9 vs. 54 ± 8%; p = 0.47) and geometric indices were similar (all p = NS). LGE-CMR tissue properties assessed by CNR (13.1 ± 13.0 vs. 1.6 ± 1.0; p < 0.001) and SNR (29.7 ± 20.4 vs. 15.0 ± 11.4, p = 0.003) were higher for CNEO, consistent with visually-assigned diagnostic categories. CTHR were more likely to localize to the right atrium (78% vs. 25%, p < 0.001); nearly all (17/18) were associated with central catheters. Lesion size (17.3 ± 23.8 vs. 2.0 ± 1.5 cm2; p < 0.001) was greater with CNEO vs. CTHR, as was systemic disease burden (cancer-involved organs: 3.6 ± 2.0 vs. 2.3 ± 2.1; p = 0.02). Mortality during a median follow-up of 2.5 years was markedly higher among patients with CNEO compared to those with CTHR (HR = 3.13 [CI 1.54-6.39], p = 0.002); prognosis was similar when patients were stratified by lesion size assessed via area (HR = 0.99 per cm2 [CI 0.98-1.01], p = 0.40) or maximal diameter (HR = 0.98 per cm [CI 0.91-1.06], p = 0.61). CTHR conferred similar mortality risk compared to cancer-matched controls without cardiac involvement (p = 0.64) whereas mortality associated with CNEO was slightly higher albeit non-significant (p = 0.12). CONCLUSIONS: Among a broad cancer cohort with cardiac masses, CNEO defined by LGE-CMR tissue characterization conferred markedly poorer prognosis than CTHR, whereas anatomic assessment via cine-CMR did not stratify mortality risk. Both CNEO and CTHR are associated with similar prognosis compared to CMASS - controls matched for cancer type and disease extent.

Scar-Related Monomorphic Ventricular Tachycardia After Treated Right Ventricular Metastatic Diffuse Large B-Cell Lymphoma.

A patient with ventricular tachycardia (VT) and right ventricular (RV) metastatic diffuse large B-cell lymphoma had persistent RV gadolinium enhancement following chemotherapy and disease remission. Electrophysiology study demonstrated inducible sustained monomorphic VT requiring subcutaneous implantable cardioverter-defibrillator implantation. This highlights the arrhythmogenic potential of residual scar after resolution of cardiac masses.

A case of surgical treatment for recurrence of right ventricular metastasis due to renal cell carcinoma after molecular targeted therapy.

BACKGROUND: Cardiac metastasis including the right ventricle from renal cell carcinoma is rare. No standard treatment for cardiac metastasis and recurrence in renal cell carcinoma has been established. CASE PRESENTATION: We present the case of a 61-year-old man who underwent the resection of recurrent right ventricular metastasis caused by renal cell carcinoma following molecular targeted therapy. The first cardiac operation was performed for right ventricular metastasis due to renal cell carcinoma. The patient had a good postoperative course. Two years after the first operation, however, follow-up computed tomography revealed the recurrence of the right ventricular tumor and metastases in both lungs. Molecular targeted therapy was carried out and effectively controlled the lung metastasis but the right ventricular lesion remained unchanged, leading to reoperation. The recurrent right ventricular tumor was completely resected through a redo median sternotomy assisted by cardiopulmonary bypass. The patient had an uneventful postoperative course and was discharged on the 13th postoperative day. Follow-ups at 2 years showed no cardiac recurrence. CONCLUSION: Surgical intervention was considered useful in managing the recurrence of right ventricular metastasis from renal cell carcinoma after molecular targeted therapy.

Radioligand therapy (RLT) used to treat cardiac metastasis of pancreatic neuroendocrine tumor.

Radioligand Therapy (RLT) in the form of [177Lu] Lu-DOTA-TATE (Lutathera®) is a promising treatment for pancreatic neuroendocrine tumors (pNETs) with cardiac metastasis. We present a patient treated with [177Lu] Lu-DOTA-TATE that showed shrinkage of metastasis after four treatments at 7.4 GBq every 8 weeks.

Stereotactic magnetic resonance imaging-guided radiotherapy for intracardiac metastases: A case report.

Adrenocortical carcinoma is a malignant tumor with a poor prognosis and a frequent metastatic extension. In very rare cases, a cardiac metastatic disease may occur, and surgical resection is essential for its management. MR-guided stereotactic radiotherapy is an attractive radiotherapy modality for the treatment of mobile thoracic tumors, enabling the target to be monitored continuously during irradiation, while the dosimetric plan can be adapted daily if necessary. We report here the case of a patient with intracardiac metastasis secondary to malignant adrenocortical carcinoma, treated with magnetic resonance imaging-guided stereotactic radiotherapy.

Metastatic Penile Squamous Cell Carcinoma: Unmasked by an Acute Myocardial Infarction and Terminal Heart Failure.

A young patient, recently treated for squamous cell penile carcinoma, presented with acute myocardial infarction and severe heart failure. Despite repeatedly ruling out metastatic disease on imaging, surgery for a mechanical assist device revealed unexpected squamous cell metastasis in the pericardium. Consequently, palliative care was initiated.

Lung Metastases to the Heart with Atypical Clinical Manifestations of Cardiac Failure.

The heart is a rare site of cancer metastases, even from the most common malignancies, such as lung cancer. Cardiac metastases may lead to myocardial dysfunction. This report presents a case of lung cancer metastases to the left ventricular myocardium that clinically manifested as atypical symptoms of cardiac dysfunction. The metastases were not revealed until after the patient died. Posthumously, the anamnesis, autopsy results, and morphological examination were evaluated. We demonstrated that the atypical symptoms of cardiac dysfunction were caused by occult (undiagnosed) metastases of lung cancer cells to the heart. The doctors did not consider this variant as possible metastatic lung cancer, because the patient had been treated radically one year earlier.

Treating unresectable intrahepatic cholangiocarcinoma with transarterial chemoembolization and an unusual progression with cardiac involvement.

Intrahepatic cholangiocarcinoma is a rare type of cancer that is usually discovered at an advanced stage where surgical treatment is not an option. When compared to standard systemic therapy, transarterial chemoembolization (TACE) can provide a survival benefit to unresectable patients. Extrahepatic tumor spread is not rare, but cardiac involvement is an unusual complication.We present the case of a 56-year-old man with histologically proven intrahepatic cholangiocarcinoma. Oncologic risk factors include hepatitis B and liver cirrhosis. Being in an unresectable stage of the disease, three TACE procedures were performed. Partial response was achieved (according to RECIST) leading to a 16-month survival. However, disease progression was present, with unusual heart metastases.TACE can bring a survival benefit to unresectable cholangiocarcinoma patients. Defining the best disease stages in which TACE can be implemented and introducing it as part of standard treatment guidelines still presents a challenge.

Melanoma With Cardiac Metastasis.

Melanoma is considered a masquerader of many diseases owing to its potential to metastasize to many organs. Several malignancies can metastasize to the heart including malignant melanoma. Historically, antemortem diagnosis of cardiac involvement of melanoma is not common, but with significant improvement in imaging modalities, the diagnosis can now be made early and accurately, aiding in treatment and improved survival. We present a case of a 36-year-old man with brief neurological symptoms and subsequent diagnosis of cerebrovascular accident (CVA). Cardiac imaging revealed incidental findings of right and left ventricular masses and lymph node biopsy, confirming metastatic melanoma. Cardioembolic etiology was suspected for his CVA. Prompt immunotherapy was initiated with improvement in his clinical condition.

Management of non-hepatic distant metastases in neuroendocrine neoplasms.

Neuroendocrine neoplasms represent an uncommon disease with an increasing incidence. Thanks to improvements in diagnostic and therapeutic methods, metastases previously considered uncommon, such as bone metastases, or even very rare, such as brain, orbital and cardiac metastases, are more frequently found in daily practice. Due to the great heterogeneity of these neoplasms, there is a lack of high-quality evidence on the management of patients with these types of metastases. The aim of this review is to provide the current state of the art, reviewing neuroendocrine neoplasm specific studies and useful information from other tumor types and to propose a treatment recommendation with algorithms to consider in daily clinical practice.

[Primary pericardial synovial sarcoma]. / Sarcoma sinovial primario de pericardio.

Primary pericardial synovial sarcoma is an extraordinarily very rare tumor with a poor prognosis, and little is known about its therapeutic management. We describe the case of a 51-year-old woman patient who underwent incomplete surgical resection, chemotherapy, and radiotherapy. To the best of our knowledge, no primary pericardial synovial sarcoma has been described which, after surgery, remains asymptomatic for 5 years, and until a control CT scan detects cardiac metastases that compromised the lumen of the right cavities and with chemotherapy, echocardiography demonstrated complete resolution of cardiac metastases.

El sarcoma sinovial primario del pericardio es un tumor muy raro y de mal pronóstico y se sabe poco en cuanto al manejo terapéutico. Presentamos el caso de una paciente de 51 años a quien se le realizó resección quirúrgica incompleta, quimioterapia y radioterapia. Hasta donde sabemos, este es el primer caso de un sarcoma sinovial primario de pericardio que luego de operado se mantuvo asintomático durante 5 años hasta que en una TAC de control se le detectaron metástasis cardiacas que comprometían las cavidades derechas y con quimioterapia, la ecocardiografía demostró la resolución completa de las mismas.

Multichamber Involvement of Metastatic Cardiac Melanoma.

A 30-year-old man with a history of an in-situ melanoma of the forehead was referred for cardiac evaluation because of tachycardia and elevated levels of serum troponin. The transthoracic echocardiogram revealed multiple masses attached to the walls of both ventricles and the right atrium (RA). A large mass was occupying almost one third of the right ventricle (RV), resulting in reduction of the end-diastolic RV volume and tachycardia. A cardiac magnetic resonance imaging confirmed multifocal myocardial infiltration and intracavitary masses and excluded the presence of thrombus in any of the cardiac chambers. Diffuse metastatic involvement in the liver, the spleen, and the brain by computed tomography precluded surgical management. Being BRAF-unmutated, the patient was initially treated with a combination of nivolumab and ipilimumab. One month later, the cardiac metastases in RA and left ventricle were unchanged on echocardiogram, while the tumor in RV was enlarged occupying the majority of the chamber, resulting in further reduction of the cardiac output and tachycardia. The treatment was changed to a combination of dacarbazine and carboplatin, but the patient eventually died two months later. Heart is not a common metastatic site of melanoma and cardiac involvement is usually clinically silent making ante mortem diagnosis difficult. Multimodalidy imaging plays a pivotal role in the diagnostic work up. Cardiac melanoma metastases indicate an advance stage disease with poor prognosis.

Cardiac Metastasis After Curative Treatment of Hepatocellular Carcinoma: Assessment of Risk Factors, Treatment Options, and Prognosis.

Hepatocellular carcinoma (HCC) is primary hepatic malignancy with a high incidence of recurrence. The risk of recurrence directly correlates to patient's overall prognosis. Management of advanced HCC involves a combination of surgical resection, locoregional therapy, and systemic treatment. Distant metastases are rare, and intraventricular cardiac metastases are even more infrequent. This brief review details an illustrative case of cardiac metastasis after curative treatment of primary HCC and then summarizes the literature on risk factors, treatment options, and patient prognosis in the setting of distant metastases from HCC. Prognosis of metastasis to the heart is generally poor, and available evidence emphasizes the importance of maintaining regular posttreatment screening for metastases in patients with HCC. Given the variable presentation and high risk of recurrence, it is critical to have individualized multimodality treatment plans.

Hepatocellular Carcinoma With Right Atrium Metastases.

Hepatocellular carcinoma is common in patients with cirrhosis regardless of the etiology. Its presentation is uncommon in patients without known cirrhosis. It can spread commonly to the lungs, abdominal lymph nodes and bone but cardiac metastases are rare. The screening and early diagnosis impact the treatment feasibility and prognosis. The most common etiologies of cirrhosis and hepatocellular carcinoma are alcohol consumption and viral hepatitis B and C, however, non-alcoholic fatty liver disease (NAFLD) is becoming a more pronounced known risk factor for steatosis, advanced liver fibrosis, cirrhosis, and thus hepatocellular carcinoma due to the rise of metabolic syndrome prevalence. Although a known risk factor, there are no current recommendations for cancer surveillance in patients with NAFLD. The aim of this paper is to raise awareness of this rising complication by describing a rare initial presentation of hepatocellular carcinoma.

Cardiac venous malformation concurrent with multiple hepatic venous malformations: A case report.

A 50-year-old woman who had previously undergone right radical mastectomy presented with chest tightness and shortness of breath after physical activities. A cardiac mass and multiple hepatic lesions were successively detected. We first performed hepatic puncture biopsy. Histopathologic examination confirmed that the multiple hepatic lesions were venous malformations. Based on the imaging findings and previous reports in the literature, we boldly speculated that the cardiac mass was also a venous malformation. The cardiac venous malformation was successfully resected, and the postoperative pathology confirmed our suspicion.

Complete heart block ensuing from a metastatic small cell carcinoma: a case report.

INTRODUCTION: Notwithstanding the diagnostic and therapeutic advancements, the incidence of cardiac metastases has increased in recent decades. Lung cancers are the most common primary malignant neoplasms with cardiac metastasis potential. The clinical presentation of cardiac metastases is either silent or vague, and largely depends on the infiltrated location and tumor burden. Although arrhythmias are not uncommon in metastatic cardiac tumors, complete heart block is relatively a rare manifestation. We present a case of complete heart block due to a metastatic small cell carcinoma in a 67-year-old male of African origin. CASE PRESENTATION: A 67-year-old male of African origin from rural Tanzania was referred to us for expert management. He is a retired agromechanic with over 30 years exposure to asbestos-containing brake linings. His past medical history was unremarkable, but the family-social history was evident for a heavy alcohol intake and chronic cigarette smoking. He presented with a 24-week history of progressive shortness of breath and an 8-week history of recurrent syncopal attacks coupled with a significant weight loss. He had normal echocardiographic findings, however, the electrocardiogram showed features of complete heart block. Chest X-ray showed a homogeneous opacification on the right side and computed tomography scan revealed a solid right lung mass with metastases to the liver, heart, bowels, and bone. He underwent bronchoscopy, which revealed an endobronchial mass obstructing the bronchus intermedius. Histological examination of a section of lung biopsy taken during bronchoscopy confirmed the diagnosis of a small cell carcinoma. The patient underwent dual chamber pacemaker implantation with successful sinus rhythm restoration. He made an informed refusal of chemotherapy and inevitably died 18 months post pacing. CONCLUSIONS: Despite the advancements in medical diagnostics and management, lung cancers are often diagnosed in advanced stages, with an inevitable grave prognosis. Small cell carcinoma has the potential to metastasize to the heart, resulting in complete heart block.