Perfusion CMR for Cancer-Associated Cardiac Masses

Feb 02, 2024
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Authors:
Chan AT, Maya TR, Park C, et al.
Citation:
Incremental Utility of First-Pass Perfusion CMR for Prognostic Risk Stratification of Cancer-Associated Cardiac Masses. JACC Cardiovasc Imaging 2024;17:128-145.
Summary By:
Debabrata Mukherjee, MD, FACC

Quick Takes

  • Contrast kinetics differ between vascular and avascular cardiac masses, as evidenced by higher upslope and peak enhancement for cardiac metastasis (CMET) vs. cardiac thrombus (CTHR) assessed using first-pass perfusion CMR.
  • LGE-CMR is superior to perfusion to differentiate CMET from CTHR, but mortality among patients with LGE-evidenced CMET is heterogeneous and varies in relation to perfusion CMR–evidenced lesion hypoperfusion.
  • These findings support integrated CMR tissue characterization for CMASS, in which initial diagnostic categorization is established by LGE and prognosis in CMET is further stratified based on perfusion CMR–evidenced lesion hypovascularity.

Study Questions:

What is the diagnostic and prognostic utility for cardiac masses (CMASS) beyond binary differentiation of cardiac metastasis (CMET) and cardiac thrombus (CTHR)?

Methods:

The investigators analyzed data from a registry of adult patients (≥18 years of age) with systemic (extracardiac) cancer and cardiac magnetic resonance (CMR)–evidenced CMASS who underwent a standardized imaging protocol, inclusive of late gadolinium enhancement (LGE) and perfusion. Adult cancer patients with CMASS on CMR; CMET and CTHR were defined using LGE-CMR: CMASS+ patients were matched to CMASS− control subjects for cancer type/stage. First-pass perfusion CMR was interpreted visually and semiquantitatively for CMASS vascularity, including contrast enhancement ratio (CER) (plateau vs. baseline) and contrast uptake rate (CUR) (slope). Follow-up was performed for all-cause mortality. Cox proportional hazards models compared mortality risk between groups. Receiver-operating characteristic analysis, including area under the curve (AUC) estimates, was used to evaluate overall diagnostic test performance of perfusion indices (absolute and normalized contrast upslope) and derive cutoffs (maximal sensitivity, specificity) for CMET as established using the reference of LGE-CMR.

Results:

A total of 462 cancer patients were studied, including patients with (CMET = 173, CTHR = 69) and without CMASS on LGE-CMR. On perfusion CMR, CER and CUR were higher within CMET vs. CTHR (p < 0.001); CUR yielded better performance (AUC: 0.89-0.93) than CER (AUC: 0.66-0.72) (both p < 0.001) to differentiate LGE-CMR–evidenced CMET and CTHR, although both CUR (p = 0.10) and CER (p = 0.01) typically misclassified CMET with minimal enhancement. During follow-up, mortality among CMET patients was high but variable; 47% of patients were alive 1-year post-CMR. Patients with semiquantitative perfusion CMR-evidenced CMET had higher mortality than control subjects (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.06-1.90; p = 0.02), paralleling visual perfusion CMR (HR, 1.47; 95% CI, 1.12-1.94; p = 0.006) and LGE-CMR (HR, 1.52; 95% CI, 1.16-2.00; p = 0.003). Among patients with CMET on LGE-CMR, mortality was highest among patients (p = 0.002) with lesions in the bottom perfusion (CER) tertile, corresponding to low vascularity. Among CMET and cancer-matched control subjects, mortality was equivalent (p = not significant) among patients with lesions in the upper CER tertile (corresponding to higher lesion vascularity). Conversely, patients with CMET in the middle (p = 0.03) and lowest (lowest vascularity) (p = 0.001) CER tertiles had increased mortality.

Conclusions:

The authors report that among cancer patients with LGE-CMR defined CMET, mortality increases in proportion to magnitude of lesion hypoperfusion.

Perspective:

This study reports that contrast kinetics differ between vascular and avascular cardiac masses, as evidenced by higher upslope and peak enhancement for CMET vs. CTHR assessed using first-pass perfusion CMR. Furthermore, while LGE-CMR is superior to perfusion to differentiate CMET from CTHR, mortality among patients with LGE-evidenced CMET is heterogeneous and varies in relation to perfusion CMR–evidenced lesion hypoperfusion. These findings support integrated CMR tissue characterization algorithm for CMASS, in which initial diagnostic categorization of CMET vs. CTHR is established by LGE and prognosis among patients with CMET is further stratified based on perfusion CMR–evidenced lesion hypovascularity. Additional research is needed to assess whether perfusion CMR predicts non–mortality-related adverse outcomes or response to specific anticancer therapies in patients with CMET, with a goal of imaging–guided tailored therapy and improved clinical outcomes for advanced cancer patients.

Clinical Topics: Cardio-Oncology, Noninvasive Imaging, Magnetic Resonance Imaging

Keywords: Cardiotoxicity, Magnetic Resonance Imaging


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