The following are key points to remember from a state-of-the-art review on multimodality imaging in the diagnostic work-up of patients with cardiac masses:

1. Cardiac masses present a complex clinical scenario, encompassing benign tumors, malignant tumors (both primary and secondary), and tumorlike masses, also known as pseudotumors.
2. 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.
3. Echocardiography is typically the initial imaging modality. Echocardiography can now be enhanced with real-time three-dimensional techniques (real-time three-dimensional echocardiography [RT3DE]), a volumetric approach that captures the entire cardiac mass, providing an accurate evaluation of its volume, attachments, and relationships with surrounding structures.
4. Cardiac magnetic resonance (CMR) is the reference standard for noninvasive assessment of cardiac masses, except for small valvular masses and calcified lesions. It enables the accurate identification of pseudotumors, reducing the need for further testing, and allows the detection of malignant cardiac masses and, in some cases, specific histotypes.
5. Computed tomography (CT) can be performed either in combination with or as an alternative to CMR. Cardiac CT is pivotal in presurgical scheduling, helping identify surgical planes, tailor surgical resection, and rule out coronary artery disease. Chest, abdominal, and pelvic (CAP) CT is typically used to identify primary extracardiac malignancies, define invasion or infiltration of surrounding extracardiac tissues, and stage malignant lesions.
6. ⁸F-fluorodeoxyglucose positron emission tomography (FDG PET) is recommended as a third-level imaging technique when CT and CMR results are inconclusive. After evaluating the metabolic activity of the mass, systemic staging of malignant cardiac masses should be performed.
7. 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.
8. In clinical practice, multimodality imaging plays a crucial role in managing cardiac masses by addressing several key diagnostic objectives: a) detecting and localizing cardiac mass; b) identifying anatomical variants; c) differentiating between cardiac tumors and pseudotumors; d) detecting malignancy in cardiac tumors; e) staging and guiding treatment; f) presurgical planning; and g) aiding in the determination of histology.
9. In practice, the diagnostic approach is often influenced by the availability of local resources and expertise. It is important to raise awareness of the significant benefits multimodality imaging offers, particularly in more complex cases. However, this does not imply that every patient with a cardiac mass should undergo all available noninvasive techniques.
10. Clinicians must understand the strengths and weaknesses of each modality to select the most appropriate and cost-effective combination tailored to the patient’s need. A multidisciplinary team approach ensures the optimal use of multimodality imaging and helps provide the best care for patients with cardiac masses. Finally, recognizing the potential of multimodality imaging helps clinicians identify when to refer patients to third-level centers if local resources are limited.

Clinical Topics: Noninvasive Imaging, Cardio-Oncology

Keywords: Cardio-oncology, Diagnostic Imaging, Multimodal Imaging, Patient Care Team

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