Abstract
BackgroundLate gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is widely used to identify cardiac neoplasms, for which diagnosis is predicated on enhancement stemming from lesion vascularity: Impact of contrast-enhancement pattern on clinical outcomes is unknown. The objective of this study was to determine whether cardiac metastasis (CMET) enhancement pattern on LGE-CMR impacts prognosis, with focus on heterogeneous lesion enhancement as a marker of tumor avascularity.MethodsAdvanced (stage IV) systemic cancer patients with and without CMET matched (1:1) by cancer etiology underwent a standardized CMR protocol. CMET was identified via established LGE-CMR criteria based on lesion enhancement; enhancement pattern was further classified as heterogeneous (enhancing and non-enhancing components) or diffuse and assessed via quantitative (contrast-to-noise ratio (CNR); signal-to-noise ratio (SNR)) analyses. Embolic events and mortality were tested in relation to lesion location and contrast-enhancement pattern.Results224 patients were studied, including 112 patients with CMET and unaffected (CMET -) controls matched for systemic cancer etiology/stage. CMET enhancement pattern varied (53% heterogeneous, 47% diffuse). Quantitative analyses were consistent with lesion classification; CNR was higher and SNR lower in heterogeneously enhancing CMET (p < 0.001)—paralleled by larger size based on linear dimensions (p < 0.05). Contrast-enhancement pattern did not vary based on lesion location (p = NS). Embolic events were similar between patients with diffuse and heterogeneous lesions (p = NS) but varied by location: Patients with right-sided lesions had threefold more pulmonary emboli (20% vs. 6%, p = 0.02); those with left-sided lesions had lower rates equivalent to controls (4% vs. 5%, p = 1.00). Mortality was higher among patients with CMET (hazard ratio [HR] = 1.64 [CI 1.17–2.29], p = 0.004) compared to controls, but varied by contrast-enhancement pattern: Diffusely enhancing CMET had equivalent mortality to controls (p = 0.21) whereas prognosis was worse with heterogeneous CMET (p = 0.005) and more strongly predicted by heterogeneous enhancement (HR = 1.97 [CI 1.23–3.15], p = 0.005) than lesion size (HR = 1.11 per 10 cm [CI 0.53–2.33], p = 0.79).ConclusionsContrast-enhancement pattern and location of CMET on CMR impacts prognosis. Embolic events vary by CMET location, with likelihood of PE greatest with right-sided lesions. Heterogeneous enhancement—a marker of tumor avascularity on LGE-CMR—is a novel marker of increased mortality risk.
Highlights
Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is widely used to identify cardiac neoplasms, for which diagnosis is predicated on enhancement stemming from lesion vascularity: Impact of contrast-enhancement pattern on clinical outcomes is unknown
Cardiovascular magnetic resonance (CMR) has been well-validated for tissue characterization of cardiac masses. [2, 4, 7–12] Whereas neoplasms can vary in morphology, vascular supply is an intrinsic requirement for tumor growth and this property can be leveraged for diagnostic purposes
Population characteristics The population comprised 224 adults with advanced systemic cancer undergoing CMR, including 112 patients with C MET as defined by late gadolinium enhancement (LGE)-CMR, and unaffected (CMET -) controls matched for primary cancer diagnosis and stage
Summary
Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is widely used to identify cardiac neoplasms, for which diagnosis is predicated on enhancement stemming from lesion vascularity: Impact of contrast-enhancement pattern on clinical outcomes is unknown. The objective of this study was to determine whether cardiac metastasis (CMET) enhancement pattern on LGE-CMR impacts prognosis, with focus on heterogeneous lesion enhancement as a marker of tumor avascularity. Using the technique of late gadolinium enhancement (LGE), CMR can identify neoplasms based on vascularity as manifested by presence of contrast-enhancement. [13] It is known that neoplasms can vary in pattern of contrast enhancement on LGE-CMR, and that some lesions can include enhancing and non-enhancing components. [14] Impact of tumor avascularity—as manifested by contrast hypo-enhancement on LGE-CMR—has yet to be tested as a prognostic marker among patients with C MET Using the technique of late gadolinium enhancement (LGE), CMR can identify neoplasms based on vascularity as manifested by presence of contrast-enhancement. [13] It is known that neoplasms can vary in pattern of contrast enhancement on LGE-CMR, and that some lesions can include enhancing and non-enhancing components. [2–4] Consistent with this, pathology studies have shown that some neoplasms can have avascular foci (“tumor necrosis”)—a finding linked to aggressive tumor growth and adverse outcomes. [14] Impact of tumor avascularity—as manifested by contrast hypo-enhancement on LGE-CMR—has yet to be tested as a prognostic marker among patients with C MET
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