Key points
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Surgical removal is the mainstay of cardiac mass diagnosis and treatment.
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When complete tumor removal of the tumor is not possible or patient intention or condition does not allow proceeding toward the surgery, interventional radiology (IR) is a good option for the cardio-oncology team to consider.
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Interventional oncology (IO) is a rapidly developing branch of IR that encompass procedures to yield tissue sample for diagnosis, assist in treatment as neoadjuvant or palliation, and management of complications due to tumoral progression or treatment adverse effects.
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Accomplishment of the cardiac interventional procedures requires demanding skill, comprehensive knowledge, and specific preparation as well as appropriate setting (including available cardiac surgeon) for handling the occasional complications.
Interventional radiology (IR) is a specialized field, in which the physician not only interprets the medical images but also uses medical imaging to guide minimally invasive surgical procedures that diagnose, treat, and cure many kinds of conditions through small incisions in the body. The treatments IR can effectively perform are ever changing and expanding. Interventional Oncology (IO) is one of the fastest growing fields in interventional radiology, dedicated to the diagnosis, treatment, and palliation of cancer and cancer-related problems that had tremendous progress over the last decade, and has now successfully established as an essential and independent pillar within the firmament of multidisciplinary oncologic care. Cardiac mass interventions are one of the ignored interdisciplinary fields that have explored new encouraging horizons during past decade.
The appropriateness of minimally invasive interventions for any patient with cardiac tumor should be assessed individually by the multidisciplinary “cardio-oncology team.”
IR role in diagnosis
Minimally invasive diagnosis of the cardiac tumors can be performed either by percutaneous or endovascular approach obviating the need for open surgery.
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Percutaneous transthoracic biopsy of cardiac masses can be applied for pericardial, intramural, or even some cavitary lesions if trajectory access is appropriate. The procedure is mainly performed under CT scan or sometimes ultrasound guidance ( Fig. 29.1 ) while the backup cardiac surgeon is available and informed. Interventionists try to choose tumoral regions with the lowest amount of vascularity in order to diminish the possible risk of hemopericardium ( Fig. 29.2 ). Filling the intralesional biopsy tract at the end of procedure with embolizing agents (e.g., gelfoam) will largely reduce the incidence.
Fig. 29.1
(A) and (B) A 48-year-old man with an infiltrative pericardial mass which extensively encased the cardiac chambers and intrapericardial portion of the great vessels and has led to severe SVC stenosis. (C) and (D) After drainage of pleural effusion, percutaneous biopsy attempted by first delineating the vascular structure with contrast enhanced CT. Transthoracic biopsy result confirmed the diagnosis of lymphoma.
Courtesy of Dr. Saleh Jafarpisheh, Isfahan University of Medical Science, Isfahan, Iran.
Fig. 29.2
A 1-year-old boy with a large incidental cardiac mass extending from inferior left atrium wall to involve inferior and lateral wall of the left ventricle. (A) Cardiac MRI was inconclusive for discriminating the neoplastic nature of the mass due to remarkable heterogeneous enhancement of the lesion. (B) Percutaneous ultrasound-guided biopsy of the mass (C) revealed hypercellular spindle cells with no atypia in favor of fibroma. (D), (E), and (F) Follow-up MRI three years later showed no significant change in extension of the fibroma with characteristic CMR features.
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Endovascular biopsy of the cardiac or central great vessel masses is a minimally invasive procedure that could be considered for right heart and septal tumor of adequate size in a manner commonly used for the blunt endomyocardial biopsy ( Figs. 29.3–29.6 ). Cases of transseptal approach of the left atrial mass are also reported . To guide the prompt site of target lesion for biopsy, concomitant echocardiography is crucial. TTE, although commonly used, gives less clear cardiac images than TEE, especially for the posterior wall mass and the patient with poor echo window, while the latter requires general anesthesia during the procedure. Intracardiac echocardiography (ICE) can provide better anatomical delineation of the lesion and targeting device without the need for general anesthesia, is more patient friendly, and will reduce radiation exposure for the echocardiographer during the procedure.
Fig. 29.3
A 70-year-old woman with a mass in the right ventricular outflow tract detected on echocardiography, during a routine workup for renal cancer. (A) and (B) Axial and oblique CT images demonstrate the exact location of the mass. (C) Pulmonary angiogram confirms the filling defect in subpulmonic region. (D) and (E) Due to the unstable position of the introducer sheath in the right ventricle, a 0.035 guide wire was positioned in the inferior left pulmonary lobar artery to stabilize the introducer in the target position. The biopsy device was advanced coaxially to the guide wire. Histopathological analysis revealed the lesion as coincidental myxoma.
Courtesy of Prof. Salah D. Qanadli, Centre Hospitalier Universitaire Vaudois (CHUV), Laussane, CH.
Fig. 29.4
A 62-year-old woman presented with dyspnea, pain, and weight loss for couple of months. (A) Axial CT images show heterogeneous enhancing intravascular mass in the right pulmonary artery extending to lobar branches. (B) Fluoroscopy view demonstrates the introducer placed in the pulmonary trunk as well as a 0.035 guide wire (Radiofocus Glidewire Advantage, Terumo) advanced to the right lobar pulmonary artery in order to stabilize the introducer in the target position. (C) The two obtained samples. Histopathological analysis revealed an intimal sarcoma of the pulmonary artery.
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