Cardiac Magnetic Resonance Imaging in Oncology

Daniel Jeong, MD; Aarti Patel, MD; Christopher J. François, MD; Kenneth L. Gage, MD, PhD; Michael G. Fradley, MD

Disclosures

Cancer Control. 2017;24(2):147-160. 

In This Article

Abstract and Introduction

Abstract

Background. Cardiac magnetic resonance imaging (MRI) is emerging as an important diagnostic modality in the management of cardiovascular-related dysfunction in oncological diseases. Advances in imaging techniques have enhanced the detection and evaluation of cardiac masses; meanwhile, innovative applications have created a growing role for cardiac MRI for the management of cardiotoxicity caused by cancer therapies.

Methods. An overview is provided of the clinical indications and technical considerations of cardiac MRI. Its role in the evaluation of cardiac masses and cardiac function is reviewed, and novel sequences are discussed that are giving rise to future directions in cardio-oncology research. A review of the literature was also performed, focusing on cardiac MRI findings associated with cardiac dysfunction related to cancer treatment.

Results. Cardiac MRI can be used to differentiate benign and malignant primary cardiac tumors, metastatic disease, and pseudotumors with high spatial and temporal resolution. Cardiac MRI can also be used to detect the early and long-term effects of cardiotoxicity related to cancer therapy. This is accomplished through a multiparametric approach that uses conventional bright blood, dark blood, and postcontrast sequences while also considering the applicability of newer T1 and T2 mapping sequences and other emerging techniques.

Conclusions. Cardio-oncology programs have an expanding presence in the multidisciplinary approach of cancer care. Consequently, knowledge of cardiac MRI and its potential applications is critical to the success of contemporary cancer diagnostics and cancer management.

Introduction

Cardiac magnetic resonance imaging (MRI) is emerging as an important diagnostic modality in the management of cardiovascular-related dysfunction in oncological diseases. With survival rates becoming longer in patients with cancer and in those with chronic cardiovascular disease, new strategies are being developed to manage the increasing overlap between these groups of patients.[1] Cardio-oncology programs have an expanding presence in the multidisciplinary approach to cancer care. Thus, knowledge of cardiac MRI and its potential applications is important to the success of contemporary oncological diagnosis and management.

Expert consensus published in 2010 on cardiac MRI includes several important indications related to oncological evaluation and monitoring.[2] Cardiac MRI may be used to characterize tissue within cardiac masses and may aid in the early differentiation between cardiac pseudotumors, benign or malignant cardiac tumors, and thrombi.[2–4] Furthermore, cardiac MRI can help the health care professional characterize extracardiac structures, including pericardial masses, and delineate the physiological sequelae of tissue involvement such as pericardial constriction.[2]

In patients with heart failure or nonischemic heart disease, cardiac MRI is indicated to quantitatively evaluate chamber size, ventricular mass and morphology, wall motion abnormalities, and systolic and diastolic function.[2,5] These evaluations are useful in patients with cardiomyopathies related to cardiotoxicity or infiltrative diseases, including amyloidosis or sarcoidosis.[2] Patients receiving chemotherapy who frequently receive blood transfusions are at risk for iron overload, which may also be evaluated with cardiac MRI.[6] In patients with cancer and comorbid, chronic cardiovascular conditions, such as coronary artery disease and ischemic heart disease, cardiac MRI may be used to assess for myocardial viability, necrosis, and scar tissue, and can be used to identify subendocardial ischemic processes.[2] Structural abnormalities, including coronary artery anomalies and valvular disorders, can also be evaluated. In pediatric patients with cancer, cardiac MRI may be an important adjunct for assessing congenital heart disease without exposing these children to ionizing radiation.

Cardiac MRI can assess a range of parameters and provides advantages over other imaging modalities. Most pulse sequences of cardiac MRI can achieve spatial resolutions of 1 × 1 × 3 mm voxel size and temporal resolutions of 20- to 40-millisecond frame rates with cine sequences (Table).[2,7,8] In addition, studies have shown high reproducibility rates and low variance of quantitative measures of cardiac MRI across different observers, scanners, and institutions.[2,9] Although a description of the underlying physics and components of pulse sequences for imaging are beyond the scope of this article, sequences of cardiac MRI can generally be categorized into bright blood (gradient echo-based or steady-state free precession [SSFP] acquisition) or dark blood (inversion recovery or spin echo acquisition) imaging sequences.[2,5] Cine bright-blood imaging sequences are optimally used to assess cardiac function, ventricular mass and volume, myocardial perfusion, and blood flow.[2,5]

Dark-blood imaging sequences, including T1-weighted, T2-weighted, and gadolinium-enhanced sequences, are used to assess cardiac and tumor morphology.[10,11] Standard cardiac MRI takes approximately 1 hour at 1.5 T or 3 T and involves localizers, cine SSFP left ventricular (LV) short- and long-axis (2-, 3-, and 4-chamber) views, and postcontrast delayed viability imaging.[12] In oncological imaging, T2-weighted, fast-spin echo or inversion recovery gradient echo and T1-weighted fast-spin echo sequences allow further lesion characterization.[2,13,14] When lesions involve the right ventricle (RV), axial cine SSFP will offer RV structure and function evaluation. First-pass arterial perfusion offers vascularity evaluation of the suspected tissue. Refer to the Table for indications of each sequence of cardiac MRI.[7]

Compared with imaging modalities — including fludeoxyglucose F 18 positron emission tomography, thallium Tl 201, single-photon emission computed tomography (CT), CT alone, and echocardiography — cardiac MRI allows the qualitative and quantitative assessment of cardiac anatomy, function, perfusion, and tissue characteristics in a single examination.[2] It avoids exposing patients to ionizing radiation, radioactive isotopes, or iodinated contrast with highly reproducible, noninvasive imaging that has significant advantages over alternative imaging modalities.[2,5] Cardiac MRI also offers superior tissue characterization, with high spatial and temporal resolution and multiplanar imaging with a larger field of view, that can be performed in patients of various body habitus.[2,5,10,13]

Limitations of cardiac MRI include the time necessary for the examination, reactions to contrast media, and its cost.[1,5] The need for breath holds and electrocardiographical gating can also reduce image quality, particularly in patients with poor pulmonary reserve or in the presence of arrhythmias.[10,13] Patients who have claustrophobia and those with non–MRI-compatible medical devices may be unable to undergo cardiac MRI.[14] Cardiac MRI also has limited abilities for the detection of calcium in the coronary arteries; thus, it should be used in conjunction with other modalities if the presence of calcium is being investigated.[10]

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