Value of Cardiac Magnetic Resonance in Cardio-oncology in Respect of a Case (QF_FR_073)

55-year-old patient. History of diabetes mellitus, systemic arterial hypertension, obesity, ischemic stroke; Uterine leiomyosarcoma diagnosed in 2018 for which she underwent radical hysterectomy and received chemotherapy treatment with anthracyclines.

She went to the outpatient clinic due to dyspnea on great effort that progressed to moderate effort, slight edema in the lower limbs.

Cardiovascular physical examination: heart sounds were rhythmic without murmurs, and on auscultation there were no additional sounds.


Diagnostic Techniques and Their Most Important Findings:

An echocardiogram was performed in which LVEF of 35% was evident, with her previous LVEF being 52%.

Ischemic etiology was considered as probable as well as cardiotoxicity secondary to anthracyclines. Therefore, a stress cardiac magnetic resonance with adenosine was performed.

The result was negative for ischemia and a mass was found in the pericardial space adjacent to the lateral wall of the left ventricle and another near the apex of the right ventricle, both of heterogeneous signal intensity, with an increase in T1 and T2 mapping times, hypointensity in the first pass sequence and late enhancement with central hypointensity. The masses compromise myocardial motility in the adjacent segments. The left ventricular systolic function was calculated to be slightly reduced (LVEF 42%) at rest, presenting an overall increase in systolic thickening, with a normal ejection fraction at stress (LVEF 59%). The right ventricular systolic function was normal, however, in the longitudinal and radial strain were found to be reduced and a greater reduction was found in the segments adjacent to the masses (Global longitudinal strain -11.3%, global cirfumferential strain 18.5 %, radial strain 18.5%).

The masses were compatible with pericardial and myocardial metastasis of the already known primary. Mild pericardial effusion. Among the extracardiac findings were multiple bilateral pulmonary nodular lesions and lesions in the left paravertebral muscles  compatible with metastasis.

The patient continued receiving medical treatment and was referred to oncology for management of the underlying neoplasia.


Learning Points from this Case:

In patients who have survived cancer, multiple complications can be found: there is an increased risk of developing cardiovascular diseases, risk of cardiotoxicity secondary to the treatment, and the possible development of cardiac masses must be evaluated. Although echocardiography is the first-line imaging method, cardiac magnetic resonance offers advantages in the evaluation of cancer patients for complications that may occur due to cancer or the treatment used by assessing the cardiac structure, assessing the systolic function of both ventricles (with CMR being the gold standard), myocardial deformation, tissue characterization, and ruling out ischemic heart disease (with with LGE and using stress CMR as in the case described).

The role of cardiac imaging is fundamental in cardio oncology. Cardiac magnetic resonance is a noninvasive imaging technique with high reproducibility in which radiation is not used.

Tissue characterization sequences allow differentiation of the different etiologies of heart failure in these patients.

A case is presented in which magnetic resonance was the method of diagnosis of the presence of these cardiac masses as metastasis of the primary cancer.

The usefulness of CMR will allow better diagnosis and management of the cardiological and oncological condition.