Clinical Investigations
Echocardiographic Features of Cardiac Masses and Diagnosis
Echocardiographic Markers in the Diagnosis of Cardiac Masses

https://doi.org/10.1016/j.echo.2022.12.022Get rights and content

Highlights

  • The echo parameters required for a comprehensive CM assessment are still unknown.

  • Six prespecified echo features of CM can rapidly raise the suspicion of malignancy.

  • Combining three or more parameters, diagnostic accuracy reaches approximately 90%.

  • An algorithm was generated that correctly classified 87.5% of malignancies.

  • These echocardiographic features also proved to have prognostic validity.

Background

The echocardiographic parameters required for a comprehensive assessment of cardiac masses (CMs) are still largely unknown. The aim of this study was to identify and integrate the echocardiographic features of CMs that can accurately predict malignancy.

Methods

An observational cohort study was conducted among 286 consecutive patients who underwent standard echocardiographic assessment for suspected CM at Bologna University Hospital between 2004 and 2022. A definitive diagnosis was achieved by histologic examination or, in the case of cardiac thrombi, with radiologic evidence of thrombus resolution after appropriate anticoagulant treatment. Logistic and multivariable regression analysis was performed to confirm the ability of six echocardiographic parameters to discriminate malignant from benign masses. The unweighted count of these parameters was used as a numeric score, ranging from 0 to 6, with a cutoff of ≥3 balancing sensitivity and specificity with respect to the histologic diagnosis of malignancy. Classification tree analysis was used to determine the ability of echocardiographic parameters to discriminate subgroups of patients with differential risk for malignancy.

Results

Benign masses were more frequently pedunculated, mobile, and adherent to the interatrial septum (P < .001). Malignant masses showed a greater diameter and exhibited a higher frequency of irregular margins, an inhomogeneous appearance, sessile implantation, polylobate shape, and pericardial effusion (P < .001). Infiltration, moderate to severe pericardial effusion, nonleft localization, sessile implantation, polylobate shape, and inhomogeneity were confirmed to be independent predictors of malignancy in both univariate and multivariable models. The predictive ability of the unweighted score of ≥3 was very high (>0.90) and similar to that of the previously published weighted score. Classification tree analysis generated an algorithm in which infiltration was the best discriminator of malignancy, followed by nonleft localization and sessile implantation. The percentage correctly classified by classification tree analysis as malignant was 87.5%. Agreement between observer readings and CM histology ranged between 85.1% and 91.5%. The presence of at least three echocardiographic parameters was associated with lower survival.

Conclusions

In the approach to CMs, some echocardiographic parameters can serve as markers to accurately predict malignancy, thereby informing the need for second-level investigations and minimizing the diagnostic delay in such a complex clinical scenario.

Section snippets

Study Population

This observational cohort study included all consecutive patients who underwent noninvasive imaging investigations (transthoracic echocardiography, CCT, and CMR) for suspected CMs at University Hospital Policlinico Sant’Orsola Malpighi in Bologna, Italy, from January 2004 to September 2022. A definitive diagnosis was achieved by the histologic examination of biopsy or surgical samples or, in the case of cardiac thrombi, by radiologic evidence of thrombus resolution after adequate anticoagulant

Results

A total of 369 patients included in the Bologna Cardiac Masses Registry underwent complete recorded transthoracic and/or transesophageal echocardiographic evaluation from January 2004 to September 2022. As shown in the study flowchart (Supplemental Figure 1), we excluded 83 cases with unavailable histology, extracardiac masses as confirmed by second-level investigations, poor acoustic windows, and masses that were not visualized on echocardiography. The latter included nine pericardial masses,

Discussion

The aim of this study was to describing the echocardiographic parameters of a large population of histologically confirmed CMs and look for practical clues to improve the diagnostic accuracy of malignancy. In the complex approach to CMs, the noninvasive echocardiographic approach may help simplify and optimize the subsequent diagnostic process with the support of second-level noninvasive imaging techniques (i.e., CMR, CCT, and positron emission tomography) when needed.

In summary, our main

Conclusion

Our study in a large cohort of patients with histologically proven CMs confirmed that certain echocardiographic features are strongly related to malignancy. Most important, we found that the simple addition of specific parameters improves the diagnostic accuracy and the correct identification of the masses’ nature. Furthermore, a step-based approach using three characteristics provides improved discrimination in the echocardiographic evaluation of such patients. The identification of these

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  • Cited by (0)

    Drs. Paolisso and Foà contributed equally to this work.

    Dr. Paolisso has received a research grant from the CardioPaTh PhD Program.

    Conflicts of interest: None.

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