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Assessing the haematology/oncology patients

Non-invasive Imaging: Magnetic Resonance Imaging

“Assessing the Haematology/Oncology patients” has been an engaging and well attended session, moderated by Alexis Jacquier and Christopher H Kramer.

Five excellent talks illustrated the role and clinical application of CMR cardio-oncology patients.

Michael Salerno (University of Virginia Health System) opened the session giving a clear excursus on chemotherapy drugs with cardiac toxicity and an exhaustive summary on management of cardio-oncology patients. The lecturer was further completed and elegantly developed by Ana Barac (Washington Hospital Center).
Focusing on LV dysfunction, Anthracyclines and Trastuzumab (Herceptin) represent the most common agents that cause chemotherapy-related cardiac dysfunction, (CRCD).
Anthracyclines, used in breast cancer, lymphoma, leukaemia and other solid tumour, cause type I CRCD, inhibiting DNA and RNA synthesis. Their effect is dose-dependent  and permanent. Trastuzumab has usually a reversible effect and is not dose-dependent. Imaging techniques used to assess LV systolic function are: MUGA, echocardiography, including 3D echo and speckle tracking and CMR.

Despite the clear benefit and accuracy of CMR imaging, nowadays in the cardio-oncology community all prognostic data are based on Echo rather than CMR.
By most recent US guidelines, CMR is recommended only when echo reaches threshold for LV dysfunction or when clear abnormalities are see in echo.
Imaging plays an undisputed role in detection and prevention of cardiotoxicity, but we still need further studies to implement the use of CMR in the diagnostic pathways.
Not much more is known in terms of specific medical treatment for CRCD:  we currently use Heart Failure guidelines. Few studies suggest that Carvedilol, Enalapril and Atorvastatin protect and preserve the EF.

Patricia Bandettini (Bethesda, Maryland) delighted us with an exhaustive overview on the role of CMR in diagnosis and  differentiation of cardiac masses.
She emphasised how much CMR clarifies the anatomy, providing not only images of the heart but also of the adjacent structures.
Beyond anatomy, tissue characterisation plays an essential role on defining and identifying the mass using SSFP, T1,T2 bright, T2 black, water and fat characterisation.
The acquired anatomical images guide the selection of slides that can be characterised further .
Caveat are still small masses with random movement, difficult to capture.
Patricia warned us on misdiagnoses:  “pseudo-tumour “, such us eustachian valve, crista terminalis, lipomatous hypertrophy of interatrial septum,  are actually normal or pseudo-normal structurer.
Guideline are useful to classify masses in thrombus, benign tumour and malignant tumour and help us to identify them, however are “guidelines” and - she concluded effectively quoting her editor - "as criminals, cardiac masses not always follow the rules" .

James Moon (Heart Hospital/Bart’s Healthcare Trust) spoke expertly on Novel Uses of Tissue Characterisation in Screening and Monitoring the Oncology/Hematology Patients.  He covered three diseases (anthracylclines, amyloid and iron overload) and three relaxation parameters(T1 native/ECV, T2 and T2* mapping).
Anthracycline cardiotoxicity makes up the largest group of patients, yet they are the most difficult to characterise as they fall into the diffuse fibrosis group as determined by native T1(ms) and ECF(%) with little in the way of detectable or specific histological changes.
In Amyloid disease, late gadolinium mapping with PSIR was emphasized. Native T1 is elevated with dose dependent changes which can predate biomarkers and gauge the severity of cardiac involvement early on.  AL and ATTR have different myocyte response with ATTR having more amyloid with different biology which may explain the less aggressive clinical course.  Native T1 and ECV predicts outcome. Hopefully, this will aid in drug development.
Iron overload has been transformed by the measurement of T2*, as with biomarker directed therapy, survival has improved dramatically.  As it turns out, T1, T2 and T2* all fall with iron (as all measure water).  Mapping technologies will help as analysis is shorter with better curve-fitting allowing for new processing pipelines which are more reliable, allow for motion correction and have higher resolution.

Lauren Simprini beautifully concluded the session explaining the clinical use of CMR in Cardio-oncology patients. As we know CMR is not limited by body habitus, acoustic window or patient’s anatomy; in addition is free from radiation and post-surgical patients experience less physical discomfort. On the other side we have some challenges: timing the study is critical and requires coordination of care, many patients are frankly sick with arrhythmias, more anxiety, which ends easily in claustrophobia. Not irrelevant is the high cost, especially when insurance coverage is required.
CMR is therefore not justified as first line modality, however T2* is essential for iron overload and chemotherapy patients, T1 mapping for pre-clinical LV  systolic and diastolic dysfunction, tissue characterisation, as said, helps substantially to identify masses. Beside these common uses, important to highlight how CMR is safer and better tolerated  in oncology and post-surgical patients to diagnose IHD, valve disease, pericardial disease and gives us valid input on heamodynamics.  
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.