Penn cardio-oncologists outline general uses for cardiac MRI in cardio-oncology patients. This includes tissue characterization, constriction assessment, and masses characterization.
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our talk is about TMR and cardio oncology and I'm sure you one of the cardiology fellow combined program between Washington pen. I'm Benedict. I'm one of the cars oncology fellow. And I just wanted to let you know that this is really a share uh effort from the three of us for that presentation. And it's meant to be like an overview of all the reasonable some of the reason that you may want to order a cardiac M. O. I. For your patient, card oncology here are some of the general uses that you may want to order A CMR. Obviously we all know that CMR is the gold standard for the evaluation, the assessment of LV function. So with the ejection fraction, the LV and also the RV function, it's also one of its an excellent tool to assess the R. B. Sides the function and also characterization. And we're thinking about RBC in this and we're not going to be talking about that. It's also an excellent tool for flow assessment. With the help of uh blow and uh with the help of the flow sequences. It's excellent to quantify valvular regurgitation. It's better in regular stations stenosis and it's really a volume quantification and not just a visual assessment. It's also a tool for assessing shunting we're taking about VSD. Or ASD in this. You may also um you CMR for profusion. Um We're thinking about Islamic work up but also it's going to be useful masses to see if there's any vascular authority. And then we're going to concentrate that a presentation a little bit of tissue characterization with the T. One T. Two and a extra cellular volume in the leg gathering of announcement also constriction tom masses characterization. And we won't be talking about special secrets such as the T. Two star but are in overload quantification. So let's start with tissue characterization. Yeah, tissue characterization can be done with T. One and T. Two mapping. T one is the longitudinal relaxation time. And this is usually prolonged in anything which with myocardial edema or anything which increases the industrial space with fibrosis, scar or amyloid deposition teen on the right is uh colored map of pre contrast, even which is essentially normal in this patient. A normal T. One. For a 1.5 Tesla magnet is 9 52,000 and for three Tesla is 1100 to 12 50. However, a normal T one time depends on the magnet strength and the sequence is used and also depends on the age gender of the patient. And this has to be not. A normal value should be established for each center. And but if you use the same sequences then it's highly reproducible. And at penn, the normal values for T. One at 1.5 Tesla magnet is 9 50 to 10 50 milliseconds. The T2 weighted sequences uh with uh this is elevated in anything which increases the myocardial water content. Um so higher teacher relaxation time is seen with oedema. Both. These can be utilized in the diagnosis of any infiltrated cardiomyopathy, myocarditis or an M. I. What is the role of these sequences in early detection of cardio toxicity with and recycling or other chemotherapy agents? There is limited clinical data overall, but these changes can occur, especially with T. two earlier. And there's ongoing research and this could potentially help with initiation of cardio protection prior to a drop in L. V. E. F. So another sequence of another measurement that we can do is extra cellular volume assessment. And this is the formula to your right that we we can we use to measure the extra seller volume so we use a T. One relaxation prior and after gadolinium announcement, Gadolinium an injection and as with the blood pool um T one pre and post uh injection. And with the help of a metro credit we can get the express similar volume assessment. So in our institution normal express similar volume PCV is between 24 30% after 30%. This may help us um uh to think that this may help us thinking that there might be a prosthesis that can happen. So to your left under graph You can see as the extra volume increases. Usually you're the one you native to. One value increases. And there's good studies that show that for let's say for amyloidosis I think an extrasolar volume of 47%. As a sensitivity Of 92 and the specificity of 82%. And there's also a good data especially in the area. Mellado says that the higher extra seller volume predict mortal can predict mortality increases your risk of mortality in the next few years. So this is like another tool that we can use. And just to let you know there's some app that can calculate the extra cellular volume for you. You don't need to use that big formula. Next. We're also going to talk about the use of gadolinium. Um so with the use of emotion recovery techniques in contrast imaging, this has improved the contrast to noise ratio. And we're able to use um gadolinium agents which can and depending on the patterns of late gadolinium enhancement, identify ideology of cardiomyopathy. So LG represents myocardial scarring and fibrosis and this can be used to differentiate the theology. Below is a picture which is taken from the Radio Graphics Journal. And uh as you can see you can see amid myocardial stripe with dilated cardiomyopathy or in uh L. G. In hypertrophic cardiomyopathy. You could see um late gadolinium enhancement at the RV insertion point or the intra ventricular septum seven myocardial L. G. E. Which can be seen in um in fort. And also the diffuse of industrial pattern with amyloid deposition. Um And seen here are some pictures. The first one is that the RV in social point in a patient with hypertrophic cardiomyopathy. Diffuse of India Korea LG in a patient with amyloid in mid my cardiology for dilated cardiomyopathy and pericardial enhancement seen here. These patterns are not routinely seen, especially with Aunt recycling induced Korea toxicity. And uncommon with her two related cardio toxicity and one of the thought process of lack of LG. With Aunt recycling Korea toxicity is thought to be from a diffuse myocardial involvement with lack of normal myocardial. Although I don't think we have a complete understanding as to why this happens next. We're going to talk about a few cases highlighting the importance of tissue characterization and what it could do in some of our patients. Mhm. So our first patient is a 70 year old gentleman with metastatic renal cell carcinoma, forest. Diffuse metastases was treated radiation. It was started a camp ascension it which is that charlie's incarnates inhibitor that had to be stopped due to disease progression. It was after it started an epilepsy map and the volume at which are both immune checkpoint inhibitors. About 15 days post people in the map and the volume map initiation it presented to the emergency room with fatigue. And this year he had also ongoing night sweats, subjective fever, My algebra witnesses and at this near on exertion for about a week. Here are the vital sign in emerges emergency room. It was slightly tachycardic at one of six beats per million. His blood pressure was normal at 123 over 78 mm of mercury. It was febrile at 38.6C and it was setting well 98 of women where it was not a flattering, there was no chest pain. Next slide. Yeah. Here are some of the blood results in the emergency room. As you can see tre penance. I were elevated up to 1.73 in our institution. Normal values are less than 0.03. Also to be noted that is creatine kinase was highly elevated more than 7000 and there's anti problem. He was also elevated more than 1800. You can backslide so we perform an echocardiogram in the emergency room just to let you know what personal long access to the left. Personal short access to your right as you can see there's no pericardial effusion and um the E. F. Appears to be normal about 60%. There's no regional wall motion abnormality based on these two the based on these images. Next time Um we perform strain on everybody and next next slide. And here's I'm giving you the both eyes is trained was decreased and -13.6. And because we didn't have a good explanation, they were still thinking that this patient could have immune checkpoint in a bit of myocarditis. Giving the elevated troponin is an anti pro Bmp. This patient on the world cardiac magnetic resonance the day after admission. And here I am showing you example of A. T. One mapping to your left and T. To mapping to your right. And with pointing with the area of interest. We were able to see that there was increasing T. One value up to 1229 to your left. That was at the basil intro septum In our institution normal is between 9:15 and 10:50. And also to your right. We were also able to show that was increasingly to value up to 60 61 millisecond in our institution is normal and then 50 milliseconds again in the basal to mid introspective segments. And with the with the sequence of Leggett and um announcement sequence. We were also able to show that there was epic cordial to mid myocardial Leggett and um announcement in the basil and to recep them at the same area where the T. One and T. Two values were elevated. Of note the cf was normal at 56% for this gentleman because we had um elevated T. One and T. Two values. And also that pattern in a specific pattern LG. We were able to diagnose him with acute myocarditis due to the immune checkpoint inhibitor. Next slide. And I just want to let you know there's an updated recommendation updated criteria for acute myocarditis. The updated lately weeks criteria that was published in uh december 2000 and 18 and now the T. One and T. Two or central. You you need to have elevated T. One and elevated T. To to be able to make the diagnosis with acute myocarditis. Obviously there's some supportive criteria with pericardial effusion or systolic LV. Dysfunction whether it's global. Original that can help you making the diagnosis. But really the T. One and T. Two characterization are key in this diagnosis. Our next case is a 63 year old male with the past history of hypertension and hypercholesterolemia who presented with four weeks of Disney on exertion and lower leg. Oedema. His E K. G. Was sinus with a normal QRS. You underwent an echo which showed an L. V. E. F. Of 45% with great three diastolic dysfunction. He did have an elevated anti pro BNP at 17 34 And the minimally elevated proponent at .22 also had two plus protein in urine analysis. His lab work given suspicion for a like. He had underwent lab work which showed an em spike of 0.2 g per deciliter, but an abnormal capital lavender right ratio with an elevated kappa free light chain. At 7.95 He underwent a bone marrow biopsy which showed 20 lambda restricted plas missiles without Amyloid deposition. Given the suspicion for cardiac involvement with abnormal cardiac biomarkers, he underwent cardiac MRI. What are some of the findings you could see With cardiac amyloid in cardiac MRI. You could see increased concentric well thickness with a pericardial effusion and with the use of gadolinium based and imaging, because there is no normal my accordion for the gadolinium to normal, you're going to see simultaneous snelling off the maya cardi. Um And the blood pool which is highly specific for amyloid. The L. G. Patterns, which can be seen with cardiac amyloid. You either see no L. G. Or southern do cardio versus a trance mural. This is not a dichotomous pattern, but it is as the disease evolves that the pattern of LG goes from none to surrender corneal to trance mural. With trance mural carrying the worst prognosis, you can also see increased native T. One and T. Two times T. two elevation is higher in untreated Ale Amyloid and is a predictor of prognosis and with T. One elevation and E. CVR elevation can be seen early before. Even elevated cardiac biomarkers for other testing which can detect cardiac amyloid, but cardiac MRI cannot differentiate between male or T Tr amyloid but can it can give you the diagnosis of cardiac amyloidosis. So going back to our patient, he underwent a cardiac MRI which showed uh increased LV wall thickness at 18 millimeters, a small pericardial effusion and diffuse suburban Korea LG. E, which can also be appreciated along the right along the right ventricle and also the atrial walls. He then underwent an and myocardial biopsy which showed cardiac amyloid deposits containing the lambda light chains. By aspect he was then started on protease um inhibitor and doxycycline for ailes amyloidosis. Next we're going to switch gears and talk about construction. The cardiac Emma is an excellent tool to diagnose constriction. So first of all, here are some of the findings. You can final cardiac my you may see a thickening of the pericardium and usually it's more than four. You may see a septal about this enter ventricular dependence. We ask uh by doing an acquisition of real time free breathing senior images. You ask the patient to breathe normally and that will allow you to visualize the inter ventricular septal bounds during inspiration. You may also see like getting an announcement in the pericardium and that is highly. That is suggested that the fibrosis of the pericardium. And this is also a special sequence called Maya cordial tacking sequence where you, the pericardium is attacked in a grid like fashion. And this will demonstrate addition between the fabric accordion um and the my accordion. So if there is non deformation, if there is a non deformation of the of the grid, it means that it would be constriction versus through sliding. With deformation agree meaning normal uh normal patient, no construction. So here I'm showing you and typical for chamber and a personal short axis demonstrating the septal bonds during free inspiration. The refree breathing as you can see the septum is bouncing during breathing. Here is the mire culture of tagging. So there is a grid like fashion. The myocardial um is uh is a stag and you can see all the small square and a certain places where the arrows showing. There is non deformation, the square meaning that the myocardial is stuck to the pericardium and that's diagnosis. That's a good diagnosed, good diagnosis tool for construction. Again, the same myocardial tagging on the on the typical for chambers and you can see a certain area, The grid is not deforming, it's staying squared and that's again as a sign of construction. And here are again two sequences of leg gathering an announcement. And as you can see, especially on the right on the difficulty chambers, uh you can see the bright para cord and a thick bright pericardium meaning that L. G. In the pericardium. And this is again a signs of construction. The MRI can also be used for diagnosis of CJD and uh in the diagnosis of acute or chronic ischemia are complications related to my especially with the chemotherapy agents used. Our patients are at risk of C. A. D. R. With accelerated CED especially with radiation induced heart disease team. Here is uh images of a patient who came in for evaluation for Disney on exertion. And he also had like regional wall motion in the typical segments of the L. B. And he had transmittal L. G. E. Of the apex. Also seen here in the inferior world. And this is a patient who had on Korea. Cat had a ceo of the mid melody and the circum flex and critic MRI can also be used for identity for quantification of valvular regurgitation with use of face contrast as well. This is a patient who um where we're doing a face contrast imaging of the aortic valve and aortic regurgitation to the dark orange is the forward flow and the reverse flow. You can see hollow diastolic florida where so Um scene with biotic regurgitation. And you can also calculate the regurgitate fraction in this patient that was 74 the gesture of severe ai the next we're going to talk a little bit about the utility of cardiac MRI in um identification of masses and characterization. So this is a great article which was published in Jack cardio oncology about cardiac US. And I would suggest uh for you to go review that article as well. And cardiac MRI can help identify the location of a mass and it's him a dynamic significance as well. And then with tissue characterization and 1st and 1st past perfusion. Also identify the characterization of the korean masses. For example, like with an angio sarcoma, it can be heterogeneous on T. One or T. Two weighted imaging. And because of its vast clarity, you can also see late gadolinium enhancement compared to like coma, which is fat tissue. So it will have the same intensity of your subcutaneous fat. So it will appear intense on your T. One and T. Two weighted imaging with no gadolinium enhancement versus the traumas. If it's an acute trauma it can appear hyper intense on T. One or T two weighted imaging but it's mostly hypo intense on T. One and T. Two weighted imaging and with delayed enhancement with more than 500 milliseconds, you will not see any LG pattern per traumas. So here I'm going to show you a couple of examples. We have a gentleman. Let's just go prior, we have a gentleman. Thank you. That was diagnosed with Rosina Felix myocarditis. So love her syndrome. And then I I just wanted to show you that on the left, on the typical for chambers, the LV wall appears thick but there is normal contraction, that's normal wall motion and the ef also appears normal. However, on the right um that's the leg continuum announcement sequence as you can see is their sub and a cordial fibrosis all the white. I don't know if you can point sri all the white. You can see the seven cordial fibrosis And in the middle can you point in the middle? Can you see my arrow? I don't see it. Mhm. Regardless. So you can see the on the left ventricle you can see the southern myocardial fibrosis that is white. And in the middle there is um like a like a V. Shaped black which is a tremendous because it appears black on the lake gathering Yemen Lanzmann as opposed to a. And that's supposed to unethical Trumpers. That will because due to L. A. D. N. Fargo Islamic disease on the left, on the epochal two chambers you can see that the LV function is severally decrease. There is a genesis at the apex. Also the walls are very thin due to the a kinesis and on the right on the leg of the impermanence man, you can see at the apex there's there's trance mural um L. G. E. So all the wall is white meaning its transmittal leg and in Yemen Enzman. And you can see again there is a it trumps the black the black the black sphere at the apex. So that would be an example and difficult trumpets from ischemia. Next line. And here we just wanted to show you um some of the sequences that we can do when people present with masses. So it was a 40 year old lady with metastatic melanoma. The first image on the left, you can see the a pickle for chamber and you see that global mass pushing onto the right each year. I mean also the right ventricle in the middle image it's what we call the first past profusion. And you can see that the masses announcing at the end of perfusion meaning there's vascular charity. And on the right is the legacy um announcement. That shows that there is some announcement. There's some legal um announcement into the mass. These are some of the the sequence that we would do when we we we see somebody with a mass to try and make the diagnosis of or to narrow the differential diagnosis for a mass. This is somewhere examples of cardiac masses. This is a patient with metastatic merkel cell carcinoma involving the intra atrial septum. There is a very slight rim of L. G. E. Around but it's predominantly there is no update by the TMR itself and this is another patient with pericardial metastasis with metastatic lung cancer which can appear heterogeneous on T. One or T two weighted imaging. But there's no L. G. E. Update with these and then a cardiac angio sarcoma. In a patient which was biopsy proven in the right atrium extending to the superior cable atrial junction. And you can see LG uptake in a cardiac angio sarcoma. And this is a patient with non bacterial traumatic endocarditis of the aortic valve with a patient with non metastatic lung cancer which can be seen on side imaging as well. So if you take home points of cardiac MRI, it is the gold standard for L. V. E. F. Assessment and it can provide a lot of information even without the use of gadolinium. The total of L. V. E. F. And T one and T two imaging can all be done within 10 to 20 minutes. And we do have more agents. And here at penn we use Daughter um which can be used regardless of your G. F. R. And can also be used in patients with Srd. And these patients get digitalized the same day. T one E C. V. And T to mapping can detect potentially detect subclinical cardiac dysfunction before the onset of a word Korea toxicity. And these sequences can be used to identify the ideology of a cardiac disease process or cardiomyopathy. It's helpful in the diagnosis of construction, myocarditis, amyloidosis and the differential diagnosis of masses. There is ongoing research with the use of MRI strain analysis which can be done with several different techniques and its utility for early detection of cardio toxicity. And there's more to come about it in the future. And we just wanted to point out another excellent state of the art review. That was that was published in the Jack Carter oncology in June 2020 on the use of magnetic resonance imaging to the deck cardiovascular effects of cancer to repeat. So thank you. Thank you.
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