Risk stratification of cardiac metastases using late gadolinium enhancement cardiovascular magnetic resonance: prognostic impact of hypo-enhancement evidenced tumor avascularity

Background Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is widely used to identify cardiac neoplasms, for which diagnosis is predicated on enhancement stemming from lesion vascularity: Impact of contrast-enhancement pattern on clinical outcomes is unknown. The objective of this study was to determine whether cardiac metastasis (C MET ) enhancement pattern on LGE-CMR impacts prognosis, with focus on heterogeneous lesion enhancement as a marker of tumor avascularity. Methods Advanced (stage IV) systemic cancer patients with and without C MET matched (1:1) by cancer etiology underwent a standardized CMR protocol. C MET was identified via established LGE-CMR criteria based on lesion enhancement; enhancement pattern was further classified as heterogeneous (enhancing and non-enhancing components) or diffuse and assessed via quantitative (contrast-to-noise ratio (CNR); signal-to-noise ratio (SNR)) analyses. Embolic events and mortality were tested in relation to lesion location and contrast-enhancement pattern. Results 224 patients were studied, including 112 patients with C MET and unaffected (C MET -) controls matched for systemic cancer etiology/stage. C MET enhancement pattern varied (53% heterogeneous, 47% diffuse). Quantitative analyses were consistent with lesion classification; CNR was higher and SNR lower in heterogeneously enhancing C MET (p < 0.001)—paralleled by larger size based on linear dimensions (p < 0.05). Contrast-enhancement pattern did not vary based on lesion location (p = NS). Embolic events were similar between patients with diffuse and heterogeneous lesions (p = NS) but varied by location: Patients with right-sided lesions had threefold more pulmonary emboli (20% vs. 6%, p = 0.02); those with left-sided lesions had lower rates equivalent to controls (4% vs. 5%, p = 1.00). Mortality was higher among patients with C MET (hazard ratio [HR] = 1.64 [CI 1.17–2.29], p = 0.004) compared to controls, but varied by contrast-enhancement pattern: Diffusely enhancing C MET had equivalent mortality to controls (p = 0.21) whereas prognosis was worse with heterogeneous C MET (p = 0.005) and more strongly predicted by heterogeneous enhancement (HR = 1.97 [CI 1.23–3.15], p = 0.005) than lesion size (HR = 1.11 per 10 cm [CI 0.53–2.33], p = 0.79). Conclusions Contrast-enhancement pattern and location of C MET on CMR impacts prognosis. Embolic events vary by C MET location, with likelihood of PE greatest with right-sided lesions. Heterogeneous enhancement—a marker of tumor avascularity on LGE-CMR—is a novel marker of increased mortality risk.