CT-Fluoroscopy Guided Percutaneous Biopsy of Cardio-Pericardial Masses

Introduction

CT-fluoroscopy allows for real-time needle visualization with potential synchronization to the patient’s movements or changes in position of the intended biopsy target. ¹ The rapidly beating heart is indisputably one of the most challenging biopsy targets due to the constant motion and the vulnerable anatomical structures. In addition, minor procedural complications may inadvertently lead to detrimental outcomes.

Materials and Methods

Patient Cohort

Twenty patients presenting with cardio-pericardial masses, referred for tissue sampling to our center between August 2018 and April 2023, were included in this study. The Institutional Ethics Board waived the need for retrospective patient consent.

Procedure

All procedures were performed on a Cardiac CT scanner (Canon Aquilion One Vision, Otawara, Japan). Intravenous sedation (50 micrograms of Fentanyl and 1 mg of Midazolam) and nasal oxygen were provided; EKG electrodes were connected to an in-room EKG monitor.

The best possible access route was determined with the following guiding principles: prefer the shortest access route, protect internal mammary and coronary vessels, and avoid penetrating ventilated lung tissue and myocardium if possible. For needle navigation, intermittent CT-fluoroscopy was either initiated by the foot pedal synchronous to the EKG monitor beeps or automatically synchronized to the EKG at end-systole to ensure the best possible reproducibility of the cardiac cycle.

Patients were monitored post-biopsy for 2 hours. Two posteroanterior chest radiographs were obtained at 1 and 2 hours post-procedure before patients were discharged home. The total procedure in-room time was taken from the Radiology Information System (RIS).

Results

Patient demographics, clinical and imaging presentations are summarized in Table 1. Mapping of the coronary arteries using cardiac CT angiography was performed in 3 patients prior to the biopsy (patients 3, 11 and 14, Figure 1). A pericardial drainage of pre-existing pericardial effusion was deemed appropriate in 1 case (patient 14). In 2 patients, we applied the technique of a protective capnothorax ² to avoid passing through aerated lung parenchyma (Figure 2); mediastinal widening through hydro-dissection was applied in 1 patient.

Table 1.

Patient Demographics, Clinical and Imaging Presentation, Biopsy Location, Final Pathology and Complications.

Pactatient	Age/Sex	Clinical Presentation	Imaging Findings	Location of Target	Method	Number of Cores/Passes	Pathology	Complication
1	70/F	Known plasma cell leukemia with cardiac tamponade and left pleural effusion	Nodular enhancement of pericardium on contrast-enhanced chest CT	Pericardial	CNB	2	Plasma cell neoplasm	None
2	48/M	Shortness of breath due to pericardial effusion	7.5 cm right atrial mass on contrast-enhanced chest CT scan and cardiac MRI	Intra-pericardial	FNA	3	Angiosarcoma	None
3	36/M	Progressive exertional chest pain and dyspnea	9 × 12 cm lipid density intrapericardial mass along the left heart border on contrast-enhanced chest CT and cardiac MRI	Intra-pericardial	CNB	3	Right atrium epicardial lipomatous hypertrophy	None
4	54/F	Recurrent breast cancer 10 years after her initial diagnosis	Cardiac and pericardial lobulated metabolically Active soft tissue masses on contrast-enhanced chest CT scan and PET	Intra-pericardial	CNB	1	IgG 4-related disease	Small hemothorax
5	50/F	Chest pain and dyspnea and clinical diagnosis of pericarditis	Thickened pericardium on contrast-enhanced chest CT	Pericardial	CNB	3	Organizing fibrin with no malignancy	None
6	57/F	Intermittent palpitations	7.8 × 5.2 cm enhancing mass along right cardiac border on contrast-enhanced chest CT	Intra-pericardial	CNB	1	Hemangioma	None
7	68/M	Chest pain and dyspnea and clinical diagnosis of pericarditis	Thickened pericardium on contrast-enhanced chest CT	Pericardial	CNB	3	Non-malignant stromal cells	Small pneumomediastinum
8	50/M	Sharp pleuritic left-sided chest pain, dry cough, and palpitations	Diffuse pericardial thickening, and increased mediastinal soft tissue infiltrating around the great vessels on contrast-enhanced chest CT	Pericardial	CNB	2	Tuberculosis	None
9	25/M	Nonspecific neck and groin pain and some abdominal symptoms	Calcified mass in the interventricular septum on contrast-enhanced chest CT and cardiac MRI	Intra-pericardial	CNB	2	Cardiac fibroma	None
10	31/M	Dyspnea	Lobulated masses encircling anterior heart extending to main pulmonary artery on contrast-enhanced chest CT scan	Intra-pericardial	CNB	3	Spindle cell sarcoma	None
11	67/F	Chest pain	Lobulated mass encircling anterior heart and great vessels	Intra-pericardial	CNB	2	B-cell lymphoma	None
12	49/F	Dyspnea	Pericardial effusion and cystic mass attached to pericardium	Pericardial	CNB	1	Pericardial cyst	None
13	61/F	Palpitation	Fat density mass within the right atrium	Intra-pericardial	CNB	1	Hibernoma	None
14	21/M	Chest pain	Large mass encircling RVOT, LVOT and left main coronary and left anterior descending and circumflex artery	Intra-pericardial	CNB	2	Poorly differentiated synovial sarcoma	None
		Repeat biopsy after chemotherapy	Significantly reduced size of the left ventricular myocardial mass	Intra-pericardial	CNB	2	No viable cancer tissue, fibrosis	None
15	33/M	Prior lung B-cell lymphoma	Nodular pericardial thickening	Pericardial	CNB	1	Lymphoma	None
16	70/F	Symptomatic DLBCL	AV grove mass infiltrating the lateral wall of the right ventricle, right atrium and coronary sinus	Intra-pericardial	CNB	1	B-lymphoblastic lymphoma	None
17	59/F	Resected thymoma 2 years prior, h/o parathyroid cancer; MEN2-syndrome	2 cm right pericardial nodule	Pericardial	CNB	1	Thymoma metastasis	None
18	63/F	Phyllodes tumour, suspected recurrence with cardiac metastasis	3 cm pericardial mass with encasement of the inferior vena cava	Pericardial	CNB	1	IgG4 vs inflammatory myofibroblastic tumour (IMT), pathology was unable to differentiate	None
19	90/M	Suspected cholangiocarcinoma, likely infected, suspected epicardial metastasis	2 cm nodule attached to the pericardium	Pericardial	CNB	1	Cholangiocarcinoma metasasis	None
20	67/F	Incidental abnormality on “health-check” EKG	5 cm fatty interventricular mass	Intra-pericardial	CNB	2	Fatty infiltration of interventricular septum, no malignancy	None

Figure 1.

A seventy-year-old woman was found to have a soft tissue mass in the right AV grove infiltrating the lateral wall of the right ventricle, right atrium and coronary sinus. Mapping of the coronary arteries visualizes the course of the RCA (A, arrow; B, three-dimensional reconstruction, the mass is coloured in yellow). The needle was navigated using EKG-gated CT- fluoroscopy into the mass right lateral to the RCA (C). Histology identified the manifestation of a B-lymphoblastic lymphoma.

Figure 2.

Twenty-one-year-old man with synovial sarcoma, second biopsy after chemotherapy. The T2-weighted free-breathing MRI (A) and contrast-enhanced CT (B) show the previously biopsied synovial sarcoma. The biopsy was indicated to assess treatment response and to evaluate subsequent surgical resection. A capnothorax was introduced to gain access from left lateral (C) without traversing ventilated lung (D). Histology confirmed treatment success, only showing fibrotic tissue without viable tumour cells.

With the exception of 1 case, an 18 gauge full-core biopsy gun was used to harvest 1-3 cores from the target lesion. A fine-needle aspiration biopsy was performed in 1 patient (patient 2).

All biopsies resulted in a definitive final diagnosis. The duration of the biopsy procedure ranged from 30-50 minutes (total in-room time). One patient developed a small hemothorax immediately detected after needle retraction and was admitted overnight as a precautionary measure. A trace of mediastinal air was detected in a single patient immediately after pericardial biopsy, likely introduced through the biopsy needle.

Discussion

All cardiac biopsies were successful, yielding definitive diagnoses with important bearings on further management, and performed under local anesthesia and intravenous sedation, obviating the need for general anesthesia. We did not experience relevant complications (extended hemorrhage, pericardial tamponade, arrhythmia, embolization), which compares favourably with individual case reports (supplemental submission).

Endoluminal access routes are often preferred to avoid excisional biopsy via mediastinoscopy or cardiac surgery;^3,4 however, physical constraints limit the ability to sample deep myocardial or pericardial masses. Several techniques have been developed to allow for more forceful transcatheter “push” to avoid superficial sampling.^5,6

Limitations of this study include its retrospective nature and the single-center experience with no alternative sampling methods tested in comparison. Also, all biopsies were performed by the same operator in collaboration with a clinical care team and highly skilled technologists and nurses, limiting the generalizability of the results.

In conclusion, this first case series highlights that CT-fluoroscopy guided cardiac biopsies are safe to perform, leading to definitive diagnoses in our study population; judicious use of this procedure in carefully selected patients appears paramount.

Supplemental Material

Supplemental Material - CT-Fluoroscopy Guided Percutaneous Biopsy of Cardio-Pericardial Masses

Supplemental Material for CT-Fluoroscopy Guided Percutaneous Biopsy of Cardio-Pericardial Masses by Patrik Rogalla, Ciara O’Brien, Mini Pakkal, Sonja Kandel, Nikta Sarie, Robert James Cusimano and Marina Pourafkari in Canadian Association of Radiologists Journal