Association between FDG uptake in the right ventricular myocardium and cancer therapy-induced cardiotoxicity

Cardiovascular imaging in cardio-oncology

Advances in cancer treatment have improved in patient survival rate. On the other hand, management of cardiovascular complications has been increasingly required in cancer patients. Thus, cardio-oncology has attracted the attention by both oncologists and cardiologists. Cardiovascular imaging has played a key role for non-invasive assessment of cardiovascular alterations complimentary to biomarkers and clinical assessment. Suitable imaging selection and interpretation may allow early diagnosis of cardiovascular injury with potential implications for therapeutic management and improved outcomes after cancer therapy. Echocardiography has been commonly used to evaluate cardiac dysfunction in cardio-oncology area. Cardiac CT is valuable for assessing structural abnormalities of the myocardium, coronary arteries, and aorta. Molecular imaging has an important role in the assessment of the pathophysiology and future treatment strategy of cardiovascular dysfunction. Cardiac MRI is valuable for characterization of myocardial tissue. PET and SPECT molecular imaging has potential roles for quantitative assessment of cardiovascular disorders. Particularly, FDG-PET is considered as an elegant approach for simultaneous assessment of tumor response to cancer therapy and early detection of possible cardiovascular involvement as well. This review describes the promising potential of these non-invasive cardiovascular imaging modalities in cardio-oncology.

A Systematic Review of the Cardiotoxic Effects of Targeted Therapies in Oncology

Cancer therapy advancements have improved survival rates but also introduced significant cardiotoxic risks. Cardiotoxicity, a critical adverse effect of cancer treatments such as doxorubicin, trastuzumab, and radiotherapy, poses substantial challenges. This systematic review synthesizes findings from studies on cardiotoxicity induced by cancer therapies, focusing on detection and management. Key predictors of chemotherapy-induced myocardial toxicity (CIMT) include advanced age, hypertension, hyperlipidemia, diabetes, and elevated N-terminal pro-B-type natriuretic peptide levels. Regular echocardiographic assessments, particularly of the left ventricular global longitudinal strain (LVGLS) and left ventricular ejection fraction (LVEF), are essential for early detection. The CardTox-Score, incorporating these risk factors, shows high sensitivity and specificity in predicting CIMT. Advanced imaging techniques and biomarkers play crucial roles in identifying at-risk patients before functional decline. Early biomarkers and imaging techniques such as LVGLS and LVEF are effective in diagnosing and managing cardiotoxicity, allowing timely interventions. Cardiology involvement in patient care significantly enhances adherence to cardiac monitoring guidelines and reduces cardiotoxicity risks. Management strategies emphasize regular cardiac monitoring, patient education, and the use of cardioprotective agents. A collaborative approach between cardiologists and oncologists is vital to assess cardiovascular risks, minimize vascular toxicity, and manage long-term adverse effects, ensuring the safety and efficacy of cancer therapies. This review underscores the importance of early detection and proactive management of cardiotoxicity in cancer patients to optimize treatment outcomes and improve quality of life.

Guarding the heart: How SGLT-2 inhibitors protect against chemotherapy-induced cardiotoxicity: SGLT-2 inhibitors and chemotherapy-induced cardiotoxicity

The introduction of chemotherapy agents has significantly transformed cancer treatment, with anthracyclines being one of the most commonly used drugs. While these agents have proven to be highly effective against various types of cancers, they come with complications, including neurotoxicity, nephrotoxicity, and cardiotoxicity. Among these side effects, cardiotoxicity is the leading cause of morbidity and mortality, with anthracyclines being the primary culprit. Chemotherapy medications have various mechanisms that can lead to cardiac injury. Hence, numerous studies have been conducted to decrease the cardiotoxicity of these treatments. Combination therapy with beta-blockers, Angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers have effectively reduced such outcomes. However, a definitive preventive strategy is yet to be established. Meanwhile, sodium-glucose co-transporter-2 (SGLT-2) inhibitors lower blood glucose levels in type 2 diabetes by reducing its re-absorption in the kidneys. They are thus considered potent drugs for glycemic control and reduction of cardiovascular risks. Recent studies have shown that SGLT-2 inhibitors are crucial in preventing chemotherapy-induced cardiotoxicity. They enhance heart cell viability, prevent degenerative changes, stimulate autophagy, and reduce cell death. This drug class also reduces inflammation by inhibiting reactive oxygen species and inflammatory cytokine production. Moreover, it can not only reverse the harmful effects of anticancer agents on the heart structure but also enhance the effectiveness of chemotherapy by minimizing potential consequences on the heart. In conclusion, SGLT-2 inhibitors hold promise as a therapeutic strategy for protecting cancer patients from chemotherapy-induced heart damage and improving cardiovascular outcomes.

Progression of Myocardial 18F-FDG Uptake in a Patient with Cardiotoxicity

The objective of this case report was to present the progression of chemotherapy-induced cardiotoxicity in a patient with lymphoma, highlighting the importance of myocardial fluor-18-fluorodeoxyglucose (18F-FDG) uptake by positron emission tomography coupled with computed tomography (PET/CT). 43-year-old female patient with uterine lymphoma, who underwent hysterectomy followed by three chemotherapy regimens and radiotherapy. The patient had episodes of acute heart failure two years after chemotherapy. Echocardiogram revealed a reduction in left ventricular ejection fraction (LVEF). A retrospective analysis of 18F-FDG PET/CT showed an increase in myocardial uptake in all tests performed during oncologic treatment. Despite disease remission, the patient developed heart failure with reduced LVEF. During chemotherapy, there was a diffuse, significant increase in myocardial 18F-FDG uptake, which preceded the decrease in myocardial performance and seemed to reflect metabolic changes in cardiomyocytes, related to cardiotoxicity. Would an analysis of myocardial 18F-FDG uptake yield a different cardiac outcome in this patient? This question is relevant, considering that other patients may benefit from the use of PET as an early marker of cardiotoxicity. Imaging tests are essential in the follow-up of patients at risk of cardiotoxicity. Although echocardiography remains the main imaging test in the diagnosis of cardiotoxicity, 18F-FDG PET/CT may be a powerful tool for the early diagnosis of this condition.

Robustness of [18F]FDG PET/CT radiomic analysis in the setting of drug-induced cardiotoxicity

BACKGROUND AND OBJECTIVES

Standardization of radiomic data acquisition protocols is still at a very early stage, revealing a strong need to work towards the definition of uniform image processing methodologies The aim of this study is to identify sources of variability in radiomic data derived from image discretization and resampling methodologies prior to image feature extraction. Furthermore, to identify robust potential image-based biomarkers for the early detection of cardiotoxicity.

METHODS

Image post-acquisition processing, interpolation, and volume of interest (VOI) segmentation were performed. Four experiments were conducted to assess the reliability in terms of the intraclass correlation coefficient (ICC) of the radiomic features and the effects of the variation of voxel size and gray level discretization. Statistical analysis was performed separating the patients according to cardiotoxicity diagnosis. Differences of texture features were studied with Mann-Whitney U test. P-values <0.05 after multiple testing correction were considered statistically significant. Additionally, a non-supervised k-Means clustering algorithm was evaluated.

RESULTS

The effect of the variation in the voxel size demonstrated a non-dependency relationship with the values of the radiomic features, regardless of the chosen discretization method. The median ICC values were 0.306 and 0.872 for absolute agreement and consistency, respectively, when varying the discretization bin number. The median ICC values were 0.678 and 0.878 for absolute agreement and consistency, respectively, when varying the discretization bin size. A total of 16 first order, 6 Gray Level Co-occurrence Matrix (GLCM), 4 Gray Level Dependence Matrix (GLDM) and 4 Gray Level Run Length Matrix (GLRLM) features demonstrated statistically significant differences between the diagnosis groups for interim scans (P<0.05) for the fixed bin size (FBS) discretization methodology. However, no statistically significant differences between diagnostic groups were found for the fixed bin number (FBN) discretization methodology. Two clusters based on the radiomic features were identified.

CONCLUSIONS

Gray level discretization has a major impact on the repeatability of the radiomic features. The selection of the optimal processing methodology has led to the identification of texture-based patterns for the differentiation of early cardiac damage profiles.

Nuclear medicine imaging methods of early radiation-induced cardiotoxicity: a ten-year systematic review

Introduction

Radiotherapy has significantly improved cancer survival rates, but it also comes with certain unavoidable complications. Breast and thoracic irradiation, for instance, can unintentionally expose the heart to radiation, leading to damage at the cellular level within the myocardial structures. Detecting and monitoring radiation-induced heart disease early on is crucial, and several radionuclide imaging techniques have shown promise in this regard.

Method

In this 10-year review, we aimed to identify nuclear medicine imaging modalities that can effectively detect early cardiotoxicity following radiation therapy. Through a systematic search on PubMed, we selected nineteen relevant studies based on predefined criteria.

Results

The data suggest that incidental irradiation of the heart during breast or thoracic radiotherapy can cause early metabolic and perfusion changes. Nuclear imaging plays a prominent role in detecting these subclinical effects, which could potentially serve as predictors of late cardiac complications.

Discussion

However, further studies with larger populations, longer follow-up periods, and specific heart dosimetric data are needed to better understand the relationship between early detection of cardiac abnormalities and radiation-induced heart disease.

Right ventricle toxicity in cancer treatment: a focused review on cardiac imaging

Background: The right ventricle (RV) remains the 'forgotten chamber' in the clinical assessment of cancer therapy-related cardiac dysfunction (CTRCD). Aim: We aimed to review the role that various cardiac imaging modalities play in RV assessment as part of the integrative management of patients undergoing cancer therapy. Discussion: RV assessment remains challenging by traditional 2D echocardiography. In this review we discuss other parameters such as right atrial strain, and other echocardiographic modalities such as 3D and stress echocardiography. We also elaborate on the specific role that cardiac magnetic resonance imaging and equilibrium radionuclide angiocardiography can play in assessing the RV. Conclusion: Biventricular function should be monitored following chemotherapy for early detection of subclinical CTRCD and possible solitary RV changes.

Tales from the future-nuclear cardio-oncology, from prediction to diagnosis and monitoring

Cancer and cardiovascular diseases (CVD) often share common risk factors, and patients with CVD who develop cancer are at high risk of experiencing major adverse cardiovascular events. Additionally, cancer treatment can induce short- and long-term adverse cardiovascular events. Given the improvement in oncological patients' prognosis, the burden in this vulnerable population is slowly shifting towards increased cardiovascular mortality. Consequently, the field of cardio-oncology is steadily expanding, prompting the need for new markers to stratify and monitor the cardiovascular risk in oncological patients before, during, and after the completion of treatment. Advanced non-invasive cardiac imaging has raised great interest in the early detection of CVD and cardiotoxicity in oncological patients. Nuclear medicine has long been a pivotal exam to robustly assess and monitor the cardiac function of patients undergoing potentially cardiotoxic chemotherapies. In addition, recent radiotracers have shown great interest in the early detection of cancer-treatment-related cardiotoxicity. In this review, we summarize the current and emerging nuclear cardiology tools that can help identify cardiotoxicity and assess the cardiovascular risk in patients undergoing cancer treatments and discuss the specific role of nuclear cardiology alongside other non-invasive imaging techniques.

Anthracycline cardiotoxicity: current methods of diagnosis and possible role of 18F-FDG PET/CT as a new biomarker

Despite advances in chemotherapy, the drugs used in cancer treatment remain rather harmful to the cardiovascular system, causing structural and functional cardiotoxic changes. Positron-emission tomography associated with computed tomography (PET/CT) has emerged like a promising technique in the early diagnosis of these adverse drug effects as the myocardial tissue uptake of fluorodeoxyglucose labeled with fluorine-18 (¹⁸F-FDG), a glucose analog, is increased after their use. Among these drugs, anthracyclines are the most frequently associated with cardiotoxicity because they promote heart damage through DNA breaks, and induction of an oxidative, proinflammatory, and toxic environment. This review aimed to present the scientific evidence available so far regarding the use of ¹⁸F-FDG PET/CT as an early biomarker of anthracycline-related cardiotoxicity. Thus, it discusses the physiological basis for its uptake, hypotheses to justify its increase in the myocardium affected by anthracyclines, importance of ¹⁸F-FDG PET/CT findings for cardio-oncology, and primary challenges of incorporating this technique in standard clinical oncology practice.

QCard-NM: Developing a semiautomatic segmentation method for quantitative analysis of the right ventricle in non-gated myocardial perfusion SPECT imaging

BACKGROUND

Recent studies have shown that the right ventricular (RV) quantitative analysis in myocardial perfusion imaging (MPI) SPECT can be beneficial in the diagnosis of many cardiopulmonary diseases. This study proposes a new algorithm for right ventricular 3D segmentation and quantification.

METHODS

The proposed Quantitative Cardiac analysis in Nuclear Medicine imaging (QCard-NM) algorithm provides RV myocardial surface estimation and creates myocardial contour using an iterative 3D model fitting method. The founded contour is then used for quantitative RV analysis. The proposed method was assessed using various patient datasets and digital phantoms. First, the physician's manually drawn contours were compared to the QCard-NM RV segmentation using the Dice similarity coefficient (DSC). Second, using repeated MPI scans, the QCard-NM's repeatability was evaluated and compared with the QPS (quantitative perfusion SPECT) algorithm. Third, the bias of the calculated RV cavity volume was analyzed using 31 digital phantoms using the QCard-NM and QPS algorithms. Fourth, the ability of QCard-NM analysis to diagnose coronary artery diseases was assessed in 60 patients referred for both MPI and coronary angiography.

RESULTS

The average DSC value was 0.83 in the first dataset. In the second dataset, the coefficient of repeatability of the calculated RV volume between two repeated scans was 13.57 and 43.41 ml for the QCard-NM and QPS, respectively. In the phantom study, the mean absolute percentage errors for the calculated cavity volume were 22.6% and 42.2% for the QCard-NM and QPS, respectively. RV quantitative analysis using QCard-NM in detecting patients with severe left coronary system stenosis and/or three-vessel diseases achieved a fair performance with the area under the ROC curve of 0.77.

CONCLUSION

A novel model-based iterative method for RV segmentation task in non-gated MPI SPECT is proposed. The precision, accuracy, and consistency of the proposed method are demonstrated by various validation techniques. We believe this preliminary study could lead to developing a framework for improving the diagnosis of cardiopulmonary diseases using RV quantitative analysis in MPI SPECT.

Anthracycline-induced cardiotoxicity: From pathobiology to identification of molecular targets for nuclear imaging

Anthracyclines are a widely used class of chemotherapy in pediatric and adult cancers, however, their use is hampered by the development of cardiotoxic side-effects and ensuing complications, primarily heart failure. Clinically used imaging modalities to screen for cardiotoxicity are mostly echocardiography and occasionally cardiac magnetic resonance imaging. However, the assessment of diastolic and global or segmental systolic function may not be sensitive to detect subclinical or early stages of cardiotoxicity. Multiple studies have scrutinized molecular nuclear imaging strategies to improve the detection of anthracycline-induced cardiotoxicity. Anthracyclines can activate all forms of cell death in cardiomyocytes. Injury mechanisms associated with anthracycline usage include apoptosis, necrosis, autophagy, ferroptosis, pyroptosis, reactive oxygen species, mitochondrial dysfunction, as well as cardiac fibrosis and perturbation in sympathetic drive and myocardial blood flow; some of which have been targeted using nuclear probes. This review retraces the pathobiology of anthracycline-induced cardiac injury, details the evidence to date supporting a molecular nuclear imaging strategy, explores disease mechanisms which have not yet been targeted, and proposes a clinical strategy incorporating molecular imaging to improve patient management.

Aumento de Captação Cardíaca de 18F-FDG Induzida por Quimioterapia em Pacientes com Linfoma: Um Marcador Precoce de Cardiotoxicidade?

Fundamento

Ainda não está estabelecido se a captação de fluorodesoxiglicose no miocárdio ocorre exclusivamente por características fisiológicas ou se representa um desarranjo metabólico causado pela quimioterapia.

Objetivo

Investigar os efeitos da quimioterapia no coração dos pacientes com linfoma por tomografia por emissão de pósitrons associada a tomografia computadorizada (PET/CT) com 2-[18F]-fluoro-2-desoxi-D-glicose (¹⁸F-FDG PET/CT) antes, durante e/ou após a quimioterapia.

Métodos

Setenta pacientes com linfoma submetidos a ¹⁸F-FDG PET/CT foram retrospectivamente analisados. O nível de significância foi de 5%. A captação de ¹⁸F-FDG foi avaliada por três medidas: captação máxima no ventrículo esquerdo ( standardized uptake value , SUV max), razão SUV cardíaco / aorta e SUV cardíaco / SUV no fígado. Também foram comparados peso corporal, glicemia de jejum, tempo pós-injeção e dose administrada de ¹⁸F-FDG entre os exames.

Resultados

A idade média foi de 50,4 ± 20,1 anos e 50% dos pacientes eram mulheres. A análise foi realizada em dois grupos – PET/CT basal vs. intermediário e PET/CT basal vs pós-terapia. Não houve diferença significativa entre as variáveis clínicas e do protocolo dos exames entre os diferentes momentos avaliados. Nós observamos um aumento na SUV máxima no ventrículo esquerdo de 3,5±1,9 (basal) para 5,6±4,0 (intermediário), p=0,01, e de 4,0±2,2 (basal) para 6,1±4,2 (pós-terapia), p<0,001. Uma porcentagem de aumento ≥30% na SUV máxima no ventrículo esquerdo ocorreu em mais da metade da amostra. O aumento da SUV cardíaca foi acompanhado por um aumento na razão SUV máxima no ventrículo esquerdo / SUV máxima na aorta e SUV média no ventrículo esquerdo /SUV média no fígado.

Conclusão

O estudo mostrou um aumento evidente na captação cardíaca de ¹⁸F-FDG em pacientes com linfoma, durante e após quimioterapia. A literatura corrobora com esses achados e sugere que a ¹⁸F-FDG PET/CT pode ser um exame de imagem sensível e confiável para detectar sinais metabólicos precoces de cardiotoxicidade.

Prediction of cardiac events following concurrent chemoradiation therapy for non-small-cell lung cancer using FDG PET

OBJECTIVE

No imaging biomarkers are available for the prediction of cardiac events following concurrent chemoradiation therapy (CCRT) for non-small-cell lung cancer (NSCLC). We evaluated whether F-18 fluorodeoxyglucose positron emission tomography (FDG PET) early after CCRT, in addition to cardiac dosimetry, could predict late cardiac events in NSCLC.

METHODS

We retrospectively enrolled 133 consecutive patients with locally advanced, unresectable stage III NSCLC, who underwent FDG PET early after CCRT and survived at least 6 months. The primary endpoint was cardiac event ≥ grade 2 according to the Common Terminology Criteria for Adverse Events (version 5.0). Myocardial FDG uptake was measured and its association with the risk of cardiac events was evaluated.

RESULTS

FDG PET was performed after a median interval of 11 days of completing CCRT. Overall, 42 (32%) patients experienced cardiac events during a median follow-up of 45 months. The mean heart dose, maximum left ventricular (LV) standardized uptake value (SUV), changes in maximum and mean LV SUV, right ventricular uptake, tumor stage, white blood cell count, and diabetes were associated with cardiac events in univariable analysis. In multivariable analysis, maximum LV SUV (cutoff > 12.84; hazard ratio [95% confidence interval] = 2.140 [1.140-4.016]; p = 0.018) was an independent predictor of cardiac events along with the mean heart dose (> 11.1 Gy; 3.646 [1.792-7.417]; p < 0.001) and tumor stage (IIIB; 1.986 [1.056-3.734]; p = 0.033). It remained predictive of cardiac events in those with higher mean heart dose but not in those with lower mean heart dose.

CONCLUSIONS

Early FDG PET after CCRT for NSCLC could aid in predicting late cardiac events, especially in patients with higher mean heart dose.

New Insights in Early Detection of Anticancer Drug-Related Cardiotoxicity Using Perfusion and Metabolic Imaging

Cardio-oncology requires a good knowledge of the cardiotoxicity of anticancer drugs, their mechanisms, and their diagnosis for better management. Anthracyclines, anti-vascular endothelial growth factor (VEGF), alkylating agents, antimetabolites, anti-human epidermal growth factor receptor (HER), and receptor tyrosine kinase inhibitors (RTKi) are therapeutics whose cardiotoxicity involves several mechanisms at the cellular and subcellular levels. Current guidelines for anticancer drugs cardiotoxicity are essentially based on monitoring left ventricle ejection fraction (LVEF). However, knowledge of microvascular and metabolic dysfunction allows for better imaging assessment before overt LVEF impairment. Early detection of anticancer drug-related cardiotoxicity would therefore advance the prevention and patient care. In this review, we provide a comprehensive overview of the cardiotoxic effects of anticancer drugs and describe myocardial perfusion, metabolic, and mitochondrial function imaging approaches to detect them before over LVEF impairment.

Cancer Therapy-Induced Cardiotoxicity-A Metabolic Perspective on Pathogenesis, Diagnosis and Therapy

Long-term cardiovascular complications of cancer therapy are becoming ever more prevalent due to increased numbers of cancer survivors. Cancer therapy-induced cardiotoxicity (CTIC) is an incompletely understood consequence of various chemotherapies, targeted anti-cancer agents and radiation therapy. It is typically detected clinically by a reduction in cardiac left ventricular ejection fraction, assessed by echocardiography. However, once cardiac functional decline is apparent, this indicates irreversible cardiac damage, highlighting a need for the development of diagnostics which can detect CTIC prior to the onset of functional decline. There is increasing evidence to suggest that pathological alterations to cardiac metabolism play a crucial role in the development of CTIC. This review discusses the metabolic alterations and mechanisms which occur in the development of CTIC, with a focus on doxorubicin, trastuzumab, imatinib, ponatinib, sunitinib and radiotherapy. Potential methods to diagnose and predict CTIC prior to functional cardiac decline in the clinic are evaluated, with a view to both biomarker and imaging-based approaches. Finally, the therapeutic potential of therapies which manipulate cardiac metabolism in the context of adjuvant cardioprotection against CTIC is examined. Together, an integrated view of the role of metabolism in pathogenesis, diagnosis and treatment is presented.

Review of cardiovascular imaging in the Journal of Nuclear Cardiology 2020: positron emission tomography, computed tomography, and magnetic resonance

Although the year 2020 was different from other years in many respects, the Journal of Nuclear Cardiology published excellent articles pertaining to imaging in patients with cardiovascular disease due to the dedication of the investigators in our field all over the world. In this review, we will summarize a selection of these articles to provide a concise review of the main advancements that have recently occurred in the field and provide the reader with an opportunity to review a wide selection of articles. We will focus on publications dealing with positron emission tomography, computed tomography, and magnetic resonance and hope that you will find this review helpful.

[123I]MIBG is a better early marker of anthracycline cardiotoxicity than [18F]FDG: a preclinical SPECT/CT and simultaneous PET/MR study

Background

During anthracycline treatment of cancer, there is a lack for biomarkers of cardiotoxicity besides the cardiac dysfunction. The objective of the present study was to compare [¹⁸F]FDG and [¹²³I]MIBG (metaiodobenzylguanidine) in a longitudinal study in a doxorubicin-induced cardiotoxicity rat model.

Methods

Male Wistar Han rats were intravenously administered 3 times at 10 days’ interval with saline or doxorubicin (5 mg/kg). [¹²³I]MIBG SPECT/CT (single photon emission computed tomography-computed tomography) and simultaneous [¹⁸F]FDG PET (positron emission tomography)/7 Tesla cardiac MR (magnetic resonance) imaging acquisitions were performed at 24 h interval before first doxorubicin / saline injection and every 2 weeks during 6 weeks. At 6 weeks, the heart tissue was collected for histomorphometry measurements.

Results

At week 4, left ventricle (LV) end-diastolic volume was significantly reduced in the doxorubicin group. At week 6, the decreased LV end-diastolic volume was maintained, and LV end-systolic volume was increased resulting in a significant reduction of LV ejection fraction (47 ± 6% vs. 70 ± 3%). At weeks 4 and 6, but not at week 2, myocardial [¹⁸F]FDG uptake was decreased compared with the control group (respectively, 4.2 ± 0.5%ID/g and 9.2 ± 0.8%ID/g at week 6). Moreover, [¹⁸F]FDG cardiac uptake correlated with cardiac function impairment. In contrast, from week 2, a significant decrease of myocardial [¹²³I]MIBG heart to mediastinum ratio was detected in the doxorubicin group and was maintained at weeks 4 and 6 with a 45.6% decrease at week 6.

Conclusion

This longitudinal study precises that after doxorubicin treatment, cardiac [¹²³I]MIBG uptake is significantly reduced as early as 2 weeks followed by the decrease of the LV end-diastolic volume and [¹⁸F]FDG uptake at 4 weeks and finally by the increase of LV end-systolic volume and decrease of LV ejection fraction at 6 weeks. Cardiac innervation imaging should thus be considered as an early key feature of anthracycline cardiac toxicity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13550-021-00835-1.

KSNM60 in Cardiology: Regrowth After a Long Pause

The Korean Society of Nuclear Medicine (KSNM) is celebrating its 60th anniversary in honor of the nuclear medicine professionals who have dedicated their efforts towards research, academics, and the more comprehensive clinical applications and uses of nuclear imaging modalities. Nuclear cardiology in Korea was at its prime time in the 1990s, but its growth was interrupted by a long pause. Despite the academic and practical challenges, nuclear cardiology in Korea now meets the second leap, attributed to the growth in molecular imaging tailored for many non-coronary diseases and the genuine values of nuclear myocardial perfusion imaging. In this review, we describe the trends, achievements, challenges, and perspectives of nuclear cardiology throughout the 60-year history of the KSNM.

Series of myocardial FDG uptake requiring considerations of myocardial abnormalities in FDG-PET/CT

Distinct from cardiac PET performed with preparation to control physiological FDG uptake in the myocardium, standard FDG-PET/CT performed with 4-6 h of fasting will show variation in myocardial FDG uptake. For this reason, important signs of myocardial and pericardial abnormality revealed by myocardial FDG uptake tend to be overlooked. However, recognition of possible underlying disease will support further patient management to avoid complications due to the disease. This review demonstrates the mechanism of FDG uptake in the myocardium, discusses the factors affecting uptake, and provides notable image findings that may suggest underlying disease.

Oncocardiology: new challenges, new opportunities

Patients with cancer are at a higher risk of cardiovascular disease, which contributes to significant morbidity and mortality. The rapid progress in the field of oncological treatments has led to a steady increase in long-term cancer survivors. Care for cardiovascular complications is therefore becoming increasingly important. In addition, the establishment of new oncological therapies has resulted in the identification of previously unknown cardiovascular side effects. Oncocardiology aims to detect and treat cardiovascular diseases associated with cancer and cancer therapy. Continuous scientific, clinical, and structural developments are necessary as the basis for the best care of the growing number of affected patients. This review summarizes current developments in the field of oncocardiology with regard to advances in cancer therapy and challenges in clinical oncocardiology work. Cardiovascular side effects by targeted cancer therapies are characterized and recent advances in the field of cardiovascular diagnostics are outlined. Developments to better integrate oncocardiology into the medical care system and perspectives for modern, patient-oriented care are shown. In light of the coronavirus disease 2019 (COVID-19) pandemic, current challenges and opportunities are highlighted. The relevance of profitable further advances in oncocardiology including standardized guidelines and educational programs is delineated as a mandatory requirement for the successful development of oncocardiology.

Right ventricular involvement in cancer therapy-related cardiotoxicity: the emerging role of strain echocardiography

The involvement of the right ventricle (RV) in various cardiovascular pathologies is usually explored and demonstrated after thorough research of the left ventricle (LV). This is also true in cardio-oncology, where multimodality imaging with cardiac magnetic resonance and nuclear imaging is essential, but echocardiography plays pivotal role in everyday clinical practice. Chemotherapy and radiotherapy effect on RV has been studied mainly in breast cancer patients and survivors from childhood cancer. Right ventricular geometry and shape limit the ability of classical echocardiographic indices like RV ejection fraction (RVEF), RV fractional area change (FAC), and tricuspid annular plane systolic excursion (TAPSE) to identify reliably subtle changes in RV systolic function in cancer patients. The assessment of diastolic function of the RV in various timepoints during or after chemotherapy leads to conflicting results too. However, longitudinal strain of the RV (RV LS) seems to detect myocardial injury with consistent results. Remarkably, cardiotoxicity of the RV is identified by RV LS almost simultaneously with LV cardiotoxicity and with similar cutoff percent change suggesting the uniform effect of cancer and its treatments on myocardium. The prognostic value of cardiotoxic effects on the RV needs to be investigated by large prospective studies.

Relationship Between Changes in Myocardial F-18 Fluorodeoxyglucose Uptake and Radiation Dose After Adjuvant Three-Dimensional Conformal Radiotherapy in Patients with Breast Cancer

This study aimed to assess the relationship between radiation dose and changes in the irradiated myocardial F-18 fluorodeoxyglucose (FDG) uptake after radiotherapy (RT) in breast cancer patients. The data of 55 patients with left and 48 patients with right breast cancer who underwent curative surgical resection and adjuvant three-dimensional conformal RT and staging (PET1), post-adjuvant chemotherapy (PET2), post-RT (PET3), and surveillance (PET4) FDG positron emission tomography/computed tomography (PET/CT) were retrospectively reviewed. The median interval between PET1 and curative surgical resection, between the end of adjuvant chemotherapy and PET2, between the end of RT and PET3, and between the end of RT and PET4 were five days, 13 days, 132 days, and 353 days, respectively. The myocardial-to-blood pool uptake ratio was measured in all patients. For patients with left breast cancer, the 30 Gy- (30 Gy) and 47.5 Gy-irradiated myocardium-to-low-irradiated myocardium (47.5 Gy) FDG uptake ratios were additionally measured. There were no differences in the myocardial-to-blood pool uptake ratios between left and right breast cancer on all PET scans. For left breast cancer, higher 30 Gy and 47.5 Gy uptake ratios were observed on PET3 than on PET1 and PET2. Both uptake ratios decreased on PET4 compared to PET3, but, were still higher compared to PET1. On PET3 and PET4, the 47.5 Gy were higher than the 30 Gy uptake ratios, while there were no differences between them on PET1 and PET2. Although the whole myocardium FDG uptake showed no significant change, the irradiated myocardium FDG uptake significantly increased after RT and was related to radiation dose to the myocardium in breast cancer patients. These results might be an imaging evidence that supports the increased risk of heart disease after RT in patients with left breast cancer.

Metabolic Imaging in Cardio-oncology

Tremendous progress in cancer detection and therapy has improved survival. However, cardiovascular complications are a major source of morbidity in cancer survivors. Cardiotoxicity is currently defined by structural myocardial changes and cardiac injury biomarkers. In many instances, such changes are late and irreversible. Therefore, diagnostic modalities that can identify early alterations in potentially reversible biochemical and molecular signaling processes are of interest. This review is focused on emerging translational metabolic imaging modalities. We present in context relevant mitochondrial biology aspects that ground the development and application of these technologies for detection of cancer therapy-related cardiac dysfunction (CTRCD). The application of these modalities may improve the assessment of cardiovascular risk when anticancer treatments with a defined cardiometabolic toxic mechanism are to be used. Also, they may serve as screening tools for cardiotoxicity when novel lines of cancer therapies are applied.