Comparison of Framingham risk score and chest-CT identified coronary artery calcification in breast cancer patients to predict cardiovascular events

Carotid Artery Stenosis and Ischemic Stroke in Patients With Head and Neck Cancer Treated With Radiation Therapy: A Critical Review

The purpose of this review is to summarize the literature on carotid artery stenosis (CAS) and ischemic stroke (IS) in patients with head and neck cancer (HNC) treated with radiation therapy (RT) to guide assessment, screening, and management strategies. Patients treated with RT for HNC are at an elevated risk of developing CAS, with published meta-analyses demonstrating that CAS >50% occurs in approximately 25% of patients. Previous research suggests a 10-year cumulative incidence of stroke between 5.7% and 12.5%. Cardiovascular disease (CVD) risk prediction tools such as Qstroke, QRISK-2, and Framingham risk score perform poorly for predicting IS for patients with HNC who received RT. Duplex ultrasound is the most common imaging modality to assess CAS, but controversy remains as to the utility of screening asymptomatic individuals. Only 3 of the 5 major HNC survivorship guidelines acknowledge RT as a risk factor for CAS or IS, while only 1 makes a specific recommendation on screening for CAS (American Head and Neck Society). Within the general population, only 1 CVD guideline discusses RT as a risk factor for CAS (Society for Vascular Surgery). Clinicians involved in the care of patients with HNC treated with RT should be aware of the increased risk of CAS and IS and the challenges in risk prediction. Although there is a lack of evidence to make firm recommendations, HNC survivorship recommendations should ensure HNC survivors and primary care providers are informed of these risks and the importance of assessment and management of CVD risk factors. Future studies are required to refine risk prediction models in patients with HNC and to determine those most likely to benefit from targeted screening and initiation of early preventative strategies.

Prevalence and clinical implications of coronary artery calcium scoring on non-gated thoracic computed tomography: a systematic review and meta-analysis

OBJECTIVES

Coronary artery calcifications (CACs) indicate the presence of coronary artery disease. CAC can be found on thoracic computed tomography (CT) conducted for non-cardiac reasons. This systematic review and meta-analysis of non-gated thoracic CT aims to assess the clinical impact and prevalence of CAC.

METHODS

Online databases were searched for articles assessing prevalence, demographic characteristics, accuracy and prognosis of incidental CAC on non-gated thoracic CT. Meta-analysis was performed using a random effects model.

RESULTS

A total of 108 studies (113,406 patients) were included (38% female). Prevalence of CAC ranged from 2.7 to 100% (pooled prevalence 52%, 95% confidence interval [CI] 46-58%). Patients with CAC were older (pooled standardised mean difference 0.88, 95% CI 0.65-1.11, p < 0.001), and more likely to be male (pooled odds ratio [OR] 1.95, 95% CI 1.55-2.45, p < 0.001), with diabetes (pooled OR 2.63, 95% CI 1.95-3.54, p < 0.001), hypercholesterolaemia (pooled OR 2.28, 95% CI 1.33-3.93, p < 0.01) and hypertension (pooled OR 3.89, 95% CI 2.26-6.70, p < 0.001), but not higher body mass index or smoking. Non-gated CT assessment of CAC had excellent agreement with electrocardiogram-gated CT (pooled correlation coefficient 0.96, 95% CI 0.92-0.98, p < 0.001). In 51,582 patients, followed-up for 51.6 ± 27.4 months, patients with CAC had increased all cause mortality (pooled relative risk [RR] 2.13, 95% CI 1.57-2.90, p = 0.004) and major adverse cardiovascular events (pooled RR 2.91, 95% CI 2.26-3.93, p < 0.001). When CAC was present on CT, it was reported in between 18.6% and 93% of reports.

CONCLUSION

CAC is a common, but underreported, finding on non-gated CT with important prognostic implications.

CLINICAL RELEVANCE STATEMENT

Coronary artery calcium is an important prognostic indicator of cardiovascular disease. It can be assessed on non-gated thoracic CT and is a commonly underreported finding. This represents a significant population where there is a potential missed opportunity for lifestyle modification recommendations and preventative therapies. This study aims to highlight the importance of reporting incidental coronary artery calcium on non-gated thoracic CT.

KEY POINTS

• Coronary artery calcification is a common finding on non-gated thoracic CT and can be reliably identified compared to gated-CT. • Coronary artery calcification on thoracic CT is associated with an increased risk of all cause mortality and major adverse cardiovascsular events. • Coronary artery calcification is frequently not reported on non-gated thoracic CT.

Cardio-oncology and radiation oncology: How collaboration between cardiologists and oncologists can be realised in radiation oncology

Increased survivorship, improvements in cancer treatments, and the potential for cardiac side effects from cancer treatments have resulted in increased collaboration between oncologists and cardiologists and the development of cardio-oncology clinics. This collaboration is important given its role in ensuring greater patient satisfaction, aiding teams of clinicians in making complex treatment decision, and ensuring cardiac complications are diagnosed at an early stage. The particularities of implementing this collaboration in the field of radiation oncology and how this setting is different from other areas of cardio-oncology have not been well detailed in the literature. This paper will discuss what is currently understood about the need for and role of cardio-oncology and what a cardio-oncology services involves, with a particular emphasis on patient and clinician needs in the field of radiation oncology. The literature and recent guidelines do advocate for a detailed baseline assessment of cancer patients undergoing radiotherapy, especially patients with treatment or patient risk factors that increase their risk of cancer-therapy related cardiotoxicity. Advancements in cardiac imaging techniques will be discussed as these may help to diagnose cardiac side effects of certain cancer treatments, including radiotherapy, at an early stage. A multi-disciplinary and collaborative approach is well received by patients and such an approach, guided by the aim of maintaining a patient's cancer treatment wherever possible, should be the cornerstone of cardio-oncology clinics regardless of the patient's treatment regime.

Opportunistic Screening for Coronary Artery Disease: An Untapped Population Health Resource

BACKGROUND

Coronary artery disease is the leading cause of death in the United States. At-risk asymptomatic adults are eligible for screening with electrocardiogram-gated coronary artery calcium (CAC) CT, which aids in risk stratification and management decision-making. Incidental CAC (iCAC) is easily quantified on chest CT in patients imaged for noncardiac indications; however, radiologists do not routinely report the finding.

OBJECTIVE

To determine the clinical significance of CAC identified incidentally on routine chest CT performed for noncardiac indications.

DESIGN

An informationist developed search strategies in MEDLINE, Embase, and SCOPUS, and two reviewers independently screened results at both the abstract and full text levels. Data extracted from eligible articles included age, rate of iCAC identification, radiologist reporting frequency, impact on downstream medical management, and association of iCAC with patient outcomes.

RESULTS

From 359 unique citations, 83 research publications met inclusion criteria. The percentage of patients with iCAC ranged from 9% to 100%. Thirty-one investigations measured association(s) between iCAC and cardiovascular morbidity and mortality, and 29 identified significant correlations, including nonfatal myocardial infarction, fatal myocardial infarction, major adverse cardiovascular event, cardiovascular death, and all-cause death. iCAC was present in 20% to 100% of the patients in these cohorts, but when present, iCAC was reported by radiologists in only 31% to 44% of cases. Between 18% and 77% of patients with iCAC were not on preventive medications in studies that reported these data. Seven studies measured the effect of reporting on guideline directed medical therapy, and 5 (71%) reported an increase in medication prescriptions after diagnosis of iCAC, with one confirming reductions in low-density lipoprotein levels. Twelve investigations reported good concordance between CAC grade on noncardiac CT and Agatston score on electrocardiogram-gated cardiac CT, and 10 demonstrated that artificial intelligence tools can reliably calculate an Agatston score on noncardiac CT.

CONCLUSION

A body of evidence demonstrates that patients with iCAC on routine chest CT are at risk for cardiovascular disease events and death, but they are often undiagnosed. Uniform reporting of iCAC in the chest CT impression represents an opportunity for radiology to contribute to early identification of high-risk individuals and potentially reduce morbidity and mortality. AI tools have been validated to calculate Agatston score on routine chest CT and hold the best potential for facilitating broad adoption.

Association between coronary artery disease and clinical outcome in cancer patients: A propensity score matching analysis

Objective

The aim of this study was to evaluate the prognostic value of coronary artery disease (CAD) detected by coronary computed tomography angiography (CTA) to predict the risk of all-cause mortality in cancer patients in a propensity score matching (PSM) analysis.

Methods

A total of 331 patients who previously had cancer and underwent coronary CTA from January 2015 to December 2019 were included. Multivariate Cox proportional hazards regression analysis and propensity-score matching analysis were performed. The primary endpoint was all-cause of mortality.

Results

In total, 125 with CAD and 206 with no CAD during a median follow-up of 3.3 years were included in this study. After PSM, age (HR, 1.040; 95%CI, 1.001-1.081; p = 0.014) and CAD (HR, 2.164; 95%CI, 1.057-4.430; p = 0.035) remained significant factors for all-cause mortality.

Conclusion

CAD evaluated by coronary CTA was found to be at higher risk for all-cause mortality in cancer patients. Due to the retrospective design and lack of information on some medical history and treatments, especially immune checkpoint inhibitors, a large-scale prospective study is needed to further determine the prognostic value of coronary CTA in cancer patients.

The Clear Value of Coronary Artery Calcification Evaluation on Non-Gated Chest Computed Tomography for Cardiac Risk Stratification

To enhance risk stratification in patients suspected of coronary artery disease, the assessment of coronary artery calcium (CAC) could be incorporated, especially when CAC can be readily assessed on previously performed non-gated chest computed tomography (CT). Guidelines recommend reporting on patients' extent of CAC on these non-cardiac directed exams and various studies have shown the diagnostic and prognostic value. However, this method is still little applied, and no current consensus exists in clinical practice. This review aims to point out the clinical utility of different kinds of CAC assessment on non-gated CTs. It demonstrates that these scans indeed represent a merely untapped and underestimated resource for risk stratification in patients with stable chest pain or an increased risk of cardiovascular events. To our knowledge, this is the first review to describe the clinical utility of different kinds of visual CAC evaluation on non-gated unenhanced chest CT. Various methods of CAC assessment on non-gated CT are discussed and compared in terms of diagnostic and prognostic value. Furthermore, the application of these non-gated CT scans in the general practice of cardiology is discussed. The clinical utility of coronary calcium assessed on non-gated chest CT, according to the current literature, is evident. This resource of information for cardiac risk stratification needs no specific requirements for scan protocol, and is radiation-free and cost-free. However, some gaps in research remain. In conclusion, the integration of CAC on non-gated chest CT in general cardiology should be promoted and research on this method should be encouraged.

Predicting Adverse Cardiac Events After Radiotherapy for Locally Advanced Non-Small Cell Lung Cancer

Background

Radiotherapy may cause grade ≥3 cardiac events, necessitating a better understanding of risk factors. The potential predictive role of imaging biomarkers with radiotherapy doses for cardiac event occurrence has not been studied.

Objectives

The aim of this study was to establish the associations between cardiac substructure dose and coronary artery calcium (CAC) scores and cardiac event occurrence.

Methods

A retrospective cohort analysis included patients with locally advanced non-small cell lung cancer treated with radiotherapy (2006-2018). Cardiac substructures, including the left anterior descending coronary artery, left main coronary artery, left circumflex coronary artery, right coronary artery, and TotalLeft (left anterior descending, left main, and left circumflex coronary arteries), were contoured. Doses were measured in 2-Gy equivalent units, and visual CAC scoring was compared with automated scoring. Grade ≥3 adverse cardiac events were recorded. Time-dependent receiver-operating characteristic modeling, the log-rank statistic, and competing-risk models were used to measure prediction performance, threshold modeling, and the cumulative incidence of cardiac events, respectively.

Results

Of the 233 eligible patients, 61.4% were men, with a median age of 68.1 years (range: 34.9-90.7 years). The median follow-up period was 73.7 months (range: 1.6-153.9 months). Following radiotherapy, 22.3% experienced cardiac events, within a median time of 21.5 months (range: 1.7-118.9 months). Visual CAC scoring showed significant correlation with automated scoring (r = 0.72; P < 0.001). In a competing-risk multivariable model, TotalLeft volume receiving 15 Gy (per 1 cc; HR: 1.38; 95% CI: 1.11-1.72; P = 0.004) and CAC score >5 (HR: 2.51; 95% CI: 1.08-5.86; P = 0.033) were independently associated with cardiac events. A model incorporating age, TotalLeft CAC (score >5), and volume receiving 15 Gy demonstrated a higher incidence of cardiac events for a high-risk group (28.9%) compared with a low-risk group (6.9%) (P < 0.001).

Conclusions

Adverse cardiac events associated with radiation occur in more than 20% of patients undergoing thoracic radiotherapy within a median time of <2 years. The present findings provide further evidence to support significant associations between TotalLeft radiotherapy dose and cardiac events and define CAC as a predictive risk factor.

Multimodality imaging in cardio-oncology: the added value of CMR and CCTA

During the last 30 years, we have assisted to a great implementation in anticancer treatment with a subsequent increase of cancer survivors and decreased mortality. This has led to an ongoing interest about the possible therapy-related side-effects and their management to better guide patients therapy and surveillance in the chronic and long-term setting. As a consequence cardio-oncology was born, involving several different specialties, among which radiology plays a relevant role. Till the end of August 2022, when European Society of Cardiology (ESC) developed the first guidelines on cardio-oncology, no general indications existed to guide diagnosis and treatment of cancer therapy-related cardiovascular toxicity (CTR-CVT). They defined multimodality imaging role in primary and secondary prevention strategies, cancer treatment surveillance and early CTR-CVT identification and management. Cardiac computed tomography angiography (CCTA) has acquired a central role in coronary assessment, as far as coronary artery disease (CAD) exclusion is concerned; but on the side of this well-known application, it also started to be considered in left ventricular function evaluation, interstitial fibrosis quantification and cardiac perfusion studies. Cardiac magnetic resonance (CMR), instead, has been acknowledged as the gold standard alternative to trans-thoracic echocardiography (TTE) poor acoustic window in quantification of heart function and strain modifications, as well as pre- and post-contrast tissue characterization by means of T1-T2 mapping, early Gadolinium enhancement (EGE), late Gadolinium enhancement (LGE) and extracellular volume (ECV) evaluation. Our review is intended to provide a focus on the actual role of CMR and CCTA in the setting of a better understanding of cardiotoxicity and to draw some possible future directions of cardiac imaging in this field, starting from the recently published ESC guidelines.

Protocol: Can coronary artery calcium score identified on thoracic planning CT scans be used and actioned to identify cancer survivors at high risk of cardiac events: A feasibility study in cancer survivors undergoing radiotherapy in Australia

INTRODUCTION

A coronary artery calcium (CAC) CT scan can identify calcified plaque and predict risk of future cardiac events. Cancer survivors undergoing thoracic radiotherapy routinely undergo a planning CT scan, which presents a unique opportunity to use already obtained medical imaging to identify those at the highest risk of cardiac events. While radiation therapy is an important modality for many cancer treatments, radiation dose to the heart in thoracic radiotherapy leads to cardiotoxicity and may accelerate pre-existing atherosclerosis. The primary aims of this study are to investigate the feasibility of using CAC scores calculated on thoracic radiotherapy planning CT scans to identify a subset of cancer survivors at an increased risk of future cardiac events, and to establish and evaluate a referral pathway for assessment and management in a cardio-oncology clinic. An optional substudy aims to investigate using abdominal aortic calcification (AAC) as a practical, low-radiation alternative to CAC to evaluate and monitor vascular health.

METHODS AND ANALYSIS

This is an observational, prospective study in a minimum of 100 cancer survivors commencing radiotherapy. Participants will have CAC scored from thoracic radiotherapy planning CT scans. Those identified as high risk (CAC score>0) will be referred to a cardio-oncology clinic. Feasibility, determined by adherence to the recommended pathway, and impact on quality of life and anxiety measured via questionnaire, will be assessed. Participants in Western Australia will be invited to participate in a 12-month observational pilot substudy, investigating lifestyle behaviours and the use of a dual-energy X-ray absorptiometry machine to measure musculoskeletal health and AAC.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from St Vincent's Hospital, Sydney (Project number 2021/ETH11847), GenesisCare and Edith Cowan University (2022-03326-DALLAVIA). Study results will be reported in peer-reviewed academic journals, at scientific conferences, and at clinical forums, irrespective of the results observed.

TRIAL REGISTRATION NUMBER

ACTRN12621001343897.

Fully automatic coronary calcium scoring in non-ECG-gated low-dose chest CT: comparison with ECG-gated cardiac CT

OBJECTIVES

To validate an artificial intelligence (AI)-based fully automatic coronary artery calcium (CAC) scoring system on non-electrocardiogram (ECG)-gated low-dose chest computed tomography (LDCT) using multi-institutional datasets with manual CAC scoring as the reference standard.

METHODS

This retrospective study included 452 subjects from three academic institutions, who underwent both ECG-gated calcium scoring computed tomography (CSCT) and LDCT scans. For all CSCT and LDCT scans, automatic CAC scoring (CAC_auto) was performed using AI-based software, and manual CAC scoring (CAC_man) was set as the reference standard. The reliability and agreement of CAC_auto was evaluated and compared with that of CAC_man using intraclass correlation coefficients (ICCs) and Bland-Altman plots. The reliability between CAC_auto and CAC_man for CAC severity categories was analyzed using weighted kappa (κ) statistics.

RESULTS

CAC_auto on CSCT and LDCT yielded a high ICC (0.998, 95% confidence interval (CI) 0.998-0.999 and 0.989, 95% CI 0.987-0.991, respectively) and a mean difference with 95% limits of agreement of 1.3 ± 37.1 and 0.8 ± 75.7, respectively. CAC_auto achieved excellent reliability for CAC severity (κ = 0.918-0.972) on CSCT and good to excellent but heterogenous reliability among datasets (κ = 0.748-0.924) on LDCT.

CONCLUSIONS

The application of an AI-based automatic CAC scoring software to LDCT shows good to excellent reliability in CAC score and CAC severity categorization in multi-institutional datasets; however, the reliability varies among institutions.

KEY POINTS

• AI-based automatic CAC scoring on LDCT shows excellent reliability with manual CAC scoring in multi-institutional datasets. • The reliability for CAC score-based severity categorization varies among datasets. • Automatic scoring for LDCT shows a higher false-positive rate than automatic scoring for CSCT, and most common causes of a false-positive are image noise and artifacts for both CSCT and LDCT.

Incidental coronary calcium in cancer patients treated with anthracycline and/or trastuzumab

AIMS

Cancer patients are at increased risk of cardiovascular disease (CVD) after treatment with potentially cardiotoxic treatments. Many cancer patients undergo non-gated chest computed tomography (NCCT) for cancer staging prior to treatment. We aimed to assess whether coronary artery calcification on NCCT predicts CVD risk in cancer patients.

METHODS AND RESULTS

Six hundred and three patients (mean age: 61.3 years, 30.8% male) with either breast cancer, lymphoma, or sarcoma were identified retrospectively. Primary endpoint was a major adverse cardiac event (MACE) composite including non-fatal myocardial infarction, new heart failure (HF) diagnosis, HF hospitalization, and cardiac death, with Fine-Gray analysis for non-cardiac death as competing risk. Secondary endpoints included a coronary composite and a HF composite. Coronary artery calcification was present in 194 (32.2%) and clinically reported in 85 (43.8%) patients. At a median follow-up of 5.3 years, 256 (42.5%) patients died of non-cardiac causes. Coronary artery calcification presence or extent was not an independent predictor of MACE [sub-distribution hazards ratio (SHR) 1.28; 0.73-2.27]. Coronary artery calcification extent was a significant predictor of the coronary composite outcome (SHR per two-fold increase 1.14; 1.01-1.28), but not of the HF composite outcome (SHR per two-fold increase 1.04; 0.95-1.14).

CONCLUSION

Coronary artery calcification detected incidentally on NCCT scans in cancer patients is prevalent and often not reported. Coronary artery calcification presence or extent did not independently predict MACE. Coronary artery calcification extent was independently associated with increased risk of CAD events but not HF events.

Impact of coexisting diabetes on survival and risk of developing second primary cancer in diabetes patients receiving drug therapy: A multicenter retrospective cohort study of patients with cancer in Japan

AIMS/INTRODUCTION

We investigated the association between coexisting diabetes at the time of cancer diagnosis, and the overall survival and incidence of second primary cancer in patients with cancer and receiving drug therapy for diabetes.

MATERIALS AND METHODS

We used cancer registry and administrative data of patients diagnosed with cancer at designated cancer care hospitals in Osaka Prefecture between 2010 and 2015. The presence of diabetes was identified from the prescription records of antidiabetic drugs in Diagnosis Procedure Combination System data. After adjusting for patient characteristics, we compared overall survival between patients with cancer with coexisting diabetes and those without coexisting diabetes using the Cox proportional hazards model. In addition, the impact of coexisting diabetes on the risk of developing second primary cancer was evaluated using a competing risk analysis.

RESULTS

Of the 131,701 patients with cancer included in the analysis, 6,135 (4.7%) had coexisting diabetes. The 5-year survival rates for patients with and without coexisting diabetes were 56.2% (95% confidence interval 54.8-57.6) and 72.7% (95% confidence interval 72.4-73.0), respectively. Coexisting diabetes was associated with a higher risk of developing second primary cancer (subdistribution hazard ratio 1.23; 95% confidence interval 1.08-1.41). In site-specific analysis, coexisting diabetes was associated with an increased risk for the development of second primary cancer of multiple myeloma, and cancer of the uterus, pancreas and liver.

CONCLUSIONS

Coexisting diabetes was associated with a higher mortality and risk of developing second primary cancer in Japanese patients with cancer and on drug therapy for diabetes.

What should we do about Coronary Calcification on Thoracic CT?

PURPOSE

Coronary artery calcification is a frequent incidental finding on thoracic computed tomography (CT) performed for non-cardiac indications. On electrocardiogram-gated cardiac CT, it is an established marker of coronary artery disease and is associated with increased risk of subsequent cardiac events.

MATERIALS AND METHODS

This review discusses the current evidence and guidelines regarding the reporting of coronary artery calcification on non-electrocardiogram-gated thoracic CT performed for non-cardiac indications.

RESULTS

For patients undergoing routine thoracic CT, coronary artery calcification is associated with an increased risk of myocardial infarction and mortality. Coronary artery calcification can be accurately assessed on non-gated thoracic CT compared to gated CT. Guidelines support the reporting of coronary artery calcification on thoracic CT. However, radiologist opinions vary. The identification of coronary artery calcification on thoracic CT may identify patients with previously unknown coronary artery disease. For asymptomatic patients this may trigger an assessment of modifiable cardiovascular risk factors and guide the appropriate use of preventative medications.

CONCLUSION

Future research will address whether changing management based on calcification on thoracic CT will improve outcomes and automated assessment of calcification using machine learning techniques.

KEY POINTS

· Coronary artery calcification is a frequent incidental finding on thoracic CT.. · The presence and severity of coronary artery calcification is associated with cardiac outcomes and mortality.. · Reporting coronary artery calcification on thoracic CT is supported by national and international guidelines..

CITATION FORMAT

· Williams MC, Llewellyn O, . What Should We Do About Coronary Calcification on Thoracic CT?. Fortschr Röntgenstr 2022; 194: 833 - 840.

Radiotherapy-Induced Cardiotoxicity: The Role of Multimodality Cardiovascular Imaging

Radiotherapy (RT) is one of the pillars of cancer therapy. High-dose radiation exposure on the thorax is mainly used in the context of adjuvant RT after breast surgery, in lung and esophageal cancer, and as a complement to systemic treatment in lymphoma. Due to the anatomical proximity, the heart inevitably receives some radiation that can result in acute and chronic cardiotoxicity, leading to heart failure, coronary artery disease, pericardial and valvular heart disease. Current evidence suggests there is no safe radiation dose to the heart, which poses a need for early recognition of RT-induced cardiac injury to initiate cardioprotective treatment and prevent further damage. Multimodality cardiac imaging provides a powerful tool to screen for structural and functional abnormalities secondary to RT. Left ventricular ejection fraction, preferably with three-dimensional echocardiography or cardiovascular magnetic resonance (CMR), and global longitudinal strain with speckle-tracking echocardiography are currently the key parameters to detect cardiotoxicity. However, several novel imaging parameters are tested in the ongoing clinical trials. CMR parametric imaging holds much promise as T1, T2 mapping and extracellular volume quantification allow us to monitor edema, inflammation and fibrosis, which are fundamental processes in RT-induced cardiotoxicity. Moreover, the association between serum biomarkers, genetic polymorphisms and the risk of developing cardiovascular disease after chest RT has been demonstrated, providing a platform for an integrative screening approach for cardiotoxicity. The present review summarizes contemporary evidence of RT-induced cardiac injury obtained from multimodality imaging—echocardiography, cardiovascular computed tomography, CMR and nuclear cardiology. Moreover, it identifies gaps in our current knowledge and highlights future perspectives to screen for RT-induced cardiotoxicity.

Radiologist opinions regarding reporting incidental coronary and cardiac calcification on thoracic CT

Objectives

Coronary and cardiac calcification are frequent incidental findings on non-gated thoracic computed tomography (CT). However, radiologist opinions and practices regarding the reporting of incidental calcification are poorly understood.

Methods

UK radiologists were invited to complete this online survey, organised by the British Society of Cardiovascular Imaging (BSCI). Questions included anonymous information on subspecialty, level of training and reporting practices for incidental coronary artery, aortic valve, mitral and thoracic aorta calcification.

Results

The survey was completed by 200 respondents: 10% trainees and 90% consultants. Calcification was not reported by 11% for the coronary arteries, 22% for the aortic valve, 35% for the mitral valve and 37% for the thoracic aorta. Those who did not subspecialise in cardiac imaging were less likely to report coronary artery calcification (p = 0.005), aortic valve calcification (p = 0.001) or mitral valve calcification (p = 0.008), but there was no difference in the reporting of thoracic aorta calcification. Those who did not subspecialise in cardiac imaging were also less likely to provide management recommendations for coronary artery calcification (p < 0.001) or recommend echocardiography for aortic valve calcification (p < 0.001), but there was no difference for mitral valve or thoracic aorta recommendations.

Conclusion

Incidental coronary artery, valvular and aorta calcification are frequently not reported on thoracic CT and there are differences in reporting practices based on subspeciality.

Advances in knowledge

On routine thoracic CT, 11% of radiologists do not report coronary artery calcification. Radiologist reporting practices vary depending on subspeciality but not level of training.

Accurate measurement of coronary artery calcium in cancer patients using the CT component of PET/CT scans

OBJECTIVE

The aim of this study is to establish the correlation between a CAC score derived from the CT component of PET/CT scan (CAC-PET) using in-house software as compared to the conventional technique (CAC-Standard). In addition, the incidence of high CAC scores in asymptomatic cancer patients with low-to-intermediate cardiovascular risk will be determined.

METHODS

100 patients referred for oncologic PET/CT were prospectively recruited to have a conventional CAC score after their PET/CT. Patients with a history of cardiac disease were excluded. The nongated CT images from the PET/CT (CAC-PET) were analysed using validated in-house software with the results compared to those from gated CT analysed using the standard technique (CAC-Standard).

RESULTS

The correlation of CAC scores between the two scan types was moderate [slope, 0.95; R2 = 0.91; limits of agreement (LOA) = 0.29-5.65]. Using a conventional categorical analysis, there was complete agreement in 73% of patients with one category difference in the remainder. [interclass correlation (ICC) = 0.90; Cohen's kappa = 0.63]. In total 28% of these asymptomatic low-to-intermediate-risk cancer patients had CAC scores over 300.

CONCLUSION

Estimation of CAC from the CT component of PET/CT scans is a reliable method for the detection of significant CAC in cancer patients and correlates well with the standard method. This technique should permit the calculation of cardiovascular risk in cancer patients undergoing PET/CT without any additional radiation exposure. A significant number of asymptomatic low-to-intermediate-risk cancer patients were found to have a high risk of cardiovascular disease.

A novel method for selecting the set optimal wavelength combination in multi-spectral transmission image

In the process of detecting heterogeneity in breast tissue based on multi-spectral transmission imaging, the detection accuracy will be affected due to the high redundancy degree of information between bands. In order to select the reasonable wavelength combination, this paper uses various nonlinear transformations to convert the multi-spectral images into spectral data for the first time, so as to select the set optimal wavelength combination based on the successive projections algorithm (SPA). Firstly, we design the collection experiment of 4-wavelength multi-spectral image. And then, K-SVD dictionary learning method, texture extraction method and gray correlation analysis method are used to obtain the feature spectral information. Finally, the set optimal wavelength combination is selected based on SPA. The experimental results show that random forest (RF) classification model and Faster-RCNN recognition models effectively verify that the combination of wavelengths 1,2,4 selected has the highest accuracy in the heterogeneous detection. In conclusion, this paper uses modulation-frame accumulation technique to improve the quality of multi-spectral transmission images. And based on the RF and Faster-RCNN models, the effectiveness of SPA-based optimal wavelength combination method proposed is verified, which will provide a new idea of feature wavelength selection for screening early breast masses through multi-spectral transmission imaging.

Cardiovascular Manifestations From Therapeutic Radiation: A Multidisciplinary Expert Consensus Statement From the International Cardio-Oncology Society

Radiation therapy is a cornerstone of cancer therapy, with >50% of patients undergoing therapeutic radiation. As a result of widespread use and improved survival, there is increasing focus on the potential long-term effects of ionizing radiation, especially cardiovascular toxicity. Radiation therapy can lead to atherosclerosis of the vasculature as well as valvular, myocardial, and pericardial dysfunction. We present a consensus statement from the International Cardio-Oncology Society based on general principles of radiotherapy delivery and cardiovascular risk assessment and risk mitigation in this population. Anatomical-based recommendations for cardiovascular management and follow-up are provided, and a priority is given to the early detection of atherosclerotic vascular disease on imaging to help guide preventive therapy. Unique management considerations in radiation-induced cardiovascular disease are also discussed. Recommendations are based on the most current literature and represent a unanimous consensus by the multidisciplinary expert panel.

•

Radiation therapy leads to short- and long-term cardiovascular adverse effects of the vasculature and the heart, including valvular, myocardial, and pericardial disease.

•

Computed tomography scans conducted for radiation planning or cancer staging provide an available opportunity to detect asymptomatic atherosclerosis and direct preventive therapies.

•

Additional practical screening recommendations for cardiovascular disease based on anatomical exposure are provided.

•

There are unique considerations in the management of radiation-induced cardiovascular disease; contemporary percutaneous treatment is often preferred over surgical options.

Reliability of Coronary Artery Calcium Severity Assessment on Non-Electrocardiogram-Gated CT: A Meta-Analysis

OBJECTIVE

The purpose of this meta-analysis was to investigate the pooled agreements of the coronary artery calcium (CAC) severities assessed by electrocardiogram (ECG)-gated and non-ECG-gated CT and evaluate the impact of the scan parameters.

MATERIALS AND METHODS

PubMed, EMBASE, and the Cochrane library were systematically searched. A modified Quality Assessment of Diagnostic Accuracy Studies-2 tool was used to evaluate the quality of the studies. Meta-analytic methods were utilized to determine the pooled weighted bias, limits of agreement (LOA), and the correlation coefficient of the CAC scores or the weighted kappa for the categorization of the CAC severities detected by the two modalities. The heterogeneity among the studies was also assessed. Subgroup analyses were performed based on factors that could affect the measurement of the CAC score and severity: slice thickness, reconstruction kernel, and radiation dose for non-ECG-gated CT.

RESULTS

A total of 4000 patients from 16 studies were included. The pooled bias was 62.60, 95% LOA were -36.19 to 161.40, and the pooled correlation coefficient was 0.94 (95% confidence interval [CI] = 0.89-0.97) for the CAC score. The pooled weighted kappa of the CAC severity was 0.85 (95% CI = 0.79-0.91). Heterogeneity was observed in the studies (I² > 50%, p < 0.1). In the subgroup analysis, the agreement between the CAC categorizations was better when the two CT examinations had reconstructions based on the same slice thickness and kernel.

CONCLUSION

The pooled agreement of the CAC severities assessed by the ECG-gated and non-ECG-gated CT was excellent; however, it was significantly affected by scan parameters, such as slice thickness and the reconstruction kernel.

Prognostic importance of coincidental coronary artery calcification on FDG-PET/CT oncology studies

Coronary artery calcification (CAC) on body CT imaging is considered a coincidental finding in cancer patients. In order to determine the significance of CAC in cancer patients we evaluated the prognostic utility of CAC detected on oncology FDG-PET/CT studies. A retrospective study was performed of consecutive FDG-PET/CT studies from January to March 2011. CAC was identified on the CT portion of FDG/PET-CT studies. Chart review documented statin use, the Framingham risk score (FRS) (includes age, diabetes, hypertension, dyslipidemia and smoking), the primary malignancy and metastases. The primary end point was a composite of death and cardiovascular (CV) events (non-fatal myocardial infarction (MI), PCI or coronary artery bypass surgery (CABG)). 266 patients had a median follow up of 41 months (95% CI 31-56 months). CAC was noted in 140 patients. Based on CAC, potentially 84 patients would have had a change in statin prescribing (p < 0.01). CAC was associated with the primary end point on univariable and multivariable analysis (OR 2.6 (95% CI 1.42-4.77) (p < 0.01). On univariable Kaplan-Meier survival analysis, CAC was associated with decreased survival only in the absence of metastases (p < 0.01). Cox proportional hazard modelling demonstrated CAC was associated with mortality and cardiac events in patients without metastases, whereas FRS was not (For CAC: HR 1.69 (95% CI 1.22-2.35), p = 0.002). CAC is commonly detected with oncology FDG-PET/CT. In cancer patients CAC was associated with an increased risk of clinical events. CAC reduced survival free time in patients without metastases. CAC might therefore be considered more than a coincidentaloma in patients without metastases.

Reporting incidental coronary, aortic valve and cardiac calcification on non-gated thoracic computed tomography, a consensus statement from the BSCI/BSCCT and BSTI

Incidental coronary and cardiac calcification are frequent findings on non-gated thoracic CT. We recommend that the heart is reviewed on all CT scans where it is visualised. Coronary artery calcification is a marker of coronary artery disease and it is associated with an adverse prognosis on dedicated cardiac imaging and on non-gated thoracic CT performed for non-cardiac indications, both with and without contrast. We recommend that coronary artery calcification is reported on all non-gated thoracic CT using a simple patient-based score (none, mild, moderate, severe). Furthermore, we recommend that reports include recommendations for subsequent management, namely the assessment of modifiable cardiovascular risk factors and, if the patient has chest pain, assessment as per standard guidelines. In most cases, this will not necessitate additional investigations. Incidental aortic valve calcification may also be identified on non-gated thoracic CT and should be reported, along with ancillary findings such as aortic root dilation. Calcification may occur in other parts of the heart including mitral valve/annulus, pericardium and myocardium, but in many cases these are an incidental finding without clinical significance.

Incidental Coronary Artery Calcium on Breast Radiation Therapy Planning Scans Identifies Patients for Cardiac Preventive Therapy

PURPOSE/OBJECTIVE(S)

The presence of coronary artery calcium (CAC>0) is associated with increased cardiac-related mortality and is a common indication to initiate statin therapy to prevent future long-term cardiac-related adverse events. CAC is also well visualized on noncontrast chest computed tomography simulation (CT sim) scans used for breast radiation planning. We hypothesize that by screening for incidental CAC on CT sims, radiation oncologists could help identify patients who may benefit from additional preventive medical interventions with their primary care physician or cardiologist.

METHODS

A retrospective analysis of 126 consecutive patients with breast cancer treated with external beam radiation therapy at a single institution was performed. Noncontrast CT sim scans were reviewed for the presence of CAC and the 10-year risk of atherosclerotic cardiovascular disease (ASCVD) was calculated to identify patients who may benefit from initiating statin therapy. Patients with CAC>0 and/or ASCVD risk >20% were identified as those who may benefit from statin therapy.

RESULTS

Out of 72 patients with CAC>0, only 12(16%) had reported pre-existing coronary artery disease and 32(44%) were not already on recommended statin therapy. CAC>0 visualized on CT sim was able to identify 29 additional patients who would benefit from statin beyond what the ASCVD risk calculator could identify.

CONCLUSION

Observation of incidental CAC on breast radiation-planning CT scans identified patients who could benefit from cardiac-related preventive strategies. By increasing attention, awareness, and reporting of incidental CAC visible on CT sims, radiation oncologists may fulfill a unique role to bridge a potential gap in cardiovascular preventive medicine.