Non-invasive imaging and monitoring cardiotoxicity of cancer therapeutic drugs

Abstract

Cardiotoxicity due to administration of cancer therapeutic agents such as anthracyclines and herceptin are well described. Established guidelines to screen for chemotherapy-related cardiotoxicity (CRC) are primarily based on serial assessment of left ventricular (LV) ejection fraction (EF). However, other parameters such as LV volume, diastolic function, and strain may also be useful in screening for cardiotoxicity. More recent advances in molecular imaging of apoptosis and tissue characterization by cardiac MRI are techniques which might allow early detection of patients at high risk for developing cardiotoxicity prior to a drop in EF. This comprehensive multi-modality review will discuss both the current established imaging techniques as well as the emerging technologies which may revolutionize the future of screening and evaluation for CRC.

Figure 1

Current SPECT guidelines for cardiac monitoring during anthracycline treatment, modified from Schwartz et al. *Risk factors for cardiotoxicity: known heart disease, abnormal ECG, radiation exposure, cyclophosphamide therapy, or cumulative dose already >450 mg/m².

Figure 2

Count time curves from a patient prior to (A) and after (B) anthracycline treatment, with marked reduction in the slope of the curve (TPFR) representing abnormal diastolic filling. Reproduced with permission.

Figure 3

Planar anterior [123I]MIBG images demonstrating reduced uptake and retention in a patient who developed severe adriamycin cardiotoxicity (upper panels), compared to normal uptake and retention in a patient who received a lower cumulative anthracycline dose (lower panels). Reproduced with permission.

Figure 4

Sagittal slice of a SPECT image in a woman with metastatic breast cancer. Strong uptake of ¹¹¹In-DTPA-traztuzumab in the liver metastasis (arrow), as well as in the anterior wall of the myocardium (arrowheads). Reproduced with permission.

Figure 5

A Four-chamber echocardiographic image demonstrating subendocardial LV calcification (arrows) with corresponding to calcification seen on gross specimen after orthotopic heart transplant (B). Masson’s trichrome staining (C) demonstrates fibrosis of the endocardium and myocardium (blue stain). Images reproduced with permission.

Figure 6

Peak longitudinal LV strain at baseline, after three cycles, and after six cycles of doxorubicin. Dashed line represents published normal value of average peak systolic strain ±1 SD (gray area) for healthy women aged 50–70 years. Reproduced with permission.

Figure 7

Short-axis mid-ventricular phase-sensitive inversion recovery delayed image in a patient with herceptin-induced cardiomyopathy demonstrating mid-myocardial lateral wall delayed enhancement. Reproduced with permission.