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Review
. 2022 Aug 15;12(8):3548-3560.
eCollection 2022.

Cardiac imaging techniques for the assessment of immune checkpoint inhibitor-induced cardiotoxicity and their potential clinical applications

Yi Li  1   2 , Pei-Jun Liu  1 , Zhuo-Li Zhang  3 , Yi-Ning Wang  1
Affiliations
Review

Cardiac imaging techniques for the assessment of immune checkpoint inhibitor-induced cardiotoxicity and their potential clinical applications

Yi Li et al. Am J Cancer Res. .

Abstract

Immune checkpoint inhibitors (ICIs) have encouraged a paradigm shift in the clinical management of patients with cancer. Despite the dramatically improved tumor response and patient prognosis, ICIs have been associated with ICI-related myocarditis, which has a high fatality rate. Cardiac imaging plays a critical role in the assessment of cardiac injury. Echocardiography, cardiac magnetic resonance imaging, and targeted tracer-based cardiac molecular imaging techniques alone or in combination reflect pathophysiology and depict different aspects of lesions at different clinical stages, i.e., they have potentially complementary value. Imaging techniques for identifying ICI-induced cardiotoxicity at the early stage may reduce the incidence of adverse cardiovascular events. Particularly in planned ICI therapy among patients with cancer, improved monitoring approaches to identify patients who are at the highest risk of ICI-related myocarditis may help in refining clinical decisions, allowing treatment to be more accurately targeted toward patients who are most likely to benefit. In this study, we systematically reviewed the studies on cardiac imaging techniques for assessing ICI-induced cardiotoxicity. We elaborated about the potential applications of cardiac imaging techniques for the optimized management of patients with ICI-related myocarditis, including risk stratification, diagnosis, and prognosis.

Keywords: Immune checkpoint inhibitors; cancer; cardiac imaging; cardiotoxicity; myocarditis.

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Conflict of interest statement

None.

Figures

Figure 1
Figure 1
Multiparameters of CMR imaging in a patient with confirmed ICI-related myocarditis. Cine showed decreased LVEF (28.3%) and RVEF (40.6%). LGE revealed patchy areas of enhancement in the septal and inferior walls. Mapping sequences showed an overall value of 1413 ms on T1 mapping and an overall value of 43 ms on T2 mapping. ICI = immune checkpoint inhibitor, LVEF = left ventricle ejection fraction, RVEF = right ventricle ejection fraction, LGE = late gadolinium enhancement.
Figure 2
Figure 2
Fused 68Ga-DOTATOC PET/CT images of patients with ICI-induced cardiotoxicity. Images show pathological uptake in the myocardium on the long axis of the LV. Picture published with permission from [49].
Figure 3
Figure 3
Medical imaging techniques in the assessment of ICI-related cardiotoxicities. At the early stage of this condition, the main changes in the myocardium were predominantly CD4+/CD8+ T lymphocytes and a few macrophages infiltration and increased the release of inflammatory factors. Molecular imaging techniques, based on molecularly targeted probes, facilitate the assessment of early cardiotoxicities, and may reflect increased risk of ICI-related myocarditis. As it progresses, the disease involves cardiomyocyte necrosis, myocardial fibrosis, and impaired cardiac function. CMR uses tissue characterization assessments, such as T1/T2 mapping, ECV, LGE, and cine, to evaluate myocardial fibrosis patterns and cardiac function. In addition, CMR biomarkers can be used predict the prognosis of ICI-related myocarditis. Echocardiography can be used to evaluate regional and global strains to assess signs of ICI-related myocarditis. ICI = immune checkpoint inhibitor; ECV = extracellular volume fraction; LGE = late gadolinium enhancement.
See this image and copyright information in PMC

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