The Chinese Anti-Cancer Association Society of Integrative Cardio-oncology, the Ultrasound Branch of the Chinese Medical Association, and the Chinese Society of Echocardiography convened experts formulated the Chinese guideline for the clinical application of noninvasive imaging technology in accessing cancer therapy-related cardiovascular toxicity (2023 edition). The guideline highlighted that cancer therapy-related cardiovascular toxicity (CTR-CVT) has become one of the major threats to the survival of cancer patients. Non-invasive imaging technologies play crucial roles in the risk stratification, early diagnosis, monitoring and follow-up of CTR-CVT. This article provided an interpretation of the non-invasive imaging examination methods and monitoring strategies for common CTR-CVT as proposed in the guideline, offering practical and effective guidance for the clinical management of CTR-CVT.
In the contemporary medical field, the incidence of cancer is on the rise, and cancer therapy - related cardiovascular toxicity (CTR-CVT) has become a crucial issue that cannot be overlooked, having a significant impact on the prognosis of patients. With the increasing diversification and sophistication of cancer treatment methods, including chemotherapy, radiotherapy, targeted therapy, and immunotherapy, while these offer hope for anti-tumor treatment to patients, they also carry the potential risk of cardiovascular toxicity, affecting treatment effectiveness and patients’ quality of life. Therefore, it is of particular importance to accurately and comprehensively assess CTR-CVT. This article evaluated cardiovascular toxicity from multiple dimensions such as clinical manifestations, electrocardiogram, imaging, and biomarkers, aiming to provide precise and practical assessment strategies for clinical practice. These strategies are intended to balance the efficacy of cancer treatment and cardiac safety, improve patients’ quality of life, optimize long-term outcomes, and enhance patients’ living standards.
The application of immune checkpoint inhibitors (ICI) in cancer treatment is on the rise, conferring substantial survival benefits to patients. Nevertheless, the development of life-threatening myocarditis induced by ICI has emerged as a novel challenge in clinical practice. Multimodality imaging, due to their non-invasive and low-risk profile, play an important role in the evaluation of ICI-associated myocarditis. This article reviewed the advancements of multimodality imaging for the assessment of ICI-associated myocarditis.
During the therapeutic management of malignant neoplasms, for instance, during radiotherapy (RT) and chemotherapeutic regimens, treatment-associated cardiotoxicity may ensue, which is typically challenging to be detected and diagnosed at an early stage. Nuclear medicine molecular imaging is capable of directly revealing physiological and pathological processes at the cellular or molecular level, enabling the visualization of cardiotoxicity associated with the treatment of malignant tumors.This article provided a comprehensive review on the diagnostic significance of nuclear medicine molecular imaging in terms of cardiotoxicity associated with malignant neoplasm treatment from multiple perspectives, including myocardial metabolism, inflammation, neural injury, and fibrosis. The aim is to further elucidate its pathophysiological evolution and enhance the early-stage diagnostic proficiency.
Objective: To evaluate the protective effects of astragaloside Ⅳ (AS-Ⅳ) against epirubicin (Epb)-induced cardiac injury in rats using speckle tracking imaging. Methods: Thirty-two SD rats were randomly assigned to four groups (n=8 per group): normal control, Epb model, low-dose AS-Ⅳ, and high-dose AS-Ⅳ. Transthoracic echocardiography (TTE) was performed at baseline and at 2, 4, and 6 weeks post-treatment to assess left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). At week 6, serum levels of CK-MB, LDH, and IL-17 were measured, and heart tissues were collected for Masson staining to evaluate myocardial fibrosis. Results: LVEF showed no significant changes across groups or over time (P>0.05). GLS, however, was significantly influenced by both factors [F group (3, 21)=11.014 2, P<0.000 1] and time [F time (3, 21)=7.215 4, P=0.001 7], with a near-significant interaction effect [F interaction (9, 63)=1.876 1, P=0.072 0]. Serum CK-MB and LDH levels showed no significant differences among groups (P>0.05). IL-17 levels were significantly elevated in the Epb model group compared to the control group, while both AS-Ⅳ treatment groups exhibited significantly reduced levels compared to the Epb model group (P<0.05). The heart weight index did not differ significantly among groups, but myocardial fibrosis area showed significant variations, worsening progressively from control to high-dose AS-Ⅳ, low-dose AS-Ⅳ and Epb model groups（P<0.000 1）. Conclusion: AS-Ⅳ may attenuate myocardial fibrosis and reduce inflammation in Epb-induced myocardial damage. GLS proved to be a more sensitive and accurate indicator than LVEF for detecting subclinical myocardial injury.
Objective: To assess the injuries of left ventricular function in breast cancer patients following anthracycline-based chemotherapy using ultrasonic vector flow mapping (VFM) combined with layer-specific two-dimensional speckle tracking imaging (LS2D-STI). Methods: A retrospective analysis was conducted on breast cancer patients who underwent chemotherapy with the TEC regimen (docetaxel 75 mg/m2, epirubicin 90 mg/m2, and cyclophosphamide 500 mg/m2) for the injuries of left ventricular function in Sichuan Provincial People’s Hospital from January to June 2017. A self-controlled study design was employed, with transthoracic echocardiography (TTE) performed before chemotherapy and at 48 h after each chemotherapy cycle, for a total of seven assessments (denoted as T0, T1, T2, T3, T4, T5, and T6) for parameters of intra-ventricular hemodynamic and transmural strain. Conventional echocardiographic parameters were collected, along with myocardial layer-specific global longitudinal strain, including endocardial global longitudinal strain (GLSendo), mid-myocardial global longitudinal strain (GLSmid), and epicardial global longitudinal strain (GLSepi). Additionally, left intra-ventricular hemodynamic parameters were measured, including global energy loss (EL), comprising early diastolic energy loss (EDC_EL), late diastolic energy loss (LDC_EL), isovolumic contraction energy loss (IVC_EL), and rapid ejection period energy loss (REP_EL). Left ventricular global circulation intensity (CIR) was also analyzed, including early diastolic circulation (EDC_CIR), late diastolic circulation (LDC_CIR), isovolumic contraction circulation (IVC_CIR), and rapid ejection period circulation (REP_CIR). The collected data were analyzed to assess changes in left ventricular function over the course of chemotherapy. Results: ① There were no significant differences in left ventricular ejection fraction (LVEF) between T1-T6 and T0 (P>0.05). The mitral inflow early diastolic peak velocity to mitral annular early diastolic peak velocity ratio (E/e’) gradually increased from T1 onward, with statistically significant differences observed (T0: 5.64 to T6: 8.76, P<0.05). ② There were no significant differences in GLSendo, GLSmid, or GLSepi at any time point compared to baseline (P>0.05). However, these parameters showed a trend of initially increasing and then decreasing, with strains at T6 being lower than baseline values. ③ EL showed an overall downward trend, while CIR exhibited an upward trend. Specifically, LDC_EL at T2-T6 was significantly lower than T0, whereas LDC_CIR at T2, T4, and T6 was higher than T0. EDC_EL and IVC_EL were significantly lower at T5 and T6, and REP_EL at T5 and T6 was significantly lower than baseline (P<0.05). Changes in LDC-phase parameters occurred earlier than those in other phases. EL and CIR changes occurred later than changes in E/e’. Conclusion: Ultrasonic VFM and LS2D-STI contribute to comprehensive assessment of cardiotoxicity in breast cancer patients undergoing anthracycline-based chemotherapy. Among these, the combination of E/e’ with EL and CIR may have more significant clinical value in evaluating changes in left ventricular diastolic function.
Objective: To compare the diagnostic value of qualitative and quantitative parameters of sound touch elastography (STE) and strain elastography (SE) in differentiating benign and malignant Breast Imaging Reporting and Data System (BI-RADS) 4 breast lesions, and to explore the correlation between the parameters and the expression of human epidermal growth factor receptor 2 (HER2) in BI-RADS 4 breast malignant lesions. Methods: The clinicopathological data of patients with BI-RADS 4 breast lesions diagnosed by ultrasound examination in The First Hospital of Shanxi Medical University were selected. The quantitative and qualitative parameters of STE and SE were obtained: STE maximum elasticity (Emax), STE qualitative score, SE strain ratio (SR) and SE qualitative score. To compare the value of two ultrasonic elastography parameters in differentiating benign and malignant BI-RADS 4 breast lesions and their correlation with HER2 expression in BI-RADS 4 breast malignant lesions. Results: A total of 106 patients with 106 lesions were included. The difference of Emax, STE score, SR and SE score between benign and malignant lesions of BI-RADS 4 breast was statistically significant (P<0.05). Compared with the pathological results, the difference of Emax, STE score, SR and SE score in the diagnosis of benign and malignant BI-RADS 4 breast lesions according to the cut-off value was statistically significant (P<0.05). The diagnostic efficacy of Emax, STE score and SR was generally consistent with that of the gold standard (Kappa=0.436, 0.420, 0.502), and the diagnostic efficacy of SE score was more consistent with that of the gold standard (Kappa=0.626). The area under the receiver operating characteristic (ROC) curve (AUC) of SE score (AUC=0.883) was higher than that of Emax (AUC=0.743), STE score (AUC=0.756) and SR (AUC=0.783) diagnosis, with the greatest diagnostic efficiency, and the difference was statistically significant (P<0.05). In BI-RADS 4 breast malignant lesions, the difference of Emax and SE scores between HER2 positive expression and negative expression was statistically significant (P<0.05). Emax and SE scores were positively correlated with HER2 positive expression (r=0.458, 0.356). The best cut-off value of Emax and SE score in the diagnosis of HER2 positive expression was 123.75 kPa and 4 points, the sensitivity was 81.2% and 62.5%, the specificity was 60.5% and 68.4%, and the AUC was 0.766 and 0.689. Conclusion: The diagnostic efficacy of SE score was higher when STE and SE techniques were used to identify BI-RADS 4 breast lesions. Emax and SE scores were positively correlated with HER2 positive expression. Emax and SE score are of great value in identifying HER2 positive expression in BI-RADS 4 breast malignant lesions.
Objective: To explore the clinical application value of the contrast-enhanced ultrasound (CEUS) scoring method in reclassifying Breast Imaging Reporting and Data System (BI-RADS) category 4 lesions. Methods: The data of patients with breast nodules diagnosed by postoperative pathology or puncture biopsy in Shanghai Yangpu District Shidong Hospital and Shanghai Fourth People’s Hospital from May 2021 to April 2024 were retrospectively analyzed. All nodules underwent routine ultrasound examination and were indicated as BI-RADS category 4. Each nodule underwent CEUS and was assigned a score. The BI-RADS classification was adjusted according to the score results, and the diagnostic efficiency before and after adjustment was compared. In addition, breast nodules were divided into 3 groups according to the maximum diameter, and the diagnostic efficacy of CEUS scoring was evaluated for nodules of different sizes. Results: A total of 105 patients with 109 nodules were included, comprising 59 benign nodules and 50 malignant nodules. BI-RADS 4b and above were considered as malignant, and the sensitivity and accuracy of diagnosis combined with CEUS scoring method (94.00% and 92.66%) were significantly higher than those of conventional ultrasound (52.00% and 75.23%, P<0.05). The area under the receiver operating characteristic (ROC) curve after adjustment was 0.95, significantly higher than that of conventional ultrasound (0.76). After integrating the CEUS scoring method, the diagnostic sensitivity significantly improved across all three groups of breast nodules stratified by size (P<0.05). The diagnostic accuracy in all three groups increased to over 90%, with the most notable improvement observed in the ≥2 cm group (65.38% vs 96.15%, P< 0.05). Conclusion: The CEUS scoring method has high diagnostic efficiency and is valuable for the readjustment of BI-RADS category 4 nodules, and has extensive clinical application value.
Objective: To evaluate the size and internal changes of bone metastases in breast cancer by spectral computed tomography (CT) images, to explore the predictive value of these multiple parameters for progression-free survival (PFS), and to overcome the limitations of conventional CT and existing criteria in the evaluation of bone metastases. Methods: The clinical and imaging data of patients with breast cancer with bone metastasis who were treated in Fudan University Shanghai Cancer Center from June 2019 to December 2022 were retrospectively analyzed. All patients underwent two contrast-enhanced spectral CT examinations, and the size indexes of bone metastases were recorded on the venous stage images: long diameter, short diameter, sum of long diameter and short diameter, and area of interest. Internal indicators of bone metastasis were CT value of conventional image (bone window) (CTv), CT value of single-level image (CT40 keV, CT80 keV, CT120 keV), CT value of calcium suppression image (CTCaSupp30, CTCaSupp50, CTCaSupp70, CTCaSupp90). Each index of all the bone metastatic target lesions measured in the patient was summed respectively, and the change rate and monthly change rate of each index were calculated. The independent risk factors of PFS were determined by univariate and multifactor Cox proportional risk regression analysis combined with stepwise regression method. Cox proportional hazard regression model was used to construct the model, and the area under the time-dependent receiver operating characteristic curve (AUC) was used to evaluate its predictive performance. DeLong test compared AUC. The threshold was determined by X-tile method and divided into high and low risk groups according to the threshold. Kaplan-Meier (KM) survival curve and log-rank test were used to analyze the difference in prognosis between groups. Results: A total of 30 patients with breast cancer with bone metastases were included. The monthly rate of change of the sum of length and diameter of bone metastases and the monthly rate of change of CTCaSupp70 are effective predictors of PFS in breast cancer patients with bone metastases. PFS was significantly prolonged in patients with the monthly change rate of the sum of length and diameter < 0.39% and the monthly change rate of CTCaSupp70>-9.75%. The AUC of 1-year PFS predicted by the sum of long and short diameters model, CTCaSupp70 model, combined model and response criteria of bone metastases at MD Anderson Cancer Center (MDA criteria) were 0.751, 0.702, 0.827 and 0.600, respectively. The predictive performance of the combined model was significantly better than that of the MDA standard (P=0.003). The PFS of high risk group were significantly lower than those of low risk group (P<0.05). There was no significant difference in PFS survival curve under MDA (P=0.091). Conclusion: The monthly rate of change in the sum of long and short diameters of bone metastases and the monthly rate of change in CTCaSupp70 are effective predictive indicators for the prognosis of breast cancer patients with bone metastasis, and their combined application can enhance predictive performance.
Objective: To explore the clinical and imaging features of diffuse high-grade gliomas in the brainstem of children based on multi parameter sequences, so as to improve the comprehensive understanding of the disease. Methods: The clinical and imaging data of pediatric brain stem diffuse high-grade gliomas confirmed by pathology from January 2022 to January 2024 were retrospectively analyzed. Results: A total of 45 children in Xinhua Hospital, Shanghai Jiao Tong University School of Medicine with diffuse high-grade gliomas in the brainstem (19 males and 26 females, aged 6.48±2.34 years) were included in this study. Among them, 4.4% (2/45) had cerebrospinal fluid dissemination, while the rest had localized or nearby infiltration and growth in the brainstem. 45 cases underwent computed tomography (CT) plain scan+ magnetic resonance imaging (MRI) plain scan/enhanced scan+diffusion-weighted imaging (DWI) basic scan, 6 cases underwent CT perfusion imaging (CTP) scan simultaneously, 8 cases underwent magnetic resonance spectroscopy (MRS) scan simultaneously, 7 cases underwent diffusion tensor imaging (DTI) scan simultaneously, and 2 cases underwent susceptibility weighted imaging (SWI) scan simultaneously. All 45 cases had endogenous swelling growth, including 36 cases with uniform swelling growth on both sides and 9 cases with lateral swelling growth (7 cases crossed the midline during the growth process, and 2 cases with diffuse growth on one side of the head and tail); 28.9% (13/45) limited brainstem growth, 2.2% (1/45) limited medullary growth, 68.9% (31/45) grew towards the head and tail (midbrain/thalamus/medulla oblongata, 21/31, 67.7%) and laterally (pons/cerebellum, 10/31, 32.3%), and 26.7% (12/45) progressed to exogeneity (including 11 cases involving the basilar artery, 11/12, 91.7%). The CT plain scan sequence showed low-density thickening shadows in the brainstem area, with a density lower than that of the normal brainstem (P<0.001). CT perfusion sequence scan showed a decrease in cerebral blood flow (CBF) in the tumor area of 83.3% (5/6) of patients (1 case showed a significantly lower than average level in the tumor center area), and 1 case showed an increase. Bilateral cerebral hemisphere perfusion abnormalities, with delayed peak time, mainly around the lateral ventricles. The MRI structural sequence showed that 8.9% (4/45) of the tumor solid components on T1-weighted imaging (T1WI) showed equal signal intensity, 11.1% (5/45) showed low signal intensity, and 80.0% showed mixed signal intensity (36/45). The T2-fluid suppressed inversion recovery (FLAIR) sequence showed slightly high to high signal intensity, and the pattern after T1WI enhancement showed diverse changes. Six cases did not show enhancement, while the rest showed varying degrees of mild to moderate enhancement. 28.2% (11/39) showed local circular enhancement, 38.5% (15/39) showed local nodular enhancement, 10.3% (4/39) showed patchy enhancement, and 23.1% (9/39) showed patchy enhancement. Manifested as gravel like enhancement, 7.7% (3/39) showed mixed mode enhancement, and some patients with unclear T1WI enhancement had better T2-FLAIR enhancement sequence contrast. In the MRI functional sequence, MRS showed varying degrees of increase in Cho peak and decrease in NAA peak, with one case showing a significant inversion of Lac peak; DTI scan showed that the nerve fiber bundles in the lesion area were pushed to the periphery by the tumor, with 5 cases showing partial interruption of the fiber bundles and 1 case only showing compression and pushing of the fiber bundles. Local low signal can be seen on the SWI phase map, indicating intratumoral microbleeds. Conclusion: The conventional CT findings of diffuse high-grade gliomas in the brain stem of children are low-density brain stem thickening, and quantification is helpful for early detection and prevention of missed diagnosis. The growth mainly occurred in the diffuse endogenetic pontine, and most of them infiltrated and grew to other brain regions along the direction of nerve fiber bundles, pushing or destroying the nearby fiber bundles. The enhancement patterns were various, and most of them were scattered mild to moderate enhancement. There may be cystic image signals inside, which may be related to the reduction of necrosis by local perfusion and absorption after microbleeds;
Objective: To compare the value of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computer tomography (CT) and 68GA-fibroblast activation protein inhibitor (FAPI) PET/CT in the diagnosis of different types of lymphoma. Methods: The clinical, pathological and imaging data of patients with lymphoma who received 18F-FDG and 68Ga-FAPI PET/CT in Fudan University Shanghai Cancer Center within one week from November 2020 to October 2022 were retrospectively analyzed, and the detection rates of the two imaging agents for lesions were compared. At the same time, the differences of maximum standard uptake value (SUVmax), target-to-background ratio (TBR) and target-to-liver ratio (TLR) between the two groups were compared. Results: A total of 197 lymphomas (167 lymph node lesions and 30 extranodal lesions) were detected in 28 patients with pathologically confirmed lymphoma, and 191 lesions (161 lymph node lesions and 30 extranodal lesions) were detected by 18F-FDG PET/CT. 68Ga-FAPI PET/CT detected 98 lesions (including 74 lymph node lesions and 24 extranodal lesions), and the detection rate of 18F-FDG PET/CT was significantly higher than that of 68Ga-FAPI PET/CT. But for gastrointestinal infiltrating lesions, 18F-FDG PET/CT has a higher false positive rate. In lymphoma patients, SUVmax-FDG > SUVmax-FAPI, TBR-FDG > TBR-FAPI, the difference was statistically significant (14.4 vs 6.5, 13.3 vs 3.4, P<0.05). However, the SUVmax and TBR of Hodgkin’s lymphoma (HL) were 12.3 vs 6.5, 11.6 vs 5.1 (P>0.05) and indolent lymphoma 10.2 vs 10.9, 21.4 vs 5.1 (P>0.05), the difference was not statistically significant. There was no significant difference in TLR between the two examinations in all lymphoma patients (5.2 vs 5.2, P>0.05). Conclusion: The diagnostic value of 18F-FDG PET/CT for lymphoma is better than 68Ga-FAPI PET/CT. But for HL and inert lymphoma, there was no significant difference in metabolic parameters between the two groups, and 68Ga-FAPI PET/CT has higher diagnostic accuracy for gastrointestinal infiltration.
Breast cancer is highly heterogeneous at the molecular level, and molecular classification of breast cancer is very important for treatment selection and prognosis assessment. As a non-invasive and convenient diagnostic method, ultrasound plays an important role in breast cancer screening and diagnosis. By analyzing ultrasound image features and artificial intelligence modeling, medical personnel are expected to achieve non-invasive and accurate diagnosis of breast cancer molecular subtypes. This article reviewed the progress of ultrasonography in determining molecular typing of breast cancer.
