A Score-Based Approach to 18F-FDG PET Images as a Tool to Describe Metabolic Predictors of Myocardial Doxorubicin Susceptibility

Abstract

Purpose: To verify the capability of 18F-fluorodeoxy-glucose positron emission tomography/computed tomography (FDG-PET/CT) to identify patients at higher risk of developing doxorubicin (DXR)-induced cardiotoxicity, using a score-based image approach. Methods: 36 patients underwent FDG-PET/CT. These patients had shown full remission after DXR-based chemotherapy for Hodgkin’s disease (DXR dose: 40–50 mg/m2 per cycle), and were retrospectively enrolled. Inclusion criteria implied the presence of both pre- and post-chemotherapy clinical evaluation encompassing electrocardiogram (ECG) and echocardiography. Myocardial metabolism at pre-therapy PET was evaluated according to both standardized uptake value (SUV)- and score-based approaches. The capability of the score-based image assessment to predict the occurrence of cardiac toxicity with respect to SUV measurement was then evaluated. Results: In contrast to the SUV-based approach, the five-point scale method does not linearly stratify the risk of the subsequent development of cardiotoxicity. However, converting the five-points scale to a dichotomic evaluation (low vs. high myocardial metabolism), FDG-PET/CT showed high diagnostic accuracy in the prediction of cardiac toxicity (specificity = 100% and sensitivity = 83.3%). In patients showing high myocardial uptake at baseline, in which the score-based method is not able to definitively exclude the occurrence of cardiac toxicity, myocardial SUV mean quantification is able to further stratify the risk between low and intermediate risk classes. Conclusions: the score-based approach to FDG-PET/CT images is a feasible method for predicting DXR-induced cardiotoxicity. This method might improve the inter-reader and inter-scanner variability, thus allowing the evaluation of FDG-PET/CT images in a multicentral setting.

An increase in myocardial 18-fluorodeoxyglucose uptake is associated with left ventricular ejection fraction decline in Hodgkin lymphoma patients treated with anthracycline

“…Since this enzyme is also thought to be responsible for the phosphorylation of 18 FDG leading to intracellular tracer retention [ 27 ], it is conceivable that the augmented myocardial uptake of 18 FDG following DOX chemotherapy is the consequence of heightened hexokinase activity. If so, this and other recent studies [ 16 , 17 , 19 , 28 ] may be viewed as indirect confirmation that anthracycline-initiated impairment of energy metabolism occurs in the human heart as it does in experimental models.…”

Myocardial Metabolic Response Predicts Chemotherapy Curative Potential on Hodgkin Lymphoma: A Proof-of-Concept Study

“…Complete remission was defined according to current guidelines [2,9,10]. Similarly, follow-up was prolonged for five years and implied ambulatory visits once every six months for the first 36 months, and each year thereafter [2,9,10].…”

Looking for trouble: Reduced myocardial flow reserve following anthracyclines

“…Bauckneht et al and others have considered the observation that in contrast to those patients without cardiac dysfunction, 18F-FDG myocardial uptake is increased in patients that develop anthracycline cardiotoxicity. 26 The impression from these observations is that whether via an inflammatory response or by induction of myocardial metabolism, anthracyclines induce FDG uptake to a greater degree in those patients who demonstrate cardiotoxicity.…”