Myocardial 18F-FDG Uptake Pattern for Cardiovascular Risk Stratification in Patients Undergoing Oncologic PET/CT

Abstract

Objective: Positron emission tomography/computed tomography with 18F-fluorodeoxy-glucose (18F-FDG-PET/CT) has become the standard staging modality in various tumor entities. Cancer patients frequently receive cardio-toxic therapies. However, routine cardiovascular assessment in oncologic patients is not performed in current clinical practice. Accordingly, this study sought to assess whether myocardial 18F-FDG uptake patterns of patients undergoing oncologic PET/CT can be used for cardiovascular risk stratification. Methods: Myocardial 18F-FDG uptake pattern was assessed in 302 patients undergoing both oncologic whole-body 18F-FDG-PET/CT and myocardial perfusion imaging by single-photon emission computed tomography (SPECT-MPI) within a six-month period. Primary outcomes were myocardial 18F-FDG uptake pattern, impaired myocardial perfusion, ongoing ischemia, myocardial scar, and left ventricular ejection fraction. Results: Among all patients, 109 (36.1%) displayed no myocardial 18F-FDG uptake, 77 (25.5%) showed diffuse myocardial 18F-FDG uptake, 24 (7.9%) showed focal 18F-FDG uptake, and 92 (30.5%) had a focal on diffuse myocardial 18F-FDG uptake pattern. In contrast to the other uptake patterns, focal myocardial 18F-FDG uptake was predominantly observed in patients with myocardial abnormalities (i.e., abnormal perfusion, impaired LVEF, myocardial ischemia, or scar). Accordingly, a multivariate logistic regression identified focal myocardial 18F-FDG uptake as a strong predictor of abnormal myocardial function/perfusion (odds ratio (OR) 5.32, 95% confidence interval (CI) 1.73–16.34, p = 0.003). Similarly, focal myocardial 18F-FDG uptake was an independent predictor of ongoing ischemia and myocardial scar (OR 4.17, 95% CI 1.53–11.4, p = 0.005 and OR 3.78, 95% CI 1.47–9.69, p = 0.006, respectively). Conclusions: Focal myocardial 18F-FDG uptake seen on oncologic PET/CT indicates a significantly increased risk for multiple myocardial abnormalities. Obtaining and taking this information into account will help to stratify patients according to risk and will reduce unnecessary cardiovascular complications in cancer patients.

Heart and bladder detection and segmentation on FDG PET/CT by deep learning

“…As such, this task may slightly differ from regular heart segmentation on CT [ 35 , 36 ] or MR [ 37 , 38 ], but, also requires both CT and FDG-PET data. The uptake of FDG in the heart muscle of patients undergoing chemo-therapy has been investigated [ 39 ] and focal myocardial FDG uptake indicates a significant increased risk for multiple myocardial abnormalities. As such, this heart segmentation model could be used as an automated tool to assist the measurement of myocardial uptake.…”

New Insights in Early Detection of Anticancer Drug-Related Cardiotoxicity Using Perfusion and Metabolic Imaging

“…As part of an oncologic PET protocol, patients were fasted to avoid myocardial 18 F-FDG uptake: 36% of patients had no 18 F-FDG uptake, 22.5% had diffuse 18 F-FDG uptake, 8% had focal 18 F-FDG uptake, and 30.5% had a focal uptake overlying the diffuse pattern 18 F-FDG uptake. Among all the patients, multivariate logistic regression identified focal myocardial 18 F-FDG uptake as a predictor of impaired LVEF and myocardial perfusion (131). It is important to bear in mind two interesting points.…”

“…Second, increased LV 18 F-FDG uptake correlated with LVEF decline after two cycles and at the end of DOX therapy in a retrospective study including a cohort of 43 patients (130). Another interesting study explored 18 F-FDG myocardial uptake and myocardial perfusion (through 99m Tc-tetrofosmin SPECT) in a retrospective cohort of 332 patients followed for malignant disorders (131). As part of an oncologic PET protocol, patients were fasted to avoid myocardial 18 F-FDG uptake: 36% of patients had no 18 F-FDG uptake, 22.5% had diffuse 18 F-FDG uptake, 8% had focal 18 F-FDG uptake, and 30.5% had a focal uptake overlying the diffuse pattern 18 F-FDG uptake.…”

Series of myocardial FDG uptake requiring considerations of myocardial abnormalities in FDG-PET/CT

“…Haider et al observed focal myocardial FDG uptake (not limited to the apex) in patients with myocardial abnormalities such as abnormal perfusion, impaired LV ejection fraction (LVEF), myocardial ischemia, and scarring. In addition, focal myocardial FDG uptake has been identified as a strong predictor of abnormal myocardial function/perfusion and as an independent predictor of ongoing ischemia and myocardial scarring [67]. Increased FDG uptake can persist for 48 h after stressinduced myocardial ischemia in stable coronary artery disease [68,69].…”