How to Use Multimodality Imaging in Cardio-Oncology

Figure 1. The assessment of left ventricular ejection fraction by 3D transthoracic echocardiography.

Figure 2. Two-dimensional speckle-tracking LV GLS displayed in the bull’s eye format. (A) Normal global and regional LV longitudinal strain (GLS −22.9%) in a 37-year-old female patient with breast cancer and associated cardiovascular risk factors (current smoker, hypercholesterolemia) who received prior treatment with doxorubicin and was referred for cardiological evaluation before initiating trastuzumab therapy. We also note a normal LV EF of 60% at this evaluation. (B) After six cycles of trastuzumab therapy, we observed a decline in LV GLS (−18.5%). In the same patient, LV EF was not significantly altered. 2D: two-dimensional; LV: left ventricular; GLS: global longitudinal strain.

Figure 3. A 65-year-old female patient, with a 12-year diagnosis of chronic lymphocytic leukemia and unfavourable evolution under multiple antineoplastic therapies, some with cardiotoxic potential, with relapse of the disease. She was referred for baseline cardiologic evaluation due to increased risk of cardiotoxicity. Following the assessment, she was started on the second-generation Bruton’s tyrosine kinase inhibitor, acalabrutinib. (A) Baseline echocardiographic evaluation showed normal phasic components of left atrial strain but with reduced LASr (20%). (B) One month after initiating acalabrutinib, the patient developed paroxysmal atrial fibrillation. Reevaluation of her echocardiogram indicated a decline in all phasic components of left atrial strain, while her left atrial volume remained unchanged. LASr: LA strain reservoir; LAScd: LA strain conduit; LASct: LA strain contractile.

Figure 4. Cardiac magnetic resonance (CMR) imaging sequences from patients with cardiac amyloidosis. (A): Cine (bSSFP) four-chamber, systolic frame showing biventricular wall thickening, thickened atrial walls and interatrial septum, as well as pericardial and right-sided pleural effusions. (B,C): Late gadolinium enhancement (LGE) sequences in four-chamber and short-axis views demonstrating diffuse transmural LGE with involvement of the right ventricular free wall, both atrial walls, and the interatrial septum. Abnormal gadolinium kinetics resulting in a “dark blood” appearance are also visible. (D,F): Parametric mapping showing elevated native T1 (D), T2 (E), and extracellular volume fraction (ECV) after contrast administration (F). (G,H): Cine two-chamber view (G) depicting a suspected mass, which was confirmed as a left atrial appendage thrombus on the early gadolinium enhancement (EGE) sequence (H) in a patient with light-chain (AL) amyloidosis.

Figure 5. Left ventricular myocardial dysfunction secondary to chemotherapy in a 56-year-old patient treated with trastuzumab. (A) Cine (bSSFP) four-chamber view demonstrated mildly reduced left ventricular ejection fraction (LVEF 50%). (B) Late gadolinium enhancement shows no evidence of myocardial scar. (C,D) Native T1 mapping in both four-chamber and short-axis views reveals diffuse myocardial fibrosis, reflected by prolonged relaxation times.

Figure 6. Immune checkpoint inhibitor (ICI)-associated myocarditis in a 58-year-old patient with melanoma treated with pembrolizumab. (A) Cine (bSSFP) four-chamber view which demonstrated mildly reduced left ventricular ejection fraction (49%). (B) Late gadolinium enhancement shows no evidence of myocardial scar. (C) Native T1 mapping in the four-chamber view reveals diffuse myocardial fibrosis, indicated by prolonged T1 relaxation time. (D) T2 mapping in the short-axis view demonstrates myocardial oedema, reflected by prolonged T2 relaxation time.

Figure 7. Myocardial perfusion SPECT imaging post-stress and at rest in a 76-year-old female patient with old anterior myocardial infarction and chronic LAD occlusion at coronarography: effort up to 95W, maximum HR of 145 bpm (99% of maximal HR), maximum BP 200/100 mmHg, no angina; resting BP 150/70 mmHg, resting HR 85 bpm. SPECT scan shows a reversible hypoperfusion area at the level of the interventricular septum, especially in the anterior territory, with a differential perfusion score of 11%. SPECT, single photon emission computed tomography; LAD, left anterior descending artery; HR, heart rate; BP, blood pressure.

Figure 8. Planar and hybrid SPECT/CT bone scintigraphy in transthyretin cardiac amyloidosis. Anterior and posterior whole-body planar images (A) show intense myocardial tracer uptake exceeding rib activity, corresponding to Perugini grade 3 myocardial uptake, highly suggestive of transthyretin cardiac amyloidosis. Hybrid SPECT/CT images (B) in coronal, sagittal, and axial views confirm myocardial localisation of radiotracer signal, clearly distinct from blood pool or skeletal activity. The fused images (bottom row) demonstrate homogeneous radiotracer accumulation throughout the left ventricular myocardium, consistent with diffuse amyloid infiltration.

Figure 9. Valvular heart disease after chemotherapy. Case report: A 64-year-old female with NYHA class III–IV dyspnea was evaluated preoperatively in the cardio-oncology department following the simultaneous diagnosis of two tumours: a left-sided thoracic sarcoma and a right-sided breast cancer. Thoracic magnetic resonance imaging revealed a large mass in the left axilla (13.3 × 12.1 × 7.1 cm), suspected to involve the thoracic wall but without evidence of pulmonary infiltration. The patient had not received any prior medical or surgical treatment for the current malignancies at the time of evaluation. Her medical history was notable for a left-sided breast cancer 29 years earlier, treated with anthracyclines, radiation therapy, and breast-conserving surgery. Staging and histopathological data from the initial diagnosis were unavailable. Based on the tumour board’s recommendations, surgical resection of the sarcoma was planned, along with initiation of aromatase inhibitor therapy for the newly diagnosed breast cancer. During the cardio-oncology consultation, the patient’s overall cardiovascular risk, assessed using the HFA-ICOS score, was classified as very high. Transthoracic…

Figure 10. Calcifications of the ascending aorta and aortic valve after radiotherapy in a 46-year-old woman with Hodgkin’s lymphoma. (A) Oblique sagittal plane of the ascending aorta, transverse arch and proximal descending aorta. (B) Maximum intensity projection of the same plane. Extensive confluent calcifications of the ascending aorta and aortic arch—porcelain aorta (white arrows) as well as aortic valve calcification (arrowheads). CT, computer tomography.