Predictive value of left ventricular 18F-FDG PET/CT derived parameters and uptake patterns for chemotherapy-induced cardiotoxicity in patients with lymphoma

BACKGROUND Anthracycline-induced cardiotoxicity significantly impacts the survival and quality of life of lymphoma patients. Since traditional echocardiographic markers often detect injury only after irreversible damage, there is an urgent need for early biomarkers. We aimed to evaluate the predictive value of myocardial FDG uptake patterns and quantitative parameters from routine oncologic PET/CT for cancer therapy-related cardiac dysfunction (CTRCD). METHODS This retrospective cohort study included lymphoma patients treated with anthracycline-based regimens at a single hospital between 2015 and 2024. Patients underwent FDG PET/CT at baseline and after chemotherapy. CTRCD was operationally defined using the LVEF-based component of the 2022 ESC cardio-oncology guidelines on follow-up echocardiography. Metabolic parameters including maximal standard uptake value (SUVmax), cardiac metabolic volume (CMV), cardiac metabolic activity (CMA), and visual uptake patterns were analyzed on pre and post-treatment PET scans. RESULTS Post-treatment SUVmax, CMV, and CMA were significantly higher in patients who developed cardiotoxicity (p = 0.04, 0.017, and 0.03, respectively). In univariable logistic regression, focal/diffuse myocardial uptake was significantly associated with CTRCD, whereas SUVmax ≥8.49 and CMV ≥66.9 showed borderline associations. In multivariable analysis including SUVmax, CMV, and focal/diffuse uptake pattern, only the focal/diffuse uptake pattern remained independently associated with CTRCD (OR = 10.71, 95% CI: 2.10-54.69, p = 0.004). Notably, absent myocardial FDG uptake after treatment was observed only in patients without CTRCD in this cohort. Baseline PET parameters showed no significant predictive value (p = n.s.). CONCLUSION Routine post-treatment oncologic FDG PET/CT may provide exploratory information on myocardial metabolic changes associated with CTRCD in lymphoma patients receiving anthracycline-based chemotherapy. Although quantitative PET parameters differed between patients with and without CTRCD, the focal/diffuse myocardial uptake pattern was the only imaging variable that remained independently associated with CTRCD after multivariable adjustment. These findings should be considered hypothesis-generating and require prospective validation using standardized myocardial metabolic preparation and predefined imaging timepoints.