Assessment of long-term impact of high-dose anthracycline chemotherapy on myocardial and local arterial stiffness in childhood cancer survivors using shear wave imaging

Background Pediatric cancer survival rates continue to improve, with overall long-term survival now over 80%. Treatment plans commonly use anthracycline (AC) chemotherapy, which poses a substantial long-term risk for cardiotoxicity and myocardial remodelling, especially for high-risk patients who receive a high AC cumulative dose (i.e. ≥250 mg/m2). Purpose We investigated the long-term impact of high-dose AC on myocardial and carotid stiffness in childhood cancer survivors (CCS) using ultrasound-based shear wave elastography (SWE). Methods This is a cross-sectional single-centre study (January 2025-December 2025). Fifty CCS off-therapy ≥5 years and treated with AC cumulative dose ≥ 250 mg/m2 were included. Data from survivors were compared to data obtained in age-matched healthy volunteers (HV). The study population underwent clinical assessment with full conventional echocardiography and SWE on the same day. Myocardial stiffness (MS) was assessed using induced SWE in the interventricular septum as per protocol, measuring both peak systolic and mean diastolic shear wave velocity (SWV). Local natural arterial pulse wave velocities (PWV) were measured in the left common carotid artery by using SWE. Both PWV at the systolic foot (PWV-sf) and at the dicrotic notch (PWV-dn) were measured. Results The CCS group (age at study: 16 [IQR 15-17] years) was treated for solid tumours (53.66%) or blood malignancies (46.34%). Conventional echocardiographic assessment of survivors showed ejection fraction and GLS in the normal range, without diastolic impairment. Table 1 reports the MS and PWV data in CCS and HV. Figure 1 depicts the MS assessed throughout the full cardiac cycle in both study populations. In the multivariable model, cancer diagnosis was the only independent predictor of peak systolic MS (β= -0.88, p< 0.001), mean diastolic MS (β= 0.41, p< 0.001) and dnPWV (β= 0.95, p= 0.001). Conclusions This study is the first investigation in a large cohort of high-risk long-term CCS to comprehensively assess myocardial and vascular health using SWE, moving beyond conventional echocardiographic metrics. In CCS population, while standard echocardiography showed preserved ejection fraction, normal GLS, and no diastolic dysfunction, SWE revealed subclinical myocardial and vascular abnormalities that would otherwise remain undetected until overt cardiotoxicity develops. We hypothesize that lower systolic MS values could indicate decreased intrinsic contractility, while higher diastolic MS values reflect cardiac remodelling after high-dose AC chemotherapy. Future studies should explore the clinical outcome of CCS based on changes in myocardial and vascular stiffness.Table 1.SWE in the study population.Figure 1.MS in the study population.