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Year : 2020  |  Volume : 30  |  Issue : 5  |  Page : 1-3

Cardiac imaging in cardio-oncology: An ongoing challenging

1 Department of Heart, University Hospital of Salerno, Salerno, Sicily, Italy
2 Department of General Surgery and Medical-Surgery Specialities, University of Catania, Catania, Sicily, Italy

Date of Submission12-Jan-2019
Date of Acceptance23-Feb-2019
Date of Web Publication10-Apr-2020

Correspondence Address:
Dr. Ines Paola Monte
Cardiology Unit, AOU Policlinico, Pad 8, Via S. Sofia 76, Catania, Sicily
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcecho.jcecho_1_19

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How to cite this article:
Citro R, Monte IP. Cardiac imaging in cardio-oncology: An ongoing challenging. J Cardiovasc Echography 2020;30, Suppl S1:1-3

How to cite this URL:
Citro R, Monte IP. Cardiac imaging in cardio-oncology: An ongoing challenging. J Cardiovasc Echography [serial online] 2020 [cited 2021 Mar 8];30, Suppl S1:1-3. Available from: https://www.jcecho.org/text.asp?2020/30/5/1/282277

During the last decades, a worldwide increment of the incidence of cancer has been reported. At the same time, the development and the diffusion of increasingly effective therapies have led to the increase of survival of the oncologic patients, associated with a parallel increasing in cancer-related complications.[1] Particularly, cardiovascular diseases represent a frequent consequence of antineoplastic treatment and may lead to premature morbidity and mortality among cancer survivors.[2] Commonly, cardiac toxicity is defined on the basis of reduced left ventricular ejection fraction (LVEF) and increased serum troponin level. Recently, the term “cardio-oncology” has been used more frequently, indicating a rapidly growing field and a new discipline aimed at improving the quality of care in cancer patients. Chemotherapy and radiation, in fact, can expose patients to a higher risk of a variety of cardiovascular disorders, including heart failure, coronary artery disease, peripheral vascular disease, thromboembolism, and valvular heart disease.[3] The most important scope of cardio-oncology is the prevention and monitoring of cardiovascular complications resulting from cancer treatment.

Owing to its wide availability, cardiac imaging plays an essential role in the baseline assessment and subsequent follow-up of cancer patients. Particularly, echocardiography, for its low cost and absence of radiation exposure, is the first-line method to assess ventricular function alterations and other frequent cardiac adverse complications.[4]

In early 2017, SIECVI sent its members an invitation to fill out a short questionnaire to highlight the impact of cardio-oncology on echocardiography laboratories and their distribution in Italy. One hundred and twenty laboratories were uniformly distributed throughout Italy, mainly with oncological activities not dedicated but within the general activity, except sporadic situations of laboratories dedicated within oncological structures. In the short period of observation, the oncology examinations were on average 15% of the total in the laboratories of the hospitals, where there were also oncological structures for 81% (oncology, onco-hematology, and radiotherapy) and 7% in the clinics outpatients in the area. In laboratories within the oncological structures, they were the whole. The examinations were mainly requested by the oncologist to a similar extent between before and after treatment.

Echocardiography is required: (1) to obtain reference parameters especially LVEF, before and during chemotherapy; (2) for an early, easy and accurate diagnosis of myocardial dysfunction; (3) to stratify the risk of heart failure; and (4) to guide treatment management. Conventional evaluation of LV EF is generally based on transthoracic bi-dimensional echocardiography. Three-dimensional echocardiography or contrast echo could be used to improve the evaluation accuracy of such parameters.[5],[6]

Unfortunately, decrease of LVEF is detectable when damage is considerable and possibility of recovery reduced; therefore, it is not suitable as an early indicator of cardiotoxicity.

Recently, advanced echocardiographic modalities, such as myocardial deformation imaging with speckle tracking strain analysis, demonstrate great potential for detecting early subclinical myocardial damage in asymptomatic oncologic patients. Global longitudinal strain is very sensitive in identifying subtle loss of myocardial function.[7] Currently, strain imaging is recommended for early detection of cardiac toxicity and to guide its appropriate management.[8]

The need for a reliable and accurate detection method for early cardiac damage has encouraged the introduction of cardiac magnetic resonance (CMR) in oncologic patients.[9] However, CMR, because of not wide availability and cost, is recommended for the quantification of LVEF when acoustic window is poor at echocardiogram or when we want to confirm the measurement of LVEF before a treatment.[8]

Ultrasound techniques could also facilitate early recognition of vascular damage, considered a frequent but often underdiagnosed complication of several antineoplastic agents. In general, the suspicion of coronary artery disease arises when symptoms such as dyspnea, angina, or palpitations occur. In this situation, the onset of wall motion abnormalities at rest or during stress should be investigated by echocardiography. CMR, myocardial scintigraphy, and other nuclear imaging modalities could alternatively be used for this purpose.[8],[9]

Of note, echocardiography is also able to detect early signs of diastolic dysfunction preceding the alteration of the myocardial contractility in the “ischemic cascade.”[6],[8]

Beyond ischemic disease, valvulopathy may be often observed in patients with cancer for several reasons, including ventricular dilatation and/or dysfunction, pre-existing valve lesions, radiotherapy, and infective endocarditis. Echocardiography is the optimal imaging technique for the noninvasive diagnostic evaluation of these complications, representing also an important tool in deciding the optimal timing of medical or surgical intervention, to improve patients' outcome.[3]

Furthermore, cancer itself and its treatment are related to an increased incidence of venous thromboembolism: indeed, oncological patients experience a significantly higher incidence of both deep-vein thrombosis (DVT) and pulmonary embolism (PE) compared to the general population.[10] Prevention and treatment of venous thromboembolism in the cancer setting represent major challenges in daily practice. In this setting, venous ultrasound is currently the imaging test of choice in the first evaluation of suspected DVT.[11] Echocardiography is also useful in detecting right ventricular dysfunction and dilatation in case of PE, even if contrast-enhanced chest computed tomography is the predominant diagnostic imaging technique for the detection of emboli in pulmonary arteries.[12]

In addition, patients affected by cancer may develop several arrhythmias, especially atrial fibrillation. In this case, imaging tools, mainly the transesophageal echocardiography, help in identifying sources of emboli into the left atrium in the context of increased thromboembolic profile.[13]

Finally, tumors of the heart represent another rare but possible scenario; again, echocardiography plays a key role in diagnosis and decision-making.[14]

Due to the great variety of possible adverse effects of cancer itself and chemotherapy on the cardiovascular system, an imaging-guided comprehensive assessment of cancer patients balancing the oncologic and the cardiac risk is an unmet need requiring strong cooperation between cardiologist and oncologist to be satisfied. Although recent studies seem to provide important information about the therapy of the cardiac toxicity, how and when to treat this pathology is still controversial.[15] Considering the ongoing development of new antineoplastic agents to clarify the additive role of cardiac imaging compared with biomarkers in early detection of cardiac toxicity and its impact on guiding therapy and patients' outcome will be an important challenging of the future research and a great opportunity to improve cancer patients care. In this issue, an up to date of the diagnostic imaging in cardio-oncology will be presented in-depth.

SIECVI 2017 Survey: Agricola Eustachio San Raffaele University Hospital, IRCCS, Milano; Aiello Alessandro Osp. San Filippo Neri, Roma; Anselmino Monica PO S.G. Bosco, Torino; Antonielli Emanuele Casa di Cura Città di Bra, Bra (CN); Aschieri Daniela Osp. Unico della Val Tidone, Piacenza; Badano Luigi Università di Padova; Banzato Alberto Istituto Oncologico Veneto, Padova; Barbieri Andrea Policlin.di Modena; Barisone Andrea Osp.S. Giacomo, Novi Ligure (AL); Barletta Giuseppe A. Osp. Careggi, Firenze; Barone Daniele Osp.S. Andrea, La Spezia; Bennati Elena Osp. Pediatrico Meyer, Firenze; Bisceglia Irma Osp.S. Camillo, Roma; Bossone Eduardo Cava dei Tirreni and Costa d'Amalfi Hospital, Cava dei Tirreni (SA); Bovelli Daniella Az. Osped. S. Maria, Terni; Bragato Renato M. Humanitas/U.O. Ecocardiografia, Rozzano (MI); Braggion Gabriele R. Osp. Santa Maria Regina degli Angeli, Adria (RO); Briguglia Daniele Humanitas Materdomini, Castellanza (VA); Busi Giovanni Osp. Angelucci, Subiaco (Roma); Cadeddu Dessalvi Christian Policlin. Universitario di Cagliari; Canale Anna L. Nuovo Osp. Versilia, Camaiore (LU); Cardinale Daniela M. Istituto Oncologico Europeo, Milano; Cascio Nicola Osp.V. Emanuele II, Castelvetrano (TP); Chiampan Andrea Osp. Sacro Cuore - Don Calabria, Negrar (VR); Chiocchi Paolo Nuovo Osp.S. Giovanni Battista, Foligno (PG); Ciampi Quirino Osp. Fatebenefratelli, Benevento; Citro Rodolfo Osp. Universitario, Salerno; Cocco Francesco Osp. Civile M. Giannuzzi, Manduria (TA); Conte Maria R. Osp. Mauriziano, Torino; Corvaglia Laura Osp. Vito Fazzi, Lecce; Cosco Carmela VIGI CENTRO ASPR VIGI 2 SRL, Vibo Valentia; Cozza Adele Osp. Santa Chiara, Trento; D'Ubaldo Francesco Osp. Misericordia, Grosseto; Da Ros Santina Ospedali Riuniti Padova Sud, Monselice (PD); De Biase Luciano Osp. Sant'Andrea, Roma; De Gennaro Luisa Osp. San Paolo, Bari; De Santis Maria T. Osp. Città di Castello (PG); De Vecchi Simona Osp.degli infermi, Ponderano (BI); Degli Esposti Daniela Osp.S. Orsola-Malpighi, Bologna; Del Vecchio Cecilia Alliance Medica, Acqui Terme (AL); Dell'Angela Luca Osp. San Giovanni di Dio, Gorizia; Demicheli Gloria Studio Cento Cannoni Alliance Medical, Alessandria; Di Bello Vitantonio Osp. Cisanello, Pisa; Di Gioia Angelo Osp. San Giuliano, Giugliano (NA); Di Lenarda Andrea Osp. Maggiore, Trieste; Di Martino Luigi Osp. Santa Maria degli Angeli, Putignano (BA); Dogliani Sarah Osp.SS Annunziata, Savigliano (CN); Erlicher Andrea Cardiologia Osp. Bolzano; Faggiano Pompilio Ospedali Civili, Brescia; Falasca Serena Osp.F. Veneziale Isernia; Fedele Francesco University “La Sapienza” - Umberto I Hospital, Roma; Ferrara Luigi Casa di Cura Villa dei Fiori, Acerra (NA); Frattini Silvia Istituti Ospitalieri, Cremona; Frigato Nicoletta Ospedale Civile, Mirano (VE); Galderisi Maurizio AOU Federico II, Napoli; Gigantino Giuseppe Osp. Umberto I, Nocera (SA); Gulizia Michele A.R.N.A.S. Garibaldi, Catania; Ignone Gianfranco “Salvatore Antonio Perrino” Hospital, Brindisi; Imperadore Ferdinando Osp.S. Marie del Carmine, Rovereto (TN); Indolfi Ciro Magna Graecia University, Catanzaro; Labanti Graziana Osp. Bellaria, Bologna; Lestuzzi Chiara Centro di Riferimento Oncologico (CRO), Aviano; Magni Lucia Osp. Civile di Cecina, Bologna; Marino Floriana PO Valle d'Itria, Martinafranca (TA); Marino Paolo N. Università del Piemonte Orientale, Maggiore Hospital, Novara; Massironi Laura AO San Paolo, Milano; Maurea Nicola Fondazione Pascale, Napoli; Mazza Stefano Osp. Maggiore Provinciale Sant'Andrea, Vercelli; Mazzola Anna A. Osp. Fatebenefratelli Oftalmico, Milano; Mele Donato AOU Ferrara; Miceli Sofia AOU Mater Domini, Grimaldi (CS); Midi Paolo Ospedali Riuniti Albano-Genzano, Albano laziale (Roma); Mongiardi Christian ASST Sette Laghi – Osp. Circolo Fondazione Macchi, Varese; Monte Ines P. AOU Policlinico Vitt. Emanuele, Catania; Mori Fabio Osp. Careggi, Firenze; Nardecchia Adele AOU Policlinico, Bari; Negrini Paola M. Osp. Treviglio (ASST BG-OVEST), Teviglio (BG); Novo Giuseppina University of Palermo, Palermo; Oliva Stefano Istituto Tumori Giovanni Paolo II, Bari; Padeletti Luigi University of Florence, Careggi Hospital, Firenze; Pagliani Leopoldo Osp. Riabilitativo di Alta Specializzazione, Motta di Livenza (TV); Palmieri Vittorio AO S.G. Moscati, Avellino; Palmiero Giuseppe AO dei Colli - Ospedale Monaldi, Napoli; Parrini Iris Osp. Mauriziano, Torino; Penco Maria University of L'Aquila; Pennacchietti Liliana Osp. Civile Augusto Murri, Fermo; Pietra Marco Osp. Civile, Dolo (VE); Piotti Patrizia Fondazione IRCCS Istituto Nazionale dei Tumori, Milano; Quadretti Laura Madonna della Salute; Porto Viro (RO); Roganti Giorgio Studio Cardiologico Vascolare, Modena; Rossi Andrea Polo Confortini, Verona; Russo Giulia AAS1 Triestina, Trieste; Sacchi Nicola Sant'Agostino-Ambulatorio di Cardiologia, Castiglione del Lago (PG); Santangelo Gloria ASST Bergamo Est, Seriate (BG); Savino Ketty AOU di Perugia; Scardovi Beatrice Osp. Santo Spirito, Roma; Scorzoni Daniela Galmarini, Tradate (VA); Severino Sergio Osp. Monaldi, Napoli; Sganzerla Paolo Osp."Treviglio - Caravaggio” Treviglio (BG); Sirugo Luana Osp.di Avola (SR); Spallarossa Paolo Osp."Treviglio - Caravaggio", Genova; Spinelli Luciano ASP Crotone, Mesoraca (KR); Stabile Amerigo A.R.N.A.S. Osp. Civico and Benfratelli, Palermo; Staine Josephine Osp. Carlo Urbani, Jesi (AN); Surace Francesca C. AOU Riuniti, Ancona; Tarantini Luigi Osp."San Martino", Belluno; Tchana Bertrand AOU Parma/Cardiologia Pediatrica, Parma; Thiebat Benedetta Osp. Generale Regionale PO U. Parini, Aosta; Tinto Monica Mater Salutis, Legnago (VR); Tocchetti Carlo G. AOU Federico II. Ambulatorio Scompenso Cardiaco, Napoli; Toglia Giuseppe IFO- Istituto Nazionale Tumori Regina Elena, Roma; Torzillo Daniela Hospital Sacco, Milano; Turiel Maurizio IRCCS Istituto Ortopedico Galeazzi, Milano; Turina Maria C. Arcispedale Santa Maria Nuova, Reggio Emilia; Vancheri Federico Osp.S. Elia, Caltanissetta; Vattimo Francesco Casa di Cura S Francesco, Bergamo; Villoni Roberta IRCCS Giovanni Paolo II, Bari; Zampi Giordano Osp. Belcolle, Viterbo; Zavatta Marco Ambulatorio di Ecocardiografia Borgo Maggiore, Rep. San Marino; Zito Concetta Policlinico G. Martino, Messina.

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