Screening Adult Survivors of Childhood Cancer for Cardiomyopathy: Comparison of Echocardiography and Cardiac Magnetic Resonance Imaging

Abstract

A B S T R A C T PurposeTo compare two-dimensional (2D) echocardiography, the current method of screening for treatment-related cardiomyopathy recommended by the Children's Oncology Group Guidelines, to cardiac magnetic resonance (CMR) imaging, the reference standard for left ventricular (LV) function. Patients and MethodsCross-sectional, contemporaneous evaluation of LV structure and function by 2D and threedimensional (3D) echocardiography and CMR imaging in 114 adult survivors of childhood cancer currently median age 39 years (range, 22 to 53 years) exposed to anthracycline chemotherapy and/or chest-directed radiation therapy. ResultsIn this survivor population, 14% (n ϭ 16) had an ejection fraction (EF) less than 50% by CMR. Survivors previously undiagnosed with cardiotoxicity (n ϭ 108) had a high prevalence of EF (32%) and cardiac mass (48%) that were more than two standard deviations below the mean of normative CMR data. 2D echocardiography overestimated the mean EF of this population by 5%. Compared with CMR, 2D echocardiography (biplane method) had a sensitivity of 25% and a false-negative rate of 75% for detection of EF less than 50%, although 3D echocardiography had 53% and 47%, respectively. Twelve survivors (11%) had an EF less than 50% by CMR but were misclassified as Ն 50% (range, 50% to 68%) by 2D echocardiography (biplane method). Detection of cardiomyopathy was improved (sensitivity, 75%) by using a higher 2D echocardiography cutoff (EF Ͻ 60%) to detect an EF less than 50% by the reference standard CMR. ConclusionCMR identified a high prevalence of cardiomyopathy among adult survivors previously undiagnosed with cardiac disease. 2D echocardiography demonstrated limited screening performance. In this high-risk population, survivors with an EF 50% to 59% by 2D echocardiography should be considered for comprehensive cardiac assessment, which may include CMR.

Traditional and novel methods to assess and prevent chemotherapy-related cardiac dysfunction noninvasively

“…45 Of the 16 patients (14%) with LVEF less than 50% by CMR, Armstrong found 2D echocardiography overestimated mean LVEF of this population by 5%. Compared with CMR, 2D echocardiography (biplane method) had a sensitivity of 25% and a false-negative rate of 75% for detection of EF less than 50%, although 3D echocardiography had 53% and 47%, respectively.…”

Cardiotoxicity From Human Epidermal Growth Factor Receptor‐2 (HER2) Targeted Therapies

“…However, its use is limited because of lesser availability and elevated operational costs. This method can be particularly helpful when echocardiographic images are suboptimal, or when LVEF assessed by other methods is borderline and discontinuation of cancer therapy is being entertained 17, 81…”

Cardiac Imaging: Multimodality Advances and Surveillance Strategies in Detection of Cardiotoxicity

“…In an ideal 3DE assessment of LVEF, the potential errors associated with geometric assumptions, foreshortened views, or suboptimally acquired orthogonal apical two-and four-chamber views are not present, as it is the case with 2DE volume calculations. Furthermore, 3DE LVEF has been demonstrated to have an improved accuracy over 2DE in detecting LVEF <50% [18], which is frequently the chosen cutoff value to warrant increased cardiac monitoring during the administration of anticancer agents associated with known cardiotoxicity. 3DE has been showed to be feasible, accurate, and reproducible for assessing changes in LV volumes and LVEF when compared with CMR, in women receiving adjuvant trastuzumab after doxorubicin for breast cancer [19].…”

“…In patients with good image quality, 3D echocardiographic measurements are accurate and reproducible and should therefore be used when available and feasible LVEF [29]. Importantly, 2DE and CMR have been compared for the screening of CTRCD in adult survivors of childhood cancer exposed to anthracyclines or left chest radiation [18]. Compared with CMR, 2DE (biplane method) had a sensitivity of 25% and a false-negative rate of 75% for detection of LVEF less than 50%.…”

“…In routine practice, a single technique ideally should be used for baseline assessment and follow-up studies during and after cancer therapy [11••]. CMR should always be considered when 2DE-derived LVEF is suboptimally visualized and/or serially noted to have discrepant findings, particularly in patients with lower limit of normal LVEF (2DE has been known to overestimate the LVEF in this population compared to CMR) [18]. Borderline low baseline LVEF holds a confirmed predictive value to identify among women treated for breast cancer those at risk of CTRCD [65,66].…”