Cardio Oncology
Eric E. Morgan, MD, PhD
Radiologist/Clinical fellow
National Heart, Lung, and Blood Institute, National Institutes of Health
Bethesda, Maryland, United States
Eric E. Morgan, MD, PhD
Radiologist/Clinical fellow
National Heart, Lung, and Blood Institute, National Institutes of Health
Bethesda, Maryland, United States
Seyed Ebrahim Kassaian, MD
Associate Investigator
Medstar Heart and Vascular Institute, United States
Joao G. Ramos, MD, PhD
Research Fellow
National Heart, Lung, and Blood Institute, National Institutes of Health, United States
Nathan M. Kattapuram
Special Volunteer
National Heart, Lung, and Blood Institute, National Institutes of Health
Bethesda, Maryland, United States
Shahrad Shadman, MD
Clinical Fellow/ Cardiologist
National Heart, Lung, and Blood Institute, National Institutes of Health, United States
Dong-Yun Kim, PhD
Statistician
National Heart, Lung, and Blood Institute, National Institutes of Health, United States
Stacian Awojoodu, DNP, ACNP
Acute Care Nurse practitioner
National Heart, Lung, and Blood Institute, National Institutes of Health, United States
Charles W. Benton, RT
MRI Technologist
National Heart, Lung, and Blood Institute, National Institutes of Health
North Bethesda, Maryland, United States
Patrick T. Bering, MD
Physician
MedStar Health and Vascular Institute, MedStar Washington Hospital Center, Washington, District of Columbia
Laurel, Maryland, United States
Gaby Weissman, MD
Section Chief, Clinical Cardiology
Medstar Heart and Vascular Institute
Washington, District of Columbia, United States
Marcus Carlsson, MD, PhD
Professor, Head of Department
Karolinska Institute, Clinical Physiology, United States
Ana Barac, MD, PhD
Staff Clinician/Cardiologist
National Heart, Lung, and Blood Institute, National Institutes of Health, District of Columbia, United States
Immune checkpoint inhibitors (ICI) have been associated with acute myocarditis. According to the modified Lake Louise Criteria (mLLC), the presence of elevated T2 with increased T1, ECV or Late Gadolinium Enhancement (LGE) is diagnostic. Meeting 1 of the 2 criteria is considered “suggestive” of myocarditis, possibly leading to interruption in cancer treatment1. While prior studies have investigated sensitivity of T1 and T2 in diagnosis of ICI-related myocarditis2, baseline levels of T1, T2 and LGE abnormalities in oncology patients have not been explored; thus, the specificity of the mLLC in this patient population is not known. We investigated the prevalence of pathological parametric values and LGE in oncology patients without myocarditis using institutional and published reference ranges to apply the mLLC to this cohort.
Methods:
Forty-two consecutive oncology patients without history or clinical suspicion of myocarditis and 24 healthy volunteers (HV) underwent CMR (1.5T Sola, Siemens Healthcare). Patients with history of myocardial infarction or cardiac amyloidosis were excluded. Multi-planar CINE stacks, 3 short and 3 long axis T2-mapping (T2-Prep b-SSFP) and T1-mapping (MOLLI) images were obtained. With the exception of 9 patients, all participants received gadolinium-based contrast for LGE and ECV assessment. Functional analysis and parametric mapping were performed by investigators blinded to clinical information. From the HV data, institutional T2/T1/ECV references ranges (HV-RR) were determined and compared against previously published ranges3 (PP-RR). These values are presented in Table 1. Data are expressed as mean + SD.
Results:
The mean age for HV was 42+12 with 54% women, 63% white, 29% black, and 8% Asian. All HV had normal LV systolic function with mean EF of 65%+8%. Patients’ demographic data, cancer diagnoses, treatment, and cardiovascular history are shown in Table 2. T2 values were normal in all participants based on HV-RR and PR-RR. Based on HV-RR, 2 patients (5%) had abnormal native T1 values, and of those who received contrast, 3 (9%) had elevated ECV. Based on the PP-RR, however, 11 patients (25%) had abnormal native T1 values, and 6 (18%) had elevated ECV (Table 2). Non-ischemic LGE was seen in 15 (45%) patients with a contrast study and in 5 (71%) of patients who received ICIs (Table 2). Absolute T1, T2 and ECV values for HV and patients are shown in the Figure.
Conclusion:
In this study of cancer patients without myocarditis, the prevalence of nonspecific, non-ischemic LGE was high. Application of institutional T1 and ECV reference ranges, rather than previously published values, decreased the number of abnormal T1 and ECV results. These findings highlight the importance of obtaining a baseline CMR and establishing institutional references for parametric imaging to ensure diagnostic accuracy of myocarditis in patients receiving multiple cancer therapeutics. Additional research is needed to establish specificity of mLLC in diagnosis of ICI-myocarditis.