Imaging side effects and complications of chemotherapy and radiation therapy: a pictorial review from head to toe

Albano, Domenico; Benenati, Massimo; Bruno, Antonio; Bruno, Federico; Calandri, Marco; Caruso, Damiano; Cozzi, Diletta; De Robertis, Riccardo; Gentili, Francesco; Grazzini, Irene; Micci, Giuseppe; Palmisano, Anna; Pessina, Carlotta; Scalise, Paola; Vernuccio, Federica; Barile, Antonio; Miele, Vittorio; Grassi, Roberto; Messina, Carmelo

doi:10.1186/s13244-021-01017-2

Insights into Imaging

Table 2 Most common RT and ChT-induced myocardial damage

From: Imaging side effects and complications of chemotherapy and radiation therapy: a pictorial review from head to toe

Treatment	Pathophysiology	Myocardial disease	Coronary CT	Cardiac MRI
RT	Endothelial injury and inflammation leading to endothelial dysfunction and acceleration of the atherosclerotic process in the coronary vessels and chronic collagen deposition lead to fibrosis of soft tissues	CAD	CAD	Perfusion defect in case of obstructive coronary artery disease
		Valvular disease	Diffuse thickening of leaflets with calcifications in late stages	Fibrotic thickening and enhancement of leaflets with dysfunction (stenosis or regurgitation) in late stages
		Constrictive pericarditis	Increased pericardial thickness Pericardial calcifications	Increased pericardial thickness with delayed enhancement Pericardial calcifications Septal flattening or bounce Inspiratory septal shift
		Cardiomyopathy	Non-obstructive CAD	Increased ECV for fibrosis 10% decline of EF or EF < 50%
ChT	Mitochondrial dysfunction, inflammation, oxidative stress, with cardiomyocyte apoptosis and necrosis, and replacement fibrosis (with reported dose-dependent mechanism)	Myocarditis (early toxicity)	Non-obstructive CAD	Slightly altered T2 mapping and ECV with or without preserved EF
ChT		Cardiomyopathy	Non-obstructive CAD	Increased ECV for diffuse fibrosis 10% decline of EF or EF < 50% in late and irreversible stage
ICI	The pathological mechanism is not fully understood, it seems to be related to hyperactivation of the immune system Histological evidences of upregulation of inflammatory cytokines and of massive inflammatory cell infiltration	Pericarditis	Pericardial thickening and enhancement Pericardial effusion	Pericardial thickening, edema and enhancement Pericardial effusion
		Myocarditis	Non-obstructive CAD	Diffuse myocardial edema, increased native T1, T2 and ECV LGE with non-ischemic pattern
		Other myocardial diseases (rare)	Non-obstructive CAD	Stress cardiomyopathy (rapid EF recovery) and Takotsubo-like cardiomyopathy Ischemic LGE for myocardial infarction (due to vasospasm)

RT, radiation therapy; ChT, chemotherapy; ICI, immune checkpoint inhibitors; CAD, coronary artery disease; EF, ejection fraction; T1, native T1 mapping; ECV, extracellular volume fraction; LGE, late gadolinium enhancement

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