Radiology:免疫检查点抑制剂诱发心肌炎的心脏MRI特征及预后价值

2022-07-06 shaosai MedSci原创

根据更新的2018-LL标准,心脏MRI现在被认为是诊断非ICI诱发的心肌炎的最佳无创成像方式。

众所周知免疫检查点抑制剂(ICI)诱导的心肌炎(ICI-M)是最严重的免疫疗法相关毒性之一。虽然这种血管事件并不常见,但病例死亡率很高,需要早期使用皮质类固醇来改善预后,因此临床需要更好地了解这种新出现的心血管疾病的特点以改变对患者的管理

心内膜活检(EMB)是诊断心肌炎的参考标准,但由于其潜在的复杂性和低敏感性,因此难以在临床上广泛应用。根据更新的2018-LL标准,心脏MRI现在被认为是诊断非ICI诱发的心肌炎的最佳无创成像方式。此外,根据晚期钆增强(LGE)的存在、定位和模式,心脏MRI具有显著的预测预后价值。

近日,发表在Radiology杂志的一项研究分析了ICI-M的心脏MRI特征,并将其与计划接受ICI治疗的无心肌炎的癌症患者(以下简称ICI前组)以及急性病毒性心肌炎患者中观察到的特征进行比较,并对能够预测ICI-M患者主要不良心血管事件(MACE)的潜在心脏MRI表现进行探索性分析。

项2017年5月至2020年1月的回顾性研究将ICI-M患者的心脏MRI结果(包括晚期钆增强[LGE]、T1和T2 mapping以及细胞外体积分数[ECV]Z评分)与计划接受ICI治疗的癌症患者(pre-ICI组)和病毒性心肌炎患者的心脏MRI结果进行了对比。作为次要目标,通过使用Cox比例危害模型,探讨了心脏MRI对于预测ICI-M患者MACE的潜在价值。

将33名ICI-M患者(平均年龄±标准差,68岁±14岁;23名男性)与21名计划接受ICI治疗的患者(平均年龄,65岁±14岁;14名男性)和85名病毒性心肌炎患者(平均年龄,32岁±13岁;67名男性)进行比较。与ICI前组相比,ICI-M患者显示出更高的整体原生T1、ECV和T2 z评分(分别为0.03 ± 0.85 vs 1.79 ± 1.93 [P < .001];1.34 ± 0.57 vs 2.59 ± 1.97 [P = .03];以及-0.76 ± 1.41 vs 0.88 ± 1.96 [P = .002]),并且更经常观察到LGE(33名患者中有27名[82%] vs 21名[10%] 2名;P< .001)。LGE在ICI-M患者中的发生率低于病毒性心肌炎患者(33名患者中的27名[82%]vs 85名患者中的85名[100%];P<.001),但更有可能涉及室间隔段(33名患者中的16名[48%]vs 85名患者中的25名[29%];P<.001)和中壁层(33名患者中的11名[33%]vs 85名中的2名[2%];P<.001)。即使在调整了肌钙蛋白峰值后,室间隔LGE仍是预测1年后MACE的唯一心脏MRI指标(调整后的危险比,2.7 [95% CI: 1.1, 6.7]; P = .03)。


 一名无症状的62岁女性,患有黑色素瘤,在定期监测中显示高敏肌钙蛋白T(35 ng/L)升高,此为其心脏MRI图像。左心室中段短轴平面的心脏MRI扫描显示室间隔中壁的异常(箭头),(A)Look-Locker反转序列图像上有高的原生T1值(1223毫秒),(B)施用0.2 mL/kg钆喷剂(的改良Look-Locker反转序列图像,(C)相应mapping上,细胞外体积分数值高(37%),(D)在T2制备的平衡稳态自由行序列图像上,T2值高(60毫秒),以及在给0.2 mL/kg钆喷剂的(E)快速低角度拍摄和(F)相位敏感反转恢复序列图像上的相应晚期钆增强

本研究表明,ICI诱导的心肌炎(ICI-M)患者的心脏MRI特征与计划接受ICI治疗的患者和病毒性心肌炎患者不同,特别是在晚期钆增强(LGE)的发病率、模式和定位方面最为明显。

原文出处:

Farah Cadour,Jennifer Cautela,Stanislas Rapacchi,et al.Cardiac MRI Features and Prognostic Value in Immune Checkpoint Inhibitor-induced Myocarditis.DOI:10.1148/radiol.211765

 

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