Incremental value of 3D echocardiography and twodimensional speckle tracking in the early detection of cardiotoxicity linked to chemotherapy and trastuzumab in patients with HER-2 positive breast cancer

Background: Chemotherapy (CT) induced cardiotoxicity is a potentially lethal complication that frequently affects patients (pts) treated with anthracyclines and targeted agents such as trastuzumab (Tr). Patients and methods: From November 2013 to April 2015 we enrolled 30 patients; median age 51 years (range 40-62) with HER2 positive breast cancer. All pts received the same schedule of CT (17 in neoadiuvant and 13 in adiuvant setting): 4 cycles of EC (Epirubicin 90 mg/mq ev q21, Cyclophosphamide 600mg/mq ev q21), followed by Paclitaxel 80 mg/mq ev q7 for 12 weeks and Tr 6 mg/Kg ev q21, (loading dose 8 mg/Kg) given concomitantly up to a year of treatment. Echo-cardiogram with two-dimensional and with threedimensional approach were performed before starting CT, after anthracyclines and then every 3 months after the start of Tr, up to one year of completion. Several parameters of ventricular remodeling and function were evaluated: two-dimensional EF ejection fraction (EF) (EF 2D), threedimensional EF (EF 3D), Global Longitudinal Strain (GLS), systolic s’ wave at TDI of the annulus (s’TDI), Ventricular Elastance and Ventricular- Arterial Coupling. Results:According to the latest data of the literature, 4 (13,3%) pts had a cardiac event linked to the toxicity by EC and Tr: 2 pts had an important reduction of LVEF under 50% and 2 pts had an event of ACS (Acute Coronary Syndrome) so discontinued treatment with tr; EF 3D and GLS were able to identify early on a significant reduction in left ventricular function, even after the first cycle of EC and before the start of Tr ; while EF 2D decreasead significantly only after the start of Tr. Neither the assessment of systolictissue speed at the level of annulus nor the ratio E/e’ (ratio between E wave of transmitral flow and wave e’ of TDI) significantly change during treatment. From baseline whether Ventricular Elastance or Ventricular- Arterial Coupling worsened progressively during the treatment. Conclusions: The evaluation of left ventricular function with new echocardiographic methods with three-dimensional approach allows early identification of cardiac-toxicity linked to CT and targeted agents, than the ventricularejection fraction evaluated two-dimensionally and tissue indices derived from TDI. This could allow a prompt treatment of cardiac demage and the completion of antineoplastic therapy.