Anthracycline-induced cardiotoxicity associated with myocardial energy metabolism: mechanisms revealed through an integration of 18F-FDG PET/CT and data-independent acquisition proteomics

Background and objectives Anthracyclines, as a type of chemotherapy drugs, are widely used in the first-line treatment of cancers. However, anthracycline-induced cardiotoxicity (AIC) in the cumulative and dose-dependent manner greatly limits the clinical application. Insufficient energy supply caused by myocardial metabolic reconstruction is an established factor for AIC. At present, the left ventricular maximum standardized uptake value (LV SUV max ) and left ventricular mean standardized uptake value (LV SUV mean ) detected via 18 F-fluorodeoxyglucose ( 18 F-FDG) positron emission tomography/computed tomography (PET/CT) are effective metrics reflecting alterations of myocardial metabolism after anthracycline medications, serving as promising targets for predicting the risk of AIC. To investigate AIC-induced myocardial metabolism changes by an integration of 18 F-FDG PET/CT and data-independent acquisition (DIA) proteomics, thus providing novel targets for predicting AIC. Methods A total of 30 patients with diffuse large B-cell lymphomas and treated with anthracycline-based chemotherapy in the Hematology Department of Jiangsu Province Hospital of Chinese Medicine from December 2023 to December 2024 were enrolled. Finally, 17 participants were included as the Diffuse Large B-cell Lymphoma (DLBCL) group. Additionally, 13 non-oncologic participants without organic heart disease, who required 18 F-FDG PET/CT for disease screening, were recruited as the control group. General data, dosage of anthracyclines, physical and chemical examination findings, and cardiac function indicators were collected. 18 F-FDG PET/CT was performed before and after 6 cycles of chemotherapy in the DLBCL group, whereas the control group underwent a single scan during the same period. Serum samples were harvested for analyzing alterations of myocardial metabolism before and after chemotherapy via DIA proteomics. Results Among 17 patients in the DLBCL group, 6 received epirubicin chemotherapy with an average dose of 59.28 ± 12.54 mg/m 2 per cycle, and 11 received liposomal doxorubicin chemotherapy with an average dose of 25.21 ± 3.14 mg/m 2 per cycle. Compared to the control group, no significant differences were observed in pre-chemotherapy LV SUV max (median: 2.40, 95% CI: 2.04–2.74) and LV SUV mean (median: 1.34, 95% CI: 1.15–1.55) in the DLBCL group ( P > 0.05). After anthracycline-based chemotherapy, both LV SUV max (median: 4.82, 95% CI: 3.50–6.05) and LV SUV mean (median: 1.93, 95% CI: 1.57–2.56) significantly increased compared to pre-chemotherapy values ( P < 0.05). The proportion of patients without 18 F-FDG uptake in the left ventricular myocardium significantly decreased relative to both pre-chemotherapy levels and the control group ( P < 0.001). Conversely, the proportions of patients exhibiting diffuse uptake and focal-on-diffuse uptake significantly increased compared to pre-chemotherapy measurements ( P < 0.01). Moreover, the incidence of abnormal 18 F-FDG uptake in the left ventricular myocardium was significantly higher after chemotherapy than both before treatment and in the control group ( P < 0.001). DIA proteomics showed that CPT1A, ACOX1, ECH1, and ACAT1 were significantly downregulated after anthracycline-based chemotherapy, which were mainly enriched in fatty acid metabolism. Their protein levels were negatively associated with left ventricular standardized uptake value (LV SUV). The Mantel test consistently proved a significant association between fatty acid metabolism and LV SUV. Conclusion An integration of 18 F-FDG PET/CT and DIA proteomics reveals a decreased fatty acid oxidation (FAO) and an increased myocardial glucose uptake after anthracycline-based chemotherapy, serving as potential mechanisms of AIC. Alterations of myocardial metabolism monitored by 18 F-FDG PET/CT may represent early indicators of metabolic remodeling, potentially identifying patients at risk for AIC. Clinical Trial Registration https://www.chictr.org.cn/ , identifier ChiCTR2400088740.