3.1. Background Data of Patients
The background data of the study participants are thoroughly examined in
Table 1. The participant group consisted of 82 patients who had been treated with Doxorubicin and 17 patients treated with Epirubicin. The mean age of the Doxorubicin group was 10.7 ± 4.4 years, while the Epirubicin group had a slightly lower mean age of 10.2 ± 3.6 years. The difference in age was not statistically significant (
p = 0.471), implying the two groups were similar in age distribution.
The analysis of the Body Mass Index (BMI) showed that the mean BMI was 20.5 ± 4.6 kg/m2 for the Doxorubicin group and 21.3 ± 5.8 kg/m2 for the Epirubicin group. The BMI between the two groups was not statistically significantly different (p = 0.308). When analyzing the BMI percentile categories, no significant difference was found between the two groups (p = 0.748). In the Doxorubicin group, 3.7% of patients were in the >85% category, 14.6% were in the 50–85% category, 37.8% were in the 15–50% category, 36.6% were in the 5–15% category, and 7.3% were in the <5% category. In the Epirubicin group, these proportions were 5.9%, 23.5%, 35.3%, 23.5%, and 11.8%, respectively. In terms of gender distribution, the Doxorubicin group comprised 58.5% males and 41.5% females, while in the Epirubicin group, 70.6% were males and 29.4% were females. No significant difference was found in the gender distribution between the two groups (p = 0.354).
3.2. Oncological Data
The cohort included a total of 99 patients, with the largest proportion diagnosed with B-cell acute lymphoblastic leukemia (B-ALL) (29.3%). Patients with T-cell acute lymphoblastic leukemia (T-ALL), Hodgkin lymphoma, nephroblastoma, and acute myeloid leukemia (AML) each made up 12.1% of the cohort. The less prevalent cancers were non-Hodgkin lymphoma (7.1%), osteosarcoma (6.1%), rhabdomyosarcoma (5.1%), and medulloblastoma (2.0%).
The incidence of cardiac toxicity was not uniformly distributed across the different cancer types and treatment protocols. It ranged from 0% in medulloblastoma patients who underwent the MET-HIT2000 protocol to 60% in patients with rhabdomyosarcoma treated with the CWS protocol. The second highest rate of cardiac toxicity was observed in osteosarcoma patients treated with the EURAMOS protocol (50.0%), followed by T-ALL and Hodgkin lymphoma patients who experienced cardiac toxicity rates of 35.7% and 33.3%, respectively. For B-ALL patients, who made up the largest percentage of the cohort, the incidence of cardiac toxicity was 24.2%, whereas for non-Hodgkin lymphoma and AML patients, the rates were 28.5% and 16.7%, respectively. Nephroblastoma patients also had a cardiac toxicity rate of 33.3%, as presented in
Table 2.
3.3. Cancer Function Assessment
Cardiac troponin I (cTnI) and troponin T (cTnT) remain sensitive and specific biomarkers of myocardial injury. According to
Table 3, the mean cTnI level in the Doxorubicin group was 3.2 ± 0.5 ng/mL, significantly higher than in the Epirubicin group (2.7 ± 0.9 ng/mL), with a
p-value of 0.002, suggesting more myocardial injury in the Doxorubicin group. Similar results were found for cTnT, with mean levels of 1.5 ± 0.6 ng/mL in the Doxorubicin group and 0.8 ± 0.5 ng/mL in the Epirubicin group. This difference was also statistically significant, with a
p-value of less than 0.001.
Brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) serve as markers of myocardial strain and heart failure. The Doxorubicin group had slightly higher mean BNP and NT-proBNP levels (260 ± 94 pg/mL and 282 ± 77 pg/mL, respectively) compared to the Epirubicin group (220 ± 61 pg/mL and 255 ± 53 pg/mL, respectively). However, these differences were not statistically significant (p = 0.096 and p = 0.172, respectively), indicating that both anthracyclines exert similar effects on myocardial strain. Creatine kinase (CK) and its isoforms are additional biomarkers of myocardial injury. The mean CK-MB level remained higher in the Doxorubicin group (33 ± 10 U/L) compared to the Epirubicin group (29 ± 8 U/L), although this difference was not statistically significant (p = 0.129). Conversely, the mean CK level (referring to the total CK level) was significantly higher in the Doxorubicin group (270 ± 91 U/L) compared to the Epirubicin group (204 ± 68 U/L), with a p-value of 0.006. These data suggest more extensive myocardial injury in the Doxorubicin group.
The ejection fraction (EF), which is an indicator of cardiac systolic function, showed a mean value of 62.1 ± 5.5% in the Doxorubicin group and 64.7 ± 5.9% in the Epirubicin group. The difference in the mean EF was not statistically significant (
p = 0.087). However, when categorized, a significant difference was noted (
p = 0.031). There were more patients with EF > 70% in the Epirubicin group (29.4%) than in the Doxorubicin group (7.3%). The mean Global Longitudinal Strain (GLS), an indicator of cardiac contractility, was −15.5 ± 4.6 in the Doxorubicin group and −18.3 ± 5.8 in the Epirubicin group, demonstrating a significantly better GLS in the Epirubicin group (
p = 0.034), as presented in
Table 4.
The Simpson method of discs (SMOD) and myocardial performance index (MPI) showed mean values of 54.4 ± 5.8 and 0.36 ± 0.05, respectively, in the Doxorubicin group and 59.2 ± 6.6 and 0.41 ± 0.07, respectively, in the Epirubicin group. These differences were statistically significant, indicating better cardiac function in the Epirubicin group (
p = 0.003 for SMOD and
p = 0.001 for MPI). Regarding the Electrocardiogram (ECG) findings, 64.6% of the Doxorubicin group and 76.5% of the Epirubicin group had normal findings, whereas abnormal findings were observed in 35.4% and 23.5% of patients, respectively. This difference, however, was not statistically significant (
p = 0.346). Cardiac ultrasound results were normal in 43.9% of the Doxorubicin group and 64.7% of the Epirubicin group, with abnormal findings in 56.1% and 35.3%, respectively. This difference was not statistically significant (
p = 0.117). In terms of cardiotoxicity, the incidence was higher in the Doxorubicin group (32.9%) than in the Epirubicin group (17.6%), but the difference was not statistically significant (
p = 0.212). Nevertheless, the Kaplan–Meier analysis of cardiotoxicity risk by treatment type, described in
Figure 2, indicated that cardiotoxicity occurs at significantly lower doses for Doxorubicin compared to Epirubicin.
3.4. Correlation Analysis and Predictive Factors
A correlation analysis was performed and is described in
Table 5 and
Figure 3. The cardiac troponin I (cTnI) showed a statistically significant positive correlation with cardiac troponin T (cTnT) (Rho = 0.559,
p = 0.001) and creatine kinase-MM (CK-MM) (Rho = 0.417,
p = 0.014). However, cTnI did not exhibit a significant correlation with brain natriuretic peptide (BNP), NT-proBNP, or creatine kinase-MB (CK-MB). The cTnT demonstrated a statistically significant positive correlation with CK-MM (Rho = 0.630,
p = 0.001) and the global longitudinal strain (GLS) (Rho = 0.388,
p = 0.001), but it did not correlate significantly with BNP, NT-proBNP, or CK-MB.
BNP showed a significant positive correlation with NT-proBNP (Rho = 0.390, p = 0.001) but had no significant correlation with CK-MB or CK-MM. Moreover, the NT-proBNP correlated significantly negatively with the Simpson method of discs (SMOD) (Rho = −0.392, p = 0.004), but not with CK-MB or CK-MM.
Regarding the speckle cardiac parameters, GLS showed a significant positive correlation with MPI (Rho = 0.379,
p = 0.020) and a significant negative correlation with SMOD (Rho = −0.411,
p = 0.001). Moreover, SMOD showed a significant negative correlation with GLS and a significant positive correlation with MPI (Rho = 0.530,
p = 0.001), as well as with CK-MM (Rho = −0.374,
p = 0.001). Although there were significant correlations identified between the cardiac measurement parameters and cardiac markers associated with cardiotoxicity after chemotherapy, the ROC analysis indicated a poor predictive value and did not show statistically significant results for GLS, SMOD, and MPI as independent predictors (
Figure 4).
3.5. Regression Analysis
Table 6 presents the results of the regression analysis for the associations between various cardiac function measurements, biomarkers, and the development of cardiac toxicity. SMOD showed a strong association, with an odds ratio of 4.05, signifying a quadrupling in the odds of cardiac toxicity for each unit increase in the SMOD measure (
p < 0.001). The MPI demonstrated a moderate association, with an odds ratio of 2.49 (
p = 0.030). LVEF had an odds ratio of 3.16, implying a little over a three-fold increase in the odds of cardiac toxicity for each unit increase in LVEF, with a significant
p-value (
p < 0.001).
In terms of cardiac biomarkers, cTnI and cTnT showed statistically significant odds ratios of 1.41 (p = 0.042) and 3.91 (p < 0.001), respectively. The NT-proBNP and CK-MM levels showed a statistically significant association with cardiac toxicity, with respective odds ratios of 2.15 (p < 0.001) and 2.58 (p < 0.001). CK-MB, however, did not show a statistically significant association.