Advanced cardiovascular imaging for cardiotoxicity detection in pediatric oncological patients

To review the current and emerging role of advanced cardiovascular imaging modalities for the detection, characterization, and follow-up of cardiotoxicity in pediatric oncology patients, in light of recent cardio-oncology guidelines. This narrative review synthesizes evidence from recent international guidelines - including the 2022 ESC Cardio-Oncology Position Paper and AHA scientific statements - alongside primary literature. The diagnostic roles of echocardiography, cardiac magnetic resonance (CMR), cardiac computed tomography (CCTA), and molecular imaging techniques are critically discussed. While echocardiography remains the first-line modality, its limited sensitivity for subclinical damage prompts the use of more advanced techniques. CMR provides unparalleled tissue characterization, allowing detection of diffuse fibrosis, inflammation, and early systolic dysfunction via T1/T2 mapping, ECV quantification, and myocardial strain. CCTA may detect radiation-induced coronary disease in high-risk survivors. Investigational imaging tools, such as ¹⁸F-FDG PET, ¹²³I-MIBG SPECT, and FAP-targeted PET, show potential in identifying early metabolic and sympathetic abnormalities before structural changes occur. Advanced cardiovascular imaging - particularly CMR - has become central to modern cardio-oncology care in pediatrics. Current recommendations advocate for personalized, risk-adapted imaging strategies, yet most protocols are extrapolated from adult data. Pediatric-specific frameworks are urgently needed to refine long-term surveillance and reduce cardiovascular late effects in childhood cancer survivors.