## 4 Discussion
Therefore, [18]FFDGPET homogeneous uptake patterns may be a marker of initial myocardial damage compared with the heterogeneity found in healthy myocardium during follow-up studies becoming a potential radiomic predictor of cardiotoxicity. Although no other studies have described texture patterns related to cardiotoxic damage so far, previous research works associated increased texture heterogeneity with poorer prognosis and response to treatment in patients with Hodgkin lymphoma [27] or cardiovascular conditions such as myocarditis [28,29]. Yet, some studies have also suggested greater homogeneity and a higher prevalence of high uptake intensities in cardiovascular disorders such as cardiac sarcoidosis [26,31]. Nevertheless, our results demonstrate, through the identified radiomic predictors, the association between texture homogeneity and lower uptake patterns in the CTRCD+ group. Some first-order features such as entropy or uniformity support this hypothesis. Entropy specifies the uncertainty/randomness of the image values, with higher values associated with CTRCD\(-\), i.e., higher heterogeneity. Uniformity is a measure of the sum of squares of each intensity value. It is a measure of the homogeneity of the image, with higher values associated with CTRCD+. Higher order radiomic features provide information about the textures in myocardial uptake. Consistent with the suggested hypothesis, these features evidence a more homogeneous texture for CTRCD+, based on the similarity of pixels from neighboring areas. For example, the GLRLM RunPercentage feature measures the coarseness of the texture, with higher values associated with CTRCD\(-\), indicating a greater presence of small groups of pixels with similar intensities (indicating a finer texture, i.e., greater heterogeneity). Similarly, the GLRLM RunLengthNonUniformity feature measures the variability in gray level intensity values in the image; a lower value indicates more homogeneity in intensity values and is associated with CTRCD+. Additionally, some texture features such as GLRLM Short-RunLowGrayLevelEmphasis measure the joint distribution of smaller similarity zones and lower intensity levels, with greater values associated with CTRCD+. In general, texture features demonstrate lower intensity values in myocardial uptake in CTRCD+. Regarding the laboratory test parameters, significant differences were identified between the CTRCD\(-\) and CTRCD+ groups at different stages of the study. Statistically significant differences were observed in the intermediate studies for ferritin, hematocrit, hemoglobin, and red blood cells, with the CTRCD+ group exhibiting lower values for the latter three. Notably, red blood cells and monocytes exhibited significant changes over time within the CTRCD\(-\) group. Specifically, red blood cells decreased and monocytes increased from baseline to EOT, even after multiple testing correction. The observed differences at the intermediate stage indicate the potential impact of antineoplastic treatments on hematological parameters and processes. They may also reflect the cardiovascular toxicity effects of these treatments. The results indicate that monitoring certain drug parameters may be crucial for patients undergoing treatment that may lead to cardiac toxicity. This study has methodological limitations, such as the retrospective nature of the study, the small single center-based study cohort, and the rough definition of cardiotoxicity. Some variables such as diet, which is known to affect the myocardial glucose uptake, could not be controlled. One of the main goals of future studies should be to assess the validity of the quantitative and radiomic features for the early diagnosis of cardiotoxicity-derived metabolic disorders prospectively in a larger patient cohort with standardized imaging and diet protocols.