2501
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DEGRO practical guidelines: radiotherapy of breast cancer III--radiotherapy of the lymphatic pathways. Strahlenther Onkol 2014; 190:342-51. [PMID: 24638236 DOI: 10.1007/s00066-013-0543-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 12/12/2013] [Indexed: 01/09/2023]
Abstract
AIM The purpose of this work is to update the practical guidelines for adjuvant radiotherapy of the regional lymphatics of breast cancer published in 2008 by the breast cancer expert panel of the German Society of Radiation Oncology (DEGRO). METHODS A comprehensive survey of the literature concerning regional nodal irradiation (RNI) was performed using the following search terms: "breast cancer", "radiotherapy", "regional node irradiation". Recent randomized trials were analyzed for outcome as well as for differences in target definition. Field arrangements in the different studies were reproduced and superimposed on CT slices with individually contoured node areas. Moreover, data from recently published meta-analyses and guidelines of international breast cancer societies, yielding new aspects compared to 2008, provided the basis for defining recommendations according to the criteria of evidence-based medicine. In addition to the more general statements of the German interdisciplinary S3 guidelines updated in 2012, this paper addresses indications, targeting, and techniques of radiotherapy of the lymphatic pathways after surgery for breast cancer. RESULTS International guidelines reveal substantial differences regarding indications for RNI. Patients with 1-3 positive nodes seem to profit from RNI compared to whole breast (WBI) or chest wall irradiation alone, both with regard to locoregional control and disease-free survival. Irradiation of the regional lymphatics including axillary, supraclavicular, and internal mammary nodes provided a small but significant survival benefit in recent randomized trials and one meta-analysis. Lymph node irradiation yields comparable tumor control in comparison to axillary lymph node dissection (ALND), while reducing the rate of lymph edema. Data concerning the impact of 1-2 macroscopically affected sentinel node (SN) or microscopic metastases on prognosis are conflicting. CONCLUSION Recent data suggest that the current restrictive use of RNI should be scrutinized because the risk-benefit relationship appears to shift towards an improvement of outcome.
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2502
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Long-term follow-up for cardiovascular disease after chemotherapy and/or radiotherapy for breast cancer in an unselected population. Support Care Cancer 2014; 22:1949-58. [PMID: 24584711 DOI: 10.1007/s00520-014-2156-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 01/28/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE Whereas earlier research focused on specific patient groups, this study assessed the risk of cardiovascular disease (CVD) in an unselected population curatively treated for breast cancer (BC), compared with an age-matched random sample of controls. METHODS Risks were determined in BC survivors and controls. CVD was divided into three categories: congestive heart failure, vascular cardiac diseases, and "other" cardiac diseases. Hazard ratios (HRs) and 95% confidence intervals (95% CI) adjusted for age, CVD, and CVD risk factors at baseline were determined by Cox regression analyses. RESULTS All 561 survivors of BC experienced surgery of whom 229 received (neo)adjuvant radiotherapy, 145 received chemotherapy (with or without radiotherapy), and 187 received no adjuvant therapy. During follow-up (median 9; range 5-57 years), CVD occurred in 176/561 (31%) survivors and in 398/1,635 (24%) controls. After radiotherapy, no increased risks of congestive heart failure (HR 0.5; 95% CI 0.2-1.8), vascular cardiac diseases (HR 1.1; 95% CI 0.7-1.7), or other cardiac diseases (HR 1.3; 95% CI 0.8-2.3) were found compared with controls. Similar results were found after chemotherapy for congestive heart failure (HR 1.8; 95% CI 0.6-5.8), vascular cardiac diseases (HR 1.1; 95% CI 0.5-2.3), and other cardiac diseases (HR 1.2; 95% CI 0.3-5.5). CONCLUSIONS In an unselected population of BC survivors, no significant increased risk of CVD after radiotherapy and/or chemotherapy was found compared with controls. However, the HRs after chemotherapy were in-line with previous studies. Future studies should include more detailed information on treatment and more specific outcome measures.
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2503
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Lenihan DJ. Reversibility of Effectively Treated Chemotherapy-Related Heart Failure: Raising Our Awareness and a Call to Action for Cardiology. J Card Fail 2014; 20:159-60. [DOI: 10.1016/j.cardfail.2014.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 01/14/2014] [Indexed: 12/20/2022]
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2504
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Daar E, Kaabar W, Woods E, Lei C, Nisbet A, Bradley D. Atomic force microscopy and mechanical testing of bovine pericardium irradiated to radiotherapy doses. Radiat Phys Chem Oxf Engl 1993 2014. [DOI: 10.1016/j.radphyschem.2013.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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2505
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Lee CL, Min H, Befera N, Clark D, Qi Y, Das S, Johnson GA, Badea CT, Kirsch DG. Assessing cardiac injury in mice with dual energy-microCT, 4D-microCT, and microSPECT imaging after partial heart irradiation. Int J Radiat Oncol Biol Phys 2014; 88:686-93. [PMID: 24521682 PMCID: PMC3985387 DOI: 10.1016/j.ijrobp.2013.11.238] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 10/28/2013] [Accepted: 11/20/2013] [Indexed: 02/07/2023]
Abstract
PURPOSE To develop a mouse model of cardiac injury after partial heart irradiation (PHI) and to test whether dual energy (DE)-microCT and 4-dimensional (4D)-microCT can be used to assess cardiac injury after PHI to complement myocardial perfusion imaging using micro-single photon emission computed tomography (SPECT). METHODS AND MATERIALS To study cardiac injury from tangent field irradiation in mice, we used a small-field biological irradiator to deliver a single dose of 12 Gy x-rays to approximately one-third of the left ventricle (LV) of Tie2Cre; p53(FL/+) and Tie2Cre; p53(FL/-) mice, where 1 or both alleles of p53 are deleted in endothelial cells. Four and 8 weeks after irradiation, mice were injected with gold and iodinated nanoparticle-based contrast agents, and imaged with DE-microCT and 4D-microCT to evaluate myocardial vascular permeability and cardiac function, respectively. Additionally, the same mice were imaged with microSPECT to assess myocardial perfusion. RESULTS After PHI with tangent fields, DE-microCT scans showed a time-dependent increase in accumulation of gold nanoparticles (AuNp) in the myocardium of Tie2Cre; p53(FL/-) mice. In Tie2Cre; p53(FL/-) mice, extravasation of AuNp was observed within the irradiated LV, whereas in the myocardium of Tie2Cre; p53(FL/+) mice, AuNp were restricted to blood vessels. In addition, data from DE-microCT and microSPECT showed a linear correlation (R(2) = 0.97) between the fraction of the LV that accumulated AuNp and the fraction of LV with a perfusion defect. Furthermore, 4D-microCT scans demonstrated that PHI caused a markedly decreased ejection fraction, and higher end-diastolic and end-systolic volumes, to develop in Tie2Cre; p53(FL/-) mice, which were associated with compensatory cardiac hypertrophy of the heart that was not irradiated. CONCLUSIONS Our results show that DE-microCT and 4D-microCT with nanoparticle-based contrast agents are novel imaging approaches complementary to microSPECT for noninvasive assessment of the change in myocardial vascular permeability and cardiac function of mice in whom myocardial injury develops after PHI.
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Affiliation(s)
- Chang-Lung Lee
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Hooney Min
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Nicholas Befera
- Center for In Vivo Microscopy, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Darin Clark
- Center for In Vivo Microscopy, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Yi Qi
- Center for In Vivo Microscopy, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Shiva Das
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - G Allan Johnson
- Center for In Vivo Microscopy, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Cristian T Badea
- Center for In Vivo Microscopy, Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - David G Kirsch
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina; Department of Pharmacology and Cancer Biology, Duke University Medical Center, Durham, North Carolina.
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2506
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Potential impact of cardiac dose–volume on acute cardiac toxicity following concurrent trastuzumab and radiotherapy. Cancer Radiother 2014; 18:119-24. [DOI: 10.1016/j.canrad.2014.01.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 12/16/2013] [Accepted: 01/30/2014] [Indexed: 12/25/2022]
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2507
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Breathing adapted radiation therapy in comparison with prone position to reduce the doses to the heart, left anterior descending coronary artery, and contralateral breast in whole breast radiation therapy. Pract Radiat Oncol 2014; 4:123-129. [DOI: 10.1016/j.prro.2013.07.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 07/03/2013] [Accepted: 07/04/2013] [Indexed: 12/25/2022]
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2508
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Adjuvant Hypofractionated Versus Conventional Whole Breast Radiation Therapy for Early-Stage Breast Cancer: Long-Term Hospital-Related Morbidity From Cardiac Causes. Int J Radiat Oncol Biol Phys 2014; 88:786-92. [DOI: 10.1016/j.ijrobp.2013.11.243] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 11/20/2013] [Accepted: 11/25/2013] [Indexed: 11/16/2022]
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2509
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Zellars R, Bravo PE, Tryggestad E, Hopfer K, Myers L, Tahari A, Asrari F, Ziessman H, Garrett-Mayer E. SPECT Analysis of Cardiac Perfusion Changes After Whole-Breast/Chest Wall Radiation Therapy With or Without Active Breathing Coordinator: Results of a Randomized Phase 3 Trial. Int J Radiat Oncol Biol Phys 2014; 88:778-85. [DOI: 10.1016/j.ijrobp.2013.12.035] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 12/06/2013] [Accepted: 12/20/2013] [Indexed: 10/25/2022]
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2510
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Fourquet A, Kirova Y, Massabeau C, Costa E, Campana F. E14. New techniques in radiotherapy of breast cancer. Eur J Cancer 2014. [DOI: 10.1016/s0959-8049(14)70066-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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2511
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Kirova YM, Hijal T, Campana F, Fournier-Bidoz N, Stilhart A, Dendale R, Fourquet A. Whole breast radiotherapy in the lateral decubitus position: A dosimetric and clinical solution to decrease the doses to the organs at risk (OAR). Radiother Oncol 2014; 110:477-81. [DOI: 10.1016/j.radonc.2013.10.038] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 09/27/2013] [Accepted: 10/19/2013] [Indexed: 10/25/2022]
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2512
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Jagsi R. Progress and controversies: radiation therapy for invasive breast cancer. CA Cancer J Clin 2014; 64:135-52. [PMID: 24357525 DOI: 10.3322/caac.21209] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 09/27/2013] [Accepted: 09/30/2013] [Indexed: 01/29/2023] Open
Abstract
Radiation therapy is a critical component of the multidisciplinary management of invasive breast cancer. In appropriately selected patients, radiation not only improves local control, sparing patients the morbidity and distress of local recurrence, but it also improves survival by preventing seeding and reseeding of distant metastases from persistent reservoirs of locoregional disease. In recent years, considerable progress has been made toward improving our ability to select patients most likely to benefit from radiotherapy and to administer treatment in ways that maximize clinical benefit while minimizing toxicity and burden. This article reviews the role of radiation therapy in invasive breast cancer management, both after breast-conserving surgery and after mastectomy. It focuses particularly on emerging evidence that helps to define the clinical situations in which radiotherapy is indicated, the appropriate targets of treatment, and optimal approaches for minimizing both the toxicity and the burden of treatment, all in the context of the evolving surgical and systemic management of this common disease. It includes a discussion of new approaches in breast cancer radiotherapy, including hypofractionation and intensity modulation, as well as a discussion of promising avenues for future research.
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Affiliation(s)
- Reshma Jagsi
- Associate Professor, Department of Radiation Oncology, Research Investigator, Center for Bioethics and Social Science in Medicine, University of Michigan, Ann Arbor, MI
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2513
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Radiation-induced heart and vessel atherosclerosis disease. Int J Cardiol 2014; 172:505-6. [DOI: 10.1016/j.ijcard.2014.01.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 01/10/2014] [Indexed: 11/20/2022]
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2514
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Vaidya JS, Wenz F, Bulsara M, Tobias JS, Joseph DJ, Keshtgar M, Flyger HL, Massarut S, Alvarado M, Saunders C, Eiermann W, Metaxas M, Sperk E, Sütterlin M, Brown D, Esserman L, Roncadin M, Thompson A, Dewar JA, Holtveg HMR, Pigorsch S, Falzon M, Harris E, Matthews A, Brew-Graves C, Potyka I, Corica T, Williams NR, Baum M. Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial. Lancet 2014; 383:603-13. [PMID: 24224997 DOI: 10.1016/s0140-6736(13)61950-9] [Citation(s) in RCA: 585] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The TARGIT-A trial compared risk-adapted radiotherapy using single-dose targeted intraoperative radiotherapy (TARGIT) versus fractionated external beam radiotherapy (EBRT) for breast cancer. We report 5-year results for local recurrence and the first analysis of overall survival. METHODS TARGIT-A was a randomised, non-inferiority trial. Women aged 45 years and older with invasive ductal carcinoma were enrolled and randomly assigned in a 1:1 ratio to receive TARGIT or whole-breast EBRT, with blocks stratified by centre and by timing of delivery of targeted intraoperative radiotherapy: randomisation occurred either before lumpectomy (prepathology stratum, TARGIT concurrent with lumpectomy) or after lumpectomy (postpathology stratum, TARGIT given subsequently by reopening the wound). Patients in the TARGIT group received supplemental EBRT (excluding a boost) if unforeseen adverse features were detected on final pathology, thus radiotherapy was risk-adapted. The primary outcome was absolute difference in local recurrence in the conserved breast, with a prespecified non-inferiority margin of 2·5% at 5 years; prespecified analyses included outcomes as per timing of randomisation in relation to lumpectomy. Secondary outcomes included complications and mortality. This study is registered with ClinicalTrials.gov, number NCT00983684. FINDINGS Patients were enrolled at 33 centres in 11 countries, between March 24, 2000, and June 25, 2012. 1721 patients were randomised to TARGIT and 1730 to EBRT. Supplemental EBRT after TARGIT was necessary in 15·2% [239 of 1571] of patients who received TARGIT (21·6% prepathology, 3·6% postpathology). 3451 patients had a median follow-up of 2 years and 5 months (IQR 12-52 months), 2020 of 4 years, and 1222 of 5 years. The 5-year risk for local recurrence in the conserved breast was 3·3% (95% CI 2·1-5·1) for TARGIT versus 1·3% (0·7-2·5) for EBRT (p=0·042). TARGIT concurrently with lumpectomy (prepathology, n=2298) had much the same results as EBRT: 2·1% (1·1-4·2) versus 1·1% (0·5-2·5; p=0·31). With delayed TARGIT (postpathology, n=1153) the between-group difference was larger than 2·5% (TARGIT 5·4% [3·0-9·7] vs EBRT 1·7% [0·6-4·9]; p=0·069). Overall, breast cancer mortality was much the same between groups (2·6% [1·5-4·3] for TARGIT vs 1·9% [1·1-3·2] for EBRT; p=0·56) but there were significantly fewer non-breast-cancer deaths with TARGIT (1·4% [0·8-2·5] vs 3·5% [2·3-5·2]; p=0·0086), attributable to fewer deaths from cardiovascular causes and other cancers. Overall mortality was 3·9% (2·7-5·8) for TARGIT versus 5·3% (3·9-7·3) for EBRT (p=0·099). Wound-related complications were much the same between groups but grade 3 or 4 skin complications were significantly reduced with TARGIT (four of 1720 vs 13 of 1731, p=0·029). INTERPRETATION TARGIT concurrent with lumpectomy within a risk-adapted approach should be considered as an option for eligible patients with breast cancer carefully selected as per the TARGIT-A trial protocol, as an alternative to postoperative EBRT. FUNDING University College London Hospitals (UCLH)/UCL Comprehensive Biomedical Research Centre, UCLH Charities, National Institute for Health Research Health Technology Assessment programme, Ninewells Cancer Campaign, National Health and Medical Research Council, and German Federal Ministry of Education and Research.
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MESH Headings
- Aged
- Breast Neoplasms/mortality
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Female
- Humans
- Intraoperative Care/methods
- Intraoperative Care/mortality
- Kaplan-Meier Estimate
- Mastectomy, Segmental/methods
- Mastectomy, Segmental/mortality
- Middle Aged
- Neoplasm Recurrence, Local/mortality
- Neoplasm Recurrence, Local/prevention & control
- Radiotherapy/methods
- Radiotherapy/mortality
- Treatment Outcome
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Affiliation(s)
- Jayant S Vaidya
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK; Department of Surgery, Royal Free Hospital, London, UK; Department of Surgery, Whittington Hopsital, London, UK.
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, UK
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Mohammed Keshtgar
- Department of Surgery, Royal Free Hospital, London, UK; Department of Surgery, Whittington Hopsital, London, UK
| | - Henrik L Flyger
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologia, Aviano, Italy
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Christobel Saunders
- Department of Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia; School of Surgery, University of Western Australia, Perth, WA, Australia
| | - Wolfgang Eiermann
- Department of Gynecology and Obstetrics, Red Cross Hospital, Munich, Germany
| | - Marinos Metaxas
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Marc Sütterlin
- Department of Gynecology and Obstetrics, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Douglas Brown
- Department of Surgery, Ninewells Hospital, Dundee, UK
| | - Laura Esserman
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Mario Roncadin
- Department of Radiation Oncology, Centro di Riferimento Oncologia, Aviano, Italy
| | | | - John A Dewar
- Department of Radiation Oncology, Ninewells Hospital, Dundee, UK
| | - Helle M R Holtveg
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - Steffi Pigorsch
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany
| | - Mary Falzon
- Department of Pathology, University College London Hospitals, London, UK
| | - Eleanor Harris
- Department of Radiation Oncology, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - April Matthews
- Psychosocial Oncology Clinical Studies Group, National Cancer Research Institute, London, UK; Independent Cancer Patients' Voice, London, UK
| | - Chris Brew-Graves
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
| | - Ingrid Potyka
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
| | - Tammy Corica
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Norman R Williams
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
| | - Michael Baum
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
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2515
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Gujral D, Shah B, Chahal N, Senior R, Harrington K, Nutting C. Clinical Features of Radiation-induced Carotid Atherosclerosis. Clin Oncol (R Coll Radiol) 2014; 26:94-102. [DOI: 10.1016/j.clon.2013.10.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Revised: 09/23/2013] [Accepted: 09/24/2013] [Indexed: 11/25/2022]
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2516
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Abstract
Everyone is exposed to natural and manmade ionizing radiation that can originate from sources in the environment and in medical and occupational settings. There is notable variation, however, among individuals and across populations in the types of sources of radiation and in the frequency, level, and duration of exposure. Adverse health effects associated with radiation exposure have been known for decades, and ionizing radiation exposure has been linked with a broad range of different types of cancer and benign neoplasms as well as birth defects, reproductive effects, and diseases of the circulatory, hematologic, and neurologic systems. Our present understanding of radiation-related health risks derives primarily from multidisciplinary health risk (epidemiologic) studies that provide the key information on radiation-associated health outcomes, quantify radiation-related disease risks, and enhance understanding of mechanisms of radiation-related disease pathogenesis. Such information is central to quantifying risks in relation to benefits; addressing public concerns, including societal and clinical needs in relation to radiation exposure; and providing the database needed for establishing recommendations for radiation protection. Because of the importance of determining risks compared to benefits for all situations where exposure to ionizing radiation might result, it is useful for planning new health risks studies to categorize exposed populations according to the sources and types of radiation. This paper describes a wide range of populations exposed to radiation and the motivation and key methodological criteria that drive the rationale and priority of studying such populations. Also, discussed are alternative methods for evaluating radiation-related health risks in these populations, with a major focus on epidemiologic approaches. This paper concludes with a short summary of major highlights from radiation epidemiologic research and important unanswered questions.Introduction of Exposed Populations (Video 1:29, http://links.lww.com/HP/A22).
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Affiliation(s)
- Steven L Simon
- *Division of Cancer Epidemiology and Genetics, National CancerInstitute, National Institutes of Health, 6120 Executive Blvd, Bethesda, MD
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2517
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Abstract
Breast cancer is the most frequently diagnosed cancer in women and ranks second among causes for cancer related death in women. The ability to identify and diagnose breast cancer has improved markedly. Treatment decisions which were based in the past predominantly on the anatomic extent of the disease are shifting to the underlying biological mechanisms. Gene array technology has led to the recognition that breast cancer is a heterogeneous disease composed of different biological subtypes, and genetic profiling enables response to chemotherapy to be predicted. Breast conservation became an established standard of care and the oncoplastic approach enables wide excisions without compromising the natural shape of the breast. Sentinel lymph node biopsy has replaced axillary dissection as the standard procedure to stage the axilla and spared many patients the excess morbidity of axillary dissection. Targeted therapy to the oestrogen receptor plays a major role in systemic therapy; pathways responsible for endocrine resistance have been targeted as well. Biological therapy has been developed to target HER2 receptor and combination of antibody drug conjugates linked cytotoxic therapy to HER2 antibodies. Meaningful improvements in survival resulted from the new effective systemic agents and patients with metastasis are likely to have a longer survival.
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Affiliation(s)
- Shai Libson
- Soroka Medical Centre, Ben Gurion University , Beer Sheva , Israel
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2518
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Marín F, Díaz-Castro Ó, Ruiz-Nodar JM, de la Villa BG, Sionis A, López J, Fernández-Ortiz A, Martínez-Sellés M. Actualización en cardiopatía isquémica y cuidados críticos cardiológicos. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2013.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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2519
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Van Parijs H, Reynders T, Heuninckx K, Verellen D, Storme G, De Ridder M. Breast conserving treatment for breast cancer: dosimetric comparison of different non-invasive techniques for additional boost delivery. Radiat Oncol 2014; 9:36. [PMID: 24467916 PMCID: PMC3907792 DOI: 10.1186/1748-717x-9-36] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 01/09/2014] [Indexed: 11/29/2022] Open
Abstract
Background Today it is unclear which technique for delivery of an additional boost after whole breast radiotherapy for breast conserved patients should be state of the art. We present a dosimetric comparison of different non-invasive treatment techniques for additional boost delivery. Methods For 10 different tumor bed localizations, 7 different non-invasive treatment plans were made. Dosimetric comparison of PTV-coverage and dose to organs at risk was performed. Results The Vero system achieved an excellent PTV-coverage and at the same time could minimize the dose to the organs at risk with an average near-maximum-dose (D2) to the heart of 0.9 Gy and the average volume of ipsilateral lung receiving 5 Gy (V5) of 1.5%. The TomoTherapy modalities delivered an average D2 to the heart of 0.9 Gy for the rotational and of 2.3 Gy for the static modality and an average V5 to the ipsilateral lung of 7.3% and 2.9% respectively. A rotational technique offers an adequate conformity at the cost of more low dose spread and a larger build-up area. In most cases a 2-field technique showed acceptable PTV-coverage, but a bad conformity. Electrons often delivered a worse PTV-coverage than photons, with the planning requirements achieved only in 2 patients and with an average D2 to the heart of 2.8 Gy and an average V5 to the ipsilateral lung of 5.8%. Conclusions We present advices which can be used as guidelines for the selection of the best individualized treatment.
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Affiliation(s)
- Hilde Van Parijs
- UZ Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
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2520
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BRCA1/2 mutation carriers are potentially at higher cardiovascular risk. Crit Rev Oncol Hematol 2014; 91:159-71. [PMID: 24529552 DOI: 10.1016/j.critrevonc.2014.01.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 12/24/2013] [Accepted: 01/14/2014] [Indexed: 01/03/2023] Open
Abstract
BRCA1/2 mutation carriers have an elevated risk of developing breast and ovarian cancer at a relatively young age. Risk-reducing salpingo-oophorectomy is an established strategy to tremendously reduce the risk of ovarian cancer. It is recommended to perform this surgery at age 35-40 years (BRCA1) and at age 40-45 years (BRCA2) resulting in an early and abrupt menopause. BRCA1/2 mutation carriers are potentially at higher risk of cardiovascular diseases due to early surgical menopause, and cardiotoxic effects of adjuvant treatment for breast cancer. Furthermore, preliminary results of experimental studies suggest a possible causative function of the BRCA genes in cardiovascular risk. More research on cardiovascular health risks in BRCA1/2 mutation carriers is needed, especially in the field of cardio-oncology, requiring additional attention to potentially cumulative effects on cardiovascular risks in this specific group of women.
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2521
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Booth CM, Tannock IF. Randomised controlled trials and population-based observational research: partners in the evolution of medical evidence. Br J Cancer 2014; 110:551-5. [PMID: 24495873 PMCID: PMC3915111 DOI: 10.1038/bjc.2013.725] [Citation(s) in RCA: 330] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- C M Booth
- Division of Cancer Care and Epidemiology, Queen's University Cancer Research Institute, 10 Stuart Street, Kingston, ON K7L 5PG, Canada
| | - I F Tannock
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
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2522
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Marín F, Díaz-Castro O, Ruiz-Nodar JM, García de la Villa B, Sionis A, López J, Fernández-Ortiz A, Martínez-Sellés M. Update on ischemic heart disease and critical care cardiology. ACTA ACUST UNITED AC 2014; 67:120-6. [PMID: 24795119 DOI: 10.1016/j.rec.2013.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 10/03/2013] [Indexed: 10/25/2022]
Abstract
This article summarizes the main developments reported in 2013 on ischemic heart disease, together with the most important innovations in the management of acute cardiac patients.
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Affiliation(s)
- Francisco Marín
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain.
| | - Oscar Díaz-Castro
- Servicio de Cardiología, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | | | | | - Alessandro Sionis
- Servicio de Cardiología, Hospital Universitario de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Javier López
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Spain
| | - Antonio Fernández-Ortiz
- Servicio de Cardiología, Hospital Clínico San Carlos, Universidad Complutense de Madrid, Madrid, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Universidad Europea de Madrid, Madrid, Spain
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2523
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Liljegren A, Unukovych D, Gagliardi G, Bjöhle J, Wickman M, Johansson H, Sandelin K. No difference in dose distribution in organs at risk in postmastectomy radiotherapy with or without breast implant reconstruction. Radiat Oncol 2014; 9:14. [PMID: 24406085 PMCID: PMC3907145 DOI: 10.1186/1748-717x-9-14] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 01/02/2014] [Indexed: 12/25/2022] Open
Abstract
The aim of this study was to quantify the variation in doses to organs at risk (ipsilateral lung and heart) and the clinical target volume (CTV) in the presence of breast implants. In this retrospective cohort study, patients were identified through the National Breast Cancer Register. Consecutive breast cancer patients undergoing mastectomy between 2009 and 2011 and completing a full course of postmastectomy radiotherapy (PMRT) were eligible. All included patients (n = 818) were identified in the ARIA© oncology information system and further stratified for immediate breast reconstruction (IBR+, n = 162) and no immediate breast reconstruction (IBR-, n = 656). Dose statistics for ipsilateral lung, heart and CTV were retrieved from the system. Radiation plans for patients with chest wall (CW) only (n = 242) and CW plus lymph nodes (n = 576) irradiation were studied separately. The outcome variables were dichotomized as follows: lung, V20Gy ≤ 30% vs. V20Gy > 30%; heart, Dmean ≤ 5 Gy vs. Dmean > 5 Gy; CTV, V95% ≥ median vs. V95% < median. In the univariate and multivariate regression models no correlation between potential confounders (i.e. breast reconstruction, side of PMRT, CW index) and the outcome variables was found. Multivariate analysis of CW plus lymph nodes radiation plans, for example, showed no association of breast reconstruction with dosimetric outcomes in neither lung nor heart- lung V20Gy (odds ratio [OR]: 0.6, 95%CI, 0.4 to 1.0, p = 0.07) or heart Dmean (OR: 1.2, 95%CI, 0.5 to 3.1, p = 0.72), respectively. CTV was statistically significantly larger in the IBR+ group (i.e. included breast implant), but no correlation between the implant type and dosimetric characteristics of the organs at risk was revealed. In the current study, the presence of breast implants during postmastectomy radiotherapy was not associated with increased doses to ipsilateral lung and heart, but CTV definition and its dosimetric characteristics urge further evaluation.
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Affiliation(s)
| | - Dmytro Unukovych
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.
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2524
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Sridharan V, Tripathi P, Sharma S, Moros EG, Zheng J, Hauer-Jensen M, Boerma M. Roles of sensory nerves in the regulation of radiation-induced structural and functional changes in the heart. Int J Radiat Oncol Biol Phys 2014; 88:167-74. [PMID: 24331664 PMCID: PMC3868013 DOI: 10.1016/j.ijrobp.2013.10.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/13/2013] [Accepted: 10/07/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE Radiation-induced heart disease (RIHD) is a chronic severe side effect of radiation therapy of intrathoracic and chest wall tumors. The heart contains a dense network of sensory neurons that not only are involved in monitoring of cardiac events such as ischemia and reperfusion but also play a role in cardiac tissue homeostasis, preconditioning, and repair. The purpose of this study was to examine the role of sensory nerves in RIHD. METHODS AND MATERIALS Male Sprague-Dawley rats were administered capsaicin to permanently ablate sensory nerves, 2 weeks before local image-guided heart x-ray irradiation with a single dose of 21 Gy. During the 6 months of follow-up, heart function was assessed with high-resolution echocardiography. At 6 months after irradiation, cardiac structural and molecular changes were examined with histology, immunohistochemistry, and Western blot analysis. RESULTS Capsaicin pretreatment blunted the effects of radiation on myocardial fibrosis and mast cell infiltration and activity. By contrast, capsaicin pretreatment caused a small but significant reduction in cardiac output 6 months after irradiation. Capsaicin did not alter the effects of radiation on cardiac macrophage number or indicators of autophagy and apoptosis. CONCLUSIONS These results suggest that sensory nerves, although they play a predominantly protective role in radiation-induced cardiac function changes, may eventually enhance radiation-induced myocardial fibrosis and mast cell activity.
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MESH Headings
- Animals
- Capsaicin/pharmacology
- Cardiac Output/drug effects
- Cardiac Output/physiology
- Cardiac Output/radiation effects
- Denervation/methods
- Echocardiography/methods
- Fibrosis
- Heart/innervation
- Heart/physiopathology
- Heart/radiation effects
- Macrophages/drug effects
- Macrophages/radiation effects
- Male
- Mast Cells/drug effects
- Mast Cells/physiology
- Mast Cells/radiation effects
- Myocardium/pathology
- Neurons, Afferent/drug effects
- Neurons, Afferent/physiology
- Neurons, Afferent/radiation effects
- Nuclear Receptor Subfamily 4, Group A, Member 1/metabolism
- Nuclear Receptor Subfamily 4, Group A, Member 1/radiation effects
- Nuclear Receptor Subfamily 4, Group A, Member 2/metabolism
- Nuclear Receptor Subfamily 4, Group A, Member 2/radiation effects
- Organ Size/radiation effects
- Radiation Injuries, Experimental/physiopathology
- Rats
- Rats, Sprague-Dawley
- Sensory Receptor Cells/drug effects
- Sensory Receptor Cells/physiology
- Sensory Receptor Cells/radiation effects
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Affiliation(s)
- Vijayalakshmi Sridharan
- Department of Pharmaceutical Sciences, Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Preeti Tripathi
- Department of Pharmaceutical Sciences, Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Sunil Sharma
- Department of Radiation Oncology, Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Eduardo G Moros
- Department of Radiation Oncology, Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Junying Zheng
- Department of Pharmaceutical Sciences, Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Martin Hauer-Jensen
- Department of Pharmaceutical Sciences, Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Surgical Service, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
| | - Marjan Boerma
- Department of Pharmaceutical Sciences, Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
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2525
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Postmastectomy internal mammary nodal irradiation: A long-term outcome. Medicina (B Aires) 2014; 50:230-6. [DOI: 10.1016/j.medici.2014.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 09/15/2014] [Indexed: 10/24/2022] Open
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2526
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Zablotska LB, Little MP, Cornett RJ. Potential increased risk of ischemic heart disease mortality with significant dose fractionation in the Canadian Fluoroscopy Cohort Study. Am J Epidemiol 2014; 179:120-31. [PMID: 24145888 DOI: 10.1093/aje/kwt244] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Risks of noncancer causes of death, particularly cardiovascular disease, associated with exposures to high-dose ionizing radiation, are well known. Recent studies have reported excess risk in workers who are occupationally exposed to low doses at a low dose rate, but the risks of moderately fractionated exposures, such as occur during diagnostic radiation procedures, remain unclear. The Canadian Fluoroscopy Cohort Study includes 63,707 tuberculosis patients exposed to multiple fluoroscopic procedures in 1930-1952 and followed-up for death from noncancer causes in 1950-1987. We used a Poisson regression to estimate excess relative risk (ERR) per Gy of cumulative radiation dose to the lung (mean dose = 0.79 Gy; range, 0-11.60). The risk of death from noncancer causes was significantly lower in these subjects compared with the Canadian general population (P < 0.001). We estimated small, nonsignificant increases in the risk of death from noncancer causes with dose. We estimated an ERR/Gy of 0.176 (95% confidence interval: 0.011, 0.393) (n = 5,818 deaths) for ischemic heart disease (IHD) after adjustment for dose fractionation. A significant (P = 0.022) inverse dose fractionation effect in dose trends of IHD was observed, with the highest estimate of ERR/Gy for those with the fewest fluoroscopic procedures per year. Radiation-related risks of IHD decreased significantly with increasing time since first exposure and age at first exposure (both P < 0.05). This is the largest study of patients exposed to moderately fractionated low-to-moderate doses of radiation, and it provides additional evidence of increased radiation-associated risks of death from IHD, in particular, significantly increased radiation risks from doses similar to those from diagnostic radiation procedures. The novel finding of a significant inverse dose-fractionation association in IHD mortality requires further investigation.
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2527
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Abstract
With the favorable trend regarding survival of cancer in the Western world, there is an increasing focus among patients, clinicians, researchers, and politicians regarding cancer survivors' health and well-being. Their number is rapidly growing and more than 3 % of the adult populations in Western countries have survived cancer for 5 years or more. Cancer survivors are at increased risk for a variety of late effects after treatment, some life-threatening such as secondary cancer and cardiac diseases, others might negatively impact on their daily functioning and quality of life. The latter might include fatigue, anxiety disorders and difficulties returning to work while depression does not seem to be more common among survivors than in the general population. Still, the majority of survivors regain their health and social functioning. The field of cancer survivorship research has been rapidly growing. Models for follow-up care of cancer survivors have been proposed, but how to best integrate the knowledge of the field into clinical practice with adequate follow-up of cancer survivors at risk for developing late effects is still an unsolved question.
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Affiliation(s)
- Cecilie E Kiserud
- National Resource Center for late effects after Cancer Treatment, Oslo University Hospital, Radiumhospitalet, 4953 Nydalen, 0424, Oslo, Norway,
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2528
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Actualités 2013 : le point de vue du comité de rédaction du Bulletin du Cancer. Bull Cancer 2014; 101:75-92. [DOI: 10.1684/bdc.2013.1874] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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2529
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Lee HY, Chang JS, Lee IJ, Park K, Kim YB, Suh CO, Kim JW, Keum KC. The deep inspiration breath hold technique using Abches reduces cardiac dose in patients undergoing left-sided breast irradiation. Radiat Oncol J 2013; 31:239-46. [PMID: 24501713 PMCID: PMC3912239 DOI: 10.3857/roj.2013.31.4.239] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 10/07/2013] [Accepted: 10/15/2013] [Indexed: 12/25/2022] Open
Abstract
Purpose We explored whether the deep inspiration breath hold (DIBH) technique using Abches during left-sided breast irradiation was effective for minimizing the amount of radiation to the heart and lung compared to free breathing (FB). Materials and Methods Between February and July 2012, a total of 25 patients with left-sided breast cancer underwent two computed tomography scans each with the DIBH using Abches and using FB after breast-conserving surgery. The scans were retrospectively replanned using standardized criteria for the purpose of this study. The DIBH plans for each patient were compared with FB plans using dosimetric parameters. Results All patients were successfully treated with the DIBH technique using Abches. Significant differences were found between the DIBH and FB plans for mean heart dose (2.52 vs. 4.53 Gy), heart V30 (16.48 vs. 45.13 cm3), V20 (21.35 vs. 54.55 cm3), mean left anterior descending coronary artery (LAD) dose (16.01 vs. 26.26 Gy, all p < 0.001), and maximal dose to 0.2 cm3 of the LAD (41.65 vs. 47.27 Gy, p = 0.017). The mean left lung dose (7.53 vs. 8.03 Gy, p = 0.073) and lung V20 (14.63% vs. 15.72%, p = 0.060) of DIBH using Abches were not different significantly compared with FB. Conclusion We report that the use of a DIBH technique using Abches in breathing adapted radiotherapy for left-sided breast cancer is easily feasible in daily practice and significantly reduces the radiation doses to the heart and LAD, therefore potentially reducing cardiac risk.
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Affiliation(s)
- Ha Yoon Lee
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Kwangwoo Park
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Ok Suh
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Ki Chang Keum
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
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2530
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Lancellotti P, Nkomo VT, Badano LP, Bergler-Klein J, Bergler J, Bogaert J, Davin L, Cosyns B, Coucke P, Dulgheru R, Edvardsen T, Gaemperli O, Galderisi M, Griffin B, Heidenreich PA, Nieman K, Plana JC, Port SC, Scherrer-Crosbie M, Schwartz RG, Sebag IA, Voigt JU, Wann S, Yang PC. Expert consensus for multi-modality imaging evaluation of cardiovascular complications of radiotherapy in adults: a report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr 2013; 26:1013-32. [PMID: 23998694 DOI: 10.1016/j.echo.2013.07.005] [Citation(s) in RCA: 162] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Cardiac toxicity is one of the most concerning side effects of anti-cancer therapy. The gain in life expectancy obtained with anti-cancer therapy can be compromised by increased morbidity and mortality associated with its cardiac complications. While radiosensitivity of the heart was initially recognized only in the early 1970s, the heart is regarded in the current era as one of the most critical dose-limiting organs in radiotherapy. Several clinical studies have identified adverse clinical consequences of radiation-induced heart disease (RIHD) on the outcome of long-term cancer survivors. A comprehensive review of potential cardiac complications related to radiotherapy is warranted. An evidence-based review of several imaging approaches used to detect, evaluate, and monitor RIHD is discussed. Recommendations for the early identification and monitoring of cardiovascular complications of radiotherapy by cardiac imaging are also proposed.
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Affiliation(s)
- Patrizio Lancellotti
- Department of Cardiology, GIGA Cardiovascular Sciences, Heart Valve Clinic, University of Liège Hospital, CHU du Sart-Tilman, Liège 4000, Belgium.
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2531
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Abstract
Patients with some progeroid syndromes, such as Werner syndrome, exhibit atherosclerotic cardiovascular disease (CVD) at a young age as a manifestation of premature aging. Recent studies have revealed that most progeroid syndromes are caused by genetic defects in specific molecules involved in the DNA damage response, a cornerstone of genome stability. Ionizing radiation is one of the most potent genotoxic stimuli and causes various kinds of DNA damage. Further, there is increasing evidence that therapeutic radiation treatments can cause cardiovascular complications. Here, we describe the DNA damage and subsequent response, review recent advances in the understanding of the molecular basis of progeroid syndromes (especially those syndromes that involve CVD), review the pathological and epidemiological analysis of radiation-induced CVD, and discuss the possible role of DNA damage and the DNA damage response in the pathogenesis of atherosclerotic CVD.
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Affiliation(s)
- Takafumi Ishida
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University
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2532
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Comsa D, Barnett E, Le K, Mohamoud G, Zaremski D, Fenkell L, Kassam Z. Introduction of moderate deep inspiration breath hold for radiation therapy of left breast: Initial experience of a regional cancer center. Pract Radiat Oncol 2013; 4:298-305. [PMID: 25194098 DOI: 10.1016/j.prro.2013.10.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 10/13/2013] [Accepted: 10/30/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE Practical aspects of introducing moderate deep inspiration breath hold (mDIBH) for treatment of left breast cancer in a regional cancer program in terms of workflow and treatment delivery requirements are described. Differences in heart and lung doses between free breathing (FB) and mDIBH plans are presented as well as heart position reproducibility and resulting dosimetric impact using cone beam computed tomography (CBCT). METHODS AND MATERIALS A mDIBH process was established. Therapists observed duration and quantity of breath holds required for setup, imaging, and beam delivery during treatment. Treatment plans were generated on the FB and mDIBH CT datasets allowing comparison of heart and lung dose-volume data for 50 patients. Five consecutive CBCT images were used to measure the distance between the heart and chest wall for 5 patients. Estimates of dose to the translated heart were then made with the treatment planning system. RESULTS When compared with FB delivery, mDIBH treatment time for tangents and boosts increased by 5 minutes, while 3- or 4-field techniques increased by 10 minutes. Differences in heart dose D10 cc, mean, V30 and V10 were statistically significant between the FB and mDIBH tangents and 3- or 4-field treatment plans. Statistically significant differences in V20, V10, V5, and mean lung doses were observed for 3- and 4-field FB and mDIBH plans. Differences between lung V5 dose metrics for FB and mDIBH 2-field plans were statistically significant. Interfraction mean translations in heart position coronally ranged from -6.2 to 2.6 mm and resulted in non-negligible increases in the heart dose. CONCLUSIONS Moderate deep inspiration breath hold has been successfully implemented in our regional cancer center for treatment of left breast cancer and is now a standard practice. This change in practice from FB to mDIBH treatment has not impacted our ability to meet provincial guidelines for patient throughput.
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Affiliation(s)
- Daria Comsa
- Medical Physics, Radiation Medicine Program, Stronach Regional Cancer Centre, Southlake Regional Health Centre, Newmarket, Ontario, Canada; Radiation Oncology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Erin Barnett
- Medical Physics, Radiation Medicine Program, Stronach Regional Cancer Centre, Southlake Regional Health Centre, Newmarket, Ontario, Canada.
| | - Ken Le
- Radiation Therapy, Radiation Medicine Program, Stronach Regional Cancer Centre, Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Gulaid Mohamoud
- Radiation Therapy, Radiation Medicine Program, Stronach Regional Cancer Centre, Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Dana Zaremski
- Radiation Therapy, Radiation Medicine Program, Stronach Regional Cancer Centre, Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Louis Fenkell
- Radiation Oncology, Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Radiation Oncology, Radiation Medicine Program, Stronach Regional Cancer Centre, Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Zahra Kassam
- Radiation Oncology, Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Radiation Oncology, Radiation Medicine Program, Stronach Regional Cancer Centre, Southlake Regional Health Centre, Newmarket, Ontario, Canada
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2533
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Chow EJ, Baker KS, Lee SJ, Flowers MED, Cushing-Haugen KL, Inamoto Y, Khera N, Leisenring WM, Syrjala KL, Martin PJ. Influence of conventional cardiovascular risk factors and lifestyle characteristics on cardiovascular disease after hematopoietic cell transplantation. J Clin Oncol 2013; 32:191-8. [PMID: 24297944 DOI: 10.1200/jco.2013.52.6582] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To determine the influence of modifiable lifestyle factors on the risk of cardiovascular disease after hematopoietic cell transplantation (HCT). PATIENTS AND METHODS HCT survivors of ≥ 1 year treated from 1970 to 2010 (n = 3,833) were surveyed from 2010 to 2011 on current cardiovascular health and related lifestyle factors (smoking, diet, recreational physical activity). Responses (n = 2,362) were compared with those from a matched general population sample (National Health and Nutrition Examination Survey [NHANES]; n = 1,192). RESULTS Compared with NHANES participants, HCT survivors (median age, 55.9 years; median 10.8 years since HCT; 71.3% allogeneic) had higher rates of cardiomyopathy (4.0% v 2.6%), stroke (4.8% v 3.3%), dyslipidemia (33.9% v 22.3%), and diabetes (14.3% v 11.7%; P < .05 for all comparisons). Prevalence of hypertension was similar (27.9% v 30.0%), and survivors were less likely to have ischemic heart disease (6.1% v 8.9%; P < .01). Among HCT survivors, hypertension, dyslipidemia, and diabetes were independent risk factors for ischemic heart disease and cardiomyopathy, and smoking was associated with ischemic heart disease and diabetes (odds ratios [ORs], 1.8 to 2.1; P = .02). Obesity was a risk factor for post-transplantation hypertension, dyslipidemia, and diabetes (ORs ≥ 2.0; P < .001). In contrast, lower fruit/vegetable intake was associated with greater risk of dyslipidemia and diabetes (ORs, 1.4 to 1.8; P ≤ .01), and lower physical activity level was associated with greater risk of hypertension and diabetes (ORs, 1.4 to 1.5; P < .05). Healthier lifestyle characteristics among HCT survivors attenuated risk of all cardiovascular conditions assessed. CONCLUSION Attention of clinicians to conventional cardiovascular risk factors and modifiable lifestyle characteristics offers hope of reducing serious cardiovascular morbidity after HCT.
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Affiliation(s)
- Eric J Chow
- Eric J. Chow, K. Scott Baker, Stephanie J. Lee, Mary E.D. Flowers, Kara L. Cushing-Haugen, Yoshihiro Inamoto, Wendy M. Leisenring, Karen L. Syrjala, and Paul J. Martin, Fred Hutchinson Cancer Research Center; Eric J. Chow, K. Scott Baker, Seattle Children's Hospital; Eric J. Chow, K. Scott Baker, Stephanie J. Lee, Mary E.D. Flowers, and Paul J. Martin, University of Washington, Seattle, WA; and Nandita Khera, Mayo Clinic, Phoenix, AZ
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2534
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Bartlett F, Yarnold J, Donovan E, Evans P, Locke I, Kirby A. Multileaf Collimation Cardiac Shielding in Breast Radiotherapy: Cardiac Doses are Reduced, But at What Cost? Clin Oncol (R Coll Radiol) 2013; 25:690-6. [DOI: 10.1016/j.clon.2013.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 08/06/2013] [Accepted: 08/23/2013] [Indexed: 10/26/2022]
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2535
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Steingart RM, Yadav N, Manrique C, Carver JR, Liu J. Cancer Survivorship: Cardiotoxic Therapy in the Adult Cancer Patient; Cardiac Outcomes With Recommendations for Patient Management. Semin Oncol 2013; 40:690-708. [DOI: 10.1053/j.seminoncol.2013.09.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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2536
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Takahashi I, Ohishi W, Mettler FA, Ozasa K, Jacob P, Ban N, Lipshultz SE, Stewart FA, Nabika T, Niwa Y, Takahashi N, Akahoshi M, Kodama K, Shore R. A report from the 2013 international workshop: radiation and cardiovascular disease, Hiroshima, Japan. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2013; 33:869-880. [PMID: 24190873 DOI: 10.1088/0952-4746/33/4/869] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Two longitudinal cohort studies of Japanese atomic bomb survivors-the life span study (LSS) and the adult health study (AHS)-from the Radiation Effects Research Foundation (RERF) indicate that total body irradiation doses less than 1 Gy are associated with an increased risk of cardiovascular disease (CVD), but several questions about this association remain.In particular, the diversity of heart disease subtypes and the high prevalence of other risk factors complicate the estimates of radiation effects. Subtype-specific analyses with more reliable diagnostic criteria and measurement techniques are needed. The radiation effects on CVD risk are probably tissue-reaction (deterministic) effects, so the dose-response relationships for various subtypes of CVD may be nonlinear and therefore should be explored with several types of statistical models.Subpopulations at high risk need to be identified because effects at lower radiation doses may occur primarily in these susceptible subpopulations. Whether other CVD risk factors modify radiation effects also needs to be determined. Finally, background rates for various subtypes of CVD have historically differed substantially between Japanese and Western populations, so the generalisability to other populations needs to be examined.Cardiovascular disease mechanisms and manifestations may differ between high-dose local irradiation and low-dose total body irradiation (TBI)-microvascular damage and altered metabolism from low-dose TBI, but coronary artery atherosclerosis and thrombotic myocardial infarcts at high localised doses. For TBI, doses to organs other than the heart may be important in pathogenesis of CVD, so data on renal and liver disorders, plaque instability, microvascular damage, metabolic disorders, hypertension and various CVD biomarkers and risk factors are needed. Epidemiological, clinical and experimental studies at doses of less than 1 Gy are necessary to clarify the effects of radiation on CVD risk.
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Affiliation(s)
- Ikuno Takahashi
- Department of Clinical Studies, Radiation Effects Research Foundation (RERF), Hiroshima, Japan
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2537
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Bartlett F, Yarnold J, Kirby A. Breast Radiotherapy and Heart Disease — Where Are We Now? Clin Oncol (R Coll Radiol) 2013; 25:687-9. [DOI: 10.1016/j.clon.2013.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 06/18/2013] [Indexed: 10/26/2022]
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2538
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Gallucci G, Storto G, Fiorentino A. The intriguing issue of genetic predisposition and the importance of identification of pre-clinical markers of endothelial damage in radiotherapy-induced cardiotoxicity. Eur Heart J Cardiovasc Imaging 2013; 15:233. [PMID: 24277781 DOI: 10.1093/ehjci/jet246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Giuseppina Gallucci
- Cardiology Unit, IRCCS-CROB Centro di Riferimento Oncologico della Basilicata, via Padre Pio, 1, Rionero in Vulture, Potenza 85028, Italy
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2539
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Duma MN, Molls M, Trott KR. From heart to heart for breast cancer patients - cardiovascular toxicities in breast cancer radiotherapy. Strahlenther Onkol 2013; 190:5-7. [PMID: 24253182 DOI: 10.1007/s00066-013-0465-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 09/11/2013] [Indexed: 12/25/2022]
Affiliation(s)
- M N Duma
- Department of Radiation Oncology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 , München, Germany,
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2540
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Cardiovascular complications of radiotherapy. Am J Cardiol 2013; 112:1688-96. [PMID: 24012026 DOI: 10.1016/j.amjcard.2013.07.031] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/12/2013] [Accepted: 07/12/2013] [Indexed: 12/17/2022]
Abstract
Chest radiotherapy is routinely used to treat malignancies such as Hodgkin disease and breast cancer but is commonly associated with a variety of cardiovascular complications involving the pericardium, myocardium, valves, coronary arteries, and conduction system. Cardiovascular complications are related to the total dose of radiation and the fractionation of the dose. They are usually progressive, portend poor prognosis, and are often refractory to treatment after significant radiation exposure. The mechanism of injury is multifactorial and likely involves endothelial damage of the microvasculature and coronary arteries and liberation of multiple inflammatory and profibrotic cytokines. In conclusion, routine follow-up with a cardiologist, which might include screening for valvular disease with echocardiography and coronary artery disease with computed tomography angiography or coronary artery calcium scoring, should be considered in patients with a history of chest radiotherapy.
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2541
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Bellon JR. Oncology scan--improving our understanding of the local management of breast cancer. Int J Radiat Oncol Biol Phys 2013; 87:627-9. [PMID: 24139691 DOI: 10.1016/j.ijrobp.2013.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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2542
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Klein Hesselink EN, Klein Hesselink MS, de Bock GH, Gansevoort RT, Bakker SJ, Vredeveld EJ, van der Horst-Schrivers AN, van der Horst IC, Kamphuisen PW, Plukker JT, Links TP, Lefrandt JD. Long-Term Cardiovascular Mortality in Patients With Differentiated Thyroid Carcinoma: An Observational Study. J Clin Oncol 2013; 31:4046-53. [DOI: 10.1200/jco.2013.49.1043] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The primary aim was to study the risk of cardiovascular mortality in patients with differentiated thyroid carcinoma (DTC). Secondary aims were to evaluate all-cause mortality and explore the relation between thyroid-stimulating hormone (TSH; also known as thyrotropin) level and these outcome parameters. Patients and Methods Subjects from two cohorts were retrospectively compared by Cox regression analyses; 524 patients with DTC and 1,572 sex- and age-matched controls from a large population-based study in the same geographic region. Results Mean age plus or minus standard deviation was 49 ± 14 years. Median follow-up was 8.5 years (interquartile range [IQR], 4.1 to 15.9 years) for patients with DTC and 10.5 years (IQR, 9.9 to 10.9 years) for controls. One hundred patients with DTC (19.1%) died, 22 (4.2%) as a result of cardiovascular disease, 39 (7.4%) as a result of DTC, and 39 (7.4%) as a result of other/unknown causes. Eighty-five controls (5.4%) died, 24 (1.5%) as a result of cardiovascular disease and 61 (3.9%) as a result of other/unknown causes. Patients with DTC had an increased risk of cardiovascular and all-cause mortality (hazard ratios [HRs], 3.35 [95% CI, 1.66 to 6.74] and 4.40 [95% CI, 3.15 to 6.14], respectively, adjusted for age, sex, and cardiovascular risk factors). Within the DTC group, TSH level was predictive for cardiovascular mortality; the adjusted HR was 3.08 (95% CI, 1.32 to 7.21) for each 10-fold decrease in geometric mean TSH level. Conclusion The risk of cardiovascular and all-cause mortality is increased in patients with DTC, independent of age, sex, and cardiovascular risk factors. A lower TSH level is associated with increased cardiovascular mortality, supporting the current European Thyroid Association and the American Thyroid Association guidelines of tempering TSH suppression in patients with low risk of cancer recurrence. Furthermore, patients with DTC may benefit from assessment and treatment of cardiovascular risk factors.
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Affiliation(s)
- Esther N. Klein Hesselink
- All authors: University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Geertruida H. de Bock
- All authors: University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Ron T. Gansevoort
- All authors: University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Stephan J.L. Bakker
- All authors: University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Eline J. Vredeveld
- All authors: University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Iwan C.C. van der Horst
- All authors: University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Pieter W. Kamphuisen
- All authors: University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - John T.M. Plukker
- All authors: University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Thera P. Links
- All authors: University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Joop D. Lefrandt
- All authors: University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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2543
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Little MP. A review of non-cancer effects, especially circulatory and ocular diseases. RADIATION AND ENVIRONMENTAL BIOPHYSICS 2013; 52:435-449. [PMID: 23903347 PMCID: PMC4074546 DOI: 10.1007/s00411-013-0484-7] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Accepted: 07/14/2013] [Indexed: 05/30/2023]
Abstract
There is a well-established association between high doses (>5 Gy) of ionizing radiation exposure and damage to the heart and coronary arteries, although only recently have studies with high-quality individual dosimetry been conducted that would enable quantification of this risk adjusting for concomitant chemotherapy. The association between lower dose exposures and late occurring circulatory disease has only recently begun to emerge in the Japanese atomic bomb survivors and in various occupationally exposed cohorts and is still controversial. Excess relative risks per unit dose in moderate- and low-dose epidemiological studies are somewhat variable, possibly a result of confounding and effect modification by well-known (but unobserved) risk factors. Radiation doses of 1 Gy or more are associated with increased risk of posterior subcapsular cataract. Accumulating evidence from the Japanese atomic bomb survivors, Chernobyl liquidators, US astronauts, and various other exposed groups suggests that cortical cataracts may also be associated with ionizing radiation, although there is little evidence that nuclear cataracts are radiogenic. The dose-response appears to be linear, although modest thresholds (of no more than about 0.6 Gy) cannot be ruled out. A variety of other non-malignant effects have been observed after moderate/low-dose exposure in various groups, in particular respiratory and digestive disease and central nervous system (and in particular neuro-cognitive) damage. However, because these are generally only observed in isolated groups, or because the evidence is excessively heterogeneous, these associations must be treated with caution.
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Affiliation(s)
- Mark P Little
- Radiation Epidemiology Branch, National Cancer Institute, 9609 Medical Center Drive MSC 9778, Bethesda, MD, 20892-9778, USA,
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2544
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Sutherland JGH, Furutani KM, Thomson RM. Monte Carlo calculated doses to treatment volumes and organs at risk for permanent implant lung brachytherapy. Phys Med Biol 2013; 58:7061-80. [PMID: 24051987 DOI: 10.1088/0031-9155/58/20/7061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Iodine-125 ((125)I) and Caesium-131 ((131)Cs) brachytherapy have been used with sublobar resection to treat stage I non-small cell lung cancer and other radionuclides, (169)Yb and (103)Pd, are considered for these treatments. This work investigates the dosimetry of permanent implant lung brachytherapy for a range of source energies and various implant sites in the lung. Monte Carlo calculated doses are calculated in a patient CT-derived computational phantom using the EGsnrc user-code BrachyDose. Calculations are performed for (103)Pd, (125)I, (131)Cs seeds and 50 and 100 keV point sources for 17 implant positions. Doses to treatment volumes, ipsilateral lung, aorta, and heart are determined and compared to those determined using the TG-43 approach. Considerable variation with source energy and differences between model-based and TG-43 doses are found for both treatment volumes and organs. Doses to the heart and aorta generally increase with increasing source energy. TG-43 underestimates the dose to the heart and aorta for all implants except those nearest to these organs where the dose is overestimated. Results suggest that model-based dose calculations are crucial for selecting prescription doses, comparing clinical endpoints, and studying radiobiological effects for permanent implant lung brachytherapy.
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Affiliation(s)
- J G H Sutherland
- Carleton Laboratory for Radiotherapy Physics, Department of Physics, Carleton University, Ottawa, Ontario, Canada
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2545
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2546
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Cucinotta FA, Kim MHY, Chappell LJ, Huff JL. How safe is safe enough? Radiation risk for a human mission to Mars. PLoS One 2013; 8:e74988. [PMID: 24146746 PMCID: PMC3797711 DOI: 10.1371/journal.pone.0074988] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Accepted: 08/06/2013] [Indexed: 01/22/2023] Open
Abstract
Astronauts on a mission to Mars would be exposed for up to 3 years to galactic cosmic rays (GCR)--made up of high-energy protons and high charge (Z) and energy (E) (HZE) nuclei. GCR exposure rate increases about three times as spacecraft venture out of Earth orbit into deep space where protection of the Earth's magnetosphere and solid body are lost. NASA's radiation standard limits astronaut exposures to a 3% risk of exposure induced death (REID) at the upper 95% confidence interval (CI) of the risk estimate. Fatal cancer risk has been considered the dominant risk for GCR, however recent epidemiological analysis of radiation risks for circulatory diseases allow for predictions of REID for circulatory diseases to be included with cancer risk predictions for space missions. Using NASA's models of risks and uncertainties, we predicted that central estimates for radiation induced mortality and morbidity could exceed 5% and 10% with upper 95% CI near 10% and 20%, respectively for a Mars mission. Additional risks to the central nervous system (CNS) and qualitative differences in the biological effects of GCR compared to terrestrial radiation may significantly increase these estimates, and will require new knowledge to evaluate.
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Affiliation(s)
- Francis A. Cucinotta
- NASA, Lyndon B. Johnson Space Center, Space Radiation Program, Houston, Texas, United States of America
- University of Nevada Las Vegas, Department of Health Physics and Diagnostic Sciences, Las Vegas, Nevada, United States of America
| | - Myung-Hee Y. Kim
- Universities Space Research Association, Division of Space Life Sciences, Houston, Texas, United States of America
| | - Lori J. Chappell
- Universities Space Research Association, Division of Space Life Sciences, Houston, Texas, United States of America
| | - Janice L. Huff
- Universities Space Research Association, Division of Space Life Sciences, Houston, Texas, United States of America
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2547
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Abstract
OPINION STATEMENT Thoracic radiation remains an effective treatment for many types of neoplasms. The clinical benefit of radiation therapy on cancer mortality is counterbalanced by an increased risk of cardiovascular events in survivors. The long-term cardiovascular sequelae of thoracic radiation include premature coronary artery disease, valvular disease, pericardial disease, myocardial disease with systolic and especially diastolic dysfunction, and conduction system abnormalities. Radiation heart disease progresses over time and may manifest decades after the initial exposure. Since the risk of cardiac complications is significantly increased following chest irradiation, appropriate screening and long-term cardiac follow-up of these patients is essential. This article will summarize the pathophysiological features, clinical presentations, and current recommendations for screening and prevention of the wide spectrum of radiation induced cardiovascular disease.
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Affiliation(s)
- Negareh Mousavi
- Section of Cardiology, Department of Medicine, St. Joseph's Health Care Center, 30 The Queensway, Toronto, ON, Canada
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2548
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Bosch DJ, Muijs CT, Mul VEM, Beukema JC, Hospers GAP, Burgerhof JGM, Plukker JTM. Impact of Neoadjuvant Chemoradiotherapy on Postoperative Course after Curative-intent Transthoracic Esophagectomy in Esophageal Cancer Patients. Ann Surg Oncol 2013; 21:605-11. [DOI: 10.1245/s10434-013-3316-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Indexed: 12/23/2022]
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2549
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The role of adjuvant radiation treatment in older women with early breast cancer. J Geriatr Oncol 2013; 4:402-12. [DOI: 10.1016/j.jgo.2013.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 03/24/2013] [Accepted: 05/24/2013] [Indexed: 11/20/2022]
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Haviland JS, Owen JR, Dewar JA, Agrawal RK, Barrett J, Barrett-Lee PJ, Dobbs HJ, Hopwood P, Lawton PA, Magee BJ, Mills J, Simmons S, Sydenham MA, Venables K, Bliss JM, Yarnold JR. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol 2013; 14:1086-1094. [PMID: 24055415 DOI: 10.1016/s1470-2045(13)70386-3] [Citation(s) in RCA: 931] [Impact Index Per Article: 84.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND 5-year results of the UK Standardisation of Breast Radiotherapy (START) trials suggested that lower total doses of radiotherapy delivered in fewer, larger doses (fractions) are at least as safe and effective as the historical standard regimen (50 Gy in 25 fractions) for women after primary surgery for early breast cancer. In this prespecified analysis, we report the 10-year follow-up of the START trials testing 13 fraction and 15 fraction regimens. METHODS From 1999 to 2002, women with completely excised invasive breast cancer (pT1-3a, pN0-1, M0) were enrolled from 35 UK radiotherapy centres. Patients were randomly assigned to a treatment regimen after primary surgery followed by chemotherapy and endocrine treatment (where prescribed). Randomisation was computer-generated and stratified by centre, type of primary surgery (breast-conservation surgery or mastectomy), and tumour bed boost radiotherapy. In START-A, a regimen of 50 Gy in 25 fractions over 5 weeks was compared with 41·6 Gy or 39 Gy in 13 fractions over 5 weeks. In START-B, a regimen of 50 Gy in 25 fractions over 5 weeks was compared with 40 Gy in 15 fractions over 3 weeks. Eligibility criteria included age older than 18 years and no immediate surgical reconstruction. Primary endpoints were local-regional tumour relapse and late normal tissue effects. Analysis was by intention to treat. Follow-up data are still being collected. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN59368779. FINDINGS START-A enrolled 2236 women. Median follow-up was 9·3 years (IQR 8·0-10·0), after which 139 local-regional relapses had occurred. 10-year rates of local-regional relapse did not differ significantly between the 41·6 Gy and 50 Gy regimen groups (6·3%, 95% CI 4·7-8·5 vs 7·4%, 5·5-10·0; hazard ratio [HR] 0·91, 95% CI 0·59-1·38; p=0·65) or the 39 Gy (8·8%, 95% CI 6·7-11·4) and 50 Gy regimen groups (HR 1·18, 95% CI 0·79-1·76; p=0·41). In START-A, moderate or marked breast induration, telangiectasia, and breast oedema were significantly less common normal tissue effects in the 39 Gy group than in the 50 Gy group. Normal tissue effects did not differ significantly between 41·6 Gy and 50 Gy groups. START-B enrolled 2215 women. Median follow-up was 9·9 years (IQR 7·5-10·1), after which 95 local-regional relapses had occurred. The proportion of patients with local-regional relapse at 10 years did not differ significantly between the 40 Gy group (4·3%, 95% CI 3·2-5·9) and the 50 Gy group (5·5%, 95% CI 4·2-7·2; HR 0·77, 95% CI 0·51-1·16; p=0·21). In START-B, breast shrinkage, telangiectasia, and breast oedema were significantly less common normal tissue effects in the 40 Gy group than in the 50 Gy group. INTERPRETATION Long-term follow-up confirms that appropriately dosed hypofractionated radiotherapy is safe and effective for patients with early breast cancer. The results support the continued use of 40 Gy in 15 fractions, which has already been adopted by most UK centres as the standard of care for women requiring adjuvant radiotherapy for invasive early breast cancer. FUNDING Cancer Research UK, UK Medical Research Council, UK Department of Health.
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Affiliation(s)
- Joanne S Haviland
- ICR-CTSU, Division of Clinical Studies, The Institute of Cancer Research, Sutton, UK; University of Southampton Clinical Trials Unit, Southampton, UK
| | - J Roger Owen
- Gloucestershire Oncology Centre, Cheltenham General Hospital, Cheltenham, UK
| | - John A Dewar
- Department of Oncology, Ninewells Hospital, Dundee, UK
| | - Rajiv K Agrawal
- Department of Oncology, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Jane Barrett
- Department of Radiotherapy, Royal Berkshire NHS Foundation Trust, Reading, UK
| | | | - H Jane Dobbs
- Department of Clinical Oncology, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Penelope Hopwood
- ICR-CTSU, Division of Clinical Studies, The Institute of Cancer Research, Sutton, UK
| | - Pat A Lawton
- Department of Oncology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Judith Mills
- ICR-CTSU, Division of Clinical Studies, The Institute of Cancer Research, Sutton, UK
| | - Sandra Simmons
- ICR-CTSU, Division of Clinical Studies, The Institute of Cancer Research, Sutton, UK
| | - Mark A Sydenham
- ICR-CTSU, Division of Clinical Studies, The Institute of Cancer Research, Sutton, UK
| | - Karen Venables
- Marie Curie Research Wing for Oncology, Mount Vernon Hospital, Northwood, UK
| | - Judith M Bliss
- ICR-CTSU, Division of Clinical Studies, The Institute of Cancer Research, Sutton, UK
| | - John R Yarnold
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, Sutton, UK; Royal Marsden NHS Foundation Trust, Sutton, UK.
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