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Smith J, Margalit D, Golledge J, Nastasi D, Nohria A, McDowell L. Carotid Artery Stenosis and Ischemic Stroke in Patients With Head and Neck Cancer Treated With Radiation Therapy: A Critical Review. Int J Radiat Oncol Biol Phys 2024; 119:1437-1454. [PMID: 38583496 DOI: 10.1016/j.ijrobp.2024.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 03/21/2024] [Accepted: 03/27/2024] [Indexed: 04/09/2024]
Abstract
The purpose of this review is to summarize the literature on carotid artery stenosis (CAS) and ischemic stroke (IS) in patients with head and neck cancer (HNC) treated with radiation therapy (RT) to guide assessment, screening, and management strategies. Patients treated with RT for HNC are at an elevated risk of developing CAS, with published meta-analyses demonstrating that CAS >50% occurs in approximately 25% of patients. Previous research suggests a 10-year cumulative incidence of stroke between 5.7% and 12.5%. Cardiovascular disease (CVD) risk prediction tools such as Qstroke, QRISK-2, and Framingham risk score perform poorly for predicting IS for patients with HNC who received RT. Duplex ultrasound is the most common imaging modality to assess CAS, but controversy remains as to the utility of screening asymptomatic individuals. Only 3 of the 5 major HNC survivorship guidelines acknowledge RT as a risk factor for CAS or IS, while only 1 makes a specific recommendation on screening for CAS (American Head and Neck Society). Within the general population, only 1 CVD guideline discusses RT as a risk factor for CAS (Society for Vascular Surgery). Clinicians involved in the care of patients with HNC treated with RT should be aware of the increased risk of CAS and IS and the challenges in risk prediction. Although there is a lack of evidence to make firm recommendations, HNC survivorship recommendations should ensure HNC survivors and primary care providers are informed of these risks and the importance of assessment and management of CVD risk factors. Future studies are required to refine risk prediction models in patients with HNC and to determine those most likely to benefit from targeted screening and initiation of early preventative strategies.
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Affiliation(s)
- Justin Smith
- Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia.
| | - Danielle Margalit
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Australia; The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Australia; The Australian Institute of Tropical Health and Medicine, Townsville, Australia
| | - Domenico Nastasi
- Department of Vascular Surgery, Gold Coast University Hospital, Gold Coast, Australia
| | - Anju Nohria
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts; Adult Survivorship Program, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Lachlan McDowell
- Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia
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Screening for irradiation vasculopathy by intima-media thickness sonography in head and neck cancer patients. Eur Arch Otorhinolaryngol 2020; 278:2017-2026. [PMID: 32870365 PMCID: PMC8131284 DOI: 10.1007/s00405-020-06301-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/15/2020] [Indexed: 11/26/2022]
Abstract
Purpose Post-irradiation vasculopathy is a severe form of atherosclerosis and affects the prognosis of head and neck cancer survivors. Sonographic intima-media thickness (IMT) precedes stenosis, plaque formation, and cerebrovascular events. Therefore, IMT may be a valuable screening marker for post-irradiation toxicity. However, the critical irradiation dose and the onset of IMT increase remain unclear. Methods The cross-sectional study analysed the carotid artery IMT in 96 irradiated patients and 41 controls regarding irradiation dose, post-irradiation-interval, and cardiovascular risk factors. Distinct irradiation doses to the tumour side and the contralateral hemineck enabled detection of dose depended effects within one patient and control of risk factors. Results Radiotherapy caused a dose-dependent increase in IMT. The toxicity did not have saturation effects for > 60 Gy. The IMT increase occurred in short-term following radiotherapy and the risk for a pathological value (> 0.9 mm) rose significantly. The correlation between IMT and radiotherapy was comparable to established cardiovascular risk factors. Conclusion Radiotherapists should consider the additional toxicity of high doses for non-metastatic head and neck cancer. If neck metastases require radiotherapy with boost, IMT measurement is suitable for early detection of carotid artery damage.
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Xu JP, Shi JJ, Duan GX, Cao YJ. Imaging Features of Symptomatic Radiation-induced Cervical Artery Stenosis. Chin Med J (Engl) 2017; 130:1876-1877. [PMID: 28748862 PMCID: PMC5547841 DOI: 10.4103/0366-6999.211553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jia-Ping Xu
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215000, China
| | - Ji-Jun Shi
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215000, China
| | - Guang-Xin Duan
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215000, China
| | - Yong-Jun Cao
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215000, China
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Roebuck-Spencer TM, Glen T, Puente AE, Denney RL, Ruff RM, Hostetter G, Bianchini KJ. Cognitive Screening Tests Versus Comprehensive Neuropsychological Test Batteries: A National Academy of Neuropsychology Education Paper†. Arch Clin Neuropsychol 2017; 32:491-498. [DOI: 10.1093/arclin/acx021] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 02/16/2017] [Indexed: 12/20/2022] Open
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Mosepele M, Hemphill LC, Palai T, Nkele I, Bennett K, Lockman S, Triant VA. Cardiovascular disease risk prediction by the American College of Cardiology (ACC)/American Heart Association (AHA) Atherosclerotic Cardiovascular Disease (ASCVD) risk score among HIV-infected patients in sub-Saharan Africa. PLoS One 2017; 12:e0172897. [PMID: 28235058 PMCID: PMC5325544 DOI: 10.1371/journal.pone.0172897] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 02/10/2017] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES HIV-infected patients are at increased risk for cardiovascular disease (CVD). However, general population CVD risk prediction equations that identify HIV-infected patients at elevated risk have not been widely assessed in sub-Saharan African (SSA). METHODS HIV-infected adults from 30-50 years of age with documented viral suppression were enrolled into a cross-sectional study in Gaborone, Botswana. Participants were screened for CVD risk factors. Bilateral carotid intima-media thickness (cIMT) was measured and 10-year predicted risk of cardiovascular disease was calculated using the Pooled Cohorts Equation for atherosclerotic CVD (ASCVD) and the 2008 Framingham Risk Score (FRS) (National Cholesterol Education Program III-NCEP III). ASCVD ≥7.5%, FRS ≥10%, and cIMT≥75th percentile were considered elevated risk for CVD. Agreement in classification of participants as high-risk for CVD by cIMT and FRS or ASCVD risk score was assessed using McNemar`s Test. The optimal cIMT cut off-point that matched ASCVD predicted risk of ≥7.5% was assessed using Youden's J index. RESULTS Among 208 HIV-infected patients (female: 55%, mean age 38 years), 78 (38%) met criteria for ASCVD calculation versus 130 (62%) who did not meet the criteria. ASCVD classified more participants as having elevated CVD risk than FRS (14.1% versus 2.6%, McNemar's exact test p = 0.01), while also classifying similar proportion of participants as having elevated CVD like cIMT (14.1% versus 19.2%, McNemar's exact test p = 0.34). Youden's J calculated the optimal cut point at the 81st percentile for cIMT to correspond to an ASCVD score ≥7.5% (sensitivity = 72.7% and specificity = 88.1% with area under the curve for the receiver operating characteristic [AUC] of 0.82, 95% Mann-Whitney CI: 0.66-0.99). CONCLUSION While the ASCVD risk score classified more patients at elevated CVD risk than FRS, ASCVD score classified similar proportion of patients as high risk when compared with established subclinical atherosclerosis. However, potential CVD risk category misclassification by established equations such as ASCVD may still exist among HIV-infected patients; hence there is still a need for development of a CVD risk prediction equation tailored to HIV-infected patients in SSA.
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Affiliation(s)
- Mosepele Mosepele
- Department of Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- * E-mail:
| | - Linda C. Hemphill
- The Heart Center, Division of Cardiology, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts, United States of America
| | - Tommy Palai
- Department of Medicine, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Isaac Nkele
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Kara Bennett
- Bennett Statistical Consulting Inc, Ballston Lake, New York, United States of America
| | - Shahin Lockman
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Division of Infectious Diseases, Brigham & Women`s Hospital, Boston, Massachusetts, United States of America
- Department of Immunology & Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Virginia A. Triant
- Division of General Internal Medicine & Division of Infectious Diseases, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts, United States of America
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Hu X, Ma X, Luo Y, Xu Y, Xiong Q, Pan X, Bao Y, Jia W. Contribution of fibroblast growth factor 23 to Framingham risk score for identifying subclinical atherosclerosis in Chinese men. Nutr Metab Cardiovasc Dis 2017; 27:147-153. [PMID: 28017526 DOI: 10.1016/j.numecd.2016.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 10/11/2016] [Accepted: 11/14/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS Fibroblast growth factor 23 (FGF23) was demonstrated to be involved in the occurrence and development of cardiovascular disease (CVD). The goal of the present study was to investigate the relationship between serum FGF23 levels and carotid intima-media thickness (C-IMT) in men with a low-to-moderate CVD risk. METHODS AND RESULTS Subjects with normal kidney function were selected from the Shanghai Obesity Study. Serum FGF23 levels were determined by sandwich enzyme-linked immunosorbent assay. C-IMT was measured by ultrasonography. The Framingham risk score (FRS) was used to assess CVD risk. A total of 392 men with low CVD risk and 372 men with moderate CVD risk were enrolled. The recognition rate of an elevated C-IMT was 85.66% with the combination of a moderate CVD risk and high serum FGF23 levels, which was greater than that with either parameter alone (65.44% and 61.03%, respectively). Subjects with high serum FGF23 levels, and either low or moderate CVD risk, were more likely to have elevated C-IMT than those with low serum FGF23 levels and low CVD risk (P = 0.014 and 0.001, respectively). The serum FGF23 levels were independently and positively associated with C-IMT in subjects with low or moderate CVD risk (both P = 0.007). CONCLUSION In men with low-to-moderate CVD risk, serum FGF23 levels were associated independently and positively with C-IMT. As a complementary index, serum FGF23 levels strengthen the capacity of the FRS to identify subclinical atherosclerosis.
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Affiliation(s)
- X Hu
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China; Shanghai Clinical Center for Diabetes, Shanghai 200233, China; Shanghai Key Clinical Center for Metabolic Disease, Shanghai 200233, China; Shanghai Diabetes Institute, Shanghai 200233, China; Shanghai Key Laboratory of Diabetes Mellitus, Shanghai 200233, China
| | - X Ma
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China; Shanghai Clinical Center for Diabetes, Shanghai 200233, China; Shanghai Key Clinical Center for Metabolic Disease, Shanghai 200233, China; Shanghai Diabetes Institute, Shanghai 200233, China; Shanghai Key Laboratory of Diabetes Mellitus, Shanghai 200233, China
| | - Y Luo
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China; Shanghai Clinical Center for Diabetes, Shanghai 200233, China; Shanghai Key Clinical Center for Metabolic Disease, Shanghai 200233, China; Shanghai Diabetes Institute, Shanghai 200233, China; Shanghai Key Laboratory of Diabetes Mellitus, Shanghai 200233, China
| | - Y Xu
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China; Shanghai Clinical Center for Diabetes, Shanghai 200233, China; Shanghai Key Clinical Center for Metabolic Disease, Shanghai 200233, China; Shanghai Diabetes Institute, Shanghai 200233, China; Shanghai Key Laboratory of Diabetes Mellitus, Shanghai 200233, China
| | - Q Xiong
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China; Shanghai Clinical Center for Diabetes, Shanghai 200233, China; Shanghai Key Clinical Center for Metabolic Disease, Shanghai 200233, China; Shanghai Diabetes Institute, Shanghai 200233, China; Shanghai Key Laboratory of Diabetes Mellitus, Shanghai 200233, China
| | - X Pan
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China; Shanghai Clinical Center for Diabetes, Shanghai 200233, China; Shanghai Key Clinical Center for Metabolic Disease, Shanghai 200233, China; Shanghai Diabetes Institute, Shanghai 200233, China; Shanghai Key Laboratory of Diabetes Mellitus, Shanghai 200233, China
| | - Y Bao
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China; Shanghai Clinical Center for Diabetes, Shanghai 200233, China; Shanghai Key Clinical Center for Metabolic Disease, Shanghai 200233, China; Shanghai Diabetes Institute, Shanghai 200233, China; Shanghai Key Laboratory of Diabetes Mellitus, Shanghai 200233, China.
| | - W Jia
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai 200233, China; Shanghai Clinical Center for Diabetes, Shanghai 200233, China; Shanghai Key Clinical Center for Metabolic Disease, Shanghai 200233, China; Shanghai Diabetes Institute, Shanghai 200233, China; Shanghai Key Laboratory of Diabetes Mellitus, Shanghai 200233, China
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