Iliac atherosclerotic occlusive disease complicating radiation therapy for cervix cancer: a case series

Case report: Iliac vein rupture during endovascular stenting in radiation-induced iliac venous stenosis

Only a few case reports in the medical literature describe radiation-induced iliac vein stenosis and endovascular therapy. We present a case of left external iliac vein stenosis resulting from radiotherapy for cervical cancer in which the iliac vein ruptured during the standard iliac vein stenting procedure. The emergency condition was resolved with the implantation of a covered stent and resuscitation with crystalloid and blood transfusion. The patient recovered without additional complications and was discharged eight days after endovascular therapy. At the six-month follow-up, the left lower limb edema had resolved completely, and the deep vein remained patent. This case might raise concerns regarding the potential risk of treating radiation-induced iliac venous stenosis, which may differ from that of a patient without a history of radiation therapy. Iliac vein rupture, iliac vein stenting, radiation-induced venous stenosis, case report.

Cardiovascular Manifestations From Therapeutic Radiation: A Multidisciplinary Expert Consensus Statement From the International Cardio-Oncology Society

Radiation therapy is a cornerstone of cancer therapy, with >50% of patients undergoing therapeutic radiation. As a result of widespread use and improved survival, there is increasing focus on the potential long-term effects of ionizing radiation, especially cardiovascular toxicity. Radiation therapy can lead to atherosclerosis of the vasculature as well as valvular, myocardial, and pericardial dysfunction. We present a consensus statement from the International Cardio-Oncology Society based on general principles of radiotherapy delivery and cardiovascular risk assessment and risk mitigation in this population. Anatomical-based recommendations for cardiovascular management and follow-up are provided, and a priority is given to the early detection of atherosclerotic vascular disease on imaging to help guide preventive therapy. Unique management considerations in radiation-induced cardiovascular disease are also discussed. Recommendations are based on the most current literature and represent a unanimous consensus by the multidisciplinary expert panel.

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Radiation therapy leads to short- and long-term cardiovascular adverse effects of the vasculature and the heart, including valvular, myocardial, and pericardial disease.

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Computed tomography scans conducted for radiation planning or cancer staging provide an available opportunity to detect asymptomatic atherosclerosis and direct preventive therapies.

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Additional practical screening recommendations for cardiovascular disease based on anatomical exposure are provided.

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There are unique considerations in the management of radiation-induced cardiovascular disease; contemporary percutaneous treatment is often preferred over surgical options.

Radiation-Induced Vascular Disease-A State-of-the-Art Review

Since the 1990s, there has been a steady increase in the number of cancer survivors to an estimated 17 million in 2019 in the US alone. Radiation therapy today is applied to a variety of malignancies and over 50% of cancer patients. The effects of ionizing radiation on cardiac structure and function, so-called radiation-induced heart disease (RIHD), have been extensively studied. We review the available published data on the mechanisms and manifestations of RIHD, with a focus on vascular disease, as well as proposed strategies for its prevention, screening, diagnosis, and management.

Radiation-induced lower-limb arteriopathy: report of 4 cases and systematic literature review

INTRODUCTION

Radiation-induced arteriopathy (RIA) is a rare complication but may become more common due to the increased use of radiotherapy and the prolonged survival of patients. There is still a lack of evidence concerning treatment options. The aim of this study is to review reported cases of lower-limb RIA in order to provide guidelines for management.

EVIDENCE ACQUISITION

We reported 4 cases treated for lower limb RIA and performed a systematic literature review without time limitation in the Medline database using the MeSh tems "iliac artery/radiation effects" OR "femoral artery/radiation effects." Main outcomes of interest were radiation dose, time before symptoms, symptoms, involved vessels, treatment and outcome.

EVIDENCE SYNTHESIS

Twenty-five studies were included, reporting a total of 43 patients. Median time between irradiation and symptoms was 12 years (range: 9 days-49 years), with a median irradiation dose of 40Gy. Clinical presentation was claudication in 18 patients (52%), critical limb threatening ischemia (CLTI) in 4 patients (11%), acute limb ischemia (ALI) in 3 patients (9%) and hemorrhage in 6 patients (17%), the remaining 4 patients were asymptomatic (11%). Vessels involved were iliac arteries in 65% of the cases, femoropopliteal arteries in 28% of cases and concomitant supra and infrainguinal vessels in 7% of the cases. Claudication was mostly treated by open surgery (62%). Treatment of CLTI included primary amputation (50%), open surgery (25%) or endovascular surgery (25%). ALI was treated medically (33%), by open surgery (33%) or in situ thrombolysis (33%). Hemorrhagic cases or pulsatile masses were mostly treated by open surgery (66%). Follow-up was reported in 26 patients (67%), with mean follow-up of 12 months (range: 2 weeks - 5 years). During follow-up, 16% of these patients presented a recurrence of symptoms, and 8% required a reintervention.

CONCLUSIONS

There seems to be no evidence for open versus endovascular treatment, but close and long-term follow-up is needed in these patients due to the possible late presentation and recurrence of symptoms after treatment.

[Treatment of radiation-induced iliofemoral arterial complications with groin radionecrosis]

Long-term iliofemoral complications induced by radiation include vascular (arterial and venous) lesions, nervous lesions and soft tissue loss that can be cutaneous and subcutaneous and potentially lead to radionecrosis with vessel exposure. We present five cases of groin radionecrosis. There were three men and two women (age 30-73 years). Radiotherapy had been delivered 15 years earlier in three cases, and 2 years earlier in two cases. Symptoms were intermittent claudication (n=1), critical ischemia (n=1), and septic hemorrhage (n=1). Two patients had no vascular symptoms. Four patients underwent scheduled surgery after complete cardiac and cardiovascular evaluation with duplex-Doppler, CT scan and/or intra-arterial angiography. One woman underwent emergency surgery after septic hemorrhage of a previous in situ femoral revascularization fashioned 2 months earlier. Revascularization was achieved with trans-iliac (n=3), trans-muscular (n=1, and in situ (n=1) iliofemoral bypass. A retroperitoneal approach with section of large muscles was used. In three cases, a trans-iliac route was used by perforating the iliac wing with a 8-mm PTFE graft. Proximal anastomosis was done on the abdominal aorta (n=1) and the homolateral common iliac artery (n=2). Distal anastomosis was done on the distal profunda artery and popliteal artery (n=1) and on the distal femoral superficial artery (n=2). In two cases, an iliofemoral bypass was done with a 7-mm PTFE vascular graft. The proximal anastomosis was done on the proximal external iliac artery and the distal anastomosis on the proximal superficial femoral artery. A plastic procedure was performed in four cases. Three patients had a homolateral (n=1) or controlateral (n=2) rectus abdominis flap. In one case, plastic coverage was done with an antebrachial flap (Chinese flap), which has been released at 6 weeks. One patient had post-radiotherapy iliofemoral vascular disease, but there was no vascular exposure, and no plastic coverage was necessary. The postoperative course was uneventful in four cases. The patient treated with an in situ bypass developed septic hemorrhage at day 10, requiring revision. The patient died of multiple organ system failure, with a patent graft and a viable flap. The other four patients had no early or late complications. These patients have been followed annually for clinical examinations and duplex scans, and angio-scans. One patient died of ischemic heart disease. The three other patients are alive with a patent bypass with 11, 8 and 3 years follow-up. One patient had a late occlusion of the bypass treated by thrombectomy after 7 and 10 years. In conclusion, patients with femoral radionecrosis can be treated by an extra-anatomic bypass, with plastic coverage. The trans-iliac is a relatively simple and safe procedure.

SCAI Expert consensus statement: Evaluation, management, and special considerations of cardio-oncology patients in the cardiac catheterization laboratory (endorsed by the cardiological society of india, and sociedad Latino Americana de Cardiologıa intervencionista)

In the United States alone, there are currently approximately 14.5 million cancer survivors, and this number is expected to increase to 20 million by 2020. Cancer therapies can cause significant injury to the vasculature, resulting in angina, acute coronary syndromes (ACS), stroke, critical limb ischemia, arrhythmias, and heart failure, independently from the direct myocardial or pericardial damage from the malignancy itself. Consequently, the need for invasive evaluation and management in the cardiac catheterization laboratory (CCL) for such patients has been increasing. In recognition of the need for a document on special considerations for cancer patients in the CCL, the Society for Cardiovascular Angiography and Interventions (SCAI) commissioned a consensus group to provide recommendations based on the published medical literature and on the expertise of operators with accumulated experience in the cardiac catheterization of cancer patients.

Risk factors for wound complications in patients undergoing primary closure of the perineal defect after total proctectomy

PURPOSE

Perineal wounds after complete proctectomy are at risk for failure, with dramatic consequences on patients' health and quality of life. This study is aimed at identifying risk factors for wound complications in patients undergoing primary closure of the perineal defect after total proctectomy.

METHODS

Data from 284 patients undergoing total proctectomy from 2002 to 2012 either at the University of Chicago Medical Center or the Catholic University of Rome Hospital were collected and analyzed.

RESULTS

Overall, the perineal wound complication rate was 21.8%. Successful conservative management was accomplished in 45.2% of cases. Complications occurred significantly more often in patients with a higher Charlson score index, with the diagnosis of rectal cancer, who had received preoperative radiation and who had a surgical drain placed at the time of initial surgery. Neoadjuvant radiation was the only significant risk factor at multivariate analysis (OR 4.40). In the rectal cancer subgroup, younger age, female gender, and preoperative radiation were predictors of wound complications. Based on that, a 3-point score (radiation, age, and gender (RAG)) was developed. Patients with a score of 3 had a 50% risk of developing a perineal wound complication.

CONCLUSIONS

Perineal wound complications are a common and burdensome problem after total proctectomy. Preoperative radiation is the single most significant and controllable risk factor predicting perineal wound failure. In the presence of multiple, non-modifiable risk factors, alternative approaches to primary closure should be considered in managing complex perineal defects.

Noncancer Causes of Death in Survivors of Testicular Cancer

BACKGROUND

Although modern treatments for testicular cancer are associated with increased survival, the long-term health effects of these treatments are unclear. We conducted a population-based study to quantify the long-term risks of mortality from noncancer causes among men with testicular cancer.

METHODS

We identified 38,907 one-year survivors of testicular cancer within 14 population-based cancer registries in North America and Europe (from 1943 through 2002). We used data from these registries to calculate standardized mortality ratios (SMRs) for noncancer deaths and to evaluate associations between histology, age at testicular cancer diagnosis, calendar year of diagnosis, and initial treatment and the risk of noncancer mortality. All statistical tests were two-sided.

RESULTS

A total of 2942 deaths from all noncancer causes were reported after a median follow-up of 10 years, exceeding the expected number of deaths from all noncancer causes in the general population by 6% (SMR = 1.06, 95% confidence interval [CI] = 1.02 to 1.10); the noncancer standardized mortality ratios did not differ statistically significantly between patients diagnosed before and after 1975, when cisplatin-based chemotherapy came into widespread use. Compared with the general population, testicular cancer survivors had higher mortality from infections (SMR = 1.28, 95% CI = 1.12 to 1.47) and from digestive diseases (SMR = 1.44, 95% CI = 1.26 to 1.64). Mortality from all circulatory diseases was statistically significantly elevated in men diagnosed with testicular cancer before age 35 years (1.23, 95% CI = 1.09 to 1.39) but not in men diagnosed at older ages (SMR = 0.94; 95% CI = 0.89 to 1.00). Men treated with chemotherapy (with or without radiotherapy) in 1975 or later had higher mortality from all noncancer causes (SMR = 1.34, 95% CI = 1.15 to 1.55), all circulatory diseases (SMR = 1.58, 95% CI = 1.25 to 2.01), all infections (SMR = 2.48, 95% CI = 1.70 to 3.50), and all respiratory diseases (SMR = 2.53, 95% CI = 1.26 to 4.53). Testicular cancer patients who were younger than 35 years at diagnosis and were treated with radiotherapy alone in 1975 or later had higher mortality from all circulatory diseases (SMR = 1.70, 95% CI = 1.21 to 2.31) compared with the general population.

CONCLUSION

Men who have survived for at least 1 year after being diagnosed with testicular cancer have a slightly higher risk of dying from noncancer causes, including infections, digestive diseases, and circulatory diseases, than the general population. Men treated with chemotherapy in 1975 or later may be at particularly high risk.

Long term morbidity of neoadjuvant chemoradiation for pancreatic head adenocarcinoma

PURPOSE

To report the long term risks of neoadjuvant chemoradiation (NCRT) after duodenopancreatectomy (DP) for adenocarcinoma of the head of pancreas.

METHODS

Between January 1996 and December 2002, 26 patients with biopsy-proven adenocarcinoma of the head of pancreas were treated by this combination of therapies.

RESULTS

Two patients had delayed NCRT-related small bowel infarction: one died from superior mesenteric artery stenosis 36 months after DP without recurrence at laparotomy; there was one limited infarction 16 months after DP.

CONCLUSIONS

Long term vascular morbidity after NCRT is significant.

Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure

PURPOSE

Neoadjuvant radiation therapy has been used increasingly to downstage rectal cancer and decrease local recurrence. Despite its efficacy, preoperative radiation therapy may inhibit healing and contribute to wound complications. This study was designed to evaluate perineal wound complications after abdominoperineal resection.

METHODS

The clinical records of a consecutive series of patients who underwent abdominoperineal resection for rectal carcinoma between 1988 and 2002 were reviewed. Demographic data, disease stage, and use of preoperative radiation therapy were recorded. Major wound complications included delayed wound healing (>1 month), wound infection requiring drainage/debridement, or reoperation.

RESULTS

A total of 160 patients underwent abdominoperineal resection with primary closure of the perineal wound (mean age, 63 +/- 12 years); 117 (73 percent) patients received preoperative radiation therapy; 114 received radiation therapy for rectal cancer (radiation therapy + chemotherapy = 107, radiation therapy alone = 7); 3 received radiation therapy for other pelvic malignancies. Median radiation dose was 5,040 (range, 900-5,400) cGY. Overall wound complication rate was 41 percent. Major wound complication rate was 35 percent. Delayed healing was the most common complication (24 percent), followed by infection (10 percent). Radiation therapy increased the risk of any wound complication (47 vs. 23 percent; P = 0.005), risk of a major wound complication (41 vs. 19 percent; P = 0.021), and risk of infection (14 vs. 0 percent; P = 0.015). Risk of wound complications did not correlate with age, gender, disease stage, smoking, or diabetes.

CONCLUSIONS

Wound complications are frequent after abdominoperineal resection and primary closure of the perineum. Preoperative radiation therapy doubles the rate of total and major perineal wound complications. Alternatives to primary perineal closure should be considered, particularly after radiation therapy.

Vessel-sparing prostate radiotherapy: Dose limitation to critical erectile vascular structures (internal pudendal artery and corpus cavernosum) defined by MRI

PURPOSE

Most evidence suggests that impotence after prostate radiation therapy has a vascular etiology. The corpus cavernosum (CC) and the internal pudendal artery (IPA) are the critical vascular structures related to erectile function. This study suggests that it is feasible to markedly decrease radiation dose to the CC and the IPA and directly determine the impact of dose limitation on potency.

METHODS AND MATERIALS

Twenty-five patients (10 external beam, 15 brachytherapy) underwent MRI/CT-based treatment planning for prostate cancer. In addition, 10 patients entered on the vessel-sparing protocol underwent a time-of-flight MRI angiography sequence to define the IPA. The distance from the MRI-defined prostate apex to the penile bulb (PB), CC, and IPA was measured and compared to the distance from the CT-defined apex. Doses (D5 and D50) to the PB, CC, and IPA were determined for an 80 Gy external beam course. In 5 patients, CT plans were generated and compared to MRI-based plans.

RESULTS

The combination of coronal, sagittal, and axial MRI data sets allowed superior definition of the prostate apex and its relationship to critical vascular structures. The apex to PB distance averaged 1.45 cm (0.36 standard deviation) with a range of 0.7 cm to 2.1 cm. Peak dose (D5) to the proximal CC in the MRI-planned 80 Gy course was 26 (9) Gy (0.36 of CT-planned dose), and peak dose to the IPA was 39 (13) Gy (0.61 of CT-planned dose).

CONCLUSION

The distance between the prostate apex and critical vascular structures is highly variable. Current empiric rules for CT contouring (apex 1.5 cm above PB) overestimate or underestimate the distance between the prostate apex and critical vascular structures. When defined by MRI T2 and MRI angiogram with CT registration, limitation of dose to critical erectile structures is possible, with a more significant gain than has been previously reported using dose limitation by commonly applied intensity modulated radiation therapy studies based on CT imaging. These techniques make "vessel-sparing" prostate radiotherapy feasible.

Innovations in the treatment of invasive cervical cancer

Invasive cervical cancer is characterized by basement membrane-invading lesions capable of metastasizing through the lymphatic and vascular systems. Treatment methods were reviewed by panelists at the Second International Conference on Cervical Cancer (Houston, TX, April 11-14, 2002), and new opportunities for translational research were discussed. Reviews encompassed hysterectomy with or without lymph node dissection or cervical conization in cases with microinvasion and radical trachelectomy with or without lymph node dissection as fertility-sparing surgery. Chemoradiation is used to treat advanced cervical malignancies, and the risks and benefits of radiotherapy are significant. Pelvic exenteration is used to treat certain types of recurrences. Use of the Miami pouch for continent urinary diversion was highlighted. Gynecologic oncologists expect novel in vivo imaging techniques currently being developed to help guide therapy choices within the next decade. The most significant research priorities are large group-randomized trials involving fertility-sparing procedures and the management of microinvasive carcinoma (MICA); better identification of candidates for chemoradiation; and the development of innovative approaches to exenteration. Improving diagnostic technologies, refining the criteria by which therapies are chosen, and preserving fertility remain challenges in selecting the most appropriate treatment for invasive cervical cancer. Research advances in both diagnosis and treatment are expected to improve therapy and outcomes.

Acute and long-term toxicity following radiotherapy alone or in combination with chemotherapy for locally advanced cervical cancer

Randomised studies in locally advanced cervical cancer patients showed that cisplatin should be given concurrently with radiotherapy, because of a better long-term survival compared to radiotherapy alone. This increases the relevance of treatment related toxicity. This review summarises the acute and long-term toxicity of radiotherapy given with or without chemotherapy for cervical cancer. Acute toxicity (all grades) of radiotherapy is reported in 61% of the patients in the rectosigmoid, in 27% as urological, in 27% as skin and in 20% as gynaecological toxicity. Moderate and severe morbidity consists of 5% to 7% gastrointestinal and 1% to 4% genitourinary toxicity. Adding chemotherapy to radiotherapy increases acute haematological toxicity to 5% to 37% of the patients and nausea and vomiting in 12% to 14%. Late effects of radiotherapy include gastrointestinal, urological, female reproductive tract, skeletal and vascular toxicity, secondary malignancies and quality of life issues. For at least 20 years after treatment, new side effects may develop. Gastrointestinal toxicity usually occurs in the first 2 years after treatment in about 10% of the patients. The incidence of moderate and severe urological toxicity can increase up to 10% and rises over time. Gynaecological toxicity usually occurs shortly after treatment while skeletal and vascular toxicity can occur years to decades later. Thus far, no increase in late toxicity has been observed after the addition of cisplatin to radiotherapy. Finally, methods to prevent or decrease late toxicity and therapeutical options are discussed. However, most randomised studies still have a limited follow-up period.