Myocardial infarction after irradiation in Hodgkin's disease: a review

Management and postoperative outcome in primary lung cancer and heart disease co-morbidity: a systematic review and meta-analysis

BACKGROUND

Co-morbidity of primary lung cancer (LC) and heart disease (HD), both requiring surgical therapy, characterizes a high risk group of patients necessitating prompt diagnosis and treatment. The aim of this study is the review of available evidence guiding the management of these patients.

METHODS

Postoperative outcome of patients operated for primary LC (first meta-analysis) and for both primary LC and HD co-morbidity (second meta-analysis), were studied. Parameters examined in both meta-analyses were thirty-day postoperative mortality, postoperative complications, three- and five-year survival probabilities. The last 36 years were reviewed by using the PubMed data base. Thirty-seven studies were qualified for both meta-analyses.

RESULTS

The pooled 30-day mortality percentages (%) were 4.16% [95% confidence interval (CI): 2.68-5.95] (first meta-analysis) and 5.26% (95% CI: 3.47-7.62) (second meta-analysis). Higher percentages of squamous histology and lobectomy, were significantly associated with increased (P=0.001) and decreased (P<0.001) thirty-day postoperative mortality, respectively (first meta-analysis). The pooled percentages for postoperative complications were 34.32% (95% CI: 24.59-44.75) (first meta-analysis) and 45.59% (95% CI: 35.62-55.74) (second meta-analysis). Higher percentages of squamous histology (P=0.001), lobectomy (P=0.002) and p-T1 or p-T2 (P=0.034) were associated with higher proportions of postoperative complications (second meta-analysis). The pooled three- and five- year survival probabilities were 68.25% (95% CI: 45.93-86.86) and 52.03% (95% CI: 34.71-69.11), respectively. Higher mean age (P=0.046) and percentage lobectomy (P=0.009) significantly reduced the five-year survival probability.

CONCLUSIONS

Lobectomy and age were both accompanied by reduced five-year survival rate. Also, combined aorto-coronary bypass grafting (CABG) with lobectomy for squamous pT1 or pT2 LC displayed a higher risk of postoperative complications. Moreover, medical decision between combined or staged surgery is suggested to be individualized based on adequacy of coronary arterial perfusion, age, patient's preoperative performance status (taking into account possible co-morbidities per patient), tumor's staging and extent of lung resection.

Cardiotoxicity of anticancer treatments: what the cardiologist needs to know

Cardiotoxicity of anticancer treatments has become an increasingly important clinical problem faced by cardiologists. Left ventricular systolic dysfunction and heart failure generate the most concern, but clinical features and prognosis vary considerably depending on the causative agent. Anthracycline-related cardiomyopathy differs fundamentally from effects associated with newer targeted agents, such as trastuzumab. Other forms of cardiovascular disease that occur as a result of cancer treatment include hypertension, thromboembolic disease, pericardial disease, arrhythmia, and myocardial ischemia. The approach to cardiovascular disease in patients with cancer is often different from that in the general population, not only because of distinct underlying mechanisms and clinical features of their heart disease, but also because of the potential ongoing need for additional cancer treatment as well as the altered duration of anticipated survival. In an effort to maximize both quality of life and survival, cardiologists and oncologists should collaborate with the aim of balancing the risks of cardiotoxicity with the benefits of oncologic therapy.

Radiation-associated cardiovascular disease

As the number of cancer survivors grows because of advances in therapy, it has become more important to understand the long-term complications of these treatments. This article presents the current knowledge of adverse cardiovascular effects of radiotherapy to the chest. Emphasis is on clinical presentations, recommendations for follow-up, and treatment of patients previously exposed to irradiation. Medline literature searches were performed, and abstracts related to this topic from oncology and cardiology meetings were reviewed. Potential adverse effects of mediastinal irradiation are numerous and can include coronary artery disease, pericarditis, cardiomyopathy, valvular disease and conduction abnormalities. Damage appears to be related to dose, volume and technique of chest irradiation. Effects may initially present as subclinical abnormalities on screening tests or as catastrophic clinical events. Estimates of relative risk of fatal cardiovascular events after mediastinal irradiation for Hodgkin's disease ranges between 2.2 and 7.2 and after irradiation for left-sided breast cancer from 1.0 to 2.2. Risk is life long, and absolute risk appears to increase with length of time since exposure. Radiation-associated cardiovascular toxicity may in fact be progressive. Long-term cardiac follow-up of these patients is therefore essential, and the range of appropriate cardiac screening is discussed, although no specific, evidence-based screening regimen was found in the literature.

High cure rates and reduced long-term toxicity in pediatric Hodgkin's disease: the German-Austrian multicenter trial DAL-HD-90. The German-Austrian Pediatric Hodgkin's Disease Study Group

PURPOSE

To further reduce therapy-related late effects in patients with pediatric Hodgkin's disease (HD) while maintaining the high cure rates achieved with vincristine, prednisone, procarbazine, and doxorubicin (OPPA) or OPPA/cyclophosphamide, vincristine, prednisone, and procarbazine (COPP) chemotherapy and involved-field radiotherapy. The risk of testicular dysfunction was addressed by substituting etoposide for procarbazine (OEPA) in the induction therapy for boys. Radiation doses and fields were further reduced.

PATIENTS AND METHODS

Three hundred nineteen boys and 259 girls younger than 18 years with previously untreated HD, enrolled onto the study between 1990 and 1995, were allocated to treatment group (TG)1 (early stages), TG2 (intermediate stages), or TG3 (advanced stages). All groups underwent two cycles of OEPA (boys) or OPPA (girls) for induction chemotherapy. TG2 and TG3 continued on additional two or four cycles, respectively, of COPP. Low-dose radiotherapy was given to the initially involved sites, ie, reduced involved fields.

RESULTS

Initial response to OPPA or OEPA induction was virtually identical. Eight of 578 patients experienced early progression of HD. Thirty-seven relapses, three secondary tumors, and no secondary leukemias have been recorded, with a median follow-up duration of 5.1 years (maximum, 8.1 years). Thirteen of 578 patients died. The probability of 5-year event-free survival/overall survival is 91%/98% in the total group, 94%/97% with OPPA, and 89%/98% with OEPA induction therapy. Risk factor analysis showed two significant prognostic factors: histologic subtype NS2 and "B" symptoms. OEPA induction therapy, large mediastinal tumor, and age were not significant. Preliminary studies of testicular function indicate a lower risk of germ cell damage than previously documented with OPPA.

CONCLUSION

OEPA is a satisfactory alternative to OPPA. Radiotherapy can be confined to involved sites when combined with appropriate chemotherapy. The DAL-HD-90 regimen represents a comprehensive treatment program for all stages of pediatric HD and offers a favorable benefit/risk ratio, combining excellent disease control, moderate acute toxicity, and reduced long-term toxicity.

No serious late cardiac effects after adjuvant radiotherapy following mastectomy in premenopausal women with early breast cancer

PURPOSE

To assess cardiac mortality, coronary artery disease, myocardial dysfunction, and valvular heart disease in women younger than 65 years of age, at least 10 years after adjuvant radiotherapy following mastectomy in early breast cancer.

METHODS AND MATERIALS

Ninety women (45-64 years old) with Stage II breast cancer without relapse, included in the South Sweden Breast Cancer Trial (premenopausal arm), with or without adjuvant postoperative radiotherapy +/- cyclophosphamide were examined with myocardial scintigraphy and echocardiography/Doppler, 10-17 years after radiotherapy. Thirty-four patients had been irradiated for left-sided tumors, 33 for right-sided tumors, and 23 patients had not been treated with radiotherapy. The radiotherapy (conventional roentgen, electron beams, and high-energy photon beams combined, in each patient) included the chest wall and the regional lymph nodes, with a specified target dose of 38-48 Gy, administered in daily fractions of 1.9-2.4 Gy, 5 days/week.

RESULTS

No cardiac deaths were found among the original 275 patients randomized to adjuvant therapy. In the 90 patients examined, abnormal findings were recorded for ECG (14 patients), exercise test (5 patients), myocardial scintigraphy (6 patients), thickening of valve cusps (14 patients), and mild valvular regurgitation (20 patients). All patients had normal systolic function. Diastolic dysfunction was observed in 6 patients (abnormal relaxation in 4 patients and restrictive filling abnormality in 2 patients). Although no significant differences were found between the 3 study groups, there was a tendency to more abnormal findings after radiotherapy.

CONCLUSION

Women younger than 50 years of age at the time of adjuvant radiotherapy following mastectomy in early breast cancer, had no serious cardiac sequelae 13 years (median) later, despite partly old-fashioned radiation techniques.

Pediatric Hodgkin's disease: treatment in the late 1990s

BACKGROUND

For two decades now combined chemo-radiotherapy has been preferred in most of the studies on childhood Hodgkin's disease (HD), because combined modality is the precondition for (1) reducing the radiation dose, (2) reducing the radiation fields, (3) shortening chemotherapy, (4) omitting splenectomy and laparotomy, and thus, for optimizing the benefit/risk ratio between cure rates and late effects. Recently, the rationale for this approach was strengthened by worrisome data about the increasing incidence of secondary breast cancer in women treated for HD in childhood, adolescence or adult age < 30 years. Nearly all breast cancers were localized in the former radiation field, and the relative risk was much higher after doses > 40 Gy than after lower doses. These findings suggest that pediatric therapy approaches abandoning radiotherapy alone with its high doses and large fields should be extended to adolescents treated outside of pediatric studies and to adults younger than 30. The risk of chemotherapy-related secondary leukemias can be limited to < 1% by omitting mechlorethamine and restricting the cumulative doses of other drugs with leukemogenic potential, as demonstrated by the experience with ABVD and the recently published data of the German-Austrian pediatric group.

PATIENTS AND METHODS

The updated results of the German-Austrian multicenter study HD-90 are presented in this paper (578 patients < 18 years, follow-up: median 4 years, maximum 7 years). Patients were allocated to three treatment groups (TG) according to disease stage. In all three TG, induction procarbazine, prednisone, adriamycin) for girls and two cycles of OEPA (etoposide instead of procarbazine) for boys. Patients of TG 2 and 3 additionally received two or four cycles of COPP (C, cyclophosphamide), respectively. CT was followed by radiotherapy to the involved sites (reduced fields if possible) of 25, 25 and 20 Gy in the 3 TG, respectively.

PRELIMINARY RESULTS

For the total group of 578 pats, overall survival (OS) at 5 years is 98% and event-free survival (EFS) 91%. In TG 1, EFS for girls (2 OPPA) is 96%, and for boys (OEPA), 94%, in TG 2 and 3 (combined), 92% and 86%, respectively. Secondary leukemias were not observed so far, thirty-one male patients of TG 1 who were tested endocrinologically showed normal FSH levels.

CONCLUSIONS

The especially high efficacy of OPPA and OPPA/COPP could be confirmed in study HD-90 with reduced radiation doses and fields. OEPA and OEPA/COPP CT also produced very favorable results, not significantly different from those with OPPA and OPPA/COPP. It may be anticipated that the ratio between cure rates and risks of late effects of study HD-90 will compare favorably to approaches of other groups. It would be useful for the future continued optimization of HD therapy to attain a rough consensus at an international level about principles which should be considered for pediatric approaches. Some proposals have been made for treatment of early stages.

Treatment of children and adolescents with Hodgkin's disease: the experience of the German-Austrian Paediatric Study Group

In treatment strategies adapted to the specific problems in children with Hodgkin's disease (HD) high priority has been given to the reduction of late effects caused by radio- and chemotherapy, without sacrificing high survival rates. Combined modality treatment, as a standard option, has enabled reduced doses and fields of radiotherapy and lower cumulative total doses of critical cytotoxic agents. In Germany and Austria 1242 children and adolescents with HD have been treated in five consecutive multicentre studies since 1978. The main general objectives were to determine the extent to which radio- and chemotherapy can be reduced within a combined modality treatment concept and to find an effective chemotherapy of low long-term toxicity. Mechlorethamine in MOPP was replaced by adriamycin (OPPA) in the first 2 cycles of CT and by cyclophosphamide (COPP) in the additional cycles. The total number of cycles was reduced for early and intermediate stages. From the second study (HD-82) onward, patients were allocated to three treatment groups (2, 4 or 6 cycles, respectively) according to disease stage, and involved-field instead of extended-field irradiation was given. With radiation doses of 35, 30 and 25 Gy, high rates for event-free survival (97, 92 and 85%, respectively) at 14 years were achieved, demonstrating that microfoci in adjacent fields are safely eradicated by the chemotherapy used. Late effects of OPPA and OPPA/COPP: the cumulative risk of secondary leukaemias in 686 patients after 15 years was 0.9% for all patients and 0.8% for those who remained in first remission. Cardiomyopathies have not been observed (cumulative total dose of adriamycin 160 mg/m2). Increased FSH-levels indicating impaired spermatogenesis were found in 40% of the male patients without relapse. The prevalence was related to the number of procarbazine containing cycles (29% after 2 cycles, 46% after 4, and 63% after 6). In study HD-90, procarbazine in OPPA was replaced by etoposide (OEPA) for the boys (cumulative dose 1000 mg/m2), whereas girls received OPPA again. In TGs 2 and 3, both boys and girls received an additional 2 or 4 COPP cycles. Standard doses of involved-field irradiation were reduced to 25, 25 and 20 Gy. The preliminary evaluation after nearly 5 years reveals that the reduction in radiation doses did not affect the results with OPPA and OPPA/COPP chemotherapy. In localized stages, 2 OEPA (boys) and 2 OPPA (girls) cycles produced identical results. An additional objective of the German-Austrian trials was to re-evaluate the relevance of exploratory laparotomy and splenectomy within a combined modality treatment concept for all patients. While all children were laparotomized and splenectomized in the first study, the frequency of splenectomy and laparotomy was reduced step by step on the basis of retrospective analyses of the study data regarding infra-diaphragmatic involvement. Splenectomy has been completely abandoned since 1990. In conclusion, the ratio of cure rates and late effects has been favourably balanced with OPPA and OPPA/COPP plus low-dose involved-field irradiation, especially in female patients. In boys, the risk of testicular dysfunction can be further reduced by substituting OEPA for OPPA. Age up to 18 years does not appear to bear any prognostic significance for the treatment results under the conditions of the therapy concept described.

The balance between cure and late effects in childhood Hodgkin's lymphoma: the experience of the German-Austrian Study-Group since 1978. German-Austrian Pediatric Hodgkin's Disease Study Group

BACKGROUND

For more than 20 years now treatment strategies geared to the specific problems in children with Hodgkin's disease (HD) have been tested by different pediatric oncologic groups. In these approaches high priority was given to the reduction of late effects caused by radio- and chemotherapy, next to the goal of achieving high survival rates. Combined modality treatment as a standard option has enabled reduced dosages and fields of radiotherapy and lowered cumulative total doses of critical cytotoxic agents.

METHODS

In Germany and Austria more than 1,200 children and adolescents with HD have been treated in 5 consecutive multicenter studies since 1978. The main general objectives were to determine the extent to which radio- and chemotherapy can be reduced within a combined treatment concept and to find an effective chemotherapy (CT) of low long-term toxicity. Nitrogen-mustard in MOPP was replaced by adriamycin (OPPA) in the first 2 cycles of CT and by cyclophosphamide (COPP) in the additional cycles. The total number of cycles was reduced for early and intermediate stages. From the second study (HD-82) onward, patients were allocated to 3 treatment groups (2, 4, 6 cycles, respectively) according to disease stage, and involved-field irradiation (IFI) was given instead of extended-field irradiation (EFI).

RESULTS

In study HD-82 standard doses of IFI in the 3 treatment groups (TG) after 2, 4, or 6 cycles of CT were 35, 30, or 25 Gy. In a total of 203 patients probabilities for event-free survival (pEFS) and survival (pSV) were 95% and 93% at 13 years. In the 3 TG pEFS was 97%, 92% and 85%. In an international study (SIOP-HD IV-87) 65 stage IV patients were treated according to the TG 3 schedule of HD-82 (2 OPPA, 4 COPP, 20 Gy IFI). After 7 years pEFS is 77% and pSV 93%. Late effects of OPPA respectively, OPPA/ COPP: The cumulative risk for secondary leukemias after 10 years is 0.5% for all patients and 0.3% for those who remained in first remission. Cardiomyopathies have not been observed (cumulative total dose of adriamycin 160 mg/m2). Increased FSH-levels indicating impaired spermatogenesis were found in 40% of the male patients without relapse. The frequency was related to the number of procarbazine containing cycles (29% after 2 cycles, 46% after 4, and 63% after 6). In study HD-90, procarbazine in OPPA was replaced by etoposide (OEPA) for the boys (cumulative dose 1,000 mg/ m2), whereas girls received OPPA again. In TG2 and 3, both boys and girls received COPP. Standard doses of IFI were reduced to 25, 25, and 20 Gy. The preliminary evaluation after nearly 5 years reveals that the reduction of radiation doses did not impair the results after OPPA and OPPA/ COPP. In localized stages 2 OEPA (boys) and 2 OPPA (girls) produced the same results. In the 15-18 years age group compared to the younger patients identical values for pEFS were achieved.

CONCLUSIONS

The ratio between cure rates and late effects has been favourably balanced with OPPA, respectively, OPPA/COPP plus low-dose IFI, especially in female patients. In boys the risk of testicular dysfunction can be further reduced by substituting OEPA for OPPA. Age up to 18 years does not appear to be of any significance for the treatment results with our therapy concept.