Late cardiac, thyroid, and pulmonary sequelae of mantle radiotherapy for Hodgkin's disease

Late effects in survivors treated for lymphoma as adolescents and young adults: a population-based analysis

PURPOSE

The study objective is to describe and quantify the incidence of treatment-induced late effects in AYA lymphoma patients.

METHODS

Consecutive patients diagnosed with Hodgkin lymphoma (HL) or non-Hodgkin lymphoma (NHL) at 15-24 years of age were identified. All patients in British Columbia who received radiation therapy (RT) from 1974 to 2014 with ≥ 5-year survival post-RT were included. Late effects' analyses included only survivors who received RT to the relevant anatomical site(s) and/or relevant chemotherapy, and were reported as cumulative incidence (CI) ± standard error.

RESULTS

Three hundred and five patients were identified (74% HL). Median age of diagnosis was 21 years. Median follow-up was 19.1 years for secondary malignancy and 7.2 years for other endpoints. Hypothyroidism was the most prevalent late effect, with a CI of 22.4 ± 2.8% and 35.1 ± 4% at 5 and 10 years, respectively. CI of in-field secondary malignancy was 0.4 ± 0.4% at 10 years and 2.8 ± 1.2% at 20 years. CI of symptomatic pulmonary toxicity was 4.6 ± 1.5% and 6.8 ± 2.0% at 5 and 10 years, respectively, and was higher in patients receiving multiple RT courses (p = 0.009). Esophageal complications occurred at a CI of 1.4 ± 0.8% at 5 years and 2.2 ± 1.1% at 10 years. CI of xerostomia/dental decay was 2.6 ± 1.3% at 5 years and 4.9 ± 2.1% at 10 years. CI of cardiac disease was at 2.3 ± 0.9% at 5 years and 4.4 ± 1.5% at 10 years. CI of infertility was 6.5 ± 1.6% at 5 years and 9.4 ± 2.1% at 10 years.

CONCLUSION

Survivors of AYA lymphoma have a high incidence and diverse presentation of late effects.

IMPLICATIONS FOR CANCER SURVIVORS

AYA lymphoma survivors should be educated about their risks of late effects and offered screening and follow-up when appropriate.

The Role of the Headmaster Collar (Cervical) for Dropped Head Syndrome in Hodgkin Lymphoma Survivors

BACKGROUND

Dropped head syndrome is a potential late neurologic complication of radiation therapy in survivors of Hodgkin lymphoma. There is limited evidence for conservative management of this condition.

OBJECTIVE

To discover patient utilization patterns of the commonly prescribed Headmaster Collar (cervical) in Hodgkin lymphoma survivors with radiation-induced dropped head syndrome.

DESIGN

Questionnaire-based retrospective observational study.

SETTING

Single-site academic cancer center.

PATIENTS

Twenty-six Hodgkin lymphoma survivors treated with radiation therapy involving the mantle who were prescribed a Headmaster Collar for dropped head syndrome.

METHODS OR INTERVENTIONS

Patients were interviewed by phone with a structured set of questions.

MAIN OUTCOME MEASUREMENTS

Compliance, patterns of use, individual modifications, and side effects of collar use.

RESULTS

Although 58% of patients who were prescribed a Headmaster Collar eventually discontinued its use, 62% of all patients used the collar for more than 6 months. The majority of users wore the collar for up to 3 hours per day, usually for static seated activities. Thirty-eight percent of patients made personal modifications to their collar, most commonly the addition of extra padding. All but one patient had complaints about the collar, most commonly discomfort, rigidity, and confinement.

CONCLUSIONS

The Headmaster Collar (cervical) is often utilized for a few hours a day, for longer than 6 months, to help with static seated activities. Insights from this study might help to improve future orthotic designs with better long-term compliance rates for the treatment of radiation-induced dropped head syndrome.

LEVEL OF EVIDENCE

IV.

Retrospective estimation of heart and lung doses in pediatric patients treated with spinal irradiation

BACKGROUND AND PURPOSE

The purpose of this study was to investigate whether treatment information from medical records can be used to estimate radiation doses to heart and lungs retrospectively in pediatric patients receiving spinal irradiation with conventional posterior fields.

MATERIAL AND METHODS

An algorithm for retrospective dosimetry in children treated with spinal irradiation was developed in a cohort of 21 pediatric patients with available CT-scans and treatment plans. We developed a multivariable linear regression model with explanatory variables identifiable in case note review for retrospective estimation of minimum, maximum, mean and V10%-V80% doses to the heart and lungs. Doses were estimated for both linear accelerator (Linac) and 60Co radiation therapy modalities.

RESULTS

Age and spinal field width were identified as statistically significant predictors of heart and lung doses in multivariable analyses (p < 0.01 in all models). Models showed excellent predictive performance with R2 = 0.70 for mean heart dose and 0.79 for mean lung dose, for Linac plans. In leave-one-out cross-validation analysis the average difference between predicted and actual mean heart dose was 6.7% and 7.6% of the prescription dose for Linac and 60Co plans, respectively, and 5.2% and 4.9% for mean lung dose. Due to the small sample size and large inter-patient variation in heart and lung dose, prospective studies validating these findings are highly warranted.

CONCLUSIONS

The models presented here provide retrospective estimates of heart and lung doses for historical cohorts of pediatric patients, thus facilitating studies of long-term adverse effects of radiation.

Late Relapse in Hodgkin's Disease: Report of Five Cases and a Review of the Literature

During the past 15 years the treatment of Hodgkin's disease (HD) with chemo/radiotherapy has been shown to appreciably improve the long-term prognosis of patients, even those with more advanced disease. In the past it was accepted that the probability of primary relapse 5 years after achieving complete remission (CR) was small and a 5-year disease-free period was sufficient to be considered as a cure. During the past 15 years, however, more data has been published relating to late relapses in these patients after an initial "cure" has been achieved. This report briefly examines our own experience with five patients initially "cured" who relapsed 5 to 11 years after achieving CR and also reviews recent literature on the subject. The phenomenon of late relapse has thus become a more important issue in the management of patients with HD.

Long-term cardiac abnormalities after cranial radiotherapy in childhood cancer survivors

BACKGROUND

Cardiac morbidity is an important late effect in long-term childhood cancer survivors (CCS) treated with cardiotoxic agents or radiotherapy (RT) on the chest. However, there is limited data on the long-term cardiac sequelae in CCS who only received cranial RT. We hypothesized that cranial RT might negatively influence cardiac structure and function.

METHODS AND RESULTS

We studied 13 CCS [mean age 30.8 (18.1-39.3) years, 7 males] who received RT only on the head for a cranial tumor and 36 age- and sex-matched healthy sibling controls. Echocardiographic follow-up was performed at median 21.7 (12.6-30.8) years after diagnosis. CCS had lower indexed diastolic LV volumes [56.0 (31.4-68.3) vs. 60.5 (41.9-94.3) mL/m(2), p = 0.024]. CCS also had reduced LV systolic and diastolic function, reflected by lower systolic LV myocardial velocities (5.3 ± 0.9 vs. 7.1 ± 1.7 cm/s, p = 0.001) and longitudinal deformation (- 17.3 ± 3.1 vs. - 20.7 ± 2.0%, p < 0.001), as well as lower diastolic LV myocardial velocities (- 10.7 ± 1.7 vs. - 12.2 ± 1.5 cm/s, p = 0.006) and deformation speed (1.1 ± 0.3 vs. 1.5 ± 0.2 1/s, p = 0.005). Additionally, in CCS insulin-like growth factor levels [15.4 (9.2-34.6) vs. 24.4 (14.8-55.5) nmol/L, p = 0.007] were lower.

CONCLUSION

Cranial RT in CCS is associated with smaller cardiac volumes and reduced systolic and diastolic LV function. This off target effect of RT might be related to lower insulin-like growth factor levels.

Pulmonary System

Pulmonary disease is a highly prevalent cause of premature morbidity and mortality in long-term childhood cancer survivors. Pulmonary toxicity is frequently reported in survivors of Hodgkin lymphoma, germ cell tumors, acute lymphoblastic lymphoma and metastatic Wilms tumor survivors, as the chemotherapy, radiation and surgeries used to treat these pediatric cancer (among others) can result in permanent lung damage. This damage can manifest as acute pneumonitis, late onset fibrosis, and structurally induced dysfunction from developmental abnormalities due to impaired growth of the thorax attributable to surgery or radiation. The cumulative incidence of pulmonary problems after childhood cancer increases with time since diagnosis, as with other late-effects, suggesting that survivors are at an elevated risk of developing later-onset pulmonary morbidities as they age.

Survivorship in adolescents and young adults

In the USA, approximately 26,000 adolescents and young adults (AYAs) aged 15-29 years are diagnosed with cancer every year. The cure rate among this population exceeds 80%, resulting in a growing number of AYA cancer survivors. AYA cancer survivors suffer from a wide range of long-term treatment-related toxicities that adversely affect quality of life and increase the risk of premature death. Therefore, it is important to recognize the unique medical needs of the AYA cancer survivors and develop a cost-effective and systemic approach to screen and prevent cancer treatment-related sequelae and the adverse health outcomes.

Pulmonary function abnormalities in childhood cancer survivors treated with bleomycin

BACKGROUND

Bleomycin is associated with pulmonary toxic side effects including pneumonitis and pulmonary fibrosis. We evaluated the prevalence of long-term pulmonary function abnormalities in children receiving bleomycin therapy in the context of current chemotherapeutic regimens.

METHODS

A retrospective review of patients who received bleomycin between January 1999 and December 2011 was conducted. Abnormalities in the most recent pulmonary function test (PFT) at least 1 year after diagnosis were analyzed.

RESULTS

Two-hundred and seven patients had received bleomycin. The results of PFT performed at least 1 year from diagnosis were available for 80 patients. Median time of follow up was 3.9 years (range 1.1-11.76 years). Median cumulative dose of bleomycin was 65 IU/m(2) (range 10-120). The most common diagnoses were Hodgkin lymphoma and germ cell tumor. At least one pulmonary function abnormality was present in 42 (52.5%) patients. When classified in groups, 22.5% patients had obstructive lung disease, 7.5% had restrictive lung disease, 28.8% had hyperinflation and 14% of patients had non-uniform distribution of ventilation. Non-Hispanic patients (OR 2.81) and children younger than 8 years (OR 4.14) had higher odds of having an abnormal PFT parameter. Very few patients had pulmonary symptoms.

CONCLUSIONS

More than half the patients who received bleomycin had subclinical pulmonary dysfunction as evidenced by abnormalities in pulmonary function tests, although the incidence of clinical symptoms was low.

TSH suppression as a possible means of protection against hypothyroidism after irradiation for childhood Hodgkins lymphoma

Hypothyroidism remains a common late effect after irradiation of the neck/mediastinum for Hodgkins lymphoma (HL). We evaluated the protective effect of TSH suppression during neck/mediastinum irradiation. From 1998 to 2001, 14 consecutive euthyroid children were given, before and until the end of their radiotherapy on neck/mediastinum, L-thyroxine at TSH-suppressive doses. The 14 patients had adequate TSH suppression during irradiation in 8, inadequate in 6. The 8-year hypothyroidism-free-survival after irradiation was 75 ± 15% for the former group, 0% for the latter (P = 0.009). TSH suppression could have a protective effect on thyroid function as shown in a small group of patients with HL.

Cardiac magnetic resonance imaging findings in 20-year survivors of mediastinal radiotherapy for Hodgkin's disease

PURPOSE

The recognition of the true prevalence of cardiac toxicity after mediastinal radiotherapy requires very long follow-up and a precise diagnostic procedure. Cardiac magnetic resonance imaging (MRI) permits excellent quantification of cardiac function and identification of localized myocardial defects and has now been applied to a group of 20-year Hodgkin's disease survivors.

METHODS AND MATERIALS

Of 143 patients treated with anterior mediastinal radiotherapy (cobalt-60, median prescribed dose 40 Gy) for Hodgkin's disease between 1978 and 1985, all 53 survivors were invited for cardiac MRI. Of those, 36 patients (68%) presented for MRI, and in 31 patients (58%) MRI could be performed 20-28 years (median, 24) after radiotherapy. The following sequences were acquired on a 1.5-T MRI: transversal T1-weighted TSE and T2-weighted half-fourier acquisition single-shot turbo-spin-echo sequences, a steady-state free precession (SSFP) cine sequence in the short heart axis and in the four-chamber view, SSFP perfusion sequences under rest and adenosine stress, and a SSFP inversion recovery sequence for late enhancement. The MRI findings were correlated with previously reconstructed doses to cardiac structures.

RESULTS

Clinical characteristics and reconstructed doses were not significantly different between survivors undergoing and not undergoing MRI. Pathologic findings were reduced left ventricular function (ejection fraction <55%) in 7 (23%) patients, hemodynamically relevant valvular dysfunction in 13 (42%), late myocardial enhancement in 9 (29%), and any perfusion deficit in 21 (68%). An association of regional pathologic changes and reconstructed dose to cardiac structures could not be established.

CONCLUSIONS

In 20-year survivors of Hodgkin's disease, cardiac MRI detects pathologic findings in approximately 70% of patients. Cardiac MRI has a potential role in cardiac imaging of Hodgkin's disease patients after mediastinal radiotherapy.

Survivorship: childhood cancer survivors

Late effects of therapy for childhood cancer are frequent and serious. Fortunately, many late effects are also modifiable. Proactive and anticipatory risk-based care can reduce the frequency and severity of treatment-related morbidity. The primary care clinician should be an integral component in risk-based care of survivors. Continued communication between the "late effects" staff at the cancer center and the primary care clinician is essential for optimum care of this high-risk population.

Inhibition of glioma cell line A-172 MMP activity and cell invasion in vitro by a nutrient mixture

Standard multimodality therapy of gliomas is associated with poor patient survival and significant toxicity. Abnormal expression of matrix metalloproteinases is associated with tumor growth and invasion. Based on reported antitumor properties, we investigated the effect of a combination of natural compounds (NM), primarily composed of lysine, proline, ascorbic acid, and green tea extract in vitro on glioma cell line A-172, by measuring MMP secretion, invasion through Matrigel, and cell proliferation. Glioma cells A-172 (ATCC) were grown in modified Dulbecco's Eagle medium with 10% fetal bovine serum and antibiotics and treated with NM at 0, 10, 50, 100, 500, and 1000 microg/mL concentration in triplicate at each dose. Cell proliferation was assayed by MTT, MMP secretion by zymography, invasion through Matrigel, and morphology by H&E staining. Zymography showed one band corresponding to MMP-2, which was inhibited by NM in a dose-dependent fashion, with virtual total inhibition at 500-microg/mL concentration. Invasion through Matrigel was completely inhibited at 1000 microg/mL NM. NM was not toxic to glioma cell line A-172 at lower concentrations and exhibited toxicity of 50% over the control at 1000 microg/mL. NM significantly inhibited MMP secretion and invasion-important parameters for cancer prevention, suggesting a possible therapeutic role.

Reassurance following breast screening recall for female survivors of Hodgkin's lymphoma

Female survivors of Hodgkin's lymphoma (HL) treated with mantle radiotherapy experience increased breast cancer risk related to radiation dose and age at diagnosis. In 2003, the Department of Health (DoH) in the UK recalled patients to explain this risk and offer screening. The aims of this paper are to describe women's emotional responses and knowledge of their personal risk following the recall. Women were interviewed before risk counselling and breast screening (Time 1, n=56) and again following screening and results (Time 2, n=50). Questionnaire measures of quality of life, anxiety, depression and cancer worries were completed at Time 2. No cases of breast cancer were identified. After the recall, 64% had learned more about late effects and 76% were reassured about their health. All but one woman intended to attend future screening. Women are keen to take advantage of screening and experience relatively little distress.

Active Breathing Control for Hodgkin’s Disease in Childhood and Adolescence: Feasibility, Advantages, and Limits

PURPOSE

The challenge in early Hodgkin's disease (HD) in children is to maintain good survival rates while sparing organs at risk. This study assesses the feasibility of active breathing control (ABC) in children, and compares normal tissue irradiation with and without ABC.

METHODS AND MATERIALS

Between May 2003 and June 2004, seven children with HD with mediastinal involvement, median age 15, were treated by chemotherapy and involved-field radiation therapy. A free-breathing computed tomography simulation scan and one additional scan during deep inspiration using ABC were performed. A comparison between planning treatment with clinical target volume including supraclavicular regions, mediastinum, and hila was performed, both in free breathing and using ABC.

RESULTS

For a prescription of 36 Gy, pulmonary dose-volume histograms revealed a mean reduction in lung volume irradiated at more than 20 Gy (V20) and 30 Gy (V30) of 25% and 26%, respectively, using ABC (p = 0.016). The mean volume of heart irradiated at 30 Gy or more decreased from 15% to 12% (nonsignificant). The mean dose delivered to breasts in girls was small in both situations (less than 2 Gy) and stable with or without ABC. Considering axillary irradiation, the mean dose delivered to breasts remained low (<9 Gy), without significant difference using ABC or not. The mean radiation dose delivered to thyroid was stable using ABC or not.

CONCLUSIONS

Using ABC is feasible in childhood. The use of ABC decreases normal lung tissue irradiation. Concerning heart irradiation, a minimal gain is also shown. No significant change has been demonstrated concerning breast and thyroid irradiation.

Evaluation of acute and early cardiotoxicity in survivors of Hodgkin's disease treated with ABVD or BEACOPP regimens

The study was conducted to compare the presence of cardiotoxicity after the treatment of Hodgkin's disease with the standard ABVD or BEACOPP protocol. We examined 29 patients treated by means of the ABVD regimen and 34 treated with the BEACOPP regimen. Using rest echocardiography we assessed the left ventricular function before and after the therapy. One year after the completion of therapy, a control examination was performed with a battery of tests; the rest and dynamic stress echocardiography and cardiopulmonary tests were carried out to assess cardiopulmonary performance. A similar significant deterioration of ejection fraction and diastolic function was apparent after the treatment in both sub-groups with a further progression at the one-year control. Only one patient from the BEACOPP sub-group showed a pathological drop of EF <50%. The most affected parameters of left ventricular function (LV) were Doppler indices. We found a significant relationship of the parameters of LV function compared with age, the cumulative dose of doxorubicin and the cumulative dose of radiotherapy. Multivariate analysis demonstrated that diastolic dysfunction correlated with advanced age and the cumulative dose of doxorubicin, and decreased cardiopulmonary performance with advanced age, radiotherapy, and female gender. Both parameters were significantly influenced by the presence of hypertension. The used regimens demonstrated similar subclinical cardiotoxicity, thus the most aggressive regimen, BEACOPP, is not accompanied by a higher rate of cardiac impairment. The clinical value of such subclinical cardiotoxicity will be estimated in a further prospective follow-up.

Stereotactic body radiation therapy for extracranial oligometastases: does the sword have a double edge?

Understanding the acute and chronic toxicities of stereotactic body radiation therapy (SBRT) for extracranial oligometastases might reveal treatment parameters that can be modulated to enhance the therapeutic ratio. Therefore, we searched PubMed from 1995 to 2005 for reports on stereotactic body radiation therapy, with emphasis on treatment of metastatic lesions of the lung and/or liver. Reports of SBRT for primary tumors of these sites were included to increase the number of evaluable patients. The reports were categorized by organ system and evaluated based on number of patients, number of lesions treated, dose fractionation scheme, and local control. A total of 15 lung studies (including 683 patients) and 7 liver studies (including 156 patients) were identified. Overall grade 3 to 5 toxicity was seen in up to 15% of patients in the lung SBRT studies and up to 18% of patients in the liver SBRT studies. Only 3 deaths were reported after SBRT of the liver and 2 after SBRT of the lung for treatment related mortality rates of 2% and 0.3%, respectively. No definitive relationship was found between radiation dose and toxicity. Conversely, radiation treatment volume may be associated with the infrequent toxicities that occur. The literature supports SBRT as a safe and effective treatment for oligometastases of the liver and lung. Further studies are needed to define the optimal dose and fractionation schedule.

Assessing the ability of the antiangiogenic and anticytokine agent thalidomide to modulate radiation-induced lung injury

PURPOSE

Thalidomide has broad anticytokine properties, which might protect normal tissues in patients undergoing chemoradiotherapy. The purpose of this study was to determine the maximal tolerated dose of thalidomide when used in combination with vinorelbine plus thoracic radiotherapy.

METHODS AND MATERIALS

Eligible patients had inoperable Stage III non-small-cell lung cancer, a Karnofsky Performance Status>or=70, and life expectancy>or=6 months. Patients underwent pretreatment evaluation of lung function. Radiotherapy consisted of 66 Gy in 6.5 weeks. Vinorelbine was administered i.v. (5 mg/m2) 3 times per week just before radiotherapy. Thalidomide was begun at 50 mg, p.o., on day 1 of chemoradiotherapy and continued once daily for 6 months. Side effects were scored using National Cancer Institute Common Toxicity Criteria.

RESULTS

Ten patients were enrolled. Of the first 6 patients, 2 developed major thrombotic events that were believed to be possibly related to thalidomide. The study was suspended and modified to require prophylactic anticoagulation. Of the last 4 patients, 2 developed dose-limiting toxicity attributable to thalidomide; both patients required a dose reduction of thalidomide to <50 mg/day. Because the drug is not available in an oral product providing <50 mg/day, the study was closed.

CONCLUSIONS

The combination of thalidomide concurrently with thoracic radiotherapy and vinorelbine resulted in excessive toxicity.

High incidence of late effects found in Hodgkin's lymphoma survivors, following recall for breast cancer screening

Assessment of late effects in a cohort of female Hodgkin's lymphoma patients treated with mantle radiotherapy, identified from the DoH breast cancer screening recall showed high mortality and frequent undiagnosed abnormalities in tissues affected by radiotherapy. With increasing age, this patient group may suffer premature cardiac and respiratory morbidity.

Evaluation of left ventricular function in long-term survivors of childhood Hodgkin disease

BACKGROUND

Data on the presence of myocardial abnormalities in long-term Hodgkin disease survivors are contradictory. The purpose of this study was to determine if myocardial performance index (MPI) was capable of discovering cardiac abnormalities.

PROCEDURE

Echocardiographic evaluation was performed in 31 survivors of Hodgkin disease (mean age 17.0 years), who received doxorubicin as part of chemotherapeutic treatment (median dose 164.8 +/- 42.5 mg/m(2)). Control group comprised 22 healthy subjects (mean age 16.7 years).

RESULTS

Peak A velocity was increased (P = 0.004) and peak E/A velocity ratio was lower (P = 0.002) in patients compared to controls. Mean isovolumetric contraction time was longer in patients than in controls (P = 0.0001). Ejection time was significantly shorter in patients than in the controls (P = 0.001). Consequently, the MPI was significantly greater in the patients than in the controls (P = 0.0001). Abnormal MPI was found in 25/31 patients (83%).

CONCLUSIONS

The Doppler-derived index of combined systolic and diastolic myocardial performance demonstrates the presence of subtle cardiac abnormalities in the majority of Hodgkin disease survivors.

Pulmonary complications of radiation therapy

There have been important developments in understanding the difference in pathogenesis and clinical significance between acute or sporadic pneumonitis and late radiation fibrosis. Corticosteroid therapy and other forms of therapy are useful in the treatment of acute pneumonitis. Late radiation fibrosis is refractory to treatment; therefore, minimizing the likelihood of developing it is particularly important. Baseline lung assessments are appropriate in patients who are clinically at risk. A new development is the use of the DVH to compare radiation treatment plans to minimize the volume of normal lung irradiated in patients who are at risk. It is hoped that the study of mechanisms that lead to the development of radiation fibrosis will point the way to possible future therapies. Patients who are included in studies of novel irradiation treatments for lung cancer need, in particular, to be monitored for late radiation lung toxicity.

Can 99mTc-DTPA aerosol scanning predict radiation pneumonitis?

PURPOSE

To investigate whether changes in diethylenetriamine pentaacetic acid (DTPA) aerosol clearance lung scans predict the development of radiation pneumonitis.

METHODS AND MATERIALS

Thirty-three patients with advanced non-small-cell lung cancer were treated with palliative radiation therapy to thorax. All patients were subjected to pretreatment and post-treatment DTPA aerosol clearance lung scans. The clearance t1/2 values were compared using the paired t test. Changes in percentage aerosol deposition were also compared. The patients were serially assessed clinically and radiologically for development of radiation pneumonitis.

RESULTS

For the whole group, the mean DTPA clearance t1/2 for the diseased lung fell from 36.33 to 28.85 min (p = 0.17). Twelve patients developed radiation pneumonitis, 8 Grade 1, 2 Grade 2, 1 Grade 3, and 1 Grade 4. In patients who developed radiation pneumonitis, the clearance t1/2 for the diseased lung decreased from 37.50 min to 29.00 min after treatment (p = 0.50). Other subgroups analyzed, including smokers, nonsmokers, those with and without endobronchial disease, as well as those free from radiation pneumonitis, also showed no significant change in the clearance of the aerosol. The difference between the percentage aerosol deposition of the diseased lung (37.92%) and that of the opposite lung (62.08%) for the entire sample was significantly different both before and after treatment (p < 0.01). Delivery of radiation did not significantly change the aerosol deposition in either lung.

CONCLUSIONS

We conclude that, in patients with advanced non-small-cell lung cancer, significant change in the pulmonary clearance of 99mTc-DTPA aerosol could not be demonstrated after radiation therapy. In such patients, clearance of the aerosol does not predict the development of radiation pneumonitis.

Effect of an intensive chemotherapy followed by mediastinal irradiation on pulmonary and cardiac function in advanced Hodgkin's disease

Mediastinal irradiation combined with chemotherapy in patients with Hodgkin's disease have been associated with cardiopulmonary toxic effects that can last over the years. In this study we monitored pulmonary and cardiac function in 39 patients affected by advanced Hodgkin's disease (stage II B-III and IV) with mediastinal involvement and submitted to an intensive chemotherapy regimen (epirubicin, vincristine, ciclophosphamide, and etoposide) followed by involved field irradiation. Pulmonary function was verified with chest x-ray, spirometric parameters, arterial blood gas analysis, single breath CO transfer factor (DLCO), and its components Dm and Vc. Cardiac function was verified with electrocardiogram (EKG) and left ventricular ejection fraction (LVEF) by means of radionuclide angiocardiography. The median follow-up was 40 months. Spirometric parameters did no show modifications at the end of treatment, on the contrary they improved during the follow-up. Chest x-ray showed radiographic parenchimal damage in 51% of patients. DLCO remained constantly decreased. sEKG did not show significant modification, whereas LVEF significantly decreased at the end of treatment and remained persistently decreased during follow-up. None of the patients with reduction of DLCO or LVEF showed clinical symptoms of heart and pulmonary dysfunctions. One patient, 49 years old, suffered from myocardial infarction 25 months after the completion of radio-chemotherapy. These data indicate that this combined regimen can induce persistent pulmonary and cardiac damages at subclinical level.

[Clinical usefulness of serum total cholesterol as an index of hypothyroidism in patients after cervical radiation]

Cervical radiation therapy is often applied to patients with head and neck cancers because radiation has a high sensitivity to these cancers and permits the preservation of functions and physical form. However, it has been shown that various complications can result from radiation therapy. We have encountered some patients who showed hypercholesterolemia resulting from cervical radiation. Therefore, we have paid close attention to the relationship between hypercholesterolemia after cervical radiation and hypothyroidism. Thyroid hormone tests in these patients with hypercholesterolemia after cervical radiation showed high thyroid stimulating hormone (TSH) and low free thyroxine (fT4), indicating the presence of hypothyroidism. After administration of levothyroxine Na, their fT4 levels increased and both TSH levels and serum total cholesterol levels decreased. In conclusion, in patients who have received cervical radiation, we recommend monitoring serum total cholesterol periodically to detect hypothyroidism easily before the appearance of its symptoms.

Pathophysiological effects of radiation on atherosclerosis development and progression, and the incidence of cardiovascular complications

Radiation therapy while important in the management of several diseases, is implicated in the causation of atherosclerosis and other cardiovascular complications. Cancer and atherosclerosis go through the same stages of initiation, promotion, and complication, beginning with a mutation in a single cell. Clinical observations before the 1960s lead to the belief that the heart is relatively resistant to the doses of radiation used in radiotherapy. Subsequently, it was discovered that the heart is sensitive to radiation and many cardiac structures may be damaged by radiation exposure. A significantly higher risk of death due to ischemic heart disease has been reported for patients treated with radiation for Hodgkin's disease and breast cancer. Certain cytokines and growth factors, such as TGF-beta1 and IL-1 beta, may stimulate radiation-induced endothelial proliferation, fibroblast proliferation, collagen deposition, and fibrosis leading to advanced lesions of atherosclerosis. The treatment for radiation-induced ischemic heart disease includes conventional pharmacological therapy, balloon angioplasty, and bypass surgery. Endovascular irradiation has been shown to be effective in reducing restenosis-like response to balloon-catheter injury in animal models. Caution must be exercised when radiation therapy is combined with doxorubicin because there appears to be a synergistic toxic effect on the myocardium. Damage to endothelial cells is a central event in the pathogenesis of damage to the coronary arteries. Certain growth factors that interfere with the apoptotic pathway may provide new therapeutic strategies for reducing the risk of radiation-induced damage to the heart. Exposure to low level occupational or environmental radiation appears to pose no undue risk of atherosclerosis development or cardiovascular mortality. But, other radiation-induced processes such as the bystander effects, abscopal effects, hormesis, and individual variations in radiosensitivity may be important in certain circumstances.

The clinical value of nuclear medicine in the assessment of irradiation-induced and anthracycline-associated cardiac damage

Two groups of patients, those treated for Hodgkin's disease and breast cancer, are particularly at risk of developing late myocardial damage, since radiotherapy (RT) techniques for both patient groups may include (large) parts of the heart, and adjuvant systemic therapy is frequently administered to these patients, in particular anthracycline-containing chemotherapy. Available literature on the monitoring and prediction of RT-induced and anthracycline-associated cardiac damage using nuclear medicine techniques is presented. Based on relevant studies, the risk of overall cardiac disease post-RT and overt congestive heart failure during anthracycline-containing chemotherapy is probably low. Conventional nuclear medicine imaging, i.e. myocardial perfusion scintigraphy, may be of complementary use to echocardiographical evaluation for routine follow-up after RT with modern techniques, in a subgroup of patients with known cardiovascular risk factors. Left ventricle ejection fraction (LVEF) measurements, as assessed by radionuclide angiography for the monitoring of anthracycline-associated cardiac injury, are not very sensitive and early detection will probably be enhanced by combining LVEF measurements with other cardiac function parameters. Also, it may be expected that nuclear medicine techniques using molecular radioligands will constitute an essential future step in the evaluation of subclinical cardiac injury afforded by the combined effect of RT and cardiotoxic chemotherapy.

Lung toxicity following chest irradiation in patients with lung cancer

Classical radiation pneumonitis has been described after single dose whole lung irradiation in experimental animals where above a threshold dose of irradiation, there is a sigmoid dose response curve with increasing morbidity and mortality. After clinical fractionated irradiation, however, acute radiation pneumonitis consisting of cough shortness of breath and patchy radiological changes, occurs in <10% of patients, has dyspnoea out of proportion to the volume of lung irradiated and usually resolves completely without long-term effects. There is increasing evidence that this represents a bilateral lymphocytic alveolitis or hypersensitivity pneumonitis and has been termed sporadic pneumonitis. Late radiation toxicity results in pulmonary fibrosis. This is a consequence of repair, which is initiated by tissue injury within the radiation portal. It follows release of chemotactic factors for fibroblasts including transforming growth factor-beta, fibronectin and platelet derived growth factor. Radiation fibrosis is the clinically more significant syndrome for patients. It may result in progressive dyspnoea and mortality in patients. The most predictable change in laboratory lung function tests is a decrease in transfer factor due to damage at the capillary-alveolar level. It also results in decreased lung compliance, which will affect the total lung capacity and the forced vital capacity. The forced expiratory volume in 1 s is less affected, although this seems to depend on the volume of lung irradiated. There is also a decrease in perfusion in the irradiated lung. Radiation fibrosis seems to depend, amongst other factors, on the volume of lung, which is irradiated above a threshold of 20-30 Gy. The morbidity of radiation fibrosis may therefore be minimized by the use of dose volume histogram to minimize the volume of normal lung irradiated in patients at high risk, e.g., patients with who present with poor lung function. The importance of the baseline perfusion in the irradiated areas continues to be studied.

Partial irradiation of the lung

Many factors like fractionation, overall treatment time, and patient specific aspects are important when studying and quantifying the effects of partial lung irradiation. The local reactions of lung tissue to irradiation are described with regard to the dose-volume effect. Different models that are used to predict the incidence of radiation pneumonitis and the influence of irradiation on the overall lung function are discussed. The easy-to-calculate mean lung dose (MLD) and the volume irradiated to 20 Gy (V20) can both be used to predict the incidence of radiation pneumonitis. These parameters represent 2 extremes in underlying local dose-effect relations for radiation pneumonitis. However, clinically applied treatment plans show a high correlation between the V20 and the MLD, so that the decision for the "best" underlying local dose-effect relation should be based on the analysis of additional patient data. Dose-escalation studies and multi-center co-operation will create more possibilities to investigate all confounding factors concerning lung irradiation.

Late mortality experience in five-year survivors of childhood and adolescent cancer: the Childhood Cancer Survivor Study

PURPOSE

Survivors of childhood and adolescent cancer are at risk for long-term effects of disease and treatment. The Childhood Cancer Survivor Study assessed overall and cause-specific mortality in a retrospective cohort of 20,227 5-year survivors.

PATIENTS AND METHODS

Eligible subjects were individuals diagnosed with cancer (from 1970 to 1986) before the age of 21 who had survived 5 years from diagnosis. Underlying cause of death was obtained from death certificates and other sources and coded and categorized as recurrent disease, sequelae of cancer treatment, or non-cancer-related. Age and sex standardized mortality ratios (SMRs) were calculated using United States population mortality data.

RESULTS

The cohort, including 208,947 person-years of follow-up, demonstrated a 10.8-fold excess in overall mortality (95% confidence interval, 10.3 to 11.3). Risk of death was statistically significantly higher in females (SMR = 18.2), individuals diagnosed with cancer before the age of 5 years (SMR = 14.0), and those with an initial diagnosis of leukemia (SMR = 15.5) or CNS tumor (SMR = 15.7). Recurrence of the original cancer was the leading cause of death among 5-year survivors, accounting for 67% of deaths. Statistically significant excess mortality rates were seen due to subsequent malignancies (SMR = 19.4), along with cardiac (SMR = 8.2), pulmonary (SMR = 9.2), and other causes (SMR = 3.3). Treatment-related associations were present for subsequent cancer mortality (radiation, alkylating agents, epipodophyllotoxins), cardiac mortality (chest irradiation, bleomycin), and other deaths (radiation, anthracyclines). No excess mortality was observed for external causes (SMR = 0.8).

CONCLUSION

While recurrent disease remains a major contributor to late mortality in 5-year survivors of childhood cancer, significant excesses in mortality risk associated with treatment-related complications exist up to 25 years after the initial cancer diagnosis.

Comparison of three rat strains for development of radiation-induced lung injury after hemithoracic irradiation

The purpose of this study is to define differences in radiation sensitivity among rat strains using breathing frequency and lung perfusion as end points of radiation-induced lung injury. The results have confirmed previous findings in mice showing that under stringently controlled iso-dose/volume irradiation conditions, substantial differences can be found in susceptibility to functional lung damage after radiation.

Structural changes in the auricles of the rat heart after local ionizing irradiation

BACKGROUND AND PURPOSE

Irradiation of the heart may lead to late cardiovascular complications and depending on the dose to cardiac-related death. There is increasing evidence that left atrial appendages play an important role in left ventricular filling especially in cardiac disease. The aim of the present study was to investigate the radiation response of the atria of the rat heart (auricles in particular) at morphological, histological and transcriptional level.

MATERIAL AND METHODS

Sprague-Dawley rats were irradiated with a single dose locally on the heart (0-22.5 Gy). End-diastolic diameters of left auricles were measured during evaluation of cardiac function. Histopathological evaluations were performed at various time points up to 16 months post irradiation. Changes in mRNA expression of procollagen types I and III and pro-fibrogenic cytokines (TGF-beta1 and IL-1beta) were investigated using competitive PCR.

RESULTS

Irradiation leads to a dose-dependent decrease in end-diastolic diameter of the left auricles. This decrease was observed at 4 months post-irradiation, where no gross damage of the ventricle has been reported. Histologically, epicardial fibrosis was found already 1 month post irradiation, and the frequency/severity of the structural changes appeared to be dose-dependent and progressive with time post irradiation. At 9 months, fibrosis was observed in all three layers (epicardium, myocardium and endocardium) of both auricles. On the level of gene expression, increases in procollagen types I and III were observed at 12 and 3 months post irradiation, respectively. Increases in IL-1beta and TGF-beta1, cytokines known to influence collagen deposition at different levels, preceded the upregulation of procollagen mRNA.

CONCLUSIONS

Auricles of the rat heart show a marked pathological response to ionizing radiation, characterized by generalized accumulation of collagen (fibrosis) and a reduction of end-diastolic diameter. The reduction of auricular volume and loss of elasticity will negatively contribute to the pump function of the irradiated ventricle.

The physical parameters and molecular events associated with radiation-induced lung toxicity

Radiation therapy (RT) is frequently used to treat patients with tumors in and around the thorax. Clinical radiation pneumonitis is a common side effect, occurring in 5% to 20% of patients. Efforts to identify patients at risk for pneumonitis have focused on physical factors, such as dose and volume. Recently, the underlying molecular biological mechanisms behind RT-induced lung injury have come under study. Improved knowledge of the molecular events associated with RT-induced lung injury may translate into a better ability to individualized therapy. This review discusses our current understanding of the physical and molecular factors contributing to RT-induced pulmonary injury.

Myocardial perfusion imaging in breast cancer patients treated with or without post-mastectomy radiotherapy

PURPOSE

To assess the occurrence and location of myocardial perfusion defects in left-sided mastectomized breast cancer patients, treated with or without postoperative radiotherapy according to the guidelines from the Danish Breast Cancer Cooperative Group (DBCG).

PATIENTS AND METHODS

Seventeen left-sided breast cancer patients, with a median age of 59 years (range, 47-75 years), randomized to post-mastectomy irradiation plus systemic treatment, or systemic treatment alone, were examined after a median follow-up of 7.9 years (range, 6.0-12.2 years). The chest wall and the ipsilateral internal mammary nodes had been treated through two anterior-shaped electron fields, and the electron energy was chosen according to chest wall thickness, measured individually by ultrasound. The median absorbed dose was 50 Gy in 25 fractions, with 5 fractions/week. Information on clinical history was obtained and symptoms of ischemic heart disease (IHD), as well as major risk factors, were recorded. All patients had a physical examination, blood chemistry, electrocardiogram (ECG), chest X-ray and myocardial perfusion imaging by sestamibi-single photon emission computerized tomography (SPECT). SPECT-scanning was performed as a rest/dipyridamole 2-day protocol. The evaluation of regional myocardial perfusion was based on scintigrams using a 20-segment model.

RESULTS

There was no significant difference between the scintigraphic findings in the two groups. Four of ten irradiated patients and four of seven non-irradiated patients showed scintigraphic defects. An anterior defect was found in one non-irradiated patient.

CONCLUSIONS

This study does not indicate that the described radiotherapy technique induces detectable coronary artery disease. However, the small number of patients does not allow strong conclusions to be drawn.

Late pulmonary effects in favorable stage I and IIA Hodgkin's disease treated with radiotherapy alone

Radiotherapy (RT) in patients with favorable-stage Hodgkin's disease can induce clinical and subclinical evidence of pulmonary damage lasting over the years. In this study, we monitored 36 patients with stage IA-IIA Hodgkin's disease treated with subtotal nodal RT. The planned dose of RT was 40 Gy to 44 Gy to the involved areas and 36 Gy to the adjacent uninvolved areas. Pulmonary function was evaluated by chest radiograph, spirometric parameters, arterial blood gas analysis, and single-breath CO transfer factor (DLCO). The tests were performed before and at the end of irradiation, and during the follow-up 1 and 3 to 5 years after the treatment. At the end of RT, we found a significant decrease of total lung capacity, vital capacity, forced expiratory volume in 1 second, residual volume, and DLCO. Spirometric parameters improved during the follow-up period, whereas the decline of DLCO (-6.4%) was persistent. No correlation was found between mantle RT dose and DLCO changes. Four patients showed a decline of DLCO of >20% from pretreatment values but only one was symptomatic. Our study confirms that RT induces a pulmonary-restrictive disease at a subclinical level that seems to be reversible in the majority of patients.

Are 18fluorodeoxyglucose positron emission tomography and magnetic resonance imaging useful in the prediction of relapse in lymphoma residual masses?

Treatment of both Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL) frequently results in a residual mass visible radiologically. Such patients may receive radiotherapy unnecessarily because the residual mass may represent benign fibrotic tissue rather than residual active lymphoma. Radiotherapy has been shown to have significant short and more worrying long-term toxicity. Refining the criteria for its use would be a major advance. A number of clinical investigations have been evaluated to more accurately determine the nature of such lesions, including erythrocyte sedimentation rate (ESR), magnetic resonance imaging (MRI) and high-dose gallium-67 scanning (HDGS) but none has proven utility. 18[F]-fluorodeoxyglucose positron emission tomography (FDG-PET) is an imaging technique that has been shown to be useful in distinguishing fibrosis from residual active disease in solid tumours. The aim of this study was to compare FDG PET and MRI in the assessment of residual masses following treatment for lymphoma. Patients with NHL/HD who had a residual mass following chemotherapy were eligible for this study. Patients had a combination of MRI and/or PET. All scans were completed within 5 months of the end of treatment. Patients were followed-up for relapse. 56 patients had an MRI scan, 24 had a PET scan and 22 patients had both investigations. Overall sensitivity and specificity, respectively, were for MRI 45% and 74%, PET 50% and 69%, and PET/MRI concurring 50% and 67%. There was a trend for improved relapse-free survival (RFS) with a negative result of both MRI and PET, but this was not statistically significant. The predictive value for both tests failed to reach statistical significance. Subgroup analysis suggests that PET may be better at predicting relapse in patients with NHL, especially those with masses above the diaphragm. There is no convincing evidence that either MRI or PET or the combination can reliably predict relapse within residual masses after treatment for lymphoma. A negative PET scan however appears to be more informative than a positive result and may well aid clinical decision making. There are a number of factors that may produce false-positive results, including post-treatment inflammatory changes, the sensitivity of the test in the setting of minimal residual disease and the heterogeneity of the histological subtypes studied. A negative PET (or MRI) result in lymphoma residual masses following therapy may negate the necessity for further therapy such as chemotherapy or radiotherapy and their concomitant toxicities.

Effect of radiotherapy and chemotherapy on pulmonary function after treatment for breast cancer and lymphoma: A follow-up study

PURPOSE

To determine the changes in pulmonary function tests (PFTs) 0 to 48 months after treatment for breast cancer and lymphoma.

PATIENTS AND METHODS

The alveolar volume (V(A)), vital capacity, forced expiratory volume in 1 second, and corrected transfer factor of carbon monoxide (T(L,COc)) were measured in 69 breast cancer and 41 lymphoma patients before treatment and 3, 18, and 48 months after treatment with radiotherapy alone or radiotherapy in combination with chemotherapy (mechlorethamine, vincristine, procarbazine, prednisone, doxorubicin, bleomycin, vinblastine; cyclophosphamide, epidoxorubicin, fluorouracil; cyclophosphamide, thiotepa, carboplatin; cyclophosphamide, methotrexate, fluorouracil). The three-dimensional dose distribution in the lung of each patient was converted to the mean lung dose. Statistical analysis was used to evaluate the changes in PFT values over time in relation to age, sex, smoking, chemotherapy, and the mean lung dose.

RESULTS

After an initial reduction in PFT values at 3 months, significant recovery was seen at 18 months for all patients. Thereafter, no further improvement could be demonstrated. Reductions in spirometry values and V(A) were related to the mean lung dose only (0.9% per Gy at 3 months and 0.4% per Gy mean dose at 18 months). T(L,COc) decreased 1. 1% per Gy mean dose and additionally decreased 6% when chemotherapy was given after radiotherapy. Chemotherapy administered before radiotherapy reduced baseline T(L,COc) values by 8% to 21%. All patients showed an improvement of 5% at 18 months.

CONCLUSION

On the basis of the mean lung dose and the chemotherapy regimen, the changes in PFT values can be estimated before treatment within 10% of the values actually observed in 72% to 85% of our patients with healthy lungs.

A neural network to predict symptomatic lung injury

A nonlinear neural network that simultaneously uses pre-radiotherapy (RT) biological and physical data was developed to predict symptomatic lung injury. The input data were pre-RT pulmonary function, three-dimensional treatment plan doses and demographics. The output was a single value between 0 (asymptomatic) and 1 (symptomatic) to predict the likelihood that a particular patient would become symptomatic. The network was trained on data from 97 patients for 400 iterations with the goal to minimize the mean-squared error. Statistical analysis was performed on the resulting network to determine the model's accuracy. Results from the neural network were compared with those given by traditional linear discriminate analysis and the dose-volume histogram reduction (DVHR) scheme of Kutcher. Receiver-operator characteristic (ROC) analysis was performed on the resulting network which had Az = 0.833 +/- 0.04. (Az is the area under the ROC curve.) Linear discriminate multivariate analysis yielded an Az = 0.813 +/- 0.06. The DVHR method had Az = 0.521 +/- 0.08. The network was also used to rank the significance of the input variables. Future studies will be conducted to improve network accuracy and to include functional imaging data.

Late medical sequelae after therapy for supradiaphragmatic Hodgkin's disease

A total of 221 consecutive early stage Hodgkin's disease (HD) patients were given mantle field irradiation only or in combination with chemotherapy in 1971-1991. In 1994 these patients responded to a mailed self-report questionnaire covering items on late medical symptoms. Of 200 patients (91%) who reported that their thyroid function had been tested, 110 patients (55% of those tested) had thyroid hypofunction at follow-up in 1994. Ninety-five patients (86% of patients with biochemical hypothyreosis) had started hormonal substitution. In 1993 and 1994, 101 of these patients who had received mantle field irradiation in 1980-1988 were called in for interview, clinical examination and thyroid function tests. Eighteen patients (18%) had started hormonal substitution treatment earlier, but 58 (70%) of the other 83 patients were found to have biochemical hypothyreosis. Of the 221 patients who completed the questionnaire, 66 patients (30%) reported dyspnoea on exertion for more than 3 years after treatment, 8 patients (4%) reported a history of myocardial infarction, 6 patients (3%) reported pericardial disease and 25 patients (11%) heart valve disease. Increased expenses incurred for dental care were reported by 106 patients (48%), increasing to 55% when Waldeyer's ring had been irradiated. The consequences of late sequelae after mantle field irradiation for future treatment are discussed.

Ischemic heart disease after mantlefield irradiation for Hodgkin's disease in long-term follow-up

BACKGROUND AND PURPOSE

In patients with Hodgkin's disease treated by radiotherapy with a moderate total dose and a low (mean) fraction dose to the heart, the risk of ischemic heart disease was investigated during long-term follow-up.

MATERIALS AND METHODS

The medical records of 258 patients treated in the period 1965-1980 with radiotherapy alone as the primary treatment were reviewed. The median follow-up was 14.2 years (range 0.7-26.2). The mean total dose and fraction dose to the heart were 37.2 Gy (SD 2.9) and 1.64 Gy (SD 0.09), respectively. The impact on the development of ischemic heart disease of treatment-related parameters, such as the applied (fraction) dose, irradiation technique (one or two fields per day), and chemotherapy in case of a relapse, was investigated. The incidence of ischemic heart disease in this patient population was compared with the expected incidence based on gender, age and calendar period-specific data for the Dutch population.

RESULTS

Thirty-one patients (12%) experienced ischemic heart disease (actuarial risk at 20-25 years: 21.2% (95% C.I. 15-30). Twenty-five of them were hospitalized. When compared with the expected incidence, the relative risk (RR) of hospital admission for ischemic heart disease was 2.7 (95% C.I. 1.7-4.0). There were 12 deaths (4.7%) due to ischemic myocardial or sudden death (actuarial risk at 25 years: 10.2% (95% C.I. 5.3-19), compared to 2.3 cases that were expected to have died from these causes, yielding a standardized mortality ratio (SMR) of 5.3 (95% C.I. 2.7-9.3). Gender (male), pretreatment cardiac medical history and increasing age appeared to be the only significant factors for the development of ischemic heart disease.

CONCLUSIONS

Despite the moderate total dose and the low (mean) fraction dose to the heart, the observed incidence of ischemic heart disease is high, especially after long follow-up periods. Treatment related cardiac disease in patients treated for Hodgkin's disease has only been reported for doses above 30 Gy. Although the optimum curative dose is still under debate, some studies recommend a dose as low as 32.5 Gy. The observed high rate of severe heart complications in this study advocates a dose reduction to this level, particularly in the regions where the coronary arteries are located.

Thallium-201 perfusion scintigraphy in the evaluation of late myocardial damage in left-side breast cancer treated with adjuvant radiotherapy

PURPOSE

To evaluate late myocardial damage after adjuvant radiotherapy using a mixed-beam (photons plus electrons) technique to treat the internal mammary lymph nodes in left-side breast cancer.

METHODS AND MATERIALS

A bicycle ergometer stress test coupled with thallium-201 perfusion scintigraphy and analysis by single-photon computed tomography (CT) was performed on 19 patients treated with left-side breast/chest wall and internal mammary radiation for breast cancer between 1987 and 1993. To be sure that we would evaluate late toxicity caused by the irradiation, patients had to fulfill the following eligibility criteria: left-side breast cancer, treatment between 1987 and 1993 and no recurrence during follow-up, age < or = 75 years, no known risk for coronary artery disease, no previous chemotherapy, internal mammary field treated with an association of photons and electrons, and CT scan-based treatment planning.

RESULTS

Median age at scintigraphy was 59 years. Two patients did not reach optimal exercise level and were not evaluable. Among the 17 evaluable patients representing 91.6 patient years of follow-up, there were no perfusion defects by visual or quantitative analysis.

CONCLUSION

The mixed-beam technique seemed to spare the heart from harmful irradiation and to protect the myocardium. Results need to be confirmed on the long-term use of this technique.

Dose-effect relations for early local pulmonary injury after irradiation for malignant lymphoma and breast cancer

PURPOSE

To quantify the influence of treatment- and patient-related factors on the severity of early local pulmonary injury and to establish whether regional differences are present for local dose-effect relations for early radiation-induced pulmonary injury.

METHODS

Forty-two patients with malignant lymphoma and 40 breast cancer patients were examined prior to and 3 months after radiotherapy. The lymphoma patients were irradiated with mantle fields to an average dose of 38 Gy and the breast cancer patients were irradiated with internal mammary node fields with or without tangential breast fields to an average dose of 50 Gy. Dose-effect relations for local perfusion, ventilation and density changes were determined using correlated single photon emission computed tomography (SPECT) and CT data. A multivariate analysis was performed to study the influence of irradiated volume, chemotherapy (CMF and MOPP/ABV), smoking, age and gender. In addition, dose-effect relations for different regions in the lung were determined.

RESULTS

A similar and almost linear increase of early functional changes as a function of radiation dose was observed for perfusion and ventilation, whereas the shape of the dose-effect relation and the magnitude of early structural changes were different for density. For the three end-points studied, regional differences in radiosensitivity could not be demonstrated. For the posterior lung region compared to the anterior lung region, however, a difference was observed, which could be attributed to a gravity-related effect in the measuring procedure. Local structural changes (density) were significantly smaller for smokers (P = 0.002) and young patients (P = 0.007), whereas the CMF chemotherapy regimen given after radiotherapy (P = 0.017) significantly increased the amount of functional changes (perfusion). The magnitude of local pulmonary changes was independent of the irradiated volume, the MOPP/ABV chemotherapy regimen and gender.

CONCLUSION

The dose-effect relations for early radiation-induced local pulmonary changes were independent of the irradiated volume, MOPP/ABV, gender and lung region. CMF, smoking and age influenced the magnitude of early pulmonary changes and should be taken into account in dose-escalation protocols.

[Late effects of ionizing radiations on the thyroid gland]

The thyroid is the purest endocrine gland in the body and is likely to produce clinically significant abnormalities after external radiotherapy. Functional clinical modifications after direct irradiation exceeding 30 Gy are essentially related to hypothyroidism which may be clinically overt or subclinical with normal serum free thyroxine levels and high thyrotropin concentrations; the risk of hyperthyroidism, silent thyroiditis and Hashimoto's disease is also increased. Secondary hypothyroidism related to irradiation of the hypothalamus and the pituitary gland may arise with doses over 40-50 Gy following treatment for brain and nasopharyngeal tumors--Morphological glandular modifications induced by radiotherapy are responsible for the appearance of benign adenomas, more rarely cystic degenerations and specially well differentiated papillary or follicular carcinomas among children and adults. After irradiation during childhood for benign or malignant tumors, thyroid cancers are more frequent, higher for younger children, and the relative excess risk is increased from 15.6-to 53-fold; tumors can belatedly occur, more than 35 years after initial therapy. Thereby, in order to limit excess morbidity, it is evident that long term supervision with careful clinical and biological evaluations is necessary for patients who previously received neck, upper mediastinum and pituitary radiation therapy.

[Pulmonary and cardiac late effects of ionizing radiations alone or combined with chemotherapy]

High doses of ionizing radiation (> 40 Gy) cause severe lung fibrosis in approximately 5% of the cases. There is a twofold increase when chemotherapy is added to ionizing radiation. Lung fibrosis is due to the destruction of lung tissue by ionizing radiation but also to various cytokine effects (PDGF-beta, TGF-beta). Only a minority of patients (approximately 10%) with abnormal X-rays will experience clinical symptoms. The most important radiobiological parameters which accounts for pulmonary tolerance is the fraction size. Irradiation of the heart begets multifarious late sequelae which are often left unrecognized. Chronic pericarditis affects approximately 5% of the patients when the irradiation dose exceeds 40 Gy. Coronary artery disease can be diagnosed in 5 to 10% of the patients. This late complication is more likely to occur if the patient was young at the time of the irradiation or if other risk factors are associated. Valvular defects can be found in 15 to 30% of the patients. However, the mortality rate is very low (0.5%). Finally, conduction defects can also be seen in approximately 5% of the patients. It is very likely that the radiation dose given to the heart should not exceed 30 Gy if late sequelae are to be avoided.

Age has no impact on acute and late toxicity of curative thoracic radiotherapy

BACKGROUND AND PURPOSE

Radiotherapy is a treatment method frequently employed in the management of thoracic tumours. Although the highest incidence of these tumours is found in elderly people, tolerance to radiotherapy is not well documented in older age groups. Many physicians are tempted to alter the radiotherapy planning in a population with a supposed lower life expectancy in order to prevent acute reactions whereas late reactions are often ignored. The current study aimed to determine the influence of age on the frequency and severity of acute and late side-effects and also whether the prognosis of tumours sufficiently differed between ages to justify different attitudes towards their management.

MATERIALS AND METHODS

Data from 1208 patients receiving chest irradiation and included in arms designed with RT of six EORTC randomized trials were evaluated. Data were extracted by a computer program elaborated for each study and were merged in a single database for analysis. Patients were split into six age ranges from 50 to 70 years and over. Survival and late toxicity were calculated with the Kaplan-Meier method and comparison between age groups was performed with the logrank test. The gamma-statistic test was used to test the impact of age on acute toxicity occurrence.

RESULTS

Survival adjusted for the primary location of the tumour was comparable in each age group (P = 0.82). Data regarding age and acute toxicity were available for 1208 patients who experienced 640 grade > or =1 toxicities. The difference in distribution over age was not significant for acute nausea, dyspnea, oesophagitis, weakness and WHO performance status alteration. Weight loss was significantly different with regards to age with a trend toward increased weight loss in older age groups (P = 0.002). To minimize actuarial bias, only patients surviving more than 90 days were analyzed for late effect risks. Late toxicities were examined only if they occurred before an eventual tumour failure in order to avoid confusion between effects of first and second line treatments. In such conditions, 1082 grade > or =1 late toxicities were recorded in 935 patients of 1106 available for analysis. The mean time to complication was 13 months and was similar in all age groups. Forty percent of patients were free of complication at 4 years, the logrank test showing no significant difference between age groups (P = 0.57). For grade >2 side-effects, the calculation did not show any difference between each age group (P = 0.1). A detailed analysis of late dyspnea and late weakness studied with the same method did not demonstrate any difference between age groups. Only grade >2 late oesophagitis demonstrated a significant trend to be more frequent in older patients (P = 0.01), but this difference disappeared after adjustment on study (P = 0.32).

CONCLUSION

The absence of toxicity observed in the current study regardless of age reinforces the conviction that age per se is not a sufficient reason to exclude patients in good general condition with thoracic tumour from curative radiotherapy when medically indicated.

Thyroid dysfunction after mantle irradiation of Hodgkin's disease patients

Thyroid dysfunction can develop in patients with Hodgkin's disease who are treated with mantle irradiation. During the period 1970-89, the records of 320 patients who received mantle irradiation and who had thyroid function tests (TFT) were retrospectively reviewed. The median age was 30 years (range, 7-69 years). The median mantle and thyroid dose was 36 Gy (range, 30-40 Gy) and 39.8 Gy (range, 32-65 Gy), respectively. Overall thyroid dysfunction was present in 39% of the patients. Clinical hypothyroidism was seen in 10% and biochemical hypothyroidism was noted in 25%. Hyperthyroidism was found in 4% of patients. Thyroid nodules had developed in six patients (2%), of which those in four patients were malignant. Age, sex, histological subtype, stage of disease, dose, lymphangiogram and treatment with chemotherapy were not significant factors in the development of thyroid dysfunction. The narrow dose range prevented adequate analysis of dose effect. The results indicate that the incidence of thyroid abnormalities is high enough to warrant regular TFT assessment with pre-irradiation levels and follow-up testing for life because the development of abnormalities can occur many years later. Thyroid examination should form part of the routine follow-up examination and any abnormality should be promptly investigated.

Cardiac risk after mediastinal irradiation for Hodgkin's disease

PURPOSE

To evaluate the risk of cardiac lesions after conventionally fractionated irradiation (Rt) of the mediastine with or without chemotherapy (Ct) in patients with Hodgkin's disease (HD) and to relate them to known cardiovascular risk factors.

PATIENTS AND METHODS

Between 1964 and 1992, 352 (total group) patients with HD were treated with curative intention using Rt with or without Ct including the mediastine and had a follow-up of at least 1 year. More than 96% of the patients had a complete follow-up. One hundred forty-four patients (64% of the living patients, heart study group) have regular follow-up in our department and had a special heart examination including rest and exercise ECG, echocardiography and myocardial perfusion scintigraphy (112 patients). Doses per fraction in the anterior heart region were between 1.3 and 2.1 Gy. Total doses were between 30.0 and 42.0 Gy in 93% of cases. The mean length of follow-up was 11.2 years (range 1.0-31.5 years). Other cardiovascular risk factors evaluated were body mass index, blood pressure, smoking history, diabetes mellitus, hypercholesterolemia and history of coronary artery disease before Rt.

RESULTS

In the total group, the risk of fatal cardiac ischemic events and/or of sudden unexpected death was significantly higher than expected with a relative risk of 4.2 for myocardial infarction and 6.7 for myocardial infarction or sudden death. In female patients and in patients without other cardiovascular risk factors, the risk of fatal or non-fatal ischemic cardiac events was not significantly different from the expected value. In the subgroup with no cardiovascular risk factors and treatment without Ct, there was no ischemic or other major cardiac event. Echocardiography showed valvular thickenings in a large amount of the patients (the cumulative risk after 30-year follow-up was above 60%) but mostly without hemodynamic disturbance. In patients without hypertension and without coronary artery disease, findings of perfusion scintigraphy and echocardiographic evaluation of systolic and diastolic function were normal. Treatment with Ct was not a significant risk factor for cardiac events but the number of patients whose treatment included adriamycin and with a follow-up exceeding 10 years is to low for a definitive evaluation.

CONCLUSIONS

In patients without the usual cardiovascular risk factors (smoking, hypertension, obesity, hypercholesterolemia, diabetes mellitus) the risk of serious cardiac lesions after conventionally fractionated irradiation of the mediastinum with an intermediate total dose between 30 and 40 Gy is low. Also the cardiac risk of the combination of this irradiation with Ct including adriamycin with a total dose between 200 and 300 mg/m2 seems low but further long-term observation is necessary.

Complete AV block following mediastinal radiation therapy: electrocardiographic and pathologic correlation and review of the world literature

The clinical, features, serial electrocardiograms, and autopsy findings of a patient with symptomatic complete AV block, who had received mediastinal radiation therapy 8 1/2 years previously, are presented. The cardiac histopathology disclosed immense fibrosis of the conduction system and of the atria and ventricles. The enormous amount of fibrosis was similar in location and intensity to that observed in our previously reported patient (Cohen et al., Arch Intern Med 1981; 141:676-679) who had undergone mediastinal radiation. We conclude that the severe fibrosis was primarily due to radiation, rather than secondary to atherosclerotic coronary artery disease, which also has been described as a consequence of mediastinal radiotherapy. This patient's serial electrocardiograms disclosed evidence of complete block both in the AV nodal area and infra His system, which correlated well with the histopathology. The characteristic clinical features of patients with symptomatic complete AV block post mediastinal radiation therapy are presented, along with a review of the world literature.

Cardiac function, perfusion, and morbidity in irradiated long-term survivors of Hodgkin's disease

PURPOSE

The incidence of cardiotoxicity and clinical cardiac events following mantle irradiation (RT) in patients with Hodgkin's disease using modern techniques is controversial. The use of quantitative, prognostically validated noninvasive tests to assess systolic and diastolic cardiac function and regional myocardial blood flow may reveal preclinical abnormalities associated with subsequent clinical events of myocardial infarction, cardiac death, or angina. The goals of this study are to determine, through noninvasive measures, the presence and time course of alterations in cardiac systolic and diastolic function and of relative myocardial blood flow in long-term survivors of Hodgkin's disease, and assess their correlation with subsequent clinical cardiac end points.

METHODS AND MATERIALS

Equilibrium radionuclide angiocardiography (ERNA) was used to assess left ventricular (LV) systolic and diastolic function by measuring LV ejection fraction (LVEF) and peak filling rate (PFR), respectively, in patients without known ischemic heart disease who received RT. Electrocardiography was performed to assess electrical cardiac function under conditions of rest and either exercise or dipyridamole vasodilator stress. Quantitative rest/stress myocardial perfusion imaging with thallium-201 and/or Tc-99m sestamibi was used to assess myocardial perfusion. Patients at least 1.0 year after RT were eligible if they were <50 years old at RT, had no known cardiac disease, and remained free of clinical recurrence of Hodgkin's disease. Fifty patients, ages 10.2-46.1 years (mean 26.0 +/- 8.6) at RT, were tested 1.1 to 29.1 years (mean 9.1 +/- 7.5) after RT. Seventeen of these patients were tested two times separated by 1.1 to 8.1 years. The mean central cardiac RT dose was 35.1 +/- 7.8 Gy (range 18.5-47.5) in daily 15-2.0 Gy fractions. Twelve patients were concomitantly irradiated to the left ventricle, usually through partial transmission left lung shields (mean 17.0 +/- 2.2 Gy, range 14.3-21.3).

RESULTS

No patients had signs or symptoms of cardiac disease at the time of evaluation. The mean LVEF at the time of initial testing was 59.6 +/- 6.2% (n = 50; range 42-73%; normal > or =50%), and the mean peak filling rate (PFR) was 3.46 +/- 0.88 end diastolic volumes per second (EDV/s) (range 1.5-5.4 EDV/s; normal > or =2.54 EDV/s). The 12 patients also treated to the left ventricle had a normal mean ejection fraction that was lower (56.6 +/- 5.0%) than that of the other 38 patients (LVEF = 60.6 +/- 6.3%, p = 0.051) when initially evaluated. Average PFR was similar in the two groups. For the 15 patients who had repeat tests, changes in LVEF were generally modest in individual patients, and there was no change in the group mean. For all patients, no significant association was found between cardiac function indices and age at RT, dose, or interval from RT to testing. Myocardial perfusion scintigraphy demonstrated mild ischemia in one or more segments in two patients, and borderline normal perfusion in three patients. Rest and stress ECG testing demonstrated mild repolarization abnormalities in three, and one patient was abnormal at rest and had nondiagnostic changes with stress.

CONCLUSIONS

Patients irradiated to the heart incidental to the treatment of Hodgkin's disease using modern techniques have generally normal measures of left ventricular function and myocardial perfusion. Modest differences in the normal left ventricular ejection fraction observed may be attributable to the cardiac volume irradiated. Some patients may manifest improved cardiac function as time from RT elapses, while a significant deterioration of ejection fraction was not observed and reduction in diastolic peak filling rate is uncommon. The previously reported increased risk of cardiac death may relate to use of older techniques of RT employing higher doses and lack of cardiac shielding, and uncontrolled patient selection with additional behaviors and cardiac risk factors.