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Chin V, Finnegan RN, Keall P, Otton J, Delaney GP, Vinod SK. Overview of cardiac toxicity from radiation therapy. J Med Imaging Radiat Oncol 2024. [PMID: 39301913 DOI: 10.1111/1754-9485.13757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 08/19/2024] [Indexed: 09/22/2024]
Abstract
Radiotherapy is an essential part of treatment for many patients with thoracic cancers. However, proximity of the heart to tumour targets can lead to cardiac side effects, with studies demonstrating link between cardiac radiation dose and adverse outcomes. Although reducing cardiac dose can reduce associated risks, most cardiac constraint recommendations in clinical use are generally based on dose to the whole heart, as dose assessment at cardiac substructure levels on individual patients has been limited historically. Furthermore, estimation of an individual's cardiac risk is complex and multifactorial, which includes radiation dose alongside baseline risk factors, and the impact of systemic therapies. This review gives an overview of the epidemiological impact of cancer and cardiac disease, risk factors contributing to radiation-related cardiotoxicity, the evidence for cardiac side effects and future directions in cardiotoxicity research. A better understanding of the interactions between risk factors, balancing treatment benefit versus toxicity and the ongoing management of cardiac risk is essential for optimal clinical care. The emerging field of cardio-oncology is thus a multidisciplinary collaborative effort to enable better understanding of cardiac risks and outcomes for better-informed patient management decisions.
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Affiliation(s)
- Vicky Chin
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia
- Image X Institute, University of Sydney, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Robert N Finnegan
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Institute of Medical Physics, University of Sydney, Sydney, New South Wales, Australia
| | - Paul Keall
- Image X Institute, University of Sydney, Sydney, New South Wales, Australia
| | - James Otton
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Geoff P Delaney
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Shalini K Vinod
- Department of Radiation Oncology, Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
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2
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Bowen Jones S, Marchant T, Saunderson C, McWilliam A, Banfill K. Moving beyond mean heart dose: The importance of cardiac substructures in radiation therapy toxicity. J Med Imaging Radiat Oncol 2024. [PMID: 39228181 DOI: 10.1111/1754-9485.13737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 07/12/2024] [Indexed: 09/05/2024]
Abstract
Normal tissue tolerance dose limits to the heart have been established to reduce the risk of radiation-induced cardiac disease (RICD). Dose constraints have been developed based on either the mean dose delivered to the whole heart (MHD) or the dose delivered to a specific volume, for example, volume of heart receiving equal to or greater than 30 Gy (V30). There is increasing evidence that the impact of thoracic radiation on cardiac morbidity and mortality has been underestimated. Consequently, there is a need to reduce the dose delivered to the heart in radical radiotherapy treatment planning. The pathophysiology of RICD may relate to dose to specific cardiac substructures (CS) rather than the traditionally observed MHD for common toxicities. The MHD or V30 Gy threshold dose rarely represents the true dose delivered to individual CS. Studies have shown the dose to specific areas may be more strongly correlated with overall survival (OS). With advances in modern radiotherapy techniques, it is vital that we develop robust, evidence-based dose limits for CS, to fully understand and reduce the risk of RICD, particularly in high-risk populations with cardiac risk factors. The following review will summarise the existing evidence of dose limits to CS, explain how dose limits may vary according to different disease sites or radiation techniques and propose how radiotherapy plans can be optimised to reduce the dose to these CS in clinical practice.
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Affiliation(s)
- Sarah Bowen Jones
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, UK
| | - Tom Marchant
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Chris Saunderson
- Department of Cardiology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Alan McWilliam
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, University of Manchester, Manchester, UK
| | - Kathryn Banfill
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, UK
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3
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Barcellini A, Rordorf R, Dusi V, Fontana G, Pepe A, Vai A, Schirinzi S, Vitolo V, Orlandi E, Greco A. Pilot study to assess the early cardiac safety of carbon ion radiotherapy for intra- and para-cardiac tumours. Strahlenther Onkol 2024:10.1007/s00066-024-02270-2. [PMID: 39212688 DOI: 10.1007/s00066-024-02270-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 07/03/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE Modern photon radiotherapy effectively spares cardiac structures more than previous volumetric approaches. Still, it is related to non-negligible cardiac toxicity due to the low-dose bath of surrounding normal tissues. However, the dosimetric advantages of particle radiotherapy make it a promising treatment for para- and intra-cardiac tumours. In the current short report, we evaluate the cardiac safety profile of carbon ion radiotherapy (CIRT) for radioresistant intra- and para-cardiac malignancies in a real-world setting. METHODS We retrospectively analysed serum biomarkers (TnI, CRP and NT-proBNP), echocardiographic, and both 12-lead and 24-hour Holter electrocardiogram (ECG) data of consecutive patients with radioresistant intra- and para-cardiac tumours irradiated with CIRT between June 2019 and September 2022. In the CIRT planning optimization process, to minimize the delivered doses, we contoured and gave a high priority to the cardiac substructures. Weekly re-evaluative 4D computed tomography scans were carried out throughout the treatment. RESULTS A total of 16 patients with intra- and para-cardiac localizations of radioresistant tumours were treated up to a total dose of 70.4 Gy relative biological effectiveness (RBE) and a mean heart dose of 2.41 Gy(RBE). We did not record any significant variation of the analysed serum biomarkers after CIRT nor significant changes of echocardiographic features, biventricular strain, or 12-lead and 24-hour Holter ECG parameters during 6 months of follow-up. CONCLUSION Our pilot study suggests that carbon ion radiotherapy is a promising radiation technique capable of sparing off-target side effects at the cardiac level. A larger cohort, long-term follow-up and further prospective studies are needed to confirm these findings.
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Affiliation(s)
- Amelia Barcellini
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100, Pavia, Italy
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100, Pavia, Italy
| | - Roberto Rordorf
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
- Arrhythmia and Electrophysiology Unit, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Veronica Dusi
- Division of Cardiology, Department of Medical Sciences, University of Turin, 10126, Torino, Italy
| | - Giulia Fontana
- Clinical Department, CNAO National Center for Oncological Hadrontherapy, Via Erminio Borloni 1, 27100, Pavia, Italy.
| | - Antonella Pepe
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
- Division of Cardiology, Cardio-Thoracic Department, San Carlo Borromeo Hospital (ASST Santi Paolo e Carlo), 20100, Milano, Italy
| | - Alessandro Vai
- Medical Physics Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100, Pavia, Italy
| | - Sandra Schirinzi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
| | - Viviana Vitolo
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100, Pavia, Italy
| | - Ester Orlandi
- Radiation Oncology Unit, Clinical Department, CNAO National Center for Oncological Hadrontherapy, 27100, Pavia, Italy
- Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100, Pavia, Italy
| | - Alessandra Greco
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, 27100, Pavia, Italy
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Vinod SK. Getting to the heart of the matter. J Med Imaging Radiat Oncol 2024. [PMID: 39208236 DOI: 10.1111/1754-9485.13749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 08/12/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Shalini K Vinod
- School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, New South Wales, Australia
- Collaboration for Cancer Outcomes Research and Evaluation (CCORE), Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Cancer Therapy Centre, Liverpool Hospital, South Western Sydney Local Health District, Sydney, New South Wales, Australia
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Walls G, McWilliam A. Association of Cardiac Substructure Radiation Dose With Arrhythmia: Time to Move Away From Mean Dose. JACC CardioOncol 2024; 6:557-559. [PMID: 39239340 PMCID: PMC11372022 DOI: 10.1016/j.jaccao.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2024] Open
Affiliation(s)
- Gerard Walls
- Cancer Centre Belfast City Hospital, Belfast, United Kingdom
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, United Kingdom
| | - Alan McWilliam
- Division of Cancer Science, University of Manchester, Manchester, United Kingdom
- The Christie NHS Foundation Trust, Manchester, United Kingdom
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Atkins KM, Zhang SC, Kehayias C, Guthier C, He J, Gasho JO, Bakhtiar M, Silos KD, Kozono DE, Zei PC, Nohria A, Nikolova AP, Mak RH. Cardiac Substructure Radiation Dose and Associations With Tachyarrhythmia and Bradyarrhythmia After Lung Cancer Radiotherapy. JACC CardioOncol 2024; 6:544-556. [PMID: 39239344 PMCID: PMC11372031 DOI: 10.1016/j.jaccao.2024.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 07/02/2024] [Accepted: 07/02/2024] [Indexed: 09/07/2024] Open
Abstract
Background Arrhythmias are common following radiotherapy for non-small cell lung cancer. Objectives The aim of this study was to analyze the association of distinct arrhythmia classes with cardiac substructure radiotherapy dose. Methods A retrospective analysis was conducted of 748 patients with locally advanced non-small cell lung cancer treated with radiotherapy. Cardiac substructure dose parameters were calculated. Receiver-operating characteristic curve analyses for predictors of Common Terminology Criteria for Adverse Events grade ≥3 atrial fibrillation (AF), atrial flutter, non-AF and non-atrial flutter supraventricular tachyarrhythmia (SVT), bradyarrhythmia, and ventricular tachyarrhythmia (VT) or asystole were calculated. Fine-Gray regression models were performed (with noncardiac death as a competing risk). Results Of 748 patients, 128 (17.1%) experienced at least 1 grade ≥3 arrhythmia, with a median time to first arrhythmia of 2.0 years (Q1-Q3: 0.9-4.2 years). The 2-year cumulative incidences of each arrhythmia group were 8.0% for AF, 2.7% for atrial flutter, 1.8% for other SVT, 1.4% for bradyarrhythmia, and 1.1% for VT or asystole. Adjusting for baseline cardiovascular risk, pulmonary vein (PV) volume receiving 5 Gy was associated with AF (subdistribution HR [sHR]: 1.04/mL; 95% CI: 1.01-1.08; P = 0.016), left circumflex coronary artery volume receiving 35 Gy with atrial flutter (sHR: 1.10/mL; 95% CI: 1.01-1.19; P = 0.028), PV volume receiving 55 Gy with SVT (sHR: 1.03 per 1%; 95% CI: 1.02-1.05; P < 0.001), right coronary artery volume receiving 25 Gy with bradyarrhythmia (sHR: 1.14/mL; 95% CI: 1.00-1.30; P = 0.042), and left main coronary artery volume receiving 5 Gy with VT or asystole (sHR: 2.45/mL; 95% CI: 1.21-4.97; P = 0.013). Conclusions This study revealed pathophysiologically distinct arrhythmia classes associated with radiotherapy dose to discrete cardiac substructures, including PV dose with AF and SVT, left circumflex coronary artery dose with atrial flutter, right coronary artery dose with bradyarrhythmia, and left main coronary artery dose with VT or asystole, guiding potential risk mitigation approaches.
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Affiliation(s)
- Katelyn M Atkins
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Samuel C Zhang
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Christopher Kehayias
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Christian Guthier
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - John He
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jordan O Gasho
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Mina Bakhtiar
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Katrina D Silos
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - David E Kozono
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Paul C Zei
- Department of Cardiovascular Medicine, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Anju Nohria
- Department of Cardiovascular Medicine, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Andriana P Nikolova
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Raymond H Mak
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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7
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Walls GM, Hill N, McMahon M, Kearney BÓ, McCann C, McKavanagh P, Giacometti V, Cole AJ, Jain S, McGarry CK, Butterworth K, McAleese J, Harbinson M, Hanna GG. Baseline Cardiac Parameters as Biomarkers of Radiation Cardiotoxicity in Lung Cancer: An NI-HEART Analysis. JACC CardioOncol 2024; 6:529-540. [PMID: 39239328 PMCID: PMC11372030 DOI: 10.1016/j.jaccao.2024.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 05/02/2024] [Accepted: 05/05/2024] [Indexed: 09/07/2024] Open
Abstract
Background Radiation-induced cardiotoxicity poses a significant challenge in lung cancer management because of the close anatomical proximity of the heart to the lungs, compounded by a high prevalence of cardiovascular risk factors among patients. Objectives The aim of this study was to assess the predictive value of routinely available clinical and imaging-based cardiac parameters in identifying "high risk" patients for major adverse cardiac events (MACE) and mortality following radiation therapy (RT). Methods The medical records of patients who underwent definitive RT for non-small cell lung cancer using modern planning techniques at a single center between 2015 and 2020 were retrospectively reviewed. Cardiac events were verified by cardiologists, and mortality data were confirmed with the national registry. Cardiac substructures were autosegmented on RT planning scans for retrospective structure and dose analysis, and their correlation with clinical factors was examined. Fine-Gray models were used to analyze relationships while considering the competing risk for death. Results Among 478 patients included in the study, 77 (16%) developed 88 MACE, with a median time to event of 16.3 months. A higher burden of pre-existing cardiac diseases was associated with an increased cumulative incidence of MACE (55% [95% CI: 12%-20%] vs 16% [95% CI: 35%-71%]; P < 0.001). Left atrial and left ventricular enlargement on RT planning scans was associated with cumulative incidence of atrial arrhythmia (14% [95% CI: 9%-20%] vs 4% [95% CI: 2%-8%]; P = 0.001) and heart failure (13% [95% CI: 8%-18%] vs 6% [95% CI: 3%-10%]; P = 0.007) at 5 years, respectively. However, myocardial infarction was not associated with the presence of coronary calcium (4.2% [95% CI: 2%-7%] vs 0% [95% CI: 0%-0%]; P = 0.094). No cardiac imaging metrics were found to be both clinically and statistically associated with survival. Conclusions The present findings suggest that cardiac history and RT planning scan parameters may offer potential utility in prospectively evaluating cardiotoxicity risk following RT for patients with lung cancer.
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Affiliation(s)
- Gerard M Walls
- Cancer Centre Belfast City Hospital, Belfast, United Kingdom
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, United Kingdom
| | - Nicola Hill
- Cancer Centre Belfast City Hospital, Belfast, United Kingdom
| | - Michael McMahon
- Cancer Centre Belfast City Hospital, Belfast, United Kingdom
| | | | - Conor McCann
- Department of Cardiology, Belfast Health & Social Care Trust, Belfast, United Kingdom
| | - Peter McKavanagh
- Department of Cardiology, South Eastern Health & Social Care Trust, Dundonald, United Kingdom
| | - Valentina Giacometti
- Cancer Centre Belfast City Hospital, Belfast, United Kingdom
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, United Kingdom
| | - Aidan J Cole
- Cancer Centre Belfast City Hospital, Belfast, United Kingdom
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, United Kingdom
| | - Suneil Jain
- Cancer Centre Belfast City Hospital, Belfast, United Kingdom
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, United Kingdom
| | - Conor K McGarry
- Cancer Centre Belfast City Hospital, Belfast, United Kingdom
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, United Kingdom
| | - Karl Butterworth
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, United Kingdom
| | - Jonathan McAleese
- Cancer Centre Belfast City Hospital, Belfast, United Kingdom
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, United Kingdom
| | - Mark Harbinson
- Department of Cardiology, South Eastern Health & Social Care Trust, Dundonald, United Kingdom
- School of Medicine, Dentistry & Biological Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Gerard G Hanna
- Cancer Centre Belfast City Hospital, Belfast, United Kingdom
- Patrick G. Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, United Kingdom
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8
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Zhang SC, Nikolova AP, Kamrava M, Mak RH, Atkins KM. A roadmap for modelling radiation-induced cardiac disease. J Med Imaging Radiat Oncol 2024. [PMID: 38985978 DOI: 10.1111/1754-9485.13716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/21/2024] [Indexed: 07/12/2024]
Abstract
Cardiac risk mitigation is a major priority in improving outcomes for cancer survivors as advances in cancer screening and treatments continue to decrease cancer mortality. More than half of adult cancer patients will be treated with radiotherapy (RT); therefore it is crucial to develop a framework for how to assess and predict radiation-induced cardiac disease (RICD). Historically, RICD was modelled solely using whole heart metrics such as mean heart dose. However, data over the past decade has identified cardiac substructures which outperform whole heart metrics in predicting for significant cardiac events. Additionally, non-RT factors such as pre-existing cardiovascular risk factors and toxicity from other therapies contribute to risk of future cardiac events. In this review, we aim to discuss the current evidence and knowledge gaps in predicting RICD and provide a roadmap for the development of comprehensive models based on three interrelated components, (1) baseline CV risk assessment, (2) cardiac substructure radiation dosimetry linked with cardiac-specific outcomes and (3) novel biomarker development.
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Affiliation(s)
- Samuel C Zhang
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Andriana P Nikolova
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Mitchell Kamrava
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Raymond H Mak
- Department of Radiation Oncology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Katelyn M Atkins
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California, USA
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Hessels AC, Visser S, Both S, Korevaar EW, Langendijk JA, Wijsman R. A planning study of proton therapy dose escalation for non-small cell lung cancer. Phys Imaging Radiat Oncol 2024; 31:100616. [PMID: 39157295 PMCID: PMC11327929 DOI: 10.1016/j.phro.2024.100616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 07/19/2024] [Accepted: 07/24/2024] [Indexed: 08/20/2024] Open
Abstract
In non-small-cell lung cancer (NSCLC), improving local control through radiotherapy dose escalation might improve survival. However, a photon-based RCT showed increased organ at risk dose exposure and worse overall survival in the dose escalation arm. In this study, intensity-modulated proton therapy plans with dose escalation to the primary tumour were created for 20 NSCLC patients. The mediastinal envelope was delineated to spare structures around the heart. It was possible to increase primary tumour dose up to 74.0 Gy without a significant increase in organ at risk doses and predicted toxicity.
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Affiliation(s)
- Arno C Hessels
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sabine Visser
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Stefan Both
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erik W Korevaar
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robin Wijsman
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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10
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Chin V, Finnegan RN, Chlap P, Holloway L, Thwaites DI, Otton J, Delaney GP, Vinod SK. Dosimetric Impact of Delineation and Motion Uncertainties on the Heart and Substructures in Lung Cancer Radiotherapy. Clin Oncol (R Coll Radiol) 2024; 36:420-429. [PMID: 38649309 DOI: 10.1016/j.clon.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 03/27/2024] [Accepted: 04/02/2024] [Indexed: 04/25/2024]
Abstract
AIMS Delineation variations and organ motion produce difficult-to-quantify uncertainties in planned radiation doses to targets and organs at risk. Similar to manual contouring, most automatic segmentation tools generate single delineations per structure; however, this does not indicate the range of clinically acceptable delineations. This study develops a method to generate a range of automatic cardiac structure segmentations, incorporating motion and delineation uncertainty, and evaluates the dosimetric impact in lung cancer. MATERIALS AND METHODS Eighteen cardiac structures were delineated using a locally developed auto-segmentation tool. It was applied to lung cancer planning CTs for 27 curative (planned dose ≥50 Gy) cases, and delineation variations were estimated by using ten mapping-atlases to provide separate substructure segmentations. Motion-related cardiac segmentation variations were estimated by auto-contouring structures on ten respiratory phases for 9/27 cases that had 4D-planning CTs. Dose volume histograms (DVHs) incorporating these variations were generated for comparison. RESULTS Variations in mean doses (Dmean), defined as the range in values across ten feasible auto-segmentations, were calculated for each cardiac substructure. Over the study cohort the median variations for delineation uncertainty and motion were 2.20-11.09 Gy and 0.72-4.06 Gy, respectively. As relative values, variations in Dmean were between 18.7%-65.3% and 7.8%-32.5% for delineation uncertainty and motion, respectively. Doses vary depending on the individual planned dose distribution, not simply on segmentation differences, with larger dose variations to cardiac structures lying within areas of steep dose gradient. CONCLUSION Radiotherapy dose uncertainties from delineation variations and respiratory-related heart motion were quantified using a cardiac substructure automatic segmentation tool. This predicts the 'dose range' where doses to structures are most likely to fall, rather than single DVH curves. This enables consideration of these uncertainties in cardiotoxicity research and for future plan optimisation. The tool was designed for cardiac structures, but similar methods are potentially applicable to other OARs.
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Affiliation(s)
- V Chin
- University of New South Wales, South Western Sydney Clinical School, Sydney, Australia; Liverpool and Macarthur Cancer Therapy Centres, Department of Radiation Oncology, Sydney, Australia; Ingham Institute for Applied Medical Research, Sydney, Australia; University of Sydney, Image X Institute, Sydney, Australia.
| | - R N Finnegan
- Ingham Institute for Applied Medical Research, Sydney, Australia; University of Sydney, Institute of Medical Physics, Sydney, Australia; Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, Australia
| | - P Chlap
- University of New South Wales, South Western Sydney Clinical School, Sydney, Australia; Liverpool and Macarthur Cancer Therapy Centres, Department of Radiation Oncology, Sydney, Australia; Ingham Institute for Applied Medical Research, Sydney, Australia
| | - L Holloway
- University of New South Wales, South Western Sydney Clinical School, Sydney, Australia; Liverpool and Macarthur Cancer Therapy Centres, Department of Radiation Oncology, Sydney, Australia; Ingham Institute for Applied Medical Research, Sydney, Australia; University of Sydney, Institute of Medical Physics, Sydney, Australia
| | - D I Thwaites
- University of Sydney, Institute of Medical Physics, Sydney, Australia; St James's Hospital and University of Leeds, Leeds Institute of Medical Research, Radiotherapy Research Group, Leeds, United Kingdom
| | - J Otton
- University of New South Wales, South Western Sydney Clinical School, Sydney, Australia; Liverpool Hospital, Department of Cardiology, Sydney, Australia
| | - G P Delaney
- University of New South Wales, South Western Sydney Clinical School, Sydney, Australia; Liverpool and Macarthur Cancer Therapy Centres, Department of Radiation Oncology, Sydney, Australia; Ingham Institute for Applied Medical Research, Sydney, Australia
| | - S K Vinod
- University of New South Wales, South Western Sydney Clinical School, Sydney, Australia; Liverpool and Macarthur Cancer Therapy Centres, Department of Radiation Oncology, Sydney, Australia; Ingham Institute for Applied Medical Research, Sydney, Australia
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Kwon J, Kim BH. Risk of clinically significant cardiovascular disease associated with postoperative radiotherapy in non-small cell lung cancer patients receiving surgical resection followed by adjuvant chemotherapy: A Korean nationwide cohort study. Radiother Oncol 2024; 195:110241. [PMID: 38522599 DOI: 10.1016/j.radonc.2024.110241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/17/2024] [Accepted: 03/20/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND There are no large-scale datasets that analyze the relationship between postoperative radiotherapy (PORT) and various cardiovascular diseases (CVDs) in patients with locally advanced non-small cell lung cancer (NSCLC). Therefore, we aimed to investigate the incidences of CVDs with PORT using a national population-based database. METHODS Patients diagnosed with NSCLC who underwent curative surgery followed by adjuvant chemotherapy were included from 2007 to 2017. Patients with a prior diagnosis of heart failure (HF), atrial fibrillation (AFib), or heart surgery were excluded. A total of 11,141 patients were included in the final analysis. PORT was used in 1334 patients. Most patients received lobectomy with mediastinal lymph node dissection. RESULTS Major adverse cardiac events mostly occurred within 3-4 years from the diagnosis. After the median follow-up duration of 70.6 months, HF was the most diagnosed disease (5.3 %), followed by AFib (4.5 %), stroke (4.1 %), and pulmonary embolism (3.5 %). All the incidences of clinically significant CVDs did not differ by PORT. This result remained unchanged after the propensity score matching comparison. Age ≥ 65, underlying hypertension, and history of ischemic heart disease were the most related factors to the occurrence of HF and AFib. No significant difference in CVD-free survivals according to PORT status was observed. When stratified by proposed scoring, there were no subgroups showed increased incidence by PORT. CONCLUSIONS These results suggest that PORT had no significant impact on various CVD occurrences in NSCLC patients without underlying heart disease.
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Affiliation(s)
- Jeanny Kwon
- Department of Radiation Oncology, Chungnam National University School of Medicine, Munhwa-ro 282, Jung-gu, Daejeon 35015, Republic of Korea
| | - Byoung Hyuck Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, Republic of Korea.
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Finnegan RN, Quinn A, Booth J, Belous G, Hardcastle N, Stewart M, Griffiths B, Carroll S, Thwaites DI. Cardiac substructure delineation in radiation therapy - A state-of-the-art review. J Med Imaging Radiat Oncol 2024. [PMID: 38757728 DOI: 10.1111/1754-9485.13668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024]
Abstract
Delineation of cardiac substructures is crucial for a better understanding of radiation-related cardiotoxicities and to facilitate accurate and precise cardiac dose calculation for developing and applying risk models. This review examines recent advancements in cardiac substructure delineation in the radiation therapy (RT) context, aiming to provide a comprehensive overview of the current level of knowledge, challenges and future directions in this evolving field. Imaging used for RT planning presents challenges in reliably visualising cardiac anatomy. Although cardiac atlases and contouring guidelines aid in standardisation and reduction of variability, significant uncertainties remain in defining cardiac anatomy. Coupled with the inherent complexity of the heart, this necessitates auto-contouring for consistent large-scale data analysis and improved efficiency in prospective applications. Auto-contouring models, developed primarily for breast and lung cancer RT, have demonstrated performance comparable to manual contouring, marking a significant milestone in the evolution of cardiac delineation practices. Nevertheless, several key concerns require further investigation. There is an unmet need for expanding cardiac auto-contouring models to encompass a broader range of cancer sites. A shift in focus is needed from ensuring accuracy to enhancing the robustness and accessibility of auto-contouring models. Addressing these challenges is paramount for the integration of cardiac substructure delineation and associated risk models into routine clinical practice, thereby improving the safety of RT for future cancer patients.
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Affiliation(s)
- Robert N Finnegan
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
| | - Alexandra Quinn
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jeremy Booth
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
| | - Gregg Belous
- Australian e-Health Research Centre, Commonwealth Scientific and Industrial Research Organisation, Brisbane, Queensland, Australia
| | - Nicholas Hardcastle
- Department of Physical Sciences, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Maegan Stewart
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Brooke Griffiths
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Susan Carroll
- Northern Sydney Cancer Centre, Royal North Shore Hospital, Sydney, New South Wales, Australia
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - David I Thwaites
- Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
- Radiotherapy Research Group, Leeds Institute of Medical Research, St James's Hospital and University of Leeds, Leeds, UK
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13
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Walls GM, McCann C, O'Connor J, O'Sullivan A, I Johnston D, McAleese J, McGarry CK, Cole AJ, Jain S, Butterworth KT, Hanna GG. Pulmonary vein dose and risk of atrial fibrillation in patients with non-small cell lung cancer following definitive radiotherapy: An NI-HEART analysis. Radiother Oncol 2024; 192:110085. [PMID: 38184145 DOI: 10.1016/j.radonc.2024.110085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/22/2023] [Accepted: 01/02/2024] [Indexed: 01/08/2024]
Abstract
BACKGROUND AND PURPOSE Symptomatic arrhythmia is common following radiotherapy for non-small cell lung cancer (NSCLC), frequently resulting in morbidity and hospitalization. Modern treatment planning technology theoretically allows sparing of cardiac substructures. Atrial fibrillation (AF) comprises the majority of post-radiotherapy arrhythmias, but efforts to prevent this cardiotoxicity have been limited as the causative cardiac substructure is not known. In this study we investigated if incidental radiation dose to the pulmonary veins (PVs) is associated with AF. MATERIAL AND METHODS A single-centre study of patients completing contemporary (chemo)radiation for NSCLC, with modern planning techniques. Oncology, cardiology and death records were examined, and AF events were verified by a cardiologist. Cardiac substructures were contoured on planning scans for retrospective dose analysis. RESULTS In 420 eligible patients with NSCLC treated with intensity-modulated (70%) or 3D-conformal (30%) radiotherapy with a median OS of 21.8 months (IQR 10.8-35.1), there were 26 cases of new AF (6%). All cases were grade 3 except two cases of grade 4. Dose metrics for both the left (V55) and right (V10) PVs were associated with the incidence of new AF. Metrics remained statistically significant after accounting for the competing risk of death and cardiovascular covariables for both the left (HR 1.02, 95%CI 1.00-1.03, p = 0.005) and right (HR 1.01 (95%CI 1.00-1.02, p = 0.033) PVs. CONCLUSION Radiation dose to the PVs during treatment of NSCLC was associated with the onset of AF. Actively sparing the PVs during treatment planning could reduce the incidence of AF during follow-up, and screening for AF may be warranted for select cases.
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Affiliation(s)
- Gerard M Walls
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, Northern Ireland.
| | - Conor McCann
- Department of Cardiology, Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland
| | - John O'Connor
- School of Engineering, University of Ulster, York Street, Belfast, Northern Ireland
| | - Anna O'Sullivan
- School of Medicine, University College Dublin, Belfield Dublin 4, Ireland
| | - David I Johnston
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, Northern Ireland
| | - Jonathan McAleese
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland
| | - Conor K McGarry
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, Northern Ireland
| | - Aidan J Cole
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland
| | - Suneil Jain
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, Northern Ireland
| | - Karl T Butterworth
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, Northern Ireland
| | - Gerard G Hanna
- Cancer Centre Belfast City Hospital, Belfast Health & Social Care Trust, Lisburn Road, Belfast, Northern Ireland; Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Jubilee Road, Belfast, Northern Ireland
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