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Figlia V, Simonetto C, Eidemüller M, Naccarato S, Sicignano G, De Simone A, Ruggieri R, Mazzola R, Matuschek C, Bölke E, Pazos M, Niyazi M, Belka C, Alongi F, Corradini S. Mammary Chain Irradiation in Left-Sided Breast Cancer: Can We Reduce the Risk of Secondary Cancer and Ischaemic Heart Disease with Modern Intensity-Modulated Radiotherapy Techniques? Breast Care (Basel) 2021; 16:358-367. [PMID: 34602941 DOI: 10.1159/000509779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/29/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction The aim of the present study was to estimate the impact of the addition of internal mammary chain (IMC) irradiation in node-positive left-sided breast cancer (BC) patients undergoing regional nodal irradiation (RNI) and comparatively evaluate excess relative and absolute risks of radiation-induced lung cancer/BC and ischaemic heart disease for intensity-modulated radiotherapy (IMRT) versus 3D conformal radiotherapy (3D-CRT). Methods Four treatment plans were created (3D-CRT and IMRT -/+ IMC) for each of the 10 evaluated patients, and estimates of excess relative risk (ERR) and 10-year excess absolute risk (EAR) were calculated for radiation-induced lung cancer/BC and coronary events using linear, linear-exponential and plateau models. Results The addition of IMC irradiation to RNI significantly increased the dose exposure of the heart, lung and contralateral breast using both techniques, increasing ERR for secondary lung cancer (58 vs. 44%, p = 0.002), contralateral BC (49 vs. 31%, p = 0.002) and ischaemic heart disease (41 vs. 27%, p = 0.002, IMRT plans). IMRT significantly reduced the mean cardiac dose and mean lung dose as compared to 3D-CRT, decreasing ERR for major coronary events (64% 3D-CRT vs. 41% IMRT, p = 0.002) and ERR for secondary lung cancer (75 vs. 58%, p = 0.004) in IMC irradiation, without a significant impact on secondary contralateral BC risks. Conclusion Although IMC irradiation has been shown to increase survival rates in node-positive BC patients, it increased dose exposure of organs at risk in left-sided BC, resulting in significantly increased risks for secondary lung cancer/contralateral BC and ischaemic heart disease. In this setting, the adoption of IMRT seems advantageous when compared to 3D-CRT.
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Affiliation(s)
- Vanessa Figlia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | | | - Markus Eidemüller
- Institute of Radiation Medicine, Helmholtz Center Munich, Munich, Germany
| | - Stefania Naccarato
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Gianluisa Sicignano
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Antonio De Simone
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Ruggero Ruggieri
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Rosario Mazzola
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Montserrat Pazos
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy.,University of Brescia, Brescia, Italy
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
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Beaton L, Bergman A, Nichol A, Aparicio M, Wong G, Gondara L, Speers C, Weir L, Davis M, Tyldesley S. Cardiac death after breast radiotherapy and the QUANTEC cardiac guidelines. Clin Transl Radiat Oncol 2019; 19:39-45. [PMID: 31485490 PMCID: PMC6715791 DOI: 10.1016/j.ctro.2019.08.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/11/2019] [Indexed: 02/08/2023] Open
Abstract
Cardiovascular risk factors predict for cardiac death after breast radiotherapy. Cardiovascular risk factors should be modified in breast cancer patients. Radiation induced cardiac death at 10-years is low if mean heart dose is <3.3 Gy. Radiation induced cardiac death at 10-years is low if maximum LAD dose is <45.4 Gy. Studies are needed to evaluate heart and LAD constraints in the CT-planning era.
Background Breast/chest wall irradiation (RT) increases risk of cardiovascular death. International Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) guidelines state for partial heart irradiation a “V25Gy <10% will be associated with a <1% probability of cardiac mortality” in long-term follow-up after RT. We assessed whether women treated with breast/chest wall RT 10-years ago who died of cardiovascular disease (CVD) violated QUANTEC guidelines. Materials/methods A population-based database identified all cardiovascular deaths in women with early-stage breast cancer <80 years, treated with adjuvant breast/chest wall RT from 2002 to 2006. Ten-year rate of cardiovascular death was calculated using a Kaplan-Meier method. Patients were matched on a 2:1 basis with controls that did not die of CVD. For left-sided cases, the heart and left anterior descending (LAD) artery were retrospectively delineated. Dose-volume histograms were calculated, and heart V25Gy compared to QUANTEC guidelines. Results 5249 eligible patients received breast/chest wall RT from 2002 to 2006: 76 (1.4% at 10-years) died of CVD by June 2015. Forty-two patients received left-sided RT (1.7% CVD death at 10-years), 34 right-sided RT (1.3% at 10-years). Heart V25Gy did not exceed 10% in any left-sided cases. No cardiac dosimetry parameter distinguished left-sided cases from controls. Conclusions QUANTEC guidelines were not violated in any patient that died of CVD after left-sided RT. The risk of radiation induced cardiac death at 10-years appears to be very low if MHD is <3.3 Gy and maximum LAD dose (EQD23 Gy) is <45.4 Gy. Further studies are needed to evaluate heart and LAD constraints in the CT-planning era.
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Affiliation(s)
- Laura Beaton
- Department of Radiation Oncology, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Alanah Bergman
- Department of Medical Physics, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Alan Nichol
- Department of Radiation Oncology, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada.,Breast Cancer Outcomes Unit, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Maria Aparicio
- Department of Radiation Oncology, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Graham Wong
- Department of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lovedeep Gondara
- Breast Cancer Outcomes Unit, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Caroline Speers
- Breast Cancer Outcomes Unit, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada
| | - Lorna Weir
- Department of Radiation Oncology, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada.,Breast Cancer Outcomes Unit, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Margot Davis
- Department of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Scott Tyldesley
- Department of Radiation Oncology, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada.,Breast Cancer Outcomes Unit, BC Cancer Agency, Vancouver Centre, Vancouver, British Columbia, Canada.,Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Corradini S, Ballhausen H, Weingandt H, Freislederer P, Schönecker S, Niyazi M, Simonetto C, Eidemüller M, Ganswindt U, Belka C. Left-sided breast cancer and risks of secondary lung cancer and ischemic heart disease : Effects of modern radiotherapy techniques. Strahlenther Onkol 2017; 194:196-205. [PMID: 28916844 DOI: 10.1007/s00066-017-1213-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 08/30/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE Modern breast cancer radiotherapy techniques, such as respiratory-gated radiotherapy in deep-inspiration breath-hold (DIBH) or volumetric-modulated arc radiotherapy (VMAT) have been shown to reduce the high dose exposure of the heart in left-sided breast cancer. The aim of the present study was to comparatively estimate the excess relative and absolute risks of radiation-induced secondary lung cancer and ischemic heart disease for different modern radiotherapy techniques. METHODS Four different treatment plans were generated for ten computed tomography data sets of patients with left-sided breast cancer, using either three-dimensional conformal radiotherapy (3D-CRT) or VMAT, in free-breathing (FB) or DIBH. Dose-volume histograms were used for organ equivalent dose (OED) calculations using linear, linear-exponential, and plateau models for the lung. A linear model was applied to estimate the long-term risk of ischemic heart disease as motivated by epidemiologic data. Excess relative risk (ERR) and 10-year excess absolute risk (EAR) for radiation-induced secondary lung cancer and ischemic heart disease were estimated for different representative baseline risks. RESULTS The DIBH maneuver resulted in a significant reduction of the ERR and estimated 10-year excess absolute risk for major coronary events compared to FB in 3D-CRT plans (p = 0.04). In VMAT plans, the mean predicted risk reduction through DIBH was less pronounced and not statistically significant (p = 0.44). The risk of radiation-induced secondary lung cancer was mainly influenced by the radiotherapy technique, with no beneficial effect through DIBH. VMAT plans correlated with an increase in 10-year EAR for radiation-induced lung cancer as compared to 3D-CRT plans (DIBH p = 0.007; FB p = 0.005, respectively). However, the EARs were affected more strongly by nonradiation-associated risk factors, such as smoking, as compared to the choice of treatment technique. CONCLUSION The results indicate that 3D-CRT plans in DIBH pose the lowest risk for both major coronary events and secondary lung cancer.
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Affiliation(s)
- Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.
| | - Hendrik Ballhausen
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Helmut Weingandt
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Philipp Freislederer
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Stephan Schönecker
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Cristoforo Simonetto
- Institute of Radiation Protection, Helmholtz Zentrum München, Neuherberg, Germany
| | - Markus Eidemüller
- Institute of Radiation Protection, Helmholtz Zentrum München, Neuherberg, Germany
| | - Ute Ganswindt
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
- Department of Radiation Oncology, Medical University, Innsbruck, Austria
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
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Dess RT, Sun Y, Matuszak MM, Sun G, Soni PD, Bazzi L, Murthy VL, Hearn JWD, Kong FM, Kalemkerian GP, Hayman JA, Ten Haken RK, Lawrence TS, Schipper MJ, Jolly S. Cardiac Events After Radiation Therapy: Combined Analysis of Prospective Multicenter Trials for Locally Advanced Non-Small-Cell Lung Cancer. J Clin Oncol 2017; 35:1395-1402. [PMID: 28301264 DOI: 10.1200/jco.2016.71.6142] [Citation(s) in RCA: 250] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Purpose Radiation therapy is a critical component in the care of patients with non-small-cell lung cancer (NSCLC), yet cardiac injury after treatment is a significant concern. Therefore, we wished to elucidate the incidence of cardiac events and their relationship to radiation dose to the heart. Patients and Materials Study eligibility criteria included patients with stage II to III NSCLC treated on one of four prospective radiation therapy trials at two centers from 2004 to 2013. All cardiac events were reviewed and graded per Common Terminology Criteria for Adverse Events (v4.03). The primary end point was the development of a grade ≥ 3 cardiac event. Results In all, 125 patients met eligibility criteria; median follow-up was 51 months for surviving patients. Median prescription dose was 70 Gy, 84% received concurrent chemotherapy, and 27% had pre-existing cardiac disease. Nineteen patients had a grade ≥ 3 cardiac event at a median of 11 months (interquartile range, 6 to 24 months), and 24-month cumulative incidence was 11% (95% CI, 5% to 16%). On multivariable analysis (MVA), pre-existing cardiac disease (hazard ratio [HR], 2.96; 95% CI, 1.07 to 8.21; P = .04) and mean heart dose (HR, 1.07/Gy; 95% CI, 1.02 to 1.13/Gy; P = .01) were significantly associated with grade ≥ 3 cardiac events. Analyzed as time-dependent variables on MVA analysis, both disease progression (HR, 2.15; 95% CI, 1.54 to 3.00) and grade ≥ 3 cardiac events (HR, 1.76; 95% CI, 1.04 to 2.99) were associated with decreased overall survival. However, disease progression (n = 71) was more common than grade ≥ 3 cardiac events (n = 19). Conclusion The 24-month cumulative incidence of grade ≥ 3 cardiac events exceeded 10% among patients with locally advanced NSCLC treated with definitive radiation. Pre-existing cardiac disease and higher mean heart dose were significantly associated with higher cardiac event rates. Caution should be used with cardiac dose to minimize risk of radiation-associated injury. However, cardiac risks should be balanced against tumor control, given the unfavorable prognosis associated with disease progression.
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Affiliation(s)
- Robert T Dess
- Robert T. Dess, Yilun Sun, Martha M. Matuszak, Grace Sun, Payal D. Soni, Latifa Bazzi, Venkatesh L. Murthy, Jason W.D. Hearn, Gregory P. Kalemkerian, James A. Hayman, Randall K. Ten Haken, Theodore S. Lawrence, Matthew J. Schipper, and Shruti Jolly, University of Michigan, Ann Arbor, MI; and Feng-Ming Kong, Indiana University, Indianapolis, IN
| | - Yilun Sun
- Robert T. Dess, Yilun Sun, Martha M. Matuszak, Grace Sun, Payal D. Soni, Latifa Bazzi, Venkatesh L. Murthy, Jason W.D. Hearn, Gregory P. Kalemkerian, James A. Hayman, Randall K. Ten Haken, Theodore S. Lawrence, Matthew J. Schipper, and Shruti Jolly, University of Michigan, Ann Arbor, MI; and Feng-Ming Kong, Indiana University, Indianapolis, IN
| | - Martha M Matuszak
- Robert T. Dess, Yilun Sun, Martha M. Matuszak, Grace Sun, Payal D. Soni, Latifa Bazzi, Venkatesh L. Murthy, Jason W.D. Hearn, Gregory P. Kalemkerian, James A. Hayman, Randall K. Ten Haken, Theodore S. Lawrence, Matthew J. Schipper, and Shruti Jolly, University of Michigan, Ann Arbor, MI; and Feng-Ming Kong, Indiana University, Indianapolis, IN
| | - Grace Sun
- Robert T. Dess, Yilun Sun, Martha M. Matuszak, Grace Sun, Payal D. Soni, Latifa Bazzi, Venkatesh L. Murthy, Jason W.D. Hearn, Gregory P. Kalemkerian, James A. Hayman, Randall K. Ten Haken, Theodore S. Lawrence, Matthew J. Schipper, and Shruti Jolly, University of Michigan, Ann Arbor, MI; and Feng-Ming Kong, Indiana University, Indianapolis, IN
| | - Payal D Soni
- Robert T. Dess, Yilun Sun, Martha M. Matuszak, Grace Sun, Payal D. Soni, Latifa Bazzi, Venkatesh L. Murthy, Jason W.D. Hearn, Gregory P. Kalemkerian, James A. Hayman, Randall K. Ten Haken, Theodore S. Lawrence, Matthew J. Schipper, and Shruti Jolly, University of Michigan, Ann Arbor, MI; and Feng-Ming Kong, Indiana University, Indianapolis, IN
| | - Latifa Bazzi
- Robert T. Dess, Yilun Sun, Martha M. Matuszak, Grace Sun, Payal D. Soni, Latifa Bazzi, Venkatesh L. Murthy, Jason W.D. Hearn, Gregory P. Kalemkerian, James A. Hayman, Randall K. Ten Haken, Theodore S. Lawrence, Matthew J. Schipper, and Shruti Jolly, University of Michigan, Ann Arbor, MI; and Feng-Ming Kong, Indiana University, Indianapolis, IN
| | - Venkatesh L Murthy
- Robert T. Dess, Yilun Sun, Martha M. Matuszak, Grace Sun, Payal D. Soni, Latifa Bazzi, Venkatesh L. Murthy, Jason W.D. Hearn, Gregory P. Kalemkerian, James A. Hayman, Randall K. Ten Haken, Theodore S. Lawrence, Matthew J. Schipper, and Shruti Jolly, University of Michigan, Ann Arbor, MI; and Feng-Ming Kong, Indiana University, Indianapolis, IN
| | - Jason W D Hearn
- Robert T. Dess, Yilun Sun, Martha M. Matuszak, Grace Sun, Payal D. Soni, Latifa Bazzi, Venkatesh L. Murthy, Jason W.D. Hearn, Gregory P. Kalemkerian, James A. Hayman, Randall K. Ten Haken, Theodore S. Lawrence, Matthew J. Schipper, and Shruti Jolly, University of Michigan, Ann Arbor, MI; and Feng-Ming Kong, Indiana University, Indianapolis, IN
| | - Feng-Ming Kong
- Robert T. Dess, Yilun Sun, Martha M. Matuszak, Grace Sun, Payal D. Soni, Latifa Bazzi, Venkatesh L. Murthy, Jason W.D. Hearn, Gregory P. Kalemkerian, James A. Hayman, Randall K. Ten Haken, Theodore S. Lawrence, Matthew J. Schipper, and Shruti Jolly, University of Michigan, Ann Arbor, MI; and Feng-Ming Kong, Indiana University, Indianapolis, IN
| | - Gregory P Kalemkerian
- Robert T. Dess, Yilun Sun, Martha M. Matuszak, Grace Sun, Payal D. Soni, Latifa Bazzi, Venkatesh L. Murthy, Jason W.D. Hearn, Gregory P. Kalemkerian, James A. Hayman, Randall K. Ten Haken, Theodore S. Lawrence, Matthew J. Schipper, and Shruti Jolly, University of Michigan, Ann Arbor, MI; and Feng-Ming Kong, Indiana University, Indianapolis, IN
| | - James A Hayman
- Robert T. Dess, Yilun Sun, Martha M. Matuszak, Grace Sun, Payal D. Soni, Latifa Bazzi, Venkatesh L. Murthy, Jason W.D. Hearn, Gregory P. Kalemkerian, James A. Hayman, Randall K. Ten Haken, Theodore S. Lawrence, Matthew J. Schipper, and Shruti Jolly, University of Michigan, Ann Arbor, MI; and Feng-Ming Kong, Indiana University, Indianapolis, IN
| | - Randall K Ten Haken
- Robert T. Dess, Yilun Sun, Martha M. Matuszak, Grace Sun, Payal D. Soni, Latifa Bazzi, Venkatesh L. Murthy, Jason W.D. Hearn, Gregory P. Kalemkerian, James A. Hayman, Randall K. Ten Haken, Theodore S. Lawrence, Matthew J. Schipper, and Shruti Jolly, University of Michigan, Ann Arbor, MI; and Feng-Ming Kong, Indiana University, Indianapolis, IN
| | - Theodore S Lawrence
- Robert T. Dess, Yilun Sun, Martha M. Matuszak, Grace Sun, Payal D. Soni, Latifa Bazzi, Venkatesh L. Murthy, Jason W.D. Hearn, Gregory P. Kalemkerian, James A. Hayman, Randall K. Ten Haken, Theodore S. Lawrence, Matthew J. Schipper, and Shruti Jolly, University of Michigan, Ann Arbor, MI; and Feng-Ming Kong, Indiana University, Indianapolis, IN
| | - Matthew J Schipper
- Robert T. Dess, Yilun Sun, Martha M. Matuszak, Grace Sun, Payal D. Soni, Latifa Bazzi, Venkatesh L. Murthy, Jason W.D. Hearn, Gregory P. Kalemkerian, James A. Hayman, Randall K. Ten Haken, Theodore S. Lawrence, Matthew J. Schipper, and Shruti Jolly, University of Michigan, Ann Arbor, MI; and Feng-Ming Kong, Indiana University, Indianapolis, IN
| | - Shruti Jolly
- Robert T. Dess, Yilun Sun, Martha M. Matuszak, Grace Sun, Payal D. Soni, Latifa Bazzi, Venkatesh L. Murthy, Jason W.D. Hearn, Gregory P. Kalemkerian, James A. Hayman, Randall K. Ten Haken, Theodore S. Lawrence, Matthew J. Schipper, and Shruti Jolly, University of Michigan, Ann Arbor, MI; and Feng-Ming Kong, Indiana University, Indianapolis, IN
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