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Locquet M, Jacob S, Geets X, Beaudart C. Dose-volume predictors of cardiac adverse events after high-dose thoracic radiation therapy for lung cancer: a systematic review and meta-analysis. BMC Cancer 2024; 24:1556. [PMID: 39702000 DOI: 10.1186/s12885-024-13281-8] [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: 09/30/2024] [Accepted: 12/02/2024] [Indexed: 12/21/2024] Open
Abstract
BACKGROUND Lung cancer is a leading cause of cancer mortality and may require high-dose thoracic radiation therapy (RT). However, RT significantly increases the risk of radiation-induced cardiac events, such as pericarditis, cardiomyopathy, and ischemic heart diseases. Despite evidence from clinical trials showing that higher RT doses are associated with poorer survival outcomes due to these cardiac effects, data on dose-volume predictors of such events in lung cancer remain sparse. OBJECTIVE To systematically synthesize the incidence of cardiac events following radiation therapy for lung cancer treatment and dose-volume metrics predictors of radiation therapy-induced cardiac events in lung cancer treatment. METHODS This systematic review, registered on PROSPERO (CRD42024565103), adhered to PRISMA guidelines to investigate cardiac events and its dose-volume predictors following high-dose radiation therapy in adults with lung cancer. Data were extracted from longitudinal observational studies and randomized controlled trials. A comprehensive literature search was conducted across MEDLINE, Cochrane CENTRAL, and Embase, with studies selected based on predefined criteria, focusing on clinical cardiac outcomes. Data extraction followed CHARMS guidelines, and study quality was reported using the PROBAST tool. Results were synthesized narratively, with meta-analyses performed where appropriate using R software to estimate pooled effect sizes, heterogeneity, and publication bias. RESULTS The systematic review included 21 studies and identified a significant association between high-dose thoracic radiation therapy (RT) and an increased incidence of cardiac adverse events in lung cancer patients. The review revealed that higher dose-volume parameters, notably higher mean heart doses (MHD), were predictive of major cardiac events such as pericardial effusion, arrhythmias, and acute coronary syndrome. The meta-analysis showed a significant 4% (95% confidence interval: 3%-6%) increased probability of the occurrence of cardiac events per additional Gray of MHD, with low heterogeneity among studies (I2 = 23%). No publication bias was evidenced. CONCLUSION This study underscores the importance of dose-volume parameters as predictors of cardiac adverse events following high-dose thoracic RT in lung cancer treatment. The findings highlight the need for careful consideration of heart dose constraints in RT planning to mitigate the risk of radiation-induced cardiotoxicity, thereby improving the therapeutic ratio for lung cancer patients. Future research should focus on refining these dose constraints and exploring cardioprotective strategies during lung cancer radiotherapy.
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Affiliation(s)
- Médéa Locquet
- Department of Biomedical Sciences, Namur Research Institute for Life Sciences, (NARILIS), Faculty of Medicine, University of Namur, Namur, Belgium.
- Clinical Pharmacology and Toxicology Research Unit, Namur Research Institute for Life Sciences, Faculty of Medicine, University of Namur, 5000, Namur, Belgium.
- National Institute for Medical Research (Inserm), Unit 1018 Centre for Research in Epidemiology and Population Health, Laboratory of "Epidemiology of Radiations, Clinical Epidemiology and Cancer Survivorship", Paris-Saclay University, Gif-Sur-Yvette, France.
| | - Sophie Jacob
- Laboratory of Epidemiology (LEPID), Institut de Radioprotection Et de Sureté Nucléaire, Fontenay-Aux-Roses, France
| | - Xavier Geets
- Radiation Oncology Department, Cliniques Universitaires Saint-Luc, 1200 Brussels, MIRO Lab. IREC - UCLouvain, Brussels, Belgium
| | - Charlotte Beaudart
- Department of Biomedical Sciences, Namur Research Institute for Life Sciences, (NARILIS), Faculty of Medicine, University of Namur, Namur, Belgium
- Clinical Pharmacology and Toxicology Research Unit, Namur Research Institute for Life Sciences, Faculty of Medicine, University of Namur, 5000, Namur, Belgium
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Lorenzo-Esteller L, Ramos-Polo R, Pons Riverola A, Morillas H, Berdejo J, Pernas S, Pomares H, Asiain L, Garay A, Martínez Pérez E, Jiménez-Marrero S, Alcoberro L, Nadal E, Gubern-Prieto P, Gual-Capllonch F, Hidalgo E, Enjuanes C, Comin-Colet J, Moliner P. Pericardial Disease in Patients with Cancer: Clinical Insights on Diagnosis and Treatment. Cancers (Basel) 2024; 16:3466. [PMID: 39456560 PMCID: PMC11505731 DOI: 10.3390/cancers16203466] [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: 08/06/2024] [Revised: 10/02/2024] [Accepted: 10/04/2024] [Indexed: 10/28/2024] Open
Abstract
Pericardial disease is increasingly recognized in cancer patients, including acute pericarditis, pericardial effusion, and constrictive pericarditis, often indicating a poor prognosis. Acute pericarditis arises from direct tumor involvement, cancer therapies, and radiotherapy. Immune checkpoint inhibitor (ICI)-related pericarditis, though rare, entails significant mortality risk. Treatment includes NSAIDs, colchicine, and corticosteroids or anti-IL1 drugs in refractory cases. Pericardial effusion is the most frequent manifestation, primarily caused by lung cancer, followed by breast cancer, lymphoma, leukemia, gastrointestinal tumors, and melanoma. Chemotherapy, immunotherapy, and radiotherapy may also cause fluid accumulation in the pericardial space. Symptomatic relief for pericardial effusion may require pericardiocentesis, prolonged catheter drainage, or a pericardial window. Instillation of intrapericardial cytostatic agents may reduce recurrence. Constrictive pericarditis, though less common, often develops from radiotherapy and requires multimodality imaging for diagnosis, with pericardiectomy as the definitive treatment. Primary pericardial tumors are rare, with metastases being more frequent. Patients with cancer and pericardial disease generally have poor survival, emphasizing the need for early detection. A multidisciplinary approach involving hematologists, oncologists, and cardiologists is crucial to tailoring pericardial disease treatment to a patient's clinical status, thereby improving the quality of life and prognosis.
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Affiliation(s)
- Laia Lorenzo-Esteller
- Cardiology Department, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.L.-E.); (R.R.-P.); (H.M.)
| | - Raúl Ramos-Polo
- Cardiology Department, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.L.-E.); (R.R.-P.); (H.M.)
- Cardio-Oncology Unit, Bellvitge University Hospital—Catalan Institute of Oncology, L’Hospitalet de Llobregat, 08908 Barcelona, Spain
- Bio-Heart Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Alexandra Pons Riverola
- Cardiology Department, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.L.-E.); (R.R.-P.); (H.M.)
- Cardio-Oncology Unit, Bellvitge University Hospital—Catalan Institute of Oncology, L’Hospitalet de Llobregat, 08908 Barcelona, Spain
- Bio-Heart Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Herminio Morillas
- Cardiology Department, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.L.-E.); (R.R.-P.); (H.M.)
- Cardio-Oncology Unit, Bellvitge University Hospital—Catalan Institute of Oncology, L’Hospitalet de Llobregat, 08908 Barcelona, Spain
- Bio-Heart Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Javier Berdejo
- Cardiology Department, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.L.-E.); (R.R.-P.); (H.M.)
- Cardio-Oncology Unit, Bellvitge University Hospital—Catalan Institute of Oncology, L’Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Sonia Pernas
- Medical Oncology Department, Catalan Institute of Oncology, L’Hospitalet de Llobregat, 08908 Barcelona, Spain; (S.P.)
| | - Helena Pomares
- Clinical Haematology Department, Catalan Institute of Oncology, L’Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Leyre Asiain
- Radiation Oncology Department, Catalan Institute of Oncology, L’Hospitalet de Llobregat, 08908 Barcelona, Spain; (L.A.)
| | - Alberto Garay
- Cardiology Department, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.L.-E.); (R.R.-P.); (H.M.)
- Cardio-Oncology Unit, Bellvitge University Hospital—Catalan Institute of Oncology, L’Hospitalet de Llobregat, 08908 Barcelona, Spain
- Bio-Heart Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, 08908 Barcelona, Spain
- Preclinical and Experimental Research in Thoracic Tumors (PRETT), Oncobell, Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Evelyn Martínez Pérez
- Radiation Oncology Department, Catalan Institute of Oncology, L’Hospitalet de Llobregat, 08908 Barcelona, Spain; (L.A.)
| | - Santiago Jiménez-Marrero
- Cardiology Department, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.L.-E.); (R.R.-P.); (H.M.)
- Cardio-Oncology Unit, Bellvitge University Hospital—Catalan Institute of Oncology, L’Hospitalet de Llobregat, 08908 Barcelona, Spain
- Bio-Heart Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, 08908 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto Salud Carlos III, 28029 Madrid, Spain
| | - Lidia Alcoberro
- Cardiology Department, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.L.-E.); (R.R.-P.); (H.M.)
- Bio-Heart Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Ernest Nadal
- Medical Oncology Department, Catalan Institute of Oncology, L’Hospitalet de Llobregat, 08908 Barcelona, Spain; (S.P.)
- Preclinical and Experimental Research in Thoracic Tumors (PRETT), Oncobell, Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Paula Gubern-Prieto
- Medical Oncology Department, Catalan Institute of Oncology, L’Hospitalet de Llobregat, 08908 Barcelona, Spain; (S.P.)
| | | | - Encarna Hidalgo
- Cardiology Department, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.L.-E.); (R.R.-P.); (H.M.)
- Cardio-Oncology Unit, Bellvitge University Hospital—Catalan Institute of Oncology, L’Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Cristina Enjuanes
- Cardiology Department, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.L.-E.); (R.R.-P.); (H.M.)
- Bio-Heart Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, 08908 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto Salud Carlos III, 28029 Madrid, Spain
| | - Josep Comin-Colet
- Cardiology Department, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.L.-E.); (R.R.-P.); (H.M.)
- Bio-Heart Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, 08908 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto Salud Carlos III, 28029 Madrid, Spain
- Department of Clinical Sciences, School of Medicine, Universitat de Barcelona (UB), L’Hospitalet de Llobregat, 08036 Barcelona, Spain
| | - Pedro Moliner
- Cardiology Department, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (L.L.-E.); (R.R.-P.); (H.M.)
- Cardio-Oncology Unit, Bellvitge University Hospital—Catalan Institute of Oncology, L’Hospitalet de Llobregat, 08908 Barcelona, Spain
- Bio-Heart Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, 08908 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto Salud Carlos III, 28029 Madrid, Spain
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Salem PP, Chami P, Daou R, Hajj J, Lin H, Chhabra AM, Simone CB, Lee NY, Hajj C. Proton Radiation Therapy: A Systematic Review of Treatment-Related Side Effects and Toxicities. Int J Mol Sci 2024; 25:10969. [PMID: 39456752 PMCID: PMC11506991 DOI: 10.3390/ijms252010969] [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: 09/20/2024] [Revised: 10/09/2024] [Accepted: 10/10/2024] [Indexed: 10/28/2024] Open
Abstract
Cancer is the second leading cause of death worldwide. Around half of all cancer patients undergo some type of radiation therapy throughout the course of their treatment. Photon radiation remains (RT) the most widely utilized modality of radiotherapy despite recent advancements in proton radiation therapy (PBT). PBT makes use of the particle's biological property known as the Bragg peak to better spare healthy tissue from radiation damage, with data to support that this treatment modality is less toxic than photon RT. Hence, proton radiation dosimetry looks better compared to photon dosimetry; however, due to proton-specific uncertainties, unexpected acute, subacute, and long-term toxicities can be encountered. Reported neurotoxicity resulting from proton radiation treatments include radiation necrosis, moyamoya syndrome, neurosensory toxicities, brain edema, neuromuscular toxicities, and neurocognitive toxicities. Pulmonary toxicities include pneumonitis and fibrosis, pleural effusions, and bronchial toxicities. Pericarditis, pericardial effusions, and atrial fibrillations are among the cardiac toxicities related to proton therapy. Gastrointestinal and hematological toxicities are also found in the literature. Genitourinary toxicities include urinary and reproductive-related toxicities. Osteological, oral, endocrine, and skin toxicities have also been reported. The side effects will be comparable to the ones following photon RT, nonetheless at an expected lower incidence. The toxicities collected mainly from case reports and clinical trials are described based on the organs affected and functions altered.
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Affiliation(s)
- Peter P. Salem
- Faculty of Medicine, American University of Beirut, Beirut 1107, Lebanon; (P.P.S.); (P.C.)
| | - Perla Chami
- Faculty of Medicine, American University of Beirut, Beirut 1107, Lebanon; (P.P.S.); (P.C.)
| | - Remy Daou
- Family Medicine Department, Hotel Dieu de France Hospital, Beirut 1660, Lebanon;
| | - Joseph Hajj
- Faculty of Medicine, University of Balamand, Beirut 1100, Lebanon;
| | - Haibo Lin
- New York Proton Center, New York, NY 10035, USA; (H.L.); (A.M.C.); (C.B.S.II); (N.Y.L.)
| | - Arpit M. Chhabra
- New York Proton Center, New York, NY 10035, USA; (H.L.); (A.M.C.); (C.B.S.II); (N.Y.L.)
| | - Charles B. Simone
- New York Proton Center, New York, NY 10035, USA; (H.L.); (A.M.C.); (C.B.S.II); (N.Y.L.)
- Memorial Sloan Kettering Cancer Center, New York, NY 10027, USA
| | - Nancy Y. Lee
- New York Proton Center, New York, NY 10035, USA; (H.L.); (A.M.C.); (C.B.S.II); (N.Y.L.)
- Memorial Sloan Kettering Cancer Center, New York, NY 10027, USA
| | - Carla Hajj
- New York Proton Center, New York, NY 10035, USA; (H.L.); (A.M.C.); (C.B.S.II); (N.Y.L.)
- Memorial Sloan Kettering Cancer Center, New York, NY 10027, USA
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4
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Uehara M, Bekki N, Shiga T. Radiation-associated cardiovascular disease in patients with cancer: current insights from a cardio-oncologist. JOURNAL OF RADIATION RESEARCH 2024; 65:575-590. [PMID: 39256035 PMCID: PMC11420984 DOI: 10.1093/jrr/rrae068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 08/04/2024] [Indexed: 09/12/2024]
Abstract
Radiation-associated cardiovascular disease (RACD), a complex disease characterized with pericarditis, myocardial damage, valvular heart diseases, heart failure, vasculopathy and ischemic heart disease, has a generally poor prognosis. While RACD may be acute, it often manifests in the late years or even decades following radiation exposure to the chest. With an increasing number of cancer survivors, RACD is likely to become an important issue in cardio-oncology. This review discusses pre-radiation therapy (RT) preparation, peri-RT patient management and long follow-up planning post-RT from a cardiology perspective. Additionally, a novel technique of stereotactic radiotherapy, which has been applied for the treatment of intractable cardiac arrhythmias, is presented. Appropriate patient examination and management during and after RT are essential to support patients undergoing cancer treatment to improve long life expectancy. A multidisciplinary team is needed to determine how to manage patients who receive RT to reduce RACD, to detect early phases of RACD and to provide the best treatment for RACD. Recent studies increasingly report advances in diagnosis using new equipment that has the potential to detect early phases of RACD, along with growing evidence for the optimal treatment for RACD. This review provides an overview of recent studies and guidelines to report on the latest findings, and to identify unresolved issues surrounding RACD that require validation in future studies.
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Affiliation(s)
- Masae Uehara
- Department of Onco-Cardiology/Cardiovascular Medicine, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo 135-8550, Japan
| | - Norifumi Bekki
- Department of Onco-Cardiology/Cardiovascular Medicine, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo 135-8550, Japan
| | - Taro Shiga
- Department of Onco-Cardiology/Cardiovascular Medicine, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo 135-8550, Japan
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5
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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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Mori S, Bertamino M, Guerisoli L, Stratoti S, Canale C, Spallarossa P, Porto I, Ameri P. Pericardial effusion in oncological patients: current knowledge and principles of management. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2024; 10:8. [PMID: 38365812 PMCID: PMC10870633 DOI: 10.1186/s40959-024-00207-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/05/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND This article provides an up-to-date overview of pericardial effusion in oncological practice and a guidance on its management. Furthermore, it addresses the question of when malignancy should be suspected in case of newly diagnosed pericardial effusion. MAIN BODY Cancer-related pericardial effusion is commonly the result of localization of lung and breast cancer, melanoma, or lymphoma to the pericardium via direct invasion, lymphatic dissemination, or hematogenous spread. Several cancer therapies may also cause pericardial effusion, most often during or shortly after administration. Pericardial effusion following radiation therapy may instead develop after years. Other diseases, such as infections, and, rarely, primary tumors of the pericardium complete the spectrum of the possible etiologies of pericardial effusion in oncological patients. The diagnosis of cancer-related pericardial effusion is usually incidental, but cancer accounts for approximately one third of all cardiac tamponades. Drainage, which is mainly attained by pericardiocentesis, is needed when cancer or cancer treatment-related pericardial effusion leads to hemodynamic impairment. Placement of a pericardial catheter for 2-5 days is advised after pericardial fluid removal. In contrast, even a large pericardial effusion should be conservatively managed when the patient is stable, although the best frequency and timing of monitoring by echocardiography in this context are yet to be established. Pericardial effusion secondary to immune checkpoint inhibitors typically responds to corticosteroid therapy. Pericardiocentesis may also be considered to confirm the presence of neoplastic cells in the pericardial fluid, but the yield of cytological examination is low. In case of newly found pericardial effusion in individuals without active cancer and/or recent cancer treatment, a history of malignancy, unremitting or recurrent course, large effusion or presentation with cardiac tamponade, incomplete response to empirical therapy with nonsteroidal anti-inflammatory, and hemorrhagic fluid at pericardiocentesis suggest a neoplastic etiology.
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Affiliation(s)
- S Mori
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - M Bertamino
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - L Guerisoli
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - S Stratoti
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - C Canale
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - P Spallarossa
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - I Porto
- Department of Internal Medicine, University of Genova, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - P Ameri
- Department of Internal Medicine, University of Genova, Genova, Italy.
- IRCCS Ospedale Policlinico San Martino, Genova, Italy.
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Liou Y, Lan TL, Lan CC. A Meta-Analysis and Review of Radiation Dose Escalation in Definitive Radiation Therapy between Squamous Cell Carcinoma and Adenocarcinoma of Esophageal Cancer. Cancers (Basel) 2024; 16:658. [PMID: 38339409 PMCID: PMC10854668 DOI: 10.3390/cancers16030658] [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: 01/15/2024] [Revised: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 02/12/2024] Open
Abstract
Esophageal cancer, ranked as the eighth most prevalent cancer globally, is characterized by a low survival rate and poor prognosis. Concurrent chemoradiation therapy (CCRT) is the standard therapy in the non-surgical treatment of localized carcinoma of the esophagus. Nevertheless, the radiation doses employed in CCRT remain notably lower compared to the curative definite chemoradiation therapy utilized in the management of other carcinomas. In order to increase the local control rates and enhance the treatment outcomes, several clinical trials have used high-dose radiation to analyze the effect of dose escalation. Despite the integration of technically advanced RT schemes such as intensity-modulated radiation therapy (IMRT), the results of these trials have failed to demonstrate a significant improvement in overall survival or local progression-free survival. In this review, we investigated previous clinical trials to determine the ineffectiveness of radiation dose escalation in the context of CCRT for esophageal cancer. We aim to clarify the factors contributing to the limited efficacy of escalated radiation doses in improving patient outcomes. Furthermore, we delve into recent research endeavors, exploring prospective radiation dose modifications being altered based on the histological characteristics of the carcinoma. The exploration of these recent studies not only sheds light on potential refinements to the existing treatment protocols but also seeks to identify novel approaches that may pave the way for more efficacious and personalized therapeutic strategies for esophageal cancer management.
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Affiliation(s)
- Yu Liou
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong Street, Beitou District, Taipei City 112, Taiwan
| | - Tien-Li Lan
- Department of Heavy Particles and Radiation Oncology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City 112, Taiwan
| | - Chin-Chun Lan
- Thoracic Surgery Group, Clinical Research Center, Department of Surgery, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua City 500, Taiwan
- Department of Emergency and Critical Care Medicine, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua City 500, Taiwan
- Post-Baccalaureate Medical School, National Chung Hsing University, 145 Xingda Rd., South District, Taichung City 402, Taiwan
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Petit C, Escande A, Sarrade T, Vaugier L, Kirova Y, Tallet A. Radiation therapy in the thoracic region: Radio-induced cardiovascular disease, cardiac delineation and sparing, cardiac dose constraints, and cardiac implantable electronic devices. Cancer Radiother 2023; 27:588-598. [PMID: 37648559 DOI: 10.1016/j.canrad.2023.06.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 09/01/2023]
Abstract
Radiation therapy in the thoracic region may deliver incidental ionizing radiation to the surrounding healthy structures, including the heart. Radio-induced heart toxicity has long been a concern in breast cancer and Hodgkin's lymphoma and was deemed a long-term event. However, recent data highlight the need to limit the dose to the heart in less favorable thoracic cancers too, such as lung and esophageal cancers in which incidental irradiation led to increased mortality. This article will summarize available cardiac dose constraints in various clinical settings and the types of radio-induced cardiovascular diseases encountered as well as delineation of cardiac subheadings and management of cardiac devices. Although still not completely deciphered, heart dose constraints remain intensively investigated and the mean dose to the heart is no longer the only dosimetric parameter to consider since the left anterior descending artery as well as the left ventricle should also be part of dosimetry constraints.
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Affiliation(s)
- C Petit
- Radiation Oncology Department, institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13273 Marseille cedex 09, France
| | - A Escande
- Service de radiothérapie, centre Léonard-de-Vinci, Dechy, France; UMR 9189, laboratoire Cristal, université de Lille, Villeneuve-d'Ascq, France
| | - T Sarrade
- Department of Radiation Oncology, hôpital Tenon, Sorbonne université, 75020 Paris, France
| | - L Vaugier
- Department of Radiation Oncology, institut de cancérologie de l'Ouest, Saint-Herblain, France
| | - Y Kirova
- Department of Radiation Oncology, institut Curie, Paris, France
| | - A Tallet
- Radiation Oncology Department, institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13273 Marseille cedex 09, France; UMR 1068, CRCM Inserm, Marseille, France.
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9
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Coma N, Resta H, Moral S, Eraso MA, Ventura M, Brugada R. Uncommon short- and long-term cardiological side effects of thoracic radiation: a report of two cases. Future Cardiol 2023; 19:529-535. [PMID: 37539682 DOI: 10.2217/fca-2023-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023] Open
Abstract
Radiotherapy is an essential treatment of more than 50% of oncohematological patients. Pericardial disorders and valvular heart disease are two common radiotherapy complications. Acute pericarditis is infrequent and usually underdiagnosed. Therefore, diagnostic suspicion and early treatment are mandatory to avoid the evolution to constrictive pericarditis. The prevalence of radiation-induced valvular heart disease is common in patients with a history of Hodgkin's lymphoma and breast cancer. It has distinctive characteristics from other etiologies and, thus, different therapeutic approaches. We present two cases of unusual complications of radiotherapy; the first one in the acute setting and the second one during the follow-up in the chronic phase. A multidisciplinary and individualized approach with specific considerations is decisive in the management of these patients.
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Affiliation(s)
- Núria Coma
- Cardiology Department, Hospital Universitari Doctor Josep Trueta, Girona, 17007, Spain
- Medical Science Department School of Medicine, University of Girona, Girona, 17007, Spain
| | - Helena Resta
- Cardiology Department, Hospital Universitari Doctor Josep Trueta, Girona, 17007, Spain
| | - Sergio Moral
- Cardiology Department, Hospital Universitari Doctor Josep Trueta, Girona, 17007, Spain
- Medical Science Department School of Medicine, University of Girona, Girona, 17007, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, 28029, Spain
| | | | - Montse Ventura
- Radiation Oncology Department, Institut Català d'Oncologia, L'Hospitalet de Llobregat, 08908, Spain
| | - Ramon Brugada
- Cardiology Department, Hospital Universitari Doctor Josep Trueta, Girona, 17007, Spain
- Medical Science Department School of Medicine, University of Girona, Girona, 17007, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, 28029, Spain
- Center for Cardiovascular Genetics, Biomedical Research Institute of Girona, Girona, 17007, Spain
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10
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Wang X, Bai H, Gao M, Guan Y, Yu L, Li J, Dong Y, Song Y, Tao Z, Meng M, Wu Z, Zhao L, Yuan Z. Impact of radiation dose to the immune system on disease progression and survival for early-stage non-small cell lung cancer treated with stereotactic body radiation therapy. Radiother Oncol 2023; 186:109804. [PMID: 37437605 DOI: 10.1016/j.radonc.2023.109804] [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: 01/11/2023] [Revised: 06/23/2023] [Accepted: 07/04/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVES Although the effects of estimated dose of radiation to immune cells (EDRIC) in stage III NSCLC, LA-NSCLC, LS-SCLC and esophageal cancer on clinical outcomes have been studied, its impact in early-stage non-small cell lung cancer (ES-NSCLC) is unknown. In this study, we evaluated the role of EDRIC and identified the factors influencing EDRIC in this population. METHODS AND MATERIALS We retrospectively analyzed 211 pathologically confirmed ES-NSCLC patients who were treated with SBRT between 2007 and 2020. EDRIC was calculated based on the model developed by Jin et al. and improved by Ladbury et al. Kaplan-Meier method and Cox proportional hazards regression were adopted to estimate CSS, PFS, LPFS, and DMFS. Pearson correlation was used to assess the correlation between variables. We further validated our findings in an independent cohort of 119 patients with ES-NSCLC. RESULTS A total of 211 patients were included with median follow-up of 48 months in the training cohort. The median EDRIC was 2.178 Gy (range: 0.426-6.015). GTV showed a positive correlation with EDRIC (r = 0.707, P = 0.000). In multivariate analysis, higher EDRIC was significantly associated with worse CSS (HR = 1.468, P = 0.009) and DMFS (HR = 1.491, P = 0.016). Considering each EDRIC quartile, there was a significant difference in CSS between 1st and 4th and 1st and 3rd quartile (P = 0.000, P = 0.004, respectively); and DMFS between 1st and 4th,1st and 3rd, and 1st and 2nd quartile (P = 0.000, P = 0.000, P = 0.008, respectively). In the subgroup and validation cohort, EDRIC was also the important prognostic predictor of CSS and DMFS using multivariate analysis. CONCLUSION EDRIC was an independent predictor of CSS and DMFS in ES-NSCLC, and it was affected by GTV and tumor location. Though EDRIC is a critical determinant of treatment outcomes, it is quantifiable and potentially modifiable. Additional researches exploring the feasibility of achieving lower EDRIC while maintaining adequate tumor coverage during radiotherapy are warranted.
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Affiliation(s)
- Xiaofeng Wang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Hui Bai
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Miaomiao Gao
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Yong Guan
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Lu Yu
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Junyi Li
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Yang Dong
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Yongchun Song
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Zhen Tao
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Maobin Meng
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Zhiqiang Wu
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Lujun Zhao
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Zhiyong Yuan
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China.
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11
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Andruska N, Schlaak RA, Frei A, Schottstaedt AM, Lin CY, Fish BL, Gasperetti T, Mpoy C, Pipke JL, Pedersen LN, Flister MJ, Javaheri A, Bergom C. Differences in radiation-induced heart dysfunction in male versus female rats. Int J Radiat Biol 2023; 99:1096-1108. [PMID: 36971580 PMCID: PMC10431914 DOI: 10.1080/09553002.2023.2194404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 02/24/2023] [Accepted: 03/14/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE Radiation therapy remains part of the standard of care for breast, lung, and esophageal cancers. While radiotherapy improves local control and survival, radiation-induced heart dysfunction is a common side effect of thoracic radiotherapy. Cardiovascular dysfunction can also result from non-therapeutic total body radiation exposures. Numerous studies have evaluated the relationship between radiation dose to the heart and cardiotoxicity, but relatively little is known about whether there are differences based on biological sex in radiation-induced heart dysfunction (RIHD). MATERIALS AND METHODS We evaluated whether male and female inbred Dahl SS rats display differences in RIHD following delivery of 24 Gy in a single fraction to the whole heart using a 1.5 cm beam size (collimater). We also compared the 2.0 cm vs. 1.5 cm collimator in males. Pleural and pericardial effusions and normalized heart weights were measured, and echocardiograms were performed. RESULTS Female SS rats displayed more severe RIHD relative to age-matched SS male rats. Normalized heart weight was significantly increased in females, but not in males. A total of 94% (15/16) of males and 55% (6/11) of females survived 5 months after completion of radiotherapy (p < .01). Among surviving rats, 100% of females and 14% of males developed moderate-to-severe pericardial effusions at 5 months. Females demonstrated increased pleural effusions, with the mean normalized pleural fluid volume for females and males being 56.6 mL/kg ± 12.1 and 10.96 mL/kg ± 6.4 in males (p = .001), respectively. Echocardiogram findings showed evidence of heart failure, which was more pronounced in females. Because age-matched female rats have smaller lungs, a higher percentage of the total lung was treated with radiation in females than males using the same beam size. After using a larger 2 cm beam in males which results in higher lung exposure, there was not a significant difference between males and females in terms of the development of moderate-to-severe pericardial effusions or pleural effusions. Treatment of males with a 2 cm beam resulted in comparable increases in LV mass and reductions in stroke volume to female rats treated with a 1.5 cm beam. CONCLUSION Together, these results illustrate that there are differences in radiation-induced cardiotoxicity between male and female SS rats and add to the data that lung radiation doses, in addition to other factors, may play an important role in cardiac dysfunction following heart radiation exposure. These factors may be important to factor into future mitigation studies of radiation-induced cardiotoxicity.
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Affiliation(s)
- Neal Andruska
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Rachel A. Schlaak
- Department of Pharmacology & Toxicology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anne Frei
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Chieh-Yu Lin
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Brian L. Fish
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tracy Gasperetti
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cedric Mpoy
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Jamie L. Pipke
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lauren N. Pedersen
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Michael J. Flister
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ali Javaheri
- Department of Medicine, Division of Cardiology, Washington University School of Medicine, St Louis, Missouri
| | - Carmen Bergom
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, Missouri
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12
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Hoppen L, Sarria GR, Kwok CS, Boda-Heggemann J, Buergy D, Ehmann M, Giordano FA, Fleckenstein J. Dosimetric benefits of adaptive radiation therapy for patients with stage III non-small cell lung cancer. Radiat Oncol 2023; 18:34. [PMID: 36814271 PMCID: PMC9945670 DOI: 10.1186/s13014-023-02222-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/06/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Daily adaptive radiation therapy (ART) of patients with non-small cell lung cancer (NSCLC) lowers organs at risk exposure while maintaining the planning target volume (PTV) coverage. Thus, ART allows an isotoxic approach with increased doses to the PTV that could improve local tumor control. Herein we evaluate daily online ART strategies regarding their impact on relevant dose-volume metrics. METHODS Daily cone-beam CTs (1 × n = 28, 1 × n = 29, 11 × n = 30) of 13 stage III NSCLC patients were converted into synthetic CTs (sCTs). Treatment plans (TPs) were created retrospectively on the first-fraction sCTs (sCT1) and subsequently transferred unaltered to the sCTs of the remaining fractions of each patient (sCT2-n) (IGRT scenario). Two additional TPs were generated on sCT2-n: one minimizing the lung-dose while preserving the D95%(PTV) (isoeffective scenario), the other escalating the D95%(PTV) with a constant V20Gy(lungipsilateral) (isotoxic scenario). RESULTS Compared to the original TPs predicted dose, the median D95%(PTV) in the IGRT scenario decreased by 1.6 Gy ± 4.2 Gy while the V20Gy(lungipsilateral) increased in median by 1.1% ± 4.4%. The isoeffective scenario preserved the PTV coverage and reduced the median V20Gy(lungipsilateral) by 3.1% ± 3.6%. Furthermore, the median V5%(heart) decreased by 2.9% ± 6.4%. With an isotoxic prescription, a median dose-escalation to the gross target volume of 10.0 Gy ± 8.1 Gy without increasing the V20Gy(lungipsilateral) and V5%(heart) was feasible. CONCLUSIONS We demonstrated that even without reducing safety margins, ART can reduce lung-doses, while still reaching adequate target coverage or escalate target doses without increasing ipsilateral lung exposure. Clinical benefits by means of toxicity and local control of both strategies should be evaluated in prospective clinical trials.
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Affiliation(s)
- Lea Hoppen
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Gustavo R. Sarria
- grid.10388.320000 0001 2240 3300Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Chung S. Kwok
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Judit Boda-Heggemann
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Daniel Buergy
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Michael Ehmann
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Frank A. Giordano
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Jens Fleckenstein
- grid.7700.00000 0001 2190 4373Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
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13
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Aguado-Barrera ME, Sosa-Fajardo P, Gómez-Caamaño A, Taboada-Valladares B, Couñago F, López-Guerra JL, Vega A. Radiogenomics in lung cancer: Where are we? Lung Cancer 2023; 176:56-74. [PMID: 36621035 DOI: 10.1016/j.lungcan.2023.01.001] [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: 10/25/2022] [Revised: 12/22/2022] [Accepted: 01/01/2023] [Indexed: 01/04/2023]
Abstract
Huge technological and biomedical advances have improved the survival and quality of life of lung cancer patients treated with radiotherapy. However, during treatment planning, a probability that the patient will experience adverse effects is assumed. Radiotoxicity is a complex entity that is largely dose-dependent but also has important intrinsic factors. One of the most studied is the genetic variants that may be associated with susceptibility to the development of adverse effects of radiotherapy. This review aims to present the current status of radiogenomics in lung cancer, integrating results obtained in association studies of SNPs (single nucleotide polymorphisms) related to radiotherapy toxicities. We conclude that despite numerous publications in this field, methodologies and endpoints vary greatly, making comparisons between studies difficult. Analyzing SNPs from the candidate gene approach, together with the study in cohorts limited by the sample size, has complicated the possibility of having validated results. All this delays the incorporation of genetic biomarkers in predictive models for clinical application. Thus, from all analysed SNPs, only 12 have great potential as esophagitis genetic risk factors and deserve further exploration. This review highlights the efforts that have been made to date in the radiogenomic study of radiotoxicity in lung cancer.
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Affiliation(s)
- Miguel E Aguado-Barrera
- Grupo Genética en Cáncer y Enfermedades Raras, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Av. Choupana s/n, Edif. D, Planta 1, 15706, Santiago de Compostela, A Coruña, Spain; Fundación Pública Galega de Medicina Xenómica (FPGMX), Av. Choupana s/n, Edif. Consultas, Planta menos 2, 15706, Santiago de Compostela, A Coruña, Spain
| | - Paloma Sosa-Fajardo
- Grupo Genética en Cáncer y Enfermedades Raras, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Av. Choupana s/n, Edif. D, Planta 1, 15706, Santiago de Compostela, A Coruña, Spain; Department of Radiation Oncology, University Hospital Virgen del Rocío, Av. Manuel Siurot, s/n, 41013, Seville, Spain
| | - Antonio Gómez-Caamaño
- Grupo Genética en Cáncer y Enfermedades Raras, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Av. Choupana s/n, Edif. D, Planta 1, 15706, Santiago de Compostela, A Coruña, Spain; Department of Radiation Oncology, Hospital Clínico Universitario de Santiago de Compostela, Servizo Galego de Saúde (SERGAS), Av. Choupana s/n, Edif. Consultas, Planta menos 3, 15706, Santiago de Compostela, A Coruña, Spain
| | - Begoña Taboada-Valladares
- Grupo Genética en Cáncer y Enfermedades Raras, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Av. Choupana s/n, Edif. D, Planta 1, 15706, Santiago de Compostela, A Coruña, Spain; Department of Radiation Oncology, Hospital Clínico Universitario de Santiago de Compostela, Servizo Galego de Saúde (SERGAS), Av. Choupana s/n, Edif. Consultas, Planta menos 3, 15706, Santiago de Compostela, A Coruña, Spain
| | - Felipe Couñago
- Department of Radiation Oncology, Hospital Universitario Quirónsalud Madrid, C. del Maestro Ángel Llorca 8, 28003, Madrid, Spain
| | - José Luis López-Guerra
- Department of Radiation Oncology, University Hospital Virgen del Rocío, Av. Manuel Siurot, s/n, 41013, Seville, Spain; Instituto de Biomedicina de Sevilla (IBIS/HUVR/CSIC/Universidad de Sevilla), C. Antonio Maura Montaner s/n, 41013, Seville, Spain
| | - Ana Vega
- Grupo Genética en Cáncer y Enfermedades Raras, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Av. Choupana s/n, Edif. D, Planta 1, 15706, Santiago de Compostela, A Coruña, Spain; Fundación Pública Galega de Medicina Xenómica (FPGMX), Av. Choupana s/n, Edif. Consultas, Planta menos 2, 15706, Santiago de Compostela, A Coruña, Spain; Biomedical Network on Rare Diseases (CIBERER), Av. Monforte de Lemos, 3-5. Pabellón 11. Planta 0, 28029, Madrid, Spain.
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14
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van der Pol LHG, Hackett SL, Hoesein FAAM, Snoeren LMW, Pomp J, Raaymakers BW, Verhoeff JJC, Fast MF. On the feasibility of cardiac substructure sparing in magnetic resonance imaging guided stereotactic lung radiotherapy. Med Phys 2023; 50:397-409. [PMID: 36210631 PMCID: PMC10092491 DOI: 10.1002/mp.16028] [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: 06/20/2022] [Revised: 08/26/2022] [Accepted: 09/25/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Lung stereotactic body radiotherapy (SBRT) has proven an effective treatment for medically inoperable lung tumors, even for (ultra-)central tumors. Recently, there has been growing interest in radiation-induced cardiac toxicity in lung radiotherapy. More specifically, dose to cardiac (sub-)structures (CS) was found to correlate with survival after radiotherapy. PURPOSE Our goal is first, to investigate the percentage of patients who require CS sparing in an magnetic resonance imaging guided lung SBRT workflow, and second, to quantify how successful implementation of cardiac sparing would be. METHODS The patient cohort consists of 34 patients with stage II-IV lung cancer who were treated with SBRT between 2017 and 2020. A mid-position computed tomography (CT) image was used to create treatment plans for the 1.5 T Unity MR-linac (Elekta AB, Stockholm, Sweden) following clinical templates. Under guidance of a cardio-thoracic radiologist, 11 CS were contoured manually for each patient. Dose constraints for five CS were extracted from the literature. Patients were stratified according to their need for cardiac sparing depending on the CS dose in their non-CS constrained MR-linac treatment plans. Cardiac sparing treatment plans (CSPs) were then created and dosimetrically compared with their non-CS constrained treatment plan counterparts. CSPs complied with the departmental constraints and were considered successful when fulfilling all CS constraints, and partially successful if some CS constraints could be fulfilled. Predictors for the need for and feasibility of cardiac sparing were explored, specifically planning target volume (PTV) size, cranio-caudal (CC) distance, 3D distance, and in-field overlap volume histograms (iOVH). RESULTS 47% of the patients (16 out of 34) were in need of cardiac sparing. A successful CSP could be created for 62.5% (10 out of 16) of these patients. Partially successful CSPs still complied with two to four CS constraints. No significant difference in dose to organs at risk (OARs) or targets was identified between CSPs and the corresponding non-CS constrained MR-linac plans. The need for cardiac sparing was found to correlate with distance in the CC direction between target and all of the individual CS (Mann-Whitney U-test p-values <10-6 ). iOVHs revealed that complying with dose constraints for CS is primarily determined by in-plane distance and secondarily by PTV size. CONCLUSION We demonstrated that CS can be successfully spared in lung SBRT on the MR-linac for most of this patient cohort, without compromising doses to the tumor or to other OARs. CC distance between the target and CS can be used to predict the need for cardiac sparing. iOVHs, in combination with PTV size, can be used to predict if cardiac sparing will be successful for all constrained CS except the left ventricle.
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Affiliation(s)
- Luuk H G van der Pol
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Sara L Hackett
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | | | - Louk M W Snoeren
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jacqueline Pomp
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Bas W Raaymakers
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Joost J C Verhoeff
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Martin F Fast
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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15
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J 2022; 43:4229-4361. [PMID: 36017568 DOI: 10.1093/eurheartj/ehac244] [Citation(s) in RCA: 956] [Impact Index Per Article: 478.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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16
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J Cardiovasc Imaging 2022; 23:e333-e465. [PMID: 36017575 DOI: 10.1093/ehjci/jeac106] [Citation(s) in RCA: 116] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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17
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Abravan A, Price G, Banfill K, Marchant T, Craddock M, Wood J, Aznar MC, McWilliam A, van Herk M, Faivre-Finn C. Role of Real-World Data in Assessing Cardiac Toxicity After Lung Cancer Radiotherapy. Front Oncol 2022; 12:934369. [PMID: 35928875 PMCID: PMC9344971 DOI: 10.3389/fonc.2022.934369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
Radiation-induced heart disease (RIHD) is a recent concern in patients with lung cancer after being treated with radiotherapy. Most of information we have in the field of cardiac toxicity comes from studies utilizing real-world data (RWD) as randomized controlled trials (RCTs) are generally not practical in this field. This article is a narrative review of the literature using RWD to study RIHD in patients with lung cancer following radiotherapy, summarizing heart dosimetric factors associated with outcome, strength, and limitations of the RWD studies, and how RWD can be used to assess a change to cardiac dose constraints.
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Affiliation(s)
- Azadeh Abravan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Gareth Price
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Kathryn Banfill
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Tom Marchant
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Matthew Craddock
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Joe Wood
- Christie Medical Physics and Engineering, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Marianne C. Aznar
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Alan McWilliam
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Marcel van Herk
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Department of Radiotherapy Related Research, The Christie National Health Service (NHS) Foundation Trust, Manchester, United Kingdom
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18
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Wang X, Palaskas NL, Hobbs BP, Abe JI, Nead KT, Yusuf SW, Hermann J, Deswal A, Lin SH. The Impact of Radiation Dose to Heart Substructures on Major Coronary Events and Patient Survival after Chemoradiation Therapy for Esophageal Cancer. Cancers (Basel) 2022; 14:cancers14051304. [PMID: 35267613 PMCID: PMC8909404 DOI: 10.3390/cancers14051304] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 02/04/2023] Open
Abstract
Background: There is a paucity of data regarding the association between radiation exposure of heart substructures and the incidence of major coronary events (MCEs) in patients with esophageal cancer (ESOC) undergoing chemoradiation therapy. We studied radiation dosimetric determinants of MCE risk and measured their impact on patient prognosis using a cohort of ESOC patients treated at a single institution. Methods: Between March 2005 and October 2015, 355 ESOC patients treated with concurrent chemoradiotherapy were identified from a prospectively maintained and institutional-regulatory-board-approved clinical database. Dose-distribution parameters of the whole heart, the atria, the ventricles, the left main coronary artery, and three main coronary arteries were extracted for analysis. Results: Within a median follow-up time of 67 months, 14 patients experienced MCEs at a median of 16 months. The incidence of MCEs was significantly associated with the left anterior descending coronary artery (LAD) receiving ≥30 Gy (V30Gy) (p = 0.048). Patients receiving LAD V30Gy ≥ 10% of volume experienced a higher incidence of MCEs versus the LAD V30Gy < 10% group (p = 0.044). The relative rate of death increased with the left main coronary artery (LMA) mean dose (Gy) (p = 0.002). Furthermore, a mutual promotion effect of hyperlipidemia and RT on MCEs was observed. Conclusion: Radiation dose to coronary substructures is associated with MCEs and overall survival in patients with ESOC. In this study, the doses to these substructures appeared to be better predictors of toxicity outcomes than mean heart dose (MHD) or whole-heart V30Gy. These findings have implications for reducing coronary events through radiation therapy planning.
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Affiliation(s)
- Xin Wang
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (X.W.); (K.T.N.)
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin 300060, China
| | - Nicolas L. Palaskas
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (N.L.P.); (J.-i.A.); (S.W.Y.); (A.D.)
| | - Brian P. Hobbs
- Department of Population Health, Dell Medical School, The University of Texas Austin, Austin, TX 78712, USA;
| | - Jun-ichi Abe
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (N.L.P.); (J.-i.A.); (S.W.Y.); (A.D.)
| | - Kevin T. Nead
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (X.W.); (K.T.N.)
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Syed Wamique Yusuf
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (N.L.P.); (J.-i.A.); (S.W.Y.); (A.D.)
| | - Joerg Hermann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Anita Deswal
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (N.L.P.); (J.-i.A.); (S.W.Y.); (A.D.)
| | - Steven H. Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (X.W.); (K.T.N.)
- Correspondence: ; Tel.: +1-713-563-8490; Fax: +1-713-563-2866
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19
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Tohidinezhad F, Pennetta F, van Loon J, Dekker A, de Ruysscher D, Traverso A. Prediction models for treatment-induced cardiac toxicity in patients with non-small-cell lung cancer: A systematic review and meta-analysis. Clin Transl Radiat Oncol 2022; 33:134-144. [PMID: 35243024 PMCID: PMC8881199 DOI: 10.1016/j.ctro.2022.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 02/17/2022] [Indexed: 12/20/2022] Open
Affiliation(s)
| | | | | | | | | | - Alberto Traverso
- Corresponding author at: Department of Radiation Oncology (Maastro Clinic), School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Doctor Tanslaan 12, 6229 ET Maastricht, Netherlands.
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20
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Chang LK, Kuo YW, Wu SG, Chung KP, Shih JY. Recurrence of pericardial effusion after different procedure modalities in patients with non-small-cell lung cancer. ESMO Open 2021; 7:100354. [PMID: 34953402 PMCID: PMC8717440 DOI: 10.1016/j.esmoop.2021.100354] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 11/05/2021] [Accepted: 11/24/2021] [Indexed: 11/25/2022] Open
Abstract
Background Lung cancer with related pericardial effusion is not rare. Intervention is a crucial step for symptomatic effusion. It is unknown, however, whether the different invasive interventions for pericardial effusion result in different survival outcomes. This study analyzed the clinical characteristics and prognostic factors for patients with non-small-cell lung cancer (NSCLC) who have undergone different procedures. Methods From January 2006 to June 2018, we collected data from patients with NSCLC who have received invasive intervention for pericardial effusions. The patients were divided into three categories: simple pericardiocentesis, balloon pericardiotomy, and surgical pericardiectomy. Kaplan–Meier curve and log-rank test were used to analyze the pericardial effusion recurrence-free survival (RFS) and overall survival (OS). Results A total of 244 patients were enrolled. Adenocarcinoma (83.6%) was the major NSCLC subtype. Invasive intervention, including simple pericardiocentesis, balloon pericardiotomy, and surgical pericardiectomy, had been carried out on 52, 170, and 22 patients, respectively. The 1-year RFS rates in simple pericardiocentesis, balloon pericardiotomy, and surgical pericardiectomy were 19.2%, 31.2%, and 31.8%, respectively (P = 0.128), and the median RFS was 1.67, 5.03, and 8.32 months, respectively (P = 0.008). There was no significant difference in OS, however, with the median OS at 1.67, 6.43, and 8.32 months, respectively (P = 0.064). According to the multivariable analysis, the gravity in pericardial fluid analysis, receiving systemic therapy after pericardial effusion, and the time period from stage IV lung cancer to the presence of pericardial effusion were independent prognostic factors for pericardial effusion RFS and OS. Conclusions Patients who have undergone simple pericardiocentesis alone for the management of NSCLC-related pericardial effusion have lower 1-year RFS rates than those who have undergone balloon pericardiotomy and surgical pericardiectomy. Therefore, balloon pericardiotomy and surgical pericardiectomy should be carried out for patients with NSCLC-related pericardial effusion if tolerable. This is the first study to compare the three common procedures to manage NSCLC-related pericardial effusion. Simple pericardiocentesis group had lower 1-year RFS rate than balloon pericardiotomy or surgical pericardiectomy group. Surgical pericardiectomy as management demonstrated an improving OS trend.
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Affiliation(s)
- L-K Chang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, BioMedical Park Hospital, Hsin-Chu, Taiwan
| | - Y-W Kuo
- Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - S-G Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - K-P Chung
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - J-Y Shih
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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21
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Gevaert SA, Halvorsen S, Sinnaeve PR, Sambola A, Gulati G, Lancellotti P, Van Der Meer P, Lyon AR, Farmakis D, Lee G, Boriani G, Wechalekar A, Okines A, Asteggiano R. Evaluation and management of cancer patients presenting with acute cardiovascular disease: a Consensus Document of the Acute CardioVascular Care (ACVC) association and the ESC council of Cardio-Oncology-Part 1: acute coronary syndromes and acute pericardial diseases. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:947-959. [PMID: 34453829 DOI: 10.1093/ehjacc/zuab056] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/22/2021] [Accepted: 06/30/2021] [Indexed: 12/24/2022]
Abstract
Advances in treatment, common cardiovascular (CV) risk factors and the ageing of the population have led to an increasing number of cancer patients presenting with acute CV diseases. These events may be related to the cancer itself or the cancer treatment. Acute cardiac care specialists must be aware of these acute CV complications and be able to manage them. This may require an individualized and multidisciplinary approach. We summarize the most common acute CV complications of cytotoxic, targeted, and immune-based therapies. This is followed by a proposal for a multidisciplinary approach where acute cardiologists work close together with the treating oncologists, haematologists, and radiation specialists, especially in situations where immediate therapeutic decisions are needed. In this first part, we further focus on the management of acute coronary syndromes and acute pericardial diseases in patients with cancer.
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Affiliation(s)
- Sofie A Gevaert
- Department of Cardiology, Ghent University Hospital, C Heymanslaan 10, 9000 Gent, Belgium
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval and University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
| | - Peter R Sinnaeve
- Department of Cardiology, University Hospital Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Antonia Sambola
- Department of Cardiology, University Hospital Vall d'Hebron, Universitat Autonòma, CIBER-CV, Passeig de la Vall d'Hebron 119, 08035 Barcelona, Spain
| | - Geeta Gulati
- Department of Cardiology, Oslo University Hospital Ulleval and University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Science and Department of Cardiology, CHU Sart Tilman, Avenue del'Hôpital 1, 4000 Liège, Belgium
| | - Peter Van Der Meer
- Department of Cardiology, University of Groningen University Medical Center Groningen and University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Alexander R Lyon
- Cardio-Oncology Clinic at Royal Brompton Hospital and Imperial College, Sydney street, SW3 6NP London, UK
| | - Dimitrios Farmakis
- University of Cyprus Medical School, Agio Nikolaou street 93, 2408 Nicosia, Cyprus
| | - Geraldine Lee
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College, Strand, WC2R 2LS London, UK
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia and Policlinico Di Modena, Via Giuseppe Campi 287, 41125 Modena, Italy
| | - Ashutosh Wechalekar
- Department of Haematology, University College London/University College London Hospitals, Huntley street 72, WC1E 6DD London, UK
| | - Alicia Okines
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Fulham road 203, SW3 6JJ London, UK
| | - Riccardo Asteggiano
- Insubria University, Via Ravasi 2, 21100 Varese, Italy.,LARC (Laboratorio Analisi e Ricerca Clinica), Via Mombarcaro 80, 10136 Turin, Italy
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22
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Fukada J, Fukata K, Koike N, Kota R, Shigematsu N. Mean heart dose-based normal tissue complication probability model for pericardial effusion: a study in oesophageal cancer patients. Sci Rep 2021; 11:18166. [PMID: 34518576 PMCID: PMC8437977 DOI: 10.1038/s41598-021-97605-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/24/2021] [Indexed: 12/13/2022] Open
Abstract
We investigated the normal tissue complication probability (NTCP) of the incidence of pericardial effusion (PCE) based on the mean heart dose (MHD) in patients with oesophageal cancer treated with definitive chemoradiotherapy. The incidences of PCE in any grade (A-PCE) and symptomatic PCE (S-PCE) were evaluated separately. To identify predictors for PCE, several clinical and dose-volume parameters were analysed using a receiver operating characteristic (ROC) curve and multivariate regression analysis. To validate its clinical applicability, the generated NTCP model was compared to the Lyman–Kutcher–Burman (LKB) model. Among 229 eligible patients, A-PCE and S-PCE were observed in 100 (43.7%) and 18 (7.9%) patients, respectively. MHD showed a preferable area under the curve (AUC) value for S-PCE (AUC = 0.821) and A-PCE (AUC = 0.734). MHD was the only significant predictor for A-PCE; MHD and hypertension were selected as significant factors for S-PCE. The estimated NTCP, using the MHD-based model, showed excellent correspondence to the LKB model in A-PCE and S-PCE. The NTCP curve of A-PCE was gentler than that of S-PCE and had no threshold. The MHD-based NTCP model was simple but comparable to the LKB model for both A-PCE and S-PCE. Therefore, the estimated NTCP may provide clinically useful parameters for predicting PCE.
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Affiliation(s)
- Junichi Fukada
- Department of Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Kyohei Fukata
- Department of Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.,Cancer Center, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Naoyoshi Koike
- Department of Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Ryuichi Kota
- Department of Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Naoyuki Shigematsu
- Department of Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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23
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Niska JR, Hu J, Li J, Herman MG, Thorpe CS, Schild SE, Fatyga M. Using Novel Statistical Techniques to Accurately Determine the Predictive Dose Range in a Study of Overall Survival after Definitive Radiotherapy for Stage III Non-Small Cell Lung Cancer in Association with Heart Dose. JOURNAL OF CANCER THERAPY 2021; 12:505-529. [PMID: 34804634 PMCID: PMC8601657 DOI: 10.4236/jct.2021.129044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE Recent studies of radiotherapy (RT) for stage III non-small-cell lung cancer (NSCLC) have associated high dose to the heart with cardiac toxicity and decreased overall survival (OS). We used advanced statistical techniques to account for correlations between dosimetric variables and more accurately determine the range of heart doses which are associated with reduced OS in patients receiving RT for stage III NSCLC. METHODS From 2006 to 2013, 119 patients with stage III NSCLC received definitive RT at our institution. OS data was obtained from institutional tumor registry. We used multivariate Cox model to determine patient specific covariates predictive for reduced overall survival. We examined age, prescription dose, mean lung dose, lung V20, RT technique, stage, chemotherapy, tumor laterality, tumor volume, and tumor site as candidate covariates. We subsequently used novel statistical techniques within multivariate Cox model to systematically search the whole heart dose-volume histogram (DVH) for dose parameters associated with OS. RESULTS Patients were followed until death or 2.5 to 81.2 months (median 30.4 months) in those alive at last follow up. On multivariate analysis of whole heart DVH, the dose of 51 Gy was identified as a threshold dose above which the dose volume relationship becomes predictive for OS. We identified V55Gy (percentage of the whole heart volume receiving at least 55 Gy) as the best single DVH index which can be used to set treatment optimization constraints (Hazard Ratio = 1.044 per 1% increase in heart volume exposed to at least 55 Gy, P = 0.03). Additional characteristics correlated with OS on multivariate analysis were age, stage (IIIA/IIIB), and administration of chemotherapy. CONCLUSION Doses above 51 Gy, applied to small volumes of the heart, are associated with worse OS in stage III NSCLC patients treated with definitive RT. Higher stage, older age and lack of chemotherapy were also associated with reduced OS.
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Affiliation(s)
- Joshua R. Niska
- Department of Radiation Oncology, Banner MD Anderson Cancer Center, Phoenix, Arizona, USA
| | - Jiuyun Hu
- School of Computing, Informatics, and Decision Systems Engineering, Tempe, Arizona, USA
| | - Jing Li
- School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Michael G. Herman
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Cameron S. Thorpe
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Steven E. Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Mirek Fatyga
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
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24
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Wei T, Cheng Y. The cardiac toxicity of radiotherapy - a review of characteristics, mechanisms, diagnosis, and prevention. Int J Radiat Biol 2021; 97:1333-1340. [PMID: 34264176 DOI: 10.1080/09553002.2021.1956007] [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] [Indexed: 12/13/2022]
Abstract
PURPOSE Radiation-induced heart disease (RIHD) is one of the most serious complications of radiotherapy. The purpose of this paper is to review recent researches about cardiac toxicity of radiotherapy in clinical characteristics, mechanisms, diagnosis, and prevention. CONCLUSIONS Powered by the rapid development of medicine, the overall survival (OS) of cancer has been improved significantly. Surgery, chemotherapy, and radiotherapy (RT) are three critical ways in the comprehensive treatments of cancer. There is a consensus that early diagnosis and interventions for the prevention of RIHD are crucial. This review concludes recent clinical and experimental studies on RIHD. RIHD, a heterogeneous and serious disease, is a spectrum of heart disease including myocardial disease, pericarditis, coronary artery disease, valvular heart disease, and conduction system dysfunction. Mean heart dose, biomarkers, and detecting techniques are important components in detecting heart injury. Improvements in radiotherapy regimens remain the primary goal of prevention. Further investigation is needed beyond the observation period of most of these studies.
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Affiliation(s)
- Tianhui Wei
- Department of Radiation Oncology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Jinan, Shandong, China
| | - Yufeng Cheng
- Department of Radiation Oncology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Jinan, Shandong, China
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25
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Cella L, Monti S, Xu T, Liuzzi R, Stanzione A, Durante M, Mohan R, Liao Z, Palma G. Probing thoracic dose patterns associated to pericardial effusion and mortality in patients treated with photons and protons for locally advanced non-small-cell lung cancer. Radiother Oncol 2021; 160:148-158. [PMID: 33979653 PMCID: PMC8238861 DOI: 10.1016/j.radonc.2021.04.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/26/2021] [Accepted: 04/29/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE To investigate thoracic dose-response patterns for pericardial effusion (PCE) and mortality in patients treated for locally advanced Non-Small-Cell Lung Cancer (NSCLC) by Intensity Modulated RT (IMRT) or Passive-Scattering Proton Therapy (PSPT). METHODS Among 178 patients, 43.5% developed grade ≥ 2 PCE. Clinical and dosimetric factors associated with PCE or overall survival (OS) were identified via multi-variable Cox proportional hazards modeling. The Voxel-Based Analyses (VBAs) of local dose differences between patients with and without PCE and mortality was performed. The robustness of VBA results was assessed by a novel characterization of spatial properties of dose distributions based on probabilistic independent component analysis (PICA) and connectograms. RESULTS Several non-dosimetric variables were selected by the multivariable analysis for the considered outcomes, while the time-dependent PCE onset was uncorrelated with the OS (p = 0.34) at a multi-variable Cox analysis. Despite the significant PSPT dosimetric advantage, the RT technique did not affect the occurrence of PCE or OS. VBAs highlighted largely overlapping clusters significantly associated with PCE endpoints in heart and lungs. No significant dosimetric patterns related to mortality endpoints were found. PICA identified 43 components homogeneously scattered within thorax, while connectograms showed modest correlations between doses in main cardio-pulmonary substructures. CONCLUSIONS Spatially resolved analysis highlighted dose patterns related to radiation-induced cardiac toxiciy and the observed organ-based dose-response mismatch in PSPT and IMRT. Indeed, the thoracic regions spared by PSPT poorly overlapped with the areas involved in PCE development, as highlited by VBA. PICA and connectograms proved valuable tools for assessing the robusteness of obtained VBA inferences.
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Affiliation(s)
- Laura Cella
- National Research Council, Institute of Biostructures and Bioimaging, Napoli, Italy.
| | - Serena Monti
- National Research Council, Institute of Biostructures and Bioimaging, Napoli, Italy
| | - Ting Xu
- MD Anderson Cancer Center, Department of Radiation Oncology, Houston, USA
| | - Raffaele Liuzzi
- National Research Council, Institute of Biostructures and Bioimaging, Napoli, Italy
| | - Arnaldo Stanzione
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Napoli, Italy
| | - Marco Durante
- GSI Helmholtz Centre for Heavy Ion Research, Department of Biophysics, Darmstadt, Germany
| | - Radhe Mohan
- MD Anderson Cancer Center, Department of Radiation Physics, Houston, USA
| | - Zhongxing Liao
- MD Anderson Cancer Center, Department of Radiation Oncology, Houston, USA
| | - Giuseppe Palma
- National Research Council, Institute of Biostructures and Bioimaging, Napoli, Italy.
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26
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Ramai D, Heaton J, Ghidini M, Chandan S, Barakat M, Dhindsa B, Dhaliwal A, Facciorusso A. Population-Based Long-term Cardiac-Specific Mortality Among Patients With Major Gastrointestinal Cancers. JAMA Netw Open 2021; 4:e2112049. [PMID: 34137831 DOI: 10.1001/jamanetworkopen.2021.12049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Patients with major gastrointestinal (GI) cancers are at long-term risk for cardiac disease and mortality. OBJECTIVE To investigate the cardiac-specific mortality rate among individuals with major GI cancers and the association of radiation and chemotherapy with survival outcomes in the United States. DESIGN, SETTING, AND PARTICIPANTS This US cohort study included individual patient-level data of men and women older than 18 years with 5 major gastrointestinal cancers, including colorectal, esophageal, gastric, pancreatic, and hepatocellular cancer from 1990 to 2016. Data was extracted from the Surveillance, Epidemiology, and End Results (SEER) national cancer database. Data cleaning and analyses were conducted between November 2020 and March 2021. EXPOSURES Patients received chemotherapy, radiotherapy, or a combination of adjuvant therapy for major GI cancers. MAIN OUTCOMES AND MEASURES The primary outcome was cardiac-specific mortality. Examined factors associated with cardiac mortality included age, sex, race, tumor location, tumor grade, SEER stage, TNM (seventh edition) staging criteria, cancer treatment (ie, the use of radiation, chemotherapy, or surgery), survival months, and cause of death. RESULTS A total of 359 032 patients (mean [SD] age at baseline, 65.1 [12.9] years; 186 921 [52.1%] men) with GI cancers were analyzed, including 313 940 patients (87.4%) with colorectal cancer, 7613 patients (2.1%) with esophageal cancer, 21 048 patients (5.9%) with gastric cancer, 7227 patients (2.0%) with pancreatic cancer, and 9204 patients (2.6%) with hepatocellular cancer. Most cancers were localized except pancreatic cancer, which presented with regional and distant involvement (3680 cancers [50.9%]). Overall, all major gastrointestinal tumors were associated with increased risk of cardiac mortality compared with noncardiac mortality (median survival time: 121 [95% CI, 120-122] months vs 287 [95% CI, 284.44-290] months). Patients with hepatocellular cancer had the lowest cardiac-specific median survival time (98 [95% CI, 90-106] months), followed by pancreatic cancer (105 [95% CI, 98-112] months), esophageal cancer (113 [95% CI, 107-119] months), gastric cancer (113 [95% CI, 110-116] months), and colorectal cancer (122 [95% CI, 121-123] months). At 15 years of follow up, the use of only chemotherapy, only radiation, or radiation and chemotherapy combined was associated with poor survival rates from cardiac causes of death (eg, colorectal: chemotherapy, 0 patients; radiation, 1 patient [1.9%]; radiation and chemotherapy, 3 patients [2.7%]). CONCLUSIONS AND RELEVANCE These findings suggest that among patients with major gastrointestinal cancers, cardiac disease is a significant cause of mortality. The use of only chemotherapy, only radiation, or both was associated with higher cardiac mortality.
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Affiliation(s)
- Daryl Ramai
- Department of Internal Medicine, Brooklyn Hospital Center, Brooklyn, New York
| | - Joseph Heaton
- Department of Internal Medicine, Brooklyn Hospital Center, Brooklyn, New York
| | - Michele Ghidini
- Division of Medical Oncology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Saurabh Chandan
- Division of Gastroenterology & Hepatology, CHI Health Creighton University Medical Center, Omaha, Nebraska
| | - Mohamed Barakat
- Division of Gastroenterology, The Brooklyn Hospital Center, Brooklyn, New York
| | - Banreet Dhindsa
- Gastroenterology & Hepatology, University of Nebraska Medical Center, Omaha
| | - Amaninder Dhaliwal
- Division of Gastroenterology, Moffitt Cancer Center, University of South Florida, Tampa
| | - Antonio Facciorusso
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia, Foggia, Italy
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Ren XY, He PK, Gao XS, Zhao ZL, Zhao B, Bai Y, Liu SW, Li K, Qin SB, Ma MW, Zhou J, Rong Y. Dosimetric feasibility of stereotactic ablative radiotherapy in pulmonary vein isolation for atrial fibrillation using intensity-modulated proton therapy. J Appl Clin Med Phys 2021; 22:79-88. [PMID: 33817981 PMCID: PMC8130224 DOI: 10.1002/acm2.13239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 03/03/2021] [Accepted: 03/06/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose To evaluate dosimetric properties of intensity‐modulated proton therapy (IMPT) for simulated treatment planning in patients with atrial fibrillation (AF) targeting left atrial‐pulmonary vein junction (LA‐PVJ), in comparison with volumetric‐modulated arc therapy (VMAT) and helical tomotherapy (TOMO). Methods Ten thoracic 4D‐CT scans with respiratory motion and one with cardiac motion were used for the study. Ten respiratory 4D‐CTs were planned with VMAT, TOMO, and IMPT for simulated AF. Targets at the LA‐PVJ were defined as wide‐area circumferential ablation line. A single fraction of 25 Gy was prescribed to all plans. The interplay effects from cardiac motion were evaluated based on the cardiac 4D‐CT scan. Dose‐volume histograms (DVHs) of the ITV and normal tissues were compared. Statistical analysis was evaluated via one‐way Repeated‐Measures ANOVA and Friedman’s test with Bonferroni’s multiple comparisons test. Results The median volume of ITV was 8.72cc. All plans had adequate target coverage (V23.75Gy ≥ 99%). Compared with VMAT and TOMO, IMPT resulted in significantly lower dose of most normal tissues. For VMAT, TOMO, and IMPT plans, Dmean of the whole heart was 5.52 ± 0.90 Gy, 5.89 ± 0.78 Gy, and 3.01 ± 0.57 Gy (P < 0.001), mean dose of pericardium was 4.74 ± 0.76 Gy, 4.98 ± 0.62 Gy, and 2.59 ± 0.44 Gy (P < 0.001), and D0.03cc of left circumflex artery (LCX) was 13.96 ± 5.45 Gy, 14.34 ± 5.91 Gy, and 8.43 ± 7.24 Gy (P < 0.001), respectively. However, no significant advantage for one technique over the others was observed when examining the D0.03cc of esophagus and main bronchi. Conclusions IMPT targeting LA‐PVJ for patients with AF has high potential to reduce dose to surrounding tissues compared to VMAT or TOMO. Motion mitigation techniques are critical for a particle‐therapy approach.
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Affiliation(s)
- Xue-Ying Ren
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Peng-Kang He
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Xian-Shu Gao
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Zhi-Lei Zhao
- Department of Radiation Oncology, Yizhou International Proton Therapy Medical Center, Hebei, China
| | - Bo Zhao
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Yun Bai
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Si-Wei Liu
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Kang Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Shang-Bin Qin
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Ming-Wei Ma
- Department of Radiation Oncology, Peking University First Hospital, Beijing, China
| | - Jing Zhou
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
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Abstract
Radiation therapy plays an integral role in the treatment of all stages of non-small cell lung cancer. Survival outcomes are improving, but radiation therapy remains associated with long-term toxicity. Recently, it has become evident that the heart is an important organ at risk for treatment-related morbidity. In this review, we discuss the hypothesis that particle radiation therapy offers superior dosimetry compared with photon-based treatment, and that this comparative advantage translates into clinically meaningful cardiac toxicity reduction with similar local tumor control. We discuss the evidence in non-small cell lung cancer to date, the ongoing prospective trials that may provide additional insight, and the opportunities to optimally integrate particle therapy into future prospective investigation.
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Banfill K, Giuliani M, Aznar M, Franks K, McWilliam A, Schmitt M, Sun F, Vozenin MC, Faivre Finn C. Cardiac Toxicity of Thoracic Radiotherapy: Existing Evidence and Future Directions. J Thorac Oncol 2021; 16:216-227. [PMID: 33278607 PMCID: PMC7870458 DOI: 10.1016/j.jtho.2020.11.002] [Citation(s) in RCA: 130] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 12/13/2022]
Abstract
The impact of radiotherapy on the heart has become an area of interest in recent years. Many different cardiac dose-volume constraints have been associated with cardiac toxicity and survival; however, no consistent constraint has been found. Many patients undergoing treatment for lung cancer have risk factors for cardiovascular disease or known cardiac comorbidities; however, there is little evidence on the effects of radiotherapy on the heart in these patients. We aim to provide a summary of the existing literature on cardiac toxicity of lung cancer radiotherapy, propose strategies to avoid and manage cardiac toxicity, and suggest avenues for future research.
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Affiliation(s)
- Kathryn Banfill
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom.
| | - Meredith Giuliani
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Marianne Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Kevin Franks
- Leeds Cancer Centre, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom; Radiotherapy Research Group, Leeds Institute of Medical Research at St James's, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Alan McWilliam
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Matthias Schmitt
- Cardiovascular Division, Manchester University Foundation Trust, North West Heart Centre, Wythenshawe Campus, Manchester, United Kingdom
| | - Fei Sun
- Leeds Cancer Centre, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom; Radiotherapy Research Group, Leeds Institute of Medical Research at St James's, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Marie Catherine Vozenin
- Laboratory of Radiation Oncology/DO/Radio-Oncology/CHUV, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Corinne Faivre Finn
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; The Christie NHS Foundation Trust, Manchester, United Kingdom
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Atkins KM, Chaunzwa TL, Lamba N, Bitterman DS, Rawal B, Bredfeldt J, Williams CL, Kozono DE, Baldini EH, Nohria A, Hoffmann U, Aerts HJWL, Mak RH. Association of Left Anterior Descending Coronary Artery Radiation Dose With Major Adverse Cardiac Events and Mortality in Patients With Non-Small Cell Lung Cancer. JAMA Oncol 2021; 7:206-219. [PMID: 33331883 PMCID: PMC7747040 DOI: 10.1001/jamaoncol.2020.6332] [Citation(s) in RCA: 126] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/01/2020] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Radiotherapy accelerates coronary heart disease (CHD), but the dose to critical cardiac substructures has not been systematically studied in lung cancer. OBJECTIVE To examine independent cardiac substructure radiotherapy factors for major adverse cardiac events (MACE) and all-cause mortality in patients with locally advanced non-small cell lung cancer (NSCLC). DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort analysis of 701 patients with locally advanced NSCLC treated with thoracic radiotherapy at Harvard University-affiliated hospitals between December 1, 2003, and January 27, 2014, was performed. Data analysis was conducted between January 12, 2019, and July 22, 2020. Cardiac substructures were manually delineated. Radiotherapy dose parameters (mean, maximum, and the volume [V, percentage] receiving a specific Gray [Gy] dose in 5-Gy increments) were calculated. Receiver operating curve and cut-point analyses estimating MACE (unstable angina, heart failure hospitalization or urgent visit, myocardial infarction, coronary revascularization, and cardiac death) were performed. Fine and Gray and Cox regressions were adjusted for preexisting CHD and other prognostic factors. MAIN OUTCOMES AND MEASURES MACE and all-cause mortality. RESULTS Of the 701 patients included in the analysis, 356 were men (50.8%). The median age was 65 years (interquartile range, 57-73 years). The optimal cut points for substructure and radiotherapy doses (highest C-index value) were left anterior descending (LAD) coronary artery V15 Gy greater than or equal to 10% (0.64), left circumflex coronary artery V15 Gy greater than or equal to 14% (0.64), left ventricle V15 Gy greater than or equal to 1% (0.64), and mean total coronary artery dose greater than or equal to 7 Gy (0.62). Adjusting for baseline CHD status and other prognostic factors, an LAD coronary artery V15 Gy greater than or equal to 10% was associated with increased risk of MACE (adjusted hazard ratio, 13.90; 95% CI, 1.23-157.21; P = .03) and all-cause mortality (adjusted hazard ratio, 1.58; 95% CI, 1.09-2.29; P = .02). Among patients without CHD, associations with increased 1-year MACE were noted for LAD coronary artery V15 Gy greater than or equal to 10% (4.9% vs 0%), left circumflex coronary artery V15 Gy greater than or equal to 14% (5.2% vs 0.7%), left ventricle V15 Gy greater than or equal to 1% (5.0% vs 0.4%), and mean total coronary artery dose greater than or equal to 7 Gy (4.8% vs 0%) (all P ≤ .001), but only a left ventricle V15 Gy greater than or equal to 1% increased the risk among patients with CHD (8.4% vs 4.1%; P = .046). Among patients without CHD, 2-year all-cause mortality was increased with an LAD coronary artery V15 Gy greater than or equal to 10% (51.2% vs 42.2%; P = .009) and mean total coronary artery dose greater than or equal to 7 Gy (53.2% vs 40.0%; P = .01). CONCLUSIONS AND RELEVANCE The findings of this cohort study suggest that optimal cardiac dose constraints may differ based on preexisting CHD. Although the LAD coronary artery V15 Gy greater than or equal to 10% appeared to be an independent estimator of the probability of MACE and all-cause mortality, particularly in patients without CHD, left ventricle V15 Gy greater than or equal to 1% appeared to confer an increased risk of MACE among patients with CHD. These constraints are worthy of further study because there is a need for improved cardiac risk stratification and aggressive risk mitigation strategies.
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Affiliation(s)
- Katelyn M. Atkins
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, Massachusetts
| | - Tafadzwa L. Chaunzwa
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, Massachusetts
| | - Nayan Lamba
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, Massachusetts
| | - Danielle S. Bitterman
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, Massachusetts
| | - Bhupendra Rawal
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Jeremy Bredfeldt
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, Massachusetts
| | - Christopher L. Williams
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, Massachusetts
| | - David E. Kozono
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, Massachusetts
| | - Elizabeth H. Baldini
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, Massachusetts
| | - Anju Nohria
- Department of Cardiovascular Medicine, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, Massachusetts
| | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Hugo J. W. L. Aerts
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Radiology, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, Massachusetts
| | - Raymond H. Mak
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women’s Hospital, Boston, Massachusetts
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Jafari F, Safaei AM, Hosseini L, Asadian S, Kamangar TM, Zadehbagheri F, Rezaeian N. The role of cardiac magnetic resonance imaging in the detection and monitoring of cardiotoxicity in patients with breast cancer after treatment: a comprehensive review. Heart Fail Rev 2020; 26:679-697. [PMID: 33029698 DOI: 10.1007/s10741-020-10028-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 01/04/2023]
Abstract
The use of chemotherapy medicines for breast cancer (BC) has been associated with an increased risk of cardiotoxicity. In recent years, there have been growing interests regarding the application of cardiovascular magnetic resonance (CMR) imaging, a safe and noninvasive modality, with the potential to identify subtle morphological and functional changes in the myocardium. In this investigation, we aimed to review the performance of various CMR methods in diagnosing cardiotoxicity in BC, induced by chemotherapy or radiotherapy. For this purpose, we reviewed the literature available in PubMed, MEDLINE, Cochrane, Google Scholar, and Scopus databases. Our literature review showed that CMR is a valuable modality for identifying and predicting subclinical cardiotoxicity induced by chemotherapy. The novel T1, T2, and extracellular volume mapping techniques may provide critical information about cardiotoxicity, in addition to other CMR features such as functional and structural changes. However, further research is needed to verify the exact role of these methods in identifying cardiotoxicity and patient management. Since multiple studies have reported the improvement of left ventricular performance following the termination of chemotherapy regimens, CMR remains an essential imaging tool for the prediction of cardiotoxicity and, consequently, decreases the mortality rate of BC due to heart failure.
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Affiliation(s)
- Fatemeh Jafari
- Department of Radiation Oncology, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran.,Radiation Oncology Research Center (RORC), Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Afsane Maddah Safaei
- Radiation Oncology Research Center (RORC), Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Hosseini
- North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Sanaz Asadian
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Tara Molanaie Kamangar
- Radiation Oncology Research Center (RORC), Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Nahid Rezaeian
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran.
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Niedzielski JS, Wei X, Xu T, Gomez DR, Liao Z, Bankson JA, Lai SY, Court LE, Yang J. Development and application of an elastic net logistic regression model to investigate the impact of cardiac substructure dose on radiation-induced pericardial effusion in patients with NSCLC. Acta Oncol 2020; 59:1193-1200. [PMID: 32678696 DOI: 10.1080/0284186x.2020.1794034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Typically, cardiac substructures are neither delineated nor analyzed during radiation treatment planning. Therefore, we developed a novel machine learning model to evaluate the impact of cardiac substructure dose for predicting radiation-induced pericardial effusion (PCE). MATERIALS AND METHODS One-hundred and forty-one stage III NSCLC patients, who received radiation therapy in a prospective clinical trial, were included in this analysis. The impact of dose-volume histogram (DVH) metrics (mean and max dose, V5Gy[%]-V70Gy[%]) for the whole heart, left and right atrium, and left and right ventricle, on pericardial effusion toxicity (≥grade 2, CTCAE v4.0 grading) were examined. Elastic net logistic regression, using repeat cross-validation (n = 100 iterations, 75%/25% training/test set data split), was conducted with cardiac-based DVH metrics as covariates. The following model types were constructed and analyzed: (i) standard model type, which only included whole-heart DVH metrics; and (ii) a model type trained with both whole-heart and substructure DVH metrics. Model performance was analyzed on the test set using area under the curve (AUC), accuracy, calibration slope and calibration intercept. A final fitted model, based on the optimal model type, was developed from the entire study population for future comparisons. RESULTS Grade 2 PCE incidence was 49.6% (n = 70). Models using whole heart and substructure dose had the highest performance (median values: AUC = 0.820; calibration slope/intercept = 1.356/-0.235; accuracy = 0.743) and outperformed the standard whole-heart only model type (median values: AUC = 0.799; calibration slope/intercept = 2.456/-0.729; accuracy = 0.713). The final fitted elastic net model showed high performance in predicting PCE (median values: AUC = 0.879; calibration slope/intercept = 1.352/-0.174; accuracy = 0.801). CONCLUSIONS We developed and evaluated elastic net regression toxicity models of radiation-induced PCE. We found the model type that included cardiac substructure dose had superior predictive performance. A final toxicity model that included cardiac substructure dose metrics was developed and reported for comparison with external datasets.
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Affiliation(s)
- Joshua S. Niedzielski
- Department of Radiation Physics, The University of Texas-MD Anderson Cancer Center, Houston, TX, USA
- Department of Imaging Physics, The University of Texas-MD Anderson Cancer Center, Houston, TX, USA
| | - Xiong Wei
- Department of Radiation Oncology, The University of Texas-MD Anderson Cancer Center, Houston, TX, USA
| | - Ting Xu
- Department of Radiation Oncology, The University of Texas-MD Anderson Cancer Center, Houston, TX, USA
| | - Daniel R. Gomez
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Zhongxing Liao
- Department of Radiation Oncology, The University of Texas-MD Anderson Cancer Center, Houston, TX, USA
| | - James A. Bankson
- Department of Imaging Physics, The University of Texas-MD Anderson Cancer Center, Houston, TX, USA
| | - Stephen Y. Lai
- Department of Head & Neck Surgery, The University of Texas-MD Anderson Cancer Center, Houston, TX, USA
| | - Laurence E. Court
- Department of Radiation Physics, The University of Texas-MD Anderson Cancer Center, Houston, TX, USA
| | - Jinzhong Yang
- Department of Radiation Physics, The University of Texas-MD Anderson Cancer Center, Houston, TX, USA
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Xue J, Lu Y, Kong FM(S. Why aren't we getting consistent results for heart dose and mortality during thoracic radiotherapy? ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1252. [PMID: 33178784 PMCID: PMC7607132 DOI: 10.21037/atm-2020-51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 03/22/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Jianxin Xue
- Department of Thoracic Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - You Lu
- Department of Thoracic Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
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Pan L, Lei D, Wang W, Luo Y, Wang D. Heart dose linked with cardiac events and overall survival in lung cancer radiotherapy: A meta-analysis. Medicine (Baltimore) 2020; 99:e21964. [PMID: 32957314 PMCID: PMC7505339 DOI: 10.1097/md.0000000000021964] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the link between heart dose and overall survival, the link between heart dose and cardiac events and whether radiation-induced heart diseases were associated with overall survival in lung cancer radiotherapy. METHODS We performed a literature search by using Pubmed, Embase, China National Knowledge Infrastructure (CNKI) databases. Pairs of reviewers independently screened literature according to the inclusion criteria, extracted data, assessed methodological quality, and publication bias. The primary end points included overall survival and cardiac events. I was calculated in a heterogeneity assessment. Publication bias was evaluated by using Begg funnel plot and Egger test. RESULTS Ten studies including 1 randomized controlled trial, 3 post hoc analysis of prospective trials, and 6 cohort studies were identified. The meta-analysis showed that heart volume receiving ≥5 Gy (HV5) (hazard ratio [HR] = 1.01; 95% confidence interval [CI]: 1.00-1.01), heart volume receiving ≥30 Gy (HV30) (HR = 1.01; 95% CI: 1.00-1.02), heart volume receiving ≥50 Gy (HV50) (HR = 1.05; 95%CI: 1.00-1.10), and mean heart dose (MHD) (HR = 1.01; 95%CI:1.00-1.02) all were associated with worse overall survival. In addition, the MHD (HR = 1.03; 95% CI: 1.02-1.05), HV5 (HR = 1.02; 95% CI: 1.01-1.03), and HV30 (HR = 1.02; 95% CI: 1.01-1.03) were significantly associated with all grade cardiac events. Meanwhile, compared with those who did not receive radiotherapy, the radiotherapy group experienced a significantly increased risk for cardiac-specific mortality (HR = 1.297; 95% CI: 1.213-1.387). However, the results did not show that cardiac events were associated with overall survival in lung cancer radiotherapy (HR = 1.472; 95% CI: 0.988-2.193). CONCLUSION Exposure of the heart to radiation increased the risk of cardiac events during radiotherapy for lung cancer. Meanwhile, heart dose including HV5 and HV30 were predictors of overall survival in lung cancer radiotherapy. It is necessary to constrain the heart dose when perform thoracic radiation therapy to decrease the incidence of cardiac events and improve the overall survival.
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Affiliation(s)
- Li Pan
- The people's Hospital of Rongchang District
| | - Dengshun Lei
- Chongqing Rongchang Maternal and Child Health Hospital, Chongqing, China
| | | | - Yanqiu Luo
- The people's Hospital of Rongchang District
| | - Dan Wang
- The people's Hospital of Rongchang District
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35
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McWilliam A, Dootson C, Graham L, Banfill K, Abravan A, van Herk M. Dose surface maps of the heart can identify regions associated with worse survival for lung cancer patients treated with radiotherapy. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2020; 15:46-51. [PMID: 33458326 PMCID: PMC7807666 DOI: 10.1016/j.phro.2020.07.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 07/06/2020] [Accepted: 07/10/2020] [Indexed: 12/13/2022]
Abstract
Creation of a modified cylindrical coordinate system to map cardiac surface dose. Validation of mapping using internal anatomical sub-structures. Identification of surface regions were excess dose is associated with poorer survival.
Background and purpose For lung cancer patients treated with radiotherapy, radiation dose to the heart has been associated with overall survival, with volumetric dose statistics widely presented. However, critical cardiac structures are present on the hearts surface, where this approach may be sub-optimal. In this work we present a methodology for creating cardiac surface dose maps and identify regions where excess dose is associated with in worse overall survival. Material and methods A modified cylindrical coordinate system was implemented to map the cardiac surface dose for lung cancer patients. Validation was performed by mapping the cardiac chambers for 55 patients, fitting a point spread function (PSF) to the blurred edge. To account for this uncertainty, dose maps were blurred by a 2D-Gaussian with width described by the PSF. Permutation testing identified regions where excess dose was associated with worse patient survival. The 99th percentile of the max t-value then defined a cardiac surface region to extract dose, from each patient, to be analysed in a multivariable cox-proportional hazards survival model. Results Cardiac surface maps were created for 648 lung cancer patients. Cardiac surface dose maps were blurred with a 2D- Gaussian filter of size σφ = 4.3° and σy = 1.3units to account for mapping uncertainties. Permutation testing identified significant differences across the surface of the right atria, p < 0.001, at all timepoints. The median dose to the region defined by the 99th percentile of the maximum t-value was 18.5 Gy. Multivariable analysis showed the dose to this region was significantly associated with survival, hazard ratio 1.01 Gy−1, p = 0.03, controlling for confounding variables. Conclusions Cardiac surface mapping was successfully implemented and identified a region where excess dose was associated with worse patient survival. This region extended over the right atria, potentially suggesting an interaction with the hearts electrical conduction system.
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Affiliation(s)
- Alan McWilliam
- Division of Clinical Cancer Science, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK.,Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, UK
| | - Chloe Dootson
- Department of Physics and Astronomy, The University of Manchester, UK
| | - Lewis Graham
- Department of Physics and Astronomy, The University of Manchester, UK
| | - Kathryn Banfill
- Division of Clinical Cancer Science, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK.,Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, UK
| | - Azadeh Abravan
- Division of Clinical Cancer Science, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK.,Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, UK
| | - Marcel van Herk
- Division of Clinical Cancer Science, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK.,Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, UK
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McWilliam A, Khalifa J, Vasquez Osorio E, Banfill K, Abravan A, Faivre-Finn C, van Herk M. Novel Methodology to Investigate the Effect of Radiation Dose to Heart Substructures on Overall Survival. Int J Radiat Oncol Biol Phys 2020; 108:1073-1081. [PMID: 32585334 DOI: 10.1016/j.ijrobp.2020.06.031] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 05/18/2020] [Accepted: 06/17/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE For patients with lung cancer treated with radiation therapy, a dose to the heart is associated with excess mortality; however, it is often not feasible to spare the whole heart. Our aim is to define cardiac substructures and dose thresholds that optimally reduce early mortality. METHODS AND MATERIALS Fourteen cardiac substructures were delineated on 5 template patients with representative anatomies. One thousand one hundred sixty-one patients with non-small cell lung cancer were registered nonrigidly to these 5 template anatomies, and their radiation therapy doses were mapped. Mean and maximum dose to each substructure were extracted, and the means were evaluated as input to prediction models. The cohort was bootstrapped into 2 variable reduction techniques: elastic net least absolute shrinkage and selection operator and the random survival forest model. Each method was optimized to extract variables contributing most to overall survival, and model coefficients were evaluated to select these substructures. The most important variables common to both models were selected and evaluated in multivariable Cox-proportional hazard models. A threshold dose was defined, and Kaplan-Meier survival curves plotted. RESULTS Nine hundred seventy-eight patients remained after visual quality assurance of the registration. Ranking the model coefficients across the bootstraps selected the maximum dose to the right atrium, right coronary artery, and ascending aorta as the most important factors associated with survival. The maximum dose to the combined cardiac region showed significance in the multivariable model, a hazard ratio of 1.01/Gy, and P = .03 after accounting for tumor volume (P < .001), N stage (P < .01), and performance status (P = .01). The optimal threshold for the maximum dose, equivalent dose in 2-Gy fractions, was 23 Gy. Kaplan-Meier survival curves showed a significant split (log-rank P = .008). CONCLUSIONS The maximum dose to the combined cardiac region encompassing the right atrium, right coronary artery, and ascending aorta was found to have the greatest effect on patient survival. A maximum equivalent dose in 2-Gy fractions of 23 Gy was identified for consideration as a dose limit in future studies.
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Affiliation(s)
- Alan McWilliam
- Division of Clinical Cancer Science, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom; Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom.
| | - Jonathan Khalifa
- Department of Radiation Oncology, Institut Universitaire du Cancer de Toulouse, Toulouse, France
| | - Eliana Vasquez Osorio
- Division of Clinical Cancer Science, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom; Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Kathryn Banfill
- Division of Clinical Cancer Science, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom; Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Azadeh Abravan
- Division of Clinical Cancer Science, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom; Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Corinne Faivre-Finn
- Division of Clinical Cancer Science, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom; Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Marcel van Herk
- Division of Clinical Cancer Science, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom; Department of Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, United Kingdom
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Mrotzek SM, Rassaf T, Totzeck M. Cardiovascular Damage Associated With Chest Irradiation. Front Cardiovasc Med 2020; 7:41. [PMID: 32266294 PMCID: PMC7103638 DOI: 10.3389/fcvm.2020.00041] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 03/03/2020] [Indexed: 12/24/2022] Open
Abstract
The improvement of anticancer-therapies results in a greater amount of long-term survivors after radiotherapy. Therefore, the understanding of cardiotoxicity after irradiation is of increasing importance. Cardiovascular adverse events after chest irradiation have been acknowledged for a long time but remain difficult to diagnose. Long-term cardiovascular adverse events may become evident years or decades after radiotherapy and the spectrum of potential cardiovascular side effects is large. Recent experimental and clinical data indicate that cardiovascular symptoms may be caused especially by heart failure with preserved ejection fraction, which remains incompletely understood in patients after radiation therapy. Heart radiation dose and co-existing cardiovascular risk factors represent some of the most important contributors for incidence and severity of radiation-induced cardiovascular side effects. In this review, we aim to elucidate the underlying patho-mechanisms and to characterize the development of radiation-induced cardiovascular damage. Additionally, approaches for clinical management and treatment options are presented.
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Affiliation(s)
- Simone M Mrotzek
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
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Chan ST, Ruan D, Shaverdian N, Raghavan G, Cao M, Lee P. Effect of Radiation Doses to the Heart on Survival for Stereotactic Ablative Radiotherapy for Early-stage Non-Small-cell Lung Cancer: An Artificial Neural Network Approach. Clin Lung Cancer 2019; 21:136-144.e1. [PMID: 31932217 DOI: 10.1016/j.cllc.2019.10.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/22/2019] [Accepted: 10/14/2019] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The cardiac radiation dose is an important predictor of cardiac toxicity and overall survival (OS) for patients with locally advanced non-small-cell lung cancer (NSCLC). However, radiation-induced cardiac toxicity among patients with early-stage NSCLC who have undergone stereotactic ablative radiotherapy (SABR) has been less well-characterized. Our objective was to assess the associations between cardiac radiation dosimetry and OS in patients with early-stage NSCLC undergoing SABR. MATERIALS AND METHODS From 2009 to 2014, 153 patients with early-stage NSCLC had undergone SABR at a single institution. The maximum dose, mean dose, V10Gy, V25Gy, and V50Gy to 15 cardiac substructures and the whole heart were analyzed for their association with OS using the Kaplan-Meier method. An artificial neural network (ANN) analysis was performed to modulate confounding behaviors of dosimetric variables to predict for OS. RESULTS A total of 112 patients were included in the present analysis. The right ventricle (RV) V10Gy most negatively predicted for OS, such that patients who had received a RV V10Gy dose < 4% had significantly longer OS than patients who had received a RV V10Gy does > 4% (5.3 years vs. 2.4 years). On ANN analysis, 74 input features, including cardiac dosimetry parameters, predicted for survival with a test accuracy of 64.7%. A repeat ANN analysis using dosimetry to dose neutral structure confirmed the predictive power of cardiac dosimetry. CONCLUSION Cardiac dosimetry to subvolumes of the heart was associated with decreased OS in patients with early-stage NSCLC undergoing SABR. These data support the importance of minimizing the radiation dose to cardiac substructures. Further prioritizing the heart as an organ at risk might be warranted. Additionally, cardiac follow-up should be considered.
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Affiliation(s)
- Shawna T Chan
- Department of Radiation Oncology, University of California, Los Angeles, School of Medicine, Los Angeles, CA; University of California, Irvine, School of Medicine, Irvine, CA
| | - Dan Ruan
- Department of Radiation Oncology, University of California, Los Angeles, School of Medicine, Los Angeles, CA
| | - Narek Shaverdian
- Department of Radiation Oncology, University of California, Los Angeles, School of Medicine, Los Angeles, CA; Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Govind Raghavan
- Department of Radiation Oncology, University of California, Los Angeles, School of Medicine, Los Angeles, CA
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, School of Medicine, Los Angeles, CA
| | - Percy Lee
- Department of Radiation Oncology, University of California, Los Angeles, School of Medicine, Los Angeles, CA; Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, CA; Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX.
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Thor M, Montovano M, Hotca A, Luo L, Jackson A, Wu AJ, Deasy JO, Rimner A. Are unsatisfactory outcomes after concurrent chemoradiotherapy for locally advanced non-small cell lung cancer due to treatment-related immunosuppression? Radiother Oncol 2019; 143:51-57. [PMID: 31615633 DOI: 10.1016/j.radonc.2019.07.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 07/09/2019] [Accepted: 07/12/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE We test the hypothesis that unsatisfactory outcomes after concurrent chemoradiotherapy (RT) for locally advanced non-small cell lung cancer (LA-NSCLC) are due to treatment-related immunosuppression. MATERIALS AND METHODS White blood cells (WBCs) data were retrospectively collected for all stage IIIA/B LA-NSCLC patients before and after (after RT: two weeks, two months, four months) concurrent chemotherapy and intensity-modulated RT in which patients were treated to a median of 63 Gy (1.8-2.0 Gy/fractions) in 2004-2014 (N = 155). Nine WBC variables were generated from pre-RT normalized absolute number of lymphocytes and neutrophils (L, N) and the N/L thereof. A WBC variable was considered a predictor for overall survival and recurrence (distant/local/nodal/regional) if p ≤ 0.006 (corrected for 9 variables) from Cox regression and competing risk analyses, respectively; both conducted using bootstrap resampling. Finally, a WBC variable predicting any of the outcomes was linearly associated with each of eleven disease/patient/treatment characteristics (p ≤ 0.005; corrected for 11 characteristics). RESULTS At the three post-RT time points both L and N significantly decreased (p < 0.0003). Overall survival was associated with N and N/L four months post-RT (p = 0.00001, 0.0003); regional recurrence was associated with L two months post-RT (p < 0.0001). None of the disease/patient/treatment characteristics was significantly associated with any of the three WBC variables that predicted OS or recurrence (lowest p-value: p = 0.006 for tumour stage,). CONCLUSION Significantly lower WBC levels after concurrent chemo-RT for LA-NSCLC are associated with worse long-term outcomes. The mechanism behind this treatment-related immunosuppression requires further analysis likely including other characteristics as no statistically significant association was established between any WBC variable and the disease/patient/treatment characteristics.
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Affiliation(s)
- Maria Thor
- Dept of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Margaret Montovano
- Dept of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Alexandra Hotca
- Dept of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Leo Luo
- Dept of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Andrew Jackson
- Dept of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Abraham J Wu
- Dept of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Joseph O Deasy
- Dept of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, United States.
| | - Andreas Rimner
- Dept of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
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Hotca A, Thor M, Deasy JO, Rimner A. Dose to the cardio-pulmonary system and treatment-induced electrocardiogram abnormalities in locally advanced non-small cell lung cancer. Clin Transl Radiat Oncol 2019; 19:96-102. [PMID: 31650044 PMCID: PMC6804651 DOI: 10.1016/j.ctro.2019.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/19/2019] [Accepted: 09/19/2019] [Indexed: 12/25/2022] Open
Abstract
ECG abnormalities after chemo-RT in LA-NSCLC are common (35%–67%). Non-specific ECG abnormalities are associated with a high superior vena cava dose. Reducing cardiopulmonary dose is likely to lead to less radiation-induced cardiac toxicity.
Introduction High dose radiotherapy (RT) has been associated with unexpectedly short survival times for locally advanced Non-Small Cell Lung Cancer (LA-NSCLC) patients. Here we tested the hypothesis that cardiac substructure dose is associated with electrocardiography (ECG) assessed abnormalities after RT for LA-NSCLC. Materials and methods Pre- and post-RT ECGs were analyzed for 155 LA-NSCLC patients treated to a median of 64 Gy in 1.8–2.0 Gy fractions using intensity-modulated RT plus chemotherapy (concurrent/sequential: 64%/36%) between 2004 and 2014. ECG abnormalities were classified as new Arrhythmic, Ischemic/Pericardial, or Non-specific (AΔECG, I/PΔECG, or NSΔECG) events. Abnormalities were modeled as time to ECG events considering death a competing risk, and the variables considered for analysis were fractionation-corrected dose-volume metrics (α/β = 3 Gy) of ten cardio-pulmonary structures (aorta, heart, heart chambers, inferior and superior vena cava, lung, pulmonary artery) and 15 disease, patient and treatment characteristics. Each abnormality was modelled using bootstrapping and a candidate predictor was suggested by a median multiple testing-adjusted p-value ≤0.05 across the 1000 generated samples. Forward-stepwise multivariate analysis was conducted in case of more than one candidate. Results At a median of eight months post-RT, the rate of AΔECG, I/PΔECG, and NSΔECG was 66%, 35%, and 67%. Both AΔECG and I/PΔECG were associated with worse performance status (p = 0.007, 0.03), while a higher superior vena cava minimum dose was associated with NSΔECG (p = 0.002). Conclusion This study suggests that higher radiation doses to the cardio-pulmonary system lead to non-specific ECG abnormalities. Reducing dose to this system, along with effective tumor control, is likely to decrease radiation-induced cardiac toxicity.
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Affiliation(s)
- Alexandra Hotca
- Dept. of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Maria Thor
- Dept. of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Joseph O Deasy
- Dept. of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Andreas Rimner
- Dept. of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
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Abstract
PURPOSE OF REVIEW This review highlights the literature related to pericardial injury following radiation for oncologic diseases. RECENT FINDINGS Radiation-associated pericardial disease can have devastating consequences. Unfortunately, there is considerably less evidence regarding pericardial syndromes following thoracic radiation as compared to other cardiovascular outcomes. Pericardial complications of radiation may arise acutely or have an insidious onset several decades after treatment. Transthoracic echocardiography is the screening imaging modality of choice, while cardiac magnetic resonance imaging further characterizes the pericardium and guides treatment decision-making. Cardiac CT can be useful for assessing pericardial calcification. Ongoing efforts to lessen inadvertent cardiac injury are directed towards the revision of radiation techniques and protocols. As survival of mediastinal and thoracic malignancies continues to improve, radiation-associated pericardial disease is increasingly relevant. Though advances in radiation oncology demonstrate promise in curtailing cardiotoxicity, the long-term effects pertaining to pericardial complications remain to be seen.
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Affiliation(s)
- Natalie Szpakowski
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH, 44195, USA
| | - Milind Y Desai
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH, 44195, USA.
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Ni L, Koshy M, Connell P, Pitroda S, Golden DW, Al-Hallaq H, Hubert G, Kauffman G, McCall A, Malik R. Heart V5 predicts cardiac events in unresectable lung cancer patients undergoing chemoradiation. J Thorac Dis 2019; 11:2229-2239. [PMID: 31372260 DOI: 10.21037/jtd.2019.06.29] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Recent studies incorporating dose escalated radiation identified heart dose as a predictor of cardiac toxicity in unresectable lung cancer patients. Whether conventionally dosed radiation impacts cardiac events remains unclear. Methods Stage III lung cancer patients undergoing definitive chemoradiation to 60-70 Gy were analyzed. Clinical and dosimetric factors (mean heart dose, heart V5-60 in 5 Gy increments) were analyzed against freedom from ≥ grade 3 cardiac events and overall survival (OS) by log-rank test. Multivariable analysis (MVA) for factors significant on univariate analysis was performed by Cox proportional hazards. Results A total of 108 patients were identified. Median follow-up was 18.0 months. One- and two-year OS were 79% and 61%, respectively. On MVA, gross tumor volume (GTV) ≥98.6 cm3 [hazard ratio (HR): 2.11, 95% confidence interval (CI): 1.15-3.93, P=0.02] and female gender (HR: 2.01, 95% CI: 1.09-3.73, P=0.03) predicted for worse survival. Twelve patients (11%) developed ≥ grade 3 cardiac events. One- and two-year freedom from cardiac events (FFCE) was 94% and 84% respectively. On MVA, heart V5 ≥49% predicted for cardiac events (HR: 11.44, 95% CI: 1.31-111.60, P=0.03) while female gender was nearly significant (HR: 3.49, 95% CI: 0.97-16.80, P=0.06). Females presented with similar comorbidity scores, GTVs, and relapse rates but experienced higher heart doses than their male counterparts. Conclusions Heart V5 ≥49% predicted for cardiac events after chemoradiation. However, cardiac dosimetry was not associated with survival. Rather, female gender and GTV ≥98.6 cm3 led to worse survival. This study corroborates emerging data that low-dose radiation to the heart impacts cardiac toxicity.
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Affiliation(s)
- Lisa Ni
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Matthew Koshy
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
| | - Philip Connell
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
| | - Sean Pitroda
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
| | - Daniel W Golden
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
| | - Hania Al-Hallaq
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
| | - Greg Hubert
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
| | - Greg Kauffman
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
| | - Anne McCall
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
| | - Renuka Malik
- University of Chicago Department of Radiation and Cellular Oncology, Chicago, IL, USA
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Cong Y, Xuan L, Sun B, Wang J, Meng X, Zhang J, Xue J, Liu J, Shen G, Wu S. Retrospective comparison of stereotactic body radiotherapy versus intensity-modulated radiotherapy for stage III ultra-central squamous non-small-cell lung cancer. Future Oncol 2019; 15:1855-1862. [PMID: 30950297 DOI: 10.2217/fon-2019-0061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
Aim: To analyze the efficacy and toxicity of stereotactic body radiotherapy (SBRT) versus intensity-modulated radiotherapy (IMRT) in stage III patients with ultra-central squamous non-small-cell lung cancer (sqNSCLC). Methods: Forty-four stage III patients with ultra-central sqNSCLC receiving SBRT (n = 15) or IMRT (n = 29) between December 2014 and August 2017 were reviewed. Results: At a median follow-up of 16.5 months, the 1-year local control rate of SBRT and IMRT was 60.8 and 37.5%, respectively (p = 0.23); the median overall survival was 17 versus 18 months (p = 0.48); ≥3 grade toxicity was 20 versus 24.1% (p = 0.83). Conclusion: SBRT is effective and patient friendly for stage III patients with ultra-central sqNSCLC. Toxicity might be tolerable with a moderate dose five to six fraction regimen. However, more prospective studies are warranted.
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Affiliation(s)
- Yang Cong
- Academy of Military Medical Sciences, No. 27 Taiping Road, Haidian District, Beijing 100039, People's Republic of China
| | - Liang Xuan
- Department of Radiation Oncology, The Fifth Medical Center of Chinese PLA General Hospital, No. 8 East Road, Fengtai District, Beijing 100071, People's Republic of China
| | - Bing Sun
- Department of Radiation Oncology, The Fifth Medical Center of Chinese PLA General Hospital, No. 8 East Road, Fengtai District, Beijing 100071, People's Republic of China
| | - Junliang Wang
- Department of Radiation Oncology, The Fifth Medical Center of Chinese PLA General Hospital, No. 8 East Road, Fengtai District, Beijing 100071, People's Republic of China
| | - Xiangying Meng
- Department of Radiation Oncology, The Fifth Medical Center of Chinese PLA General Hospital, No. 8 East Road, Fengtai District, Beijing 100071, People's Republic of China
| | - Junjian Zhang
- Department of Radiation Oncology, The Fifth Medical Center of Chinese PLA General Hospital, No. 8 East Road, Fengtai District, Beijing 100071, People's Republic of China
| | - Junxia Xue
- Department of Radiation Oncology, The Fifth Medical Center of Chinese PLA General Hospital, No. 8 East Road, Fengtai District, Beijing 100071, People's Republic of China
| | - Jiannan Liu
- Department of Radiation Oncology, The Fifth Medical Center of Chinese PLA General Hospital, No. 8 East Road, Fengtai District, Beijing 100071, People's Republic of China
| | - Ge Shen
- Department of Oncology, Beijing Fengtai You Anmen Hospital, No.199 You Anmen Outer street, Fengtai District, Beijing 100069, People's Republic of China
| | - Shikai Wu
- Department of Radiation Oncology, The Fifth Medical Center of Chinese PLA General Hospital, No. 8 East Road, Fengtai District, Beijing 100071, People's Republic of China
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Is the Importance of Heart Dose Overstated in the Treatment of Non-Small Cell Lung Cancer? A Systematic Review of the Literature. Int J Radiat Oncol Biol Phys 2019; 104:582-589. [PMID: 30630029 DOI: 10.1016/j.ijrobp.2018.12.044] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 12/12/2018] [Accepted: 12/15/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE Some recent studies have suggested a relationship between cardiac dose and mortality in non-small cell lung cancer (NSCLC), but others have reported conflicting data. The goal of this study was to conduct a systematic review and meta-analysis to provide an evidence-based estimate of the relationship between cardiac dose and mortality in these patients. METHODS AND MATERIALS A systematic review of MEDLINE (PubMed) and Embase databases (inception to January 2018) was performed according to PRISMA guidelines. Studies that evaluated cardiac dosimetric factors in patients with NSCLC and included outcomes of cardiac events, cardiac mortality, and/or overall survival were identified. RESULTS From 5614 patients across 22 studies, a total of 214 cardiac dosimetric parameters (94 unique) were assessed as possible predictors of cardiac toxicity or death. Assessed predictors included general (eg, mean heart dose [MHD]), threshold-based (eg, heart V5), and anatomic-based (eg, atria, ventricles) dosimetric factors. The most commonly analyzed parameters were MHD, heart V5, and V30. Most studies did not make corrections for multiplicity of testing. For overall survival, V5 was found to be significant on multivariable analysis (MVA) in 1 of 11 studies and V30 in 2 of 12 studies; MHD was not significant in any of 8 studies. For cardiac events, V5 was found to be significant on multivariable analysis in 1 of 2 studies, V30 in 1 of 3 studies, and MHD in 2 of 4 studies. A meta-analysis of the data could not be performed because most negative studies did not report effect estimates. CONCLUSIONS Consistent heart dose-volume parameters associated with overall survival of patients with NSCLC were not identified. Multiplicity of testing is a major issue and likely inflates the overall risk of type I errors in the literature. Future studies should specify predictors a priori, correct for multiplicity of testing, and report effect estimates for nonsignificant variables.
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Xue J, Han C, Jackson A, Hu C, Yao H, Wang W, Hayman J, Chen W, Jin J, Kalemkerian GP, Matuzsak M, Jolly S, Kong FMS. Doses of radiation to the pericardium, instead of heart, are significant for survival in patients with non-small cell lung cancer. Radiother Oncol 2018; 133:213-219. [PMID: 30416046 DOI: 10.1016/j.radonc.2018.10.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 10/14/2018] [Accepted: 10/23/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE Higher cardiac dose was associated with worse overall survival in the RTOG0617 study. Pericardial effusion (PCE) is a common cardiac complication of thoracic radiation therapy (RT). We investigated whether doses of radiation to the heart and pericardium are associated with PCE and overall survival in patients treated with thoracic radiation for non-small cell lung cancer (NSCLC). MATERIALS AND METHODS A total of 94 patients with medically inoperable/unresectable NSCLC treated with definitive RT in prospective studies were reviewed for this secondary analysis. Heart and pericardium were contoured consistently according to the RTOG1106 Atlas, with the great vessels and thymus of the upper mediastinal structures included in the upper part of pericardium, only heart chambers included in the heart structure. Clinical factors and dose-volume parameters associated with PCE or survival were identified via Cox proportional hazards modeling. The risk of PCE and death were mapped using DVH atlases. RESULTS Median follow-up for surviving patients was 58 months. The overall rate of PCE was 40.4%. On multivariable analysis, dosimetric factors of heart and pericardium were significantly associated with the risk of PCE. Pericardial V30 and V55 were significantly correlated with overall survival, but presence of PCE and heart dosimetric factors were not. CONCLUSION PCE was associated with both heart and pericardial doses. The significance of pericardial dosimetric parameters, but not heart chamber parameters, on survival suggests the potential significance of radiation damage to the cranial region of pericardium.
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Affiliation(s)
- Jianxin Xue
- Department of Radiation Oncology, University of Michigan, Ann Arbor, USA; Department of Thoracic Oncology, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China
| | - Chengbo Han
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Andrew Jackson
- Departments of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Chen Hu
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, USA
| | - Huan Yao
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, USA
| | - Weili Wang
- Department of Radiation Oncology, Case Western Reserve University, Cleveland, USA
| | - James Hayman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, USA
| | - Weijun Chen
- Department of Radiation Oncology, Zhejiang Cancer Hospital, Hanzhou, China
| | - Jianyue Jin
- Department of Radiation Oncology, Case Western Reserve University, Cleveland, USA
| | | | - Martha Matuzsak
- Department of Radiation Oncology, University of Michigan, Ann Arbor, USA
| | - Struti Jolly
- Department of Radiation Oncology, University of Michigan, Ann Arbor, USA
| | - Feng-Ming Spring Kong
- Department of Radiation Oncology, University of Michigan, Ann Arbor, USA; Department of Radiation Oncology, Case Western Reserve University, Cleveland, USA.
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Niska JR, Thorpe CS, Allen SM, Daniels TB, Rule WG, Schild SE, Vargas CE, Mookadam F. Radiation and the heart: systematic review of dosimetry and cardiac endpoints. Expert Rev Cardiovasc Ther 2018; 16:931-950. [DOI: 10.1080/14779072.2018.1538785] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Joshua R. Niska
- Mayo Clinic - Department of Radiation Oncology, Phoenix, AZ, USA
| | | | - Sorcha M. Allen
- Mayo Clinic - Department of Cardio-Oncology, Scottsdale, AZ, USA
| | | | - William G. Rule
- Mayo Clinic - Department of Radiation Oncology, Phoenix, AZ, USA
| | - Steven E. Schild
- Mayo Clinic - Department of Radiation Oncology, Phoenix, AZ, USA
| | - Carlos E. Vargas
- Mayo Clinic - Department of Radiation Oncology, Phoenix, AZ, USA
| | - Farouk Mookadam
- Mayo Clinic - Department of Cardio-Oncology, Scottsdale, AZ, USA
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Yegya-Raman N, Wang K, Kim S, Reyhan M, Deek MP, Sayan M, Li D, Patel M, Malhotra J, Aisner J, Marks LB, Jabbour SK. Dosimetric Predictors of Symptomatic Cardiac Events After Conventional-Dose Chemoradiation Therapy for Inoperable NSCLC. J Thorac Oncol 2018; 13:1508-1518. [PMID: 29883836 PMCID: PMC10905612 DOI: 10.1016/j.jtho.2018.05.028] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/23/2018] [Accepted: 05/25/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION We hypothesized that higher cardiac doses correlates with clinically significant cardiotoxicity after standard-dose chemoradiation therapy (CRT) (∼60 Gy) for inoperable NSCLC. METHODS We retrospectively reviewed the records of 140 patients with inoperable NSCLC treated with concurrent CRT from 2007 to 2015. Extracted data included baseline cardiac status, dosimetric parameters to the whole heart (WH) and cardiac substructures, and the development of post-CRT symptomatic cardiac events (acute coronary syndrome [ACS], arrhythmia, pericardial effusion, pericarditis, and congestive heart failure [CHF]). Competing risks analysis was used to estimate time to cardiac events. RESULTS Median follow-up was 47.4 months. Median radiation therapy dose was 61.2 Gy (interquartile range, 60 to 66 Gy). Forty patients (28.6%) developed 47 symptomatic cardiac events at a median of 15.3 months to first event. On multivariate analysis, higher WH doses and baseline cardiac status were associated with an increased risk of symptomatic cardiac events. The 4-year cumulative incidence of symptomatic cardiac events was 48.6% versus 18.5% for mean WH dose ≥ 20 Gy versus < 20 Gy, respectively (p = 0.0002). Doses to the WH, ventricles, and left anterior descending artery were associated with ACS/CHF, whereas doses to the WH and atria were not associated with supraventricular arrhythmias. Symptomatic cardiac events (p = 0.0001) were independently associated with death. CONCLUSIONS Incidental cardiac irradiation was associated with subsequent symptomatic cardiac events, particularly ACS/CHF, and symptomatic cardiac events were associated with inferior survival. These results support the minimization of cardiac doses among patients with inoperable NSCLC receiving standard-dose CRT.
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Affiliation(s)
- Nikhil Yegya-Raman
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Kyle Wang
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Sinae Kim
- Department of Biostatistics, School of Public Health, Rutgers University, Piscataway, New Jersey; Biometrics Division, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Meral Reyhan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Matthew P Deek
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey; Department of Radiation Oncology & Molecular Radiation Sciences, the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mutlay Sayan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Diana Li
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Malini Patel
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Jyoti Malhotra
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Joseph Aisner
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey.
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Abstract
PURPOSE OF REVIEW Pericardial effusion is commonly associated with malignancy. The goals of treatment should include optimizing symptom relief, minimizing repeat interventions, and restoring as much functional status as possible. RECENT FINDINGS Pericardiocentesis should be the first intervention but has high recurrence rates (30-60%). For patients with recurrence, repeat pericardiocentesis is indicated in those with limited expected lifespans. Extended pericardial drainage decreases recurrence to 10-20%. The addition of sclerosing agents decreases recurrence slightly but creates significant pain and can lead to pericardial constriction and therefore has fallen out of favor. Most patients with symptomatic pericardial disease have a short median survival time due to their underlying disease. In patients with a longer life expectancy, surgical drainage offers the lowest recurrence rate. Surgical approach is based on effusion location and clinical condition. Subxiphoid and thoracoscopic approaches lead to similar outcomes. Thoracotomy should be avoided as it increases morbidity without improving outcomes.
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Yegya-Raman N, Zou W, Nie K, Malhotra J, Jabbour SK. Advanced radiation techniques for locally advanced non-small cell lung cancer: intensity-modulated radiation therapy and proton therapy. J Thorac Dis 2018; 10:S2474-S2491. [PMID: 30206493 DOI: 10.21037/jtd.2018.07.29] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Radiation therapy (RT) represents an integral part of a multimodality treatment plan in the definitive, preoperative and postoperative management of non-small cell lung cancer (NSCLC). Technological advances in RT have enabled a shift from two-dimensional radiotherapy to more conformal techniques. Three-dimensional conformal radiotherapy (3DCRT), the current minimum technological standard for treating NSCLC, allows for more accurate delineation of tumor burden by using computed tomography-based treatment planning instead of two-dimensional radiographs. Intensity-modulated RT (IMRT) and proton therapy represent advancements over 3DCRT that aim to improve the conformity of RT and provide the possibility for dose escalation to the tumor by minimizing radiation dose to organs at risk. Both techniques likely confer benefits to certain anatomic subgroups of NSCLC requiring RT. This article reviews pertinent studies evaluating the use of IMRT and proton therapy in locally advanced NSCLC, and outlines challenges, indications for use, and areas for future research.
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Affiliation(s)
- Nikhil Yegya-Raman
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Wei Zou
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Ke Nie
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Jyoti Malhotra
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
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Reshko LB, Kalman NS, Hugo GD, Weiss E. Cardiac radiation dose distribution, cardiac events and mortality in early-stage lung cancer treated with stereotactic body radiation therapy (SBRT). J Thorac Dis 2018; 10:2346-2356. [PMID: 29850140 DOI: 10.21037/jtd.2018.04.42] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background The impact of radiation dose to the heart in early-stage lung cancer patients treated with definitive stereotactic body radiation therapy (SBRT) is not well known. We, therefore, analyzed whether higher radiation dose to the heart would lead to an increase in cardiac toxicity and overall mortality. Methods Seventy-four patients with 75 tumors treated definitively with SBRT for early-stage non-small cell lung cancer (NSCLC) and two cases of limited-stage small cell lung cancer (SCLC) with an average follow-up of 35 months (range, 1-130 months) were retrospectively analyzed. The whole heart and cardiac substructures including atria, ventricles, heart valves, atrioventricular (AV) node and four major coronary artery branches were contoured using commercial treatment planning software. For each structure, multiple dose-volume parameters were recorded. The relation between radiation doses to the heart, tumor location, and preexisting medical conditions with the development of cardiac events and mortality was assessed. Results Overall, there was large variability in dose to cardiac substructures: mean heart dose (MHD) averaged 1.90 Gy (range, 0.04-11.00 Gy) equivalent 2 Gy dose (EQD2) and average max dose to the left anterior descending artery (LAD) was 5.67 Gy (range, 0.04-48.60 Gy) EQD2. Patients with tumor location in the upper lobes received higher cardiac radiation dose compared to other lobes (P<0.0001). There was no difference in MHD between central and peripheral tumor locations. The distance between heart and tumor was negatively associated with MHD (r=-0.61, P<0.0001). Eighteen patients developed cardiac complications including the need for defibrillator placement, arrhythmia development and worsening heart failure. Preexisting cardiac disease was associated with an increased number of cardiac events after radiotherapy (P=0.039). However, neither radiation dose to the whole heart or the cardiac substructures, nor comorbidities such as diabetes, hypercholesterolemia, hypertension or COPD were associated with the number of cardiac events or overall mortality. Conclusions Radiation doses to the heart and its substructures show large variability. Cardiac events occurred more frequently in patients with a history of heart problems. At present, the effect of radiation dose on cardiac toxicity is unclear in patients undergoing SBRT for early-stage lung cancer. Longer follow-up and a larger cohort are needed to assess for late cardiac sequelae.
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Affiliation(s)
- Leonid B Reshko
- Department of Education, Riverside Regional Medical Center, Newport News, VA, USA
| | - Noah S Kalman
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | - Geoffrey D Hugo
- Department of Radiation Oncology, Washington University, St. Louis, MO, USA
| | - Elisabeth Weiss
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
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