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Feat-Vetel J, Suffee N, Bachelot F, Dos Santos M, Mougenot N, Delage E, Saliou F, Martin S, Brunet I, Sicard P, Monceau V. X-ray Radiotherapy Impacts Cardiac Dysfunction by Modulating the Sympathetic Nervous System and Calcium Transients. Int J Mol Sci 2024; 25:9483. [PMID: 39273430 PMCID: PMC11394929 DOI: 10.3390/ijms25179483] [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: 08/05/2024] [Revised: 08/28/2024] [Accepted: 08/29/2024] [Indexed: 09/15/2024] Open
Abstract
Recent epidemiological studies have shown that patients with right-sided breast cancer (RBC) treated with X-ray irradiation (IR) are more susceptible to developing cardiovascular diseases, such as arrhythmias, atrial fibrillation, and conduction disturbances after radiotherapy (RT). Our aim was to investigate the mechanisms induced by low to moderate doses of IR and to evaluate changes in the cardiac sympathetic nervous system (CSNS), atrial remodeling, and calcium homeostasis involved in cardiac rhythm. To mimic the RT of the RBC, female C57Bl/6J mice were exposed to X-ray doses ranging from 0.25 to 2 Gy targeting 40% of the top of the heart. At 60 weeks after RI, Doppler ultrasound showed a significant reduction in myocardial strain, ejection fraction, and atrial function, with a significant accumulation of fibrosis in the epicardial layer and apoptosis at 0.5 mGy. Calcium transient protein expression levels, such as RYR2, NAK, Kir2.1, and SERCA2a, increased in the atrium only at 0.5 Gy and 2 Gy at 24 h, and persisted over time. Interestingly, 3D imaging of the cleaned hearts showed an early reduction of CSNS spines and dendrites in the ventricles and a late reorientation of nerve fibers, combined with a decrease in SEMA3a expression levels. Our results showed that local heart IR from 0.25 Gy induced late cardiac and atrial dysfunction and fibrosis development. After IR, ventricular CSNS and calcium transient protein expression levels were rearranged, which affected cardiac contractility. The results are very promising in terms of identifying pro-arrhythmic mechanisms and preventing arrhythmias during RT treatment in patients with RBC.
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Affiliation(s)
- Justyne Feat-Vetel
- Laboratoire de Pharmacologie Expérimentale et Moléculaire (LPEM), Service d'Ingénierie Moléculaire Pour la Santé (SIMoS), Département Médicaments et Technologies Pour la Santé (DMTS), CEA, 91191 Gif-sur-Yvette, France
| | - Nadine Suffee
- UMR 1166, Unité de Recherche sur les Maladies Cardiovasculaires et Métaboliques, INSERM, 75013 Paris, France
| | - Florence Bachelot
- PSE-SANTE/SESANE/LRTOX, Institut de Radioprotection et de Sûreté Nucléaire-IRSN, 92260 Fontenay-aux-Roses, France
| | - Morgane Dos Santos
- PSE-SANTE/SERAMED/LRAcc, Institut de Radioprotection et de Sûreté Nucléaire-IRSN, 92260 Fontenay-aux-Roses, France
| | - Nathalie Mougenot
- UMS28, INSERM, Sorbonne Université, Plateforme PECMV, 75005 Paris, France
| | - Elise Delage
- CellTechs Laboratory, SupBiotech, 94800 Villejuif, France
- Service d'Etude des Prions et des Infections Atypiques, Institut François Jacob, Commissariat à l'Energie Atomique et aux Energies Alternatives, Université Paris Saclay, 91405 Fontenay-aux-Roses, France
| | - Florian Saliou
- PSE-SANTE/SESANE/LRTOX, Institut de Radioprotection et de Sûreté Nucléaire-IRSN, 92260 Fontenay-aux-Roses, France
| | - Sabrina Martin
- Center for Interdisciplinary Research in Biology (CIRB), College de France, 75001 Paris, France
| | - Isabelle Brunet
- Center for Interdisciplinary Research in Biology (CIRB), College de France, 75001 Paris, France
| | - Pierre Sicard
- PhyMedExp, IPAM/Biocampus, INSERM, CNRS, Université de Montpellier, 34095 Montpellier, France
| | - Virginie Monceau
- PSE-SANTE/SESANE/LRTOX, Institut de Radioprotection et de Sûreté Nucléaire-IRSN, 92260 Fontenay-aux-Roses, France
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Langeron M, Khen-Dunlop N, Helfre S, Sarnacki S. Efficacy of an expandable prosthesis placement after left pneumonectomy for soft tissue Ewing sarcoma in a 5-year-old child: 10 years follow-up. Eur J Cardiothorac Surg 2024; 66:ezae259. [PMID: 38960727 DOI: 10.1093/ejcts/ezae259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 05/31/2024] [Accepted: 07/02/2024] [Indexed: 07/05/2024] Open
Abstract
We report the case of a 5-year-old girl who underwent left pneumonectomy for Ewing sarcoma of the lung. Two expandable prostheses were placed in the left hemi-thorax to prevent post-pneumonectomy syndrome and to protect the heart from radiotherapy. With a follow-up of 10 years, the procedure proved to be effective both on post-pneumonectomy syndrome and on cardiac protection.
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Affiliation(s)
- Margaux Langeron
- Department of Pediatric Surgery, Necker Enfants-Malades Hospital, AP-HP, Université de Paris Cite, Paris, France
| | - Naziha Khen-Dunlop
- Department of Pediatric Surgery, Necker Enfants-Malades Hospital, AP-HP, Université de Paris Cite, Paris, France
| | - Sylvie Helfre
- Department of Pediatric Oncology, Curie Institute, Paris, France
| | - Sabine Sarnacki
- Department of Pediatric Surgery, Necker Enfants-Malades Hospital, AP-HP, Université de Paris Cite, Paris, France
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Yamauchi R, Akiyama S, Mizuno N, Kobayashi T, Itazawa T, Masuda T, Hirano M, Tomita F, Hosoya Y, Kawamori J. Dosimetric Comparison of 3D Conformal Radiotherapy (3D-CRT), Intensity-Modulated Radiotherapy (IMRT), and Volumetric-Modulated Arc Therapy (VMAT) in Cardiac-Sparing Whole Lung Irradiation. Cureus 2023; 15:e51047. [PMID: 38264368 PMCID: PMC10805560 DOI: 10.7759/cureus.51047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 01/25/2024] Open
Abstract
Introduction Whole lung irradiation (WLI) is used for the treatment of lung metastasis in Wilms tumor and Ewing sarcoma; however, cardiac complications are one of the concerns. We report the dosimetric advantages of WLI using volumetric-modulated arc therapy (VMAT) and present a dosimetric comparison of VMAT with anteroposterior-posteroanterior (AP-PA) and static-field intensity-modulated radiation therapy (IMRT). Additionally, we evaluated the dosimetric impact of respiratory motion and intra-fractional motion during VMAT treatment. Methods Seven patients were recruited in this study. AP-PA, IMRT, one-isocenter (1-IC) VMAT, and 2-IC VMAT were planned on the maximum inspiration and expiration CT, respectively. The prescribed dose was 15 Gy in 10 fractions. To determine the effects of respiratory motion, the CT series was replaced and the dose was evaluated while maintaining the beam information. To determine the effect of patient motion, perturbed dose calculations were performed using a two-IC VMAT. The perturbation doses were calculated by shifting only the IC of the one side beam by 3 mm or 5 mm in the right-to-left (RL) direction. Results The mean heart dose was 1467.0 cGy, 790.0 cGy, 764.2 cGy, and 738.4 cGy for AP-PA, IMRT, 1-IC VMAT, and 2-IC VMAT, respectively. When the expiration CT plan was recalculated with inspiration CT, Dmax increased approximately by 8%. In the 2-IC VMAT plan, the D50%, D98%, and D2% dose differences were within ±2%, even with a 5 mm IC shift. Conclusion We confirmed a significant dosimetric advantage of VMAT over other techniques. 2-IC VMAT should be considered an effective treatment option during irradiation for large target volumes.
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Affiliation(s)
- Ryohei Yamauchi
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
| | - Shinobu Akiyama
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
| | - Norifumi Mizuno
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
| | - Takako Kobayashi
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
| | - Tomoko Itazawa
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
| | - Tomoyuki Masuda
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
| | - Miki Hirano
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
| | - Fumihiro Tomita
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
| | - Yosuke Hosoya
- Department of Pediatrics, St. Luke's International Hospital, Tokyo, JPN
| | - Jiro Kawamori
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, JPN
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Ehrhardt MJ, Leerink JM, Mulder RL, Mavinkurve-Groothuis A, Kok W, Nohria A, Nathan PC, Merkx R, de Baat E, Asogwa OA, Skinner R, Wallace H, Lieke Feijen EAM, de Ville de Goyet M, Prasad M, Bárdi E, Pavasovic V, van der Pal H, Fresneau B, Demoor-Goldschmidt C, Hennewig U, Steinberger J, Plummer C, Chen MH, Teske AJ, Haddy N, van Dalen EC, Constine LS, Chow EJ, Levitt G, Hudson MM, Kremer LCM, Armenian SH. Systematic review and updated recommendations for cardiomyopathy surveillance for survivors of childhood, adolescent, and young adult cancer from the International Late Effects of Childhood Cancer Guideline Harmonization Group. Lancet Oncol 2023; 24:e108-e120. [PMID: 37052966 DOI: 10.1016/s1470-2045(23)00012-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/07/2022] [Accepted: 01/10/2023] [Indexed: 02/16/2023]
Abstract
Survivors of childhood, adolescent, and young adult cancer, previously treated with anthracycline chemotherapy (including mitoxantrone) or radiotherapy in which the heart was exposed, are at increased risk of cardiomyopathy. Symptomatic cardiomyopathy is typically preceded by a series of gradually progressive, asymptomatic changes in structure and function of the heart that can be ameliorated with treatment, prompting specialist organisations to endorse guidelines on cardiac surveillance in at-risk survivors of cancer. In 2015, the International Late Effects of Childhood Cancer Guideline Harmonization Group compiled these guidelines into a uniform set of recommendations applicable to a broad spectrum of clinical environments with varying resource availabilities. Since then, additional studies have provided insight into dose thresholds associated with a risk of asymptomatic and symptomatic cardiomyopathy, have characterised risk over time, and have established the cost-effectiveness of different surveillance strategies. This systematic Review and guideline provides updated recommendations based on the evidence published up to September, 2020.
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5
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Totzeck M, Aide N, Bauersachs J, Bucerius J, Georgoulias P, Herrmann K, Hyafil F, Kunikowska J, Lubberink M, Nappi C, Rassaf T, Saraste A, Sciagra R, Slart RHJA, Verberne H, Rischpler C. Nuclear medicine in the assessment and prevention of cancer therapy-related cardiotoxicity: prospects and proposal of use by the European Association of Nuclear Medicine (EANM). Eur J Nucl Med Mol Imaging 2023; 50:792-812. [PMID: 36334105 PMCID: PMC9852191 DOI: 10.1007/s00259-022-05991-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
Cardiotoxicity may present as (pulmonary) hypertension, acute and chronic coronary syndromes, venous thromboembolism, cardiomyopathies/heart failure, arrhythmia, valvular heart disease, peripheral arterial disease, and myocarditis. Many of these disease entities can be diagnosed by established cardiovascular diagnostic pathways. Nuclear medicine, however, has proven promising in the diagnosis of cardiomyopathies/heart failure, and peri- and myocarditis as well as arterial inflammation. This article first outlines the spectrum of cardiotoxic cancer therapies and the potential side effects. This will be complemented by the definition of cardiotoxicity using non-nuclear cardiovascular imaging (echocardiography, CMR) and biomarkers. Available nuclear imaging techniques are then presented and specific suggestions are made for their application and potential role in the diagnosis of cardiotoxicity.
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Affiliation(s)
- Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Nicolas Aide
- Nuclear Medicine Department, University Hospital, Caen, France
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Jan Bucerius
- Department of Nuclear Medicine, University Medicine Göttingen, Georg-August-University Göttingen, Göttingen, Germany
| | - Panagiotis Georgoulias
- Department of Nuclear Medicine, Faculty of Medicine, University of Thessaly, University Hospital of Larissa, Larissa, Greece
| | - Ken Herrmann
- Clinic for Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Fabien Hyafil
- Department of Nuclear Medicine, DMU IMAGINA, Georges-Pompidou European Hospital, Assistance-Publique – Hôpitaux de Paris, University of Paris, Paris, France
| | - Jolanta Kunikowska
- Nuclear Medicine Department, Medical University of Warsaw, Warsaw, Poland
| | - Mark Lubberink
- Medical Physics, Uppsala University Hospital, Uppsala, Sweden
| | - Carmela Nappi
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, Naples, Italy
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Antti Saraste
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Roberto Sciagra
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, Florence, Italy
| | - Riemer H. J. A. Slart
- Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands ,Department of Biomedical Photonic Imaging, Faculty of Science and Technology, Enschede, The Netherlands
| | - Hein Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Christoph Rischpler
- Clinic for Nuclear Medicine, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Liu XC, Zhou PK. Tissue Reactions and Mechanism in Cardiovascular Diseases Induced by Radiation. Int J Mol Sci 2022; 23:ijms232314786. [PMID: 36499111 PMCID: PMC9738833 DOI: 10.3390/ijms232314786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 11/16/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
The long-term survival rate of cancer patients has been increasing as a result of advances in treatments and precise medical management. The evidence has accumulated that the incidence and mortality of non-cancer diseases have increased along with the increase in survival time and long-term survival rate of cancer patients after radiotherapy. The risk of cardiovascular disease as a radiation late effect of tissue damage reactions is becoming a critical challenge and attracts great concern. Epidemiological research and clinical trials have clearly shown the close association between the development of cardiovascular disease in long-term cancer survivors and radiation exposure. Experimental biological data also strongly supports the above statement. Cardiovascular diseases can occur decades post-irradiation, and from initiation and development to illness, there is a complicated process, including direct and indirect damage of endothelial cells by radiation, acute vasculitis with neutrophil invasion, endothelial dysfunction, altered permeability, tissue reactions, capillary-like network loss, and activation of coagulator mechanisms, fibrosis, and atherosclerosis. We summarize the most recent literature on the tissue reactions and mechanisms that contribute to the development of radiation-induced cardiovascular diseases (RICVD) and provide biological knowledge for building preventative strategies.
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7
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Applying global longitudinal strain in assessing cardiac dysfunction after radiotherapy among breast cancer patients: a systemic review and meta-analysis. Clin Transl Imaging 2022. [DOI: 10.1007/s40336-022-00493-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Xiao H, Wang X, Li S, Liu Y, Cui Y, Deng X. Advances in Biomarkers for Detecting Early Cancer Treatment-Related Cardiac Dysfunction. Front Cardiovasc Med 2021; 8:753313. [PMID: 34859069 PMCID: PMC8631401 DOI: 10.3389/fcvm.2021.753313] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/18/2021] [Indexed: 12/15/2022] Open
Abstract
With the gradual prolongation of the overall survival of cancer patients, the cardiovascular toxicity associated with oncology drug therapy and radiotherapy has attracted increasing attention. At present, the main methods to identify early cancer treatment-related cardiac dysfunction (CTRCD) include imaging examination and blood biomarkers. In this review, we will summarize the research progress of subclinical CTRCD-related blood biomarkers in detail. At present, common tumor therapies that cause CTRCD include: (1) Chemotherapy—The CTRCD induced by chemotherapy drugs represented by anthracycline showed a dose-dependent characteristic and most of the myocardial damage is irreversible. (2) Targeted therapy—Cardiovascular injury caused by molecular-targeted therapy drugs such as trastuzumab can be partially or completely alleviated via timely intervention. (3) Immunotherapy—Patients developed severe left ventricular dysfunction who received immune checkpoint inhibitors have been reported. (4) Radiotherapy—CTRCD induced by radiotherapy has been shown to be significantly associated with cardiac radiation dose and radiation volume. Numerous reports have shown that elevated troponin and B-type natriuretic peptide after cancer treatment are significantly associated with heart failure and asymptomatic left ventricular dysfunction. In recent years, a few emerging subclinical CTRCD potential biomarkers have attracted attention. C-reactive protein and ST2 have been shown to be associated with CTRCD after chemotherapy and radiation. Galectin-3, myeloperoxidas, placental growth factor, growth differentiation factor 15 and microRNAs have potential value in predicting CTRCD. In this review, we will summarize CTRCD caused by various tumor therapies from the perspective of cardio-oncology, and focus on the latest research progress of subclinical CTRCD biomarkers.
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Affiliation(s)
- Huiyu Xiao
- Department of Radiation Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaojie Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Shuang Li
- Department of Radiation Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ying Liu
- Heart Failure and Structural Cardiology Ward, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yijie Cui
- Department of Radiation Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaoqin Deng
- Department of Radiation Oncology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
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Xu P, Yi Y, Luo Y, Liu Z, Xu Y, Cai J, Zeng Z, Liu A. Radiation‑induced dysfunction of energy metabolism in the heart results in the fibrosis of cardiac tissues. Mol Med Rep 2021; 24:842. [PMID: 34633055 PMCID: PMC8524410 DOI: 10.3892/mmr.2021.12482] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 06/29/2021] [Indexed: 12/13/2022] Open
Abstract
Thoracic radiotherapy increases the risk of radiation‑induced heart damage (RIHD); however, the molecular mechanisms underlying these changes are not fully understood. The aim of the present study was to investigate the effects of radiation on the mouse heart using high‑throughput proteomics. Male C57BL/6J mice were used to establish a model of RIHD by exposing the entire heart to 16 Gy high‑energy X‑rays, and cardiac injuries were verified using a cardiac echocardiogram, as well as by measuring serum brain natriuretic peptide levels and conducting H&E and Masson staining 5 months after irradiation. Proteomics experiments were performed using the heart apex of 5‑month irradiated mice and control mice that underwent sham‑irradiation. The most significantly differentially expressed proteins were enriched in 'cardiac fibrosis' and 'energy metabolism'. Next, the cardiac fibrosis and changes to energy metabolism were confirmed using immunohistochemistry staining and western blotting. Extracellular matrix proteins, such as collagen type 1 α 1 chain, collagen type III α 1 chain, vimentin and CCCTC‑binding factor, along with metabolism‑related proteins, such as fatty acid synthase and solute carrier family 25 member 1, exhibited upregulated expression following exposure to ionizing radiation. Additionally, the myocardial mitochondria inner membranes were injured, along with a decrease in ATP levels and the accumulation of lactic acid in the irradiated heart tissues. These results suggest that the high doses of ionizing radiation used lead to structural remodeling, functional injury and fibrotic alterations in the mouse heart. Radiation‑induced mitochondrial damage and metabolic alterations of the cardiac tissue may thus be a pathogenic mechanism of RIHD.
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Affiliation(s)
- Peng Xu
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Yali Yi
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Yijing Luo
- Department of Clinical Medicine, The First Clinical College of Nanchang University, Nanchang, Jiangxi 330031, P.R. China
| | - Zhicheng Liu
- Department of Clinical Medicine, The First Clinical College of Nanchang University, Nanchang, Jiangxi 330031, P.R. China
| | - Yilin Xu
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Jing Cai
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Zhimin Zeng
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Anwen Liu
- Department of Oncology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
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Chauhan V, Hamada N, Monceau V, Ebrahimian T, Adam N, Wilkins RC, Sebastian S, Patel ZS, Huff JL, Simonetto C, Iwasaki T, Kaiser JC, Salomaa S, Moertl S, Azimzadeh O. Expert consultation is vital for adverse outcome pathway development: a case example of cardiovascular effects of ionizing radiation. Int J Radiat Biol 2021; 97:1516-1525. [PMID: 34402738 DOI: 10.1080/09553002.2021.1969466] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The circulatory system distributes nutrients, signaling molecules, and immune cells to vital organs and soft tissues. Epidemiological, animal, and in vitro cellular mechanistic studies have highlighted that exposure to ionizing radiation (IR) can induce molecular changes in cellular and subcellular milieus leading to long-term health impacts, particularly on the circulatory system. Although the mechanisms for the pathologies are not fully elucidated, endothelial dysfunction is proven to be a critical event via radiation-induced oxidative stress mediators. To delineate connectivities of events specifically to cardiovascular disease (CVD) initiation and progression, the adverse outcome pathway (AOP) approach was used with consultation from field experts. AOPs are a means to organize information around a disease of interest to a regulatory question. An AOP begins with a molecular initiating event and ends in an adverse outcome via sequential linkages of key event relationships that are supported by evidence in the form of the modified Bradford-Hill criteria. Detailed guidelines on building AOPs are provided by the Organisation for Economic Cooperation and Development (OECD) AOP program. Here, we report on the questions and discussions needed to develop an AOP for CVD resulting from IR exposure. A recent workshop jointly organized by the MELODI (Multidisciplinary European Low Dose Initiative) and the ALLIANCE (European Radioecology Alliance) associations brought together experts from the OECD to present the AOP approach and tools with examples from the toxicology field. As part of this workshop, four working groups were formed to discuss the identification of adverse outcomes relevant to radiation exposures and development of potential AOPs, one of which was focused on IR-induced cardiovascular effects. Each working group comprised subject matter experts and radiation researchers interested in the specific disease area and included an AOP coach. CONCLUSION The CVD working group identified the critical questions of interest for AOP development, including the exposure scenario that would inform the evidence, the mechanisms of toxicity, the initiating event, intermediate key events/relationships, and the type of data currently available. This commentary describes the four-day discussion of the CVD working group, its outcomes, and demonstrates how collaboration and expert consultation is vital to informing AOP construction.
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Affiliation(s)
- Vinita Chauhan
- Consumer and Clinical Radiation Bureau, Health Canada, Ottawa, Canada
| | - Nobuyuki Hamada
- Radiation Safety Unit, Biology and Environmental Chemistry Division, Sustainable System Research Laboratory, Central Research Institute of Electric Power Industry (CRIEPI), Tokyo, Japan
| | - Virginie Monceau
- Institute of Radiation and Nuclear Safety (IRSN), Radiotoxicology and Radiobiology Research Laboratory (LRTOX), Fontenay-Aux-Roses, France
| | - Teni Ebrahimian
- Institute of Radiation and Nuclear Safety (IRSN), Radiotoxicology and Radiobiology Research Laboratory (LRTOX), Fontenay-Aux-Roses, France
| | - Nadine Adam
- Consumer and Clinical Radiation Bureau, Health Canada, Ottawa, Canada
| | - Ruth C Wilkins
- Consumer and Clinical Radiation Bureau, Health Canada, Ottawa, Canada
| | - Soji Sebastian
- Radiobiology, Canadian Nuclear Laboratories, Chalk River, Canada
| | - Zarana S Patel
- KBR Inc, Houston, TX, USA.,NASA Johnson Space Center, Houston, TX, USA
| | | | - Cristoforo Simonetto
- Helmholtz Zentrum München, Institute of Radiation Medicine (HMGU-IRM), Neuherberg, Germany
| | - Toshiyasu Iwasaki
- Radiation Safety Unit, Biology and Environmental Chemistry Division, Sustainable System Research Laboratory, Central Research Institute of Electric Power Industry (CRIEPI), Tokyo, Japan
| | - Jan Christian Kaiser
- Helmholtz Zentrum München, Institute of Radiation Medicine (HMGU-IRM), Neuherberg, Germany
| | - Sisko Salomaa
- Department of Environmental and Biological Sciences, University of Eastern Finland, Kuopio, Finland
| | - Simone Moertl
- Section Radiation Biology, Federal Office for Radiation Protection (BfS), Neuherberg, Germany
| | - Omid Azimzadeh
- Section Radiation Biology, Federal Office for Radiation Protection (BfS), Neuherberg, Germany
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11
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Simonetto C, Wollschläger D, Kundrát P, Ulanowski A, Becker J, Castelletti N, Güthlin D, Shemiakina E, Eidemüller M. Estimating long-term health risks after breast cancer radiotherapy: merging evidence from low and high doses. RADIATION AND ENVIRONMENTAL BIOPHYSICS 2021; 60:459-474. [PMID: 34275005 PMCID: PMC8310522 DOI: 10.1007/s00411-021-00924-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/05/2021] [Indexed: 05/03/2023]
Abstract
In breast cancer radiotherapy, substantial radiation exposure of organs other than the treated breast cannot be avoided, potentially inducing second primary cancer or heart disease. While distant organs and large parts of nearby ones receive doses in the mGy-Gy range, small parts of the heart, lung and bone marrow often receive doses as high as 50 Gy. Contemporary treatment planning allows for considerable flexibility in the distribution of this exposure. To optimise treatment with regards to long-term health risks, evidence-based risk estimates are required for the entire broad range of exposures. Here, we thus propose an approach that combines data from medical and epidemiological studies with different exposure conditions. Approximating cancer induction as a local process, we estimate organ cancer risks by integrating organ-specific dose-response relationships over the organ dose distributions. For highly exposed organ parts, specific high-dose risk models based on studies with medical exposure are applied. For organs or their parts receiving relatively low doses, established dose-response models based on radiation-epidemiological data are used. Joining the models in the intermediate dose range leads to a combined, in general non-linear, dose response supported by data over the whole relevant dose range. For heart diseases, a linear model consistent with high- and low-dose studies is presented. The resulting estimates of long-term health risks are largely compatible with rate ratios observed in randomised breast cancer radiotherapy trials. The risk models have been implemented in a software tool PASSOS that estimates long-term risks for individual breast cancer patients.
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Affiliation(s)
- Cristoforo Simonetto
- Institute of Radiation Medicine, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany
| | - Daniel Wollschläger
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center Mainz, Obere Zahlbacher Str. 69, 55131, Mainz, Germany
| | - Pavel Kundrát
- Institute of Radiation Medicine, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany
- Department of Radiation Dosimetry, Nuclear Physics Institute of the Czech Academy of Sciences, Na Truhlářce 39/64, 180 00, Prague 8, Czech Republic
| | - Alexander Ulanowski
- Institute of Radiation Medicine, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany
- IAEA Environment Laboratories, International Atomic Energy Agency, 2444, Seibersdorf, Austria
| | - Janine Becker
- Institute of Radiation Medicine, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany
| | - Noemi Castelletti
- Institute of Radiation Medicine, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany
- Division of Infectious Diseases and Tropical Medicine, University Hospital, Ludwig-Maximilians-Universität (LMU) Munich, 80802, Munich, Germany
| | - Denise Güthlin
- Institute of Radiation Medicine, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany
- Department of Radiation Protection and Health, Federal Office for Radiation Protection, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany
| | - Elena Shemiakina
- Institute of Radiation Medicine, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany
| | - Markus Eidemüller
- Institute of Radiation Medicine, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Neuherberg, Germany.
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12
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Sha X, Duan J, Lin X, Zhu J, Zhang R, Sun T, Wang H, Meng X, Yin Y. A New Proton Therapy Solution Provides Superior Cardiac Sparing Compared With Photon Therapy in Whole Lung Irradiation for Pediatric Tumor Patients. Front Oncol 2021; 10:611514. [PMID: 33604292 PMCID: PMC7884855 DOI: 10.3389/fonc.2020.611514] [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: 09/29/2020] [Accepted: 12/14/2020] [Indexed: 11/21/2022] Open
Abstract
Objective Whole lung irradiation (WLI) plays a crucial role in local control in pediatric patients with lung metastases and improves patient survival. The intention of this research was to explore the advantage of cardiac sparing between photons and protons during WLI. We also propose a new solution for cardiac sparing with proton techniques. Methods Eleven patients with pediatric tumors and pulmonary metastasis treated with 12 Gy WLI (all received volumetric-modulated arc therapy (VMAT)) in our institute between 2010 and 2019 were retrospectively selected. Each patient was replanned with intensity-modulated radiation therapy (IMRT), helical tomotherapy (HT), and two intensity-modulated proton radiotherapy (IMPT) plans (IMPT-1 and IMPT-2). IMPT-1 considered the whole lung as the planning target volume (PTV), utilizing the anteroposterior technique (0/180°). IMPT-2 was a new proton solution that we proposed in this research. This approach considered the unilateral lung as the PTV, and 3 ipsilateral fields were designed for each lung. Then, IMPT-2 was generated by summing two unilateral lung plans. The primary objective was to obtain adequate coverage (95% of the prescription dose to the PTV) while maximally sparing the dose to the heart. The PTV coverage, conformity index (CI), homogeneity index (HI), and dose–volume statistics of the heart and substructures were assessed by means of the averages of each comparison parameter. Results All treatment techniques achieved the target volume coverage required by clinical practice. HT yielded the best coverage and homogeneity for the target structure compared with other techniques. The CI from IMRT was excellent. For photon radiation therapy, the HT plan afforded superior dose sparing for the V5, V6, V7, V8, and Dmean of the heart and Dmean of the right ventricle (RV). IMRT displayed the most notable dose reductions in the V9, V10, V11, and V12 of the heart and Dmean of the right atrium (RA). The VMAT plan was the least effective on the heart and substructures. However, compared with photon radiation therapy, IMPT-1 did not show an advantage for heart protection. Interestingly, IMPT-2 provided significant superiority in cardiac sparing, including maximum dose sparing for the V5, V6, V7, V8, V9 and Dmean of the heart and Dmean of the RA, RV, left atrium (LA) and left ventricle (LV) compared to all other techniques. Conclusions Considering the complex anatomical relation between target volumes and organs at risk (OARs), IMPT can provide a dose advantage for organs located outside of the target area rather than within or surrounding the area. It is hoped that advances in proton therapy (PT) plan design will lead to further improvements in radiotherapy approaches and provide the best treatment choice for individual patients.
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Affiliation(s)
- Xue Sha
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Jinghao Duan
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Xiutong Lin
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Jian Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China.,Shandong Provincial Key Laboratory of Digital Medicine and Computer-Assisted Surgery, Qingdao, China
| | - Ruohui Zhang
- Department of Radiation Oncology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Tao Sun
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Hui Wang
- Department of Radiation Oncology, Qingdao Central Hospital, Qingdao, China
| | - Xiangjuan Meng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Yong Yin
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
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13
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Fernandes RRA, Vianna CMDM, Guerra RL, Cancela MDC, Almeida LMD, Pereira AJDC, Viégas CMP, Ferman SE, Corrêa FD. Cost-Effectiveness of Proton Versus Photon Therapy in Pediatric Medulloblastoma Treatment: A Patient Volume–Based Analysis. Value Health Reg Issues 2019; 20:122-128. [DOI: 10.1016/j.vhri.2019.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/29/2019] [Accepted: 03/07/2019] [Indexed: 10/26/2022]
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14
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Desai MY, Jellis CL, Kotecha R, Johnston DR, Griffin BP. Radiation-Associated Cardiac Disease: A Practical Approach to Diagnosis and Management. JACC Cardiovasc Imaging 2019; 11:1132-1149. [PMID: 30092970 DOI: 10.1016/j.jcmg.2018.04.028] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 04/12/2018] [Accepted: 04/13/2018] [Indexed: 01/14/2023]
Abstract
Radiation-associated cardiac disease (RACD) results in complex clinical presentations, unique management issues, and increased morbidity and mortality. Patients typically present years or even decades after radiation exposure, with delayed-onset cardiac damage sustained from high cumulative doses. Multimodality imaging is crucial to determine the manifestations and severity of disease because symptoms are often nonspecific. Comprehensive screening using a coordinated approach may enable early detection. However, timing of intervention should be carefully considered in these patients because surgery is often complex and high-risk second surgeries should be minimized in the long-term. This review aims to provide treating physicians with a comprehensive and clinically focused overview of RACD, including clinical/imaging manifestations, multi-modality screening recommendations, and management options.
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Affiliation(s)
- Milind Y Desai
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | | | - Rupesh Kotecha
- Department of Radiation Oncology, Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Brian P Griffin
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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15
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16
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Seravalli E, Bosman M, Lassen-Ramshad Y, Vestergaard A, Oldenburger F, Visser J, Koutsouveli E, Paraskevopoulou C, Horan G, Ajithkumar T, Timmermann B, Fuentes CS, Whitfield G, Marchant T, Padovani L, Garnier E, Gandola L, Meroni S, Hoeben BAW, Kusters M, Alapetite C, Losa S, Goudjil F, Magelssen H, Evensen ME, Saran F, Smyth G, Rombi B, Righetto R, Kortmann RD, Janssens GO. Dosimetric comparison of five different techniques for craniospinal irradiation across 15 European centers: analysis on behalf of the SIOP-E-BTG (radiotherapy working group) . Acta Oncol 2018; 57:1240-1249. [PMID: 29698060 DOI: 10.1080/0284186x.2018.1465588] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE Conventional techniques (3D-CRT) for craniospinal irradiation (CSI) are still widely used. Modern techniques (IMRT, VMAT, TomoTherapy®, proton pencil beam scanning [PBS]) are applied in a limited number of centers. For a 14-year-old patient, we aimed to compare dose distributions of five CSI techniques applied across Europe and generated according to the participating institute protocols, therefore representing daily practice. MATERIAL AND METHODS A multicenter (n = 15) dosimetric analysis of five different techniques for CSI (3D-CRT, IMRT, VMAT, TomoTherapy®, PBS; 3 centers per technique) was performed using the same patient data, set of delineations and dose prescription (36.0/1.8 Gy). Different treatment plans were optimized based on the same planning target volume margin. All participating institutes returned their best treatment plan applicable in clinic. RESULTS The modern radiotherapy techniques investigated resulted in superior conformity/homogeneity-indices (CI/HI), particularly in the spinal part of the target (CI: 3D-CRT:0.3 vs. modern:0.6; HI: 3D-CRT:0.2 vs. modern:0.1), and demonstrated a decreased dose to the thyroid, heart, esophagus and pancreas. Dose reductions of >10.0 Gy were observed with PBS compared to modern photon techniques for parotid glands, thyroid and pancreas. Following this technique, a wide range in dosimetry among centers using the same technique was observed (e.g., thyroid mean dose: VMAT: 5.6-24.6 Gy; PBS: 0.3-10.1 Gy). CONCLUSIONS The investigated modern radiotherapy techniques demonstrate superior dosimetric results compared to 3D-CRT. The lowest mean dose for organs at risk is obtained with proton therapy. However, for a large number of organs ranges in mean doses were wide and overlapping between techniques making it difficult to recommend one radiotherapy technique over another.
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Affiliation(s)
- Enrica Seravalli
- Department of Radiation Oncology, University Medical Center Utrecht and Princess Maxima Centre for Pediatric Oncology, Utrecht, The Netherlands
| | - Mirjam Bosman
- Department of Radiation Oncology, University Medical Center Utrecht and Princess Maxima Centre for Pediatric Oncology, Utrecht, The Netherlands
| | - Yasmin Lassen-Ramshad
- Department of Oncology and Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Anne Vestergaard
- Department of Oncology and Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Foppe Oldenburger
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jorrit Visser
- Department of Radiation Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - Efi Koutsouveli
- Department of Radiation Oncology, Hygeia Hospital, Athens, Greece
| | | | - Gail Horan
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Thankamma Ajithkumar
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Beate Timmermann
- Clinic for Particle Therapy, West German Protontherapy Center Essen, University Hospital Essen, Essen, Germany
| | - Carolina-Sofia Fuentes
- Clinic for Particle Therapy, West German Protontherapy Center Essen, University Hospital Essen, Essen, Germany
| | - Gillian Whitfield
- The University of Manchester, Manchester Academic Health Science Centre, The Christie NHS Foundation Trust, Manchester, UK and The Children's Brain Tumour Research Network, University of Manchester, Royal Mancheste Children's Hospital, Manchester, UK
| | | | - Laetitia Padovani
- Department of Radiotherapy, Centre Hospitalier Universitaire de La Timone, Marseille, France
| | - Eloise Garnier
- Department of Radiotherapy, Centre Hospitalier Universitaire de La Timone, Marseille, France
| | - Lorenza Gandola
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Silvia Meroni
- Pediatric Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Bianca A. W. Hoeben
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martijn Kusters
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Claire Alapetite
- Department of Radiation Oncology, Institut Curie and Centre de protontherapie, Paris and Orsay, France
| | - Sandra Losa
- Department of Radiation Oncology, Institut Curie and Centre de protontherapie, Paris and Orsay, France
| | - Farid Goudjil
- Department of Radiation Oncology, Institut Curie and Centre de protontherapie, Paris and Orsay, France
| | - Henriette Magelssen
- Department of Oncology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Morten Egeberg Evensen
- Department of Oncology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Frank Saran
- The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Gregory Smyth
- Joint Department of Physics at The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Barbara Rombi
- Protontherapy Center, Azienda Provinciale per i Servizi Sanitari APSS, Trento, Italy
| | - Roberto Righetto
- Protontherapy Center, Azienda Provinciale per i Servizi Sanitari APSS, Trento, Italy
| | | | - Geert O. Janssens
- Department of Radiation Oncology, University Medical Center Utrecht and Princess Maxima Centre for Pediatric Oncology, Utrecht, The Netherlands
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17
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Kalapurakal JA, Gopalakrishnan M, Walterhouse DO, Rigsby CK, Rademaker A, Helenowski I, Kessel S, Morano K, Laurie F, Ulin K, Esiashvili N, Katzenstein H, Marcus K, Followill DS, Wolden SL, Mahajan A, Fitzgerald TJ. Cardiac-Sparing Whole Lung IMRT in Patients With Pediatric Tumors and Lung Metastasis: Final Report of a Prospective Multicenter Clinical Trial. Int J Radiat Oncol Biol Phys 2018; 103:28-37. [PMID: 30170102 DOI: 10.1016/j.ijrobp.2018.08.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 08/13/2018] [Accepted: 08/23/2018] [Indexed: 12/01/2022]
Abstract
PURPOSE A prospective clinical trial was conducted for patients undergoing cardiac sparing (CS) whole lung irradiation (WLI) using intensity modulated radiation therapy (IMRT). The 3 trial aims were (1) to demonstrate the feasibility of CS IMRT with real-time central quality control; (2) to determine the dosimetric advantages of WLI using IMRT compared with standard anteroposterior (AP) techniques; and (3) to determine acute tolerance and short-term efficacy after a protocol-mandated minimum 2-year follow-up for all patients. METHODS AND MATERIALS All patients underwent a 3-dimensional chest computed tomography scan and a contrast-enhanced 4-dimensional (4D) gated chest computed tomography scan using a standard gating device. The clinical target volume was the entire bilateral 3-dimensional lung volume, and the internal target volume was the 4D minimum intensity projection of both lungs. The internal target volume was expanded by 1 cm to get the planning target volume. All target volumes, cardiac contours, and treatment plans were centrally reviewed before treatment. The different cardiac volumes receiving percentages of prescribed radiation therapy (RT) doses on AP and IMRT WLI plans were estimated and compared. RESULTS The target 20 patients were accrued in 2 years. Median RT dose was 15 Gy. Real-time central quality assurance review and plan preapproval were obtained for all patients. WLI using IMRT was feasible in all patients. Compared with standard AP WLI, CS IMRT resulted in a statistically significant reduction in radiation doses to the whole heart, atria, ventricles, and coronaries. One child developed cardiac dysfunction and pulmonary restrictive disease 5.5 years after CS IMRT (15 Gy) and doxorubicin (375 mg/m2). The 2- and 3-year lung metastasis progression-free survival was 65% and 52%, respectively. CONCLUSIONS We have demonstrated the feasibility of WLI using CS IMRT and confirmed the previously reported advantages of IMRT, including superior cardiac protection and superior dose coverage of 4D lung volumes. Further studies are required to establish the efficacy and safety of this irradiation technique.
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Affiliation(s)
| | | | - David O Walterhouse
- Pediatric Oncology and Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Cynthia K Rigsby
- Pediatric Oncology and Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | | | - Sandy Kessel
- Imaging and Radiation Oncology Core, Providence, Rhode Island
| | - Karen Morano
- Imaging and Radiation Oncology Core, Providence, Rhode Island
| | - Fran Laurie
- Imaging and Radiation Oncology Core, Providence, Rhode Island
| | - Ken Ulin
- Imaging and Radiation Oncology Core, Providence, Rhode Island
| | | | | | - Karen Marcus
- Radiation Oncology, Harvard University, Boston, Massachusetts
| | | | - Suzanne L Wolden
- Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Anita Mahajan
- Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
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18
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Abstract
PURPOSE OF REVIEW Thoracic radiation therapy is an effective treatment for several malignancies, such as Hodgkin's lymphoma and breast cancer. Over the years, however, the incidence of cardiovascular events has increased in these patients, notably in younger survivors who do not have traditional risk factors. This review summarizes the pathology, incidence, clinical presentation, and management of cardiac events after radiation therapy. RECENT FINDINGS Mediastinal radiation therapy accelerates the atherosclerosis process, resulting in early onset coronary artery disease. Valvular disease due to radiation therapy typically affects the left-sided valves, with aortic regurgitation being the most common. Rarely, it may lead to aortic stenosis requiring surgical interventions. Pericardial involvement includes acute and chronic pericardial disease and pericardial effusion. New studies are investigating the prevalence and pathogenesis of autonomic dysfunction in cancer survivors who have undergone mediastinal and neck radiation. Radiation therapy itself causes vascular endothelial dysfunction, resulting in clinical cardiovascular events, manifesting many years after completion of therapy. There remains little guidance regarding screening and therapies to prevent cardiovascular events in this population.
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Affiliation(s)
- Deepa Raghunathan
- University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | | | - Saamir A Hassan
- University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
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Clinical and diagnosis characteristics of breast cancers in women with a history of radiotherapy in the first 30years of life: A French multicentre cohort study. Radiother Oncol 2017; 124:200-203. [PMID: 28733054 DOI: 10.1016/j.radonc.2017.06.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 06/22/2017] [Accepted: 06/29/2017] [Indexed: 11/21/2022]
Abstract
PURPOSE Irradiation (>3Gy) to the breast or axillae before 30years of age increases the risk of secondary breast cancer (SBC). The purpose of this article is to describe the clinical characteristics of SBC and the way of diagnosis in young women (before the age of national screening) in France who had received previous radiotherapy for a childhood or a young adulthood cancer. PATIENTS AND METHODS This retrospective, multicentre study reviewed the medical records of women with SBC before the age of the national screening who had received irradiation (≥3Gy) on part or all of the breast before 30years of age, for any type of tumour except BC. RESULTS A total of 121 SBC were detected in 104 women with previous radiotherapy. Twenty percent of SBC were detected during regular breast screening and 16% of the women had a regular radiological follow-up. CONCLUSION Our results points out that the main proportion of childhood cancer survivors did not benefit from the recommended breast cancer screening. This result is comparable to other previously published studies in other countries. A national screening programme is necessary and should take into account the patient's age, family history, personal medical history and previous radiotherapy to reduce the number of SBC diagnosed at an advanced stage.
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20
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Chaikh A, Docquière N, Bondiau PY, Balosso J. Impact of dose calculation models on radiotherapy outcomes and quality adjusted life years for lung cancer treatment: do we need to measure radiotherapy outcomes to tune the radiobiological parameters of a normal tissue complication probability model? Transl Lung Cancer Res 2016; 5:673-680. [PMID: 28149761 DOI: 10.21037/tlcr.2016.11.04] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The equivalent uniform dose (EUD) radiobiological model can be applied for lung cancer treatment plans to estimate the tumor control probability (TCP) and the normal tissue complication probability (NTCP) using different dose calculation models. Then, based on the different calculated doses, the quality adjusted life years (QALY) score can be assessed versus the uncomplicated tumor control probability (UTCP) concept in order to predict the overall outcome of the different treatment plans. METHODS Nine lung cancer cases were included in this study. For the each patient, two treatments plans were generated. The doses were calculated respectively from pencil beam model, as pencil beam convolution (PBC) turning on 1D density correction with Modified Batho's (MB) method, and point kernel model as anisotropic analytical algorithm (AAA) using exactly the same prescribed dose, normalized to 100% at isocentre point inside the target and beam arrangements. The radiotherapy outcomes and QALY were compared. The bootstrap method was used to improve the 95% confidence intervals (95% CI) estimation. Wilcoxon paired test was used to calculate P value. RESULTS Compared to AAA considered as more realistic, the PBCMB overestimated the TCP while underestimating NTCP, P<0.05. Thus the UTCP and the QALY score were also overestimated. CONCLUSIONS To correlate measured QALY's obtained from the follow-up of the patients with calculated QALY from DVH metrics, the more accurate dose calculation models should be first integrated in clinical use. Second, clinically measured outcomes are necessary to tune the parameters of the NTCP model used to link the treatment outcome with the QALY. Only after these two steps, the comparison and the ranking of different radiotherapy plans would be possible, avoiding over/under estimation of QALY and any other clinic-biological estimates.
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Affiliation(s)
- Abdulhamid Chaikh
- Department of Radiation Oncology and Medical Physics, University Hospital of Grenoble, Grenoble, France; ; France HADRON National Research Infrastructure, Lyon, France
| | - Nicolas Docquière
- Department of Radiation Oncology and Medical Physics, University Hospital of Grenoble, Grenoble, France
| | - Pierre-Yves Bondiau
- France HADRON National Research Infrastructure, Lyon, France; ; Centre Antoine Lacassagne, Nice, France
| | - Jacques Balosso
- Department of Radiation Oncology and Medical Physics, University Hospital of Grenoble, Grenoble, France; ; France HADRON National Research Infrastructure, Lyon, France; ; University Grenoble-Alpes, Grenoble, France
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21
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Haddy N, Diallo S, El-Fayech C, Schwartz B, Pein F, Hawkins M, Veres C, Oberlin O, Guibout C, Pacquement H, Munzer M, N’Guyen TD, Bondiau PY, Berchery D, Laprie A, Scarabin PY, Jouven X, Bridier A, Koscielny S, Deutsch E, Diallo I, de Vathaire F. Cardiac Diseases Following Childhood Cancer Treatment. Circulation 2016; 133:31-8. [DOI: 10.1161/circulationaha.115.016686] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 10/09/2015] [Indexed: 11/16/2022]
Abstract
Background—
Cardiac disease (CD) is one of the major side effects of childhood cancer therapy, but until now little has been known about the relationship between the heart radiation dose (HRD) received during childhood and the risk of CD.
Methods and Results—
The cohort comprised 3162 5-year survivors of childhood cancer. Chemotherapy information was collected and HRD was estimated. There were 347 CDs in 234 patients, 156 of them were rated grade ≥3. Cox and Poisson regression models were used. The cumulative incidence of any type of CD at 40 years of age was 11.0% (95% confidence interval [CI], 9.5–12.7) and 7·4% (95% CI, 6.2–8.9) when only the CDs of grade ≥3 were considered. In comparison with patients who received no anthracycline and either no radiotherapy or an HRD<0·1Gy, the risk was multiplied by 18·4 (95% CI, 7.1–48.0) in patients who had received anthracycline and no radiotherapy or a HRD <0.1Gy, by 60.4 (95% CI, 22.4–163.0) in those who had received no anthracycline and an HRD≥30Gy, and 61.5 (95% CI, 19.6–192.8) in those who had received both anthracycline and an HRD≥30Gy.
Conclusions—
Survivors of childhood cancers treated with radiotherapy and anthracycline run a high dose-dependent risk of developing CD. CDs develop earlier in patients treated with anthracycline than in those treated without it.
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Affiliation(s)
- Nadia Haddy
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Stéphanie Diallo
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Chiraz El-Fayech
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Boris Schwartz
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - François Pein
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Mike Hawkins
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Cristina Veres
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Odile Oberlin
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Catherine Guibout
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Hélène Pacquement
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Martine Munzer
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Tan Dat N’Guyen
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Pierre-Yves Bondiau
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Delphine Berchery
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Anne Laprie
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Pierre-Yves Scarabin
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Xavier Jouven
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - André Bridier
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Serge Koscielny
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Eric Deutsch
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Ibrahima Diallo
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
| | - Florent de Vathaire
- From Radiation Epidemiology Group, INSERM, UMR1018, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., S.K., I.D., F.d.V.); Gustave Roussy, Villejuif, France (N.H., C.E.-F., B.S., C.V., O.O., C.G., A.B., S.K., E.D., I.D., F.d.V.); Université Paris XI, Villejuif, France (N.H., C.E.-F., B.S., C.V., C.G., I.D., F.d.V.); Centre Hospitalier de Gonesse, Service Pharmacie, Gonesse, France (S.D.); Institut de Cancérologie de l’Ouest, site René Gauducheau CLCC Nantes-Atlantique, Département de
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22
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Armstrong GT, Joshi VM, Ness KK, Marwick TH, Zhang N, Srivastava D, Griffin BP, Grimm RA, Thomas J, Phelan D, Collier P, Krull KR, Mulrooney DA, Green DM, Hudson MM, Robison LL, Plana JC. Comprehensive Echocardiographic Detection of Treatment-Related Cardiac Dysfunction in Adult Survivors of Childhood Cancer: Results From the St. Jude Lifetime Cohort Study. J Am Coll Cardiol 2015; 65:2511-22. [PMID: 26065990 DOI: 10.1016/j.jacc.2015.04.013] [Citation(s) in RCA: 204] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 03/24/2015] [Accepted: 04/07/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Treatment-related cardiac death is the primary, noncancer cause of mortality in adult survivors of childhood malignancies. Early detection of cardiac dysfunction may identify a high-risk subset of survivors for early intervention. OBJECTIVES This study sought to determine the prevalence of cardiac dysfunction in adult survivors of childhood malignancies. METHODS Echocardiographic assessment included 3-dimensional (3D) left ventricular ejection fraction (LVEF), global longitudinal and circumferential myocardial strain, and diastolic function, graded per American Society of Echocardiography guidelines in 1,820 adult (median age 31 years; range: 18 to 65 years) survivors of childhood cancer (median time from diagnosis 23 years; range: 10 to 48 years) exposed to anthracycline chemotherapy (n = 1,050), chest-directed radiotherapy (n = 306), or both (n = 464). RESULTS Only 5.8% of survivors had abnormal 3D LVEFs (<50%). However, 32.1% of survivors with normal 3D LVEFs had evidence of cardiac dysfunction by global longitudinal strain (28%), American Society of Echocardiography-graded diastolic assessment (8.7%), or both. Abnormal global longitudinal strain was associated with chest-directed radiotherapy at 1 to 19.9 Gy (rate ratio [RR]: 1.38; 95% confidence interval [CI]: 1.14 to 1.66), 20 to 29.9 Gy (RR: 1.65; 95% CI: 1.31 to 2.08), and >30 Gy (RR: 2.39; 95% CI: 1.79 to 3.18) and anthracycline dose > 300 mg/m(2) (RR: 1.72; 95% CI: 1.31 to 2.26). Survivors with metabolic syndrome were twice as likely to have abnormal global longitudinal strain (RR: 1.94; 95% CI: 1.66 to 2.28) and abnormal diastolic function (RR: 1.68; 95% CI: 1.39 to 2.03) but not abnormal 3D LVEFs (RR: 1.07; 95% CI: 0.74 to 1.53). CONCLUSIONS Abnormal global longitudinal strain and diastolic function are more prevalent than reduced 3D LVEF and are associated with treatment exposure. They may identify a subset of survivors at higher risk for poor clinical cardiac outcomes who may benefit from early medical intervention.
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Affiliation(s)
- Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee.
| | - Vijaya M Joshi
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Thomas H Marwick
- Menzies Research Institute, University of Tasmania, Hobart, Australia
| | - Nan Zhang
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - DeoKumar Srivastava
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Brian P Griffin
- Department of Cardiovascular Medicine, The Cleveland Clinic, Cleveland, Ohio
| | - Richard A Grimm
- Department of Cardiovascular Medicine, The Cleveland Clinic, Cleveland, Ohio
| | - James Thomas
- Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Chicago, Illinois
| | - Dermot Phelan
- Department of Cardiovascular Medicine, The Cleveland Clinic, Cleveland, Ohio
| | - Patrick Collier
- Department of Cardiovascular Medicine, The Cleveland Clinic, Cleveland, Ohio
| | - Kevin R Krull
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Daniel A Mulrooney
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Daniel M Green
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Melissa M Hudson
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
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23
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Adverse health events and late mortality after pediatric allogeneic hematopoietic SCT-two decades of longitudinal follow-up. Bone Marrow Transplant 2015; 50:850-7. [PMID: 25798676 DOI: 10.1038/bmt.2015.43] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 01/19/2015] [Accepted: 02/02/2015] [Indexed: 01/19/2023]
Abstract
Treatment-related late toxicities after pediatric allogeneic hematopoietic SCT (allo-HSCT) are increasingly important as long-term survival has become an expected outcome for many transplanted children and adolescents. In a retrospective cohort study, we assessed long-term health outcomes in 204 allo-HSCT survivors transplanted in childhood or adolescence (<20 years) between 1978 through 2000 after a median follow-up time of 12 (range 4-28) years. Data on conditioning regimen, adverse health events (AE) and growth and hormonal substitutions (hormone replacement therapies (HRTs)) were obtained from medical records. AEs were graded retrospectively according to Common Terminology Criteria for Adverse Events v3.0. Late deaths (⩾48 months after allo-HSCT) were evaluated separately. Multivariate analysis demonstrated that chronic GVHD (P<0.000) and longer follow-up time (P<0.05) correlated with AEs, whereas CY-based conditioning was inversely correlated (P<0.002). TBI and longer follow-up duration predicted more severe AEs (P<0.001 and P<0.001, respectively). HRTs were more frequent after TBI. Diabetes type II, dyslipidemia and hypertension were detected in 9, 7 and 7% of the survivors, respectively. Late deaths (n=22) were most frequently due to pulmonary failure (n=7), followed by secondary malignancy (n=5). The occurrence of AEs after pediatric allo-HSCT is high and likely to increase during extended follow-up, particularly in patients who have received TBI.
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Armenian SH, Hudson MM, Mulder RL, Chen MH, Constine LS, Dwyer M, Nathan PC, Tissing WJE, Shankar S, Sieswerda E, Skinner R, Steinberger J, van Dalen EC, van der Pal H, Wallace WH, Levitt G, Kremer LCM. Recommendations for cardiomyopathy surveillance for survivors of childhood cancer: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group. Lancet Oncol 2015; 16:e123-36. [PMID: 25752563 PMCID: PMC4485458 DOI: 10.1016/s1470-2045(14)70409-7] [Citation(s) in RCA: 374] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Survivors of childhood cancer treated with anthracycline chemotherapy or chest radiation are at an increased risk of developing congestive heart failure. In this population, congestive heart failure is well recognised as a progressive disorder, with a variable period of asymptomatic cardiomyopathy that precedes signs and symptoms. As a result, several clinical practice guidelines have been developed independently to help with detection and treatment of asymptomatic cardiomyopathy. These guidelines differ with regards to definitions of at-risk populations, surveillance modality and frequency, and recommendations for interventions. Differences between these guidelines could hinder the effective implementation of these recommendations. We report on the results of an international collaboration to harmonise existing cardiomyopathy surveillance recommendations using an evidence-based approach that relied on standardised definitions for outcomes of interest and transparent presentation of the quality of the evidence. The resultant recommendations were graded according to the quality of the evidence and the potential benefit gained from early detection and intervention.
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Affiliation(s)
- Saro H Armenian
- Department of Population Sciences, City of Hope, Duarte, USA.
| | - Melissa M Hudson
- Departments of Oncology and Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Renee L Mulder
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - Ming Hui Chen
- Department of Pediatrics, Boston Children's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Mary Dwyer
- Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia
| | - Paul C Nathan
- The Hospital for Sick Children and the University of Toronto, Department of Pediatrics and Institute of Health Policy, Management and Evaluation, Toronto, ON, Canada
| | - Wim J E Tissing
- Division of Pediatric Oncology and Pediatric Hematology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Sadhna Shankar
- Division of Oncology, Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC, USA
| | - Elske Sieswerda
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - Rod Skinner
- Department of Paediatric and Adolescent Haematology/Oncology, Great North Children's Hospital and University of Newcastle, Newcastle upon Tyne, UK
| | - Julia Steinberger
- Department of Pediatrics, Division of Cardiology, University of Minnesota Amplatz Childrens' Hospital, Minneapolis, MN, USA
| | - Elvira C van Dalen
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Helena van der Pal
- Department of Pediatric Oncology and Medical Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - W Hamish Wallace
- Department of Hematology/Oncology, Royal Hospital for Sick Children, Edinburgh, Scotland
| | - Gill Levitt
- Department of Oncology/Haematology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Leontien C M Kremer
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
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25
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Wong FL, Bhatia S, Landier W, Francisco L, Leisenring W, Hudson MM, Armstrong GT, Mertens A, Stovall M, Robison LL, Lyman GH, Lipshultz SE, Armenian SH. Cost-effectiveness of the children's oncology group long-term follow-up screening guidelines for childhood cancer survivors at risk for treatment-related heart failure. Ann Intern Med 2014; 160:672-83. [PMID: 24842414 PMCID: PMC4073480 DOI: 10.7326/m13-2498] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Childhood cancer survivors treated with anthracyclines are at high risk for asymptomatic left ventricular dysfunction (ALVD), subsequent heart failure, and death. The consensus-based Children's Oncology Group (COG) Long-Term Follow-up Guidelines recommend lifetime echocardiographic screening for ALVD. OBJECTIVE To evaluate the efficacy and cost-effectiveness of the COG guidelines and to identify more cost-effective screening strategies. DESIGN Simulation of life histories using Markov health states. DATA SOURCES Childhood Cancer Survivor Study; published literature. TARGET POPULATION Childhood cancer survivors. TIME HORIZON Lifetime. PERSPECTIVE Societal. INTERVENTION Echocardiographic screening followed by angiotensin-converting enzyme (ACE) inhibitor and β-blocker therapies after ALVD diagnosis. OUTCOME MEASURES Quality-adjusted life-years (QALYs), costs, incremental cost-effectiveness ratios (ICERs) in dollars per QALY, and cumulative incidence of heart failure. RESULTS OF BASE-CASE ANALYSIS The COG guidelines versus no screening have an ICER of $61 500, extend life expectancy by 6 months and QALYs by 1.6 months, and reduce the cumulative incidence of heart failure by 18% at 30 years after cancer diagnosis. However, less frequent screenings are more cost-effective than the guidelines and maintain 80% of the health benefits. RESULTS OF SENSITIVITY ANALYSIS The ICER was most sensitive to the magnitude of ALVD treatment efficacy; higher treatment efficacy resulted in lower ICER. LIMITATION Lifetime non-heart failure mortality and the cumulative incidence of heart failure more than 20 years after diagnosis were extrapolated; the efficacy of ACE inhibitor and β-blocker therapy in childhood cancer survivors with ALVD is undetermined (or unknown). CONCLUSION The COG guidelines could reduce the risk for heart failure in survivors at less than $100 000/QALY. Less frequent screening achieves most of the benefits and would be more cost-effective than the COG guidelines.
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Monceau V, Llach A, Azria D, Bridier A, Petit B, Mazevet M, Strup-Perrot C, To THV, Calmels L, Germaini MM, Gourgou S, Fenoglietto P, Bourgier C, Gomez AM, Escoubet B, Dörr W, Haagen J, Deutsch E, Morel E, Vozenin MC. Epac contributes to cardiac hypertrophy and amyloidosis induced by radiotherapy but not fibrosis. Radiother Oncol 2014; 111:63-71. [PMID: 24721545 DOI: 10.1016/j.radonc.2014.01.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Revised: 01/06/2014] [Accepted: 01/28/2014] [Indexed: 01/22/2023]
Abstract
BACKGROUND Cardiac toxicity is a side-effect of anti-cancer treatment including radiotherapy and this translational study was initiated to characterize radiation-induced cardiac side effects in a population of breast cancer patients and in experimental models in order to identify novel therapeutic target. METHODS The size of the heart was evaluated in CO-HO-RT patients by measuring the Cardiac-Contact-Distance before and after radiotherapy (48months of follow-up). In parallel, fibrogenic signals were studied in a severe case of human radiation-induced pericarditis. Lastly, radiation-induced cardiac damage was studied in mice and in rat neonatal cardiac cardiomyocytes. RESULTS In patients, time dependent enhancement of the CCD was measured suggesting occurrence of cardiac hypertrophy. In the case of human radiation-induced pericarditis, we measured the activation of fibrogenic (CTGF, RhoA) and remodeling (MMP2) signals. In irradiated mice, we documented decreased contractile function, enlargement of the ventricular cavity and long-term modification of the time constant of decay of Ca(2+) transients. Both hypertrophy and amyloid deposition were correlated with the induction of Epac-1; whereas radiation-induced fibrosis correlated with Rho/CTGF activation. Transactivation studies support Epac contribution in hypertrophy stimulation and showed that radiotherapy and Epac displayed specific and synergistic signals. CONCLUSION Epac-1 has been identified as a novel regulator of radiation-induced hypertrophy and amyloidosis but not fibrosis in the heart.
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Affiliation(s)
- Virginie Monceau
- INSERM U1030, LabEx LERMIT, Villejuif, France; Faculté de Médecine Paris-Sud, Université Paris-Sud 11, Le Kremlin-Bicêtre, France
| | - Anna Llach
- INSERM U769, IFR141, LabEx LERMIT, Faculté de Pharmacie, Châtenay-Malabry, France
| | - David Azria
- Department of Radiation Oncology, CRLC Val d'Aurelle, Montpellier, France
| | - André Bridier
- Département de radiothérapie, Institut Gustave Roussy, Villejuif, France
| | - Benoît Petit
- INSERM U1030, LabEx LERMIT, Villejuif, France; Faculté de Médecine Paris-Sud, Université Paris-Sud 11, Le Kremlin-Bicêtre, France
| | - Marianne Mazevet
- INSERM U769, IFR141, LabEx LERMIT, Faculté de Pharmacie, Châtenay-Malabry, France
| | | | - Thi-Hong-Van To
- INSERM U1030, LabEx LERMIT, Villejuif, France; Faculté de Médecine Paris-Sud, Université Paris-Sud 11, Le Kremlin-Bicêtre, France
| | - Lucie Calmels
- Département de radiothérapie, Institut Gustave Roussy, Villejuif, France
| | | | - Sophie Gourgou
- Department of Radiation Oncology, CRLC Val d'Aurelle, Montpellier, France
| | - Pascal Fenoglietto
- Department of Radiation Oncology, CRLC Val d'Aurelle, Montpellier, France
| | - Céline Bourgier
- INSERM U1030, LabEx LERMIT, Villejuif, France; Department of Radiation Oncology, CRLC Val d'Aurelle, Montpellier, France; Département de radiothérapie, Institut Gustave Roussy, Villejuif, France
| | - Ana-Maria Gomez
- INSERM U769, IFR141, LabEx LERMIT, Faculté de Pharmacie, Châtenay-Malabry, France
| | - Brigitte Escoubet
- Département de Physiologie, Explorations Fonctionnelles, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France; Université Paris Diderot, France; INSERM U872, Paris, France
| | - Wolfgang Dörr
- Department of Radiotherapy and Radiation Oncology, Technical University, Dresden, Germany; Department of Radiation Oncology & Christian Doppler Laboratory for Medical Radiation Research in Radiooncology Medical University, Vienna, Austria
| | - Julia Haagen
- Department of Radiotherapy and Radiation Oncology, Technical University, Dresden, Germany
| | - Eric Deutsch
- INSERM U1030, LabEx LERMIT, Villejuif, France; Faculté de Médecine Paris-Sud, Université Paris-Sud 11, Le Kremlin-Bicêtre, France; Département de radiothérapie, Institut Gustave Roussy, Villejuif, France
| | - Eric Morel
- INSERM U769, IFR141, LabEx LERMIT, Faculté de Pharmacie, Châtenay-Malabry, France
| | - Marie Catherine Vozenin
- INSERM U1030, LabEx LERMIT, Villejuif, France; Faculté de Médecine Paris-Sud, Université Paris-Sud 11, Le Kremlin-Bicêtre, France; Laboratoire de Radio-oncologie, CHUV, Lausanne, Switzerland.
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Zhang R, Howell RM, Homann K, Giebeler A, Taddei PJ, Mahajan A, Newhauser WD. Predicted risks of radiogenic cardiac toxicity in two pediatric patients undergoing photon or proton radiotherapy. Radiat Oncol 2013; 8:184. [PMID: 23880421 PMCID: PMC3751146 DOI: 10.1186/1748-717x-8-184] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 07/21/2013] [Indexed: 01/12/2023] Open
Abstract
Background Hodgkin disease (HD) and medulloblastoma (MB) are common malignancies found in children and young adults, and radiotherapy is part of the standard treatment. It was reported that these patients who received radiation therapy have an increased risk of cardiovascular late effects. We compared the predicted risk of developing radiogenic cardiac toxicity after photon versus proton radiotherapies for a pediatric patient with HD and a pediatric patient with MB. Methods In the treatment plans, each patient’s heart was contoured in fine detail, including substructures of the pericardium and myocardium. Risk calculations took into account both therapeutic and stray radiation doses. We calculated the relative risk (RR) of cardiac toxicity using a linear risk model and the normal tissue complication probability (NTCP) values using relative seriality and Lyman models. Uncertainty analyses were also performed. Results The RR values of cardiac toxicity for the HD patient were 7.27 (proton) and 8.37 (photon), respectively; the RR values for the MB patient were 1.28 (proton) and 8.39 (photon), respectively. The predicted NTCP values for the HD patient were 2.17% (proton) and 2.67% (photon) for the myocardium, and were 2.11% (proton) and 1.92% (photon) for the whole heart. The predicted ratios of NTCP values (proton/photon) for the MB patient were much less than unity. Uncertainty analyses revealed that the predicted ratio of risk between proton and photon therapies was sensitive to uncertainties in the NTCP model parameters and the mean radiation weighting factor for neutrons, but was not sensitive to heart structure contours. The qualitative findings of the study were not sensitive to uncertainties in these factors. Conclusions We conclude that proton and photon radiotherapies confer similar predicted risks of cardiac toxicity for the HD patient in this study, and that proton therapy reduced the predicted risk for the MB patient in this study.
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Affiliation(s)
- Rui Zhang
- The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX, USA.
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Monceau V, Meziani L, Strup-Perrot C, Morel E, Schmidt M, Haagen J, Escoubet B, Dörr W, Vozenin MC. Enhanced sensitivity to low dose irradiation of ApoE-/- mice mediated by early pro-inflammatory profile and delayed activation of the TGFβ1 cascade involved in fibrogenesis. PLoS One 2013; 8:e57052. [PMID: 23451141 PMCID: PMC3579799 DOI: 10.1371/journal.pone.0057052] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 01/17/2013] [Indexed: 12/15/2022] Open
Abstract
Aim Investigating long-term cardiac effects of low doses of ionizing radiation is highly relevant in the context of interventional cardiology and radiotherapy. Epidemiological data report that low doses of irradiation to the heart can result in significant increase in the cardiovascular mortality by yet unknown mechanisms. In addition co-morbidity factor such as hypertension or/and atherosclerosis can enhance cardiac complications. Therefore, we explored the mechanisms that lead to long-term cardiac remodelling and investigated the interaction of radiation-induced damage to heart and cardiovascular systems with atherosclerosis, using wild-type and ApoE-deficient mice. Methods and Results ApoE−/− and wild-type mice were locally irradiated to the heart at 0, 0.2 and 2 Gy (RX). Twenty, 40 and 60 weeks post-irradiation, echocardiography were performed and hearts were collected for cardiomyocyte isolation, histopathological analysis, study of inflammatory infiltration and fibrosis deposition. Common and strain-specific pathogenic pathways were found. Significant alteration of left ventricular function (eccentric hypertrophy) occurred in both strains of mice. Low dose irradiation (0.2 Gy) induced premature death in ApoE−/− mice (47% died at 20 weeks). Acute inflammatory infiltrate was observed in scarring areas with accumulation of M1-macrophages and secretion of IL-6. Increased expression of the fibrogenic factors (TGF-β1 and PAI-1) was measured earlier in cardiomyocytes isolated from ApoE−/− than in wt animals. Conclusion The present study shows that cardiac exposure to low dose of ionizing radiation induce significant physiological, histopathological, cellular and molecular alterations in irradiated heart with mild functional impairment. Atherosclerotic predisposition precipitated cardiac damage induced by low doses with an early pro-inflammatory polarization of macrophages.
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de Ville de Goyet M, Moniotte S, Brichard B. Cardiotoxicity of childhood cancer treatment: update and current knowledge on long-term follow-up. Pediatr Hematol Oncol 2012; 29:395-414. [PMID: 22732022 DOI: 10.3109/08880018.2012.694092] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Therapeutic advances in paediatric oncology allowed increasing numbers of children to survive until adulthood. However, chemotherapy and radiotherapy are potentially cardiotoxic and contribute to a significant morbidity and mortality, cardiovascular events remaining the leading cause of death among survivors. This review summarizes the physiopathology of treatment-related cardiovascular diseases, their incidence, and the risk factors associated with each specific therapy. Few studies have investigated the cardiac outcomes of adult surviving from childhood cancers but all demonstrated a substantial risk for late cardiac effects. Cardiovascular monitoring, prevention, and early detection of cardiac dysfunction are, therefore, the keystones of an improved long-term outcome.
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Affiliation(s)
- Maëlle de Ville de Goyet
- Department of Paediatric Haematology and Oncology, Cliniques universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
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Siddiqui F, Mathews T, Teh BS, Kalapurakal JA, Butler EB, Chintagumpala M, Paulino AC. Whole lung irradiation in pediatric patients using helical tomotherapy to minimize cardiac, breast, and thyroid dose. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/s13566-012-0056-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Brodin NP, Munck Af Rosenschöld P, Aznar MC, Kiil-Berthelsen A, Vogelius IR, Nilsson P, Lannering B, Björk-Eriksson T. Radiobiological risk estimates of adverse events and secondary cancer for proton and photon radiation therapy of pediatric medulloblastoma. Acta Oncol 2011; 50:806-16. [PMID: 21767178 DOI: 10.3109/0284186x.2011.582514] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The aim of this model study was to estimate and compare the risk of radiation-induced adverse late effects in pediatric patients with medulloblastoma (MB) treated with either three-dimensional conformal radiotherapy (3D CRT), inversely-optimized arc therapy (RapidArc(®) (RA)) or spot-scanned intensity-modulated proton therapy (IMPT). The aim was also to find dose-volume toxicity parameters relevant to children undergoing RT to be used in the inverse planning of RA and IMPT, and to use in the risk estimations. MATERIAL AND METHODS Treatment plans were created for all three techniques on 10 pediatric patients that have been treated with craniospinal irradiation (CSI) at our institution in 2007-2009. Plans were generated for two prescription CSI doses, 23.4 Gy and 36 Gy. Risk estimates were based on childhood cancer survivor data when available and secondary cancer (SC) risks were estimated as a function of age at exposure and attained age according to the organ-equivalent dose (OED) concept. RESULTS Estimates of SC risk was higher for the RA plans and differentiable from the estimates for 3D CRT at attained ages above 40 years. The risk of developing heart failure, hearing loss, hypothyroidism and xerostomia was highest for the 3D CRT plans. The risks of all adverse effects were estimated as lowest for the IMPT plans, even when including secondary neutron (SN) irradiation with high values of the neutron radiation weighting factors (WR(neutron)). CONCLUSIONS When comparing RA and 3D CRT treatment for pediatric MB it is a matter of comparing higher SC risk against higher risks of non-cancer adverse events. Considering time until onset of the different complications is necessary to fully assess patient benefit in such a comparison. The IMPT plans, including SN dose contribution, compared favorably to the photon techniques in terms of all radiobiological risk estimates.
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Affiliation(s)
- N Patrik Brodin
- Radiation Medicine Research Center, Department of Radiation Oncology, Rigshospitalet, University of Copenhagen, Denmark.
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Haddy N, Mousannif A, Tukenova M, Guibout C, Grill J, Dhermain F, Pacquement H, Oberlin O, El-Fayech C, Rubino C, Thomas-Teinturier C, Le-Deley MC, Hawkins M, Winter D, Chavaudra J, Diallo I, de Vathaire F. Relationship between the brain radiation dose for the treatment of childhood cancer and the risk of long-term cerebrovascular mortality. Brain 2011; 134:1362-72. [DOI: 10.1093/brain/awr071] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Semrau S, Klautke G, Fietkau R. Baseline cardiopulmonary function as an independent prognostic factor for survival of inoperable non-small-cell lung cancer after concurrent chemoradiotherapy: a single-center analysis of 161 cases. Int J Radiat Oncol Biol Phys 2010; 79:96-104. [PMID: 20350789 DOI: 10.1016/j.ijrobp.2009.10.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2009] [Revised: 10/09/2009] [Accepted: 10/14/2009] [Indexed: 11/17/2022]
Abstract
PURPOSE Little is known about the effects of cardiopulmonary function on the prognosis of concurrent chemoradiotherapy in patients with inoperable non-small-cell lung cancer (NSCLC). METHODS AND MATERIALS A retrospective analysis of the effects of tumor- and patient-related factors and parameters of cardiopulmonary function and heart morphology on the feasibility, toxicity, and prognosis was performed. RESULTS Cardiopulmonary function had no effect on the toxicity or feasibility of treatment; effects on survival were observed in the univariate analysis. Median survival varied as follows: cardiac function: 13.0 ± 1.6 months for left ventricular ejection fraction (LVEF) > 50% vs. 10.0 ± 1.9 months for LVEF ≤ 50% (p = 0.003); pulmonary function: 16.0 ± 0.6 months for no lung function deficits (vital capacity [VC] ≥ 60%, forced expiratory volume in 1 s ≥ 80%, and diffusing capacity of the lung for carbon monoxide (DLCO) ≥60%) vs. 14.0 ± 1.5 months for one or two function deficits vs. 8.0 ± 1.5 months for three lung function deficits (p = 0.001); T stage: 19.0 ± 3.1 months for rcT0/cT1/cT2 vs. 12.0 ± 0.8 months for cT3/cT4 (p = 0.039); and age: 11.0 ± 1.5 months for <60 years vs. 18.0 ± 2.5 months for 60-69 years vs. 12.0 ± 1.2 months for ≥70 years (p = 0.008). Prognostic factors identified in the multivariate analysis were LVEF ≤50% (p = 0.043; hazard ratio [HR], 1.74), reduced pulmonary function (p = 0.001; HR, 1.71 or 5.05) and T stage (p = 0.026; HR: 1.71). CONCLUSIONS In addition to T-stage, cardiac and pulmonary function variables affected the survival of non-small-cell lung cancer patients after chemoradiotherapy.
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Affiliation(s)
- Sabine Semrau
- Department of Radiation Oncology, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany.
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Tukenova M, Guibout C, Oberlin O, Doyon F, Mousannif A, Haddy N, Guérin S, Pacquement H, Aouba A, Hawkins M, Winter D, Bourhis J, Lefkopoulos D, Diallo I, de Vathaire F. Role of cancer treatment in long-term overall and cardiovascular mortality after childhood cancer. J Clin Oncol 2010; 28:1308-15. [PMID: 20142603 DOI: 10.1200/jco.2008.20.2267] [Citation(s) in RCA: 303] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE The purpose of this study was to assess the role of treatment in long-term overall and cardiovascular mortality after childhood cancer. PATIENTS AND METHODS We studied 4,122 5-year survivors of a childhood cancer diagnosed before 1986 in France and the United Kingdom. Information on chemotherapy was collected, and the radiation dose delivered to the heart was estimated for 2,870 patients who had received radiotherapy. RESULTS After 86,453 person-years of follow-up (average, 27 years), 603 deaths had occurred. The overall standardized mortality ratio (SMR) was 8.3-fold higher (95% CI, 7.6-fold to 9.0-fold higher) in relation to the general populations in France and the United Kingdom. Thirty-two patients had died as a result of cardiovascular diseases (ie, 5.0-fold [95% CI, 3.3-fold to 6.7-fold] more than expected). The risk of dying as a result of cardiac diseases (n = 21) was significantly higher in individuals who had received a cumulative anthracycline dose greater than 360 mg/m(2) (relative risk [RR], 4.4; 95% CI, 1.3 to 15.3) and in individuals who received an average radiation dose that exceeded 5 Gy (RR, 12.5 and 25.1 for 5 to 14.9 Gy and > 15 Gy, respectively) to the heart. A linear relationship was found between the average dose of radiation to the heart and the risk of cardiac mortality (estimated excess [corrected] RR at 1 Gy, 60%). CONCLUSION This study is the first, to our knowledge, to establish a relationship between the radiation dose received by the heart during radiotherapy for a childhood cancer and long-term cardiac mortality. This study also confirms a significant excess risk of cardiac mortality associated with a high cumulative dose of anthracyclines.
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Affiliation(s)
- Markhaba Tukenova
- L'Institut National de la Santé et de la Recherche Médicale,Institut Gustave Roussy, 94805 Villejuif Cedex, France
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Fossati P, Ricardi U, Orecchia R. Pediatric medulloblastoma: toxicity of current treatment and potential role of protontherapy. Cancer Treat Rev 2008; 35:79-96. [PMID: 18976866 DOI: 10.1016/j.ctrv.2008.09.002] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Revised: 08/30/2008] [Accepted: 09/03/2008] [Indexed: 11/25/2022]
Abstract
Post-operative craniospinal irradiation and systemic chemotherapy are both necessary in the treatment of pediatric medulloblastoma. Late toxicity is a major problem in long term survivors and significantly affects their quality of life. We have systematically reviewed the literature to examine data on late toxicity, specifically focusing on: endocrine function, growth and bone development, neurocognitive development, second cancers, ototoxicity, gynecological toxicity and health of the offspring, cardiac toxicity and pulmonary toxicity. In this paper, we describe qualitatively the kind of detected side effects and, whenever possible, try to assess their incidence and the relative role of craniospinal irradiation (as opposed to other treatments and to the disease itself) in producing them. Subsequently we examine the possible approach to reduce unwanted effects from craniospinal irradiation to target and non-target tissues and we consider briefly the role of hyperfractionation, tomotherapy and IMRT. We describe the characteristics of protontherapy and its potential for non-target tissues toxicity reduction reviewing the existing physical and dosimetric studies and the (still very limited) clinical experiences. Finally we propose intensity modulated spot scanning protontherapy with multiportal simultaneous optimization (IMPT) as a possible tool for dose distribution optimization within different areas of CNS and potential reduction of target tissues toxicity.
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Affiliation(s)
- Piero Fossati
- Institute of Radiological Sciences, University of Milan, Milano, Italy.
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Carver JR, Ng A, Meadows AT, Vaughn DJ. Cardiovascular late effects and the ongoing care of adult cancer survivors. ACTA ACUST UNITED AC 2008; 11:1-6. [PMID: 18279108 DOI: 10.1089/dis.2008.111714] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Joseph R Carver
- Abramson Family Cancer Research Institute, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Semrau S, Klautke G, Virchow J, Kundt G, Fietkau R. Impact of comorbidity and age on the outcome of patients with inoperable NSCLC treated with concurrent chemoradiotherapy. Respir Med 2008; 102:210-8. [DOI: 10.1016/j.rmed.2007.09.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2007] [Revised: 09/20/2007] [Accepted: 09/20/2007] [Indexed: 10/22/2022]
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Poortmans P. Evidence based radiation oncology: Breast cancer. Radiother Oncol 2007; 84:84-101. [PMID: 17599597 DOI: 10.1016/j.radonc.2007.06.002] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Revised: 05/30/2007] [Accepted: 06/02/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE Radiotherapy is, similar to surgery, a local treatment. In the case of breast cancer, it is generally given after conservative or after more extensive, tumour and patient adapted, surgery. The target volumes can be the breast and/or the thoracic wall and/or the regional lymph node areas. The integration and the extent of radiotherapy as part of the comprehensive treatment of the breast cancer patient, including the amount of surgery and the sequencing with the systemic treatments, has to be well discussed with all medical specialists involved in treating breast cancer on a multidisciplinary basis. Guidelines for the appropriate prescription and execution of radiotherapy are of utmost importance. However, individualisation based on the individual patients' and tumours' characteristics should always be envisaged. MATERIALS AND METHODS Based on a review of the literature the level of evidence that is available for the indications for radiotherapy is summarised, as well as the main clinical questions that are unanswered today. An overview of the recent and ongoing clinical trails in breast cancer will highlight some of the current ongoing debates. CONCLUSIONS In the case of breast cancer, radiotherapy, given after as well conservative as extensive risk-adapted surgery, significantly reduces the risk of local and regional recurrences. Especially for patients with an intermediate to high absolute risk for local recurrences, a positive influence on overall survival has been shown, notably when appropriate radiotherapy techniques are used. Most important is that the best results that we can offer to our breast cancer patients for all clinical endpoints (local and regional control; quality of life; cosmetic results; survival) can be obtained by a multidisciplinary and patient-oriented approach, involving all those involved in the treatment of breast cancer patients.
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Affiliation(s)
- Philip Poortmans
- Dr. Bernard Verbeeten Instituut, Radiotherapy, Tilburg, Netherlands.
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