1
|
Seth L, Makram O, Essa A, Patel V, Jiang S, Bhave A, Yerraguntla S, Gopu G, Malik S, Swaby J, Rast J, Padgett CA, Shetewi A, Nain P, Weintraub N, Miller ED, Dent S, Barac A, Shiradkar R, Madabhushi A, Ferguson C, Guha A. Laterality of Radiation Therapy in Breast Cancer is Not Associated With Increased Risk of Coronary Artery Disease in the Contemporary Era. Adv Radiat Oncol 2024; 9:101583. [PMID: 39258143 PMCID: PMC11385753 DOI: 10.1016/j.adro.2024.101583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 07/02/2024] [Indexed: 09/12/2024] Open
Abstract
Purpose External beam radiation therapy (EBRT) is a critical component of breast cancer (BC) therapy. Given the improvement in technology in the contemporary era, we hypothesized that there is no difference in the development of or worsening of existing coronary artery disease (CAD) in patients with BC receiving left versus right-sided radiation. Methods and Materials For the meta-analysis portion of our study, we searched PubMed, Web of Science, and Scopus and included studies from January 1999 to September 2022. CAD was identified using a homogenous metric across multiple studies included. We computed the risk ratio (RR) for included studies using a random effects model. For the institutional cohort portion of our study, we selected high cardiovascular-risk patients who received diagnoses of BC between 2010 and 2022 if they met our inclusion criteria. We performed a Cox proportional hazards model with stepwise adjustment. Results A pooled random effects model with 9 studies showed that patients with left-sided BC receiving EBRT had a 10% increased risk of CAD when compared with patients with right-sided BC receiving EBRT (RR, 1.10; 95% CI, 1.02-1.18; P = .01). However, subgroup analysis of 6 studies that included patients diagnosed after 1980 did not show a significant difference in CAD based on BC laterality (RR, 1.07; 95% CI, 0.95-1.20; P = .27). For the institutional cohort portion of the study, we found that patients with left-sided BC who received EBRT did not have a significantly higher risk of CAD when compared with their right-sided counterparts (hazard ratios [HR], 0.73; 95% CI, 0.34-1.54; P = .402). Conclusions Our study suggests a historical trend of increased CAD in BC patients receiving left-sided EBRT. Data from patients diagnosed after 2010 in our institutional cohort did not show a significant difference, emphasizing that modern EBRT regimens are safe, and laterality of BC does not affect CAD outcomes in the short term after a BC diagnosis.
Collapse
Affiliation(s)
- Lakshya Seth
- Department of Medicine, Medical College of Georgia, Augusta, Georgia
| | - Omar Makram
- Department of Medicine, Medical College of Georgia, Augusta, Georgia
| | - Amr Essa
- Department of Medicine, Medical College of Georgia, Augusta, Georgia
| | - Vraj Patel
- Department of Medicine, Medical College of Georgia, Augusta, Georgia
| | - Stephanie Jiang
- Department of Medicine, Medical College of Georgia, Augusta, Georgia
| | - Aditya Bhave
- Department of Medicine, Medical College of Georgia, Augusta, Georgia
| | | | - Gaurav Gopu
- Department of Medicine, Medical College of Georgia, Augusta, Georgia
| | - Sarah Malik
- Department of Medicine, Medical College of Georgia, Augusta, Georgia
| | - Justin Swaby
- Department of Medicine, Medical College of Georgia, Augusta, Georgia
| | - Johnathon Rast
- Department of Medicine, Medical College of Georgia, Augusta, Georgia
| | - Caleb A Padgett
- Department of Medicine, Medical College of Georgia, Augusta, Georgia
| | - Ahmed Shetewi
- Department of Medicine, Medical College of Georgia, Augusta, Georgia
| | - Priyanshu Nain
- Department of Medicine, Medical College of Georgia, Augusta, Georgia
| | - Neal Weintraub
- Department of Medicine, Medical College of Georgia, Augusta, Georgia
| | - Eric D Miller
- Department of Radiation Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Susan Dent
- Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Ana Barac
- Division of Cardio-Oncology, Inova Schar Cancer Institute and Inova Heart and Vascular Institute, Fairfax, Virginia
| | - Rakesh Shiradkar
- Wallace H Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia
| | - Anant Madabhushi
- Wallace H Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia
| | - Catherine Ferguson
- Department of Radiation Oncology, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Avirup Guha
- Cardio-Oncology Program, Medical College of Georgia, Augusta, Georgia
| |
Collapse
|
2
|
Kuru O, Ozan Goksel E, Volkan Demircan N, Sengoz M. Evaluation of helical tomotherapy as an alternative for left-sided breast cancer patients not compliant with deep inspiration breath hold. Tech Innov Patient Support Radiat Oncol 2024; 31:100268. [PMID: 39247163 PMCID: PMC11380380 DOI: 10.1016/j.tipsro.2024.100268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 07/31/2024] [Accepted: 08/03/2024] [Indexed: 09/10/2024] Open
Abstract
Purpose The aim of this study is to investigate, from a dosimetric perspective, whether helical Tomotherapy (HT) during free breathing (FB) can serve as an alternative technique for treating left-sided breast cancer patients who are unable to comply with the deep inspiration breath hold (DIBH) technique. Material and Methods For this purpose, the CT images of 20 left breast-only cancer patients acquired in both FB and DIBH phases were utilized. The left breast was contoured as the target volume, while the heart, LAD, ipsilateral and contralateral lungs, and contralateral breast were contoured as organs at risk on the CT images obtained in both DIBH and FB. Planning with the volumetric modulated arc therapy (VMAT) technique was performed on the CT scans obtained in the DIBH (VMAT-DIBH), while planning with the HT technique was carried out on the CT scans obtained in the FB (HT-FB). Subsequently, dosimetric comparison of the plans were done in terms of target coverage and preservation of normal tissues. Results Both techniques achieved the desired target coverage; however, in terms of D2, Vpres values, Conformity Number (CN), and Homogeneity Index (HI), the HT-FB technique was found to be superior. While the mean doses to the heart were similar for both techniques, doses to the LAD and left lung were found to be superior in plans generated with the HT-FB technique. When compared in terms of contralateral breast and right lung protection, VMAT-DIBH technique was found to be significantly superior. Conclusion The treatment of left breast-only patients with the HT-FB technique has been observed to provide similar heart protection and better LAD and ipsilateral lung protection compared to the VMAT-DIBH technique without compromising target coverage. However, when the HT-FB technique is used, doses to the contralateral lung and contralateral breast should be carefully evaluated.
Collapse
Affiliation(s)
- Okan Kuru
- Eastern Mediterranean University, School of Health Services, Radiotherapy Program, Famagusta, North Cyprus, via Mersin 10, Turkey
| | - Evren Ozan Goksel
- Acibadem MAA University, Vocational School of Health Services, Radiotherapy Program, Istanbul, Turkey
| | - Niyazi Volkan Demircan
- Bahcesehir University Hospital, Medical Park Goztepe, Department of Radiation Oncology, Istanbul, Turkey
| | - Meric Sengoz
- Acibadem Altunizade Hospital, Department of Radiation Oncology, Istanbul, Turkey
| |
Collapse
|
3
|
Siman-Tov M, Ostrovski A, Mast M, Struikmans H, Bogers L, Fortpied C, Hol S, Petoukhova A, van Egmond J, Poortmans P, Kaidar-Person O. Dosimetric Analyses of the Three Radiation Techniques Used in the EORTC 22922/10925 IM-MS Breast Cancer Trial. Clin Oncol (R Coll Radiol) 2024:S0936-6555(24)00369-8. [PMID: 39261237 DOI: 10.1016/j.clon.2024.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 08/16/2024] [Accepted: 08/21/2024] [Indexed: 09/13/2024]
Abstract
PURPOSE The aim of the current study is to compare the dosimetry of 3 radiation therapy (RT) techniques used in the EORTC 22922/10925 trial for irradiating the internal mammary (IM) and medial supraclavicular nodes (MS) using a treatment planning system available nowadays for dose calculation. METHODS We performed a retrospective dosimetry analysis of anonymised data; thus, ethics approval was not required. Ten cases of left-sided breast were randomly selected for RT planning to a total dose of 50 Gy in 25 fractions. The treatment planning was done according to the trial's protocol and under the supervision of the EORTC trial's coordinators. Doses to planning target volumes (PTV) and to organs at risk (OARs) are reported. Data is presented in descriptive statistics. RESULTS A total of 10 cases and 40 treatment plans (4 plans per case: standard-plan A, modified standard-plan B, individualised-plan C and breast-only-plan D). For all planning techniques, the mean dose to the PTV of the left breast (plan A-D) and the PTV-MS (plan A-C) exceeded 95% of the prescribed dose (>47.5 Gy). The individualised technique (plan C) had a lower coverage for PTV-IM, with a mean of 87% of the prescribed dose compared to ∼102% for plans A and B. The dose to OARs varied between techniques, with the mean heart dose being higher in the standard and modified standard techniques (18.3 and 16.6 Gy, respectively) compared to the individualised technique (9.5 Gy). CONCLUSIONS The 3 RT techniques used in the trial varied in target coverage and OARs dose. Our results may help to understand the observed larger absolute benefit of individualised IM-MS treatment planning in terms of breast cancer outcomes.
Collapse
Affiliation(s)
- M Siman-Tov
- Department of Radiation Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - A Ostrovski
- Department of Radiation Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - M Mast
- Department of Radiation Oncology, Haaglanden Medical Center, Leidschendam, The Netherlands
| | - H Struikmans
- Department of Radiation Oncology, Haaglanden Medical Center, Leidschendam, The Netherlands
| | - L Bogers
- Department of Medical Physics, Haaglanden Medical Center, Leidschendam, The Netherlands
| | - C Fortpied
- The European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - S Hol
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, The Netherlands
| | - A Petoukhova
- Department of Medical Physics, Haaglanden Medical Center, Leidschendam, The Netherlands
| | - J van Egmond
- Department of Medical Physics, Haaglanden Medical Center, Leidschendam, The Netherlands
| | - P Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk-Antwerp, Belgium
| | - O Kaidar-Person
- Department of Radiation Oncology, Sheba Medical Center, Ramat Gan, Israel; School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; GROW-School for Oncology and Developmental Biology or GROW (Maastro), Maastricht University, Maastricht, The Netherlands.
| |
Collapse
|
4
|
Riazi G, Brizais C, Garali I, Al-rifai R, Quelquejay H, Monceau V, Vares G, Ould-Boukhitine L, Aubeleau D, Gilain F, Gloaguen C, Dos Santos M, Ait-Oufella H, Ebrahimian T. Effects of moderate doses of ionizing radiation on experimental abdominal aortic aneurysm. PLoS One 2024; 19:e0308273. [PMID: 39088551 PMCID: PMC11293671 DOI: 10.1371/journal.pone.0308273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 07/18/2024] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND Exposure to ionizing radiation has been linked to cardiovascular diseases. However, the impact of moderate doses of radiation on abdominal aortic aneurysm (AAA) remains unknown. METHODS Angiotensin II-infused Apoe-/- mice were irradiated (acute, 1 Gray) either 3 days before (Day-3) or 1 day after (Day+1) pomp implantation. Isolated primary aortic vascular smooth muscle cells (VSMCs) were irradiated (acute 1 Gray) for mechanistic studies and functional testing in vitro. RESULTS Day-3 and Day+1 irradiation resulted in a significant reduction in aorta dilation (Control: 1.39+/-0.12; Day-3: 1.12+/-0.11; Day+1: 1.15+/-0.08 mm, P<0.001) and AAA incidence (Control: 81.0%; Day-3: 33.3%, Day+1: 53.3%) compared to the non-irradiated group. Day-3 and Day+1 irradiation led to an increase in collagen content in the adventitia (Thickness control: 23.64+/-2.9; Day-3: 54.39+/-15.5; Day+1 37.55+/-10.8 mm, P = 0.006). However, the underlying protective mechanisms were different between Day-3 and Day+1 groups. Irradiation before Angiotensin II (AngII) infusion mainly modulated vascular smooth muscle cell (VSMC) phenotype with a decrease in contractile profile and enhanced proliferative and migratory activity. Irradiation after AngII infusion led to an increase in macrophage content with a local anti-inflammatory phenotype characterized by the upregulation of M2-like gene and IL-10 expression. CONCLUSION Moderate doses of ionizing radiation mitigate AAA either through VSCM phenotype or inflammation modulation, depending on the time of irradiation.
Collapse
MESH Headings
- Animals
- Aortic Aneurysm, Abdominal/pathology
- Aortic Aneurysm, Abdominal/metabolism
- Aortic Aneurysm, Abdominal/etiology
- Mice
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/radiation effects
- Muscle, Smooth, Vascular/pathology
- Radiation, Ionizing
- Angiotensin II/pharmacology
- Myocytes, Smooth Muscle/metabolism
- Myocytes, Smooth Muscle/radiation effects
- Myocytes, Smooth Muscle/pathology
- Male
- Disease Models, Animal
- Interleukin-10/metabolism
- Interleukin-10/genetics
- Collagen/metabolism
- Cell Proliferation/radiation effects
Collapse
Affiliation(s)
- Goran Riazi
- Experimental Radiotoxicology and Radiobiology Laboratory (LRTOX), Institute for Radiobiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Chloe Brizais
- Experimental Radiotoxicology and Radiobiology Laboratory (LRTOX), Institute for Radiobiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Imene Garali
- Experimental Radiotoxicology and Radiobiology Laboratory (LRTOX), Institute for Radiobiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Rida Al-rifai
- Université de Paris, Inserm U970, Paris-Cardiovascular Research Center, Paris, France
| | - Helene Quelquejay
- Experimental Radiotoxicology and Radiobiology Laboratory (LRTOX), Institute for Radiobiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Virginie Monceau
- Experimental Radiotoxicology and Radiobiology Laboratory (LRTOX), Institute for Radiobiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Guillaume Vares
- Experimental Radiotoxicology and Radiobiology Laboratory (LRTOX), Institute for Radiobiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Lea Ould-Boukhitine
- Experimental Radiotoxicology and Radiobiology Laboratory (LRTOX), Institute for Radiobiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Damien Aubeleau
- Experimental Radiotoxicology and Radiobiology Laboratory (LRTOX), Institute for Radiobiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Florian Gilain
- Experimental Radiotoxicology and Radiobiology Laboratory (LRTOX), Institute for Radiobiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Celine Gloaguen
- Experimental Radiotoxicology and Radiobiology Laboratory (LRTOX), Institute for Radiobiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Morgane Dos Santos
- Accidental Exposure Radiobiology Laboratory (LRACC), Institute for Radiobiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Hafid Ait-Oufella
- Université de Paris, Inserm U970, Paris-Cardiovascular Research Center, Paris, France
- Medical Intensive Care Unit, Hôpital Saint-Antoine, AP-HP, Sorbonne Université, Paris, France
| | - Teni Ebrahimian
- Experimental Radiotoxicology and Radiobiology Laboratory (LRTOX), Institute for Radiobiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| |
Collapse
|
5
|
Recht A. Internal Mammary Node Irradiation Debate: Case Closed? Not Yet, and Maybe Never. J Clin Oncol 2024; 42:1871-1874. [PMID: 38498804 DOI: 10.1200/jco.23.02480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/03/2024] [Accepted: 02/05/2024] [Indexed: 03/20/2024] Open
Abstract
The IMN debate is still open and may never be closed for reasons outlined in this Comments and Controversies piece.
Collapse
Affiliation(s)
- Abram Recht
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| |
Collapse
|
6
|
Rey N, Ebrahimian T, Gloaguen C, Kereselidze D, Christelle E, Brizais C, Bachelot F, Riazi G, Monceau V, Demarquay C, Zineddine IG, Klokov D, Lehoux S, Ebrahimian TG. Low to moderate dose 137Cs (γ) radiation promotes M2 type macrophage skewing and reduces atherosclerotic plaque CD68+ cell content in ApoE (-/-) mice. Sci Rep 2024; 14:12450. [PMID: 38816571 PMCID: PMC11139881 DOI: 10.1038/s41598-024-63084-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/24/2024] [Indexed: 06/01/2024] Open
Abstract
The effects of low doses of ionizing radiation on atherosclerosis remain uncertain, particularly as regards the generation of pro- or anti-inflammatory responses, and the time scale at which such effects can occur following irradiation. To explore these phenomena, we exposed atheroprone ApoE(-/-) mice to a single dose of 0, 0.05, 0.5 or 1 Gy of 137Cs (γ) administered at a 10.35 mGy min-1 dose rate and evaluated short-term (1-10 days) and long-term consequences (100 days). Bone marrow-derived macrophages were derived from mice 1 day after exposure. Irradiation was associated with a significant skewing of M0 and M2 polarized macrophages towards the M2 phenotype, as demonstrated by an increased mRNA expression of Retnla, Arg1, and Chil3 in cells from mice exposed to 0.5 or 1 Gy compared with non-irradiated animals. Minimal effects were noted in M1 cells or M1 marker mRNA. Concurrently, we observed a reduced secretion of IL-1β but enhanced IL-10 release from M0 and M2 macrophages. Effects of irradiation on circulating monocytes were most marked at day 10 post-exposure, when the 1 Gy dose was associated with enhanced numbers of both Ly6CHigh and Ly6Low cells. By day 100, levels of circulating monocytes in irradiated and non-irradiated mice were equivalent, but anti-inflammatory Ly6CLow monocytes were significantly increased in the spleen of mice exposed to 0.05 or 1 Gy. Long term exposures did not affect atherosclerotic plaque size or lipid content, as determined by Oil red O staining, whatever the dose applied. Similarly, irradiation did not affect atherosclerotic plaque collagen or smooth muscle cell content. However, we found that lesion CD68+ cell content tended to decrease with rising doses of radioactivity exposure, culminating in a significant reduction of plaque macrophage content at 1 Gy. Taken together, our results show that short- and long-term exposures to low to moderate doses of ionizing radiation drive an anti-inflammatory response, skewing bone marrow-derived macrophages towards an IL-10-secreting M2 phenotype and decreasing plaque macrophage content. These results suggest a low-grade athero-protective effect of low and moderate doses of ionizing radiation.
Collapse
Affiliation(s)
- N Rey
- Institut de Radioprotection et de Sûreté Nucléaire, Laboratoire de Radiotoxicologie et de Radiobiologie Expérimentale, 92262, Fontenay-Aux Roses, France
| | - T Ebrahimian
- Department of Medicine, Lady Davis Institute for Biomedical Research, McGill University, Montreal, Canada
| | - C Gloaguen
- Institut de Radioprotection et de Sûreté Nucléaire, Laboratoire de Radiotoxicologie et de Radiobiologie Expérimentale, 92262, Fontenay-Aux Roses, France
| | - D Kereselidze
- Institut de Radioprotection et de Sûreté Nucléaire, Laboratoire de Radiotoxicologie et de Radiobiologie Expérimentale, 92262, Fontenay-Aux Roses, France
| | - E Christelle
- Institut de Radioprotection et de Sûreté Nucléaire, Laboratoire de Radiotoxicologie et de Radiobiologie Expérimentale, 92262, Fontenay-Aux Roses, France
| | - C Brizais
- Institut de Radioprotection et de Sûreté Nucléaire, Laboratoire de Radiotoxicologie et de Radiobiologie Expérimentale, 92262, Fontenay-Aux Roses, France
| | - F Bachelot
- Institut de Radioprotection et de Sûreté Nucléaire, Laboratoire de Radiotoxicologie et de Radiobiologie Expérimentale, 92262, Fontenay-Aux Roses, France
| | - G Riazi
- Institut de Radioprotection et de Sûreté Nucléaire, Laboratoire de Radiotoxicologie et de Radiobiologie Expérimentale, 92262, Fontenay-Aux Roses, France
| | - V Monceau
- Institut de Radioprotection et de Sûreté Nucléaire, Laboratoire de Radiotoxicologie et de Radiobiologie Expérimentale, 92262, Fontenay-Aux Roses, France
| | - C Demarquay
- Institut de Radioprotection et de Sûreté Nucléaire, Laboratoire de Radiotoxicologie et de Radiobiologie Expérimentale, 92262, Fontenay-Aux Roses, France
| | - I Garali Zineddine
- Institut de Radioprotection et de Sûreté Nucléaire, Laboratoire de Radiotoxicologie et de Radiobiologie Expérimentale, 92262, Fontenay-Aux Roses, France
| | - D Klokov
- Institut de Radioprotection et de Sûreté Nucléaire, Laboratoire de Radiotoxicologie et de Radiobiologie Expérimentale, 92262, Fontenay-Aux Roses, France
| | - S Lehoux
- Department of Medicine, Lady Davis Institute for Biomedical Research, McGill University, Montreal, Canada.
| | - Teni G Ebrahimian
- Institut de Radioprotection et de Sûreté Nucléaire, Laboratoire de Radiotoxicologie et de Radiobiologie Expérimentale, 92262, Fontenay-Aux Roses, France.
| |
Collapse
|
7
|
Yan T, Yu H, Li T, Dong Y. Mechanisms of Cardiovascular Toxicities Induced by Cancer Therapies and Promising Biomarkers for Their Prediction: A Scoping Review. Heart Lung Circ 2024; 33:605-638. [PMID: 38242833 DOI: 10.1016/j.hlc.2023.12.006] [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: 05/31/2023] [Revised: 10/16/2023] [Accepted: 12/01/2023] [Indexed: 01/21/2024]
Abstract
AIM With the advancement of anti-cancer medicine, cardiovascular toxicities due to cancer therapies are common in oncology patients, resulting in increased mortality and economic burden. Cardiovascular toxicities caused by cancer therapies include different severities of cardiomyopathy, arrhythmia, myocardial ischaemia, hypertension, and thrombosis, which may lead to left ventricular dysfunction and heart failure. This scoping review aimed to summarise the mechanisms of cardiovascular toxicities following various anti-cancer treatments and potential predictive biomarkers for early detection. METHODS PubMed, Cochrane, Embase, Web of Science, Scopus, and CINAHL databases were searched for original studies written in English related to the mechanisms of cardiovascular toxicity induced by anti-cancer therapies, including chemotherapy, targeted therapy, immunotherapy, radiation therapy, and relevant biomarkers. The search and title/abstract screening were conducted independently by two reviewers, and the final analysed full texts achieved the consensus of the two reviewers. RESULTS A total of 240 studies were identified based on their titles and abstracts. In total, 107 full-text articles were included in the analysis. Cardiomyocyte and endothelial cell apoptosis caused by oxidative stress injury, activation of cell apoptosis, blocking of normal cardiovascular protection signalling pathways, overactivation of immune cells, and myocardial remodelling were the main mechanisms. Promising biomarkers for anti-cancer therapies related to cardiovascular toxicity included placental growth factor, microRNAs, galectin-3, and myeloperoxidase for the early detection of cardiovascular toxicity. CONCLUSION Understanding the mechanisms of cardiovascular toxicity following various anti-cancer treatments could provide implications for future personalised treatment methods to protect cardiovascular function. Furthermore, specific early sensitive and stable biomarkers of cardiovascular system damage need to be identified to predict reversible damage to the cardiovascular system and improve the effects of anti-cancer agents.
Collapse
Affiliation(s)
- Tingting Yan
- Nursing Department, Liaocheng Vocational and Technical College, Liaocheng City, Shandong Province, China
| | - Hailong Yu
- Department of Gastrointestinal Surgery, Liaocheng People's Hospital, Liaocheng City, Shandong Province, China
| | - Tai Li
- Nursing Department, Liaocheng Vocational and Technical College, Liaocheng City, Shandong Province, China
| | - Yanhong Dong
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| |
Collapse
|
8
|
Zhao LY, Wang XY, Wen ML, Pan NN, Yin XQ, An MW, Wang L, Liu Y, Song JB. Advances in injectable hydrogels for radiation-induced heart disease. JOURNAL OF BIOMATERIALS SCIENCE. POLYMER EDITION 2024; 35:1031-1063. [PMID: 38340315 DOI: 10.1080/09205063.2024.2314364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/11/2024] [Indexed: 02/12/2024]
Abstract
Radiological heart damage (RIHD) is damage caused by unavoidable irradiation of the heart during chest radiotherapy, with a long latency period and a progressively increasing proportion of delayed cardiac damage due to conventional doses of chest radiotherapy. There is a risk of inducing diseases such as acute/chronic pericarditis, myocarditis, delayed myocardial fibrosis and damage to the cardiac conduction system in humans, which can lead to myocardial infarction or even death in severe cases. This paper details the pathogenesis of RIHD and gives potential targets for treatment at the molecular and cellular level, avoiding the drawbacks of high invasiveness and immune rejection due to drug therapy, medical device implantation and heart transplantation. Injectable hydrogel therapy has emerged as a minimally invasive tissue engineering therapy to provide necessary mechanical support to the infarcted myocardium and to act as a carrier for various bioactive factors and cells to improve the cellular microenvironment in the infarcted area and induce myocardial tissue regeneration. Therefore, this paper combines bioactive factors and cellular therapeutic mechanisms with injectable hydrogels, presents recent advances in the treatment of cardiac injury after RIHD with different injectable gels, and summarizes the therapeutic potential of various types of injectable hydrogels as a potential solution.
Collapse
Affiliation(s)
- Lu-Yao Zhao
- Institute of Biomedical Engineering, College of Biomedical Engineering, Taiyuan University of Technology, Shanxi Key Laboratory of Material Strength & Structural Impact, Taiyuan, China
| | - Xin-Yue Wang
- Institute of Biomedical Engineering, College of Biomedical Engineering, Taiyuan University of Technology, Shanxi Key Laboratory of Material Strength & Structural Impact, Taiyuan, China
| | - Mei-Ling Wen
- Institute of Biomedical Engineering, College of Biomedical Engineering, Taiyuan University of Technology, Shanxi Key Laboratory of Material Strength & Structural Impact, Taiyuan, China
| | - Ning-Ning Pan
- Institute of Biomedical Engineering, College of Biomedical Engineering, Taiyuan University of Technology, Shanxi Key Laboratory of Material Strength & Structural Impact, Taiyuan, China
| | - Xing-Qi Yin
- Institute of Biomedical Engineering, College of Biomedical Engineering, Taiyuan University of Technology, Shanxi Key Laboratory of Material Strength & Structural Impact, Taiyuan, China
| | - Mei-Wen An
- Institute of Biomedical Engineering, College of Biomedical Engineering, Taiyuan University of Technology, Shanxi Key Laboratory of Material Strength & Structural Impact, Taiyuan, China
| | - Li Wang
- Institute of Biomedical Engineering, College of Biomedical Engineering, Taiyuan University of Technology, Shanxi Key Laboratory of Material Strength & Structural Impact, Taiyuan, China
| | - Yang Liu
- Institute of Biomedical Engineering, College of Biomedical Engineering, Taiyuan University of Technology, Shanxi Key Laboratory of Material Strength & Structural Impact, Taiyuan, China
- Department of Nuclear Medicine, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Jian-Bo Song
- Shanghai NewMed Medical Corporation, Shanghai, China
| |
Collapse
|
9
|
Perman M, Johansson KA, Holmberg E, Karlsson P. Doses to the right coronary artery and the left anterior descending coronary artery and death from ischemic heart disease after breast cancer radiotherapy: a case-control study in a population-based cohort. Acta Oncol 2024; 63:240-247. [PMID: 38682458 PMCID: PMC11332482 DOI: 10.2340/1651-226x.2024.19677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/29/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND AND PURPOSE Doses to the coronary arteries in breast cancer (BC) radiotherapy (RT) have been suggested to be a risk predictor of long-term cardiac toxicity after BC treatment. We investigated the dose-risk relationships between near maximum doses (Dmax) to the right coronary artery (RCA) and left anterior descending coronary artery (LAD) and ischemic heart disease (IHD) mortality after BC RT. PATIENTS AND METHODS In a cohort of 2,813 women diagnosed with BC between 1958 and 1992 with a follow-up of at least 10 years, we identified 134 cases of death due to IHD 10-19 years after BC diagnosis. For each case, one control was selected within the cohort matched for age at diagnosis. 3D-volume and 3D-dose reconstructions were obtained from individual RT charts. We estimated the Dmax to the RCA and the LAD and the mean heart dose (MHD). We performed conditional logistic regression analysis comparing piecewise spline transformation and simple linear modeling for best fit. RESULTS There was a linear dose-risk relationship for both the Dmax to the RCA (odds ratio [OR]/Gray [Gy] 1.03 [1.01-1.05]) and the LAD (OR/Gy 1.04 [1.02-1.06]) in a multivariable model. For MHD there was a linear dose-risk relationship (1,14 OR/Gy [1.08-1.19]. For all relationships, simple linear modelling was superior to spline transformations. INTERPRETATION Doses to both the RCA and LAD are independent risk predictors of long-term cardiotoxicity after RT for BC In addition to the LAD, the RCA should be regarded as an organ at risk in RT planning.
Collapse
Affiliation(s)
- Mats Perman
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Karl-Axel Johansson
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
10
|
Chang X, Deng W, Yu R, Wang W. Conditional survival and annual hazard of death in older patients with esophageal cancer receiving definitive chemoradiotherapy. BMC Geriatr 2024; 24:348. [PMID: 38632503 PMCID: PMC11025141 DOI: 10.1186/s12877-024-04939-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Definitive chemoradiotherapy is one of the primary treatment modalities for older patients with esophageal cancer (EC). However, the evolution of prognosis over time and the factors affected non-EC deaths remain inadequately studied. We examined the conditional survival and annual hazard of death in older patients with EC after chemoradiotherapy. METHODS We collected data from patients aged 65 or older with EC registered in the Surveillance, Epidemiology, and End Results database during 2000-2019. Conditional survival was defined as the probability of survival given a specific time survived. Annual hazard of death was defined the yearly event rate. Restricted cubic spline (RCS) analysis identified the association of age at diagnosis with mortality. RESULTS Among 3739 patients, the 3-year conditional overall survival increased annually by 7-10%. Non-EC causes accounted for 18.8% of deaths, predominantly due to cardio-cerebrovascular diseases. The hazard of death decreased from 40 to 10% in the first 6 years and then gradually increased to 20% in the tenth year. Non-EC causes surpassed EC causes in hazard starting 5 years post-treatment. RCS indicated a consistent increase in death hazard with advancing age, following a linear relationship. The overall cohort was divided into two groups: 65-74 and ≥ 75 years old, with the ≥ 75-year-old group showing poorer survival and earlier onset of non-EC deaths (HR = 1.36, 95% CI: 1.15-1.62, P < 0.001). Patients with early-stage disease (I-II) had higher risks of death from non-EC causes (HR = 0.82, 95% CI: 0.68-0.98, P = 0.035). Tumor histology had no significant impact on non-EC death risk (HR = 1.17, 95% CI: 0.98-1.39, P = 0.081). CONCLUSIONS Survival probability increases with time for older patients with EC treated with chemoradiotherapy. Clinicians and patients should prioritize managing and preventing age-related comorbidities, especially in older cohorts and those with early-stage disease.
Collapse
Affiliation(s)
- Xiao Chang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, 100142, Beijing, China
| | - Wei Deng
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, 100142, Beijing, China
| | - Rong Yu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, 100142, Beijing, China.
| | - Weihu Wang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Radiation Oncology, Peking University Cancer Hospital and Institute, 100142, Beijing, China.
| |
Collapse
|
11
|
Chua GWY, Li L. Treatment Options for Early Stage Inoperable Breast Cancer: Cryoablation or Radiotherapy? Breast Care (Basel) 2024; 19:106-115. [PMID: 38645759 PMCID: PMC11026071 DOI: 10.1159/000536413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 01/18/2024] [Indexed: 04/23/2024] Open
Abstract
Background Surgical removal of the tumour is the gold standard treatment for early stage invasive breast cancer. However, with a global ageing population, a larger number of diagnoses are occurring in women with comorbidities that render them unsuitable for surgery. Hence, it is of interest to explore alternative treatment strategies for this group of women. Summary Our narrative review aims to explore two such techniques, cryoablation and external beam radiotherapy, providing a brief summary of the evidence behind each technique. Following this, we discuss which groups of patients would gain the most benefit from each technique. Factors favouring the use of radiotherapy include patients with larger tumours, more superficial tumours, and those with less well-demarcated tumours where there is uncertainty regarding tumour extent. Meanwhile, patients who may benefit more from cryoablation include those who desire a smaller number of treatment sessions, have concerns regarding cosmesis and skin pigmentation, or who have relative contraindications to radiotherapy such as scleroderma, systemic lupus erythematosus, reduced lung function, or cardiac comorbidities. Key Messages Continued advancements in both cryoablation and radiotherapy technologies are taking place, in tandem with imaging technologies enabling greater certainty in tumour detection and delineation. These factors will help increase local control rates in this group of non-operable early stage breast cancer patients. Through this review, we hope to aid in the clinical decision-making process regarding the selection and referral of patients for each treatment.
Collapse
Affiliation(s)
- Gail Wan Ying Chua
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore, Singapore
| | - Lucia Li
- Medical Sciences Division, University of Cambridge, Cambridge, UK
| |
Collapse
|
12
|
Rautiola J, Björklund J, Zelic R, Edgren G, Bottai M, Nilsson M, Vincent PH, Fredholm H, Falconer H, Sjövall A, Nilsson PJ, Wiklund P, Aly M, Akre O. Risk of Postoperative Ischemic Stroke and Myocardial Infarction in Patients Operated for Cancer. Ann Surg Oncol 2024; 31:1739-1748. [PMID: 38091152 PMCID: PMC10838243 DOI: 10.1245/s10434-023-14688-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/13/2023] [Indexed: 02/06/2024]
Abstract
BACKGROUND Risk assessment for ischemic stroke (IS) and myocardial infarction (MI) is done routinely before surgery, but the increase in risks associated with surgery is not known. The aim of this study is to assess the risk of arterial ischemic events during the first year after oncological surgery. METHODS We used Swedish healthcare databases to identify 443,300 patients who underwent cancer surgery between 1987 and 2016 and 4,127,761 matched comparison subjects. We estimated odds ratios (ORs) for myocardial infarction and ischemic stroke during the hospitalization with logistic regression and calculated 1-year cumulative incidences and hazard ratios (HRs) with 95% confidence intervals (CIs) for the outcomes after discharge. RESULTS The cumulative incidences of myocardial infarction and ischemic stroke during the first postoperative year were 1.33% and 1.25%, respectively. In the comparison cohort, the corresponding 1-year cumulative incidences were 1.04% and 1.00%. During the hospitalization, the OR for myocardial infarction was 8.81 (95% CI 8.24-9.42) and the OR for ischemic stroke was 6.71 (95% CI 6.22-7.23). After discharge, the average HR during follow-up for 365 days was 0.90 (95% CI 0.87-0.93) for myocardial infarction and 1.02 (95% CI 0.99-1.05) for ischemic stroke. CONCLUSIONS We found an overall increased risk of IS and MI during the first year after cancer surgery that was attributable to events occurring during the hospitalization period. After discharge from the hospital, the overall risk of myocardial infarction was lower among the cancer surgery patients than among matched comparison subjects.
Collapse
Affiliation(s)
- Juhana Rautiola
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden.
| | - Johan Björklund
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Renata Zelic
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Gustaf Edgren
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Södersjukhuset, Stockholm, Sweden
| | - Matteo Bottai
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Nilsson
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Per Henrik Vincent
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Hanna Fredholm
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Falconer
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Annika Sjövall
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Per J Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Wiklund
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Markus Aly
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Olof Akre
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Pelvic Cancer, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
13
|
Liang B, Gong G, Tong Y, Wang L, Su Y, Wang H, Li Z, Yan H, Zhang X, Yin Y. Quantitative analysis of the impact of respiratory state on the heartbeat-induced movements of the heart and its substructures. Radiat Oncol 2024; 19:18. [PMID: 38317205 PMCID: PMC10840203 DOI: 10.1186/s13014-023-02396-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 12/23/2023] [Indexed: 02/07/2024] Open
Abstract
PURPOSE This study seeks to examine the influence of the heartbeat on the position, volume, and shape of the heart and its substructures during various breathing states. The findings of this study will serve as a valuable reference for dose-volume evaluation of the heart and its substructures in radiotherapy for treating thoracic tumors. METHODS Twenty-three healthy volunteers were enrolled in this study, and cine four-dimensional magnetic resonance images were acquired during periods of end-inspiration breath holding (EIBH), end-expiration breath holding (EEBH), and deep end-inspiration breath holding (DIBH). The MR images were used to delineate the heart and its substructures, including the heart, pericardium, left ventricle (LV), left ventricular myocardium, right ventricle (RV), right ventricular myocardium (RVM), ventricular septum (VS), atrial septum (AS), proximal and middle portions of the left anterior descending branch (pmLAD), and proximal portion of the left circumflex coronary branch (pLCX). The changes in each structure with heartbeat were compared among different respiratory states. RESULTS Compared with EIBH, EEBH increased the volume of the heart and its substructures by 0.25-3.66%, while the average Dice similarity coefficient (DSC) increased by - 0.25 to 8.7%; however, the differences were not statistically significant. Conversely, the VS decreased by 0.89 mm in the left-right (LR) direction, and the displacement of the RV in the anterior-posterior (AP) direction significantly decreased by 0.76 mm (p < 0.05). Compared with EIBH and EEBH, the average volume of the heart and its substructures decreased by 3.08-17.57% and 4.09-20.43%, respectively, during DIBH. Accordingly, statistically significant differences (p < 0.05) were observed in the volume of the heart, pericardium, LV, RV, RVM, and AS. The average DSC increased by 0-37.04% and - 2.6 to 32.14%, respectively, with statistically significant differences (p < 0.05) found in the right ventricular myocardium and interatrial septum. Furthermore, the displacements under DIBH decreased in the three directions (i.e.,- 1.73 to 3.47 mm and - 0.36 to 2.51 mm). In this regard, the AP displacement of the heart, LV, RV, RVM, LR direction, LV, RV, and AS showed statistically significant differences (p < 0.05). The Hausdorff distance (HD) of the heart and its substructures under the three breathing states are all greater than 11 mm. CONCLUSION The variations in the displacement and shape alterations of the heart and its substructures during cardiac motion under various respiratory states are significant. When assessing the dose-volume index of the heart and its substructures during radiotherapy for thoracic tumors, it is essential to account for the combined impacts of cardiac motion and respiration.
Collapse
Affiliation(s)
- Benzhe Liang
- College of materials science and technology, Nanjing University of Aeronautics and Astronautics, Nanjing, China
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Guanzhong Gong
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Ying Tong
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Lizhen Wang
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Ya Su
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Huadong Wang
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Zhenkai Li
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Hongyu Yan
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China
| | - Xiaohong Zhang
- College of materials science and technology, Nanjing University of Aeronautics and Astronautics, Nanjing, China.
| | - Yong Yin
- Department of Radiation Oncology Physics and Technology, Shandong Cancer Hospital and Institute, Shandong First Medical University, Shandong Academy of Medical Sciences, Jinan, China.
| |
Collapse
|
14
|
Lai TY, Hu YW, Wang TH, Chen JP, Shiau CY, Huang PI, Lai IC, Tseng LM, Huang N, Liu CJ. Association of radiation dose to cardiac substructures with major ischaemic events following breast cancer radiotherapy. Eur Heart J 2023; 44:4796-4807. [PMID: 37585426 DOI: 10.1093/eurheartj/ehad462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 05/18/2023] [Accepted: 07/13/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND AND AIMS Patients with left-sided breast cancer receive a higher mean heart dose (MHD) after radiotherapy, with subsequent risk of ischaemic heart disease. However, the optimum dosimetric predictor among cardiac substructures has not yet been determined. METHODS AND RESULTS This study retrospectively reviewed 2158 women with breast cancer receiving adjuvant radiotherapy. The primary endpoint was a major ischaemic event. The dose-volume parameters of each delineated cardiac substructure were calculated. The risk factors for major ischaemic events and the association between MHD and major ischaemic events were analysed by Cox regression. The optimum dose-volume predictors among cardiac substructures were explored in multivariable models by comparing performance metrics of each model. At a median follow-up of 7.9 years (interquartile range 5.6-10.8 years), 89 patients developed major ischaemic events. The cumulative incidence rate of major ischaemic events was significantly higher in left-sided disease (P = 0.044). Overall, MHD increased the risk of major ischaemic events by 6.2% per Gy (hazard ratio 1.062, 95% confidence interval 1.01-1.12; P = 0.012). The model containing the volume of the left ventricle receiving 25 Gy (LV V25) with the cut-point of 4% presented with the best goodness of fit and discrimination performance in left-sided breast cancer. Age, chronic kidney disease, and hyperlipidaemia were also significant risk factors. CONCLUSION Risk of major ischaemic events exist in the era of modern radiotherapy. LV V25 ≥ 4% appeared to be the optimum parameter and was superior to MHD in predicting major ischaemic events. This dose constraint could aid in achieving better heart protection in breast cancer radiotherapy, though a further validation study is warranted.
Collapse
Affiliation(s)
- Tzu-Yu Lai
- Department of Heavy Particles & Radiation Oncology, Taipei Veterans General Hospital, 112201 Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
- Institute of Public Health, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
| | - Yu-Wen Hu
- Department of Heavy Particles & Radiation Oncology, Taipei Veterans General Hospital, 112201 Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
- Institute of Public Health, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
| | - Ti-Hao Wang
- Department of Radiation Oncology, China Medical University Hospital, 404327 Taichung, Taiwan
- Department of Medicine, China Medical University, 404333 Taichung, Taiwan
- Everfortune.AI, 403020 Taichung, Taiwan
| | - Jui-Pin Chen
- Department of Heavy Particles & Radiation Oncology, Taipei Veterans General Hospital, 112201 Taipei, Taiwan
| | - Cheng-Ying Shiau
- Department of Heavy Particles & Radiation Oncology, Taipei Veterans General Hospital, 112201 Taipei, Taiwan
| | - Pin-I Huang
- Department of Heavy Particles & Radiation Oncology, Taipei Veterans General Hospital, 112201 Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
| | - I Chun Lai
- Department of Heavy Particles & Radiation Oncology, Taipei Veterans General Hospital, 112201 Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
| | - Ling-Ming Tseng
- School of Medicine, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
- Comprehensive Breast Health Center & Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, 112201 Taipei, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
| | - Chia-Jen Liu
- School of Medicine, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
- Institute of Public Health, National Yang Ming Chiao Tung University, 112304 Taipei, Taiwan
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, 112201 Taipei, Taiwan
| |
Collapse
|
15
|
Bhimani F, McEvoy M, Gupta A, Pastoriza J, Shihabi A, Basavatia A, Tomé WA, Fox J, Mehta K, Feldman S. Case Report: Bilateral targeted intraoperative radiotherapy: a safe and effective alternative for synchronous bilateral breast cancer. Front Oncol 2023; 13:1276766. [PMID: 37941541 PMCID: PMC10628514 DOI: 10.3389/fonc.2023.1276766] [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] [Received: 08/13/2023] [Accepted: 10/13/2023] [Indexed: 11/10/2023] Open
Abstract
Background The incidence of bilateral breast cancer (BBC) ranges from 1.4% to 11.8%. BBC irradiation is a challenge in current clinical practice due to the large target volume that must be irradiated while minimizing the dose to critical organs. Supine or prone breast techniques can be used, with the latter providing better organ sparing; both, however, result in lengthy treatment times. The use of Intra-operative radiotherapy (IORT) in breast cancer patients who choose breast conservation has been highlighted in previous studies, but there is a scarcity of literature analyzing the utility and applicability of IORT in BBC. This case series aims to highlight the applicability of administering bilateral IORT in patients with BBC. Case reports Five patients with bilateral early-stage breast cancer (or DCIS) were treated with breast-conserving surgery followed by bilateral IORT. Of the 10 breast cancers, 8 were diagnosed as either DCIS or IDC, while the other 2 were diagnosed as invasive lobular carcinoma and invasive carcinoma, respectively. During surgery, all patients received bilateral IORT. Furthermore, 1 patient received external beam radiation therapy after her final pathology revealed grade 3 DCIS. The IORT procedure was well tolerated by all five patients, and all patients received aromatase inhibitors as adjuvant therapy. Additionally, none of these patients showed evidence of disease after a 36-month median follow-up. Conclusion Our findings demonstrate the successful use of IORT for BCS in patients with BBC. Furthermore, none of the patients in our study experienced any complications, suggesting the feasibility of the use of IORT in BBC. Considering the benefits of improved patient compliance and a reduced number of multiple visits, IORT may serve as an excellent patient-centered alternative for BBC. Future studies are recommended to reinforce the applicability of IORT in patients with BBC.
Collapse
Affiliation(s)
- Fardeen Bhimani
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Maureen McEvoy
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Anjuli Gupta
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Jessica Pastoriza
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Areej Shihabi
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Amar Basavatia
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Wolfgang A. Tomé
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Jana Fox
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Keyur Mehta
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Sheldon Feldman
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| |
Collapse
|
16
|
von Kemp BA, Cosyns B. Radiation-Induced Pericardial Disease: Mechanisms, Diagnosis, and Treatment. Curr Cardiol Rep 2023; 25:1113-1121. [PMID: 37584875 DOI: 10.1007/s11886-023-01933-3] [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] [Accepted: 07/31/2023] [Indexed: 08/17/2023]
Abstract
PURPOSE OF REVIEW We aim to give a concise overview of the different clinical manifestations of both acute and long-term radiotherapy-related pericardial diseases, the underlying pathophysiology as well as the diagnosis and treatment options. RECENT FINDINGS Radiotherapy-related pericardial disease is common, but despite radiotherapy being a cornerstone of many cancer treatments, this disease entity is relatively underrepresented in clinical trials, resulting in a paucity of research data on pathophysiology and management. Since the development of innovative cancer treatments, survival has significantly improved. Therefore, the importance of long-term treatment-related side effects increases, most notably cancer treatment-related cardiovascular toxicity. In patients undergoing radiotherapy as a part of their cancer treatment, radiotherapy-related pericardial disease can manifest early (during or shortly after radiotherapy administration) or very late (several years to decades after treatment). This exceptionally long latency period confronts physicians with treatment-related side effects of radiotherapy regimens that may have been abandoned already.
Collapse
Affiliation(s)
- Berlinde A von Kemp
- Dienst Cardiologie, Centrum Hart- en Vaatziekten, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Bernard Cosyns
- Dienst Cardiologie, Centrum Hart- en Vaatziekten, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| |
Collapse
|
17
|
Teimouri K, Khoshgard K, Farshchian N, Rouzbahani M, Azimivaghar J. Investigation of electrocardiography and echocardiography changes after adjuvant radiation therapy of left-sided breast cancer. J Med Imaging Radiat Sci 2023; 54:495-502. [PMID: 37183077 DOI: 10.1016/j.jmir.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 03/30/2023] [Accepted: 04/17/2023] [Indexed: 05/16/2023]
Abstract
INTRODUCTION The primary objective of radiation therapy (RT) is to deliver lethal radiation doses to abnormal cancer cells so that healthy cells are exposed to minimal radiation. In the present study, changes in electrocardiography (ECG) and echocardiography(ECHO) following adjuvant RT were investigated in patients with left-sided breast cancer. MATERIALS AND METHODS 30 patients with left-sided breast cancer who had previously undergone breast-conserving surgery or mastectomy underwent RT after completing chemotherapy from February 2019 to January 2020. ECG and ECHO tests were performed before RT, immediately following RT, and three months after RT. Dose-volume parameters of the heart and its substructures as an organ at risk were analyzed. RESULTS The mean heart dose (±SD) for all patients was 7.51 ± 2.42 Gy. T-wave inversion was observed 3 months after RT in 47% of patients. T-wave decline was associated with mean heart radiation dose (β = 0.605, p-value = 0.005). The present study showed that the left ventricular volume receiving the 5 Gy (LV-V5) parameter was associated with a reduction in ST segment duration (p-value = 0.027) as well as with an increase in left ventricular systolic diameter (LVESD, mm) (P-value = 0.027). CONCLUSION RT-induced ECG and ECHO changes are frequent in patients with left breast cancer. LVEF and Twave abnormalities were observed after RT in our patients. ECG and ECHO modalities can be used to monitor the cardiac function after RT in patients with left-sided breast cancer.
Collapse
Affiliation(s)
- Kolsoum Teimouri
- Students Research Committee, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Karim Khoshgard
- Department of Medical Physics, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Negin Farshchian
- Department of Radiation Oncology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohammad Rouzbahani
- Department of Cardiology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Javad Azimivaghar
- Department of Cardiology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| |
Collapse
|
18
|
Nielsen AWM, Spejlborg H, Lutz CM, Rugaard Poulsen P, Offersen BV. Difference between planned and delivered radiotherapy dose to the internal mammary nodes in high-risk breast cancer patients. Phys Imaging Radiat Oncol 2023; 27:100470. [PMID: 37533551 PMCID: PMC10393587 DOI: 10.1016/j.phro.2023.100470] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 08/04/2023] Open
Abstract
Background and purpose Chest wall movement during radiotherapy can impact the delivered dose to the internal mammary nodes (IMN) in high-risk breast cancer patients. Using portal imaging and dose reconstruction we aimed to examine the delivered IMN dose coverage. Material and methods Cine MV images were recorded for 39 breast cancer patients treated with daily image-guided radiotherapy (IGRT) in deep-inspiration breath-hold (DIBH). On the final frame of each cine MV recording the chest wall was matched with the Digitally Reconstructed Radiograph (DRR) from the treatment plan. The geometrical chest wall error was determined in the imager-plane perpendicular to the cranio-caudal direction, rounded to integer millimeters, and binned. For each 1 mm bin, an isocenter-shifted treatment plan was recalculated assuming that the projected error observed in the cine MV image was caused by anterior-posterior chest wall movement in the IMN region. A weighted plan sum yielded the IMN clinical target volume receiving at least 90% dose (V90_CTVn_IMN). Results The mean number of cine MV observations per patient was 36 (range 26-55). Most patients (67%) had on average a posterior chest wall position at treatment compared to planned. This translated into a change in the delivered median V90_CTVn_IMN of -0.7% (range, -11.9-2.9%; p < 0.001). The V90_CTVn_IMN reduction was greater than 9% in three patients. No clinically relevant differences were found for the mean lung dose or mean heart dose. Conclusion Using cine MV images, we found that the delivered V90_CTVn_IMN was significantly lower than planned. In 8% of the patients, the V90_CTVn_IMN reduction exceeded 9%.
Collapse
Affiliation(s)
| | - Harald Spejlborg
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | | | - Per Rugaard Poulsen
- Danish Center for Particle Therapy, Aarhus University Hospital, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Birgitte Vrou Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
- Danish Center for Particle Therapy, Aarhus University Hospital, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
19
|
Eber J, Schmitt M, Dehaynin N, Le Fèvre C, Antoni D, Noël G. Evaluation of Cardiac Substructures Exposure of DIBH-3DCRT, FB-HT, and FB-3DCRT in Hypofractionated Radiotherapy for Left-Sided Breast Cancer after Breast-Conserving Surgery: An In Silico Planning Study. Cancers (Basel) 2023; 15:3406. [PMID: 37444516 DOI: 10.3390/cancers15133406] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Left-sided breast cancer radiotherapy can lead to late cardiovascular complications, including ischemic events. To mitigate these risks, cardiac-sparing techniques such as deep-inspiration breath-hold (DIBH) and intensity-modulated radiotherapy (IMRT) have been developed. However, recent studies have shown that mean heart dose is not a sufficient dosimetric parameter for assessing cardiac exposure. In this study, we aimed to compare the radiation exposure to cardiac substructures for ten patients who underwent hypofractionated radiotherapy using DIBH three-dimensional conformal radiation therapy (3DCRT), free-breathing (FB)-3DCRT, and FB helical tomotherapy (HT). Dosimetric parameters of cardiac substructures were analyzed, and the results were statistically compared using the Wilcoxon signed-rank test. This study found a significant reduction in the dose to the heart, left anterior descending coronary artery, and ventricles with DIBH-3DCRT and FB-HT compared to FB-3DCRT. While DIBH-3DCRT was very effective in sparing the heart, in some cases, it provided little or no cardiac sparing. FB-HT can be an interesting treatment modality to reduce the dose to major coronary vessels and ventricles and may be of interest for patients with cardiovascular risks who do not benefit from or cannot perform DIBH. These findings highlight the importance of cardiac-sparing techniques for precise delivery of radiation therapy.
Collapse
Affiliation(s)
- Jordan Eber
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), 67033 Strasbourg, France
| | - Martin Schmitt
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), 67033 Strasbourg, France
| | - Nicolas Dehaynin
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), 67033 Strasbourg, France
| | - Clara Le Fèvre
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), 67033 Strasbourg, France
| | - Delphine Antoni
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), 67033 Strasbourg, France
| | - Georges Noël
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), 67033 Strasbourg, France
- Centre Paul Strauss, Strasbourg University, CNRS, IPHC UMR 7178, UNICANCER, 67000 Strasbourg, France
| |
Collapse
|
20
|
Chau OW, Islam A, Lock M, Yu E, Dinniwell R, Yaremko B, Brackstone M, Pavlosky W, Butler J, Biernaski H, Graf C, Wisenberg G, Prato FS, Gaede S. PET/MRI Assessment of Acute Cardiac Inflammation 1 Month After Left-Sided Breast Cancer Radiation Therapy. J Nucl Med Technol 2023; 51:133-139. [PMID: 37192822 DOI: 10.2967/jnmt.122.264960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 03/30/2023] [Indexed: 05/18/2023] Open
Abstract
Our purpose was to investigate the utility of 18F-FDG PET/MRI and serial blood work to detect early inflammatory responses and cardiac functionality changes at 1 mo after radiation therapy (RT) in patients with left-sided breast cancer. Methods: Fifteen left-sided breast cancer patients who enrolled in the RICT-BREAST study underwent cardiac PET/MRI at baseline and 1 mo after standard RT. Eleven patients received deep-inspiration breath-hold RT, whereas the others received free-breathing RT. A list-mode 18F-FDG PET scan with glucose suppression was acquired. Myocardial inflammation was quantified by the change in 18F-FDG SUVmean (based on body weight) and analyzed on the basis of the myocardial tissue associated with the left anterior descending, left circumflex, or right coronary artery territories. MRI assessments, including left ventricular functional and extracellular volumes (ECVs), were extracted from T1 (before and during a constant infusion of gadolinium) and cine images, respectively, acquired simultaneously during the PET acquisition. Cardiac injury and inflammation biomarker measurements of high-sensitivity troponin T, high-sensitivity C-reactive protein, and erythrocyte sedimentation rate were measured at the 1-mo follow-up and compared with preirradiation values. Results: At the 1-mo follow-up, a significant increase (10%) in myocardial SUVmean in left anterior descending segments (P = 0.04) and ECVs in slices at the apex (6%) and base (5%) was detected (P ≤ 0.02). Further, a significant reduction in left ventricular stroke volume (-7%) was seen (P < 0.02). No significant changes in any circulating biomarkers were seen at follow-up. Conclusion: Myocardial 18F-FDG uptake and functional MRI, including stroke volume and ECVs, were sensitive to changes at 1 mo after breast cancer RT, with findings suggesting an acute cardiac inflammatory response to RT.
Collapse
Affiliation(s)
- Oi Wai Chau
- London Regional Cancer Program, London, Ontario, Canada;
- Western University, London, Ontario, Canada
| | - Ali Islam
- Western University, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada; and
| | - Michael Lock
- London Regional Cancer Program, London, Ontario, Canada
- Western University, London, Ontario, Canada
- London Health Sciences Centre, London, Ontario, Canada
| | - Edward Yu
- London Regional Cancer Program, London, Ontario, Canada
- Western University, London, Ontario, Canada
- London Health Sciences Centre, London, Ontario, Canada
| | - Robert Dinniwell
- London Regional Cancer Program, London, Ontario, Canada
- Western University, London, Ontario, Canada
- London Health Sciences Centre, London, Ontario, Canada
| | - Brian Yaremko
- London Regional Cancer Program, London, Ontario, Canada
- Western University, London, Ontario, Canada
- London Health Sciences Centre, London, Ontario, Canada
| | - Muriel Brackstone
- Western University, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada; and
- London Health Sciences Centre, London, Ontario, Canada
| | - William Pavlosky
- Lawson Health Research Institute, London, Ontario, Canada; and
- London Health Sciences Centre, London, Ontario, Canada
| | - John Butler
- Lawson Health Research Institute, London, Ontario, Canada; and
| | | | - Chantelle Graf
- Lawson Health Research Institute, London, Ontario, Canada; and
| | - Gerald Wisenberg
- Western University, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada; and
- London Health Sciences Centre, London, Ontario, Canada
| | - Frank S Prato
- Western University, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada; and
| | - Stewart Gaede
- London Regional Cancer Program, London, Ontario, Canada
- Western University, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada; and
- London Health Sciences Centre, London, Ontario, Canada
| |
Collapse
|
21
|
Gambril JA, Sofowora G, Ahmad U. Phasic Diastolic Coronary Artery Compression: A Rare Cause of Chest Pain at Rest. Cureus 2023; 15:e38883. [PMID: 37303420 PMCID: PMC10257404 DOI: 10.7759/cureus.38883] [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: 05/10/2023] [Indexed: 06/13/2023] Open
Abstract
Phasic diastolic coronary artery compression (PDCAC) is a rare phenomenon caused by the compression of a coronary artery between expanding myocardium and a non-compliant overlying structure. We report a unique case of an elderly female who presented with recurrent paradoxical substernal chest pain at rest caused by PDCAC of the proximal left circumflex artery (LCx). Her chest pain likely occurred at rest due to longer diastolic compression time at slower heart rates. Pericardial adhesion secondary to past breast radiation was the likely cause of PDCAC. She was treated successfully with oral anti-hypertensive and anti-anginal medical therapy. PDCAC is a rare phenomenon but should be on the differential for chest pain occurring at rest, especially if there is a history of mediastinal or cardiac radiation or inflammation. PDCAC treatment depends on the underlying cause but can be treated successfully with medical therapy alone.
Collapse
Affiliation(s)
- John A Gambril
- Pediatrics, Nationwide Children's Hospital, Columbus, USA
- Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Gbemiga Sofowora
- Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Umair Ahmad
- Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, USA
| |
Collapse
|
22
|
Andruska N, Schlaak RA, Frei A, Schottstaedt AM, Lin CY, Fish BL, Gasperetti T, Mpoy C, Pipke JL, Pedersen LN, Flister MJ, Javaheri A, Bergom C. Differences in radiation-induced heart dysfunction in male versus female rats. Int J Radiat Biol 2023; 99:1096-1108. [PMID: 36971580 PMCID: PMC10431914 DOI: 10.1080/09553002.2023.2194404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 02/24/2023] [Accepted: 03/14/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE Radiation therapy remains part of the standard of care for breast, lung, and esophageal cancers. While radiotherapy improves local control and survival, radiation-induced heart dysfunction is a common side effect of thoracic radiotherapy. Cardiovascular dysfunction can also result from non-therapeutic total body radiation exposures. Numerous studies have evaluated the relationship between radiation dose to the heart and cardiotoxicity, but relatively little is known about whether there are differences based on biological sex in radiation-induced heart dysfunction (RIHD). MATERIALS AND METHODS We evaluated whether male and female inbred Dahl SS rats display differences in RIHD following delivery of 24 Gy in a single fraction to the whole heart using a 1.5 cm beam size (collimater). We also compared the 2.0 cm vs. 1.5 cm collimator in males. Pleural and pericardial effusions and normalized heart weights were measured, and echocardiograms were performed. RESULTS Female SS rats displayed more severe RIHD relative to age-matched SS male rats. Normalized heart weight was significantly increased in females, but not in males. A total of 94% (15/16) of males and 55% (6/11) of females survived 5 months after completion of radiotherapy (p < .01). Among surviving rats, 100% of females and 14% of males developed moderate-to-severe pericardial effusions at 5 months. Females demonstrated increased pleural effusions, with the mean normalized pleural fluid volume for females and males being 56.6 mL/kg ± 12.1 and 10.96 mL/kg ± 6.4 in males (p = .001), respectively. Echocardiogram findings showed evidence of heart failure, which was more pronounced in females. Because age-matched female rats have smaller lungs, a higher percentage of the total lung was treated with radiation in females than males using the same beam size. After using a larger 2 cm beam in males which results in higher lung exposure, there was not a significant difference between males and females in terms of the development of moderate-to-severe pericardial effusions or pleural effusions. Treatment of males with a 2 cm beam resulted in comparable increases in LV mass and reductions in stroke volume to female rats treated with a 1.5 cm beam. CONCLUSION Together, these results illustrate that there are differences in radiation-induced cardiotoxicity between male and female SS rats and add to the data that lung radiation doses, in addition to other factors, may play an important role in cardiac dysfunction following heart radiation exposure. These factors may be important to factor into future mitigation studies of radiation-induced cardiotoxicity.
Collapse
Affiliation(s)
- Neal Andruska
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Rachel A. Schlaak
- Department of Pharmacology & Toxicology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anne Frei
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Chieh-Yu Lin
- Department of Pathology & Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Brian L. Fish
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tracy Gasperetti
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cedric Mpoy
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Jamie L. Pipke
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lauren N. Pedersen
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Michael J. Flister
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ali Javaheri
- Department of Medicine, Division of Cardiology, Washington University School of Medicine, St Louis, Missouri
| | - Carmen Bergom
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, Missouri
| |
Collapse
|
23
|
Mahani L, Kazemzadeh A, Saeb M, Kianinia M, Akhavan A. Dosimetric impact of different multileaf collimators on cardiac and left anterior descending coronary artery dose reduction. J Cancer Res Ther 2023; 19:633-638. [PMID: 37470586 DOI: 10.4103/jcrt.jcrt_668_21] [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] [Indexed: 11/04/2022]
Abstract
Introduction Radiotherapy (RT) may increase the dose of heart structure like left anterior descending coronary artery (LAD). The purpose of this paper was to evaluate the impact of various multileaf collimators (MLCs) in shielding organ at risks (OARs), especially LAD, of patients with left breast cancer. Materials and Methods Forty-five patients with left breast cancer were selected. The treatment plans were created applying three techniques for all patients. In the first plan (uncovered LAD), the treatment plan was made without considering LAD as OARs. In the two other plans, two MLCs with different leaf widths (6.8 mm and 5 mm) were used to shield the LAD. For all plans, MLC was shielded as much of OAR as possible without compromising planning target volume (PTV) coverage. Dosimetric parameters of the heart, LAD, and ipsilateral lung were assessed. Results Compared to other plans, the covered LAD plan 1(CL1) obtained lower lung, cardiac, and LAD doses with the same PTV coverage. On average, the mean heart dose decreased from 6.2 Gy to 5.4 Gy by CL1, and the average mean dose to the LAD was reduced from 36.4 Gy to 33.7 Gy, which was statistically significant. The average lung volume receiving >20 Gy was significantly reduced from 24.6% to 23.4%. Moreover, the results show that covered LAD plan 2(CL2) is less useful for shielding OARs compared to CL1. Conclusion CL1 plans may reduce OAR dose for patients without compromising the target coverage. Hence, the proper implementation of MLC can decrease the side effects of RT.
Collapse
Affiliation(s)
- Leili Mahani
- Seyed-Al-Shohada Hospital, Isfahan University of Medical Science, Isfahan, Iran
| | - Arezoo Kazemzadeh
- Seyed-Al-Shohada Hospital, Isfahan University of Medical Science, Isfahan, Iran
| | - Mohsen Saeb
- Seyed-Al-Shohada Hospital, Isfahan University of Medical Science; Department of Medical Physics, School of Medicine, Isfahan University of Medical Sciences; Department of Radio-Oncology, Seyed-Al-Shohada Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahsa Kianinia
- Seyed-Al-Shohada Hospital, Isfahan University of Medical Science; Department of Radio-Oncology, Seyed-Al-Shohada Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Akhavan
- Seyed-Al-Shohada Hospital, Isfahan University of Medical Science; Department of Radio-Oncology, Seyed-Al-Shohada Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
24
|
Tian Y, Wang T, Tian L, Yang Y, Xue C, Sheng W, Wang C. Early detection and serial monitoring during chemotherapy-radiation therapy: Using T1 and T2 mapping cardiac magnetic resonance imaging. Front Cardiovasc Med 2023; 10:1085737. [PMID: 37063950 PMCID: PMC10090395 DOI: 10.3389/fcvm.2023.1085737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
PurposeTo confirm the ability of native T1 and T2 values in detecting and monitoring early myocardial injuries of chest radiotherapy in neoplasm patients.Materials and methodsFifteen participants received non-anthracycline chemotherapy and chest radiotherapy, and 30 age/gender-matched controls were enrolled in this prospective study. Cardiac magnetic resonance scans were performed within 2 days, 3 months, and 6 months after chest radiotherapy. Myocardial native T1 and T2 values were measured in irradiated and nonirradiated areas. Meanwhile, the parameters of left ventricular function and left ventricular myocardial strain were obtained.ResultsThere were no significant differences in left ventricular function, native T1, T2, and strain between patients and controls before chest radiotherapy. In 15 participants who were followed up for 6 months, there was a significant change only in left ventricular ejection fraction (LVEF) among baseline and the first follow-up (P = 0.021), while the adjusted P-value was higher than 0.05 after Bonferroni correction, as well as other parameters. Native T1 values were elevated at 3 and 6 months in irradiated areas compared with baseline (1,288.72 ± 66.59 ms vs. 1,212.51 ± 45.41 ms; 1,348.01 ± 54.16 ms vs. 1,212.51 ± 45.41 ms; P < 0.001 for both). However, T2 values only changed at 3 months in irradiated areas compared with baseline (44.21 ± 3.35 ms vs. 39.14 ± 1.44 ms; P = 0.006). Neither the native T1 nor T2 values changed in nonirradiated areas during the follow-up period (all P > 0.05). There were no significant differences in strain changes during the follow-up period (all P > 0.05).ConclusionNative T1 and T2 values elevated at 3 months after chest radiotherapy, whereas LVEF showed no significant change during the 6-month follow-up.
Collapse
Affiliation(s)
- Yaotian Tian
- Department of Radiology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Teng Wang
- Department of Radiology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Liwen Tian
- Department of Radiology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Yucheng Yang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Chen Xue
- Department of Radiology, Shandong Provincial Hospital, Binzhou Medical University, Jinan, China
| | - Wei Sheng
- Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Cuiyan Wang
- Department of Radiology, Shandong Provincial Hospital, Shandong University, Jinan, China
- Correspondence: Cuiyan Wang
| |
Collapse
|
25
|
Holm Milo ML, Slot Møller D, Bisballe Nyeng T, Hoffmann L, Dahl Nissen H, Jensen I, Laugaard Lorenzen E, Bech Jellesmark Thorsen L, Melgaard Nielsen K, Paaske Johnsen S, Brink Valentin J, Alsner J, Vrou Offersen B. Radiation dose to heart and cardiac substructures and risk of coronary artery disease in early breast cancer patients: A DBCG study based on modern radiation therapy techniques. Radiother Oncol 2023; 180:109453. [PMID: 36642388 DOI: 10.1016/j.radonc.2022.109453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 12/10/2022] [Accepted: 12/16/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Coronary artery disease (CAD) has been reported as a late effect following radiation therapy (RT) of early breast cancer (BC). This study aims to report individual RT doses to the heart and cardiac substructures in patients treated with CT-based RT and to investigate if a dose-response relationship between RT dose and CAD exists using modern radiation therapy techniques. METHODS Patients registered in the Danish Breast Cancer Group database from 2005 to 2016 with CT-based RT were eligible. Among 15,765 patients, the study included 204 with CAD after irradiation (cases) and 408 matched controls. Individual planning CTs were retrieved, the heart and cardiac substructures were delineated and dose-volume parameters were extracted. RESULTS The median follow-up time was 7.3 years (IQR: 4.6-10.0). Among cases, the median mean heart dose was 1.6 Gy (IQR 0.2-6.1) and 0.8 Gy (0.1-2.9) for left-sided and right-sided patients, respectively (p < 0.001). The highest RT doses were observed in the left ventricle and left anterior descending coronary artery for left-sided RT and in the right atrium and the right coronary artery after right-sided RT. The highest left-minus-right dose-difference was located in the distal part of the left anterior descending coronary artery where also the highest left-versus-right ratio of events was observed. However, no significant difference in the distribution of CAD was observed by laterality. Furthermore, no significant differences in the dose-volume parameters were observed for cases versus controls. CONCLUSIONS CAD tended to occur in the part of the heart with the highest left-minus- right dose difference, however, no significant risk of CAD was observed at 7 years' median follow-up.
Collapse
Affiliation(s)
- Marie Louise Holm Milo
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark; Department of Oncology, Aalborg University Hospital, Denmark.
| | - Ditte Slot Møller
- Department of Medical Physics, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
| | | | - Lone Hoffmann
- Department of Medical Physics, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
| | | | - Ingelise Jensen
- Department of Medical Physics, Aalborg University Hospital, Denmark
| | | | - Lise Bech Jellesmark Thorsen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark; Department of Oncology, Aarhus University Hospital, Denmark
| | | | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University Hospital, Denmark
| | - Jan Brink Valentin
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University Hospital, Denmark
| | - Jan Alsner
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Birgitte Vrou Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark; Department of Oncology, Aarhus University Hospital, Denmark; Danish Center for Particle Therapy, Aarhus, Denmark
| |
Collapse
|
26
|
Abubakar A, Shaukat SI, Karim NKA, Kassim MZ, Lim SY, Appalanaido GK, Zin HM. Accuracy of a time-of-flight (ToF) imaging system for monitoring deep-inspiration breath-hold radiotherapy (DIBH-RT) for left breast cancer patients. Phys Eng Sci Med 2023; 46:339-352. [PMID: 36847965 PMCID: PMC9969933 DOI: 10.1007/s13246-023-01227-6] [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] [Received: 09/07/2022] [Accepted: 01/27/2023] [Indexed: 03/01/2023]
Abstract
Deep inspiration breath-hold radiotherapy (DIBH-RT) reduces cardiac dose by over 50%. However, poor breath-hold reproducibility could result in target miss which compromises the treatment success. This study aimed to benchmark the accuracy of a Time-of-Flight (ToF) imaging system for monitoring breath-hold during DIBH-RT. The accuracy of an Argos P330 3D ToF camera (Bluetechnix, Austria) was evaluated for patient setup verification and intra-fraction monitoring among 13 DIBH-RT left breast cancer patients. The ToF imaging was performed simultaneously with in-room cone beam computed tomography (CBCT) and electronic portal imaging device (EPID) imaging systems during patient setup and treatment delivery, respectively. Patient surface depths (PSD) during setup were extracted from the ToF and the CBCT images during free breathing and DIBH using MATLAB (MathWorks, Natick, MA) and the chest surface displacement were compared. The mean difference ± standard deviation, correlation coefficient, and limit of agreement between the CBCT and ToF were 2.88 ± 5.89 mm, 0.92, and - 7.36, 1.60 mm, respectively. The breath-hold stability and reproducibility were estimated using the central lung depth extracted from the EPID images during treatment and compared with the PSD from the ToF. The average correlation between ToF and EPID was - 0.84. The average intra-field reproducibility for all the fields was within 2.70 mm. The average intra-fraction reproducibility and stability were 3.74 mm, and 0.80 mm, respectively. The study demonstrated the feasibility of using ToF camera for monitoring breath-hold during DIBH-RT and shows good breath-hold reproducibility and stability during the treatment delivery.
Collapse
Affiliation(s)
- Auwal Abubakar
- Biomedical Imaging Department/Oncology and Radiotherapy Unit, Advanced Medical & Dental Institute, Universiti Sains Malaysia, Bertam, 13200, Kepala Batas, Pulau Pinang, Malaysia.
- Department of Medical Radiography, Faculty of Allied Health Sciences, College of Medical Sciences, University of Maiduguri, Maiduguri, Nigeria.
| | - Shazril Imran Shaukat
- Biomedical Imaging Department/Oncology and Radiotherapy Unit, Advanced Medical & Dental Institute, Universiti Sains Malaysia, Bertam, 13200, Kepala Batas, Pulau Pinang, Malaysia
- Oncology Unit, Pantai Hospital Sungai Petani, Bandar Amanjaya, 08000, Sungai Petani, Kedah, Malaysia
| | - Noor Khairiah A Karim
- Biomedical Imaging Department/Oncology and Radiotherapy Unit, Advanced Medical & Dental Institute, Universiti Sains Malaysia, Bertam, 13200, Kepala Batas, Pulau Pinang, Malaysia
- Breast Cancer Translational Research Programme (BCTRP), Advanced Medical & Dental Institute, Universiti Sains Malaysia, Bertam, 13200, Kepala Batas, Pulau Pinang, Malaysia
| | - Mohammed Zakir Kassim
- Biomedical Imaging Department/Oncology and Radiotherapy Unit, Advanced Medical & Dental Institute, Universiti Sains Malaysia, Bertam, 13200, Kepala Batas, Pulau Pinang, Malaysia
| | - Siew Yong Lim
- Biomedical Imaging Department/Oncology and Radiotherapy Unit, Advanced Medical & Dental Institute, Universiti Sains Malaysia, Bertam, 13200, Kepala Batas, Pulau Pinang, Malaysia
| | - Gokula Kumar Appalanaido
- Biomedical Imaging Department/Oncology and Radiotherapy Unit, Advanced Medical & Dental Institute, Universiti Sains Malaysia, Bertam, 13200, Kepala Batas, Pulau Pinang, Malaysia
| | - Hafiz Mohd Zin
- Biomedical Imaging Department/Oncology and Radiotherapy Unit, Advanced Medical & Dental Institute, Universiti Sains Malaysia, Bertam, 13200, Kepala Batas, Pulau Pinang, Malaysia.
- Breast Cancer Translational Research Programme (BCTRP), Advanced Medical & Dental Institute, Universiti Sains Malaysia, Bertam, 13200, Kepala Batas, Pulau Pinang, Malaysia.
| |
Collapse
|
27
|
Screening for Coronary Artery Disease in Cancer Survivors: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2023; 5:22-38. [PMID: 36875910 PMCID: PMC9982229 DOI: 10.1016/j.jaccao.2022.12.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 12/19/2022] [Accepted: 12/20/2022] [Indexed: 02/24/2023] Open
Abstract
Coronary artery disease (CAD) is an important contributor to the cardiovascular burden in cancer survivors. This review identifies features that could help guide decisions about the benefit of screening to assess the risk or presence of subclinical CAD. Screening may be appropriate in selected survivors based on risk factors and inflammatory burden. In cancer survivors who have undergone genetic testing, polygenic risk scores and clonal hematopoiesis markers may become useful CAD risk prediction tools in the future. The type of cancer (especially breast, hematological, gastrointestinal, and genitourinary) and the nature of treatment (radiotherapy, platinum agents, fluorouracil, hormonal therapy, tyrosine kinase inhibitors, endothelial growth factor inhibitors, and immune checkpoint inhibitors) are also important in determining risk. Therapeutic implications of positive screening include lifestyle and atherosclerosis interventions, and in specific instances, revascularization may be indicated.
Collapse
Key Words
- ACS, acute coronary syndrome
- AYA, adolescent and young adult
- CAC, coronary artery calcium
- CAD, coronary artery disease
- CHIP, clonal hematopoiesis of indeterminate potential
- CMR, cardiac magnetic resonance
- CTA, computed tomography angiography
- CVD, cardiovascular disease
- IGF, insulin-like growth factor
- LDL, low-density lipoprotein
- PCE, pooled cohort equations
- PCI, percutaneous coronary intervention
- PRS, polygenic risk score
- ROS, reactive oxygen species
- TKI, tyrosine kinase inhibitor
- VEGF, vascular endothelial growth factor
- calcification
- coronary artery calcium
- coronary artery disease
- prevention
- risk factor
- risk prediction
Collapse
|
28
|
Whole Breast Irradiation Versus Intraoperative Electron Radiation Therapy for Breast Conserving Therapy: A Large Mature Single Institution Matched-Pair Evaluation of True Local Relapse, Progression Free Survival, and Overall Survival. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)00098-6. [PMID: 36736632 DOI: 10.1016/j.ijrobp.2023.01.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/17/2023] [Accepted: 01/21/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE Comparative outcome data after intraoperative radiation therapy and whole breast irradiation (WBI) for breast cancer at >10 years median follow-up are rare. We present a mature, single-institution, matched-pair comparison reporting survival and relapse rates in patients treated with either modality. METHODS AND MATERIALS Complete data sets for 258 intraoperative electron radiation therapy (IOERT) patients treated between 2000 and 2010 were matched with 258 patients postoperatively treated with WBI by age/histology/tumor size, grading/lymph-node-status/hormone receptors/type of adjuvant therapy/surgical margins, and treatment date. Relapse at surgical intervention site was classified as true local recurrence (LR). All recurrences in the treated breast (any quadrant) were classified as ipsilateral recurrence (IR). RESULTS Median follow-up was 157 months (12-251) for the IOERT group and 154 months (31-246) for the WBI group. Cumulative incidence of IR at 5, 10, and 15 years was 2.4%, 7.9%, and 12.7% for IOERT and 1.2%, 4.1%, and 5.0% for WBI (P = .02). Cumulative incidence of LR at 5, 10, and 15 years was 1.6%, 5.1%, and 8.3% for IOERT and 0.4%, 2.1%, and 2.5% for WBI (P = .02). No differences in overall survival, disease-free survival, second cancer incidence, or cardiac events were recorded in either treatment group. Outcome was better in the accelerated partial breast irradiation (APBI)-suitable group than in the APBI-unsuitable group (2009 criteria) (cumulative incidence of IR at 5, 10, and 15 years was 0% vs 7.3%, 6.1% vs 13.3%, and 7.3% vs 19.9% for IOERT and 0% vs 1.8%, 2.0% vs 3.9%, and 3.1% vs 3.9% for WBI) and in the revised APBI-suitable group than in the APBI-cautionary group (2017 criteria) (cumulative incidence of IR at 5, 10, and 15 years was 1.1% vs 6.4%, 6.2% vs 13.3%, and 7.8% vs 27.5% for IOERT and 1.7% vs 0%, 4.1% vs 4.4%, and 5.4% vs 4.4% for WBI). CONCLUSIONS The IR and LR rate were higher after IOERT than after WBI for the American Society for Radiation Oncology suitable patient group, although without reaching statistical significance. Thus, IOERT could be an alternative to WBI upon stringent patient selection, but patients should be counseled carefully about the potential for increased IR rate with IOERT. Second cancer incidence and cardiac events did not differ between IOERT and WBI.
Collapse
|
29
|
Ye J, Zhang L, Lyu J, Wang Y, Yuan S, Qin Z, Liu Y, Huang T, Tian J, Yin H. Malignant cancer may increase the risk of all-cause in-hospital mortality in patients with acute myocardial infarction: a multicenter retrospective study of two large public databases. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2023; 9:6. [PMID: 36670511 PMCID: PMC9862556 DOI: 10.1186/s40959-023-00156-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 01/09/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Acute myocardial infarction (AMI) and cancer are diseases with high morbidity and mortality worldwide, bringing a serious economic burden, and they share some risk factors. The purpose of this study was to determine the effect of cancer on the all-cause in-hospital mortality of patients with AMI. METHODS This multicenter retrospective study analyzed patients with AMI from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database and eICU Collaborative Research Database (eICU-CRD) in the United States. Patients were divided into two groups based on whether they had concomitant malignant cancer: cancer and noncancer groups. The outcome was all-cause in-hospital mortality. The association between the two groups and their outcomes were analyzed using Kaplan-Meier and Cox proportional-hazards regression models. Propensity score matching (PSM) and propensity score based inverse probability of treatment weighting (IPTW) were used to further adjust for confounding variables to verify the stability of the results. RESULTS The study included 3,034 and 5,968 patients with AMI from the MIMIC-IV database and the eICU-CRD, respectively. Kaplan-Meier survival curves indicated that the probability of in-hospital survival was lower in patients with cancer than in those without cancer. After adjusting for potential confounding variables using multivariable Cox proportional hazards regression, the risk of all-cause in-hospital mortality was significantly higher in the cancer than the noncancer group, and the HR (95% CI) values for the cancer group were 1.56(1.22,1.98) and 1.35(1.01,1.79) in the MIMIC-IV database and the eICU-CRD, respectively. The same results were obtained after using PSM and IPTW, which further verified the results. CONCLUSIONS Among the patients with AMI, the all-cause in-hospital mortality risk of those with cancer was higher than those without cancer. Therefore, when treating such patients, comprehensive considerations should be made from a multidisciplinary perspective involving cardiology and oncology, with the treatment plan adjusted accordingly.
Collapse
Affiliation(s)
- Jianfeng Ye
- grid.412601.00000 0004 1760 3828Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province China
| | - Luming Zhang
- grid.412601.00000 0004 1760 3828Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province China
| | - Jun Lyu
- grid.412601.00000 0004 1760 3828Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province China
| | - Yidan Wang
- grid.412463.60000 0004 1762 6325Department of Cardiology, The Key Laboratory of Myocardial Ischemia, The Second Affiliated Hospital of Harbin Medical University, Chinese Ministry of Education, Harbin, Heilongjiang Province China
| | - Shiqi Yuan
- grid.412601.00000 0004 1760 3828Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province China
| | - Zhifeng Qin
- grid.412463.60000 0004 1762 6325Department of Cardiology, The Key Laboratory of Myocardial Ischemia, The Second Affiliated Hospital of Harbin Medical University, Chinese Ministry of Education, Harbin, Heilongjiang Province China
| | - Yu Liu
- grid.412601.00000 0004 1760 3828Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province China
| | - Tao Huang
- grid.412601.00000 0004 1760 3828Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province China
| | - Jinwei Tian
- grid.412463.60000 0004 1762 6325Department of Cardiology, The Key Laboratory of Myocardial Ischemia, The Second Affiliated Hospital of Harbin Medical University, Chinese Ministry of Education, Harbin, Heilongjiang Province China
| | - Haiyan Yin
- grid.412601.00000 0004 1760 3828Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province China
| |
Collapse
|
30
|
Impact of a COmprehensive cardiac REhabilitation framework among high cardiovascular risk cancer survivors: Protocol for the CORE trial. Int J Cardiol 2023; 371:384-390. [PMID: 36216089 DOI: 10.1016/j.ijcard.2022.09.075] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 08/30/2022] [Accepted: 09/29/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cancer survivors are challenging patients, as they often present increased cardiovascular risk. In this background, cardio-oncology rehabilitation frameworks for specific cancer patients have been proposed. However, optimal program designs, as well as their overall safety and efficacy in different subsets of patients, are not fully ascertained. DESIGN Single-center, pragmatic, prospective, randomized controlled trial performed in Portugal aiming to evaluate the impact of a center-based cardiac rehabilitation program, consisting of exercise training, nutritional counselling, psychosocial management and lifestyle behavior change, compared to community-based exercise training, in cancer survivors. METHODS Adult cancer survivors (N = 80) exposed to cardiotoxic cancer treatment and/or with previous cardiovascular disease will be randomized (1:1) to receive either an eight-week cardiac rehabilitation program or community-based exercise training. Primary endpoint is cardiorespiratory fitness; secondary endpoints are physical activity, psychosocial parameters, blood pressure, body composition, lipids and inflammatory parameters. Physical function, quality of life, fatigue, health literacy, and feasibility will be assessed; a cost-effectiveness evaluation will also be performed. Between-group differences at baseline and in the change from baseline to the end of the study will be tested with unpaired t-tests or Mann-Whitney U test. Paired t-tests or Wilcoxon signed-rank test will be performed for within-group comparisons. CONCLUSION This trial will address the overall impact of a contemporary cardiac rehabilitation program framework in cancer survivors, as compared to a community-based exercise training. Given the higher cardiovascular risk in several groups of cancer patients, our results could provide novel insights into optimized preventive strategies in this complex patient population.
Collapse
|
31
|
Sharifkazemi M, Elahi M, Sayad M. Case report: Early acute myocarditis after radiation therapy for breast cancer: A case presentation and review of literature. Front Cardiovasc Med 2023; 10:1020082. [PMID: 37153473 PMCID: PMC10154576 DOI: 10.3389/fcvm.2023.1020082] [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] [Received: 08/15/2022] [Accepted: 03/24/2023] [Indexed: 05/09/2023] Open
Abstract
Breast cancer is the most commonly diagnosed cancer in women worldwide, and with the increased survival of patients by novel treatments, the frequency of complications of cancer treatments rises. Radiotherapy, especially on the chest wall, can damage different cardiac structures. Radiotherapy-induced cardiomyopathy mainly occurs over 10 years after breast cancer treatment; however, there is a gap in the literature on acute myocarditis following radiotherapy. Here, we present a 54-year-old woman who developed acute myocarditis shortly after 25 sessions of radiotherapy with 50 Gy of radiation, successfully diagnosed with the use of speckle tracking echocardiography (STE) and cardiac magnetic resonance (CMR), and responded to the medical treatment with relative clinical improvement until the final follow-up. This case suggests the necessity of detailed examination of patients after radiotherapy, not only for chronic occurrence of cardiomyopathy but also for acute myocarditis. Although STE and CMR resulted in accurate diagnosis, in this case, further studies are required to determine the diagnostic accuracy of these two imaging methods compared with other imaging modalities in such patients and investigate the best diagnostic tool and therapeutic approach for these patients.
Collapse
Affiliation(s)
- Mohammadbagher Sharifkazemi
- Department of Cardiology, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
- Correspondence: Mohammadbagher Sharifkazemi
| | - Mahsa Elahi
- Radiation Oncology Department, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Masoud Sayad
- Cardio-Oncology Department, Rajaie Heart Hospital, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
32
|
Patil S, Pingle SR, Shalaby K, Kim AS. Mediastinal irradiation and valvular heart disease. CARDIO-ONCOLOGY 2022; 8:7. [PMID: 35395814 PMCID: PMC8991889 DOI: 10.1186/s40959-022-00133-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/18/2022] [Indexed: 12/21/2022]
Abstract
AbstractAnticancer therapy has the potential to cause unwanted cardiovascular side effects. Utilization of radiation therapy to treat tumors near the heart can result in radiation-induced valvular heart disease among other cardiovascular pathologies. The aim of this review is to describe the epidemiology, pathophysiology, risk prediction, non-invasive imaging modalities and management of radiation-induced valvular heart disease with a focus on pre-operative risk assessment and contemporary treatment options.
Collapse
|
33
|
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.
Collapse
|
34
|
Honaryar MK, Allodji R, Ferrières J, Panh L, Locquet M, Jimenez G, Lapeyre M, Camilleri J, Broggio D, de Vathaire F, Jacob S. Early Coronary Artery Calcification Progression over Two Years in Breast Cancer Patients Treated with Radiation Therapy: Association with Cardiac Exposure (BACCARAT Study). Cancers (Basel) 2022; 14:cancers14235724. [PMID: 36497205 PMCID: PMC9735519 DOI: 10.3390/cancers14235724] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/08/2022] [Accepted: 11/20/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Radiotherapy (RT) for breast cancer (BC) can induce coronary artery disease many years after RT. At an earlier stage, during the first two years after RT, we aimed to evaluate the occurrence of increased coronary artery calcium (CAC) and its association with cardiac exposure. Methods: This prospective study included 101 BC patients treated with RT without chemotherapy. Based on CAC CT scans performed before and two years after RT, the event ‘CAC progression’ was defined by an increase in overall CAC score (CAC RT+ two years—CAC before RT > 0). Dosimetry was evaluated for whole heart, left ventricle (LV), and coronary arteries. Multivariable logistic regression models were used to assess association with doses. Results: Two years after RT, 28 patients presented the event ‘CAC progression’, explained in 93% of cases by a higher CAC score in the left anterior descending coronary (LAD). A dose−response relationship was observed with LV exposure (for Dmean LV: OR = 1.15, p = 0.04). LAD exposure marginally explained increased CAC in the LAD (for D2 LV: OR =1.03, p = 0.07). Conclusion: The risk of early CAC progression may be associated with LV exposure. This progression might primarily be a consequence of CAC increase in the LAD and its exposure.
Collapse
Affiliation(s)
| | - Rodrigue Allodji
- INSERM U 1018, CESP, Radiation Epidemiology Team, 94800 Villejuif, France
- Institute Gustave Roussy, 94800 Villejuif, France
- University Paris-Saclay, 94800 Villejuif, France
| | - Jean Ferrières
- Department of Cardiology and INSERM UMR 1295, Rangueil University Hospital, 31400 Toulouse, France
| | - Loïc Panh
- Department of Cardiology, Clinique Pasteur, 31076 Toulouse, France
| | - Médéa Locquet
- Laboratory of Epidemiology, Institute for Radiation Protection and Nuclear Safety (IRSN), 92260 Fontenay-Aux-Roses, France
| | - Gaelle Jimenez
- Department of Radiation Oncology (Oncorad), Clinique Pasteur, 31076 Toulouse, France
| | - Matthieu Lapeyre
- Department of Radiology (GRX), Clinique Pasteur, 31076 Toulouse, France
| | - Jérémy Camilleri
- Department of Radiation Oncology (Oncorad), Clinique Pasteur, 31076 Toulouse, France
| | - David Broggio
- Department of Dosimetry, Institute for Radiation Protection and Nuclear Safety (IRSN), 92260 Fontenay-Aux-Roses, France
| | - Florent de Vathaire
- INSERM U 1018, CESP, Radiation Epidemiology Team, 94800 Villejuif, France
- Institute Gustave Roussy, 94800 Villejuif, France
- University Paris-Saclay, 94800 Villejuif, France
| | - Sophie Jacob
- Laboratory of Epidemiology, Institute for Radiation Protection and Nuclear Safety (IRSN), 92260 Fontenay-Aux-Roses, France
- Correspondence:
| |
Collapse
|
35
|
Supraventricular cardiac conduction system exposure in breast cancer patients treated with radiotherapy and association with heart and cardiac chambers doses. Clin Transl Radiat Oncol 2022; 38:62-70. [DOI: 10.1016/j.ctro.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/27/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022] Open
|
36
|
Lowe D, Roy L, Tabocchini MA, Rühm W, Wakeford R, Woloschak GE, Laurier D. Radiation dose rate effects: what is new and what is needed? RADIATION AND ENVIRONMENTAL BIOPHYSICS 2022; 61:507-543. [PMID: 36241855 PMCID: PMC9630203 DOI: 10.1007/s00411-022-00996-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/13/2022] [Indexed: 05/04/2023]
Abstract
Despite decades of research to understand the biological effects of ionising radiation, there is still much uncertainty over the role of dose rate. Motivated by a virtual workshop on the "Effects of spatial and temporal variation in dose delivery" organised in November 2020 by the Multidisciplinary Low Dose Initiative (MELODI), here, we review studies to date exploring dose rate effects, highlighting significant findings, recent advances and to provide perspective and recommendations for requirements and direction of future work. A comprehensive range of studies is considered, including molecular, cellular, animal, and human studies, with a focus on low linear-energy-transfer radiation exposure. Limits and advantages of each type of study are discussed, and a focus is made on future research needs.
Collapse
Affiliation(s)
- Donna Lowe
- UK Health Security Agency, CRCE Chilton, Didcot, OX11 0RQ, Oxfordshire, UK
| | - Laurence Roy
- Institut de Radioprotection Et de Sûreté Nucléaire, Fontenay-Aux-Roses, France
| | - Maria Antonella Tabocchini
- Istituto Nazionale i Fisica Nucleare, Sezione i Roma, Rome, Italy
- Istituto Superiore Di Sanità, Rome, Italy
| | - Werner Rühm
- Institute of Radiation Medicine, Helmholtz Center Munich, Ingolstädter Landstr. 1, 85764, Neuherberg, Germany
| | - Richard Wakeford
- Centre for Occupational and Environmental Health, The University of Manchester, Manchester, M13 9PL, UK
| | - Gayle E Woloschak
- Department of Radiation Oncology, Northwestern University School of Medicine, Chicago, IL, USA.
| | - Dominique Laurier
- Institut de Radioprotection Et de Sûreté Nucléaire, Fontenay-Aux-Roses, France
| |
Collapse
|
37
|
Baaken D, Merzenich H, Schmidt M, Bekes I, Schwentner L, Janni W, Wöckel A, Mayr M, Mose S, Merz T, Ghilescu V, Renner J, Bartkowiak D, Wiegel T, Blettner M, Schmidberger H, Wollschläger D. A nested case-control study on radiation dose-response for cardiac events in breast cancer patients in Germany. Breast 2022; 65:1-7. [PMID: 35716531 PMCID: PMC9207715 DOI: 10.1016/j.breast.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/20/2022] [Accepted: 05/30/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Previous studies with the majority of breast cancer (BC) patients treated up to 2000 provided evidence that radiation dose to the heart from radiotherapy (RT) was linearly associated with increasing risk for long-term cardiac disease. RT techniques changed substantially over time. This study aimed to investigate the dose-dependent cardiac risk in German BC patients treated with more contemporary RT. METHODS In a cohort of 11,982 BC patients diagnosed in 1998-2008, we identified 494 women treated with 3D-conformal RT who subsequently developed a cardiac event. Within a nested case-control approach, these cases were matched to 988 controls. Controls were patients without a cardiac event after RT until the index date of the corresponding case. Separate multivariable conditional logistic regression models were used to assess the association of radiation to the complete heart and to the left anterior heart wall (LAHW) with cardiac events. RESULTS Mean dose to the heart for cases with left-sided BC was 4.27 Gy and 1.64 Gy for cases with right-sided BC. For controls, corresponding values were 4.31 Gy and 1.66 Gy, respectively. The odds ratio (OR) per 1 Gy increase in dose to the complete heart was 0.99 (95% confidence interval (CI): 0.94-1.05, P = .72). The OR per 1 Gy increase in LAHW dose was 1.00 (95% CI: 0.98-1.01, P = .68). CONCLUSIONS Contrary to previous studies, our study provided no evidence that radiation dose to the heart from 3D-conformal RT for BC patients treated between 1998 and 2008 was associated with risk of cardiac events.
Collapse
Affiliation(s)
- Dan Baaken
- University Medical Center of the Johannes Gutenberg-University Mainz, Institute of Medical Biostatistics, Epidemiology and Informatics, 55101, Mainz, Germany.
| | - Hiltrud Merzenich
- University Medical Center of the Johannes Gutenberg-University Mainz, Institute of Medical Biostatistics, Epidemiology and Informatics, 55101, Mainz, Germany
| | - Marcus Schmidt
- University Medical Center of the Johannes Gutenberg-University Mainz, Department of Obstetrics and Gynecology, 55101, Mainz, Germany
| | - Inga Bekes
- University Hospital Ulm, Department of Gynecology and Obstetrics, 89075, Ulm, Germany
| | - Lukas Schwentner
- University Hospital Ulm, Department of Gynecology and Obstetrics, 89075, Ulm, Germany
| | - Wolfgang Janni
- University Hospital Ulm, Department of Gynecology and Obstetrics, 89075, Ulm, Germany
| | - Achim Wöckel
- University Hospital Ulm, Department of Gynecology and Obstetrics, 89075, Ulm, Germany; University Hospital Würzburg, 97080, Würzburg, Germany
| | - Manfred Mayr
- Strahlentherapie Süd am Klinikum Kaufbeuren, 87600, Kaufbeuren, Germany
| | - Stephan Mose
- Schwarzwald-Baar Klinikum, Klinik für Strahlentherapie und Radioonkologie, 78052, Villingen-Schwenningen, Germany
| | - Thomas Merz
- Kliniken Landkreis Heidenheim gGmbH, Department of Radiation Oncology and Radiotherapy, 89522, Heidenheim, Germany
| | - Voica Ghilescu
- Kliniken Landkreis Heidenheim gGmbH, Department of Radiation Oncology and Radiotherapy, 89522, Heidenheim, Germany
| | - Jona Renner
- University Hospital Ulm, Department of Radiation Oncology, 89081, Ulm, Germany
| | - Detlef Bartkowiak
- University Hospital Ulm, Department of Radiation Oncology, 89081, Ulm, Germany
| | - Thomas Wiegel
- University Hospital Ulm, Department of Radiation Oncology, 89081, Ulm, Germany
| | - Maria Blettner
- University Medical Center of the Johannes Gutenberg-University Mainz, Institute of Medical Biostatistics, Epidemiology and Informatics, 55101, Mainz, Germany
| | - Heinz Schmidberger
- University Medical Center of the Johannes Gutenberg-University Mainz, Department of Radiation Oncology and Radiation Therapy, 55101, Mainz, Germany
| | - Daniel Wollschläger
- University Medical Center of the Johannes Gutenberg-University Mainz, Institute of Medical Biostatistics, Epidemiology and Informatics, 55101, Mainz, Germany
| |
Collapse
|
38
|
Bamias A, Tzannis K, Zakopoulou R, Sakellakis M, Dimitriadis J, Papatheodoridi A, Rallidis L, Halvatsiotis P, Tsiara A, Kaparelou M, Kostouros E, Barbarousi D, Koutsoukos K, Fragiadis E, Dellis AE, Anastasiou I, Stravodimos K, Pinitas A, Papatsoris A, Adamakis I, Varkarakis I, Fragoulis C, Pagoni S, Matsouka C, Skolarikos A, Mitropoulos D, Doumas K, Deliveliotis C, Constantinides C, Dimopoulos MA. Risk for Arterial Thromboembolic Events (ATEs) in Patients with Advanced Urinary Tract Cancer (aUTC) Treated with First-Line Chemotherapy: Single-Center, Observational Study. Curr Oncol 2022; 29:6077-6090. [PMID: 36135047 PMCID: PMC9498031 DOI: 10.3390/curroncol29090478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 11/16/2022] Open
Abstract
Arterial thromboembolism has been associated with cancer or its treatment. Unlike venous thromboembolism, the incidence and risk factors have not been extensively studied. Here, we investigated the incidence of arterial thromboembolic events (ATEs) in an institutional series of advanced urinary tract cancer (aUTC) treated with cytotoxic chemotherapy. The ATE definition included peripheral arterial embolism/thrombosis, ischemic stroke and coronary events. A total of 354 aUTC patients were analyzed. Most patients (95.2%) received platinum-based chemotherapy. A total of 12 patients (3.4%) suffered an ATE within a median time of 3.6 months from the start of chemotherapy. The most frequent ATE was ischemic stroke (n = 7). Two ATEs were fatal. The 6-month and 24-month incidence were 2.1% (95% confidence interval [CI]: 0.9-4.1) and 3.6% (95% CI: 1.9-6.2), respectively. Perioperative chemotherapy increased the risk for ATE by 5.55-fold. Tumors other than UTC and pure non-transitional cell carcinoma histology were also independent risk factors. No association with the type of chemotherapy was found. Overall, ATEs occur in 4.6% of aUTC patients treated with chemotherapy and represent a clinically relevant manifestation. Perioperative chemotherapy significantly increases the risk for ATE. The role of prophylaxis in high-risk groups should be prospectively studied.
Collapse
Affiliation(s)
- Aristotelis Bamias
- 2nd Propaedeutic Dept of Internal Medicine, National & Kapodistrian University of Athens, ATTIKON University Hospital, Rimini st 1, 12642 Chaidari, Attiki, Greece
- Hellenic GU Cancer Group, Evrou st 89, 11527 Athens, Attiki, Greece
| | - Kimon Tzannis
- 2nd Propaedeutic Dept of Internal Medicine, National & Kapodistrian University of Athens, ATTIKON University Hospital, Rimini st 1, 12642 Chaidari, Attiki, Greece
- Hellenic GU Cancer Group, Evrou st 89, 11527 Athens, Attiki, Greece
| | - Roubini Zakopoulou
- Dept of Clinical Therapeutics, National & Kapodistrian University of Athens, ALEXNADRA Hospital, Vas. Sofias Ave 80, 11528 Athens, Attiki, Greece
| | - Minas Sakellakis
- Hellenic GU Cancer Group, Evrou st 89, 11527 Athens, Attiki, Greece
| | - John Dimitriadis
- Dept of Clinical Therapeutics, National & Kapodistrian University of Athens, ALEXNADRA Hospital, Vas. Sofias Ave 80, 11528 Athens, Attiki, Greece
| | - Alkistis Papatheodoridi
- Dept of Clinical Therapeutics, National & Kapodistrian University of Athens, ALEXNADRA Hospital, Vas. Sofias Ave 80, 11528 Athens, Attiki, Greece
| | - Loukianos Rallidis
- 2nd Department of Cardiology, National & Kapodistrian University of Athens, ATTIKON University Hospital, Rimini st 1, 12642 Chaidari, Attiki, Greece
| | - Panagiotis Halvatsiotis
- 2nd Propaedeutic Dept of Internal Medicine, National & Kapodistrian University of Athens, ATTIKON University Hospital, Rimini st 1, 12642 Chaidari, Attiki, Greece
| | - Anna Tsiara
- Dept of Clinical Therapeutics, National & Kapodistrian University of Athens, ALEXNADRA Hospital, Vas. Sofias Ave 80, 11528 Athens, Attiki, Greece
| | - Maria Kaparelou
- Dept of Clinical Therapeutics, National & Kapodistrian University of Athens, ALEXNADRA Hospital, Vas. Sofias Ave 80, 11528 Athens, Attiki, Greece
| | - Efthymios Kostouros
- Oncology Department, Athens General Hospital “G. Gennimatas”, Mesogeion 154, 11527 Athens, Attiki, Greece
| | - Despina Barbarousi
- Haematology Division, Alexandra Hospital, Vasilissis Sofias 80, 11528 Athens, Attiki, Greece
| | - Konstantinos Koutsoukos
- Dept of Clinical Therapeutics, National & Kapodistrian University of Athens, ALEXNADRA Hospital, Vas. Sofias Ave 80, 11528 Athens, Attiki, Greece
| | - Evangelos Fragiadis
- 1st Dept of Urology, National & Kapodistrian University of Athens, LAIKON Hospital, Agiou Thoma st 17, 11527 Athens, Attiki, Greece
| | - Athanasios E. Dellis
- 2nd Dept of Surgery, Aretaieion Academic Hospital, National & Kapodistrian University of Athens, Vas. Sofias Ave 76, 11528 Athens, Attiki, Greece
| | - Ioannis Anastasiou
- 1st Dept of Urology, National & Kapodistrian University of Athens, LAIKON Hospital, Agiou Thoma st 17, 11527 Athens, Attiki, Greece
| | - Konstantinos Stravodimos
- 1st Dept of Urology, National & Kapodistrian University of Athens, LAIKON Hospital, Agiou Thoma st 17, 11527 Athens, Attiki, Greece
| | - Alexandros Pinitas
- 2nd Dept of Urology, National & Kapodistrian University of Athens, Sismanoglio General Hospital, Sismanoglou st 1, 15126 Athens, Attiki, Greece
| | - Athanasios Papatsoris
- 2nd Dept of Urology, National & Kapodistrian University of Athens, Sismanoglio General Hospital, Sismanoglou st 1, 15126 Athens, Attiki, Greece
| | - Ioannis Adamakis
- 1st Dept of Urology, National & Kapodistrian University of Athens, LAIKON Hospital, Agiou Thoma st 17, 11527 Athens, Attiki, Greece
| | - Ioannis Varkarakis
- 2nd Dept of Urology, National & Kapodistrian University of Athens, Sismanoglio General Hospital, Sismanoglou st 1, 15126 Athens, Attiki, Greece
| | - Charalampos Fragoulis
- Department of Urology, Athens General Hospital “G. Gennimatas”, Mesogeion 154, 11527 Athens, Attiki, Greece
| | - Stamatina Pagoni
- Oncology Department, Athens General Hospital “G. Gennimatas”, Mesogeion 154, 11527 Athens, Attiki, Greece
| | - Charis Matsouka
- Oncology Department, Athens General Hospital “G. Gennimatas”, Mesogeion 154, 11527 Athens, Attiki, Greece
| | - Andreas Skolarikos
- 2nd Dept of Urology, National & Kapodistrian University of Athens, Sismanoglio General Hospital, Sismanoglou st 1, 15126 Athens, Attiki, Greece
| | - Dionysios Mitropoulos
- 1st Dept of Urology, National & Kapodistrian University of Athens, LAIKON Hospital, Agiou Thoma st 17, 11527 Athens, Attiki, Greece
| | - Konstantinos Doumas
- Department of Urology, Athens General Hospital “G. Gennimatas”, Mesogeion 154, 11527 Athens, Attiki, Greece
| | - Charalampos Deliveliotis
- 2nd Dept of Urology, National & Kapodistrian University of Athens, Sismanoglio General Hospital, Sismanoglou st 1, 15126 Athens, Attiki, Greece
| | - Constantinos Constantinides
- 1st Dept of Urology, National & Kapodistrian University of Athens, LAIKON Hospital, Agiou Thoma st 17, 11527 Athens, Attiki, Greece
| | - Meletios-Athanasios Dimopoulos
- Dept of Clinical Therapeutics, National & Kapodistrian University of Athens, ALEXNADRA Hospital, Vas. Sofias Ave 80, 11528 Athens, Attiki, Greece
| |
Collapse
|
39
|
Koric A, Chang CP, Mark B, Rowe K, Snyder J, Dodson M, Deshmukh VG, Newman MG, Fraser AM, Smith KR, Date AP, Gren LH, Porucznik CA, Haaland BA, Henry NL, Hashibe M. Cardiovascular disease risk in long-term breast cancer survivors: A population-based cohort study. Cancer 2022; 128:2826-2835. [PMID: 35561317 PMCID: PMC9991862 DOI: 10.1002/cncr.34224] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/22/2022] [Accepted: 03/03/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Breast cancer survival is increasing, making late effects such as cardiovascular disease (CVD) more relevant. The purpose of this study was to evaluate incident CVD following breast cancer diagnosis among long-term survivors and to investigate possible risk factors for CVD. METHODS A population-based cohort of 6641 breast cancer survivors diagnosed between 1997 and 2009 who survived at least 10 years was identified within the Utah Cancer Registry. In addition, 36,612 cancer-free women from the general population, matched by birth year and state, were identified within the Utah Population Database. Cox proportional hazards models were used to calculate CVD hazard ratios (HRs) for >10 to 15 and >15 years. RESULTS Long-term breast cancer survivors had an increased risk of newly diagnosed diseases of the circulatory system (HR, 1.32; 99% confidence interval [CI], 1.00-1.75) from 10 to 15 years following cancer diagnosis compared with the general population. No increased CVD risks were observed after 15 years. Breast cancer survivors with Charlson Comorbidity Index score ≥2 had a significantly higher risk of diseases of the circulatory system (HR, 2.64; 95% CI, 1.08-6.45) beyond 10 years following breast cancer diagnosis. Similarly, older age, obesity, lower education, and family history of CVD and breast cancer were risk factors for heart and circulatory system diseases among long-term breast cancer survivors. CONCLUSION Risk of CVD compared to the general population was moderate among this cohort of long-term breast cancer survivors between 10 to 15 years since cancer diagnosis. Awareness of CVD risks is important for breast cancer survivors.
Collapse
Affiliation(s)
- Alzina Koric
- Huntsman Cancer Institute, Salt Lake City, Utah.,Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Chun-Pin Chang
- Huntsman Cancer Institute, Salt Lake City, Utah.,Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Bayarmaa Mark
- Huntsman Cancer Institute, Salt Lake City, Utah.,Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Kerry Rowe
- Intermountain Healthcare, Salt Lake City, Utah
| | - John Snyder
- Intermountain Healthcare, Salt Lake City, Utah
| | - Mark Dodson
- Intermountain Healthcare, Salt Lake City, Utah
| | | | - Michael G Newman
- Huntsman Cancer Institute, Salt Lake City, Utah.,University of Utah Health Sciences Center, Salt Lake City, Utah
| | - Alison M Fraser
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Ken R Smith
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Ankita P Date
- Pedigree and Population Resource, Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Lisa H Gren
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Christina A Porucznik
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Benjamin A Haaland
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - N Lynn Henry
- Division of Hematology and Oncology, University of Michigan Medical School, University of Michigan Rogel Cancer Center, Ann Arbor, Michigan
| | - Mia Hashibe
- Huntsman Cancer Institute, Salt Lake City, Utah.,Division of Public Health, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| |
Collapse
|
40
|
Bhimani F, Johnson K, Brodin NP, Tomé WA, Fox J, Mehta K, McEvoy M, Feldman S. Case Report: Can Targeted Intraoperative Radiotherapy in Patients With Breast Cancer and Pacemakers be the New Standard of Care? Front Oncol 2022; 12:927174. [PMID: 35903710 PMCID: PMC9315093 DOI: 10.3389/fonc.2022.927174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background Partial breast irradiation with Intra-operative radiotherapy (IORT) has become a popular management option as opposed to whole breast radiation using external beam radiotherapy for breast cancer patients. While previous studies have highlighted the use of IORT in breast cancer patients, there is a scarcity of literature on the use of IORT in those who also have ipsilateral pacemakers. Thus, the aim of our case report is to highlight the applicability of IORT in breast cancer patients who also have a pacemaker. Case Reports Two female patients with an implanted dual-chamber pacemaker presented with a diagnosis of left-sided invasive ductal carcinoma on mammogram. Mammography of the left breast revealed a 10 mm and 7 mm spiculated mass, respectively, further confirmed with an ultrasound-guided core biopsy that was conclusive of clinical Stage I T1 N0 grade 2, ER +, PR + Her2 – invasive ductal carcinoma. They met our eligibility criteria for IORT, which is being performed as a registry trial. These patients underwent a wide excision lumpectomy along with IORT. Conclusion Our findings underscore the successful use of targeted IORT for breast-conserving surgery in a patient with invasive ductal carcinoma and pacemaker, hence eliminating the necessity for relocating pacemaker surgeries in these patients. Furthermore, no device failure or malfunction for the pacemaker was recorded before, during, or after the surgery, demonstrating the safety of using IORT in patients with preinstalled pacemaker despite a lack of evidence on safe radiation dosage or manufacturer guidelines. Nonetheless, the effects of IORT on pacemaker < 10 cm were not studied in our patients and further clinical studies are recommended to reinforce the applicability and safe distance of IORT in breast cancer patients with pacemaker.
Collapse
Affiliation(s)
- Fardeen Bhimani
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Kelly Johnson
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - N. Patrik Brodin
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Wolfgang A. Tomé
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Jana Fox
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Keyur Mehta
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Maureen McEvoy
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Sheldon Feldman
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
- *Correspondence: Sheldon Feldman,
| |
Collapse
|
41
|
Errahmani MY, Locquet M, Spoor D, Jimenez G, Camilleri J, Bernier MO, Broggio D, Monceau V, Ferrières J, Thariat J, Boveda S, Kirova Y, Loap P, Langendijk JA, Crijns A, Jacob S. Association Between Cardiac Radiation Exposure and the Risk of Arrhythmia in Breast Cancer Patients Treated With Radiotherapy: A Case–Control Study. Front Oncol 2022; 12:892882. [PMID: 35860581 PMCID: PMC9289188 DOI: 10.3389/fonc.2022.892882] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/02/2022] [Indexed: 12/25/2022] Open
Abstract
Background Previous studies suggested that radiation therapy (RT) for breast cancer (BC) can induce cardiac arrhythmias and conduction disorders. However, the association with mean heart dose and specific cardiac substructures doses was less studied. Materials and Methods We conducted a nested case–control study based on French BC patients, enrolled in the European MEDIRAD-BRACE study (https://clinicaltrials.gov, Identifier: NCT03211442), who underwent three-dimensional conformal radiation therapy (3D-CRT) between 2009 and 2013 and were retrospectively followed until 2019. Cases were incident cases of cardiac arrhythmia. Controls without arrhythmia were selected with propensity-scored matching by age, duration of follow-up, chemotherapy, hypertension, and diabetes (ratio 1:4 or 5). Doses to the whole heart (WH), left and right atria (LA and RA), and left and right ventricles (LV and RV) were obtained after delineation with multi-atlas-based automatic segmentation. Results The study included 116 patients (21 cases and 95 controls). Mean age at RT was 64 ± 10 years, mean follow-up was 7.0 ± 1.3 years, and mean interval from RT to arrhythmia was 4.3 ± 2.1 years. None of the results on association between arrhythmia and cardiac doses reached statistical significance. However, the proportion of right-sided BC was higher among patients with arrhythmia than among controls (57% vs. 51%, OR = 1.18, p = 0.73). Neither mean WH dose, nor LV, RV, and LA doses were associated with an increased risk of arrhythmia (OR = 1.00, p > 0.90). In contrast, the RA dose was slightly higher for cases compared to controls [interquartile range (0.61–1.46 Gy) vs. (0.49–1.31 Gy), p = 0.44], and a non-significant trend toward a potentially higher risk of arrhythmia with increasing RA dose was observed (OR = 1.19, p = 0.60). Subanalysis according to BC laterality showed that the association with RA dose was reinforced specifically for left-sided BC (OR = 1.76, p = 0.75), while for right-sided BC, the ratio of mean RA/WH doses may better predict arrhythmia (OR = 2.39, p = 0.35). Conclusion Despite non-significant results, our exploratory investigation on BC patients treated with RT is the first study to suggest that right-sided BC patients and the right atrium irradiation may require special attention regarding the risk of cardiac arrhythmia and conduction disorders. Further studies are needed to expand on this topic.
Collapse
Affiliation(s)
- Mohamed Yassir Errahmani
- Laboratory of Epidemiology, Institute for Radiation Protection and Nuclear Safety (IRSN), Fontenay-Aux-Roses, France
- University Paris-Saclay, Gif-sur-Yvette, France
| | - Médéa Locquet
- Laboratory of Epidemiology, Institute for Radiation Protection and Nuclear Safety (IRSN), Fontenay-Aux-Roses, France
| | - Daan Spoor
- Department of Radiation Oncology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, Netherlands
| | - Gaelle Jimenez
- Department of Radiation Oncology (Oncorad), Clinique Pasteur, Toulouse, France
| | - Jérémy Camilleri
- Department of Radiation Oncology (Oncorad), Clinique Pasteur, Toulouse, France
| | - Marie-Odile Bernier
- Laboratory of Epidemiology, Institute for Radiation Protection and Nuclear Safety (IRSN), Fontenay-Aux-Roses, France
| | - David Broggio
- Department of Dosimetry, Institute for Radiation Protection and Nuclear Safety (IRSN), Fontenay-Aux-Roses, France
| | - Virginie Monceau
- Laboratory of Radiotoxicology and Radiobiology, Institute for Radiation Protection and Nuclear Safety (IRSN), Fontenay-Aux-Roses, France
| | - Jean Ferrières
- Department of Cardiology and INSERM UMR 1295, Rangueil University Hospital, Toulouse, France
| | - Juliette Thariat
- Department of Radiotherapy, Centre de Lutte Contre le Cancer A. Baclesse, University of Caen Normandie, Caen, France
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | - Youlia Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Pierre Loap
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Johannes A. Langendijk
- Department of Radiation Oncology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, Netherlands
| | - Anne Crijns
- Department of Radiation Oncology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, Netherlands
| | - Sophie Jacob
- Laboratory of Epidemiology, Institute for Radiation Protection and Nuclear Safety (IRSN), Fontenay-Aux-Roses, France
- *Correspondence: Sophie Jacob,
| |
Collapse
|
42
|
Oncological Benefit versus Cardiovascular Risk in Breast Cancer Patients Treated with Modern Radiotherapy. J Clin Med 2022; 11:jcm11133889. [PMID: 35807180 PMCID: PMC9267636 DOI: 10.3390/jcm11133889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/22/2022] [Accepted: 06/26/2022] [Indexed: 11/28/2022] Open
Abstract
Radiotherapy (RT) is an essential part of breast cancer (BC) treatments. Unfortunately, heart exposure to radiation can also impair the long-term survival of patients. Our study aimed to quantify the oncological benefit and the cardiovascular (CV) risk associated with modern RT in a real-world cohort of BC patients. Our descriptive study enrolled BC patients who received adjuvant RT. Ten-year overall survival (OS) was estimated using Predict® version 2.1 (National Health Service, London, UK). The basal risk of CV events was estimated using the American Heart Association (ACC/AHA) CV score. Treatment volumes and mean cardiac doses were obtained from RT treatment plan records. The increased risk of CV events due to RT was estimated using a model proposed by Darby. The risk of acute myocardial infarction or stroke mortality was estimated using HeartScore® (European Society of Cardiology, Brussels, Belgium). A total of 256 BC patients were included in the study. The average age of patients was 57 years old (range: 25–91); 49.6% had left BC. The mean cardiac dose was 166 cGy (interquartile range (IQR) 94–273); the estimated hazard ratio (HR) for CV disease was HR 1.12 (confidence interval (CI) 1.04–1.24). The estimated baseline 10-year CV risk was 5.6% (0.2 to 51.2); CV risk increased by 0.9% (range 0.02–35.47%) after RT. The absolute risk of 10-year mortality from CV disease was 2.5% (0.1–9); RT was associated with an estimated 4.9% survival benefit (3.73–6.07) against BC death and a 0.23% (0.17–0.29) estimated increase in CV mortality. Modern RT decreased 10-year BC mortality by 4% but increased CV mortality by 0.2% in this cohort. Our findings encourage the implementation of personalized adjuvant RT treatments that balance risks and benefits to improve long-term BC patient survival.
Collapse
|
43
|
Kearney M, Keys M, Faivre-Finn C, Wang Z, Aznar MC, Duane F. Exposure of the heart in lung cancer radiation therapy: A systematic review of heart doses published during 2013 to 2020. Radiother Oncol 2022; 172:118-125. [PMID: 35577022 DOI: 10.1016/j.radonc.2022.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/26/2022] [Accepted: 05/08/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Lung cancer radiotherapy increases the risk of cardiotoxicity and heart radiation dose is an independent predictor of poor survival. This study describes heart doses and strategies aiming to reduce exposure. MATERIALS AND METHODS A systematic review of lung cancer dosimetry studies reporting heart doses published 2013-2020 was undertaken. Doses were compared according to laterality, region irradiated, treatment modality (stereotactic ablative body radiotherapy (SABR) and non-SABR), planning technique, and respiratory motion management. RESULTS For 392 non-SABR regimens in 105 studies, the average MHD was 10.3 Gy (0.0-48.4) and was not significantly different between left and right-sided tumours. It was similar between IMRT and 3DCRT (10.9 Gy versus 10.6 Gy) and lower with particle beam therapy (proton 7.0 Gy; carbon-ion 1.9 Gy). Active respiratory motion management reduced exposure (7.4 Gy versus 9.3 Gy). For 168 SABR regimens in 35 studies, MHD was 4.0 Gy (0.0-32.4). Exposure was higher in central and lower lobe lesions (6.3 and 5.8 Gy respectively). MHD was lowest for carbon ions (0.5 Gy) compared to other techniques. Active respiratory motion management reduced exposure (2.4 Gy versus 5.0 Gy). Delineation guidelines and Dose Volume Constraints for the heart varied substantially. CONCLUSIONS There is scope to reduce heart radiation dose in lung cancer radiotherapy. Consensus on planning objectives, contouring and DVCs for the heart may lead to reduced heart doses in the future. For IMRT, more stringent optimisation objectives may reduce heart dose. Active respiratory motion management or particle therapy may be considered in situations where cardiac dose is high.
Collapse
Affiliation(s)
- Maeve Kearney
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity College Dublin, Ireland.
| | - Maeve Keys
- St Luke's Radiation Oncology Network, St. Luke's Hospital, Dublin, Ireland; The Christie NHS Foundation Trust, University of Manchester, United Kingdom
| | | | - Zhe Wang
- Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Marianne C Aznar
- Nuffield Department of Population Health, University of Oxford, United Kingdom; Manchester Cancer Research Centre, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
| | - Frances Duane
- St Luke's Radiation Oncology Network, St. Luke's Hospital, Dublin, Ireland; School of Medicine, Trinity College Dublin, Ireland; Trinity St James's Cancer Institute, St. James's Hospital, Dublin, Ireland
| |
Collapse
|
44
|
Kaidar-Person O, Fortpied C, Hol S, Weltens C, Kirkove C, Budach V, Peignaux-Casasnovas K, van der Leij F, Vonk E, Valli M, Weidner N, Guckenberger M, Koiter E, Fourquet A, Bartelink H, Struikmans H, Poortmans P. The association of internal mammary and medial supraclavicular lymph node radiation technique with clinical outcomes: Results from the EORTC 22922/10925 randomised trial. Radiother Oncol 2022; 172:99-110. [PMID: 35568284 DOI: 10.1016/j.radonc.2022.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/25/2022] [Accepted: 05/08/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE The multicentre EORTC 22922/10925 trial (ClinicalTrials.gov, NCT00002851) was conducted between 1996 and 2004. The trial evaluated the effect of irradiation of the internal mammary and medial supraclavicular lymph node chains (IM-MS) vs no further radiation therapy (RT) on survival and cause of death in breast cancer stage I-III patients. At 15.7 years of median follow-up, a significant reduction of breast cancer specific mortality (BCSM) and any recurrence, not translating in improved overall survival (OS), and low absolute rates of side effects were found. The aim of the current analysis was to evaluate the association of RT techniques of IM-MS lymph node irradiation with long-term outcomes. PATIENTS AND METHODS Three RT techniques were used for IM-MS: a standard technique using a fixed set-up combining photon/electron beams to the IM and tangential fields to the breast or chest wall vs a standard-modified technique with minor adaptation for beam settings vs a more individualised technique based on individual localisation of the IM. Techniques used were fixed per institution over the duration of the trial. We performed an exploratory and descriptive analysis of the outcomes after 15 years follow-up for the three RT techniques. RESULTS Between July 1996 and January 2004, 46 radiation oncology departments from 13 countries accrued 4004 patients. Median follow-up was 15.7 years. The number of patients treated by each technique was 2440 (61%) by standard vs 635 (16%) by standard-modified vs 929 (23%) patients by individualised technique. The absolute improvements of oncological outcomes in terms of disease-free survival (DFS), OS and BCSM with IM-MS RT compared to no IM-MS RT were 6.8%, 4.9% and -5.8% for the individualised technique, vs 1.6%, 2.9% and -4.3% for modified standard and -1.4%, 1.1% and -3% for standard technique, respectively. The increase in 15-year rates of side effects due to IM-MS RT, both scored longitudinally and cross-sectionally, were similar among the techniques. CONCLUSION Even though a straightforward comparison by technique is not possible because of variations in baseline characteristics between institutions, our findings suggest that the use of more individualised RT techniques is associated with higher rates of oncological improvements without increased risks for late side effects.
Collapse
Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Israel; GROW-School for Oncology and Developmental Biology or GROW (Maastro), Maastricht University, The Netherlands.
| | - Catherine Fortpied
- The European Organisation for Research and Treatment of Cancer (EORTC) Headquarters, Brussels, Belgium
| | - Sandra Hol
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, The Netherlands
| | - Caroline Weltens
- Department of Radiation Oncology, University Hospital Leuven, KU Leuven Faculty of Medicine, Belgium
| | - Carine Kirkove
- Department of Radiation Oncology, University Hospital Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Volker Budach
- Department of Radiation Oncology and Radiotherapy, Comprehensive Cancer Center, Charite University Medicine, Berlin, Germany
| | | | - Femke van der Leij
- Department of Radiation Oncology, University Medical Centre Utrecht, The Netherlands
| | - Ernest Vonk
- Institute for Radiation Oncology RISO, Deventer, The Netherlands
| | - Mariacarla Valli
- Department of Radiation Oncology, Sant Anna Hospital, Como, Italy
| | - Nicola Weidner
- Department of Radiation Oncology, University Hospital, Tübingen, Germany
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Switzerland
| | - Eveline Koiter
- Department of Radiation Oncology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Alain Fourquet
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Harry Bartelink
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Henk Struikmans
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
| |
Collapse
|
45
|
Lin H, Dong L, Jimenez RB. Emerging Technologies in Mitigating the Risks of Cardiac Toxicity From Breast Radiotherapy. Semin Radiat Oncol 2022; 32:270-281. [DOI: 10.1016/j.semradonc.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
46
|
Exposure of the heart and cardiac valves in women irradiated for breast cancer 1970-2009. Clin Transl Radiat Oncol 2022; 36:132-139. [PMID: 36034326 PMCID: PMC9399376 DOI: 10.1016/j.ctro.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 07/11/2022] [Accepted: 07/11/2022] [Indexed: 11/22/2022] Open
Abstract
Cardiac exposure decreased substantially 1970–2009. Direct megavoltage IMC beams likely increase the risks of IHD and VHD. Cardiac dosimetry from past regimens is highly heterogeneous. Dosimetry from past decades is key for dose–response relationships for late effects. A wide variation in valve doses may enable a dose–response relationship for VHD.
Purpose To describe cardiac exposure from breast cancer radiotherapy regimens used during 1970–2009 for the development of dose–response relationships and to consider the associated radiation-risks using existing dose–response relationships. Material and methods Radiotherapy charts for 771 women in the Netherlands selected for case control studies of heart disease after breast cancer radiotherapy were used to reconstruct 44 regimens on a typical CT-dataset. Doses were estimated for the whole heart (WH), left ventricle (LV) and cardiac valves. Results For breast/chest wall radiotherapy average WH doses decreased during 1970–2009. For internal mammary chain (IMC) radiotherapy WH doses were highest during the 1980s and 1990s when direct anterior fields were used and reduced in the 2000s when oblique fields were introduced. Average doses varied substantially for IMC regimens (WH 2–33 Gy, LV < 1–23 Gy). For cardiac valves, at least one valve received >30 Gy from most regimens. Conclusions Radiation-risks of IHD from breast/chest wall regimens likely reduced during 1970–2009. Direct anterior IMC regimens likely increased the risks of IHD and VHD over this time period but the use of oblique IMC fields from 2003 may have lowered these risks. These data provide a unique opportunity to develop dose–response relationships.
Collapse
|
47
|
Gue YX, Bisson A, Bodin A, Herbert J, Lip GYH, Fauchier L. Breast cancer and incident cardiovascular events: A systematic analysis at the nationwide level. Eur J Clin Invest 2022; 52:e13754. [PMID: 35113450 PMCID: PMC9285743 DOI: 10.1111/eci.13754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/24/2022] [Accepted: 01/27/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Breast cancer (BC) is one of the most common cancers worldwide, and the treatments are frequently cardiotoxic. Whether BC is associated with a higher risk of cardiovascular events is a matter of debate. We evaluated the associations among BC and incident cardiovascular events in a contemporary population. METHODS All female patients discharged from French hospitals in 2013 with at least 5 years of follow-up and without a history of major adverse cardiovascular event (myocardial infarction [MI], heart failure [HF], ischaemic stroke or all-cause death, and MACE-HF, which includes cardiovascular death, MI, ischaemic stroke or HF) or cancer (except BC) were identified. After propensity score matching, patients with BC were matched 1:1 with patients with no BC. Hazard ratios (HRs) for cardiovascular events during follow-up were adjusted on age, sex and smoking status at baseline. RESULTS 1,795,759 patients were included, among whom 64,480 (4.3%) had history of BC. During a mean follow-up of 5.1 years, matched female patients with BC had a higher risk of all-cause death (HR 3.55, 95% confidence interval [CI]: 3.47-3.64), new-onset HF (HR 1.08, 95% CI 1.04-1.11), major bleeding (HR 1.43, 95% CI 1.36-1.49), MACE-HF (HR 1.07, 95% CI 1.04-1.11) and net adverse clinical events (NACE) including all-cause death, MI, ischaemic stroke, HF or major bleeding (HR 2.53, 95% CI 2.48-2.58) compared with those with no BC. By contrast, risks were not higher for cardiovascular death (HR 0.94, 95% CI 0.88-1.00) and were lower for MI (HR 0.81, 95% CI 0.75-0.88) and ischaemic stroke (HR 0.85, 95% CI 0.79-1.11). CONCLUSIONS In a large and contemporary analysis of female patients seen in French hospitals, women with history of breast cancer had a higher risk of all-cause mortality, new-onset heart failure and major bleeding compared to a matched cohort of women without breast cancer. In contrast, they have a reduced risk of cardiovascular mortality, MI and stroke.
Collapse
Affiliation(s)
- Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Arnaud Bisson
- Service de Cardiologie, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, Tours, France
| | - Alexandre Bodin
- Service de Cardiologie, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, Tours, France
| | - Julien Herbert
- Service de Cardiologie, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, Tours, France.,Service d'information médicale, d'épidémiologie et d'économie de la santé, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, Tours, France
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire et Faculté de Médecine, Université de Tours, Tours, France
| |
Collapse
|
48
|
Ellahham S, Khalouf A, Elkhazendar M, Dababo N, Manla Y. An overview of radiation-induced heart disease. Radiat Oncol J 2022; 40:89-102. [PMID: 35796112 PMCID: PMC9262704 DOI: 10.3857/roj.2021.00766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 11/03/2022] Open
Abstract
Radiation therapy (RT) has dramatically improved cancer survival, leading to several inevitable complications. Unintentional irradiation of the heart can lead to radiation-induced heart disease (RIHD), including cardiomyopathy, pericarditis, coronary artery disease, valvular heart disease, and conduction system abnormalities. Furthermore, the development of RIHD is aggravated with the addition of chemotherapy. The screening, diagnosis, and follow-up for RIHD in patients who have undergone RT are described by the consensus guidelines from the European Association of Cardiovascular Imaging (EACVI) and the American Society of Echocardiography (ASE). There is compelling evidence that chest RT can increase the risk of heart disease. Although the prevalence and severity of RIHD are likely to be reduced with modern RT techniques, the incidence of RIHD is expected to rise in cancer survivors who have been treated with old RT regimens. However, there remains a gap between guidelines and clinical practice. Currently, therapeutic modalities followed in the treatment of RIHD are similar to the non-irradiated population. Preventive measures mainly reduce the radiation dose and radiation volume of the heart. There is no concrete evidence to endorse the preventive role of statins, angiotensin-converting enzyme inhibitors, and antioxidants. This review summarizes the current evidence of RIHD subtypes and risk factors and suggests screening regimens, diagnosis, treatment, and preventive approaches.
Collapse
Affiliation(s)
- Samer Ellahham
- Cleveland Clinic, Lyndhurst, OH, USA
- Heart & Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Amani Khalouf
- Emergency Medicine Institute, Cleveland Clinic Abu Dhabi, UAE
| | - Mohammed Elkhazendar
- Heart & Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
- Pathology & Laboratory Medicine Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Nour Dababo
- Pathology & Laboratory Medicine Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Yosef Manla
- Heart & Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| |
Collapse
|
49
|
Battisti NML, Welch CA, Sweeting M, de Belder M, Deanfield J, Weston C, Peake MD, Adlam D, Ring A. Prevalence of Cardiovascular Disease in Patients With Potentially Curable Malignancies. JACC CardioOncol 2022; 4:238-253. [PMID: 35818547 PMCID: PMC9270631 DOI: 10.1016/j.jaccao.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Although a common challenge for patients and clinicians, there is little population-level evidence on the prevalence of cardiovascular disease (CVD) in individuals diagnosed with potentially curable cancer. Objectives We investigated CVD rates in patients with common potentially curable malignancies and evaluated the associations between patient and disease characteristics and CVD prevalence. Methods The study included cancer registry patients diagnosed in England with stage I to III breast cancer, stage I to III colon or rectal cancer, stage I to III prostate cancer, stage I to IIIA non-small-cell lung cancer, stage I to IV diffuse large B-cell lymphoma, and stage I to IV Hodgkin lymphoma from 2013 to 2018. Linked hospital records and national CVD databases were used to identify CVD. The rates of CVD were investigated according to tumor type, and associations between patient and disease characteristics and CVD prevalence were determined. Results Among the 634,240 patients included, 102,834 (16.2%) had prior CVD. Men, older patients, and those living in deprived areas had higher CVD rates. Prevalence was highest for non-small-cell lung cancer (36.1%) and lowest for breast cancer (7.7%). After adjustment for age, sex, the income domain of the Index of Multiple Deprivation, and Charlson comorbidity index, CVD remained higher in other tumor types compared to breast cancer patients. Conclusions There is a significant overlap between cancer and CVD burden. It is essential to consider CVD when evaluating national and international treatment patterns and cancer outcomes.
Collapse
|
50
|
Carrabba N, Pontone G, Andreini D, Buffa V, Cademartiri F, Carbone I, Clemente A, Guaricci AI, Guglielmo M, Indolfi C, La Grutta L, Ligabue G, Liguori C, Mercuro G, Mushtaq S, Neglia D, Palmisano A, Sciagrà R, Seitun S, Vignale D, Francone M, Esposito A. Appropriateness criteria for the use of cardiac computed tomography, SIC-SIRM part 2: acute chest pain evaluation; stent and coronary artery bypass graft patency evaluation; planning of coronary revascularization and transcatheter valve procedures; cardiomyopathies, electrophysiological applications, cardiac masses, cardio-oncology and pericardial diseases evaluation. J Cardiovasc Med (Hagerstown) 2022; 23:290-303. [PMID: 35486680 DOI: 10.2459/jcm.0000000000001303] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In the past 20 years, cardiac computed tomography (CCT) has become a pivotal technique for the noninvasive diagnostic workup of coronary and cardiac diseases. Continuous technical and methodological improvements, combined with fast growing scientific evidence, have progressively expanded the clinical role of CCT. Randomized clinical trials documented the value of CCT in increasing the cost-effectiveness of the management of patients with acute chest pain presenting in the emergency department, also during the pandemic. Beyond the evaluation of stents and surgical graft patency, the anatomical and functional coronary imaging have the potential to guide treatment decision-making and planning for complex left main and three-vessel coronary disease. Furthermore, there has been an increasing demand to use CCT for preinterventional planning in minimally invasive procedures, such as transcatheter valve implantation and mitral valve repair. Yet, the use of CCT as a roadmap for tailored electrophysiological procedures has gained increasing importance to assure maximum success. In the meantime, innovations and advanced postprocessing tools have generated new potential applications of CCT from the simple coronary anatomy to the complete assessment of structural, functional and pathophysiological biomarkers of cardiac disease. In this complex and revolutionary scenario, it is urgently needed to provide an updated guide for the appropriate use of CCT in different clinical settings. This manuscript, endorsed by the Italian Society of Cardiology (SIC) and the Italian Society of Medical and Interventional Radiology (SIRM), represents the second of two consensus documents collecting the expert opinion of cardiologists and radiologists about current appropriate use of CCT.
Collapse
Affiliation(s)
- Nazario Carrabba
- Department of Cardiothoracovascular Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence
| | | | - Daniele Andreini
- Centro Cardiologico Monzino IRCCS.,Department of Clinical Sciences and Community Health, University of Milan, Milan
| | - Vitaliano Buffa
- Department of Radiology, Azienda Ospedaliera San Camillo Forlanini, Rome
| | | | - Iacopo Carbone
- Department of Radiological, Oncological and Pathological Sciences, 'Sapienza' University of Rome, Rome
| | - Alberto Clemente
- Department of Radiology, CNR (National Council of Research)/Tuscany Region 'Gabriele Monasterio' Foundation (FTGM), Massa
| | - Andrea Igoren Guaricci
- University Cardiology Unit, Cardiothoracic Department, Policlinic University Hospital, Bari
| | | | - Ciro Indolfi
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro
| | - Ludovico La Grutta
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties-ProMISE, University of Palermo
| | - Guido Ligabue
- Department of Medical and Surgical Sciences, Modena and Raggio Emilia University.,Radiology Department, AOU of Modena, Modena
| | - Carlo Liguori
- Radiology Unit, Ospedale del Mare -A.S.L Na1- Centro, Naples
| | - Giuseppe Mercuro
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari
| | | | - Danilo Neglia
- Cardiovascular Department, CNR (National Council of Research)/Tuscany Region 'Gabriele Monasterio' Foundation (FTGM), Pisa
| | - Anna Palmisano
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS Ospedale San Raffaele.,Vita-Salute San Raffaele University, Milan
| | - Roberto Sciagrà
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences 'Mario Serio', University of Florence, Florence
| | - Sara Seitun
- Radiology Department, Ospedale Policlinico San Martino, IRCCS Per L'Oncologia e le Neuroscienze, Genoa, Italy
| | - Davide Vignale
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS Ospedale San Raffaele.,Vita-Salute San Raffaele University, Milan
| | - Marco Francone
- Department of Radiological, Oncological and Pathological Sciences, 'Sapienza' University of Rome, Rome
| | - Antonio Esposito
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS Ospedale San Raffaele.,Vita-Salute San Raffaele University, Milan
| |
Collapse
|