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Polomski EAS, de Graaf MA, Jukema JW, Antoni ML. Plaque Rupture in a Hodgkin Lymphoma Survivor without Cardiovascular Risk Factors 20 Years after Thoracic Radiotherapy: A Case Report. J Cardiovasc Dev Dis 2023; 10:324. [PMID: 37623337 PMCID: PMC10456011 DOI: 10.3390/jcdd10080324] [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: 06/28/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Major improvements in cancer therapies have significantly contributed to increased survival rates of Hodgkin lymphoma (HL) survivors, outweighing cardiovascular side effects and the risks of radiation-induced heart disease. Non-invasive screening for coronary artery disease (CAD) starting five years after irradiation is recommended, as plaque development and morphology may differ in this high-risk population. Due to rapid plaque progression and a possibly higher incidence of non-calcified plaques, coronary artery calcium scoring may not be sufficient as a screening modality in HL survivors treated with thoracic radiotherapy. CASE SUMMARY A 42-year-old man with a history of HL treated with thoracic radiotherapy presented at the emergency department 20 years after cancer treatment with an ST-elevation myocardial infarction, in the absence of cardiovascular risk factors, for which primary percutaneous coronary intervention of the left anterior descending artery was performed. Four months prior to acute myocardial infarction, invasive coronary angiography only showed wall irregularities. Two years earlier, the Agatston calcium score was zero. DISCUSSION In HL survivors treated with thoracic radiotherapy, a calcium score of zero may not give the same warranty period for cardiac event-free survival compared to the general population. Coronary computed tomography angiography can be a proper diagnostic tool to detect CAD at an early stage after mediastinal irradiation, as performing calcium scoring may not be sufficient in this population to detect non-calcified plaques, which may show rapid progression and lead to acute coronary syndrome. Also, intensive lipid-lowering therapy should be considered in the presence of atherosclerosis in this patient population.
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Affiliation(s)
| | | | | | - M. Louisa Antoni
- Department of Cardiology, Heart Lung Center, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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2
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Özkan U, Gürdoğan M. Comparison of Myocardial Perfusion Scintigraphy and Coronary Angiography Results in Breast Cancer Patients Treated with Radiotherapy. Curr Oncol 2023; 30:4575-4585. [PMID: 37232804 PMCID: PMC10217202 DOI: 10.3390/curroncol30050346] [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: 04/04/2023] [Accepted: 04/27/2023] [Indexed: 05/27/2023] Open
Abstract
Breast cancer is the most common type of malignancy in women and radiotherapy (RT) is an important part of treatment. Although it reduces cancer recurrence, it has been shown to cause accerelerated athnerosclerosis. This study aimed to compare the results of myocardial perfusion scintigraphy (MPS) for ischemia investigation with coronary angiography (CAG) findings and to investigate the effect of RT on the development of coronary artery disease in breast cancer patients who underwent RT. The results of 660 patients were analyzed and compared with each other in terms of clinical, demographic, laboratory parameters and MPS results. The mean age was 57.5 years and all of them were female. When the groups were compared, the Gensini score and marking of the left anterior descending artery (LAD) area as ischemic area localization were found more, but angiographically, the rate of severe stenosis in the area indicated by MPS was found to be lower in the RT group (p < 0.001). While the sensitivity of MPS in the RT group was 67.5% and non-RT group was 88.5% (p < 0.001), the result of our study shows that the sensitivity of the MPS test is significantly lower in the patient group receiving RT.
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Affiliation(s)
- Uğur Özkan
- Department of Cardiology, School of Medicine, Trakya University, Edirne 22030, Turkey
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3
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Stowe HB, Andruska ND, Reynoso F, Thomas M, Bergom C. Heart Sparing Radiotherapy Techniques in Breast Cancer: A Focus on Deep Inspiration Breath Hold. BREAST CANCER: TARGETS AND THERAPY 2022; 14:175-186. [PMID: 35899145 PMCID: PMC9309321 DOI: 10.2147/bctt.s282799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 06/04/2022] [Indexed: 11/23/2022]
Abstract
Adjuvant radiation therapy is a critical component of breast cancer management. However, when breast cancer patients receive incidental radiation to the heart, there is an increased risk of cardiac disease and mortality. This is most common for patients with left-sided breast cancers and those receiving nodal irradiation as part of treatment. The overall risk of cardiac toxicity increases 4–16% with each Gray increase in mean heart radiation dose, with data suggesting that no lower limit exists which would eliminate cardiac risk entirely. Radiation techniques have improved over time, leading to lower cardiac radiation exposure than in the past. This decline is expected to reduce the incidence of radiation-induced heart dysfunction in patients. Deep inspiration breath hold (DIBH) is one such technique that was developed to reduce the risk of cardiac death and coronary events. DIBH is a non-invasive approach that capitalizes on the natural physiology of the respiratory cycle to increase the distance between the heart and the therapeutic target throughout the course of radiation therapy. DIBH has been shown to decrease the mean incidental radiation doses to the heart and left anterior descending coronary artery by approximately 20–70%. In this review, we summarize different techniques for DIBH and discuss recent data on this technique.
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Affiliation(s)
- Hayley B Stowe
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Neal D Andruska
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Francisco Reynoso
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Maria Thomas
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Carmen Bergom
- Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Cardio-Oncology Center of Excellence, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Alvin J. Siteman Center, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Correspondence: Carmen Bergom, Department of Radiation Oncology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA, Email
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4
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Polomski EAS, Antoni ML, Jukema JW, Kroep JR, Dibbets-Schneider P, Sattler MGA, de Geus-Oei LF. Nuclear medicine imaging methods of radiation-induced cardiotoxicity. Semin Nucl Med 2022; 52:597-610. [PMID: 35246310 DOI: 10.1053/j.semnuclmed.2022.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/06/2022] [Indexed: 12/21/2022]
Abstract
Breast cancer survival is significantly improved over the past decades due to major improvements in anti-tumor therapies and the implementation of regular screening, which leads to early detection of breast cancer. Therefore, it is of utmost importance to prevent patients from long-term side effects, including radiotherapy-induced cardiotoxicity. Radiotherapy may contribute to damage of myocardial structures on the cellular level, which eventually could result in various types of cardiovascular problems, including coronary artery disease and (non-)ischemic cardiomyopathy, leading to heart failure. These cardiac complications of radiotherapy are preceded by alterations in myocardial perfusion and blood flow. Therefore, early detection of these alterations is important to prevent the progression of these pathophysiological processes. Several radionuclide imaging techniques may contribute to the early detection of these changes. Single-Photon Emission Computed Tomography (SPECT) cameras can be used to create Multigated Acquisition scans in order to assess the left ventricular systolic and diastolic function. Furthermore, SPECT cameras are used for myocardial perfusion imaging with radiopharmaceuticals such as 99mTc-sestamibi and 99mTc-tetrofosmin. Accurate quantitative measurement of myocardial blood flow (MBF), can be performed by Positron Emission Tomography (PET), as the uptake of some of the tracers used for PET-based MBF measurement almost creates a linear relationship with MBF, resulting in very accurate blood flow quantification. Furthermore, there are PET and SPECT tracers that can assess inflammation and denervation of the cardiac sympathetic nervous system. Research over the past decades has mainly focused on the long-term development of left ventricular impairment and perfusion defects. Considering laterality of the breast cancer, some early studies have shown that women irradiated for left-sided breast cancer are more prone to cardiotoxic side effects than women irradiated for right-sided breast cancer. The left-sided radiation field in these trials, which predominantly used older radiotherapy techniques without heart-sparing techniques, included a larger volume of the heart and left ventricle, leading to increased unavoidable radiation exposure to the heart due to the close proximity of the radiation treatment volume. Although radiotherapy for breast cancer exposes the heart to incidental radiation, several improvements and technical developments over the last decades resulted in continuous reduction of radiation dose and volume exposure to the heart. In addition, radiotherapy reduces loco-regional tumor recurrences and death from breast cancer and improves survival. Therefore, in the majority of patients, the benefits of radiotherapy outweigh the potential very low risk of cardiovascular adverse events after radiotherapy. This review addresses existing nuclear imaging techniques, which can be used to evaluate (long-term) effects of radiotherapy-induced mechanical cardiac dysfunction and discusses the potential use of more novel nuclear imaging techniques, which are promising in the assessment of early signs of cardiac dysfunction in selected irradiated breast cancer patients.
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Affiliation(s)
| | - Maria Louisa Antoni
- Department of Cardiology, Heart and Lung Centre, Leiden University Medical Center, Leiden, The Netherlands
| | - Johan Wouter Jukema
- Department of Cardiology, Heart and Lung Centre, Leiden University Medical Center, Leiden, The Netherlands
| | - Judith Rian Kroep
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Petra Dibbets-Schneider
- Department of Radiology, section Nuclear Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Margriet G A Sattler
- Department of Radiotherapy, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Lioe-Fee de Geus-Oei
- Department of Radiology, section Nuclear Medicine, Leiden University Medical Center, Leiden, The Netherlands; Biomedical Photonic Imaging Group, University of Twente, Enschede, The Netherlands
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Sarkar RR, Hatamipour A, Panjwani N, Courtney PT, Cherry DR, Salans MA, Yip AT, Rose BS, Simpson DR, Banegas MP, Murphy JD. Impact of Radiation on Cardiovascular Outcomes in Older Resectable Esophageal Cancer Patients With Medicare. Am J Clin Oncol 2021; 44:275-282. [PMID: 33782335 PMCID: PMC8141011 DOI: 10.1097/coc.0000000000000815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Preoperative radiotherapy improves outcomes for operable esophageal cancer patients, though the proximity of the heart to the esophagus puts patients at risk of radiation-induced cardiovascular disease. This study characterizes the impact of radiotherapy and different radiation techniques on cardiovascular morbidity among a cohort of esophageal cancer patients. MATERIALS AND METHODS We identified 1125 patients aged 65 and older diagnosed between 2000 and 2011 with esophageal cancer who received surgery alone, or surgery preceded by either preoperative chemotherapy or preoperative chemoradiation from the Surveillance Epidemiology and End Results (SEER)-Medicare database. We used Medicare claims to identify severe perioperative and late cardiovascular events. Multivariable logistic regression and Fine-Gray models were used to determine the effect of presurgery treatment on the risk of perioperative and late cardiovascular disease. RESULTS Preoperative chemotherapy or chemoradiation did not significantly increase the risk of perioperative cardiovascular complications compared with surgery alone. Patients treated with preoperative chemoradiation had a 36% increased risk of having a late cardiovascular event compared with patients treated with surgery alone (subdistribution hazard ratio [SDHR]: 1.36; P=0.035). There was no significant increase in late cardiovascular events among patients treated with preoperative chemotherapy (SDHR: 1.18; P=0.40). Among patients treated with preoperative chemoradiation, those receiving intensity modulated radiotherapy had a 68% decreased risk of having a late cardiovascular event compared with patients receiving conventional radiation (SDHR: 0.32; P=0.007). CONCLUSIONS This study demonstrates an increased risk of cardiovascular complications among operative esophageal cancer patients treated with preoperative chemoradiation, though these risks might be reduced with more cardioprotective radiation techniques such as intensity modulated radiotherapy.
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Affiliation(s)
- Reith R Sarkar
- University of California San Diego School of Medicine
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla
| | - Ahmadreza Hatamipour
- University of California San Diego School of Medicine
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla
| | - Neil Panjwani
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - P Travis Courtney
- University of California San Diego School of Medicine
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla
| | - Daniel R Cherry
- University of California San Diego School of Medicine
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla
| | - Mia A Salans
- University of California San Diego School of Medicine
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla
| | - Anthony T Yip
- University of California San Diego School of Medicine
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla
| | - Brent S Rose
- University of California San Diego School of Medicine
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla
| | - Daniel R Simpson
- University of California San Diego School of Medicine
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla
| | - Matthew P Banegas
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - James D Murphy
- University of California San Diego School of Medicine
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla
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de Groot C, Beukema JC, Langendijk JA, van der Laan HP, van Luijk P, van Melle JP, Muijs CT, Prakken NHJ. Radiation-Induced Myocardial Fibrosis in Long-Term Esophageal Cancer Survivors. Int J Radiat Oncol Biol Phys 2021; 110:1013-1021. [PMID: 33577960 DOI: 10.1016/j.ijrobp.2021.02.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 12/09/2020] [Accepted: 02/03/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE Radiation-induced cardiac toxicity is a potential lethal complication. The aim of this study was to assess whether there is a dose-dependent relationship between radiation dose and myocardial fibrosis in patients who received neoadjuvant chemoradiation (nCRT) for esophageal cancer (EC). METHODS AND MATERIALS Forty patients with EC treated with a transthoracic esophagectomy with (n = 20) or without (n = 20) nCRT (CROSS study regimen) were included. Cardiovascular magnetic resonance imaging (1.5 Tesla) for left ventricular (LV) function, late gadolinium enhancement, and T1 mapping were performed. Extracellular volume (ECV), as a surrogate for collagen burden, was measured for all LV segments separately. The dose-response relationship between ECV and mean radiation dose per LV myocardial segment was evaluated using a mixed-model analysis. RESULTS Seventeen nCRT and 16 control patients were suitable for analysis. The mean time after treatment was 67.6 ± 8.1 (nCRT) and 122 ± 35 (controls) months (P = .02). In nCRT patients, we found a significantly higher mean global ECV of 28.2% compared with 24.0% in the controls (P < .001). After nCRT, LV myocardial segments with elevated ECV had received significantly higher radiation doses. In addition, a linear dose-effect relation was found with a 0.136% point increase of ECV for each Gy (P < .001). There were no differences in LV function measures and late gadolinium enhancement between both groups. CONCLUSIONS Myocardial ECV was significantly higher in long-term EC survivors after nCRT compared with surgery only. Moreover, this ECV increase was linear with the radiation dose per LV segment, indicating radiation-induced myocardial fibrosis.
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Affiliation(s)
- Crystal de Groot
- Department of Radiation Oncology, Isala Hospital, Zwolle, Netherlands; Department of Radiation Oncology, University Medical Center, Groningen, Netherlands.
| | - Jannet C Beukema
- Department of Radiation Oncology, University Medical Center, Groningen, Netherlands
| | | | | | - Peter van Luijk
- Department of Radiation Oncology, University Medical Center, Groningen, Netherlands
| | - Joost P van Melle
- Department of Cardialogy, University Medical Center, Groningen, Netherlands
| | - Christina T Muijs
- Department of Radiation Oncology, University Medical Center, Groningen, Netherlands
| | - Niek H J Prakken
- Department of Radiology, University Medical Center, Groningen, Netherlands
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7
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Burrage MK, Ferreira VM. The use of cardiovascular magnetic resonance as an early non-invasive biomarker for cardiotoxicity in cardio-oncology. Cardiovasc Diagn Ther 2020; 10:610-624. [PMID: 32695641 DOI: 10.21037/cdt-20-165] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Contemporary cancer therapy has resulted in significant survival gains for patients. However, many current and emerging cancer therapies have an associated risk of cardiotoxicity, either acutely or later in life. Regular cardiac screening and surveillance is recommended for patients undergoing treatment for cancer, with emphasis on the early detection of cardiotoxicity before irreversible complications develop. Cardiovascular magnetic resonance imaging is able to accurately assess cardiac structure, function, and perform advanced myocardial tissue characterisation, including perfusion, features which may facilitate the diagnosis and management of cardiotoxicity in cancer survivors. This review outlines the current standards for the diagnosis and screening of cardiotoxicity, with particular focus on current and future applications of cardiovascular magnetic resonance imaging.
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Affiliation(s)
- Matthew K Burrage
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Vanessa M Ferreira
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
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8
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Skyttä T, Tuohinen S, Luukkaala T, Virtanen V, Raatikainen P, Kellokumpu-Lehtinen PL. Adjuvant radiotherapy-induced cardiac changes among patients with early breast cancer: a three-year follow-up study . Acta Oncol 2019; 58:1250-1258. [PMID: 31219359 DOI: 10.1080/0284186x.2019.1630751] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: In this study, we evaluate the evolution of cardiac changes during a three-year follow-up after adjuvant breast radiotherapy (RT). Methods: Sixty patients with left-sided and 20 patients with right-sided early stage breast cancer without chemotherapy were included in this prospective study. Echocardiography and cardiac biomarkers were evaluated before, immediately after and 3 years after RT. Radiation doses to cardiac structures were calculated. Results: In echocardiography, left ventricle (LV) systolic measurements had impaired at 3 years compared to baseline: the mean global longitudinal strain (GLS) worsened from -18 ± 3 to -17 ± 3 (p = .015), LV ejection fraction from 62 ± 5% to 60 ± 4% (p = .003) and the stroke volume from 73 ± 16 mL to 69 ± 15 mL (p = .015). LV diastolic function was also negatively affected: the isovolumetric relaxation time was prolonged (p = .006) and the first peak of diastole decreased (p = .022). Likewise, left atrial (LA) measurements impaired. These changes in echocardiography were more prominent in left-sided than in right-sided patients. The concurrent aromatase inhibitor (AI) use was associated with GLS impairment. In all patients, the N-terminal pro-brain natriuretic peptide (proBNP) values were median (interquartile range) 74 (41-125) ng/L at baseline, 75 (41-125) ng/L at the end of RT and 96 (56-162) ng/L at 3 years (p < .001 from baseline to 3 years). However, proBNP did not increase in right-sided patients. Conclusion: During the 3-year follow-up after RT, negative subclinical changes in cardiac biomarkers and in LV systolic and diastolic function were observed. The measured changes were more pronounced in left-sided patients. In addition, AI use was associated with impaired cardiac systolic function.
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Affiliation(s)
- Tanja Skyttä
- Department of Oncology, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Suvi Tuohinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Heart Center, Tampere University Hospital, Tampere, Finland
- Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Tiina Luukkaala
- Research Innovation and Development Center, Tampere University Hospital and Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Vesa Virtanen
- Heart Center, Tampere University Hospital, Tampere, Finland
| | - Pekka Raatikainen
- Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Pirkko-Liisa Kellokumpu-Lehtinen
- Department of Oncology, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Radiation-induced myocardial damage indicated by focal defect on 123I-MIBG SPECT. Eur J Nucl Med Mol Imaging 2019; 46:2404-2405. [PMID: 31309257 DOI: 10.1007/s00259-019-04416-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 06/25/2019] [Indexed: 10/26/2022]
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10
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Xu Y, Wang J, Hu Z, Tian Y, Ma P, Li S, Dai J, Wang S. Locoregional irradiation including internal mammary nodal region for left-sided breast cancer after breast conserving surgery: Dosimetric evaluation of 4 techniques. Med Dosim 2019; 44:e13-e18. [DOI: 10.1016/j.meddos.2018.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 08/30/2018] [Accepted: 09/24/2018] [Indexed: 12/18/2022]
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Tang S, Otton J, Holloway L, Delaney GP, Liney G, George A, Jameson M, Tran D, Batumalai V, Thomas L, Koh ES. Quantification of cardiac subvolume dosimetry using a 17 segment model of the left ventricle in breast cancer patients receiving tangential beam radiotherapy. Radiother Oncol 2018; 132:257-265. [PMID: 30446318 DOI: 10.1016/j.radonc.2018.09.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 09/23/2018] [Accepted: 09/27/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE Subacute changes following breast radiotherapy have been demonstrated in discrete areas of the left ventricle (LV), with recent guidelines being developed to help determine dose to subvolumes of the LV. This study aims to determine doses to the 17 segments of the LV as per the American Heart Association (AHA) and other cardiac subvolumes, and to correlate mean heart (MHD) dose with various subvolume dosimetric indices. These results may direct focus to specific left ventricular segments in studies of radiation-related heart disease incorporating surveillance imaging, help to determine more precise dose response relationships, and potentially aid prediction of late radiation effects. METHODS AND MATERIALS The heart and cardiac subvolumes of 29 patients treated with tangential radiotherapy for left breast cancer were contoured. Delineation of cardiac subvolumes (cardiac chambers, cardiac valves and the 17 segments of the LV) was undertaken using a novel contouring method on planning CT data reformatted into the cardiac axis. Individual segments were then combined to determine doses to the basal, mid and apical left ventricular regions, and the anterior, septal, inferior and lateral ventricular walls. Radiotherapy doses (including maximum, mean, D1cc, V25) were determined. Correlation analyses were performed between MHD and various substructure dosimetric indices. RESULTS Twenty five patients received tangential breast free breathing radiotherapy alone, and four patients received regional nodal irradiation including the internal mammary chain with deep inspiration breath hold (DIBH). For patients receiving breast only radiation, the median mean heart radiation dose was 2.62 Gy (range 1.52-3.90 Gy), and a heterogeneous dose distribution to the LV was noted, with the apical region receiving the highest median mean dose (14.99 Gy) compared with the mid and basal regions (3.10 Gy and 1.51 Gy respectively). The anterior LV wall received the highest median mean dose (9.21 Gy) with the remaining walls receiving similar mean doses (range 1.79-3.05 Gy). The anterior LV apical segment (segment 13) and apex (segment 17) received the highest individual median mean segment doses (26.73 Gy and 30.02 Gy respectively). Apical segments received the highest median mean doses (segments 13, 14, 15, 16), followed by the mid anterior (segment 7) and anteroseptal (segment 8) segments. Segments receiving the highest doses remained unchanged between the DIBH cohort and free breathing cohort. MHD showed a high correlation with the anterior wall r = 0.71, p < 0.05 and entire left ventricle r = 0.82, p < 0.05, but correlations varied from weak to high when MHD was correlated with segments receiving highest doses (range r = 0.43-0.76), p < 0.05. CONCLUSIONS In the setting of breast cancer radiotherapy, there are substantial RT dose variations within specific LV segments, with mid and apical anterior ventricular segments (segments 7, 13) and the apical region of the LV (segments 13, 14, 15, 16, 17) being consistently exposed to the highest radiation doses. Determining segmental and regional RT doses to the left ventricle may help guide focus in diagnostic cardiology in the post radiotherapy setting.
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Affiliation(s)
- Simon Tang
- Ingham Institute of Applied Medical Research, Liverpool Hospital, Australia; University of New South Wales, Australia; Cancer Therapy Centre, Liverpool Hospital, Australia.
| | - James Otton
- University of New South Wales, Australia; Department of Cardiology, Liverpool Hospital, Australia
| | - Lois Holloway
- Ingham Institute of Applied Medical Research, Liverpool Hospital, Australia; University of New South Wales, Australia; Cancer Therapy Centre, Liverpool Hospital, Australia; University of Sydney, Australia
| | - Geoffrey P Delaney
- Ingham Institute of Applied Medical Research, Liverpool Hospital, Australia; University of New South Wales, Australia; Cancer Therapy Centre, Liverpool Hospital, Australia
| | - Gary Liney
- Ingham Institute of Applied Medical Research, Liverpool Hospital, Australia; University of New South Wales, Australia; Cancer Therapy Centre, Liverpool Hospital, Australia
| | - Armia George
- Cancer Therapy Centre, Liverpool Hospital, Australia
| | - Michael Jameson
- Ingham Institute of Applied Medical Research, Liverpool Hospital, Australia; University of New South Wales, Australia; Cancer Therapy Centre, Liverpool Hospital, Australia
| | | | - Vikneswary Batumalai
- Ingham Institute of Applied Medical Research, Liverpool Hospital, Australia; Cancer Therapy Centre, Liverpool Hospital, Australia
| | - Liza Thomas
- University of New South Wales, Australia; University of Sydney, Australia; Department of Cardiology, Westmead Hospital, Australia
| | - Eng-Siew Koh
- Ingham Institute of Applied Medical Research, Liverpool Hospital, Australia; University of New South Wales, Australia; Cancer Therapy Centre, Liverpool Hospital, Australia
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12
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Yegya-Raman N, Wang K, Kim S, Reyhan M, Deek MP, Sayan M, Li D, Patel M, Malhotra J, Aisner J, Marks LB, Jabbour SK. Dosimetric Predictors of Symptomatic Cardiac Events After Conventional-Dose Chemoradiation Therapy for Inoperable NSCLC. J Thorac Oncol 2018; 13:1508-1518. [PMID: 29883836 PMCID: PMC10905612 DOI: 10.1016/j.jtho.2018.05.028] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/23/2018] [Accepted: 05/25/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION We hypothesized that higher cardiac doses correlates with clinically significant cardiotoxicity after standard-dose chemoradiation therapy (CRT) (∼60 Gy) for inoperable NSCLC. METHODS We retrospectively reviewed the records of 140 patients with inoperable NSCLC treated with concurrent CRT from 2007 to 2015. Extracted data included baseline cardiac status, dosimetric parameters to the whole heart (WH) and cardiac substructures, and the development of post-CRT symptomatic cardiac events (acute coronary syndrome [ACS], arrhythmia, pericardial effusion, pericarditis, and congestive heart failure [CHF]). Competing risks analysis was used to estimate time to cardiac events. RESULTS Median follow-up was 47.4 months. Median radiation therapy dose was 61.2 Gy (interquartile range, 60 to 66 Gy). Forty patients (28.6%) developed 47 symptomatic cardiac events at a median of 15.3 months to first event. On multivariate analysis, higher WH doses and baseline cardiac status were associated with an increased risk of symptomatic cardiac events. The 4-year cumulative incidence of symptomatic cardiac events was 48.6% versus 18.5% for mean WH dose ≥ 20 Gy versus < 20 Gy, respectively (p = 0.0002). Doses to the WH, ventricles, and left anterior descending artery were associated with ACS/CHF, whereas doses to the WH and atria were not associated with supraventricular arrhythmias. Symptomatic cardiac events (p = 0.0001) were independently associated with death. CONCLUSIONS Incidental cardiac irradiation was associated with subsequent symptomatic cardiac events, particularly ACS/CHF, and symptomatic cardiac events were associated with inferior survival. These results support the minimization of cardiac doses among patients with inoperable NSCLC receiving standard-dose CRT.
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Affiliation(s)
- Nikhil Yegya-Raman
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Kyle Wang
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Sinae Kim
- Department of Biostatistics, School of Public Health, Rutgers University, Piscataway, New Jersey; Biometrics Division, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Meral Reyhan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Matthew P Deek
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey; Department of Radiation Oncology & Molecular Radiation Sciences, the Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mutlay Sayan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Diana Li
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Malini Patel
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Jyoti Malhotra
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Joseph Aisner
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey.
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Donis N, Oury C, Moonen M, Lancellotti P. Treating cardiovascular complications of radiotherapy: a role for new pharmacotherapies. Expert Opin Pharmacother 2018; 19:431-442. [DOI: 10.1080/14656566.2018.1446080] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Nathalie Donis
- Laboratory of Thrombosis, Haemostasis and Valvular Heart Diseases, GIGA-Cardiovascular Sciences, Department of Cardiology, University of Liège, CHU Liège, Liège, Belgium
| | - Cécile Oury
- Laboratory of Thrombosis, Haemostasis and Valvular Heart Diseases, GIGA-Cardiovascular Sciences, Department of Cardiology, University of Liège, CHU Liège, Liège, Belgium
| | - Marie Moonen
- Laboratory of Thrombosis, Haemostasis and Valvular Heart Diseases, GIGA-Cardiovascular Sciences, Department of Cardiology, University of Liège, CHU Liège, Liège, Belgium
| | - Patrizio Lancellotti
- Laboratory of Thrombosis, Haemostasis and Valvular Heart Diseases, GIGA-Cardiovascular Sciences, Department of Cardiology, University of Liège, CHU Liège, Liège, Belgium
- Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
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Gallucci G, Capobianco AM, Coccaro M, Venetucci A, Suriano V, Fusco V. Myocardial Perfusion Defects after Radiation Therapy and Anthracycline Chemotherapy for Left Breast Cancer: A Possible Marker of Microvascular Damage. Three Cases and Review of the Literature. TUMORI JOURNAL 2018; 94:129-33. [DOI: 10.1177/030089160809400124] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Radiation therapy to the thorax may induce early and late cardiac adverse effects if large parts of the heart have been included in the irradiation field and particularly if anthracycline-containing chemotherapy is concomitantly administered. We describe 3 cases of cardiotoxicity in patients with left breast cancer treated with anthracycline-containing chemotherapy and left thoracic radiotherapy. In 2 cases we observed asymptomatic electrocardiographic abnormalities of ventricular repolarization mimicking anterior myocardial ischemia and SPECT reversible myocardial perfusion defects. In 1 case we observed echocardiographic abnormalities of left ventricular wall motion and reversible myocardial perfusion abnormalities. We recommend close cardiac monitoring of patients treated with anthracycline chemotherapy and left thoracic radiotherapy to better understand the clinical impact of these abnormalities.
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Affiliation(s)
- Giuseppina Gallucci
- Cardiology Unit, CROB Regional Cancer Hospital, Rionero in Vulture (Potenza), Italy
| | | | - Mariarosa Coccaro
- Oncology Unit, CROB Regional Cancer Hospital, Rionero in Vulture (Potenza), Italy
| | - Angela Venetucci
- Nuclear Medicine Unit, CROB Regional Cancer Hospital, Rionero in Vulture (Potenza), Italy
| | - Vincenzo Suriano
- Nuclear Medicine Unit, CROB Regional Cancer Hospital, Rionero in Vulture (Potenza), Italy
| | - Vincenzo Fusco
- Radiotherapy Unit, CROB Regional Cancer Hospital, Rionero in Vulture (Potenza), Italy
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Are heart toxicities in breast cancer patients important for radiation oncologists? A practice pattern survey in German speaking countries. BMC Cancer 2017; 17:563. [PMID: 28835224 PMCID: PMC5569472 DOI: 10.1186/s12885-017-3548-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 08/14/2017] [Indexed: 12/25/2022] Open
Abstract
Background To assess the personal beliefs of radiation oncologists regarding heart sparing techniques in breast cancer patients. Methods Between August 2015 and September 2015, a survey was sent to radiation oncology departments in Germany, Austria and Switzerland. 82 radiation oncology departments answered the questionnaire: 16 university clinics and 66 other departments. Most (87.2%) of the participants had >10 years of radiation oncology experience. Results 89.2% of the participants felt that there is enough evidence to support heart sparing for breast cancer patients. The most important dose parameter was considered the mean heart dose (69.1%). The personal “safe” dose to the heart was considered to be 5 Gy (range: 0–40 Gy). The main impediment in offering all breast cancer patients heart-sparing techniques seems to be the fact that these techniques are time/ resource consuming (46.5% of the participants). Conclusions Most radiation oncologists believe that there is enough evidence to support heart sparing for breast cancer patients. But translating this belief into a wide practice will need better dosimetric and clinical data on what patients are expected to profit most, specific guidelines for which patients’ heart sparing techniques should be performed, as well as recognition of the time/resource consumption of these techniques.
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Slezak J, Kura B, Babal P, Barancik M, Ferko M, Frimmel K, Kalocayova B, Kukreja RC, Lazou A, Mezesova L, Okruhlicova L, Ravingerova T, Singal PK, Szeiffova Bacova B, Viczenczova C, Vrbjar N, Tribulova N. Potential markers and metabolic processes involved in the mechanism of radiation-induced heart injury. Can J Physiol Pharmacol 2017; 95:1190-1203. [PMID: 28750189 DOI: 10.1139/cjpp-2017-0121] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Irradiation of normal tissues leads to acute increase in reactive oxygen/nitrogen species that serve as intra- and inter-cellular signaling to alter cell and tissue function. In the case of chest irradiation, it can affect the heart, blood vessels, and lungs, with consequent tissue remodelation and adverse side effects and symptoms. This complex process is orchestrated by a large number of interacting molecular signals, including cytokines, chemokines, and growth factors. Inflammation, endothelial cell dysfunction, thrombogenesis, organ dysfunction, and ultimate failing of the heart occur as a pathological entity - "radiation-induced heart disease" (RIHD) that is major source of morbidity and mortality. The purpose of this review is to bring insights into the basic mechanisms of RIHD that may lead to the identification of targets for intervention in the radiotherapy side effect. Studies of authors also provide knowledge about how to select targeted drugs or biological molecules to modify the progression of radiation damage in the heart. New prospective studies are needed to validate that assessed factors and changes are useful as early markers of cardiac damage.
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Affiliation(s)
- Jan Slezak
- a Institute for Heart Research, Slovak Academy of Sciences, 840 05 Bratislava, Slovakia
| | - Branislav Kura
- a Institute for Heart Research, Slovak Academy of Sciences, 840 05 Bratislava, Slovakia
| | - Pavel Babal
- b Institute of Pathology, Medical Faculty of Comenius University, Bratislava, Slovakia
| | - Miroslav Barancik
- a Institute for Heart Research, Slovak Academy of Sciences, 840 05 Bratislava, Slovakia
| | - Miroslav Ferko
- a Institute for Heart Research, Slovak Academy of Sciences, 840 05 Bratislava, Slovakia
| | - Karel Frimmel
- a Institute for Heart Research, Slovak Academy of Sciences, 840 05 Bratislava, Slovakia
| | - Barbora Kalocayova
- a Institute for Heart Research, Slovak Academy of Sciences, 840 05 Bratislava, Slovakia
| | - Rakesh C Kukreja
- c Division of Cardiology, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA, USA
| | - Antigone Lazou
- d School of Biology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lucia Mezesova
- a Institute for Heart Research, Slovak Academy of Sciences, 840 05 Bratislava, Slovakia
| | - Ludmila Okruhlicova
- a Institute for Heart Research, Slovak Academy of Sciences, 840 05 Bratislava, Slovakia
| | - Tanya Ravingerova
- a Institute for Heart Research, Slovak Academy of Sciences, 840 05 Bratislava, Slovakia
| | - Pawan K Singal
- e University of Manitoba, St. Boniface Research Centre, Winnipeg, MB R2H 2A6, Canada
| | | | - Csilla Viczenczova
- a Institute for Heart Research, Slovak Academy of Sciences, 840 05 Bratislava, Slovakia
| | - Norbert Vrbjar
- a Institute for Heart Research, Slovak Academy of Sciences, 840 05 Bratislava, Slovakia
| | - Narcis Tribulova
- a Institute for Heart Research, Slovak Academy of Sciences, 840 05 Bratislava, Slovakia
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17
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Early cardiac perfusion defects after left-sided radiation therapy for breast cancer: is there a volume response? Breast Cancer Res Treat 2017; 164:253-262. [DOI: 10.1007/s10549-017-4248-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 04/12/2017] [Indexed: 02/04/2023]
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18
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Zagar TM, Kaidar-Person O, Tang X, Jones EE, Matney J, Das SK, Green RL, Sheikh A, Khandani AH, McCartney WH, Oldan JD, Wong TZ, Marks LB. Utility of Deep Inspiration Breath Hold for Left-Sided Breast Radiation Therapy in Preventing Early Cardiac Perfusion Defects: A Prospective Study. Int J Radiat Oncol Biol Phys 2017; 97:903-909. [DOI: 10.1016/j.ijrobp.2016.12.017] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 11/14/2016] [Accepted: 12/08/2016] [Indexed: 12/16/2022]
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19
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Wang K, Eblan MJ, Deal AM, Lipner M, Zagar TM, Wang Y, Mavroidis P, Lee CB, Jensen BC, Rosenman JG, Socinski MA, Stinchcombe TE, Marks LB. Cardiac Toxicity After Radiotherapy for Stage III Non-Small-Cell Lung Cancer: Pooled Analysis of Dose-Escalation Trials Delivering 70 to 90 Gy. J Clin Oncol 2017; 35:1387-1394. [PMID: 28113017 DOI: 10.1200/jco.2016.70.0229] [Citation(s) in RCA: 281] [Impact Index Per Article: 40.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose The significance of radiotherapy (RT) -associated cardiac injury for stage III non-small-cell lung cancer (NSCLC) is unclear, but higher heart doses were associated with worse overall survival in the Radiation Therapy Oncology Group (RTOG) 0617 study. We assessed the impact of heart dose in patients treated at our institution on several prospective dose-escalation trials. Patients and Methods From 1996 to 2009, 127 patients with stage III NSCLC (Eastern Cooperative Oncology Group performance status, 0 to 1) received dose-escalated RT to 70 to 90 Gy (median, 74 Gy) in six trials. RT plans and cardiac doses were reviewed. Records were reviewed for the primary end point: symptomatic cardiac events (symptomatic pericardial effusion, acute coronary syndrome, pericarditis, significant arrhythmia, and heart failure). Cardiac risk was assessed by noting baseline coronary artery disease and calculating the WHO/International Society of Hypertension score. Competing risks analysis was used. Results In all, 112 patients were analyzed. Median follow-up for surviving patients was 8.8 years. Twenty-six patients (23%) had one or more events at a median of 26 months to first event (effusion [n = 7], myocardial infarction [n = 5], unstable angina [n = 3], pericarditis [n = 2], arrhythmia [n = 12], and heart failure [n = 1]). Heart doses (eg, heart mean dose; hazard ratio, 1.03/Gy; P = .002,), coronary artery disease ( P < .001), and WHO/International Society of Hypertension score ( P = .04) were associated with events on univariable analysis. Heart doses remained significant on multivariable analysis that accounted for baseline risk. Two-year competing risk-adjusted event rates for patients with heart mean dose < 10 Gy, 10 to 20 Gy, or ≥ 20 Gy were 4%, 7%, and 21%, respectively. Heart doses were not associated with overall survival. Conclusion Cardiac events were relatively common after high-dose thoracic RT and were independently associated with both heart dose and baseline cardiac risk. RT-associated cardiac toxicity after treatment of stage III NSCLC may occur earlier than historically understood, and heart doses should be minimized.
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Affiliation(s)
- Kyle Wang
- Kyle Wang, Michael J. Eblan, Matthew Lipner, Timothy M. Zagar, Panayiotis Mavroidis, Carrie B. Lee, Brian C. Jensen, Julian G. Rosenman, and Lawrence B. Marks, University of North Carolina Hospitals; Allison M. Deal and Yue Wang, Lineberger Comprehensive Cancer Center Biostatistics Core, University of North Carolina Hospitals, Chapel Hill; Thomas E. Stinchcombe, Duke University Hospitals, Durham, NC; and Mark A. Socinski, Florida Hospital Cancer Institute, Orlando, FL
| | - Michael J Eblan
- Kyle Wang, Michael J. Eblan, Matthew Lipner, Timothy M. Zagar, Panayiotis Mavroidis, Carrie B. Lee, Brian C. Jensen, Julian G. Rosenman, and Lawrence B. Marks, University of North Carolina Hospitals; Allison M. Deal and Yue Wang, Lineberger Comprehensive Cancer Center Biostatistics Core, University of North Carolina Hospitals, Chapel Hill; Thomas E. Stinchcombe, Duke University Hospitals, Durham, NC; and Mark A. Socinski, Florida Hospital Cancer Institute, Orlando, FL
| | - Allison M Deal
- Kyle Wang, Michael J. Eblan, Matthew Lipner, Timothy M. Zagar, Panayiotis Mavroidis, Carrie B. Lee, Brian C. Jensen, Julian G. Rosenman, and Lawrence B. Marks, University of North Carolina Hospitals; Allison M. Deal and Yue Wang, Lineberger Comprehensive Cancer Center Biostatistics Core, University of North Carolina Hospitals, Chapel Hill; Thomas E. Stinchcombe, Duke University Hospitals, Durham, NC; and Mark A. Socinski, Florida Hospital Cancer Institute, Orlando, FL
| | - Matthew Lipner
- Kyle Wang, Michael J. Eblan, Matthew Lipner, Timothy M. Zagar, Panayiotis Mavroidis, Carrie B. Lee, Brian C. Jensen, Julian G. Rosenman, and Lawrence B. Marks, University of North Carolina Hospitals; Allison M. Deal and Yue Wang, Lineberger Comprehensive Cancer Center Biostatistics Core, University of North Carolina Hospitals, Chapel Hill; Thomas E. Stinchcombe, Duke University Hospitals, Durham, NC; and Mark A. Socinski, Florida Hospital Cancer Institute, Orlando, FL
| | - Timothy M Zagar
- Kyle Wang, Michael J. Eblan, Matthew Lipner, Timothy M. Zagar, Panayiotis Mavroidis, Carrie B. Lee, Brian C. Jensen, Julian G. Rosenman, and Lawrence B. Marks, University of North Carolina Hospitals; Allison M. Deal and Yue Wang, Lineberger Comprehensive Cancer Center Biostatistics Core, University of North Carolina Hospitals, Chapel Hill; Thomas E. Stinchcombe, Duke University Hospitals, Durham, NC; and Mark A. Socinski, Florida Hospital Cancer Institute, Orlando, FL
| | - Yue Wang
- Kyle Wang, Michael J. Eblan, Matthew Lipner, Timothy M. Zagar, Panayiotis Mavroidis, Carrie B. Lee, Brian C. Jensen, Julian G. Rosenman, and Lawrence B. Marks, University of North Carolina Hospitals; Allison M. Deal and Yue Wang, Lineberger Comprehensive Cancer Center Biostatistics Core, University of North Carolina Hospitals, Chapel Hill; Thomas E. Stinchcombe, Duke University Hospitals, Durham, NC; and Mark A. Socinski, Florida Hospital Cancer Institute, Orlando, FL
| | - Panayiotis Mavroidis
- Kyle Wang, Michael J. Eblan, Matthew Lipner, Timothy M. Zagar, Panayiotis Mavroidis, Carrie B. Lee, Brian C. Jensen, Julian G. Rosenman, and Lawrence B. Marks, University of North Carolina Hospitals; Allison M. Deal and Yue Wang, Lineberger Comprehensive Cancer Center Biostatistics Core, University of North Carolina Hospitals, Chapel Hill; Thomas E. Stinchcombe, Duke University Hospitals, Durham, NC; and Mark A. Socinski, Florida Hospital Cancer Institute, Orlando, FL
| | - Carrie B Lee
- Kyle Wang, Michael J. Eblan, Matthew Lipner, Timothy M. Zagar, Panayiotis Mavroidis, Carrie B. Lee, Brian C. Jensen, Julian G. Rosenman, and Lawrence B. Marks, University of North Carolina Hospitals; Allison M. Deal and Yue Wang, Lineberger Comprehensive Cancer Center Biostatistics Core, University of North Carolina Hospitals, Chapel Hill; Thomas E. Stinchcombe, Duke University Hospitals, Durham, NC; and Mark A. Socinski, Florida Hospital Cancer Institute, Orlando, FL
| | - Brian C Jensen
- Kyle Wang, Michael J. Eblan, Matthew Lipner, Timothy M. Zagar, Panayiotis Mavroidis, Carrie B. Lee, Brian C. Jensen, Julian G. Rosenman, and Lawrence B. Marks, University of North Carolina Hospitals; Allison M. Deal and Yue Wang, Lineberger Comprehensive Cancer Center Biostatistics Core, University of North Carolina Hospitals, Chapel Hill; Thomas E. Stinchcombe, Duke University Hospitals, Durham, NC; and Mark A. Socinski, Florida Hospital Cancer Institute, Orlando, FL
| | - Julian G Rosenman
- Kyle Wang, Michael J. Eblan, Matthew Lipner, Timothy M. Zagar, Panayiotis Mavroidis, Carrie B. Lee, Brian C. Jensen, Julian G. Rosenman, and Lawrence B. Marks, University of North Carolina Hospitals; Allison M. Deal and Yue Wang, Lineberger Comprehensive Cancer Center Biostatistics Core, University of North Carolina Hospitals, Chapel Hill; Thomas E. Stinchcombe, Duke University Hospitals, Durham, NC; and Mark A. Socinski, Florida Hospital Cancer Institute, Orlando, FL
| | - Mark A Socinski
- Kyle Wang, Michael J. Eblan, Matthew Lipner, Timothy M. Zagar, Panayiotis Mavroidis, Carrie B. Lee, Brian C. Jensen, Julian G. Rosenman, and Lawrence B. Marks, University of North Carolina Hospitals; Allison M. Deal and Yue Wang, Lineberger Comprehensive Cancer Center Biostatistics Core, University of North Carolina Hospitals, Chapel Hill; Thomas E. Stinchcombe, Duke University Hospitals, Durham, NC; and Mark A. Socinski, Florida Hospital Cancer Institute, Orlando, FL
| | - Thomas E Stinchcombe
- Kyle Wang, Michael J. Eblan, Matthew Lipner, Timothy M. Zagar, Panayiotis Mavroidis, Carrie B. Lee, Brian C. Jensen, Julian G. Rosenman, and Lawrence B. Marks, University of North Carolina Hospitals; Allison M. Deal and Yue Wang, Lineberger Comprehensive Cancer Center Biostatistics Core, University of North Carolina Hospitals, Chapel Hill; Thomas E. Stinchcombe, Duke University Hospitals, Durham, NC; and Mark A. Socinski, Florida Hospital Cancer Institute, Orlando, FL
| | - Lawrence B Marks
- Kyle Wang, Michael J. Eblan, Matthew Lipner, Timothy M. Zagar, Panayiotis Mavroidis, Carrie B. Lee, Brian C. Jensen, Julian G. Rosenman, and Lawrence B. Marks, University of North Carolina Hospitals; Allison M. Deal and Yue Wang, Lineberger Comprehensive Cancer Center Biostatistics Core, University of North Carolina Hospitals, Chapel Hill; Thomas E. Stinchcombe, Duke University Hospitals, Durham, NC; and Mark A. Socinski, Florida Hospital Cancer Institute, Orlando, FL
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20
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Marks LB, Zagar TM, Kaidar-Person O. Reassessing the Time Course for Radiation-Induced Cardiac Mortality in Patients With Breast Cancer. Int J Radiat Oncol Biol Phys 2016; 97:303-305. [PMID: 28068237 DOI: 10.1016/j.ijrobp.2016.10.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 10/17/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina.
| | - Timothy M Zagar
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Orit Kaidar-Person
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
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21
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Abstract
Breast cancer treatments have evolved over the past decades, although several widely used treatments have adverse cardiac effects. Radiotherapy generally improves the survival of women with breast cancer, although its deleterious cardiovascular effects pose competing risks of morbidity and/or mortality. In the past, radiation-associated cardiovascular disease was a phenomenon considered to take more than a decade to manifest, but newer research suggests that this latency is much shorter. Knowledge of coronary anatomy relative to the distribution of the delivered radiation dose has improved over time, and as a result, techniques have enabled this risk to be decreased. Studies continue to be performed to better understand, prevent and mitigate against radiation-associated cardiovascular disease. Treatments such as anthracyclines, which are a mainstay of chemotherapy for breast cancer, and newer targeted agents such as trastuzumab both have established risks of cardiotoxicity, which can limit their effectiveness and result in increased morbidity and/or mortality. Interest in whether β-blockers, statins and/or angiotensin-converting enzyme (ACE)-inhibitors might have therapeutic and/or preventative effects in these patients is currently increasing. This Review summarizes the incidence, risks and effects of treatment-induced cardiovascular disease in patients with breast cancer and describes strategies that might be used to minimize this risk.
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22
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Benveniste MF, Gomez D, Carter BW, Betancourt Cuellar SL, De Groot PM, Marom EM. Radiation Effects in the Mediastinum and Surroundings: Imaging Findings and Complications. Semin Ultrasound CT MR 2015; 37:268-80. [PMID: 27261350 DOI: 10.1053/j.sult.2015.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Radiotherapy is one of the cornerstones for treatment of patients with cancer. Although advances in radiotherapy technology have considerably improved radiation delivery, potential adverse effects are still common. Postradiation changes to the mediastinum can include different structures such as the heart, great vessels, and esophagus. The purpose of the article was to illustrate the expected variety of changes to the mediastinum and adjacent lung resulting from external beam radiotherapy and radiotherapy-induced complications to the mediastinum and to discuss different radiotherapy delivery techniques.
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Affiliation(s)
- Marcelo F Benveniste
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Daniel Gomez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brett W Carter
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Patricia M De Groot
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Edith M Marom
- Department of Diagnostic Radiology, The Chaim Sheba Medical Center, Tel Hashomer, Israel
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Abstract
Long-term cardiac effects are an important component of survivorship after breast radiotherapy. The pathophysiology of cardiotoxicity, history of breast radiotherapy, current methods of cardiac avoidance, modern outcomes, context of historical outcomes, quantifying cardiac effects, and future directions are reviewed in this article. Radiation-induced oxidative stress induces proinflammatory cytokines and is a process that potentiates late effects of fibrosis and intimal proliferation in endothelial vasculature. Breast radiation therapy has changed substantially in recent decades. Several modern technologies exist to improve cardiac avoidance such as deep inspiration breath hold, gating, accelerated partial breast irradiation, and use of modern 3-dimensional planning. Modern outcomes may vary notably from historical long-term cardiac outcomes given the differences in cardiac dose with modern techniques. Methods of quantifying radiation-related cardiotoxicity that correlate with future cardiac risks are needed with current data exploring techniques such as measuring computed tomography coronary artery calcium score, single-photon emission computed tomography imaging, and biomarkers. Placing historical data, dosimetric correlations, and relative cardiac risk in context are key when weighing the benefits of radiotherapy in breast cancer control and survival. Estimating present day cardiac risk in the modern treatment era includes challenges in length of follow-up and the use of confounding cardiotoxic agents such as evolving systemic chemotherapy and targeted therapies. Future directions in both multidisciplinary management and advancing technology in radiation oncology may provide further improvements in patient risk reduction and breast cancer survivorship.
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Affiliation(s)
- Debra Nana Yeboa
- Department of Therapeutic Radiology, Yale School of Medicine, Smilow Cancer Center at Yale-New Haven Hospital, New Haven, CT
| | - Suzanne Buckley Evans
- Department of Therapeutic Radiology, Yale School of Medicine, Smilow Cancer Center at Yale-New Haven Hospital, New Haven, CT.
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Heggemann F, Grotz H, Welzel G, Dösch C, Hansmann J, Kraus-Tiefenbacher U, Attenberger U, Schönberg SO, Borggrefe M, Wenz F, Papavassiliu T, Lohr F. Cardiac Function After Multimodal Breast Cancer Therapy Assessed With Functional Magnetic Resonance Imaging and Echocardiography Imaging. Int J Radiat Oncol Biol Phys 2015; 93:836-44. [PMID: 26530752 DOI: 10.1016/j.ijrobp.2015.07.2287] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 07/13/2015] [Accepted: 07/29/2015] [Indexed: 12/13/2022]
Abstract
PURPOSE Breast intensity modulated radiation therapy (IMRT) reduces high-dose heart volumes but increases low-dose volumes. We prospectively assessed heart changes after 3D conformal RT (3DCRT) and IMRT for left-sided breast cancer. Heart dose was analyzed individually, 3DCRT patients were moderately exposed, and IMRT was performed only in patients with unacceptably high heart doses upon 3DCRT planning. METHODS AND MATERIALS In 49 patients (38 patients received 3DCRT; 11 patients received IMRT; and 20 patients received neoadjuvant or adjuvant chemotherapy) magnetic resonance imaging (MRI) and echocardiography were performed before and at 6, 12, and 24 months after treatment. RESULTS Mean heart dose for IMRT was 12.9 ± 3.9 Gy versus 4.5 ± 2.4 Gy for 3DCRT. Heart volumes receiving >40 Gy were 2.6% (3DCRT) versus 1.3% (IMRT); doses were >50 Gy only with 3DCRT. Temporary ejection fraction (EF) decrease was observed on MRI after 6 months (63%-59%, P=.005) resolving at 24 months. Only 3 patients had pronounced largely transient changes of EF and left ventricular enddiastolic diameter (LVEDD). Mitral (M) and tricuspid (T) annular plane systolic excursion (MAPSE and TAPSE) were reduced over the whole cohort (still within normal range). After 24 months left ventricular remodeling index decreased in patients receiving chemotherapy (0.80 vs 0.70, P=.028). Neither wall motion abnormalities nor late enhancements were found. On echocardiography, in addition to EF findings that were similar to those on MRI, global strain was unchanged over the whole cohort at 24 months after a transient decrease at 6 and 12 months. Longitudinal strain decreased in the whole cohort after 24 months in some segments, whereas it increased in others. CONCLUSIONS Until 24 months after risk-adapted modern multimodal adjuvant therapy, only subclinical cardiac changes were observed in both 3DCRT patients with inclusion of small to moderate amounts of heart volume in RT tangents and in the patients treated with IMRT and reduced high-dose heart exposure.
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Affiliation(s)
- Felix Heggemann
- First Medical Department, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany; German Center for Cardiovascular Research, Mannheim, Germany.
| | - Hanna Grotz
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Grit Welzel
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christina Dösch
- First Medical Department, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany; German Center for Cardiovascular Research, Mannheim, Germany
| | - Jan Hansmann
- Institute of Diagnostic Radiology and Nuclear Medicine, University Medical Center Mannheim University of Heidelberg, Mannheim, Germany
| | - Uta Kraus-Tiefenbacher
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ulrike Attenberger
- German Center for Cardiovascular Research, Mannheim, Germany; Institute of Diagnostic Radiology and Nuclear Medicine, University Medical Center Mannheim University of Heidelberg, Mannheim, Germany
| | - Stephan Oswald Schönberg
- German Center for Cardiovascular Research, Mannheim, Germany; Institute of Diagnostic Radiology and Nuclear Medicine, University Medical Center Mannheim University of Heidelberg, Mannheim, Germany
| | - Martin Borggrefe
- First Medical Department, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany; German Center for Cardiovascular Research, Mannheim, Germany
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Theano Papavassiliu
- First Medical Department, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany; German Center for Cardiovascular Research, Mannheim, Germany
| | - Frank Lohr
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
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Skyttä T, Tuohinen S, Boman E, Virtanen V, Raatikainen P, Kellokumpu-Lehtinen PL. Troponin T-release associates with cardiac radiation doses during adjuvant left-sided breast cancer radiotherapy. Radiat Oncol 2015; 10:141. [PMID: 26159409 PMCID: PMC4496940 DOI: 10.1186/s13014-015-0436-2] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 06/05/2015] [Indexed: 12/13/2022] Open
Abstract
Background Adjuvant radiotherapy (RT) for left-sided breast cancer increases cardiac morbidity and mortality. For the heart, no safe radiation threshold has been established. Troponin T is a sensitive marker of myocardial damage. Our aim was to evaluate the effect of left-sided breast cancer RT on serum high sensitivity troponin T (hscTnT) levels and its association with cardiac radiation doses and echocardiographic parameters. Methods A total of 58 patients with an early stage, left-sided breast cancer or ductal carcinoma in situ (DCIS) who received adjuvant breast RT without prior chemotherapy were included in this prospective, non-randomized study. Serum samples were taken before, during and after RT. An increase of hscTnT >30 % was predefined as significant. A comprehensive 2D echocardiograph and electrocardiogram (ECG) were performed before and after RT. Dose-volume histograms (DVHs) were generated for different cardiac structures. Results The hscTnT increased during RT from baseline in 12/58 patients (21 %). Patients with increased hscTnT values (group A, N = 12) had significantly higher radiation doses for the whole heart (p = 0.02) and left ventricle (p = 0.03) than patients without hscTnT increase (group B, N = 46). For the left anterior descending artery (LAD), differences between groups A and B were found in volumes receiving 15 Gy (p = 0.03) and 20 Gy (p = 0.03) Furthermore, after RT, the interventricular septum thickened (p = 0.01), and the deceleration time was prolonged (p = 0.008) more in group A than in group B. Conclusions The increase in hscTnT level during adjuvant RT was positively associated with the cardiac radiation doses for the whole heart and LV in chemotherapy-naive breast cancer patients. Whether these acute subclinical changes increase the risk of excessive long-term cardiovascular morbidity or mortality, will be addressed in the follow-up of our patients.
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Affiliation(s)
- Tanja Skyttä
- Department of Oncology and School of Medicine, Tampere University Hospital, University of Tampere, 33521, Tampere, Finland.
| | - Suvi Tuohinen
- Heart Center Co and School of Medicine, University of Tampere, Tampere University Hospital, Tampere, Finland
| | - Eeva Boman
- Department of Oncology, Tampere University Hospital and Department of Medical Physics, Medical Imaging Center and Hospital Pharmacy, Tampere, Finland
| | - Vesa Virtanen
- Heart Center Co and School of Medicine, University of Tampere, Tampere University Hospital, Tampere, Finland
| | - Pekka Raatikainen
- Department of Medicine, Central Finland Health Care District and University of Eastern Finland, Jyväskylä, Finland
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Yusuf SW, Howell RM, Gomez D, Pinnix CC, Iliescu CA, Banchs J. Radiation-related heart and vascular disease. Future Oncol 2015. [DOI: 10.2217/fon.15.129] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Improvement in cancer therapy has led to increasing number of cancer survivors, some of whom have previously been treated with mediastinal radiation. Cardiac complication may manifest years after completion of radiation therapy. Hence long-term follow-up is essential in these patients. In this paper, we have discussed the short- and long-term cardiovascular side effects of radiation therapy.
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Affiliation(s)
- Syed Wamique Yusuf
- Department of Cardiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Rebecca M Howell
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Daniel Gomez
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Chelsea C Pinnix
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Cezar A Iliescu
- Department of Cardiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Jose Banchs
- Department of Cardiology, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
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Slezak J, Kura B, Ravingerová T, Tribulova N, Okruhlicova L, Barancik M. Mechanisms of cardiac radiation injury and potential preventive approaches. Can J Physiol Pharmacol 2015; 93:737-53. [PMID: 26030720 DOI: 10.1139/cjpp-2015-0006] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In addition to cytostatic treatment and surgery, the most common cancer treatment is gamma radiation. Despite sophisticated radiological techniques however, in addition to irradiation of the tumor, irradiation of the surrounding healthy tissue also takes place, which results in various side-effects, depending on the absorbed dose of radiation. Radiation either damages the cell DNA directly, or indirectly via the formation of oxygen radicals that in addition to the DNA damage, react with all cell organelles and interfere with their molecular mechanisms. The main features of radiation injury besides DNA damage is inflammation and increased expression of pro-inflammatory genes and cytokines. Endothelial damage and dysfunction of capillaries and small blood vessels plays a particularly important role in radiation injury. This review is focused on summarizing the currently available data concerning the mechanisms of radiation injury, as well as the effectiveness of various antioxidants, anti-inflammatory cytokines, and cytoprotective substances that may be utilized in preventing, mitigating, or treating the toxic effects of ionizing radiation on the heart.
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Affiliation(s)
- Jan Slezak
- Institute for Heart Research, Slovak Academy of Sciences, Dúbravská cesta 9, 842 33 Bratislava, Slovak Republic.,Institute for Heart Research, Slovak Academy of Sciences, Dúbravská cesta 9, 842 33 Bratislava, Slovak Republic
| | - Branislav Kura
- Institute for Heart Research, Slovak Academy of Sciences, Dúbravská cesta 9, 842 33 Bratislava, Slovak Republic.,Institute for Heart Research, Slovak Academy of Sciences, Dúbravská cesta 9, 842 33 Bratislava, Slovak Republic
| | - Táňa Ravingerová
- Institute for Heart Research, Slovak Academy of Sciences, Dúbravská cesta 9, 842 33 Bratislava, Slovak Republic.,Institute for Heart Research, Slovak Academy of Sciences, Dúbravská cesta 9, 842 33 Bratislava, Slovak Republic
| | - Narcisa Tribulova
- Institute for Heart Research, Slovak Academy of Sciences, Dúbravská cesta 9, 842 33 Bratislava, Slovak Republic.,Institute for Heart Research, Slovak Academy of Sciences, Dúbravská cesta 9, 842 33 Bratislava, Slovak Republic
| | - Ludmila Okruhlicova
- Institute for Heart Research, Slovak Academy of Sciences, Dúbravská cesta 9, 842 33 Bratislava, Slovak Republic.,Institute for Heart Research, Slovak Academy of Sciences, Dúbravská cesta 9, 842 33 Bratislava, Slovak Republic
| | - Miroslav Barancik
- Institute for Heart Research, Slovak Academy of Sciences, Dúbravská cesta 9, 842 33 Bratislava, Slovak Republic.,Institute for Heart Research, Slovak Academy of Sciences, Dúbravská cesta 9, 842 33 Bratislava, Slovak Republic
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Kohli K, Liu J, Schellenberg D, Karvat A, Parameswaran A, Grewal P, Thomas S. Prototype development of an electrical impedance based simultaneous respiratory and cardiac monitoring system for gated radiotherapy. Biomed Eng Online 2014; 13:144. [PMID: 25316509 PMCID: PMC4209026 DOI: 10.1186/1475-925x-13-144] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 10/07/2014] [Indexed: 12/25/2022] Open
Abstract
Background In radiotherapy, temporary translocations of the internal organs and tumor induced by respiratory and cardiac activities can undesirably lead to significantly lower radiation dose on the targeted tumor but more harmful radiation on surrounding healthy tissues. Respiratory and cardiac gated radiotherapy offers a potential solution for the treatment of tumors located in the upper thorax. The present study focuses on the design and development of simultaneous acquisition of respiratory and cardiac signal using electrical impedance technology for use in dual gated radiotherapy. Methods An electronic circuitry was developed for monitoring the bio-impedance change due to respiratory and cardiac motions and extracting the cardiogenic ECG signal. The system was analyzed in terms of reliability of signal acquisition, time delay, and functionality in a high energy radiation environment. The resulting signal of the system developed was also compared with the output of the commercially available Real-time Position Management™ (RPM) system in both time and frequency domains. Results The results demonstrate that the bioimpedance-based method can potentially provide reliable tracking of respiratory and cardiac motion in humans, alternative to currently available methods. When compared with the RPM system, the impedance-based system developed in the present study shows similar output pattern but different sensitivities in monitoring different respiratory rates. The tracking of cardiac motion was more susceptible to interference from other sources than respiratory motion but also provided synchronous output compared with the ECG signal extracted. The proposed hardware-based implementation was observed to have a worst-case time delay of approximately 33 ms for respiratory monitoring and 45 ms for cardiac monitoring. No significant effect on the functionality of the system was observed when it was tested in a radiation environment with the electrode lead wires directly exposed to high-energy X-Rays. Conclusion The developed system capable of rendering quality signals for tracking both respiratory and cardiac motions can potentially provide a solution for simultaneous dual-gated radiotherapy.
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Affiliation(s)
- Kirpal Kohli
- Department of Medical Physics, Fraser Valley Center, BC Cancer Agency, 13750 96th Avenue, Surrey V3V 1Z2, BC, Canada.
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Walker CM, Saldaña DA, Gladish GW, Dicks DL, Kicska G, Mitsumori LM, Reddy GP. Cardiac Complications of Oncologic Therapy. Radiographics 2013; 33:1801-15. [DOI: 10.1148/rg.336125005] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Umezawa R, Takase K, Jingu K, Takanami K, Ota H, Kaneta T, Takeda K, Matsushita H, Ariga H, Takahashi S, Yamada S. Evaluation of radiation-induced myocardial damage using iodine-123 β-methyl-iodophenyl pentadecanoic acid scintigraphy. JOURNAL OF RADIATION RESEARCH 2013; 54:880-9. [PMID: 23412468 PMCID: PMC3766284 DOI: 10.1093/jrr/rrt011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
We evaluated radiation-induced myocardial damage using iodine-123 β-methyl-iodophenyl pentadecanoic acid (I-123 BMIPP) scintigraphy. Between May 2010 and April 2011 we performed I-123 BMIPP scintigraphy for patients who had maintained complete response to curative radiotherapy (RT) for esophageal cancer for more than six months. We compared the area of the myocardium in the RT fields with that of reduced I-123 BMIPP uptake using a 15-segment model that is based on axial computed tomography (CT) images. We classified the segments into three categories: segments receiving 40 Gy (Segment 40 Gy), segments receiving 60 Gy (Segment 60 Gy) and segments out of the radiation fields (Segment 0 Gy). A segment with reduced uptake in the RT fields was defined as positive. A total of 510 segments in 34 patients were used for analysis. The median interval from completion of RT to I-123 BMIPP scintigraphy was 22 months (range, 6-103 months). The numbers of Segment 0 Gy, Segment 40 Gy and Segment 60 Gy were 324, 133 and 53, respectively. Reduced uptake was detected in 42.9% (57/133) of Segment 40 Gy, 67.9% (36/53) of Segment 60 Gy and 13.3% (43/324) of Segment 0 Gy. The odds ratios of 40 Gy and 60 Gy compared with regions out of the RT fields were 5.2 (95% confidence interval [CI]: 3.7-7.4) and 15.4 (95% CI: 6.9-34.6), respectively. Reduced myocardial I-123 BMIPP uptake in RT fields, suggesting RT-induced myocardial damage, was frequently observed. I-123 BMIPP myocardial scintigraphy may be useful for identifying RT-induced myocardial damage.
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Affiliation(s)
- Rei Umezawa
- Department of Radiation Oncology, Tohoku University School of Medicine, Seiryou-machi 1-1, Aobaku, Sendai 980-8574, Japan
- Corresponding author. Department of Radiation Oncology, Tohoku University School of Medicine, Seiryou-machi 1-1, Aobaku, Sendai 980-8574, Japan. Tel: +81-22-717-7312; Fax: +81-22-717-7316;
| | - Kei Takase
- Department of Diagnostic Radiology, Tohoku University School of Medicine, Seiryou-machi 1-1, Aobaku, Sendai 980-8574, Japan
| | - Keiichi Jingu
- Department of Radiation Oncology, Tohoku University School of Medicine, Seiryou-machi 1-1, Aobaku, Sendai 980-8574, Japan
| | - Kentaro Takanami
- Department of Diagnostic Radiology, Tohoku University School of Medicine, Seiryou-machi 1-1, Aobaku, Sendai 980-8574, Japan
| | - Hideki Ota
- Department of Diagnostic Radiology, Tohoku University School of Medicine, Seiryou-machi 1-1, Aobaku, Sendai 980-8574, Japan
| | - Tomohiro Kaneta
- Department of Diagnostic Radiology, Tohoku University School of Medicine, Seiryou-machi 1-1, Aobaku, Sendai 980-8574, Japan
| | - Ken Takeda
- Department of Radiation Oncology, Tohoku University School of Medicine, Seiryou-machi 1-1, Aobaku, Sendai 980-8574, Japan
| | - Haruo Matsushita
- Department of Radiation Oncology, Tohoku University School of Medicine, Seiryou-machi 1-1, Aobaku, Sendai 980-8574, Japan
| | - Hisanori Ariga
- Department of Radiation Oncology, Tohoku University School of Medicine, Seiryou-machi 1-1, Aobaku, Sendai 980-8574, Japan
| | - Shoki Takahashi
- Department of Diagnostic Radiology, Tohoku University School of Medicine, Seiryou-machi 1-1, Aobaku, Sendai 980-8574, Japan
| | - Shogo Yamada
- Department of Radiation Oncology, Tohoku University School of Medicine, Seiryou-machi 1-1, Aobaku, Sendai 980-8574, Japan
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Stewart FA, Seemann I, Hoving S, Russell NS. Understanding radiation-induced cardiovascular damage and strategies for intervention. Clin Oncol (R Coll Radiol) 2013; 25:617-24. [PMID: 23876528 DOI: 10.1016/j.clon.2013.06.012] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 04/26/2013] [Accepted: 06/30/2013] [Indexed: 12/22/2022]
Abstract
There is a clear association between therapeutic doses of thoracic irradiation and an increased risk of cardiovascular disease (CVD) in cancer survivors, although these effects may take decades to become symptomatic. Long-term survivors of Hodgkin's lymphoma and childhood cancers have two-fold to more than seven-fold increased risks for late cardiac deaths after total tumour doses of 30-40 Gy, given in 2 Gy fractions, where large volumes of heart were included in the field. Increased cardiac mortality is also seen in women irradiated for breast cancer. Breast doses are generally 40-50 Gy in 2 Gy fractions, but only a small part of the heart is included in the treatment fields and mean heart doses rarely exceeded 10-15 Gy, even with older techniques. The relative risks of cardiac mortality (1.1-1.4) are consequently lower than for Hodgkin's lymphoma survivors. Some epidemiological studies show increased risks of cardiac death after accidental or environmental total body exposures to much lower radiation doses. The mechanisms whereby these cardiac effects occur are not fully understood and different mechanisms are probably involved after high therapeutic doses to the heart, or part of the heart, than after low total body exposures. These various mechanisms probably result in different cardiac pathologies, e.g. coronary artery atherosclerosis leading to myocardial infarct, versus microvascular damage and fibrosis leading to congestive heart failure. Experimental studies can help to unravel some of these mechanisms and may identify suitable strategies for managing or inhibiting CVD. In this overview, the main epidemiological and clinical evidence for radiation-induced CVD is summarised. Experimental data shedding light on some of the underlying pathologies and possible targets for intervention are also discussed.
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Affiliation(s)
- F A Stewart
- Division of Biological Stress Response, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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Abstract
Epidemiological studies have shown a clear association between therapeutic doses of thoracic irradiation and increased risk of cardiovascular disease in long-term cancer survivors. Survivors of Hodgkin's lymphoma and childhood cancers, for example, show 2- to >7-fold increases in risk of cardiac death after total tumour doses of 30-40 Gy, given in 2-Gy fractions. The risk of cardiac mortality increases linearly with dose, although there are large uncertainties for mean cardiac doses <5 Gy. Experimental studies show that doses of ≥ 2 Gy induce the expression of inflammatory and thrombotic molecules in endothelial cells. In the heart, this causes progressive loss of capillaries and eventually leads to reduced perfusion, myocardial cell death, and fibrosis. In large arteries, doses of ≥ 8 Gy, combined with elevated cholesterol, initiates atherosclerosis and predisposes to the formation of inflammatory, unstable lesions, which are prone to rupture and may cause a fatal heart attack or stroke. In contrast, doses <1 Gy inhibit inflammatory cell adhesion to endothelial cells and inhibit the development of atherosclerosis in mice. It seems likely that mechanisms other than accelerated atherosclerosis are responsible for cardiovascular effects after low total-body exposures of radiation (e.g. impaired T-cell immunity or persistent increase in systemic cytokines).
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Affiliation(s)
- F A Stewart
- Experimental Therapy, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
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Yu XL, Zhang Q, Chen JY, Zhang Z, Wang JZ, Hu WG, Pan ZQ, Hu SL, Zhang YJ, Feng Y, Shao ZM, Orecchia R, Guo XM. Delineation of the cardiac substructures based on PET-CT and contrast-enhanced CT in patients with left breast cancer treated with postoperative radiotherapy. Technol Cancer Res Treat 2012; 12:99-107. [PMID: 22974330 DOI: 10.7785/tcrt.2012.500299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
The aim of this study is to evaluate the volume differences between contrast-enhanced CT-based left ventricle (LV) and PET-CT-based LV and assess the impact of dose on the substructure volume differences in patients with left breast cancer treated with adjuvant radiotherapy. From October 2008 to February 2009, 14 patients with post-operatively confirmed left breast cancer were enrolled in the current study. The patients were scanned using contrast-enhanced CT for simulation, and (18)F-FDG PET-CT was employed to display the structure of the left ventricle of each before radiotherapy (RT). The LV was delineated based on both contrast-enhanced CT and PET-CT. And other substructures, such as the left anterior descending coronary artery (LAD), were contoured in each patient, with the six-field simple intensity modulated radiotherapy (sIMRT) technique created for all. The mean volumes of the left ventricle based on contrast-enhanced CT (LV-CT) and PET-CT (LV-PET) were found to be 107.296 cm(3) and 112.931 cm(3), respectively (p = 0.06). The volume of LV receiving ≥ 50% prescription dose was significantly correlated with the volume of the heart receiving the same dosage (γ = 0.869). There was less correlation between the volume of LAD and that of the heart under the same condition (γ = 0.22). As a conclusion, the left ventricle can be delineated effectively based on the image of PET-CT, the contrast-enhanced CT based LV can serve as an appropriate alternative. Moreover, the volume of LV receiving high dose in RT closely correlated with the volume of the heart using sIMRT technique, which may pave the way for further exploring radiation-induced cardiac injuries in patients with left breast cancer.
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Affiliation(s)
- X-L Yu
- Department of Radiation Oncology, Cancer Hospital of Fudan University, Shanghai Medical College, Fudan University, Shanghai, China
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Robbins ME, Brunso-Bechtold JK, Peiffer AM, Tsien CI, Bailey JE, Marks LB. Imaging radiation-induced normal tissue injury. Radiat Res 2012; 177:449-66. [PMID: 22348250 DOI: 10.1667/rr2530.1] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Technological developments in radiation therapy and other cancer therapies have led to a progressive increase in five-year survival rates over the last few decades. Although acute effects have been largely minimized by both technical advances and medical interventions, late effects remain a concern. Indeed, the need to identify those individuals who will develop radiation-induced late effects, and to develop interventions to prevent or ameliorate these late effects is a critical area of radiobiology research. In the last two decades, preclinical studies have clearly established that late radiation injury can be prevented/ameliorated by pharmacological therapies aimed at modulating the cascade of events leading to the clinical expression of radiation-induced late effects. These insights have been accompanied by significant technological advances in imaging that are moving radiation oncology and normal tissue radiobiology from disciplines driven by anatomy and macrostructure to ones in which important quantitative functional, microstructural, and metabolic data can be noninvasively and serially determined. In the current article, we review use of positron emission tomography (PET), single photon emission tomography (SPECT), magnetic resonance (MR) imaging and MR spectroscopy to generate pathophysiological and functional data in the central nervous system, lung, and heart that offer the promise of, (1) identifying individuals who are at risk of developing radiation-induced late effects, and (2) monitoring the efficacy of interventions to prevent/ameliorate them.
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Affiliation(s)
- Mike E Robbins
- Department of Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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Stewart FA, Akleyev AV, Hauer-Jensen M, Hendry JH, Kleiman NJ, Macvittie TJ, Aleman BM, Edgar AB, Mabuchi K, Muirhead CR, Shore RE, Wallace WH. ICRP publication 118: ICRP statement on tissue reactions and early and late effects of radiation in normal tissues and organs--threshold doses for tissue reactions in a radiation protection context. Ann ICRP 2012; 41:1-322. [PMID: 22925378 DOI: 10.1016/j.icrp.2012.02.001] [Citation(s) in RCA: 771] [Impact Index Per Article: 64.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
This report provides a review of early and late effects of radiation in normal tissues and organs with respect to radiation protection. It was instigated following a recommendation in Publication 103 (ICRP, 2007), and it provides updated estimates of 'practical' threshold doses for tissue injury defined at the level of 1% incidence. Estimates are given for morbidity and mortality endpoints in all organ systems following acute, fractionated, or chronic exposure. The organ systems comprise the haematopoietic, immune, reproductive, circulatory, respiratory, musculoskeletal, endocrine, and nervous systems; the digestive and urinary tracts; the skin; and the eye. Particular attention is paid to circulatory disease and cataracts because of recent evidence of higher incidences of injury than expected after lower doses; hence, threshold doses appear to be lower than previously considered. This is largely because of the increasing incidences with increasing times after exposure. In the context of protection, it is the threshold doses for very long follow-up times that are the most relevant for workers and the public; for example, the atomic bomb survivors with 40-50years of follow-up. Radiotherapy data generally apply for shorter follow-up times because of competing causes of death in cancer patients, and hence the risks of radiation-induced circulatory disease at those earlier times are lower. A variety of biological response modifiers have been used to help reduce late reactions in many tissues. These include antioxidants, radical scavengers, inhibitors of apoptosis, anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, growth factors, and cytokines. In many cases, these give dose modification factors of 1.1-1.2, and in a few cases 1.5-2, indicating the potential for increasing threshold doses in known exposure cases. In contrast, there are agents that enhance radiation responses, notably other cytotoxic agents such as antimetabolites, alkylating agents, anti-angiogenic drugs, and antibiotics, as well as genetic and comorbidity factors. Most tissues show a sparing effect of dose fractionation, so that total doses for a given endpoint are higher if the dose is fractionated rather than when given as a single dose. However, for reactions manifesting very late after low total doses, particularly for cataracts and circulatory disease, it appears that the rate of dose delivery does not modify the low incidence. This implies that the injury in these cases and at these low dose levels is caused by single-hit irreparable-type events. For these two tissues, a threshold dose of 0.5Gy is proposed herein for practical purposes, irrespective of the rate of dose delivery, and future studies may elucidate this judgement further.
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Zagar TM, Marks LB. Breast cancer radiotherapy and coronary artery stenosis: location, location, location. J Clin Oncol 2011; 30:350-2. [PMID: 22203762 DOI: 10.1200/jco.2011.38.9304] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Wang W, Wainstein R, Freixa X, Dzavik V, Fyles A. Quantitative coronary angiography findings of patients who received previous breast radiotherapy. Radiother Oncol 2011; 100:184-8. [DOI: 10.1016/j.radonc.2011.03.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Revised: 03/16/2011] [Accepted: 03/20/2011] [Indexed: 11/29/2022]
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Gallucci G, Coccaro M, Storto G, Lapadula L, Tartarone A, Nappi A, Cammarota A, Buonerba C, Di Lorenzo G, Fusco V, Aieta M. The clinical impact of a cardiologic follow-up in breast cancer survivors: an observational study. Int J Immunopathol Pharmacol 2011; 23:1221-7. [PMID: 21244771 DOI: 10.1177/039463201002300426] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Anthracycline-containing chemotherapy (A-CHT) can induce late cardiotoxicity adding a considerable burden to cardiovascular risk. Irradiation of left breast cancer has also been associated to an increased risk of cardiovascular disease. The aim of this observational study is to prove the usefulness of an accurate cardiovascular evaluation in left breast cancer survivors treated with radiotherapy (RT) and A-CHT. Patients with left breast cancer, on follow-up after treatment with A-CHT plus RT in an adjuvant setting, were eligible for this observational study. Patients underwent cardiovascular assessment with myocardial perfusion imaging. Thirty patients were enrolled in the study: mean age at diagnosis 55.8 years; stage: I/III; Er and/or pgR status: positive in 24/30 pts; 3 patients in pre-menopausal status. Twenty-two patients (73.3 percent) had normal perfusion imaging, 1 patient (3.3 percent) had a fixed myocardial perfusion defect, 7 patients (23.3 percent) had reversible myocardial perfusion defects; 1 patient (3 percent) with normal perfusion scan showed depressed rest and stress LVEF. Only 1 patient had a large defect and underwent coronary angiography and percutaneous coronary intervention. Five patients with small defect showed normal coronary arteries at Multislice Computed Tomography. Cardiovascular followup may reveal signs of A-CHT or RT-induced cardiotoxicity. A stress test combined with MPI- and GATED-derived data of ventricular systolic performance after stress can give information on the coronary reserve and the contractile reserve and allow early appropriate treatment.
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Affiliation(s)
- G Gallucci
- Cardiologia, Centro di Riferimento Oncologico di Basilicata IRCCS Rionero in Vulture, Potenza. Italy.
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Yusuf SW, Sami S, Daher IN. Radiation-induced heart disease: a clinical update. Cardiol Res Pract 2011; 2011:317659. [PMID: 21403872 PMCID: PMC3051159 DOI: 10.4061/2011/317659] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 12/15/2010] [Indexed: 01/28/2023] Open
Abstract
Cardiovascular diseases and cancer are the two leading causes of morbidity and mortality worldwide. Improvement in cancer therapy has led to increasing number of cancer survivors, some of whom may suffer from adverse cardiovascular effects of radiation therapy. Longterm followup is essential, as the cardiac complication may manifest years after completion of radiation therapy. In this paper, we have discussed the cardiovascular effects of radiation therapy.
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Affiliation(s)
- Syed Wamique Yusuf
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Unit 1451, Houston, TX 77030, USA
| | - Shehzad Sami
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Unit 1451, Houston, TX 77030, USA
| | - Iyad N. Daher
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Unit 1451, Houston, TX 77030, USA
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Does Previous Chest Wall Irradiation Increase Vascular Complications in Free Autologous Breast Reconstruction? Plast Reconstr Surg 2011; 127:496-504. [DOI: 10.1097/prs.0b013e3181fed560] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bouillon K, Haddy N, Delaloge S, Garbay JR, Garsi JP, Brindel P, Mousannif A, Lê MG, Labbe M, Arriagada R, Jougla E, Chavaudra J, Diallo I, Rubino C, de Vathaire F. Long-Term Cardiovascular Mortality After Radiotherapy for Breast Cancer. J Am Coll Cardiol 2011; 57:445-52. [DOI: 10.1016/j.jacc.2010.08.638] [Citation(s) in RCA: 136] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Revised: 07/13/2010] [Accepted: 08/10/2010] [Indexed: 10/18/2022]
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Wang W, Purdie TG, Rahman M, Marshall A, Liu FF, Fyles A. Rapid automated treatment planning process to select breast cancer patients for active breathing control to achieve cardiac dose reduction. Int J Radiat Oncol Biol Phys 2010; 82:386-93. [PMID: 21093165 DOI: 10.1016/j.ijrobp.2010.09.026] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 09/10/2010] [Accepted: 09/12/2010] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate a rapid automated treatment planning process for the selection of patients with left-sided breast cancer for a moderate deep inspiration breath-hold (mDIBH) technique using active breathing control (ABC); and to determine the dose reduction to the left anterior descending coronary artery (LAD) and the heart using mDIBH. METHOD AND MATERIALS Treatment plans were generated using an automated method for patients undergoing left-sided breast radiotherapy (n = 53) with two-field tangential intensity-modulated radiotherapy. All patients with unfavorable cardiac anatomy, defined as having >10 cm(3) of the heart receiving 50% of the prescribed dose (V(50)) on the free-breathing automated treatment plan, underwent repeat scanning on a protocol using a mDIBH technique and ABC. The doses to the LAD and heart were compared between the free-breathing and mDIBH plans. RESULTS The automated planning process required approximately 9 min to generate a breast intensity-modulated radiotherapy plan. Using the dose-volume criteria, 20 of the 53 patients were selected for ABC. Significant differences were found between the free-breathing and mDIBH plans for the heart V(50) (29.9 vs. 3.7 cm(3)), mean heart dose (317 vs. 132 cGy), mean LAD dose (2,047 vs. 594 cGy), and maximal dose to 0.2 cm(3) of the LAD (4,155 vs. 1,507 cGy, all p <.001). Of the 17 patients who had a breath-hold threshold of ≥ 0.8 L, 14 achieved a ≥ 90% reduction in the heart V(50) using the mDIBH technique. The 3 patients who had had a breath-hold threshold <0.8 L achieved a lower, but still significant, reduction in the heart V(50). CONCLUSIONS A rapid automated treatment planning process can be used to select patients who will benefit most from mDIBH. For selected patients with unfavorable cardiac anatomy, the mDIBH technique using ABC can significantly reduce the dose to the LAD and heart, potentially reducing the cardiac risks.
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Affiliation(s)
- Wei Wang
- Radiation Medicine Program, Princess Margaret Hospital, University Health Network, Toronto, ON, Canada.
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Andratschke N, Maurer J, Molls M, Trott KR. Late radiation-induced heart disease after radiotherapy. Clinical importance, radiobiological mechanisms and strategies of prevention. Radiother Oncol 2010; 100:160-6. [PMID: 20826032 DOI: 10.1016/j.radonc.2010.08.010] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Revised: 07/06/2010] [Accepted: 08/12/2010] [Indexed: 12/14/2022]
Abstract
The clinical importance of radiation-induced heart disease, in particular in post-operative radiotherapy of breast cancer patients, has been recognised only recently. There is general agreement, that a co-ordinated research effort would be needed to explore all the potential strategies of how to reduce the late risk of radiation-induced heart disease in radiotherapy. This approach would be based, on one hand, on a comprehensive understanding of the radiobiological mechanisms of radiation-induced heart disease after radiotherapy which would require large-scale long-term animal experiments with high precision local heart irradiation. On the other hand - in close co-operation with mechanistic in vivo research studies - clinical studies in patients need to determine the influence of dose distribution in the heart on the risk of radiation-induced heart disease. The aim of these clinical studies would be to identify the critical structures within the organ which need to be spared and their radiation sensitivity as well as a potential volume and dose effect. The results of the mechanistic studies might also provide concepts of how to modify the gradual progression of radiation damage in the heart by drugs or biological molecules. The results of the studies in patients would need to also incorporate detailed dosimetric and imaging studies in order to develop early indicators of impending radiation-induced heart disease which would be a pre-condition to develop sound criteria for treatment plan optimisation.
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Affiliation(s)
- Nicolaus Andratschke
- Klinik und Poliklinik für Strahlentherapie und Radiologische Onkologie, Technische Universität München, Munich, Germany.
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Sas-Korczyńska B, Sladowska A, Rozwadowska-Bogusz B, Dyczek S, Lesiak J, Kokoszka A, Korzeniowski S. Comparison between intensity modulated radiotherapy (IMRT) and 3D tangential beams technique used in patients with early-stage breast cancer who received breast-conserving therapy. Rep Pract Oncol Radiother 2010; 15:79-86. [PMID: 24376929 DOI: 10.1016/j.rpor.2010.06.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Revised: 06/22/2010] [Accepted: 06/24/2010] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND The most often found complications in patients with breast cancer who received radiotherapy are cardiac and pulmonary function disorders and development of second malignancies. AIM To compare the intensity modulated radiotherapy with the 3D tangential beams technique in respect of dose distribution in target volume and critical organs they generate in patients with early-stage breast cancer who received breast-conserving therapy. MATERIALS AND METHODS A dosimetric analysis was performed to assess the three radiotherapy techniques used in each of 10 consecutive patients with early-stage breast cancer treated with breast-conserving therapy. Radiotherapy was planned with the use of all the three techniques: 3D tangential beams with electron boost, IMRT with electron boost, and intensity modulated radiotherapy with simultaneous integrated boost. RESULTS The use of the IMRT techniques enables more homogenous dose distribution in target volume. The range of mean and median dose to the heart and lung was lower with the IMRT techniques in comparison to the 3D tangential beams technique. The range of mean dose to the heart amounted to 0.3-3.5 Gy for the IMRT techniques and 0.4-4.3 for the tangential beams technique. The median dose to the lung on the irradiated side amounted to 4.9-5 Gy for the IMRT techniques and 5.6 Gy for the 3D tangential beams technique. CONCLUSION The application of the IMRT techniques in radiotherapy patients with early-stage breast cancer allows to obtain more homogenous dose distribution in target volume, while permitting to reduce the dose to critical organs.
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Affiliation(s)
- Beata Sas-Korczyńska
- Breast and Thoracic Cancer Unit, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Garncarska 11, 31-115 Kraków, Poland
| | - Anna Sladowska
- Medical Physics, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Garncarska 11, 31-115 Kraków, Poland
| | - Bożena Rozwadowska-Bogusz
- Medical Physics, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Garncarska 11, 31-115 Kraków, Poland
| | - Sonia Dyczek
- Diagnostic Radiology, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Garncarska 11, 31-115 Kraków, Poland
| | - Jan Lesiak
- Medical Physics, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Garncarska 11, 31-115 Kraków, Poland
| | - Anna Kokoszka
- Breast and Thoracic Cancer Unit, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Garncarska 11, 31-115 Kraków, Poland
| | - Stanisław Korzeniowski
- Breast and Thoracic Cancer Unit, Centre of Oncology, Maria Skłodowska-Curie Memorial Institute, Cracow Branch, Garncarska 11, 31-115 Kraków, Poland
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The clinical implications of myocardial perfusion abnormalities in patients with esophageal or lung cancer after chemoradiation therapy. Int J Cardiovasc Imaging 2009; 25:487-95. [DOI: 10.1007/s10554-009-9440-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2008] [Accepted: 02/06/2009] [Indexed: 10/21/2022]
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Gayed IW, Liu HH, Wei X, Liao Z, Yusuf SW, Chang JY, Bassett R, Komaki R. Patterns of Cardiac Perfusion Abnormalities After Chemoradiotherapy in Patients with Lung Cancer. J Thorac Oncol 2009; 4:179-84. [DOI: 10.1097/jto.0b013e3181990c46] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gale AA, Jain AK, Vallow LA, Serago CF, Buskirk SJ, Heckman MG. Cardiac dose evaluation for 3-dimensional conformal partial breast irradiation compared with whole breast irradiation. J Appl Clin Med Phys 2009; 10:3-13. [PMID: 19223835 PMCID: PMC5720506 DOI: 10.1120/jacmp.v10i1.2868] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Revised: 08/26/2008] [Accepted: 08/20/2008] [Indexed: 11/24/2022] Open
Abstract
To compare the radiation dose to normal cardiac tissue for 3Dimensional (3D) conformal external beam partial breast irradiation (PBI) and standard whole breast irradiation (WBI), and examine the effect of tumor bed location. For 14 patients with left breast tumors randomized on the National Surgical Adjuvant Breast and Bowel Project B-39 protocol, computer-generated radiotherapy treatment plans were devised for WBI and PBI. Tumor bed location was designated according to whether more than 50% of the excision cavity was medial or lateral to the nipple line. The volume of heart receiving doses of 2.5, 5, 10, and 20 Gy was calculated for all PBI and WBI plans. Dose to 5% of the heart volume (D5) and mean heart dose were also calculated. The biologically-equivalent dose (BED) was calculated to account for the different fractionation used in PBI and WBI. Of the 14 patients, 8 had lateral tumor beds, and 6 had medial tumor beds. The volumes of heart receiving 2.5, 5, 10, and 20 Gy were significantly lower for lateral PBI compared with WBI. For medial PBI, significant cardiac sparing was only seen at a dose of 20 Gy. The difference of D5 values was significant for lateral PBI compared with WBI (p=0.008), but not for medial PBI compared with WBI (p=0.84). The mean dose was also significantly lower for lateral PBI compared with WBI (p=0.008), but not for medial PBI (p=0.16). The results from BED calculations did not change this outcome. Both 3D conformal PBI and standard WBI can deliver relatively low doses to the heart. For patients with lateralized tumor beds, PBI offers significant cardiac sparing compared with WBI. Patients with medial lesions have relatively similar heart dosimetry with PBI and WBI. 3D conformal PBI is an emerging treatment modality and continued participation on clinical trials is encouraged. Patients with left-sided lesions and lateralized tumor beds warrant special consideration for PBI, given the significant cardiac dose sparing.
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Affiliation(s)
- Ashley A. Gale
- Department of Radiation OncologyMayo ClinicJacksonvilleFloridaU.S.A.
| | - Anudh K. Jain
- Department of Radiation OncologyMayo ClinicJacksonvilleFloridaU.S.A.
| | - Laura A. Vallow
- Department of Radiation OncologyMayo ClinicJacksonvilleFloridaU.S.A.
| | | | - Steven J. Buskirk
- Department of Radiation OncologyMayo ClinicJacksonvilleFloridaU.S.A.
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Ahmed RS, De Los Santos JF, Fiveash JB, Keene KS, Popple RA. An imrt technique to increase therapeutic ratio of breast irradiation in patients with early-stage left breast cancer: limiting second malignancies. Med Dosim 2008; 33:71-7. [DOI: 10.1016/j.meddos.2007.10.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Revised: 07/25/2007] [Accepted: 10/01/2007] [Indexed: 12/11/2022]
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Taylor CW, Nisbet A, McGale P, Darby SC. Cardiac Exposures in Breast Cancer Radiotherapy: 1950s–1990s. Int J Radiat Oncol Biol Phys 2007; 69:1484-95. [DOI: 10.1016/j.ijrobp.2007.05.034] [Citation(s) in RCA: 201] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2007] [Revised: 05/14/2007] [Accepted: 05/14/2007] [Indexed: 10/22/2022]
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