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Mohamed AA, Douglas MN, Bruners P, Eble MJ. Dosimetric advantages for cardiac substructures in radiotherapy of esophageal cancer in deep-inspiration breath hold. Strahlenther Onkol 2024; 200:624-632. [PMID: 38315236 PMCID: PMC11186874 DOI: 10.1007/s00066-024-02197-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 01/03/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Radiotherapy is one of the main treatment options for patients with esophageal cancer; however, it has been linked with an increased risk of cardiac toxicities. In the current study, we evaluated the effect of planning the radiation in deep-inspiration breath hold (DIBH) on the dose sparing of cardiac substructures and lung. MATERIALS AND METHODS In this study, we analyzed 30 radiation therapy plans from 15 patients diagnosed with esophageal cancer planned for neoadjuvant radiotherapy. Radiation plans were generated for 41.4 Gy and delivered in 1.8 Gy per fraction for free-breathing (FB) and DIBH techniques. We then conducted a comparative dosimetric analysis, evaluating target volume coverage, the impact on cardiac substructures, and lung doses across the two planning techniques for each patient. RESULTS There was no significant disparity in target volume dose coverage between DIBH and FB plans. However, the Dmean, D2%, and V30% of the heart experienced substantial reductions in DIBH relative to FB, with values of 6.21 versus 7.02 Gy (p = 0.011), 35.28 versus 35.84 Gy (p = 0.047), and 5% versus 5.8% (p = 0.048), respectively. The Dmean of the left ventricle was notably lower in DIBH compared to FB (4.27 vs. 5.12 Gy, p = 0.0018), accompanied by significant improvements in V10. Additionally, the Dmean and D2% of the left coronary artery, as well as the D2% of the right coronary artery, were significantly lower in DIBH. The dosimetric impact of DIBH on cardiac substructures proved more advantageous for middle esophageal (ME) than distal esophageal (DE) tumors. CONCLUSION Radiotherapy in DIBH could provide a method to reduce the radiation dose to the left ventricle and coronaries, which could reduce the cardiac toxicity of the modality.
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Affiliation(s)
- Ahmed Allam Mohamed
- Department of Radiation Oncology, RWTH Aachen University Hospital, Pauwelstr. 30, 52074, Aachen, Germany.
- Center for Integrated Oncology Aachen, Bonn, Cologne and Duesseldorf (CIO ABCD), Aachen, Germany.
| | - Melina Nausikaa Douglas
- Department of Radiation Oncology, RWTH Aachen University Hospital, Pauwelstr. 30, 52074, Aachen, Germany
- Center for Integrated Oncology Aachen, Bonn, Cologne and Duesseldorf (CIO ABCD), Aachen, Germany
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, Germany
- Center for Integrated Oncology Aachen, Bonn, Cologne and Duesseldorf (CIO ABCD), Aachen, Germany
| | - Michael J Eble
- Department of Radiation Oncology, RWTH Aachen University Hospital, Pauwelstr. 30, 52074, Aachen, Germany
- Center for Integrated Oncology Aachen, Bonn, Cologne and Duesseldorf (CIO ABCD), Aachen, Germany
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Wang JZ, Wang Y, Shao Q, Li JB. Dynamic changes in cardiac biomarkers in radiotherapy for oesophageal cancer and their correlations with cardiac radiation dosimetry. Clin Transl Radiat Oncol 2024; 45:100750. [PMID: 38406646 PMCID: PMC10885730 DOI: 10.1016/j.ctro.2024.100750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 02/06/2024] [Accepted: 02/15/2024] [Indexed: 02/27/2024] Open
Abstract
Background and purpose To investigate the dynamic changes in cardiac enzymes, high-sensitivity troponin T (hs-TnT), pro-brain natriuretic peptide (pro-BNP) and left ventricular ejection fraction (LVEF) during radiotherapy (RT) and 6 months after RT for oesophageal squamous cell carcinoma (ESCC) in the middle and lower locations and to analyse the correlations between these indicators and cardiac radiation dosimetry parameters. Methods For 35 patients with ESCC in the middle and lower locations receiving radical concurrent chemoradiotherapy (cCRT), intensity-modulated RT was performed at 1.8 Gy or 2.0 Gy per day, and the totle dose was 50.4 Gy or 60 Gy. Serum creatine kinase (CK), creatine kinase isoenzyme (CK-MB), lactate dehydrogenase (LDH), alpha-hydroxybutyrate dehydrogenase (α-HBDH), hs-TnT, pro-BNP and LVEF were measured before, during, and at the end of RT and 1, 3 and 6 months after RT, and correlations of these indicators with mean heart dose (MHD) and heart V5-V50 were analysed. Results hs-TnT during, at the end and 6 months after RT for oesophageal cancer showed increasing trends, however, LVEF showed a downward trend. pro-BNP showed an increasing trend during RT and gradually returned to normal after RT. CK and CK-MB showed decreasing trends during RT and continued until one month after RT and then gradually returned to normal. Compared with the low-dose group (MHD < 2000 cGy), the high-dose group (MHD ≥ 2000 cGy) had larger increases in hs-TnT and pro-BNP, a more significant decrease in LVEF, and a longer recovery time for these indicators. MHD and V35 were positively correlated with dynamic changes in hs-TnT. Conclusions Cardiac injury caused by cCRT for ESCC in the middle and lower locations led to increased hs-TnT and pro-BNP levels and a decrease in LVEF in the early stage of treatment, effects that were more pronounced in the high-dose group. MHD and V35 may be potential indicators to predict the degree of cardiac damage. hs-TnT and pro-BNP are sensitive indicators reflecting cardiac injury in RT for oesophageal cancer. Continuous dynamic monitoring of these markers can provide a reference for cardiac protection in clinical RT.
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Affiliation(s)
- Jin-zhi Wang
- Shandong University Cancer Center, Jinan, Shandong Province 250012, PR China
- Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province 250012, PR China
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong Province 250117, PR China
| | - Yue Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong Province 250117, PR China
- Department of Radiology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong Province 250117, PR China
| | - Qian Shao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong Province 250117, PR China
| | - Jian-bin Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong Province 250117, PR China
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Dreyfuss AD, Velalopoulou A, Avgousti H, Bell BI, Verginadis II. Preclinical models of radiation-induced cardiac toxicity: Potential mechanisms and biomarkers. Front Oncol 2022; 12:920867. [PMID: 36313656 PMCID: PMC9596809 DOI: 10.3389/fonc.2022.920867] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 09/12/2022] [Indexed: 12/24/2022] Open
Abstract
Radiation therapy (RT) is an important modality in cancer treatment with >50% of cancer patients undergoing RT for curative or palliative intent. In patients with breast, lung, and esophageal cancer, as well as mediastinal malignancies, incidental RT dose to heart or vascular structures has been linked to the development of Radiation-Induced Heart Disease (RIHD) which manifests as ischemic heart disease, cardiomyopathy, cardiac dysfunction, and heart failure. Despite the remarkable progress in the delivery of radiotherapy treatment, off-target cardiac toxicities are unavoidable. One of the best-studied pathological consequences of incidental exposure of the heart to RT is collagen deposition and fibrosis, leading to the development of radiation-induced myocardial fibrosis (RIMF). However, the pathogenesis of RIMF is still largely unknown. Moreover, there are no available clinical approaches to reverse RIMF once it occurs and it continues to impair the quality of life of long-term cancer survivors. Hence, there is an increasing need for more clinically relevant preclinical models to elucidate the molecular and cellular mechanisms involved in the development of RIMF. This review offers an insight into the existing preclinical models to study RIHD and the suggested mechanisms of RIMF, as well as available multi-modality treatments and outcomes. Moreover, we summarize the valuable detection methods of RIHD/RIMF, and the clinical use of sensitive radiographic and circulating biomarkers.
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Radiation-Induced Cardiovascular Toxicities. Curr Treat Options Oncol 2022; 23:1388-1404. [DOI: 10.1007/s11864-022-01012-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 11/03/2022]
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Miller E, Mikrut K, Addison D. Assessing Silent Cardiotoxicity in Long-Term Lymphoma Survivors Treated With Radiotherapy. JACC CardioOncol 2021; 3:707-710. [PMID: 34988479 PMCID: PMC8702787 DOI: 10.1016/j.jaccao.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Eric Miller
- Department of Radiation Oncology, James Cancer Hospital and Solove Research Institute at The Ohio State University, Columbus, Ohio, USA
| | - Katarzyna Mikrut
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Daniel Addison
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, Ohio, USA
- Division of Cancer Prevention and Control, The Ohio State University, Columbus, Ohio, USA
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Lind L, Araujo JA, Barchowsky A, Belcher S, Berridge BR, Chiamvimonvat N, Chiu WA, Cogliano VJ, Elmore S, Farraj AK, Gomes AV, McHale CM, Meyer-Tamaki KB, Posnack NG, Vargas HM, Yang X, Zeise L, Zhou C, Smith MT. Key Characteristics of Cardiovascular Toxicants. ENVIRONMENTAL HEALTH PERSPECTIVES 2021; 129:95001. [PMID: 34558968 PMCID: PMC8462506 DOI: 10.1289/ehp9321] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND The concept of chemical agents having properties that confer potential hazard called key characteristics (KCs) was first developed to identify carcinogenic hazards. Identification of KCs of cardiovascular (CV) toxicants could facilitate the systematic assessment of CV hazards and understanding of assay and data gaps associated with current approaches. OBJECTIVES We sought to develop a consensus-based synthesis of scientific evidence on the KCs of chemical and nonchemical agents known to cause CV toxicity along with methods to measure them. METHODS An expert working group was convened to discuss mechanisms associated with CV toxicity. RESULTS The group identified 12 KCs of CV toxicants, defined as exogenous agents that adversely interfere with function of the CV system. The KCs were organized into those primarily affecting cardiac tissue (numbers 1-4 below), the vascular system (5-7), or both (8-12), as follows: 1) impairs regulation of cardiac excitability, 2) impairs cardiac contractility and relaxation, 3) induces cardiomyocyte injury and death, 4) induces proliferation of valve stroma, 5) impacts endothelial and vascular function, 6) alters hemostasis, 7) causes dyslipidemia, 8) impairs mitochondrial function, 9) modifies autonomic nervous system activity, 10) induces oxidative stress, 11) causes inflammation, and 12) alters hormone signaling. DISCUSSION These 12 KCs can be used to help identify pharmaceuticals and environmental pollutants as CV toxicants, as well as to better understand the mechanistic underpinnings of their toxicity. For example, evidence exists that fine particulate matter [PM ≤2.5μm in aerodynamic diameter (PM2.5)] air pollution, arsenic, anthracycline drugs, and other exogenous chemicals possess one or more of the described KCs. In conclusion, the KCs could be used to identify potential CV toxicants and to define a set of test methods to evaluate CV toxicity in a more comprehensive and standardized manner than current approaches. https://doi.org/10.1289/EHP9321.
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Affiliation(s)
- Lars Lind
- Department of Medical Sciences, Clinical Epidemiology, University of Uppsala, Sweden
| | - Jesus A. Araujo
- Division of Cardiology, David Geffen School of Medicine at University of California Los Angeles (UCLA), UCLA, Los Angeles, California, USA
- Department of Environmental Health Sciences, Fielding School of Public Health and Molecular Biology Institute, UCLA, Los Angeles, California, USA
| | - Aaron Barchowsky
- Department of Environmental and Occupational Health, Graduate School of Public Health, University of Pittsburgh, Pennsylvania, USA
| | - Scott Belcher
- Department of Biological Sciences, North Carolina State University, North Carolina, USA
| | - Brian R. Berridge
- Division of the National Toxicology Program, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, North Carolina, USA
| | - Nipavan Chiamvimonvat
- Department of Internal Medicine, University of California, Davis, Davis, California, USA
| | - Weihsueh A. Chiu
- College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, Texas, USA
| | - Vincent J. Cogliano
- Office of Environmental Health Hazard Assessment, California Environmental Protection Agency (EPA), Oakland, California, USA
| | - Sarah Elmore
- Office of Environmental Health Hazard Assessment, California Environmental Protection Agency (EPA), Oakland, California, USA
| | - Aimen K. Farraj
- Public Health and Integrated Toxicology Division, Center for Public Health and Environmental Assessment, U.S. EPA, Research Triangle Park, North Carolina, USA
| | - Aldrin V. Gomes
- Department of Neurobiology, Physiology and Behavior, College of Biological Sciences, University of California, Davis, Davis, California, USA
| | - Cliona M. McHale
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | | | - Nikki Gillum Posnack
- Children’s National Heart Institute and the Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC, USA
| | - Hugo M. Vargas
- Translational Safety & Bioanalytical Sciences, Amgen, Inc., Thousand Oaks, California, USA
| | - Xi Yang
- Division of Pharmacology and Toxicology, Office of Cardiology, Hematology, Endocrinology, and Nephrology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lauren Zeise
- Office of Environmental Health Hazard Assessment, California Environmental Protection Agency (EPA), Oakland, California, USA
| | - Changcheng Zhou
- Division of Biomedical Sciences, School of Medicine, University of California, Riverside, Riverside, California, USA
| | - Martyn T. Smith
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, California, USA
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Cardiomyocyte-Specific Circulating Cell-Free Methylated DNA in Esophageal Cancer Patients Treated with Chemoradiation. GASTROINTESTINAL DISORDERS 2021; 3:100-112. [PMID: 35531260 PMCID: PMC9074856 DOI: 10.3390/gidisord3030011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Thoracic high-dose radiation therapy (RT) for cancer has been associated with early and late cardiac toxicity. To assess altered rates of cardiomyocyte cell death due to RT we monitored changes in cardiomyocyte-specific, cell-free methylated DNA (cfDNA) shed into the circulation. Eleven patients with distal esophageal cancer treated with neoadjuvant chemoradiation to 50.4 Gy (RT) and concurrent carboplatin and paclitaxel were enrolled. Subjects underwent fasting blood draws prior to the initiation and after completion of RT as well as 4–6 months following RT. An island of six unmethylated CpGs in the FAM101A locus was used to identify cardiomyocyte-specific cfDNA in serum. After bisulfite treatment this specific cfDNA was quantified by amplicon sequencing at a depth of >35,000 reads/molecule. Cardiomyocyte-specific cfDNA was detectable before RT in the majority of patient samples and showed some distinct changes during the course of treatment and recovery. We propose that patient-specific cardiac damages in response to the treatment are indicated by these changes although co-morbidities may obscure treatment-specific events.
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Lee SL, Bassetti M, Meijer GJ, Mook S. Review of MR-Guided Radiotherapy for Esophageal Cancer. Front Oncol 2021; 11:628009. [PMID: 33828980 PMCID: PMC8019940 DOI: 10.3389/fonc.2021.628009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/02/2021] [Indexed: 12/24/2022] Open
Abstract
In this review, we outline the potential benefits and the future role of MRI and MR-guided radiotherapy (MRgRT) in the management of esophageal cancer. Although not currently used in most clinical practice settings, MRI is a useful non-invasive imaging modality that provides excellent soft tissue contrast and the ability to visualize cancer physiology. Chemoradiation therapy with or without surgery is essential for the management of locally advanced esophageal cancer. MRI can help stage esophageal cancer, delineate the gross tumor volume (GTV), and assess the response to chemoradiotherapy. Integrated MRgRT systems can help overcome the challenge of esophageal motion due to respiratory motion by using real-time imaging and tumor tracking with respiratory gating. With daily on-table MRI, shifts in tumor position and tumor regression can be taken into account for online-adaptation. The combination of accurate GTV visualization, respiratory gating, and online adaptive planning, allows for tighter treatment volumes and improved sparing of the surrounding normal organs. This could lead to a reduction in radiotherapy induced cardiac toxicity, pneumonitis and post-operative complications. Tumor physiology as seen on diffusion weighted imaging or dynamic contrast enhancement can help individualize treatments based on the response to chemoradiotherapy. Patients with a complete response on MRI can be considered for organ preservation while patients with no response can be offered an earlier resection. In patients with a partial response to chemoradiotherapy, areas of residual cancer can be targeted for dose escalation. The tighter and more accurate targeting enabled with MRgRT may enable hypofractionated treatment schedules.
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Affiliation(s)
- Sangjune Laurence Lee
- Department of Oncology, Division of Radiation Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada
| | - Michael Bassetti
- Department of Human Oncology, University of Wisconsin Hospital and Clinics, Madison, WI, United States
| | - Gert J. Meijer
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Stella Mook
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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