Cardiovascular complications after radiotherapy

Cardiac substructures dosimetric predicts cardiac toxicity and prognosis in esophageal squamous cell cancer treated by radiotherapy

PURPOSE

To look into the relationship between cardiac substructures (CS) dosimetric parameters and cardiac events (CE) or overall survival (OS) in patients undergoing radiation therapy (RT) for esophageal squamous cell carcinoma (ESCC).

METHODS AND MATERIALS

A retrospective study included 350 patients with ESCC receiving definitive chemoradiotherapy or radiotherapy (d-CRT/d-RT) or neoadjuvant chemoradiotherapy (NCRT) from March 2013 to May 2022. Our study examined the adverse cardiac events of any grade or G3+, as defined by the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. Competing risk analysis and Cox regression analysis were used to assess the relationship between CS doses and CEs or OS.

RESULTS

201 (57.4 %) patients received any grade CEs over a median follow-up time of 22.50 months (IQR, 12.40-45.60), and 24 (6.86 %) patients suffered G3+ CEs. On landmark analysis, patients with any grade CEs had significantly lower OS (P = 0.003). Multivariable analysis revealed that any grade CEs were predicted by the dose of CSs in all populations. In addition, for G3+ cardiac events, arrhythmic and small probability of cardiac events, LAD V20 ((HR: 1.02, 95 % CI: 1.00-1.03, P = 0.012; HR: 1.01, 95 % CI: 1.00-1.02, P = 0.005; HR; 1.01, 95 % CI: 1.00-1.02, P = 0.012) was also an independent predictive factor. LAD V50 (HR: 1.07, 95 % CI: 1.03-1.10, P <0.001) predicted pericardium effusion events. Moreover, the multivariable analysis revealed that OS was predicted by LAD V30 (HR: 1.03; 95 % CI, 1.01-1.05, P = 0.015).

CONCLUSIONS

In the population of ESCC patients receiving RT, we showed that the CS factors had a substantial predictive value for the various types and grades of CEs. The elevated radiation dose of LAD was a significant contributor to a higher rate of cardiac events and a worse prognosis.

Predicting Adverse Cardiac Events After Radiotherapy for Locally Advanced Non-Small Cell Lung Cancer

Background

Radiotherapy may cause grade ≥3 cardiac events, necessitating a better understanding of risk factors. The potential predictive role of imaging biomarkers with radiotherapy doses for cardiac event occurrence has not been studied.

Objectives

The aim of this study was to establish the associations between cardiac substructure dose and coronary artery calcium (CAC) scores and cardiac event occurrence.

Methods

A retrospective cohort analysis included patients with locally advanced non-small cell lung cancer treated with radiotherapy (2006-2018). Cardiac substructures, including the left anterior descending coronary artery, left main coronary artery, left circumflex coronary artery, right coronary artery, and TotalLeft (left anterior descending, left main, and left circumflex coronary arteries), were contoured. Doses were measured in 2-Gy equivalent units, and visual CAC scoring was compared with automated scoring. Grade ≥3 adverse cardiac events were recorded. Time-dependent receiver-operating characteristic modeling, the log-rank statistic, and competing-risk models were used to measure prediction performance, threshold modeling, and the cumulative incidence of cardiac events, respectively.

Results

Of the 233 eligible patients, 61.4% were men, with a median age of 68.1 years (range: 34.9-90.7 years). The median follow-up period was 73.7 months (range: 1.6-153.9 months). Following radiotherapy, 22.3% experienced cardiac events, within a median time of 21.5 months (range: 1.7-118.9 months). Visual CAC scoring showed significant correlation with automated scoring (r = 0.72; P < 0.001). In a competing-risk multivariable model, TotalLeft volume receiving 15 Gy (per 1 cc; HR: 1.38; 95% CI: 1.11-1.72; P = 0.004) and CAC score >5 (HR: 2.51; 95% CI: 1.08-5.86; P = 0.033) were independently associated with cardiac events. A model incorporating age, TotalLeft CAC (score >5), and volume receiving 15 Gy demonstrated a higher incidence of cardiac events for a high-risk group (28.9%) compared with a low-risk group (6.9%) (P < 0.001).

Conclusions

Adverse cardiac events associated with radiation occur in more than 20% of patients undergoing thoracic radiotherapy within a median time of <2 years. The present findings provide further evidence to support significant associations between TotalLeft radiotherapy dose and cardiac events and define CAC as a predictive risk factor.

[Left ventricular dysfunction in patients following high-dose chemotherapy and autologous hematopoietic stem cell transplantation]

AIM

To evaluate the dynamics of LV global longitudinal strain (GLS) and other EchoCG parameters after high-dose chemotherapy (HDCT) and autologous hematopoietic stem cell transplantation (aHSCT).

MATERIAL AND METHODS

The risk of LV dysfunction in patients after HDCT followed by aHSCT has not been sufficiently studied. This study included 74 patients with hemoblastosis aged 20 to 65 years who had undergone HDCT followed by aHSCT. All patients had a history of antitumor treatment. EchoCG with assessment of LV GLS and measurements of troponin T and N-terminal pro-brain natriuretic peptide (NT-proBNP) were performed for all patients before and after the treatment.

RESULTS

A decrease in GLS by 15 % or more from the baseline was detected in 6 (8.1 %) patients. The decrease in GLS was associated with increased NT-proBNP >125 pg / ml at baseline (odds ratio, 8.667; 95 % confidence interval, 1.419-52.942; p=0.022).

CONCLUSION

The decrease in LV GLS in patients after aHSCT was associated with increased NT-proBNP before the intervention.

Premature senescence and cardiovascular disease following cancer treatments: mechanistic insights

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality, especially among the aging population. The "response-to-injury" model proposed by Dr. Russell Ross in 1999 emphasizes inflammation as a critical factor in atherosclerosis development, with atherosclerotic plaques forming due to endothelial cell (EC) injury, followed by myeloid cell adhesion and invasion into the blood vessel walls. Recent evidence indicates that cancer and its treatments can lead to long-term complications, including CVD. Cellular senescence, a hallmark of aging, is implicated in CVD pathogenesis, particularly in cancer survivors. However, the precise mechanisms linking premature senescence to CVD in cancer survivors remain poorly understood. This article aims to provide mechanistic insights into this association and propose future directions to better comprehend this complex interplay.

Accelerated Atherosclerosis and Cardiovascular Toxicity Induced by Radiotherapy in Breast Cancer

The number of patients diagnosed with breast cancer and cardiovascular disease is continuously rising. Treatment options for breast cancer have greatly evolved, but radiotherapy (RT) still has a key role in it. Despite many advances in RT techniques, cardiotoxicity is one of the most important side effects. The new cardio-oncology guidelines recommend a baseline evaluation, risk stratification and follow-up of these patients. Cardiotoxicity induced by RT can be represented by almost all forms of cardiovascular disease, with atherosclerosis being the most frequent. An interdisciplinary team should manage these patients, in order to have maximum therapeutic effect and minimum cardiovascular toxicity. This review will summarize the current incidence, risk factors, mechanisms and follow-up of RT-induced cardiovascular toxicity.

Quantitative assessment of radiotherapy-induced myocardial damage using MRI: a systematic review

PURPOSE

To determine the role of magnetic resonance imaging (MRI)-based metrics to quantify myocardial toxicity following radiotherapy (RT) in human subjects through review of current literature.

METHODS

Twenty-one MRI studies published between 2011-2022 were identified from available databases. Patients received chest irradiation with/without other treatments for various malignancies including breast, lung, esophageal cancer, Hodgkin's, and non-Hodgkin's lymphoma. In 11 longitudinal studies, the sample size, mean heart dose, and follow-up times ranged from 10-81 patients, 2.0-13.9 Gy, and 0-24 months after RT (in addition to a pre-RT assessment), respectively. In 10 cross-sectional studies, the sample size, mean heart dose, and follow-up times ranged from 5-80 patients, 2.1-22.9 Gy, and 2-24 years from RT completion, respectively. Global metrics of left ventricle ejection fraction (LVEF) and mass/dimensions of cardiac chambers were recorded, along with global/regional values of T1/T2 signal, extracellular volume (ECV), late gadolinium enhancement (LGE), and circumferential/radial/longitudinal strain.

RESULTS

LVEF tended to decline at >20 years follow-up and in patients treated with older RT techniques. Changes in global strain were observed after shorter follow-up (13±2 months) for concurrent chemoradiotherapy. In concurrent treatments with longer follow-up (8.3 years), increases in left ventricle (LV) mass index were correlated with LV mean dose. In pediatric patients, increases in LV diastolic volume were correlated with heart/LV dose at 2 years post-RT. Regional changes were observed earlier post-RT. Dose-dependent responses were reported for several parameters, including: increased T1 signal in high-dose regions, a 0.136% increase of ECV per Gy, progressive increase of LGE with increasing dose at regions receiving >30 Gy, and correlation between increases in LV scarring volume and LV mean/V10/V25 Gy dose.

CONCLUSION

Global metrics only detected changes over longer follow-up, in older RT techniques, in concurrent treatments, and in pediatric patients. In contrast, regional measurements detected myocardial damage at shorter follow-up and in RT treatments without concurrent treatment and had greater potential for dose-dependent response. The early detection of regional changes suggests the importance of regional quantification of RT-induced myocardial toxicity at early stages, before damage becomes irreversible. Further works with homogeneous cohorts are required to examine this matter.

Cardio-Oncology: Mechanisms, Drug Combinations, and Reverse Cardio-Oncology

Chemotherapy, radiotherapy, targeted therapy, and immunotherapy have brought hope to cancer patients. With the prolongation of survival of cancer patients and increased clinical experience, cancer-therapy-induced cardiovascular toxicity has attracted attention. The adverse effects of cancer therapy that can lead to life-threatening or induce long-term morbidity require rational approaches to prevention and treatment, which requires deeper understanding of the molecular biology underpinning the disease. In addition to the drugs used widely for cardio-protection, traditional Chinese medicine (TCM) formulations are also efficacious and can be expected to achieve “personalized treatment” from multiple perspectives. Moreover, the increased prevalence of cancer in patients with cardiovascular disease has spurred the development of “reverse cardio-oncology”, which underscores the urgency of collaboration between cardiologists and oncologists. This review summarizes the mechanisms by which cancer therapy induces cardiovascular toxicity, the combination of antineoplastic and cardioprotective drugs, and recent advances in reverse cardio-oncology.

Differential Radiomodulating Action of Olea europaea L. cv. Caiazzana Leaf Extract on Human Normal and Cancer Cells: A Joint Chemical and Radiobiological Approach

The identification of a natural compound with selectively differential radiomodulating activity would arguably represent a valuable asset in the striving quest for widening the therapeutic window in cancer radiotherapy (RT). To this end, we fully characterized the chemical profile of olive tree leaf polyphenols from the Caiazzana cultivar (OLC), autochthonous to the Campania region (Italy), by ultra-high-performance liquid chromatography–high-resolution mass spectrometry (UHPLC-HR-MS). Oleacein was the most abundant molecule in the OLC. Two normal and two cancer cells lines were X-ray-irradiated following 24-h treatment with the same concentration of the obtained crude extract and were assessed for their radioresponse in terms of micronucleus (MN) induction and, for one of the normal cell lines, of premature senescence (PS). Irradiation of pre-treated normal cells in the presence of the OLC reduced the frequency of radiation-induced MN and the onset of PS. Conversely, the genotoxic action of ionising radiation was exacerbated in cancer cells under the same experimental conditions. To our knowledge, this is the first report on the dual action of a polyphenol-rich olive leaf extract on radiation-induced damage. If further confirmed, these findings may be pre-clinically relevant and point to a substance that may potentially counteract cancer radioresistance while reducing RT-associated normal tissue toxicity.

Post-Cardiac Arrest PCI is Underutilized Among Cancer Patients: Machine Learning Augmented Nationally Representative Case-Control Study of 30 Million Hospitalizations

BACKGROUND

Cancer patients are less likely to undergo percutaneous coronary intervention (PCI) after cardiac arrest, although they demonstrate improved mortality benefit from the procedure. We produced the largest nationally representative analysis of mortality of cardiac arrest and PCI for patients with cancer versus non-cancer.

METHODS

Propensity score adjusted multivariable regression for mortality was performed in this case-control study of the United States' largest all-payer hospitalized dataset, the 2016 National Inpatient Sample. Regression models of mortality and PCI weighted by the complex survey design were fully adjusted for age, race, income, cancer metastases, NIS-calculated mortality risk by Diagnosis Related Group (DRG), acute coronary syndrome, and likelihood of undergoing PCI RESULTS: Of the 30,195,722 hospitalized adult patients, 15.43% had cancer, and 0.79% of the whole sample presented with cardiac arrest (of whom 20.57% underwent PCI). In fully adjusted regression analysis among patients with cardiac arrest, PCI significantly reduced mortality (OR 0.15, 95%CI 0.13-0.19; p<0.001) among patients with cancer greater than those without it (OR 0.21, 95%CI 0.20-0.23; p<0.001).

CONCLUSIONS

This nationally representative study suggests that post-cardiac arrest PCI is underutilized among patients with cancer despite its significant mortality reduction for such patients (independent of clinical acuity).

The Influence of Radiotherapy on the Function of the Left and Right Ventricles in Relation to the Radiation Dose Administered to the Left Anterior Descending Coronary Artery—From a Cardiologist’s Point of View

The aim of this study was to assess the effects of radiotherapy involving the heart on LV and RV function using modern speckle-tracking echocardiography (STE), and in relation to the radiation dose applied to the LAD. This retrospective, single-centre study included 12 patients after a median of 51 months after irradiation for mediastinal lymphoma, in whom we were able to delineate the LAD. Correlations between doses of ionising radiation and echocardiographic parameters reflecting the systolic function of the LV and RV were analysed. The median irradiation dose delivered to the whole heart was 16.4 Gy (0.5–36.2 Gy), and to the LAD it was 15.1 Gy (0.3–35.3 Gy). LV longitudinal strain (LS) was impaired in the anteroseptal and anterior walls. Parameters reflecting RV function were normal, with the exception of RV myocardial performance index (RIMP). Significant correlations were found between the median dose to the LAD and LV global LS (rho = 0.6468, p = 0.034), the maximum dose to the LAD and LV anterior LS (rho = 0.6046, p = 0.049), the median and the mean dose to the whole heart and LV anterior LS (R = 0.772, p = 0.009 and rho = 0.7676, p = 0.01, respectively), and the total irradiation dose and RIMP (rho = 0.5981, p = 0.04). The calculation of irradiation doses allows the identification of patients at risk of cardiac dysfunction detected by modern STE.

Long-Term Cardiac Damage Associated With Abdominal Irradiation in Mice

Aims: Irradiation is an effective treatment for tumors but has been associated with cardiac dysfunction. However, the precise mechanisms remain incompletely elucidated. This study investigated the long-term cardiac damage associated with abdominal irradiation and explored possible mechanisms.

Methods and Results: Wild-type C57BL6/J mice were divided into two groups: untreated controls (Con) and treatment group receiving 15 Gy of abdominal gamma irradiation (AIR). Both groups received normal feeding for 12 months. The AIR group showed reductions in left ventricular ejection fraction (LVEF), fractional shortening (FS), left ventricular end-diastolic internal diameter (LVID; d), left ventricular end-diastolic volume (LV Vol. diastolic volume (LV Vol; d) and mitral transtricuspid flow late diastolic filling velocity (MV A). It also showed increased fibrosis, reduced conduction velocity and increased conduction heterogeneity. Non-targeted metabolomics showed the differential metabolites were mainly from amino acid metabolism. Further KEGG pathway annotation and enrichment analysis revealed that abnormalities in arginine and proline metabolism, lysine degradation, d-arginine and d-ornithine metabolism, alanine, aspartate and glutamate metabolism, and arginine biosynthesis.

Conclusion: Abdominal irradiation causes long-term damage to the non-irradiated heart, as reflected by electrical and structural remodeling and mechanical dysfunction associated with abnormal amino acid biosynthesis and metabolism.

Breast Radiotherapy-Related Cardiotoxicity. When, How, Why. Risk Prevention and Control Strategies

In recent decades, improvements in breast cancer management have increased overall patient survival; however, many cancer therapies have been linked to an important risk of cardiovascular adverse events. Cardio-oncology has been proposed as an emerging specialty to coordinate preventive strategies that improve the cardiovascular health of oncologic patients. It employs the most suitable personalized multidisciplinary management approach for each patient to optimize their cardiovascular health and improve their survival and quality of life. Radiotherapy is an essential part of the therapeutic regimen in breast cancer patients but can also increase the risk of cardiovascular disease. Therefore, minimizing the negative impact of radiation therapy is an important challenge for radiotherapy oncologists and cardiologists specializing in this field. The aim of the present review is to update our knowledge about radiation-induced cardiotoxicity in breast cancer patients by undertaking a critical review of the relevant literature to determine risk prevention and control strategies currently available.

Aortic valve stenosis and cancer: a common and complex association

Introduction. The prevalence of aortic valve stenosis (AS) and malignancy are both high, especially in elderly people and in developed countries. These two conditions frequently coexist and share the same risk factors as atherosclerotic disease.Area covered. The progression of calcified AS may be accelerated by both cardiovascular risk factors and cancer treatments, such as radiotherapy. The standard treatment for symptomatic severe AS is surgical aortic valve replacement; however, in cancer patients, transcatheter implantation may be preferred as they are often at high-risk for cardiac surgery. In patients with AS and cancer, physicians may face difficult treatment decisions.To date, there is limited information on the impact of malignancy on outcomes in patients with severe AS; hence, there is no established treatment policy.Expert Opinion. Treating clinicians must integrate complex information about the severity of valve disease and expected cardiac outcomes with information regarding the cancer prognosis and the need for specific treatment, including surgery. Other comorbidities, age and frailty also contribute to decision-making about whether, when, and how to perform aortic valve replacement.

Attenuating Treatment-Related Cardiotoxicity in Women Recently Diagnosed With Breast Cancer via a Tailored Therapeutic Exercise Program: Protocol of the ATOPE Trial

OBJECTIVE

Therapeutic exercise is already used to ameliorate some of the side effects of cancer treatment. Recent studies examined its preventive potential regarding treatment-related toxicity, which can increase the risk of functional decline and lead to disease recurrence and death. This trial will examine whether the Tailored Therapeutic Exercise and Recovery Strategies (ATOPE) program, performed before treatment, can mitigate the onset and extent of cardiotoxicity beyond that achieved when the program is followed during treatment in recently diagnosed breast cancer patients.

METHODS

The intervention has a preparatory phase plus 12 to 18 sessions of tailored, high-intensity exercise, and post-exercise recovery strategies. A total of 120 women recently diagnosed with breast cancer, at risk of cardiotoxicity due to anticancer treatment awaiting surgery followed by chemotherapy and/or radiotherapy, will be randomized to either group. In a feasibility study, measurements related to recruitment rate, satisfaction with the program, adherence to them, the retention of participants, safety, and adverse effects will be explored. In the main trial, the efficacy of these interventions will be examined. The major outcome will be cardiotoxicity, assessed echocardiographically via the left ventricular ejection fraction. Other clinical, physical, and anthropometric outcomes and biological and hormonal variables will also be assessed after diagnosis, after treatment, 1 year after treatment ends, and 3 years after treatment ends.

CONCLUSION

Given its potential effect on patient survival, the mitigation of cardiotoxicity is a priority, and physical therapists have an important role in this mitigation. If the ATOPE intervention performed before treatment returns better cardioprotection results, it may be recommendable that patients recently diagnosed follow this program.

IMPACT

The ATOPE program will highlight the need for a physical therapist intervention from the moment of diagnosis, in the prevention or mitigation of cardiotoxicity, in women with breast cancer. It could help physical therapists to establish an adequate therapeutic exercise dose adapted to breast cancer patients and to propose correct therapeutic exercise prescription according to the assimilation of the sessions.

Case Report: Adjuvant Radiotherapy Can Be an Effective Treatment for Intimal Sarcoma of the Heart

Intimal sarcoma of the heart is a sporadic disease, which involves symptoms of cardiac insufficiency due to a fast-growing intraluminal mass. Tumor resection is the first-line treatment, although its location precludes excision with wide uninvolved margins. Despite the aggressiveness of this neoplasm and a high risk of recurrence even after removal by microscopically radical surgery, no standard adjuvant therapy has been established. Chemotherapy is used either as an adjuvant treatment or in cases of advanced disease. In contrast, the use of radiotherapy is rare and usually considered in a palliative setting because the risk of radiation-induced heart disease after high-dose radiotherapy to the heart is significant. Herein, we present the cases of two patients, both diagnosed with cardiac intimal sarcoma, who received irradiation after tumor resection. In both cases, radiotherapy was effective, providing long-lasting local disease control. We regularly monitored cardiac function in both patients to assess the impact of radiotherapy on tumor-free heart structures. The excellent local control of the disease with only mild long-term cardiac dysfunction in both patients suggests that radiotherapy can be a useful treatment modality in this indication.

Clinical Outcomes after Transcatheter Aortic Valve Replacement in Cancer Survivors Treated with Ionizing Radiation

BACKGROUND

Improved cancer survival in patients treated with thoracic ionizing radiation (XRT) has resulted in unanticipated surge of aortic stenosis. Transcatheter aortic valve replacement (TAVR) has revolutionized the management of severe aortic stenosis. However, long-term clinical outcomes in radiation-exposed cohorts undergoing TAVR are unknown. We compared the all-cause mortality and major adverse cardiac events (MACE) in patients with prior chest XRT (C-XRT) undergoing TAVR.

METHODS

This is an observational cohort study in subjects who underwent TAVR for symptomatic severe aortic stenosis from 2012 to 2017 in a tertiary care referral center. We examined the all-cause mortality and MACE using cox proportional hazard analysis to identify the clinical predictors of survival in the cohort of patients who had a history of prior C-XRT for malignancy.

RESULTS

Of the 610 patients who underwent TAVR for symptomatic severe aortic stenosis, 75 had prior C-XRT. The majority of C-XRT patients had prior breast cancer (44%) followed by Hodgkin's lymphoma (31%), with the median time from XRT to TAVR of 19.0 years. During a mean follow up of 17.1 months after TAVR, all-cause mortality was 17%. Those with prior C-XRT had higher all-cause mortality (XRT: 29%; non-XRT:15%, p<0.01) and MACE (XRT: 57%; non-XRT: 27%, p<0.001) after TAVR. Patients with prior XRT had a higher incidence of atrial fibrillation (XRT: 48 %; non-XRT: 2.4%, p<0.01) and high-grade heart block (XRT: 20%; non-XRT: 9.1%, p=0.007) requiring pacemaker implant after TAVR. On multivariate cox proportional hazard analysis, prior XRT (HR: 2.07, p=0.003), poor renal function (HR: 1.29, p<0.001) and post-operative anemia requiring transfusion (HR: 1.16, p:0.001) were the strongest predictors of reduced survival.

CONCLUSIONS

Cancer survivors with prior C- XRT have higher incidence of all-cause mortality and MACE after TAVR. Careful patient selection and follow-up strategies are needed to improve outcomes.