Radiation-induced coronary artery disease: a difficult clinical conundrum

Surgical coronary angioplasty of both coronary ostia after chest radiotherapy. Is it good alternative to conventional coronary bypass surgery?

INTRODUCTION

Isolated coronary ostial stenosis of both ostia is a rare, potentially life-threatening condition, occurring in 0.1%-0.2% of patients undergoing coronary angiography.

CASE REPORT

We present a case of a 69-year-old woman with a past medical history of breast cancer, who had been treated with radiotherapy, which most likely caused significant stenosis of both coronary ostia and likely accelerated aortic stenosis. Surgical angioplasty with autopericardium patch reconstruction of the left main coronary artery and right coronary arteries due to proximal stenotic disease was performed instead of venous or arterial bypasses with concomitant aortic valve replacement. The postoperative course was uneventful. There were no cardiovascular events 5 years after operation, and the patient remained free of any symptoms.

CONCLUSIONS

Surgical coronary angioplasty offers an alternative to conventional coronary artery bypass grafting in isolated coronary ostial lesions and is advantageous in restoring more physiological myocardial perfusion, especially in those cases when conduits are suspected to be fibrotic, scarred or stenosed after radiation therapy or if there is the need to preserve conduits for future myocardial revascularisation in young patients.

Navigating the Complexities of Radiation Injuries: Therapeutic Principles and Reconstructive Strategies

Radiation injuries, particularly those resulting from therapeutic or accidental exposure, present complex challenges for medical management. These injuries can manifest localized skin damage or extend to deeper tissues, presenting as various clinical entities that require treatment strategies, ranging from conservative management to complex surgical interventions. Radiation treatment constitutes a fundamental component of neoplastic management, with nearly two out of three oncological instances undergoing it as an element of their therapeutic strategy. The therapeutic approach to radiation injury consists of expanding prophylactic measures while maintaining the efficacy of treatment, such as conservative treatment or local debridement followed by reconstruction. The armamentarium of reconstructive methods available for plastic surgeons, from secondary healing to free tissue transfer, can be successfully applied to radiation injuries. However, the unique pathophysiological changes induced by radiation necessitate a careful and specialized approach for their application, considering the altered tissue characteristics and healing dynamics. The therapeutic strategy is guided by both the severity and progression of the injury, with the primary aim of restoring functionality and aesthetic aspects while simultaneously minimizing the risk of complications. This paper explores the various conditions encompassed by the term "radiation injury," reviews both non-surgical and surgical therapeutic strategies for managing these injuries, and highlights the unique challenges associated with treating irradiated tissues within specific oncological contexts.

Pulsed Electromagnetic Fields (PEMFs) Trigger Cell Death and Senescence in Cancer Cells

The currently available anti-cancer therapies, such as gamma-radiation and chemotherapeutic agents, induce cell death and cellular senescence not only in cancer cells but also in the adjacent normal tissue. New anti-tumor approaches focus on limiting the side effects on normal cells. In this frame, the potential anti-tumor properties of Pulsed Electromagnetic Fields (PEMFs) through the irradiation of breast cancer epithelial cells (MCF-7 and MDA-MB-231) and normal fibroblasts (FF95) were investigated. PEMFs had a frequency of 8 Hz, full-square wave type and magnetic flux density of 0.011 T and were applied twice daily for 5 days. The data collected showcase that PEMF application decreases the proliferation rate and viability of breast cancer cells while having the opposite effect on normal fibroblasts. Moreover, PEMF irradiation induces cell death and cellular senescence only in breast cancer cells without any effect in the non-cancerous cells. These findings suggest PEMF irradiation as a novel, non-invasive anti-cancer strategy that, when combined with senolytic drugs, may eliminate both cancer and the remaining senescent cells, while simultaneously avoiding the side effects of the current treatments.

Cardiac surgery for radiation associated heart disease in Hodgkin lymphoma patients

Much of the modern focus of Hodgkin's Lymphoma (HL) treatment involves the prevention of secondary organ injury. Despite rationalisations of radiotherapy fields, many patients still develop late radiation-related cardiotoxicity that is severe and requires interventional management. No guidelines exist to direct management of these complex patients who often present with multiple concurrent cardiac pathologies. Despite possessing a greater mortality risk than in the general population, cardiac surgery has an important role in treating radiation-associated heart disease. This review summarises the body of literature surrounding cardiac surgery in HL survivors post-radiotherapy, highlighting the benefits and risks unique to this cohort. The pathophysiology and presentation of radiation-associated heart disease is also explored in relation to HL patients.

The role of cardiac surgery in radiation-associated heart disease: a scoping review

BACKGROUND

Thoracic irradiation is an important tool in the treatment of breast cancer, non-Hodgkin's lymphoma, and other cancers of the chest. The heart is commonly involved in these radiation fields, and young patients can present with severe cardiac pathologies requiring surgical intervention. However, this population poses a high surgical risk due to involvement of mediastinal tissues, and there are no consensus guidelines on best practice management.

AIM

This review aims to summarise the current experience of surgical correction of radiation-associated heart disease. We explore outcomes, technique modifications and alternative therapies for the three primary procedures performed: coronary artery bypass grafting, valvular intervention and pericardiectomy.

METHODS

OVID Medline and PubMed databases were comprehensively searched to identify all studies involving surgery in patients with prior chest radiotherapy. All relevant studies within the past 25 years have been discussed.

CONCLUSION

Irradiated patients have heightened peri-operative risk, but other than redo surgery, these operations are not as treacherous as once thought. Involvement of all layers of the heart, especially the myocardium, is such that long-term mortality suffers despite optimal surgical correction. The goal of surgery in this cohort should be for a quick and safe operation, rather than a technically difficult procedure aimed at longevity.

Sex-Based Differences in Clinical Outcomes of Acute Coronary Syndrome Among Patients With Mediastinal Radiation Exposure: Insights From The National Inpatient Sample (2009-2020)

There is a paucity of data about the sex differences in acute coronary syndrome (ACS) outcomes in patients with prior mediastinal radiation. The National Inpatient Sample database from years 2009 to 2020 were queried for ACS hospitalizations of patients with prior mediastinal radiation. The primary outcome was MACCE (major cardiovascular events), and secondary outcomes included other clinical outcomes. A total of 23,385 hospitalizations for ACS with prior mediastinal radiation exposure ([15,904 (68.01%) females, and 7481 (31.99%) males]) were included in analysis. Males were slightly younger than females (median, age (70 [62-78] vs 72 [64-80]). Female patients with ACS had a higher burden of hypertension (80.82% vs 73.55%), diabetes mellitus (33% vs 28.35%), hyperlipidemia (66.09% vs 62.2%), obesity (17.02% vs 8.6%) however, males had a higher burden of peripheral vascular disease (18.29% vs 12.51%), congestive heart failure (41.8% vs 39.35%) and smoking (70.33% vs 46.92%). After propensity matching, primary outcome MACCE was higher in males (20.85% vs 13.29%, aOR: 1.80 95% CI (1.65-1.96), P < 0.0001) along with cardiogenic shock (8.74% vs 2.42%, aOR: 1.77 95% CI (1.55-2.02), P < 0.0001) and mechanical circulatory support use (aOR: 1.48 95% CI [1.29 -1.71], P < 0.0001). We observed no differences in the length of hospital stay, however total hospitalization cost was higher in males. This nationwide analysis showed significant disparities in outcomes among male and female ACS patients with prior mediastinal radiation history, with increasing trend in hospitalization for ACS among males and females but decreasing mortality among females.

Forty years after mediastinal radiotherapy for Hodgkin lymphoma: how late is late cardiotoxicity? A case report

Radiation-associated cardiovascular disease is well-described yet under-recognized. Mediastinal radiation is known to affect any component of the heart. We present a case of valvular, coronary, and conduction abnormalities up to decades after initial radiotherapy.

Imaging in translational cancer research

This review is aimed at presenting some of the recent developments in translational cancer imaging research, with a focus on novel, recently established, or soon to be established cross-sectional imaging techniques for computed tomography (CT), magnetic resonance imaging (MRI), and positron-emission tomography (PET) imaging, including computational investigations based on machine-learning techniques.

Myocardial Ischemia Related to Common Cancer Therapy-Prevention Insights

Modern antineoplastic therapy improves survival and quality of life in cancer patients, but its indisputable benefits are accompanied by multiple and major side effects, such as cardiovascular ones. Endothelial dysfunction, arterial spasm, intravascular thrombosis, and accelerated atherosclerosis affect the coronary arteries, leading to acute and chronic coronary syndromes that negatively interfere with the oncologic treatment. The cardiac toxicity of antineoplastic agents may be mitigated by using adequate prophylactic measures. In the absence of dedicated guidelines, our work provides the most comprehensive, systematized, structured, and up-to-date analyses of the available literature focusing on measures aiming to protect the coronary arteries from the toxicity of cancer therapy. Our work facilitates the implementation of these measures in daily practice. The ultimate goal is to offer clinicians the necessary data for a personalized therapeutic approach for cancer patients receiving evidence-based oncology treatments with potential cardiovascular toxicity.