1
|
Robinson CG, Contreras C, Moore KMS, Rentschler S, Schwarz JK, Bergom C, Knutson N, Prusator MT, Goddu SM, Hugo GD, Cuculich P, Samson P. Radiotherapy Dose as a Predictor of Outcomes Following Cardiac Radioablation for High-risk Refractory VT. Int J Radiat Oncol Biol Phys 2023; 117:e204. [PMID: 37784859 DOI: 10.1016/j.ijrobp.2023.06.1084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Cardiac radioablation (CRA) is an emerging treatment for high-risk refractory ventricular tachycardia (VT). Despite a fixed prescription dose to the planning target volume (PTV) there is still considerable heterogeneity in the radiotherapy dose distribution due to planning technique, proximity to organs at risk, and radiation oncologist preference. The hypothesis is that plans with an inherently "hotter" internal dose to the PTV may lead to improved VT outcomes. MATERIALS/METHODS Single-center, IRB-approved retrospective case series of patients with refractory VT who had failed at least one prior CA (or were unfit for CA) treated with CRA. All patients were treated with a single fraction of 25 Gy prescribed to the PTV. Maximum dose to PTV was collected from each plan and stratified as high vs low above and below the median. Maximum dose was defined as the highest dose delivered to the "hottest" 0.035 cc of the PTV to avoid known variability in reporting of dose to single voxels within the treatment planning system. Rates of survival (OS), freedom from shock and/or storm (FFSS), and freedom from death, shock, and/or storm (FFDSS) were collected, and stratified by maximum dose to the PTV. Formal statistical comparisons were not performed due to limited patient numbers. RESULTS From 2015-2020, 22 patients were treated with CRA (18 with prior CA, 4 unfit for CA) for high-risk refractory VT. Median age was 64.5 years (range, 49-84), and 90.9% were male. 50% had ICM, with a median NYHA class of 3 (range, 1-4) and median EF of 25% (range, 15-58%). Median follow-up was 31.3 months. 2-year OS was 54.5%, FFSS was 42.4%, and FFDSS was 27.3%. Median maximum dose to the PTV was 42.2 Gy (range, 29.2-45.8 Gy). PTV maximum dose (high vs low) discriminated 2-year OS (63.6% vs 45.5%), FFSS (50% vs 30%) and FFDSS (36.4% vs 18.2%). For all endpoints, Kaplan-Meier curves overlapped for the first 6 months, and then diverged. CONCLUSION In patients with high-risk refractory VT treated with CRA, survival and VT outcomes were similar between both groups out to 6 months, with improved OS and VT control noted after that with higher maximum doses. With a prescription dose of 25 Gy to the PTV, adjusting planning parameters to maintain maximum doses > 42 Gy may improve durable outcomes and requires validation in a larger cohort.
Collapse
Affiliation(s)
- C G Robinson
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - C Contreras
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - K M S Moore
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - S Rentschler
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - J K Schwarz
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - C Bergom
- Washington University in St. Louis, St. Louis, MO
| | - N Knutson
- Washington University School of Medicine in St. Louis, Department of Radiation Oncology, St. Louis, MO
| | - M T Prusator
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - S M Goddu
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - G D Hugo
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - P Cuculich
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | - P Samson
- Washington University in St. Louis, St. Louis, MO
| |
Collapse
|
2
|
Zhang DM, Navara R, Yin T, Szymanski J, Goldsztejn U, Kenkel C, Lang A, Mpoy C, Lipovsky CE, Qiao Y, Hicks S, Li G, Moore KMS, Bergom C, Rogers BE, Robinson CG, Cuculich PS, Schwarz JK, Rentschler SL. Cardiac radiotherapy induces electrical conduction reprogramming in the absence of transmural fibrosis. Nat Commun 2021; 12:5558. [PMID: 34561429 PMCID: PMC8463558 DOI: 10.1038/s41467-021-25730-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 08/25/2021] [Indexed: 02/08/2023] Open
Abstract
Cardiac radiotherapy (RT) may be effective in treating heart failure (HF) patients with refractory ventricular tachycardia (VT). The previously proposed mechanism of radiation-induced fibrosis does not explain the rapidity and magnitude with which VT reduction occurs clinically. Here, we demonstrate in hearts from RT patients that radiation does not achieve transmural fibrosis within the timeframe of VT reduction. Electrophysiologic assessment of irradiated murine hearts reveals a persistent supraphysiologic electrical phenotype, mediated by increases in NaV1.5 and Cx43. By sequencing and transgenic approaches, we identify Notch signaling as a mechanistic contributor to NaV1.5 upregulation after RT. Clinically, RT was associated with increased NaV1.5 expression in 1 of 1 explanted heart. On electrocardiogram (ECG), post-RT QRS durations were shortened in 13 of 19 patients and lengthened in 5 patients. Collectively, this study provides evidence for radiation-induced reprogramming of cardiac conduction as a potential treatment strategy for arrhythmia management in VT patients.
Collapse
Affiliation(s)
- David M Zhang
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Rachita Navara
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Tiankai Yin
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Jeffrey Szymanski
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Uri Goldsztejn
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Biomedical Engineering, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Camryn Kenkel
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Biomedical Engineering, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Adam Lang
- Department of Pathology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Cedric Mpoy
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Catherine E Lipovsky
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Developmental Biology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Yun Qiao
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Biomedical Engineering, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Stephanie Hicks
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Gang Li
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Biomedical Engineering, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Kaitlin M S Moore
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Carmen Bergom
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Buck E Rogers
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Clifford G Robinson
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Phillip S Cuculich
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Julie K Schwarz
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
- Department of Radiation Oncology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA
| | - Stacey L Rentschler
- Center for Noninvasive Cardiac Radioablation, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA.
- Department of Medicine, Cardiovascular Division, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA.
- Department of Biomedical Engineering, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA.
- Department of Developmental Biology, Washington University in St. Louis, School of Medicine, Saint Louis, MO, USA.
| |
Collapse
|
3
|
Robinson CG, Samson PP, Moore KMS, Hugo GD, Knutson N, Mutic S, Goddu SM, Lang A, Cooper DH, Faddis M, Noheria A, Smith TW, Woodard PK, Gropler RJ, Hallahan DE, Rudy Y, Cuculich PS. Phase I/II Trial of Electrophysiology-Guided Noninvasive Cardiac Radioablation for Ventricular Tachycardia. Circulation 2019; 139:313-321. [PMID: 30586734 DOI: 10.1161/circulationaha.118.038261] [Citation(s) in RCA: 252] [Impact Index Per Article: 50.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Case studies have suggested the efficacy of catheter-free, electrophysiology-guided noninvasive cardiac radioablation for ventricular tachycardia (VT) using stereotactic body radiation therapy, although prospective data are lacking. METHODS We conducted a prospective phase I/II trial of noninvasive cardiac radioablation in adults with treatment-refractory episodes of VT or cardiomyopathy related to premature ventricular contractions (PVCs). Arrhythmogenic scar regions were targeted by combining noninvasive anatomic and electric cardiac imaging with a standard stereotactic body radiation therapy workflow followed by delivery of a single fraction of 25 Gy to the target. The primary safety end point was treatment-related serious adverse events in the first 90 days. The primary efficacy end point was any reduction in VT episodes (tracked by indwelling implantable cardioverter defibrillators) or any reduction in PVC burden (as measured by a 24-hour Holter monitor) comparing the 6 months before and after treatment (with a 6-week blanking window after treatment). Health-related quality of life was assessed using the Short Form-36 questionnaire. RESULTS Nineteen patients were enrolled (17 for VT, 2 for PVC cardiomyopathy). Median noninvasive ablation time was 15.3 minutes (range, 5.4-32.3). In the first 90 days, 2/19 patients (10.5%) developed a treatment-related serious adverse event. The median number of VT episodes was reduced from 119 (range, 4-292) to 3 (range, 0-31; P<0.001). Reduction was observed for both implantable cardioverter defibrillator shocks and antitachycardia pacing. VT episodes or PVC burden were reduced in 17/18 evaluable patients (94%). The frequency of VT episodes or PVC burden was reduced by 75% in 89% of patients. Overall survival was 89% at 6 months and 72% at 12 months. Use of dual antiarrhythmic medications decreased from 59% to 12% ( P=0.008). Quality of life improved in 5 of 9 Short Form-36 domains at 6 months. CONCLUSIONS Noninvasive electrophysiology-guided cardiac radioablation is associated with markedly reduced ventricular arrhythmia burden with modest short-term risks, reduction in antiarrhythmic drug use, and improvement in quality of life. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov/ . Unique identifier: NCT02919618.
Collapse
Affiliation(s)
- Clifford G Robinson
- Department of Radiation Oncology (C.G.R., P.P.S., G.D.H., N.K., S.M., S.M.G., D.E.H.), Washington University, St Louis, MO
| | - Pamela P Samson
- Department of Radiation Oncology (C.G.R., P.P.S., G.D.H., N.K., S.M., S.M.G., D.E.H.), Washington University, St Louis, MO
| | - Kaitlin M S Moore
- Department of Internal Medicine, Cardiovascular Division (K.M.S.M., D.H.C., M.F., A.N., T.W.S., P.S.C.), Washington University, St Louis, MO
| | - Geoffrey D Hugo
- Department of Radiation Oncology (C.G.R., P.P.S., G.D.H., N.K., S.M., S.M.G., D.E.H.), Washington University, St Louis, MO
| | - Nels Knutson
- Department of Radiation Oncology (C.G.R., P.P.S., G.D.H., N.K., S.M., S.M.G., D.E.H.), Washington University, St Louis, MO
| | - Sasa Mutic
- Department of Radiation Oncology (C.G.R., P.P.S., G.D.H., N.K., S.M., S.M.G., D.E.H.), Washington University, St Louis, MO
| | - S Murty Goddu
- Department of Radiation Oncology (C.G.R., P.P.S., G.D.H., N.K., S.M., S.M.G., D.E.H.), Washington University, St Louis, MO
| | - Adam Lang
- Department of Pathology (A.L.), Washington University, St Louis, MO
| | - Daniel H Cooper
- Department of Internal Medicine, Cardiovascular Division (K.M.S.M., D.H.C., M.F., A.N., T.W.S., P.S.C.), Washington University, St Louis, MO
| | - Mitchell Faddis
- Department of Internal Medicine, Cardiovascular Division (K.M.S.M., D.H.C., M.F., A.N., T.W.S., P.S.C.), Washington University, St Louis, MO
| | - Amit Noheria
- Department of Internal Medicine, Cardiovascular Division (K.M.S.M., D.H.C., M.F., A.N., T.W.S., P.S.C.), Washington University, St Louis, MO
| | - Timothy W Smith
- Department of Internal Medicine, Cardiovascular Division (K.M.S.M., D.H.C., M.F., A.N., T.W.S., P.S.C.), Washington University, St Louis, MO
| | - Pamela K Woodard
- Mallinckrodt Institute of Radiology (P.K.W., R.J.G.), Washington University, St Louis, MO
| | - Robert J Gropler
- Mallinckrodt Institute of Radiology (P.K.W., R.J.G.), Washington University, St Louis, MO
| | - Dennis E Hallahan
- Department of Radiation Oncology (C.G.R., P.P.S., G.D.H., N.K., S.M., S.M.G., D.E.H.), Washington University, St Louis, MO
| | - Yoram Rudy
- Departments of Biomedical Engineering, Cell Biology and Physiology, Medicine, Radiology, and Pediatrics (Y.R.), Washington University, St Louis, MO
| | - Phillip S Cuculich
- Department of Internal Medicine, Cardiovascular Division (K.M.S.M., D.H.C., M.F., A.N., T.W.S., P.S.C.), Washington University, St Louis, MO
| |
Collapse
|