1
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Supraventricular cardiac conduction system exposure in breast cancer patients treated with radiotherapy and association with heart and cardiac chambers doses. Clin Transl Radiat Oncol 2022; 38:62-70. [DOI: 10.1016/j.ctro.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/27/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022] Open
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2
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Errahmani MY, Locquet M, Spoor D, Jimenez G, Camilleri J, Bernier MO, Broggio D, Monceau V, Ferrières J, Thariat J, Boveda S, Kirova Y, Loap P, Langendijk JA, Crijns A, Jacob S. Association Between Cardiac Radiation Exposure and the Risk of Arrhythmia in Breast Cancer Patients Treated With Radiotherapy: A Case–Control Study. Front Oncol 2022; 12:892882. [PMID: 35860581 PMCID: PMC9289188 DOI: 10.3389/fonc.2022.892882] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/02/2022] [Indexed: 12/25/2022] Open
Abstract
Background Previous studies suggested that radiation therapy (RT) for breast cancer (BC) can induce cardiac arrhythmias and conduction disorders. However, the association with mean heart dose and specific cardiac substructures doses was less studied. Materials and Methods We conducted a nested case–control study based on French BC patients, enrolled in the European MEDIRAD-BRACE study (https://clinicaltrials.gov, Identifier: NCT03211442), who underwent three-dimensional conformal radiation therapy (3D-CRT) between 2009 and 2013 and were retrospectively followed until 2019. Cases were incident cases of cardiac arrhythmia. Controls without arrhythmia were selected with propensity-scored matching by age, duration of follow-up, chemotherapy, hypertension, and diabetes (ratio 1:4 or 5). Doses to the whole heart (WH), left and right atria (LA and RA), and left and right ventricles (LV and RV) were obtained after delineation with multi-atlas-based automatic segmentation. Results The study included 116 patients (21 cases and 95 controls). Mean age at RT was 64 ± 10 years, mean follow-up was 7.0 ± 1.3 years, and mean interval from RT to arrhythmia was 4.3 ± 2.1 years. None of the results on association between arrhythmia and cardiac doses reached statistical significance. However, the proportion of right-sided BC was higher among patients with arrhythmia than among controls (57% vs. 51%, OR = 1.18, p = 0.73). Neither mean WH dose, nor LV, RV, and LA doses were associated with an increased risk of arrhythmia (OR = 1.00, p > 0.90). In contrast, the RA dose was slightly higher for cases compared to controls [interquartile range (0.61–1.46 Gy) vs. (0.49–1.31 Gy), p = 0.44], and a non-significant trend toward a potentially higher risk of arrhythmia with increasing RA dose was observed (OR = 1.19, p = 0.60). Subanalysis according to BC laterality showed that the association with RA dose was reinforced specifically for left-sided BC (OR = 1.76, p = 0.75), while for right-sided BC, the ratio of mean RA/WH doses may better predict arrhythmia (OR = 2.39, p = 0.35). Conclusion Despite non-significant results, our exploratory investigation on BC patients treated with RT is the first study to suggest that right-sided BC patients and the right atrium irradiation may require special attention regarding the risk of cardiac arrhythmia and conduction disorders. Further studies are needed to expand on this topic.
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Affiliation(s)
- Mohamed Yassir Errahmani
- Laboratory of Epidemiology, Institute for Radiation Protection and Nuclear Safety (IRSN), Fontenay-Aux-Roses, France
- University Paris-Saclay, Gif-sur-Yvette, France
| | - Médéa Locquet
- Laboratory of Epidemiology, Institute for Radiation Protection and Nuclear Safety (IRSN), Fontenay-Aux-Roses, France
| | - Daan Spoor
- Department of Radiation Oncology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, Netherlands
| | - Gaelle Jimenez
- Department of Radiation Oncology (Oncorad), Clinique Pasteur, Toulouse, France
| | - Jérémy Camilleri
- Department of Radiation Oncology (Oncorad), Clinique Pasteur, Toulouse, France
| | - Marie-Odile Bernier
- Laboratory of Epidemiology, Institute for Radiation Protection and Nuclear Safety (IRSN), Fontenay-Aux-Roses, France
| | - David Broggio
- Department of Dosimetry, Institute for Radiation Protection and Nuclear Safety (IRSN), Fontenay-Aux-Roses, France
| | - Virginie Monceau
- Laboratory of Radiotoxicology and Radiobiology, Institute for Radiation Protection and Nuclear Safety (IRSN), Fontenay-Aux-Roses, France
| | - Jean Ferrières
- Department of Cardiology and INSERM UMR 1295, Rangueil University Hospital, Toulouse, France
| | - Juliette Thariat
- Department of Radiotherapy, Centre de Lutte Contre le Cancer A. Baclesse, University of Caen Normandie, Caen, France
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | - Youlia Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Pierre Loap
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Johannes A. Langendijk
- Department of Radiation Oncology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, Netherlands
| | - Anne Crijns
- Department of Radiation Oncology, University Medical Center Groningen (UMCG), University of Groningen, Groningen, Netherlands
| | - Sophie Jacob
- Laboratory of Epidemiology, Institute for Radiation Protection and Nuclear Safety (IRSN), Fontenay-Aux-Roses, France
- *Correspondence: Sophie Jacob,
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3
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Fonseca M, Cheng E, Do D, Haldar S, Kutty S, Yang EH, Ghosh AK, Guha A. Bradyarrhythmias in Cardio-Oncology. South Asian J Cancer 2021; 10:195-210. [PMID: 34966697 PMCID: PMC8710146 DOI: 10.1055/s-0041-1731907] [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] [Indexed: 11/17/2022] Open
Abstract
The relationship between bradyarrhythmias and cancer therapies has not been well described but is increasingly recognized. There have been extensive advances in oncological pharmacotherapy, with several new classes of drugs available including targeted agents, immune checkpoint inhibitors and CAR T cell therapy. This increasing repertoire of available drugs has revolutionized overall prognosis and survival of cancer patients but the true extent of their cardiovascular toxicity is only beginning to be understood. Previous studies and published reviews have traditionally focused on conventional chemotherapies and in arrhythmias in general, particularly tachyarrhythmias. The number of patients with both cancer and cardiovascular problems is increasing globally and oncologists and cardiologists need to be adept at managing arrythmia based scenarios. Greater collaboration between the two specialties including studies with prospective data collection in Cardio-Oncology are much needed to fill in knowledge gaps in this arena. This case-based review summarizes current available evidence of cancer treatment-related bradyarrhythmia incidence (including its different subtypes), possible mechanisms and outcomes. Furthermore, we propose a stepwise surveillance and management protocol for patients with suspected bradyarrhythmia related to cancer treatment.
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Affiliation(s)
- Marta Fonseca
- Division of Cardiology, Cardiac-Oncology Service, Bart's Heart Centre, St Bartholomew's Hospital West Smithfield, London, United Kingdom.,Hatter Cardiovascular Institute, Institute of Cardiovascular Science UCL, University College London Hospital, London, United Kingdom
| | - Evaline Cheng
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, California, United States
| | - Duc Do
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, California, United States
| | - Shouvik Haldar
- Division of Cardiology, Heart Rhythm Centre, The Royal Brompton and Harefield Hospitals, Guys & St Thomas' NHS Foundation Trust, London, United Kingdom.,National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Shelby Kutty
- The Helen B. Taussig Heart Center, The Johns Hopkins Hospital and Johns Hopkins University, Baltimore, Maryland, United States
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, California, United States
| | - Arjun K Ghosh
- Division of Cardiology, Cardiac-Oncology Service, Bart's Heart Centre, St Bartholomew's Hospital West Smithfield, London, United Kingdom.,Hatter Cardiovascular Institute, Institute of Cardiovascular Science UCL, University College London Hospital, London, United Kingdom
| | - Avirup Guha
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, United States.,Division of Cardiology, Department of Medicine, Augusta University, Augusta, Georgia, United States.,Division of Cardiology-Oncology Program, The Ohio State University, Columbus, Ohio, United States
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4
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Bansal N, Joshi C, Adams MJ, Hutchins K, Ray A, Lipshultz SE. Cardiotoxicity in pediatric lymphoma survivors. Expert Rev Cardiovasc Ther 2021; 19:957-974. [PMID: 34958622 DOI: 10.1080/14779072.2021.2013811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Over the past five decades, the diagnosis and management of children with various malignancies have improved tremendously. As a result, an increasing number of children are long-term cancer survivors. With improved survival, however, has come an increased risk of treatment-related cardiovascular complications that can appear decades later. AREAS COVERED This review discusses the pathophysiology, epidemiology and effects of treatment-related cardiovascular complications from anthracyclines and radiotherapy in pediatric lymphoma survivors. There is a paucity of evidence-based recommendations for screening for and treatment of cancer therapy-induced cardiovascular complications. We discuss current preventive measures and strategies for their treatment. EXPERT OPINION Significant cardiac adverse effects occur due to radiation and chemotherapy received by patients treated for lymphoma. Higher lifetime cumulative doses, female sex, longer follow-up, younger age, and preexisting cardiovascular disease are associated with a higher incidence of cardiotoxicity. With deeper understanding of the mechanisms of these adverse cardiac effects and identification of driver mutations causing these effects, personalized cancer therapy to limit cardiotoxic effects while ensuring an adequate anti-neoplastic effect would be ideal. In the meantime, expanding the use of cardioprotective agents with the best evidence such as dexrazoxane should be encouraged and further studied.
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Affiliation(s)
- Neha Bansal
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx NY, USA
| | - Chaitya Joshi
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo NY, USA
| | - Michael Jacob Adams
- Department of Public Health Sciences, University of Rochester, Rochester NY, USA
| | - Kelley Hutchins
- John A. Burns School of Medicine, Pediatric Hematology/Oncology, Kapiolani Medical Center for Women and Children, Honolulu HI, USA
| | - Andrew Ray
- Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo NY, USA
| | - Steven E Lipshultz
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo NY, USA.,Department of Cancer Prevention and Control, Roswell Park Comprehensive Cancer Center, Buffalo NY, USA.,Pediatrics Department, John R. Oishei Children's Hospital, UBMD Pediatrics Practice Group, Buffalo NY, USA
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5
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Pathomechanisms and therapeutic opportunities in radiation-induced heart disease: from bench to bedside. Clin Res Cardiol 2021; 110:507-531. [PMID: 33591377 PMCID: PMC8055626 DOI: 10.1007/s00392-021-01809-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 01/16/2021] [Indexed: 12/14/2022]
Abstract
Cancer management has undergone significant improvements, which led to increased long-term survival rates among cancer patients. Radiotherapy (RT) has an important role in the treatment of thoracic tumors, including breast, lung, and esophageal cancer, or Hodgkin's lymphoma. RT aims to kill tumor cells; however, it may have deleterious side effects on the surrounding normal tissues. The syndrome of unwanted cardiovascular adverse effects of thoracic RT is termed radiation-induced heart disease (RIHD), and the risk of developing RIHD is a critical concern in current oncology practice. Premature ischemic heart disease, cardiomyopathy, heart failure, valve abnormalities, and electrical conduct defects are common forms of RIHD. The underlying mechanisms of RIHD are still not entirely clear, and specific therapeutic interventions are missing. In this review, we focus on the molecular pathomechanisms of acute and chronic RIHD and propose preventive measures and possible pharmacological strategies to minimize the burden of RIHD.
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6
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Sacher F, Gandjbakhch E, Maury P, Jenny C, Khalifa J, Boveda S, Defaye P, Gras D, Klug D, Laurent G, Lellouche N, Mansourati J, Marijon E, Piot O, Taieb J, Cochet H, Maingon P, Pruvot E, Fauchier L. Focus on stereotactic radiotherapy: A new way to treat severe ventricular arrhythmias? Arch Cardiovasc Dis 2021; 114:140-149. [PMID: 33478860 DOI: 10.1016/j.acvd.2020.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 02/07/2023]
Abstract
Ventricular tachycardia has a significant recurrence rate after ablation for several reasons, including inaccessible substrate. A non-invasive technique to ablate any defined areas of myocardium involved in arrhythmogenesis would be a potentially important therapeutic improvement if shown to be safe and effective. Early feasibility studies of single-fraction stereotactic body radiotherapy have demonstrated encouraging results, but rigorous evaluation and follow-up are required. In this document, the basic concepts of stereotactic body radiotherapy are summarized, before focusing on stereotactic arrhythmia radioablation. We describe the effect of radioablation on cardiac tissue and its interaction with intracardiac devices, depending on the dose. The different clinical studies on ventricular tachycardia radioablation are analysed, with a focus on target identification, which is the key feature of this approach. Our document ends with the indications and requirements for practicing this type of procedure in 2020. Finally, because of the limited number of patients treated so far, we encourage multicentre registries with long-term follow-up.
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Affiliation(s)
- Frédéric Sacher
- Department of cardiology, IHU Liryc, electrophysiology and heart modelling institute, Bordeaux university hospital (CHU), university of Bordeaux, 33600 Pessac, France.
| | - Estelle Gandjbakhch
- Department of cardiology, La Pitié-Salpétrière university hospital, AP-HP, 75013 Paris, France
| | - Philippe Maury
- Department of cardiology, Toulouse university hospital, 31059 Toulouse, France
| | - Catherine Jenny
- Department of radiotherapy, La Pitié-Salpétrière university hospital, AP-HP, 75013 Paris, France
| | - Jonathan Khalifa
- Departments of radiotherapy and cardiology, Toulouse university hospital, 31059 Toulouse, France
| | - Serge Boveda
- Department of cardiology, clinique Pasteur, 31076 Toulouse, France
| | - Pascal Defaye
- Department of cardiology, Grenoble university hospital, 38700 La Tronche, France
| | - Daniel Gras
- Department of cardiology, nouvelles cliniques nantaises, 44277 Nantes, France
| | - Didier Klug
- Department of cardiology, Lille university hospital, 59000 Lille, France
| | - Gabriel Laurent
- Department of cardiology, Dijon university hospital, 21000 Dijon, France
| | - Nicolas Lellouche
- Department of cardiology, hôpital Henri-Mondor, AP-HP, 94010 Créteil, France
| | - Jacques Mansourati
- Department of cardiology, Brest university hospital, 29609 Brest, France
| | - Eloi Marijon
- Department of cardiology, hôpital européen Georges-Pompidou, AP-HP, 75015 Paris, France
| | - Olivier Piot
- Department of cardiology, centre cardiologique du nord, 93200 Saint-Denis, France
| | - Jerome Taieb
- Department of cardiology, Aix-en-Provence hospital, 13616 Aix-en-Provence, France
| | - Hubert Cochet
- Department of radiology, IHU Liryc, electrophysiology and heart modelling institute, Bordeaux university hospital (CHU), university of Bordeaux, 33600 Pessac, France
| | - Philippe Maingon
- Department of radiotherapy, La Pitié-Salpétrière university hospital, AP-HP, 75013 Paris, France
| | - Etienne Pruvot
- Department of cardiology, CHUV, 1011 Lausanne, Switzerland
| | - Laurent Fauchier
- Department of cardiology, Tours university hospital, 37000 Tours, France
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7
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Abstract
PURPOSE OF REVIEW Cardiovascular autonomic dysfunction (AD) among cancer survivors is increasingly being recognized. However, the mechanisms and incidence are poorly understood. In this review, the clinical features, diagnostic modalities, proposed mechanisms, and currently available treatments of cardiovascular AD in cancer survivors are described. RECENT FINDINGS Much of our current understanding of cardiovascular AD is based on disease states such as diabetes, multisystem atrophy, and Parkinson's disease. Several non-invasive tests, measurements, and scoring systems have been developed as surrogates for autonomic function, with some even demonstrating associations with all-cause mortality. The mechanism of cardiovascular AD specifically in the cancer population, however, has not been directly studied. The etiology of cardiovascular AD in cancer survivors is likely multifactorial, and proposed mechanisms include direct nerve damage by chemoradiation, the pro-inflammatory state associated with malignancy, and paraneoplastic syndromes. It may also be that cardiovascular AD is an early marker of global cardiomyopathy rather than its own condition. Current pharmacologic options for cardiovascular AD are extrapolated from how it has been treated in other disease processes, and these agents have not been studied in the cancer population or compared head-to-head. Cardiovascular AD in cancer survivors can cause significant debilitation and may be associated with all-cause mortality. Current diagnostic modalities have several limitations, such as standardization and validity. However, given the nonspecific nature of cardiovascular AD, these tools provide an objective marker for diagnosis and tracking treatment response. While the mechanism of cardiovascular AD in cancer survivors has not been directly studied, it may be useful to evoke mechanisms of cardiovascular AD in other disease states such as diabetes, Parkinson's disease, and multisystem atrophy in addition to identifying unique conditions associated with malignancy like a pro-inflammatory state. Until further studies are performed, management of cardiovascular AD as seen in other disease states may serve as a guide for symptom management in cancer survivors.
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8
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Romitan DM, Rădulescu D, Berindan-Neagoe I, Stoicescu L, Grosu A, Rădulescu L, Gulei D, Ciuleanu TE. Cardiomyopathies and Arrhythmias Induced by Cancer Therapies. Biomedicines 2020; 8:biomedicines8110496. [PMID: 33198152 PMCID: PMC7696637 DOI: 10.3390/biomedicines8110496] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/17/2022] Open
Abstract
Cardiology and oncology are two fields dedicated to the study of various types of oncological and cardiac diseases, but when they collide, a new specialty is born, i.e., cardio-oncology. Continuous research on cancer therapy has brought into the clinic novel therapeutics that have significantly improved patient survival. However, these therapies have also been associated with adverse effects that can impede the proper management of oncological patients through the necessity of drug discontinuation due to life-threatening or long-term morbidity risks. Cardiovascular toxicity from oncological therapies is the main issue that needs to be solved. Proper knowledge, interpretation, and management of new drugs are key elements for developing the best therapeutic strategies for oncological patients. Upon continuous investigations, the profile of cardiotoxicity events has been enlarged with the inclusion of myocarditis upon administration of immune checkpoint inhibitors and cardiac dysfunction in the context of cytokine release syndrome with chimeric antigen receptor T cell therapy. Affinity enhanced and chimeric antigen receptor T cells have both been associated with hypotension, arrhythmia, and left ventricular dysfunction, typically in the setting of cytokine release syndrome. Therefore, the cardiologist must adhere to the progressing field of cancer therapy and become familiar with the adverse effects of novel drugs, and not only the ones of standard care, such as anthracycline, trastuzumab, and radiation therapy. The present review provides essential information summarized from the latest studies from cardiology, oncology, and hematology to bring together the three specialties and offers proper management options for oncological patients.
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Affiliation(s)
- Dragoș-Mihai Romitan
- Department of Cardiology, Municipal Clinical Hospital of Cluj-Napoca, 400139 Cluj-Napoca, Romania; (D.R.); (L.S.); (A.G.); (L.R.)
- Correspondence:
| | - Dan Rădulescu
- Department of Cardiology, Municipal Clinical Hospital of Cluj-Napoca, 400139 Cluj-Napoca, Romania; (D.R.); (L.S.); (A.G.); (L.R.)
| | - Ioana Berindan-Neagoe
- Research Center for Functional Genomic, Biomedicine and Translational Medicine, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400139 Cluj-Napoca, Romania;
| | - Laurențiu Stoicescu
- Department of Cardiology, Municipal Clinical Hospital of Cluj-Napoca, 400139 Cluj-Napoca, Romania; (D.R.); (L.S.); (A.G.); (L.R.)
| | - Alin Grosu
- Department of Cardiology, Municipal Clinical Hospital of Cluj-Napoca, 400139 Cluj-Napoca, Romania; (D.R.); (L.S.); (A.G.); (L.R.)
| | - Liliana Rădulescu
- Department of Cardiology, Municipal Clinical Hospital of Cluj-Napoca, 400139 Cluj-Napoca, Romania; (D.R.); (L.S.); (A.G.); (L.R.)
| | - Diana Gulei
- Research Center for Advanced Medicine-Medfuture, “Iuliu Hațieganu” University of Medicine and Pharmacy Cluj-Napoca, 400139 Cluj-Napoca, Romania;
| | - Tudor-Eliade Ciuleanu
- Department of Chemotherapy, Ion Chiricuta Clinical Cancer Center, 400139 Cluj Napoca, Romania;
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9
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Abstract
Remarkable progress has been made in the development of new therapies for cancer, dramatically changing the landscape of treatment approaches for several malignancies and continuing to increase patient survival. Accordingly, adverse effects of cancer therapies that interfere with the continuation of best-possible care, induce life-threatening risks or lead to long-term morbidity are gaining increasing importance. Cardiovascular toxic effects of cancer therapeutics and radiation therapy are the epitome of such concerns, and proper knowledge, interpretation and management are needed and have to be placed within the context of the overall care of individual patients with cancer. Furthermore, the cardiotoxicity spectrum has broadened to include myocarditis with immune checkpoint inhibitors and cardiac dysfunction in the setting of cytokine release syndrome with chimeric antigen receptor T cell therapy. An increase in the incidence of arrhythmias related to inflammation such as atrial fibrillation can also be expected, in addition to the broadening set of cancer therapeutics that can induce prolongation of the corrected QT interval. Therefore, cardiologists of today have to be familiar not only with the cardiotoxicity associated with traditional cancer therapies, such as anthracycline, trastuzumab or radiation therapy, but even more so with an ever-increasing repertoire of therapeutics. This Review provides this information, summarizing the latest developments at the juncture of cardiology, oncology and haematology.
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Affiliation(s)
- Joerg Herrmann
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
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10
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Jumeau R, Ozsahin M, Schwitter J, Elicin O, Reichlin T, Roten L, Andratschke N, Mayinger M, Saguner AM, Steffel J, Blanck O, Vozenin MC, Moeckli R, Zeverino M, Vallet V, Herrera-Siklody C, Pascale P, Bourhis J, Pruvot E. Stereotactic Radiotherapy for the Management of Refractory Ventricular Tachycardia: Promise and Future Directions. Front Cardiovasc Med 2020; 7:108. [PMID: 32671101 PMCID: PMC7329991 DOI: 10.3389/fcvm.2020.00108] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/22/2020] [Indexed: 01/22/2023] Open
Abstract
Ventricular tachycardia (VT) caused by myocardial scaring bears a significant risk of mortality and morbidity. Antiarrhythmic drug therapy (AAD) and catheter ablation remain the cornerstone of VT management, but both treatments have limited efficacy and potential adverse effects. Stereotactic body radiotherapy (SBRT) is routinely used in oncology to treat non-invasively solid tumors with high precision and efficacy. Recently, this technology has been evaluated for the treatment of VT. This review presents the basic underlying principles, proof of concept, and main results of trials and case series that used SBRT for the treatment of VT refractory to AAD and catheter ablation.
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Affiliation(s)
- Raphael Jumeau
- Department of Radiation Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Multidisciplinary Cancer Care Service, Radiation Oncology Unit, Riviera-Chablais Hospital, Rennaz, Switzerland
| | - Mahmut Ozsahin
- Department of Radiation Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Juerg Schwitter
- Heart and Vessel Department, Cardiac MR Center, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Olgun Elicin
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Laurent Roten
- Department of Cardiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, Zürich, Switzerland
| | - Michael Mayinger
- Department of Radiation Oncology, University Hospital Zurich, Zürich, Switzerland
| | - Ardan M Saguner
- Department of Cardiology, University Heart Center Zurich, Zürich, Switzerland
| | - Jan Steffel
- Department of Cardiology, University Heart Center Zurich, Zürich, Switzerland
| | - Oliver Blanck
- Department of Radiation Oncology and Department of Internal Medicine III, Cardiology, Section for Electrophysiology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Marie-Catherine Vozenin
- Radio-Oncology Research Laboratory, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Raphael Moeckli
- Institute of Radiation Physics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Michele Zeverino
- Institute of Radiation Physics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Véronique Vallet
- Institute of Radiation Physics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Claudia Herrera-Siklody
- Heart and Vessel Department, Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Patrizio Pascale
- Heart and Vessel Department, Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jean Bourhis
- Department of Radiation Oncology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Etienne Pruvot
- Heart and Vessel Department, Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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11
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Zou B, Schuster JP, Niu K, Huang Q, Rühle A, Huber PE. Radiotherapy-induced heart disease: a review of the literature. PRECISION CLINICAL MEDICINE 2019; 2:270-282. [PMID: 35693876 PMCID: PMC8985808 DOI: 10.1093/pcmedi/pbz025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/25/2019] [Accepted: 11/25/2019] [Indexed: 11/20/2022] Open
Abstract
Radiotherapy as one of the four pillars of cancer therapy plays a critical role in the multimodal treatment of thoracic cancers. Due to significant improvements in overall cancer survival, radiotherapy-induced heart disease (RIHD) has become an increasingly recognized adverse reaction which contributes to major radiation-associated toxicities including non-malignant death. This is especially relevant for patients suffering from diseases with excellent prognosis such as breast cancer or Hodgkin’s lymphoma, since RIHD may occur decades after radiotherapy. Preclinical studies have enriched our knowledge of many potential mechanisms by which thoracic radiotherapy induces heart injury. Epidemiological findings in humans reveal that irradiation might increase the risk of cardiac disease at even lower doses than previously assumed. Recent preclinical studies have identified non-invasive methods for evaluation of RIHD. Furthermore, potential options preventing or at least attenuating RIHD have been developed. Ongoing research may enrich our limited knowledge about biological mechanisms of RIHD, identify non-invasive early detection biomarkers and investigate potential treatment options that might attenuate or prevent these unwanted side effects. Here, we present a comprehensive review about the published literature regarding clinical manifestation and pathological alterations in RIHD. Biological mechanisms and treatment options are outlined, and challenges in RIHD treatment are summarized.
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Affiliation(s)
- Bingwen Zou
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
- Department of Molecular Radiation Oncology, German Cancer Research Center, Im Neuenheimer Feld 280, Heidelberg 69120, Germany
| | - Julius Philipp Schuster
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
- Department of Molecular Radiation Oncology, German Cancer Research Center, Im Neuenheimer Feld 280, Heidelberg 69120, Germany
| | - Kerun Niu
- Department of Molecular Radiation Oncology, German Cancer Research Center, Im Neuenheimer Feld 280, Heidelberg 69120, Germany
| | - Qianyi Huang
- Department of Molecular Radiation Oncology, German Cancer Research Center, Im Neuenheimer Feld 280, Heidelberg 69120, Germany
| | - Alexander Rühle
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
- Department of Molecular Radiation Oncology, German Cancer Research Center, Im Neuenheimer Feld 280, Heidelberg 69120, Germany
- Heidelberg Institute for Radiation Oncology (HIRO) and National Center for Radiation Oncology (NCRO), Im Neuenheimer Feld 280, Heidelberg 69120, Germany
| | - Peter Ernst Huber
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
- Department of Molecular Radiation Oncology, German Cancer Research Center, Im Neuenheimer Feld 280, Heidelberg 69120, Germany
- Heidelberg Institute for Radiation Oncology (HIRO) and National Center for Radiation Oncology (NCRO), Im Neuenheimer Feld 280, Heidelberg 69120, Germany
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13
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Báez-Ferrer N, Izquierdo-Gómez MM, Beyello-Belkasem C, Jorge-Pérez P, García-González MJ, Ferrer-Hita JJ, De la Rosa-Hernández A, García-Niebla J, Lacalzada-Almeida J. Long-Term Radiotherapy-Induced Cardiac Complications: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:1182-1188. [PMID: 31401643 PMCID: PMC6753667 DOI: 10.12659/ajcr.917224] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Patient: Male, 48 Final Diagnosis: Late cardiac complications postradiotherapy Symptoms: Chest pain • dyspnea • syncope Medication: — Clinical Procedure: Diagnostic and therapeutic techniques in cardiology Specialty: Cardiology
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Affiliation(s)
- Néstor Báez-Ferrer
- Department of Cardiology, University Hospital of the Canary Islands, Tenerife, Spain
| | | | | | - Pablo Jorge-Pérez
- Department of Cardiology, University Hospital of the Canary Islands, Tenerife, Spain
| | | | - Julio J Ferrer-Hita
- Department of Cardiology, University Hospital of the Canary Islands, Tenerife, Spain
| | | | - Javier García-Niebla
- Department of Cardiology, University Hospital of the Canary Islands, Tenerife, Spain
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Donnellan E, Jellis CL, Griffin BP. Radiation-Associated Cardiac Disease: From Molecular Mechanisms to Clinical Management. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:22. [PMID: 31020465 DOI: 10.1007/s11936-019-0726-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Radiation-associated cardiac disease (RACD) is an increasingly recognized latent manifestation of chest and mediastinal radiation therapy. The delayed presentation reflects increased survival rates from malignancies successfully treated decades previously. However, individuals are now presenting with multiple coexistent manifestations of RACD and pulmonary disease as a consequence of high-dose radiation administered prior to the routine institution of modern dose-modulating regimens. Increased awareness of RACD is critical for implementation of appropriate screening algorithms and for specific management strategies involving the timing and strategies of intervention in these patients. RECENT FINDINGS Recent advances in multimodality cardiac imaging have demonstrated pathognomonic findings of RACD, which can predict outcomes including mortality. Accurate diagnosis of these typically concurrent manifestations is critical and should prompt referral to a center experienced in managing RACD as surgical risk is significantly increased for this patient cohort, particularly for those undergoing redo operation. The latent effect of RACD and its unique combination of manifestations means that these patients will increasingly present with challenging management issues, resulting in increased rates of morbidity and mortality. Timing of treatment intervention must be carefully considered, although percutaneous options may provide alternative future strategies for this higher risk cohort.
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Affiliation(s)
- Eoin Donnellan
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Christine L Jellis
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Brian P Griffin
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA. .,Department of Cardiovascular Medicine, Desk J1-5, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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15
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Risk of cardiotoxicity induced by adjuvant anthracycline-based chemotherapy and radiotherapy in young and old Asian women with breast cancer. Strahlenther Onkol 2019; 195:629-639. [PMID: 30690687 DOI: 10.1007/s00066-019-01428-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 12/24/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE The risk of cardiotoxicity induced by adjuvant anthracycline-based chemotherapy (CT) and radiotherapy (RT) is yet to be investigated in a large-scale randomized controlled trial with an adequate sample size of young and old women with breast cancer. PATIENTS AND METHODS To compare the occurrence of major heart events (heart failure and coronary artery disease) in patients with breast cancer, 3489 women who underwent surgical resection of the breast tumor were retrospectively selected from the Taiwan National Health Insurance Research Database. The patients were categorized into the following groups based on their treatment modalities: group 1 (n = 1113), no treatment; group 2 (n = 646), adjuvant RT alone; group 3 (n = 705), adjuvant anthracycline-based CT alone; and group 4 (n = 1025), combined adjuvant RT and anthracycline-based CT. RESULTS The mean patient age was 50.35 years. Subsequent coronary artery disease and heart failure were identified in 244 (7.0%) and 206 (5.9%) patients, respectively. All three adjuvant therapies were significant independent prognostic factors of major heart events (adjusted hazard ratio [95% confidence interval]: 1.47 [1.24-1.73]; 1.48 [1.25-1.75], and 1.92 [1.65-2.23] in groups 2, 3, and 4, respectively). In patients aged ≥50 years with breast cancer who underwent surgery, the log-rank p values of groups 2 and 3 after adjustment were 0.537 and 0.001, respectively. CONCLUSION Adjuvant RT can increase cardiotoxicity in patients with breast cancer, particularly when used in combination with anthracycline-based CT. Therefore, it should be offered with optimal heart-sparing techniques, particularly in younger patients with good prognosis and long life expectancy.
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Al-Hammadi N, Caparrotti P, Naim C, Hayes J, Rebecca Benson K, Vasic A, Al-Abdulla H, Hammoud R, Divakar S, Petric P. Voluntary Deep Inspiration Breath-hold Reduces the Heart Dose Without Compromising the Target Volume Coverage During Radiotherapy for Left-sided Breast Cancer. Radiol Oncol 2018. [PMID: 29520213 PMCID: PMC5839089 DOI: 10.1515/raon-2018-0008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background During radiotherapy of left-sided breast cancer, parts of the heart are irradiated, which may lead to late toxicity. We report on the experience of single institution with cardiac-sparing radiotherapy using voluntary deep inspiration breath hold (V-DIBH) and compare its dosimetric outcome with free breathing (FB) technique. Patients and methods Left-sided breast cancer patients, treated at our department with postoperative radiotherapy of breast/chest wall +/- regional lymph nodes between May 2015 and January 2017, were considered for inclusion. FB-computed tomography (CT) was obtained and dose-planning performed. Cases with cardiac V25Gy ≥ 5% or risk factors for heart disease were coached for V-DIBH. Compliant patients were included. They underwent additional CT in V-DIBH for planning, followed by V-DIBH radiotherapy. Dose volume histogram parameters for heart, lung and optimized planning target volume (OPTV) were compared between FB and BH. Treatment setup shifts and systematic and random errors for V-DIBH technique were compared with FB historic control. Results Sixty-three patients were considered for V-DIBH. Nine (14.3%) were non-compliant at coaching, leaving 54 cases for analysis. When compared with FB, V-DIBH resulted in a significant reduction of mean cardiac dose from 6.1 +/- 2.5 to 3.2 +/- 1.4 Gy (p < 0.001), maximum cardiac dose from 51.1 +/- 1.4 to 48.5 +/- 6.8 Gy (p = 0.005) and cardiac V25Gy from 8.5 +/- 4.2 to 3.2 +/- 2.5% (p < 0.001). Heart volumes receiving low (10-20 Gy) and high (30-50 Gy) doses were also significantly reduced. Mean dose to the left anterior coronary artery was 23.0 (+/- 6.7) Gy and 14.8 (+/- 7.6) Gy on FB and V-DIBH, respectively (p < 0.001). Differences between FB- and V-DIBH-derived mean lung dose (11.3 +/- 3.2 vs. 10.6 +/- 2.6 Gy), lung V20Gy (20.5 +/- 7 vs. 19.5 +/- 5.1 Gy) and V95% for the OPTV (95.6 +/- 4.1 vs. 95.2 +/- 6.3%) were non-significant. V-DIBH-derived mean shifts for initial patient setup were ≤ 2.7 mm. Random and systematic errors were ≤ 2.1 mm. These results did not differ significantly from historic FB controls. Conclusions When compared with FB, V-DIBH demonstrated high setup accuracy and enabled significant reduction of cardiac doses without compromising the target volume coverage. Differences in lung doses were non-significant.
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Affiliation(s)
- Noora Al-Hammadi
- Department of Radiation Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Palmira Caparrotti
- Department of Radiation Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Carole Naim
- Department of Radiation Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Jillian Hayes
- Department of Radiation Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Katherine Rebecca Benson
- Department of Radiation Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Ana Vasic
- Department of Radiation Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Hissa Al-Abdulla
- Department of Radiation Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Rabih Hammoud
- Department of Radiation Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Saju Divakar
- Department of Radiation Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Primoz Petric
- Department of Radiation Oncology, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
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Harvey LAC, DeMaio SJ, Roberts WC. Radiation-Induced Cardiovascular Disease Including Stenosis of Coronary Ostium, Coronary and Carotid Arteries, and Aortic Valve. Proc (Bayl Univ Med Cent) 2018. [DOI: 10.1080/08998280.1994.11929882] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Adams H, Martin W, Wilson A, Palmer S. Radiation Therapy Induced Cardiovascular Disease. HEART VESSELS AND TRANSPLANTATION 2017. [DOI: 10.24969/hvt.2017.25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Contemporary treatment modalities for malignancy including radiation therapy have led to improved survival. However treatment related complications manifesting later in life including cardiovascular disease has led to survivors exhibiting a lower long term survival rate, when compared to age matched controls. This narrative review will discuss the pathophysiology, risk factors, clinical presentation, management and preventative techniques related to radiotherapy-induced cardiotoxicity.
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Abstract
PURPOSE OF REVIEW Thoracic radiation therapy is an effective treatment for several malignancies, such as Hodgkin's lymphoma and breast cancer. Over the years, however, the incidence of cardiovascular events has increased in these patients, notably in younger survivors who do not have traditional risk factors. This review summarizes the pathology, incidence, clinical presentation, and management of cardiac events after radiation therapy. RECENT FINDINGS Mediastinal radiation therapy accelerates the atherosclerosis process, resulting in early onset coronary artery disease. Valvular disease due to radiation therapy typically affects the left-sided valves, with aortic regurgitation being the most common. Rarely, it may lead to aortic stenosis requiring surgical interventions. Pericardial involvement includes acute and chronic pericardial disease and pericardial effusion. New studies are investigating the prevalence and pathogenesis of autonomic dysfunction in cancer survivors who have undergone mediastinal and neck radiation. Radiation therapy itself causes vascular endothelial dysfunction, resulting in clinical cardiovascular events, manifesting many years after completion of therapy. There remains little guidance regarding screening and therapies to prevent cardiovascular events in this population.
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Affiliation(s)
- Deepa Raghunathan
- University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | | | - Saamir A Hassan
- University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
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21
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Nielsen KM, Offersen BV, Nielsen HM, Vaage-Nilsen M, Yusuf SW. Short and long term radiation induced cardiovascular disease in patients with cancer. Clin Cardiol 2017; 40:255-261. [PMID: 28139844 DOI: 10.1002/clc.22634] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 09/13/2016] [Accepted: 09/19/2016] [Indexed: 11/11/2022] Open
Abstract
Radiation-induced cardiovascular disease is well described as a late effect in cancer patients treated with radiation therapy. Advancements in surgery, radiotherapy, and chemotherapy have led to an increasing number of cancer survivors with resultant long-term side effects related to their cancer treatments. In this review, we describe the short- and long-term cardiovascular consequences of mediastinal radiotherapy and discuss the optimal cardiovascular assessments and diagnostic tools in asymptomatic and symptomatic patients.
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Affiliation(s)
| | | | | | | | - Syed Wamique Yusuf
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
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Rehammar JC, Johansen JB, Jensen MB, Videbæk L, Jørgensen OD, Lorenzen E, Ewertz M. Risk of pacemaker or implantable cardioverter defibrillator after radiotherapy for early-stage breast cancer in Denmark, 1982–2005. Radiother Oncol 2017; 122:60-65. [DOI: 10.1016/j.radonc.2016.08.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 07/02/2016] [Accepted: 08/29/2016] [Indexed: 11/26/2022]
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Marmagkiolis K, Finch W, Tsitlakidou D, Josephs T, Iliescu C, Best JF, Yang EH. Radiation Toxicity to the Cardiovascular System. Curr Oncol Rep 2016; 18:15. [PMID: 26838585 DOI: 10.1007/s11912-016-0502-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Radiation therapy is an important component of cancer treatment, and today, it is applied to approximately 50% of malignancies, including valvular, myocardial, pericardial, coronary or peripheral vascular disease, and arrhythmias. An increased clinical suspicion and knowledge of those mechanisms is important to initiate appropriate screening for the optimal diagnosis and treatment. As the number of cancer survivors has been steadily increasing over the last decades, cardio-oncology, an evolving subspecialty of cardiology, will soon play a pivotal role in raising awareness of the increased cardiovascular risk and formulate strategies to optimally manage patients in this unique population.
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Affiliation(s)
- Konstantinos Marmagkiolis
- CMH Heart and Vascular Institute, 1500 N Oakland Rd, Bolivar, MO, 65613, USA. .,University of Missouri, Columbia, MO, USA.
| | - William Finch
- Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
| | | | - Tyler Josephs
- Kansas City University of Medicine and Biosciences, 1750 Independence Ave, Kansas City, MO, 64106, USA.
| | - Cezar Iliescu
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA.
| | - John F Best
- CMH Heart and Vascular Institute, 1500 N Oakland Rd, Bolivar, MO, 65613, USA.
| | - Eric H Yang
- Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
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Lezcano Gort LE, Gómez Barrado JJ, Kounka Z, Sánchez Calderón P, Romero Castro MJ. Radioterapia supradiafragmática y bloqueo auriculoventricular completo. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2015.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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25
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Lehmann HI, Richter D, Prokesch H, Graeff C, Prall M, Simoniello P, Fournier C, Bauer J, Kaderka R, Weymann A, Szabó G, Sonnenberg K, Constantinescu AM, Johnson SB, Misiri J, Takami M, Miller RC, Herman MG, Asirvatham SJ, Brons S, Jäkel O, Haberer T, Debus J, Durante M, Bert C, Packer DL. Atrioventricular node ablation in Langendorff-perfused porcine hearts using carbon ion particle therapy: methods and an in vivo feasibility investigation for catheter-free ablation of cardiac arrhythmias. Circ Arrhythm Electrophysiol 2015; 8:429-38. [PMID: 25609687 DOI: 10.1161/circep.114.002436] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 01/08/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Particle therapy, with heavy ions such as carbon-12 ((12)C), delivered to arrhythmogenic locations of the heart could be a promising new means for catheter-free ablation. As a first investigation, we tested the feasibility of in vivo atrioventricular node ablation, in Langendorff-perfused porcine hearts, using a scanned 12C beam. METHODS AND RESULTS Intact hearts were explanted from 4 (30-40 kg) pigs and were perfused in a Langendorff organ bath. Computed tomographic scans (1 mm voxel and slice spacing) were acquired and (12)C ion beam treatment planning (optimal accelerator energies, beam positions, and particle numbers) for atrioventricular node ablation was conducted. Orthogonal x-rays with matching of 4 implanted clips were used for positioning. Ten Gray treatment plans were repeatedly administered, using pencil beam scanning. After delivery, positron emission tomography-computed tomographic scans for detection of β(+) ((11)C) activity were obtained. A (12)C beam with a full width at half maximum of 10 mm was delivered to the atrioventricular node. Delivery of 130 Gy caused disturbance of atrioventricular conduction with transition into complete heart block after 160 Gy. Positron emission computed tomography demonstrated dose delivery into the intended area. Application did not induce arrhythmias. Macroscopic inspection did not reveal damage to myocardium. Immunostaining revealed strong γH2AX signals in the target region, whereas no γH2AX signals were detected in the unirradiated control heart. CONCLUSIONS This is the first report of the application of a (12)C beam for ablation of cardiac tissue to treat arrhythmias. Catheter-free ablation using 12C beams is feasible and merits exploration in intact animal studies as an energy source for arrhythmia elimination.
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Affiliation(s)
- H Immo Lehmann
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.).
| | - Daniel Richter
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Hannah Prokesch
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Christian Graeff
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Matthias Prall
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Palma Simoniello
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Claudia Fournier
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Julia Bauer
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Robert Kaderka
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Alexander Weymann
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Gábor Szabó
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Karin Sonnenberg
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Anna M Constantinescu
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Susan B Johnson
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Juna Misiri
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Mitsuru Takami
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Robert C Miller
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Michael G Herman
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Samuel J Asirvatham
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Stephan Brons
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Oliver Jäkel
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Thomas Haberer
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Jürgen Debus
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Marco Durante
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Christoph Bert
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
| | - Douglas L Packer
- From the Mayo Clinic Translational Interventional Electrophysiology Laboratory (H.I.L., S.B.J., J.M., M.T., S.J.A., D.L.P.) and Department of Radiation Oncology (R.C.M., M.G.H.), Mayo Clinic, Rochester, MN; Department of Biophysics, GSI Helmholtzzentrum für Schwerionenforschung, Darmstadt, Germany (D.R., C.G., M.P., P.S., C.F., R.K., A.M.C., M.D., C.B.); Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany (D.R., C.B.); Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg, Germany (H.P., J.B., S.B., T.H., J.D.); Department of Experimental Cardiothoracic Surgery, University of Heidelberg, Heidelberg, Germany (A.W., G.S., K.S.); and German Cancer Research Center (DKFZ), Heidelberg, Germany (O.J.)
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Travis LB, Ng AK, Allan JM, Pui CH, Kennedy AR, Xu XG, Purdy JA, Applegate K, Yahalom J, Constine LS, Gilbert ES, Boice JD. Second malignant neoplasms and cardiovascular disease following radiotherapy. HEALTH PHYSICS 2014; 106:229-246. [PMID: 24378498 DOI: 10.1097/hp.0000000000000013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Second malignant neoplasms (SMNs) and cardiovascular disease (CVD) are among the most serious and life-threatening late adverse effects experienced by the growing number of cancer survivors worldwide and are due in part to radiotherapy. The National Council on Radiation Protection and Measurements (NCRP) convened an expert scientific committee to critically and comprehensively review associations between radiotherapy and SMNs and CVD, taking into account radiobiology; genomics; treatment (i.e., radiotherapy with or without chemotherapy and other therapies); type of radiation; and quantitative considerations (i.e., dose-response relationships). Major conclusions of the NCRP include: (1) the relevance of older technologies for current risk assessment when organ-specific absorbed dose and the appropriate relative biological effectiveness are taken into account and (2) the identification of critical research needs with regard to newer radiation modalities, dose-response relationships, and genetic susceptibility. Recommendation for research priorities and infrastructural requirements include (1) long-term large-scale follow-up of extant cancer survivors and prospectively treated patients to characterize risks of SMNs and CVD in terms of radiation dose and type; (2) biological sample collection to integrate epidemiological studies with molecular and genetic evaluations; (3) investigation of interactions between radiotherapy and other potential confounding factors, such as age, sex, race, tobacco and alcohol use, dietary intake, energy balance, and other cofactors, as well as genetic susceptibility; (4) focusing on adolescent and young adult cancer survivors, given the sparse research in this population; and (5) construction of comprehensive risk prediction models for SMNs and CVD to permit the development of follow-up guidelines and prevention and intervention strategies.
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Affiliation(s)
- Lois B Travis
- *Rubin Center for Cancer Survivorship and Department of Radiation Oncology, James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY; †Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and the Dana-Farber Cancer Institute, Boston, MA; ‡Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK; §Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN; and the University of Tennessee Health Science Center, Memphis, TN; **Department of Radiation Oncology, University of Pennsylvania School of Medicine, Philadelphia, PA; ††Nuclear Engineering and Engineering Physics Program, Rensselaer Polytechnic Institute, Troy, NY; ‡‡Department of Radiation Oncology, University of California at Davis, Davis, CA; §§Department of Radiology, Emory University, Atlanta, GA; ***Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY; †††Division ofCancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD; ‡‡‡National Council on Radiation Protection and Measurements, Bethesda, MD, and the Department of Medicine, Vanderbilt University, Nashville, TN
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27
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Cardiovascular complications of radiotherapy. Am J Cardiol 2013; 112:1688-96. [PMID: 24012026 DOI: 10.1016/j.amjcard.2013.07.031] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/12/2013] [Accepted: 07/12/2013] [Indexed: 12/17/2022]
Abstract
Chest radiotherapy is routinely used to treat malignancies such as Hodgkin disease and breast cancer but is commonly associated with a variety of cardiovascular complications involving the pericardium, myocardium, valves, coronary arteries, and conduction system. Cardiovascular complications are related to the total dose of radiation and the fractionation of the dose. They are usually progressive, portend poor prognosis, and are often refractory to treatment after significant radiation exposure. The mechanism of injury is multifactorial and likely involves endothelial damage of the microvasculature and coronary arteries and liberation of multiple inflammatory and profibrotic cytokines. In conclusion, routine follow-up with a cardiologist, which might include screening for valvular disease with echocardiography and coronary artery disease with computed tomography angiography or coronary artery calcium scoring, should be considered in patients with a history of chest radiotherapy.
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28
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Lipshultz SE, Adams MJ, Colan SD, Constine LS, Herman EH, Hsu DT, Hudson MM, Kremer LC, Landy DC, Miller TL, Oeffinger KC, Rosenthal DN, Sable CA, Sallan SE, Singh GK, Steinberger J, Cochran TR, Wilkinson JD. Long-term cardiovascular toxicity in children, adolescents, and young adults who receive cancer therapy: pathophysiology, course, monitoring, management, prevention, and research directions: a scientific statement from the American Heart Association. Circulation 2013; 128:1927-95. [PMID: 24081971 DOI: 10.1161/cir.0b013e3182a88099] [Citation(s) in RCA: 360] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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29
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Educational paper: decreasing the burden of cardiovascular disease in childhood cancer survivors: an update for the pediatrician. Eur J Pediatr 2013; 172:1149-60. [PMID: 23361962 DOI: 10.1007/s00431-013-1931-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Accepted: 01/08/2013] [Indexed: 12/31/2022]
Abstract
The cardiovascular impact of cancer therapies on the heart is one of the major concerns in the long-term follow-up of childhood cancer survivors (CCSs). Long-term cardiovascular effects include the development of left ventricular dysfunction resulting in congestive heart failure and ischemic heart disease, as well as valvular and pericardial disease. This is mainly ascribed to the cardiotoxic side effects of chemotherapeutic agents (especially anthracyclines) and radiotherapy, but other factors such as radiation and inflammation play a role in the effect of childhood cancer on the cardiovascular health. The most concerning effect is the high incidence of symptomatic heart failure in CCS patients treated with anthracyclines. More than 50 % of CCSs treated with anthracyclines develop asymptomatic left ventricular dysfunction after cancer therapy, with approximately 5 % developing clinical signs of heart failure during long-term follow-up. Once CCS patients develop congestive heart failure, prognosis is poor and is not influenced by current medical treatment strategies. To reduce the long-term burden of cardiovascular disease in pediatric cancer patients, a diversified approach will be necessary. In the acute phase, prevention of cardiac damage through the use of cardioprotective agents (e.g., dexrazoxane) or by administering less cardiotoxic chemotherapeutic agents is to be considered. A recent randomized trial suggested that the use of dexrazoxane reduced cardiac toxicity without affecting cancer outcomes. Especially patients requiring high doses of chemotherapeutic agents could benefit from this approach. Recent data suggest that genetic testing might identify patients at higher risk for cardiotoxicity. This seems mainly related to genes involved in drug metabolism. This would allow personalized approach adjusting chemotherapy based on cardiovascular risk profiling. This could be combined with newer monitoring strategies in the acute phase using newer echocardiographic techniques and biomarker screening to identify patients with early damage to the myocardium. For the long-term CCS cohort, early detection and treatment of early dysfunction prior to the development of congestive heart failure could potentially improve long-term outcomes. Promoting healthy lifestyles and controlling additional cardiovascular risk factors (e.g., obesity, diabetes, arterial hypertension) is an important task for every physician involved in the care of this growing cohort.
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30
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Abstract
Radiation-induced heart disease (RIHD) is becoming an increasing concern for patients and clinicians alike as the use of radiation therapy for the treatment of certain malignancies increases, and patient mortality secondary to neoplasms of the thorax, in particular Hodgkin's lymphoma and breast cancer, decreases. The spectrum of pathology affecting the heart spans from acute to chronic and can affect almost all facets of the heart, including but not restricted to the pericardial sac, coronary arteries, myocardium, and heart valves. Significant research has been conducted over the past 40 years to further understand the toxic effects of radiation therapy and those protective methods that could curtail these adverse reactions. This article will focus on RIHD, the pathophysiological mechanisms for RIHD, the clinical presentations, and current and future directions for attempting to reduce the incidence of this condition.
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BARRA SÉRGIONUNOCRAVEIRO, PROVIDÊNCIA RUI, PAIVA LUÍS, NASCIMENTO JOSÉ, MARQUES ANTÓNIOLEITÃO. A Review on Advanced Atrioventricular Block in Young or Middle-Aged Adults. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:1395-405. [DOI: 10.1111/j.1540-8159.2012.03489.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Garcipérez de Vargas FJ, Gómez-Barrado JJ, Sánchez-Calderón P, Lezcano-Gort LE, Ortiz C, Mendoza J. [Complete atrioventricular block secondary to radiotherapy]. Med Intensiva 2012; 37:211-2. [PMID: 22749002 DOI: 10.1016/j.medin.2012.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 05/21/2012] [Indexed: 10/28/2022]
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Travis LB, Ng AK, Allan JM, Pui CH, Kennedy AR, Xu XG, Purdy JA, Applegate K, Yahalom J, Constine LS, Gilbert ES, Boice JD. Second malignant neoplasms and cardiovascular disease following radiotherapy. J Natl Cancer Inst 2012; 104:357-70. [PMID: 22312134 PMCID: PMC3295744 DOI: 10.1093/jnci/djr533] [Citation(s) in RCA: 148] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 11/21/2011] [Accepted: 11/30/2011] [Indexed: 12/29/2022] Open
Abstract
Second malignant neoplasms (SMNs) and cardiovascular disease (CVD) are among the most serious and life-threatening late adverse effects experienced by the growing number of cancer survivors worldwide and are due in part to radiotherapy. The National Council on Radiation Protection and Measurements (NCRP) convened an expert scientific committee to critically and comprehensively review associations between radiotherapy and SMNs and CVD, taking into account radiobiology; genomics; treatment (ie, radiotherapy with or without chemotherapy and other therapies); type of radiation; and quantitative considerations (ie, dose-response relationships). Major conclusions of the NCRP include: 1) the relevance of older technologies for current risk assessment when organ-specific absorbed dose and the appropriate relative biological effectiveness are taken into account and 2) the identification of critical research needs with regard to newer radiation modalities, dose-response relationships, and genetic susceptibility. Recommendation for research priorities and infrastructural requirements include 1) long-term large-scale follow-up of extant cancer survivors and prospectively treated patients to characterize risks of SMNs and CVD in terms of radiation dose and type; 2) biological sample collection to integrate epidemiological studies with molecular and genetic evaluations; 3) investigation of interactions between radiotherapy and other potential confounding factors, such as age, sex, race, tobacco and alcohol use, dietary intake, energy balance, and other cofactors, as well as genetic susceptibility; 4) focusing on adolescent and young adult cancer survivors, given the sparse research in this population; and 5) construction of comprehensive risk prediction models for SMNs and CVD to permit the development of follow-up guidelines and prevention and intervention strategies.
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MESH Headings
- Adult
- Age of Onset
- Arrhythmias, Cardiac/epidemiology
- Arrhythmias, Cardiac/etiology
- Cardiovascular Diseases/epidemiology
- Cardiovascular Diseases/etiology
- Cardiovascular Diseases/genetics
- Cardiovascular Diseases/prevention & control
- Child
- Confounding Factors, Epidemiologic
- Dose-Response Relationship, Radiation
- Female
- Genetic Predisposition to Disease
- Heart Block/epidemiology
- Heart Block/etiology
- Humans
- Incidence
- Male
- Myocardial Infarction/epidemiology
- Myocardial Infarction/etiology
- Neoplasms/radiotherapy
- Neoplasms, Radiation-Induced/epidemiology
- Neoplasms, Radiation-Induced/etiology
- Neoplasms, Radiation-Induced/genetics
- Neoplasms, Radiation-Induced/prevention & control
- Neoplasms, Second Primary/epidemiology
- Neoplasms, Second Primary/etiology
- Neoplasms, Second Primary/genetics
- Neoplasms, Second Primary/prevention & control
- Polymorphism, Genetic
- Radiotherapy/adverse effects
- Radiotherapy/methods
- Radiotherapy Dosage
- Radiotherapy, Adjuvant/adverse effects
- Radiotherapy, Conformal/adverse effects
- Radiotherapy, Conformal/methods
- Radiotherapy, Intensity-Modulated
- Risk Assessment
- Risk Factors
- SEER Program
- Stroke/epidemiology
- Stroke/etiology
- Survivors/statistics & numerical data
- United States/epidemiology
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Affiliation(s)
- Lois B Travis
- Rubin Center for Cancer Survivorship and Department of Radiation Oncology, James P. Wilmot Cancer Center, University of Rochester Medical Center, 265 Crittenden Blvd, CU 420318, Rochester, NY 14642, USA.
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34
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Le alterazioni elettrocardiografiche espressione di cardiotossicità. J Cardiovasc Echogr 2011. [DOI: 10.1016/j.jcecho.2011.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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35
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Abstract
Innovative anticancer strategies have contributed to an improved survival of patients suffering from malignancies, and in some cases, have turned cancer into a chronic disease. Therefore, the early and particularly late onsets of adverse cardiovascular effects of systemic anticancer treatments are of increasing interest. Among a rapidly increasing variety of anticancer drugs, the anthracyclines and the monoclonal antibody, trastuzumab, are the agents with a well-known cardiotoxicity. The diagnostic work-up, the cardiotoxic risk of anthracyclines and trastuzumab, and additionally, cardiotoxicity as a risk factor of a multimodal therapeutic approach in breast cancer patients is discussed in this study.
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36
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Chopra RR, Bogart JA. Radiation Therapy–Related Toxicity (Including Pneumonitis and Fibrosis). Hematol Oncol Clin North Am 2010; 24:625-42. [DOI: 10.1016/j.hoc.2010.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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37
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Mediastinal radiation and adverse outcomes after heart transplantation. J Heart Lung Transplant 2010; 29:378-81. [DOI: 10.1016/j.healun.2009.08.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2009] [Revised: 08/05/2009] [Accepted: 08/06/2009] [Indexed: 11/21/2022] Open
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38
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Abstract
Survivors of childhood cancer and hematopoietic stem cell transplantation are subject to a range of cardiac late effects including conduction abnormalities. We present, the case of a 12-year-old girl diagnosed with inappropriate sinus tachycardia after a history of multiply relapsed acute lymphoblastic leukemia and an exposure history including anthracycline-based chemotherapy followed by the total body irradiation in the context of a hematopoietic stem cell transplant. The clinical importance of this late cardiac effect along with the potential options for therapy is discussed.
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39
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Chopra RR, Bogart JA. Radiation Therapy–Related Toxicity (Including Pneumonitis and Fibrosis). Emerg Med Clin North Am 2009; 27:293-310. [DOI: 10.1016/j.emc.2009.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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40
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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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41
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Kuhnt T, Friese M, Janich M, Gerlach R, Pelz T, Haensgen G. Possibility of radiotherapy-associated cardiovascular side effects in breast cancer patients by modern radiotherapy techniques. Breast J 2007; 13:103-5. [PMID: 17214809 DOI: 10.1111/j.1524-4741.2006.00378.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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42
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Abstract
This case report describes a 51-year-old man who presented with syncope. His electrocardiogram showed an abnormally long pause and the electrophysiology study revealed a prolonged H-V interval. This was attributed to the radiation therapy he received to the chest. He was successfully treated with implantation of a permanent pacemaker. This case highlights this rare complication of radiation-induced conduction system disease and management of this potentially life-threatening condition.
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Affiliation(s)
- Siddharth Mukerji
- Sparrow Health System, Division of Cardiology, Michigan State University, East Lansing, Michigan, USA
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43
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FitzGerald TJ, Aronowitz J, Giulia Cicchetti M, Fisher G, Kadish S, Lo YC, Mayo C, McCauley S, Meyer J, Pieters R, Sherman A. The Effect of Radiation Therapy on Normal Tissue Function. Hematol Oncol Clin North Am 2006; 20:141-63. [PMID: 16580561 DOI: 10.1016/j.hoc.2006.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
As more patients are treated for their primary malignancy with cure or increased disease-free intervals, injury to normal tissues will become more detectable and an important endpoint for study. Future protocols will probably be modified based on toxicity endpoints. In Hodgkin's disease, current protocols use response-based treatment strategies to limit therapy. The objective is to provide the same level of tumor control and follow normal tissue endpoints for outcome analysis. DVH analysis has improved the ability to analyze endpoint data for normal tissues. These image-guided platforms will provide the infrastructure needed to continue efforts in improving the delivery of radiation therapy.
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Affiliation(s)
- T J FitzGerald
- Department of Radiation Oncology and the Cancer Center, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01625, USA.
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44
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Patt DA, Goodwin JS, Kuo YF, Freeman JL, Zhang DD, Buchholz TA, Hortobagyi GN, Giordano SH. Cardiac Morbidity of Adjuvant Radiotherapy for Breast Cancer. J Clin Oncol 2005; 23:7475-82. [PMID: 16157933 DOI: 10.1200/jco.2005.13.755] [Citation(s) in RCA: 160] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Adjuvant breast irradiation has been associated with an increase in cardiac mortality, because left-sided breast radiation can produce cardiac damage. The purpose of this study was to determine whether modern adjuvant radiotherapy is associated with increased risk of cardiac morbidity. Patients and Methods Data from the Surveillance, Epidemiology, and End Results–Medicare database were used for women who were diagnosed with nonmetastatic breast cancer from 1986 to 1993, had known disease laterality, underwent breast surgery, and received adjuvant radiotherapy. The Cox proportional-hazards model was used to compare patients with left- versus right-sided breast cancer for the end points of hospitalization with the following discharge diagnoses (International Classification of Diseases, 9th Revision codes): ischemic heart disease (410-414, 36.0, and 36.1), valvular heart disease (394-397, 424, 35), congestive heart failure (428, 402.01, 402.11, 402.91, and 425), and conduction abnormalities (426, 427, 37.7-37.8, and 37.94-37.99). Results Eight thousand three hundred sixty-three patients had left-sided breast cancer, and 7,907 had right-sided breast cancer. Mean follow-up was 9.5 years (range, 0 to 15 years). There were no significant differences in patients with left- versus right-sided cancers for hospitalization for ischemic heart disease (9.9% v 9.7%), valvular heart disease (2.9% v 2.8%), conduction abnormalities (9.7% v 9.6%), or heart failure (9.7% v 9.7%). The adjusted hazard ratio for left- versus right-sided breast cancer was 1.05 (95% CI, 0.94 to 1.16) for ischemic heart disease, 1.07 (95% CI, 0.89 to 1.30) for valvular heart disease, 1.07 (95% CI, 0.96 to 1.19) for conduction abnormalities, and 1.05 (95% CI, 0.95 to 1.17) for heart failure. Conclusion With up to 15 years of follow-up there were no significant differences in cardiac morbidity after radiation for left- versus right-sided breast cancer.
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Affiliation(s)
- Debra A Patt
- Department of Medical Oncology, Houston, TX 77030, USA
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45
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Abstract
AIMS To present an overview of cardiac complications arising from radiation therapy. MATERIALS AND METHODS Medline the (February 2004) and Embase (1974 to February 2004) searches of the medical literature relating to the cardiac complications of radiotherapy were conducted. RESULTS Radiation damage may affect the pericardium, myocardium or coronary vasculature, and consists of fibrotic or small vessel damage. Cardiac complications are a particular problem with radiation treatments to the mediastinum and breast, especially when greater than 65% of the heart is irradiated. Most of the literature relates to the treatment of Hodgkin's disease, as patients with this disease tend to be young and live long enough to manifest late cardiac complications. Pericarditis, angina, myocardial infarction and arrhythmias are the most frequent causes of morbidity, with myocardial infarction being the most common fatal complication. The incidence of ischaemic heart disease does not increase rapidly until 10 years from treatment. CONCLUSIONS Much of the evidence relates to the use of outdated radiation therapy equipment and techniques. Today's patients almost certainly have a lower risk of cardiac complications. Cardiac complications are probably under-reported, as they occur long after cured patients have been discharged from follow-up.
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Affiliation(s)
- A M Gaya
- Department of Medical Oncology, Mount Vernon Hospital, Northwood, Middlesex, UK.
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46
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Abstract
Radiation induced heart diseases (RIHD) are increasingly recognized as more patients who received radiation therapy survive their diseases with improved management of various malignancies. Radiation affects every component of the heart, ranging from subclinical histopathologic changes to overt clinical disease. Pericardial involvement is the most common and includes asymptomatic pericardial effusion and constrictive pericarditis. The diseases involving the myocardium, valvular apparatus, and conduction system are often subclinical. When symptomatic, they are often the harbinger of more lethal, but treatable, radiation-induced coronary artery disease (CAD). Improvements in the modern radiation delivery systems have minimized irradiation of the heart. However, with increased and emerging indications for radiation therapy for various malignancies in the chest, as a part of bone marrow transplantations, and as the main agent of brachytherapy for advanced preexisting CAD, the incidence of RIHD is likely to increase. Appropriate management of RIHD, either overt or occult, must include understanding the natural history of RIHD, recognition of symptoms by careful history, and vigilant search for treatable causes of the RIHD or other diseases that might mimic RIHD. This article focuses on providing practical yet comprehensive clinical information for general internal medicine and cardiology practices.
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Affiliation(s)
- Peter J Lee
- Section of Cardiology, Department of Medicine, University of Illinois at Chicago, IL 60612, USA.
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47
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Adams MJ, Lipshultz SE. Pathophysiology of anthracycline- and radiation-associated cardiomyopathies: implications for screening and prevention. Pediatr Blood Cancer 2005; 44:600-6. [PMID: 15856486 DOI: 10.1002/pbc.20352] [Citation(s) in RCA: 174] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Great progress has been made in treating childhood cancers over the past 40 years. Along with second malignancies, a major complication of anti-cancer therapies is adverse cardiovascular effects, especially cardiomyopathy and coronary artery disease. The pathophysiology and characteristics of cardiomyopathy associated with radiation therapy and anthracycline therapy are distinctive. We describe each type of cardiomyopathy, along with its risk factors. These distinctive cardiomyopathies require different screening tests. Appropriate screening of the entire cardiovascular system should be performed because radiation and chemotherapy affect the entire system. Prevention recommendations focus on cardiomyopathy and coronary artery disease.
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Affiliation(s)
- M Jacob Adams
- Department of Community and Preventive Medicine, The University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
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48
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Guerra PG, Talajic M, Thibault B, Dubuc M, Roy D, Macle L, Leung TK, Arsenault A, Harel F, Grégoire J, Bonan R. β-Radiation for the Creation of Linear Lesions in the Canine Atrium. Circulation 2004; 110:911-4. [PMID: 15302779 DOI: 10.1161/01.cir.0000139865.39885.03] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Creating linear lesions is important for the treatment of arrhythmias such as atrial flutter and fibrillation. Making these lesions with standard radiofrequency catheters can be difficult and may result in charring and thrombosis. The purpose of this study was to evaluate β-radiation as a novel energy source for creating linear myocardial lesions.
Methods and Results—
Eight dogs with intact conduction across the cavotricuspid isthmus were studied. The isthmus was irradiated (25 to 50 Gy) with strontium/yttrium-90 delivered via a deflectable 7F catheter (Novoste Corporation). There were no immediate effects, but bidirectional conduction block developed during follow-up studies in 7 of 8 dogs. The dog without conduction block received 25 Gy. After the animals were euthanized, histology revealed transmural, linear areas of fibrosis without any thrombus.
Conclusions—
β-Radiation can safely and effectively create linear lesions that are contiguous and nonthrombogenic. This energy source may become an interesting adjunct to radiofrequency for the treatment of atrial flutter and fibrillation.
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Affiliation(s)
- Peter G Guerra
- Department of Medicine and Research Center, Montreal Heart Institute, 5000 Belanger East, Montreal, Quebec, Canada H1T 1C8.
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49
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Snopek G, Bruszewska E, Rywik T, Sobieszczańska-Małek M. Diastolic heart failure in female patient 20 years after radiotherapy due to Hodgkin’s disease—a case report. Int J Cardiol 2004; 93:309-10. [PMID: 14975568 DOI: 10.1016/s0167-5273(03)00163-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2002] [Accepted: 01/08/2003] [Indexed: 10/27/2022]
Abstract
We present the case of a 36-year-old female with severe heart failure which developed 20 years after irradiation due to Hodgkin's disease.
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50
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Adams MJ, Hardenbergh PH, Constine LS, Lipshultz SE. Radiation-associated cardiovascular disease. Crit Rev Oncol Hematol 2003; 45:55-75. [PMID: 12482572 DOI: 10.1016/s1040-8428(01)00227-x] [Citation(s) in RCA: 398] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
As the number of cancer survivors grows because of advances in therapy, it has become more important to understand the long-term complications of these treatments. This article presents the current knowledge of adverse cardiovascular effects of radiotherapy to the chest. Emphasis is on clinical presentations, recommendations for follow-up, and treatment of patients previously exposed to irradiation. Medline literature searches were performed, and abstracts related to this topic from oncology and cardiology meetings were reviewed. Potential adverse effects of mediastinal irradiation are numerous and can include coronary artery disease, pericarditis, cardiomyopathy, valvular disease and conduction abnormalities. Damage appears to be related to dose, volume and technique of chest irradiation. Effects may initially present as subclinical abnormalities on screening tests or as catastrophic clinical events. Estimates of relative risk of fatal cardiovascular events after mediastinal irradiation for Hodgkin's disease ranges between 2.2 and 7.2 and after irradiation for left-sided breast cancer from 1.0 to 2.2. Risk is life long, and absolute risk appears to increase with length of time since exposure. Radiation-associated cardiovascular toxicity may in fact be progressive. Long-term cardiac follow-up of these patients is therefore essential, and the range of appropriate cardiac screening is discussed, although no specific, evidence-based screening regimen was found in the literature.
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Affiliation(s)
- M Jacob Adams
- Department of Pediatrics, Division of Pediatric Cardiology, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 631, Rochester, NY 14642, USA
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