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Krug P, Geets X, Berlière M, Duhoux F, Beauloye C, Pasquet A, Vancraeynest D, Pouleur AC, Gerber BL. Cardiac structure, function, and coronary anatomy 10 years after isolated contemporary adjuvant radiotherapy in breast cancer patients with low cardiovascular baseline risk. Eur Heart J Cardiovasc Imaging 2024; 25:645-656. [PMID: 38128112 DOI: 10.1093/ehjci/jead338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 11/07/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
AIMS The effects of isolated contemporary low-dose breast cancer (BC) radiotherapy (RT) on the heart remain poorly understood. This study aims to assess the long-term impacts of BC-RT on cardiac structure and function. METHODS AND RESULTS Seventy-six women (62 ± 7 years) without history of prior heart disease, who had undergone RT for either first left (n = 36) or right (n = 40) BC, without additional medical oncology therapy apart from hormonal treatment 11 ± 1 years earlier, underwent transthoracic echocardiography, cardiac magnetic resonance imaging (CMR), computed tomography coronary angiography (CTCA), NT-proBNP, and a 6-min walk test (6MWT). They were compared with 54 age-matched healthy female controls. By CTCA, 68% of BC patients exhibited no or very mild coronary disease, while only 11% had moderate stenosis (50-69%) and 3% had significant stenosis (>70%). Despite slightly reduced regional echocardiographic midventricular strains, BC patients exhibited similar global left and right ventricular volumes, ejection fractions, and global strains by echocardiography and CMR as controls. Mitral E/e' ratios were slightly higher, and mitral deceleration times were slightly lower, but NT-proBNP was similar to controls. Also, 6MWT was normal. None had late gadolinium enhancement, and extracellular volume fraction was similar in BC (28 ± 3 vs. 29 ± 3, P = 0.15) and controls. No differences were observed relative to dose or side of RT. CONCLUSION Aside from minor alterations of regional strains and diastolic parameters, women who received isolated RT for BC had low prevalence of coronary disease, normal global systolic function, NT-proBNP, and exercise capacity and showed no structural changes by CMR, refuting significant long-term cardiotoxicity in such low-risk patients.
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Affiliation(s)
- Pauline Krug
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St.Luc, Av Hippocrate 10/2806, B-1200 Woluwe-Saint-Lambert, Belgium
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Avenue Hippocrate, 55 bte B1.55.02 Université Catholique de Louvain (UCLouvain), B-1200 Woluwe St. Lambert, Belgium
| | - Xavier Geets
- Division of Radiotherapy, Cliniques Universitaires St.Luc, Av Hippocrate 10/2806, B-1200 Woluwe-Saint-Lambert, Belgium
- Pole d'Imagerie Médicale, Radiothérapie et Oncologie (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), Avenue Hippocrate 54/B1.54.07, B-1200 Woluwe St. Lambert, Belgium
| | - Martine Berlière
- Division of Medical Oncology, Institut Roi Albert II, Cliniques Universitaires St.Luc, Brussels, Belgium
- Pôle de Gynécologie (GYNE), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), Avenue Mounier 52 bte B1.52.02, B1200 Woluwe St Lambert, Belgium
| | - François Duhoux
- Pole d'Imagerie Médicale, Radiothérapie et Oncologie (MIRO), Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain (UCLouvain), Avenue Hippocrate 54/B1.54.07, B-1200 Woluwe St. Lambert, Belgium
- Division of Medical Oncology, Institut Roi Albert II, Cliniques Universitaires St.Luc, Brussels, Belgium
| | - Christophe Beauloye
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St.Luc, Av Hippocrate 10/2806, B-1200 Woluwe-Saint-Lambert, Belgium
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Avenue Hippocrate, 55 bte B1.55.02 Université Catholique de Louvain (UCLouvain), B-1200 Woluwe St. Lambert, Belgium
| | - Agnès Pasquet
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St.Luc, Av Hippocrate 10/2806, B-1200 Woluwe-Saint-Lambert, Belgium
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Avenue Hippocrate, 55 bte B1.55.02 Université Catholique de Louvain (UCLouvain), B-1200 Woluwe St. Lambert, Belgium
| | - David Vancraeynest
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St.Luc, Av Hippocrate 10/2806, B-1200 Woluwe-Saint-Lambert, Belgium
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Avenue Hippocrate, 55 bte B1.55.02 Université Catholique de Louvain (UCLouvain), B-1200 Woluwe St. Lambert, Belgium
| | - Anne-Catherine Pouleur
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St.Luc, Av Hippocrate 10/2806, B-1200 Woluwe-Saint-Lambert, Belgium
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Avenue Hippocrate, 55 bte B1.55.02 Université Catholique de Louvain (UCLouvain), B-1200 Woluwe St. Lambert, Belgium
| | - Bernhard L Gerber
- Division of Cardiology, Department of Cardiovascular Diseases, Cliniques Universitaires St.Luc, Av Hippocrate 10/2806, B-1200 Woluwe-Saint-Lambert, Belgium
- Pôle de Recherche Cardiovasculaire (CARD), Institut de Recherche Expérimentale et Clinique (IREC), Avenue Hippocrate, 55 bte B1.55.02 Université Catholique de Louvain (UCLouvain), B-1200 Woluwe St. Lambert, Belgium
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Chufal K, Ahmad I, Prakash A, Miller A, Umesh P, Koul V, Bajpai R, Dua B, Gupta P, Gairola M. Cardiac markers in left-sided breast cancer patients receiving adjuvant radiotherapy: a prospective study. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2024; 10:21. [PMID: 38589947 PMCID: PMC11000277 DOI: 10.1186/s40959-024-00225-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/25/2024] [Indexed: 04/10/2024]
Abstract
OBJECTIVES To investigate the association between radiotherapy (RT) and cardiac biomarkers in women with left-sided breast cancer. METHODS This prospective observational study recruited patients with stage I-III left-sided breast cancer without coronary heart disease who required adjuvant RT. High-sensitivity troponin I(hsTnI), N-terminal pro-brain natriuretic peptide(NT-proBNP), and high-sensitivity C-reactive protein(hsCRP) levels were measured pre-RT, immediately after RT, and 3 months post-RT. Cardiac-sparing RT techniques were utilized (Field-in-Field IMRT/VMAT ± voluntary deep inspiration breath-hold). Statistical analyses were performed using non-parametric tests and multivariable quantile regression (QR). RESULTS One hundred five patients completed the study, with 63 evaluable at three months post-RT. Pre- and post-RT biomarkers showed no significant differences. Median pre-RT and post-RT values were: hsTnI (0.012ng/mL; 0.012ng/mL), hsCRP (3.1 mg/L; 2.8 mg/L), and NT-proBNP (59pg/mL; 45pg/mL). Three months post-RT, hsTnI, hsCRP and NT-proBNP levels also showed no significant differences. Multivariable QR revealed no association between heart Dmean [median(IQR): 2.87 Gy (2.05-3.94)] and post-RT biomarkers. Age and BMI were associated with hsCRP and NT-proBNP, respectively. CONCLUSIONS hsTnI, NT-proBNP, and hsCRP are not correlated with contemporary low cardiac exposure in left-sided breast cancer patients treated with contemporary RT techniques.
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Affiliation(s)
- Kundan Chufal
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Irfan Ahmad
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India.
| | - Anuj Prakash
- Department of Biochemistry, Medanta Hospital, Gurugram, Haryana, India
| | - Alexis Miller
- Department of Radiation Oncology, Illawara Cancer Care Centre, Wollongong, NSW, Australia
| | - Preetha Umesh
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
| | - Varsha Koul
- Department of Cardiology, Batra Hospital and Medical Research Centre, New Delhi, India
| | - Ram Bajpai
- School of Medicine, Keele University, Staffordshire, UK
| | - Bharat Dua
- Department of Radiation Oncology, Venkateshwar Hospital, New Delhi, India
| | - Priya Gupta
- School of Medicine, Keele University, Staffordshire, UK
| | - Munish Gairola
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
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Zampieri M, Di Filippo C, Zocchi C, Fico V, Golinelli C, Spaziani G, Calabri G, Bennati E, Girolami F, Marchi A, Passantino S, Porcedda G, Capponi G, Gozzini A, Olivotto I, Ragni L, Favilli S. Focus on Paediatric Restrictive Cardiomyopathy: Frequently Asked Questions. Diagnostics (Basel) 2023; 13:3666. [PMID: 38132249 PMCID: PMC10742619 DOI: 10.3390/diagnostics13243666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023] Open
Abstract
Restrictive cardiomyopathy (RCM) is characterized by restrictive ventricular pathophysiology determined by increased myocardial stiffness. While suspicion of RCM is initially raised by clinical evaluation and supported by electrocardiographic and echocardiographic findings, invasive hemodynamic evaluation is often required for diagnosis and management of patients during follow-up. RCM is commonly associated with a poor prognosis and a high incidence of heart failure, and PH is reported in paediatric patients with RCM. Currently, only a few therapies are available for specific RCM aetiologies. Early referral to centres for advanced heart failure treatment is often necessary. The aim of this review is to address questions frequently asked when facing paediatric patients with RCM, including issues related to aetiologies, clinical presentation, diagnostic process and prognosis.
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Affiliation(s)
- Mattia Zampieri
- Pediatric Cardiology, Meyer Children’s University Hospital IRCCS, 50134 Florence, Italy (S.F.)
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Chiara Di Filippo
- Local Health Unit, Outpatient Cardiology Clinic, 84131 Salerno, Italy
| | - Chiara Zocchi
- Cardiovascular Department, San Donato Hospital, 52100 Arezzo, Italy
| | - Vera Fico
- Pediatric Cardiology, Meyer Children’s University Hospital IRCCS, 50134 Florence, Italy (S.F.)
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Cristina Golinelli
- Pediatric Cardiology and Adult Congenital Heart Disease Program, Department of Cardio—Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero—Universitaria di Bologna, 40138 Bologna, Italy
| | - Gaia Spaziani
- Pediatric Cardiology, Meyer Children’s University Hospital IRCCS, 50134 Florence, Italy (S.F.)
| | - Giovanni Calabri
- Pediatric Cardiology, Meyer Children’s University Hospital IRCCS, 50134 Florence, Italy (S.F.)
| | - Elena Bennati
- Pediatric Cardiology, Meyer Children’s University Hospital IRCCS, 50134 Florence, Italy (S.F.)
| | - Francesca Girolami
- Pediatric Cardiology, Meyer Children’s University Hospital IRCCS, 50134 Florence, Italy (S.F.)
| | - Alberto Marchi
- Pediatric Cardiology, Meyer Children’s University Hospital IRCCS, 50134 Florence, Italy (S.F.)
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Silvia Passantino
- Pediatric Cardiology, Meyer Children’s University Hospital IRCCS, 50134 Florence, Italy (S.F.)
| | - Giulio Porcedda
- Pediatric Cardiology, Meyer Children’s University Hospital IRCCS, 50134 Florence, Italy (S.F.)
| | - Guglielmo Capponi
- Pediatric Cardiology, Meyer Children’s University Hospital IRCCS, 50134 Florence, Italy (S.F.)
| | - Alessia Gozzini
- Pediatric Cardiology, Meyer Children’s University Hospital IRCCS, 50134 Florence, Italy (S.F.)
| | - Iacopo Olivotto
- Pediatric Cardiology, Meyer Children’s University Hospital IRCCS, 50134 Florence, Italy (S.F.)
- Cardiomyopathy Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Luca Ragni
- Pediatric Cardiology and Adult Congenital Heart Disease Program, Department of Cardio—Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero—Universitaria di Bologna, 40138 Bologna, Italy
| | - Silvia Favilli
- Pediatric Cardiology, Meyer Children’s University Hospital IRCCS, 50134 Florence, Italy (S.F.)
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Abbasi MA, Bruno G, Di Stefano C, Garcia Bello L, Laack NN, Corbin KS, Whitaker TJ, Pellikka PA, Mutter RW, Villarraga HR. Detection of Early Myocardial Dysfunction by Imaging Biomarkers in Cancer Patients Undergoing Photon Beam vs. Proton Beam Radiotherapy: A Prospective Study. J Cardiovasc Dev Dis 2023; 10:418. [PMID: 37887865 PMCID: PMC10607871 DOI: 10.3390/jcdd10100418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/30/2023] [Accepted: 10/02/2023] [Indexed: 10/28/2023] Open
Abstract
1. Background: We sought to determine acute and subacute changes in cardiac function after proton beam (PBT) and photon beam (PhT) radiotherapy (RT) using conventional and two-dimensional speckle tracking echocardiography (2D-STE) in patients with malignant breast and thoracic tumors. 2. Methods: Between March 2016 and March 2017, 70 patients with breast or thoracic cancer were prospectively enrolled and underwent transthoracic echocardiography with comprehensive strain analysis at pretreatment, mid-treatment, end of treatment, and 3 months after RT. 3. Results: PBT was used to treat 44 patients; PhT 26 patients. Mean ± SD age was 55 ± 12 years; most patients (93%) were women. The median (interquartile range) of the mean heart dose was lower in the PBT than the PhT group (47 [27-79] vs. 217 [120-596] cGy, respectively; p < 0.001). Ejection fraction did not change in either group. Only the PhT group had reduced systolic tissue Doppler velocities at 3 months. 2D-STE showed changes in endocardial and epicardial longitudinal, radial, and circumferential early diastolic strain rate (SRe) in patients undergoing PhT (global longitudinal SRe, pretreatment vs. end of treatment (p = 0.04); global circumferential SRe, pretreatment vs. at 3-month follow-up (p = 0.003); global radial SRe, pretreatment vs. at 3-month follow-up (p = 0.02) for endocardial values). Epicardial strain values decreased significantly only in patients treated with PhT. Patients in the PhT group had a significant decrease in epicardial global longitudinal systolic strain rate (GLSRs) (epicardial GLSRs, at baseline vs. at end of treatment [p = 0.009]) and in GCSRe and GRSRe (epicardial GCSRe, at baseline vs. at 3-month follow-up (p = 0.02); epicardial GRSRe, at baseline vs. at 3-month follow-up (p = 0.03)) during treatment and follow-up. No changes on 2D-STE were detected in the PBT group. 4. Conclusions: Patients who underwent PhT but not PBT had reduced tissue Doppler velocities and SRe values during follow-up, suggesting early myocardial relaxation abnormalities. PBT shows promise as a cardiac-sparing RT technology.
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Affiliation(s)
| | - Giulia Bruno
- Hypertension Unit, Department of Medical Sciences, Città della Salute e della Scienza, University of Torino, 3-10126 Torino, Italy
| | - Cristina Di Stefano
- Hypertension Unit, Department of Medical Sciences, Città della Salute e della Scienza, University of Torino, 3-10126 Torino, Italy
| | - Laura Garcia Bello
- Department of Cardiovascular Medicine Mayo Clinic, Rochester, MN 55905, USA
| | - Nadia N. Laack
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | | | | | | | - Robert W. Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
- Department of Pharmacology, Mayo Clinic, Rochester, MN 55905, USA
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Teimouri K, Khoshgard K, Farshchian N, Rouzbahani M, Azimivaghar J. Investigation of electrocardiography and echocardiography changes after adjuvant radiation therapy of left-sided breast cancer. J Med Imaging Radiat Sci 2023; 54:495-502. [PMID: 37183077 DOI: 10.1016/j.jmir.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 03/30/2023] [Accepted: 04/17/2023] [Indexed: 05/16/2023]
Abstract
INTRODUCTION The primary objective of radiation therapy (RT) is to deliver lethal radiation doses to abnormal cancer cells so that healthy cells are exposed to minimal radiation. In the present study, changes in electrocardiography (ECG) and echocardiography(ECHO) following adjuvant RT were investigated in patients with left-sided breast cancer. MATERIALS AND METHODS 30 patients with left-sided breast cancer who had previously undergone breast-conserving surgery or mastectomy underwent RT after completing chemotherapy from February 2019 to January 2020. ECG and ECHO tests were performed before RT, immediately following RT, and three months after RT. Dose-volume parameters of the heart and its substructures as an organ at risk were analyzed. RESULTS The mean heart dose (±SD) for all patients was 7.51 ± 2.42 Gy. T-wave inversion was observed 3 months after RT in 47% of patients. T-wave decline was associated with mean heart radiation dose (β = 0.605, p-value = 0.005). The present study showed that the left ventricular volume receiving the 5 Gy (LV-V5) parameter was associated with a reduction in ST segment duration (p-value = 0.027) as well as with an increase in left ventricular systolic diameter (LVESD, mm) (P-value = 0.027). CONCLUSION RT-induced ECG and ECHO changes are frequent in patients with left breast cancer. LVEF and Twave abnormalities were observed after RT in our patients. ECG and ECHO modalities can be used to monitor the cardiac function after RT in patients with left-sided breast cancer.
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Affiliation(s)
- Kolsoum Teimouri
- Students Research Committee, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Karim Khoshgard
- Department of Medical Physics, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Negin Farshchian
- Department of Radiation Oncology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohammad Rouzbahani
- Department of Cardiology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Javad Azimivaghar
- Department of Cardiology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Wang S, Tsai W, Lin K, Yu C, Yang S, Shueng P, Wu Y, Hsu C, Wu T. Integrating subvolume dose and myocardial perfusion imaging parameters to assess the impact of radiation therapy on heart function in breast cancer patients: A comparative analysis between left- and right-sided breast cancer. Thorac Cancer 2023; 14:2696-2706. [PMID: 37553772 PMCID: PMC10493477 DOI: 10.1111/1759-7714.15056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND This study aimed to utilize an innovative method of integrating the 20 subvolume dose of left ventricle and the Tl-201 single photon emission computed tomography (SPECT) with myocardial perfusion imaging (MPI) parameters in patients with left- and right-sided breast cancer after radiation therapy. METHODS Female patients with breast cancer underwent SPECT MPI before commencing radiotherapy and 12 months later were enrolled from January 2014 to December 2018. The images of CT simulation and SPECT MPI were integrated into the treatment planning system. The differences of doses and parameters of MPI in all cardiac subvolumes between left- and right-sided breast cancer patients were analyzed. RESULTS Patients with left-sided breast cancer (n = 61) received a higher radiation dose to the heart, left ventricular, and its territories and subvolumes, compared to patients with right-sided breast cancer (n = 19). The 20-segment analysis also showed statistically significant disparities in the average radiation doses received by the two groups. In different coronary artery territories, the end-diastolic perfusion and end-systolic perfusion showed a decrease in both sides, with no significant differences. However, the wall motion and wall thickening showed a significant decline in subregions within the left- and right-sided coronary artery territories. CONCLUSION This study demonstrates an innovative integrated method combining the left ventricular 20 regional doses with SPECT MPI which shows that left-sided breast cancer patients receive a higher subvolume dose than right-sided breast cancer patients. Further research is needed to confirm the potential impact on heart function after radiotherapy on both sides.
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Affiliation(s)
- Shan‐Ying Wang
- Department of Biomedical Imaging and Radiological SciencesNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Department of Nuclear MedicineFar Eastern Memorial HospitalNew Taipei CityTaiwan
| | - Wei‐Ta Tsai
- Department of Biomedical Imaging and Radiological SciencesNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Department of Radiation Oncology, Dalin Tzu Chi HospitalBuddhist Tzu Chi Medical FoundationChiayiTaiwan
| | - Kuan‐Heng Lin
- Department of Biomedical Imaging and Radiological SciencesNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Division of Radiation Oncology, Department of RadiologyFar Eastern Memorial HospitalNew Taipei CityTaiwan
- Industrial Ph.D. Program of Biomedical Science and EngineeringNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Chih‐Wei Yu
- Department of Radiation OncologyChina Medical University Hsinchu HospitalZhubei CityTaiwan
- Institute of Nuclear Engineering and ScienceNational Tsing Hua UniversityHsinchu CityTaiwan
| | - Shu‐Ya Yang
- Department of Nuclear MedicineCheng Hsin General HospitalTaipeiTaiwan
| | - Pei‐Wei Shueng
- Division of Radiation Oncology, Department of RadiologyFar Eastern Memorial HospitalNew Taipei CityTaiwan
- School of Medicine, College of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Yen‐Wen Wu
- Department of Nuclear MedicineFar Eastern Memorial HospitalNew Taipei CityTaiwan
- School of Medicine, College of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Division of Cardiology, Cardiovascular Medical CenterFar Eastern Memorial HospitalNew Taipei CityTaiwan
| | - Chen‐Xiong Hsu
- Department of Biomedical Imaging and Radiological SciencesNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Division of Radiation Oncology, Department of RadiologyFar Eastern Memorial HospitalNew Taipei CityTaiwan
| | - Tung‐Hsin Wu
- Department of Biomedical Imaging and Radiological SciencesNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
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Barnafi Wittwer E, Rippker C, Caprile P, Torres DE, El Far R, Gago-Arias A, Merino T. Dosimetric Evaluation of Cardiac Structures on Left Breast Cancer Radiotherapy: Impact of Movement, Dose Calculation Algorithm and Treatment Technique. Cardiol Res 2023; 14:279-290. [PMID: 37559707 PMCID: PMC10409545 DOI: 10.14740/cr1486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/05/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Breast cancer is the most frequently diagnosed and leading cause of cancer-related deaths among females. The treatment of breast cancer with radiotherapy, albeit effective, has been shown to be toxic to the heart, resulting in an elevated risk of cardiovascular disease and associated fatalities. METHODS In this study, we evaluated the impact of respiratory movement, treatment plans and dose calculation algorithm on the dose delivered to the heart and its substructures during left breast radiotherapy over a cohort of 10 patients. We did this through three image sets, four different treatment plans and the employment of three algorithms on the same treatment plan. The dose parameters were then employed to estimate the impact on the 9-year excess cumulative risk for acute cardiac events by applying the model proposed by Darby. RESULTS The left ventricle was the structure most irradiated. Due to the lack of four-dimensional computed tomography (4DCT), we used a set of images called phase-average CT that correspond to the average of the images from the respiratory cycle (exhale, exhale 50%, inhale, inhale 50%). When considering these images, nearly 10% of the heart received more than 5 Gy and doses were on average 27% higher when compared to free breathing images. Deep inspiration breath-hold plans reduced cardiac dose for nine out of 10 patients and reduced mean heart dose in about 50% when compared to reference plans. We also found that the implementation of deep inspiration breath-hold would reduce the relative lifetime risk of ischemic heart disease to 10%, in comparison to 21% from the reference plan. CONCLUSION Our findings illustrate the importance of a more accurate determination of the dose and its consideration in cardiologists' consultation, a factor often overlooked during clinical examination. They also motivate the evaluation of the dose to the heart substructures to derive new heart dose constraints, and a more mindful and individualized clinical practice depending on the treatment employed.
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Affiliation(s)
- Esteban Barnafi Wittwer
- Medicine Faculty, Pontificia Universidad Catolica de Chile, Santiago, Chile
- These authors contributed equally to this work
| | - Carolin Rippker
- Physics Faculty, Heidelberg University, Heidelberg, Germany
- These authors contributed equally to this work
| | - Paola Caprile
- Physics Institute, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | | | - Rodrigo El Far
- Cancer Center UC, Red de Salud Christus-UC, Santiago, Chile
| | - Araceli Gago-Arias
- Physics Institute, Pontificia Universidad Catolica de Chile, Santiago, Chile
- Group of Medical Physics and Biomathematics, Instituto de Investigacion Sanitaria de Santiago (IDIS), Santiago de Compostela, Spain
| | - Tomas Merino
- Medicine Faculty, Pontificia Universidad Catolica de Chile, Santiago, Chile
- Cancer Center UC, Red de Salud Christus-UC, Santiago, Chile
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Stefan MF, Herghelegiu CG, Magda SL. Accelerated Atherosclerosis and Cardiovascular Toxicity Induced by Radiotherapy in Breast Cancer. Life (Basel) 2023; 13:1631. [PMID: 37629488 PMCID: PMC10455250 DOI: 10.3390/life13081631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023] Open
Abstract
The number of patients diagnosed with breast cancer and cardiovascular disease is continuously rising. Treatment options for breast cancer have greatly evolved, but radiotherapy (RT) still has a key role in it. Despite many advances in RT techniques, cardiotoxicity is one of the most important side effects. The new cardio-oncology guidelines recommend a baseline evaluation, risk stratification and follow-up of these patients. Cardiotoxicity induced by RT can be represented by almost all forms of cardiovascular disease, with atherosclerosis being the most frequent. An interdisciplinary team should manage these patients, in order to have maximum therapeutic effect and minimum cardiovascular toxicity. This review will summarize the current incidence, risk factors, mechanisms and follow-up of RT-induced cardiovascular toxicity.
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Affiliation(s)
- Miruna Florina Stefan
- Department of Cardiology, University and Emergency Hospital, 050098 Bucharest, Romania;
| | - Catalin Gabriel Herghelegiu
- Institutul National Pentru Sanatatea Mamei si a Copilului “Alessandrescu Rusescu”, 020395 Bucharest, Romania;
| | - Stefania Lucia Magda
- Department of Cardiology, University and Emergency Hospital, 050098 Bucharest, Romania;
- Department of Cardiology and Cardiovascular Surgery, University of Medicine and Pharmacy Carol Davila, 020021 Bucharest, Romania
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9
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Spoor DS, van den Bogaard VAB, Sijtsema NM, Van der Meer P, de Bock GH, Langendijk JA, Maduro JH, Crijns APG. A comparison of cardiovascular and pulmonary morbidities and risk factors in breast cancer survivors compared to an age-matched female control group in the Lifelines prospective population cohort. Breast 2023; 70:49-55. [PMID: 37331094 DOI: 10.1016/j.breast.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/21/2023] [Accepted: 06/05/2023] [Indexed: 06/20/2023] Open
Abstract
PURPOSE To provide more insight into late treatment-related toxicities among breast cancer (BC) survivors by comparing morbidities and risk factors between BC survivors and age-matched controls. MATERIALS AND METHODS All female participants diagnosed with BC before inclusion in Lifelines, a population-based cohort in the Netherlands, were selected and matched 1:4 to female controls without any oncological history on birth year. Baseline was defined as the age at BC diagnosis. Outcomes were obtained from questionnaires and functional analyses performed at entry to Lifelines (follow-up 1; FU1) and several years later (FU2). Cardiovascular and pulmonary events were defined as morbidities that were absent at baseline but present at FU1 or FU2. RESULTS The study consisted of 1,325 BC survivors and 5,300 controls. The median period from baseline (i.e., BC treatment) to FU1 and FU2 was 7 and 10 years, respectively. Among BC survivors more events of heart failure (OR: 1.72 [1.10-2.68]) and less events of hypertension (OR: 0.79 [0.66-0.94]) were observed. At FU2, more electrocardiographic abnormalities were found among BC survivors compared to controls (4.1% vs. 2.7%, respectively; p = 0.027) and Framingham scores for the 10-year risk of coronary heart disease were lower (difference: 0.37%; 95% CI [-0.70 to -0.03%]). At FU2, BC survivors had more frequently a forced vital capacity below the lower limit of normal than controls (5.4% vs. 2.9%, respectively; p = 0.040). CONCLUSION BC survivors are at risk of late treatment-related toxicities despite a more favourable cardiovascular risk profile compared to age-matched female controls.
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Affiliation(s)
- D S Spoor
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - V A B van den Bogaard
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - N M Sijtsema
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - P Van der Meer
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - G H de Bock
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - J A Langendijk
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - J H Maduro
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - A P G Crijns
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
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10
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Nemec-Bakk AS, Sridharan V, Seawright JW, Nelson GA, Cao M, Singh P, Cheema AK, Singh B, Li Y, Koturbash I, Miousse IR, Ewing LE, Skinner CM, Landes RD, Lowery JD, Mao XW, Singh SP, Boerma M. Effects of proton and oxygen ion irradiation on cardiovascular function and structure in a rabbit model. LIFE SCIENCES IN SPACE RESEARCH 2023; 37:78-87. [PMID: 37087182 PMCID: PMC10122719 DOI: 10.1016/j.lssr.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/13/2023] [Accepted: 03/27/2023] [Indexed: 05/03/2023]
Abstract
PURPOSE Astronauts on missions beyond low Earth orbit will be exposed to galactic cosmic radiation, and there is concern about potential adverse cardiovascular effects. Most of the research to identify cardiovascular risk of space radiation has been performed in rodent models. To aid in the translation of research results to humans, the current study identified long-term effects of high-energy charged particle irradiation on cardiovascular function and structure in a larger non-rodent animal model. MATERIALS AND METHODS At the age of 12 months, male New Zealand white rabbits were exposed to whole-body protons (250 MeV) or oxygen ions (16O, 600 MeV/n) at a dose of 0 or 0.5 Gy and were followed for 12 months after irradiation. Ultrasonography was used to measure in vivo cardiac function and blood flow parameters at 10- and 12-months post-irradiation. At 12 months after irradiation, blood cell counts and blood chemistry values were assessed, and cardiac tissue and aorta were collected for histological as well as molecular and biochemical analyses. Plasma was used for metabolomic analysis and to quantify common markers of cardiac injury. RESULTS A small but significant decrease in the percentage of circulating lymphocytes and an increase in neutrophil percentage was seen 12 months after 0.5 Gy protons, while 16O exposure resulted in an increase in monocyte percentage. Markers of cardiac injury, cardiac troponin I (cTnI) and N-Terminal pro-B-type Natriuretic Peptide were modestly increased in the proton group, and cTnI was also increased after 16O. On the other hand, metabolomics on plasma at 12 months revealed no changes. Both types of irradiation demonstrated alterations in cardiac mitochondrial morphology and an increase in left ventricular protein levels of inflammatory cell marker CD68. However, changes in cardiac function were only mild. CONCLUSION Low dose charged particle irradiation caused mild long-term changes in inflammatory markers, cardiac function, and structure in the rabbit heart, in line with previous studies in mouse and rat models.
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Affiliation(s)
- Ashley S Nemec-Bakk
- Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Vijayalakshmi Sridharan
- Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - Gregory A Nelson
- Departments of Basic Sciences and Radiation Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Maohua Cao
- College of Dentistry, Texas A&M, Dallas, TX, USA
| | | | - Amrita K Cheema
- Department of Oncology, Georgetown University Medical Center, Washington, DC, USA
| | - Bhaldev Singh
- Department of Oncology, Georgetown University Medical Center, Washington, DC, USA
| | - Yaoxiang Li
- Department of Oncology, Georgetown University Medical Center, Washington, DC, USA
| | - Igor Koturbash
- Department of Environmental Health Sciences, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Isabelle R Miousse
- Department of Biochemistry and Molecular Biology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Laura E Ewing
- Natural State Laboratories and Natural State Genomics, North Little Rock, AR, USA
| | - Charles M Skinner
- Department of Biochemistry and Molecular Biology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Reid D Landes
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - John D Lowery
- Department of Laboratory Animal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Xiao-Wen Mao
- Departments of Basic Sciences and Radiation Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Sharda P Singh
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Marjan Boerma
- Division of Radiation Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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11
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Vasbinder A, Cheng RK, Heckbert SR, Thompson H, Zaslavksy O, Chlebowski RT, Shadyab AH, Johnson L, Wactawski-Wende J, Wells G, Yung R, Martin LW, Paskett ED, Reding K. Chronic Oxidative Stress as a Marker of Long-term Radiation-Induced Cardiovascular Outcomes in Breast Cancer. J Cardiovasc Transl Res 2023; 16:403-413. [PMID: 36178659 PMCID: PMC10060433 DOI: 10.1007/s12265-022-10320-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 09/06/2022] [Indexed: 10/14/2022]
Abstract
While biomarkers have been proposed to identify individuals at risk for radiation-induced cardiovascular disease (RICVD), little is known about long-term associations with cardiac events. We examined associations of biomarkers of oxidative stress (myeloperoxidase, growth differentiation factor-15, 8-hydroxy-2'-deoxyguanosine [8-OH-dG], placental growth factor), cardiac injury (troponin I, cystatin-C), inflammation (interleukin-6, C-reactive protein), and myocardial fibrosis (transforming growth factor-ß) with long-term RICVD in breast cancer (BC) survivors. We conducted a nested case-control study within the Women's Health Initiative of postmenopausal women with incident BC stages I-III, who received radiation and had pre- and post-BC diagnosis serum samples. Cases (n = 55) were defined as developing incident, physician-adjudicated myocardial infarction, coronary heart disease death, other CVD death, heart failure, or stroke after BC. Cases were matched to three controls (n = 158). After adjustment, a higher 8-OH-dG ratio was significantly associated with an elevated long-term risk of RICVD, suggesting oxidative DNA damage may be a putative pathway for RICVD.
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Affiliation(s)
- Alexi Vasbinder
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, USA
| | - Richard K Cheng
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, USA
| | - Susan R Heckbert
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, USA
| | - Hilaire Thompson
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, USA
| | - Oleg Zaslavksy
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, USA
| | - Rowan T Chlebowski
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, USA
| | - Aladdin H Shadyab
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, USA
| | - Lisa Johnson
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, USA
| | - Jean Wactawski-Wende
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University of Buffalo, Buffalo, USA
| | - Gretchen Wells
- Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington-Fayette, USA
| | - Rachel Yung
- Division of Medical Oncology, University of Washington, Seattle, USA
| | - Lisa Warsinger Martin
- Division of Cardiology, School of Medicine and Health Sciences, George Washington University, Seattle, USA
| | - Electra D Paskett
- Comprehensive Cancer Center, Department of Medicine, The Ohio State University, Columbus, USA
| | - Kerryn Reding
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, USA.
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12
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Joolharzadeh P, Rodriguez M, Zaghlol R, Pedersen LN, Jimenez J, Bergom C, Mitchell JD. Recent Advances in Serum Biomarkers for Risk Stratification and Patient Management in Cardio-Oncology. Curr Cardiol Rep 2023; 25:133-146. [PMID: 36790618 PMCID: PMC9930715 DOI: 10.1007/s11886-022-01834-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2022] [Indexed: 02/16/2023]
Abstract
PURPOSE OF REVIEW Following significant advancements in cancer therapeutics and survival, the risk of cancer therapy-related cardiotoxicity (CTRC) is increasingly recognized. With ongoing efforts to reduce cardiovascular morbidity and mortality in cancer patients and survivors, cardiac biomarkers have been studied for both risk stratification and monitoring during and after therapy to detect subclinical disease. This article will review the utility for biomarker use throughout the cancer care continuum. RECENT FINDINGS A recent meta-analysis shows utility for troponin in monitoring patients at risk for CTRC during cancer therapy. The role for natriuretic peptides is less clear but may be useful in patients receiving proteasome inhibitors. Early studies explore use of myeloperoxidase, growth differentiation factor 15, galectin 3, micro-RNA, and others as novel biomarkers in CTRC. Biomarkers have potential to identify subclinical CTRC and may reveal opportunities for early intervention. Further research is needed to elucidate optimal biomarkers and surveillance strategies.
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Affiliation(s)
- Pouya Joolharzadeh
- General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Mario Rodriguez
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
| | - Raja Zaghlol
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
| | - Lauren N Pedersen
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jesus Jimenez
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
| | - Carmen Bergom
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J. Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA
| | - Joshua D Mitchell
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St. Louis, MO, USA.
- Alvin J. Siteman Cancer Center, Washington University in St. Louis, St. Louis, MO, USA.
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13
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Loap P, Vu-Bezin J, Monceau V, Jacob S, Fourquet A, Kirova Y. Dosimetric evaluation of the benefit of deep inspiration breath hold (DIBH) for locoregional irradiation of right breast cancer with volumetric modulated arctherapy (VMAT). Acta Oncol 2023; 62:150-158. [PMID: 36786671 DOI: 10.1080/0284186x.2023.2177976] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
INTRODUCTION Right-lateralized cardiac substructures can be substantially exposed during right breast cancer (R-BC) radiotherapy. The cardiac benefit of deep inspiration breath hold (DIBH) is established in combination with volumetric modulated arctherapy (VMAT) for left breast cancer with regional node irradiation but is unknown for R-BC. This study evaluated the dosimetric benefit of DIBH for locoregional irradiation of R-BC with VMAT. MATERIAL AND METHODS All patients treated for R-BC with adjuvant locoregional DIBH-VMAT in the Department of Radiation Oncology of the Institut Curie (Paris, France) until December 2022 were included, corresponding to 15 patients. FB- and DIBH-VMAT plans were compared both for a normofractionated regimen (50 Gy/25fx) used for treatment and a replanned hypofractionated regimen (40 Gy/15fx). Dose to the heart, cardiac substructures (sinoatrial node (SAN), atrio-ventricular node (AVN), right coronary artery, left anterior descending coronary artery, left ventricle), ipsilateral lung and liver were retrieved and compared. RESULTS Mean heart dose (MHD) was 3.33 Gy with FB vs. 3.10 Gy with DIBH on normofractionated plans (p = 0.489), and 2.58 Gy with FB vs. 2.41 Gy with DIBH on hypofractionated plan (p = 0.489). The benefit of DIBH was not significant for any cardiac substructure. The most exposed cardiac substructure were the SAN (mean dose of 6.62 Gy for FB- and 5.64 Gy for DIBH-VMAT on normofractionated plans) and the RCA (mean dose of 4.21 Gy for FB- and 4.06 Gy for DIBH-VMAT on normofractionated plans). The maximum benefit was observed for the RCA with a median individual dose reduction of 0.84 Gy on normofractionated plans (p = 0.599). No significant dosimetric difference were observed for right lung. Liver mean dose was significantly lower with DIBH with median values decreasing from 2.54 Gy to 0.87 Gy (p = 0.01). CONCLUSION Adding DIBH to efficient cardiac-sparing radiotherapy techniques, such as VMAT, is not justified in the general case for locoregional R-BC irradiation. Specific R-BC patient subpopulations who could benefit from additional DIBH combination with locoregional VMAT are yet to be identified.
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Affiliation(s)
- Pierre Loap
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Jeremi Vu-Bezin
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Virginie Monceau
- Institute for Radiation Protection and Nuclear Safety (IRSN), Fontenay-Aux-Roses, France
| | - Sophie Jacob
- Institute for Radiation Protection and Nuclear Safety (IRSN), Fontenay-Aux-Roses, France
| | - Alain Fourquet
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Youlia Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
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14
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Podlesnikar T, Berlot B, Dolenc J, Goričar K, Marinko T. Radiotherapy-Induced Cardiotoxicity: The Role of Multimodality Cardiovascular Imaging. Front Cardiovasc Med 2022; 9:887705. [PMID: 35966531 PMCID: PMC9366112 DOI: 10.3389/fcvm.2022.887705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/05/2022] [Indexed: 12/04/2022] Open
Abstract
Radiotherapy (RT) is one of the pillars of cancer therapy. High-dose radiation exposure on the thorax is mainly used in the context of adjuvant RT after breast surgery, in lung and esophageal cancer, and as a complement to systemic treatment in lymphoma. Due to the anatomical proximity, the heart inevitably receives some radiation that can result in acute and chronic cardiotoxicity, leading to heart failure, coronary artery disease, pericardial and valvular heart disease. Current evidence suggests there is no safe radiation dose to the heart, which poses a need for early recognition of RT-induced cardiac injury to initiate cardioprotective treatment and prevent further damage. Multimodality cardiac imaging provides a powerful tool to screen for structural and functional abnormalities secondary to RT. Left ventricular ejection fraction, preferably with three-dimensional echocardiography or cardiovascular magnetic resonance (CMR), and global longitudinal strain with speckle-tracking echocardiography are currently the key parameters to detect cardiotoxicity. However, several novel imaging parameters are tested in the ongoing clinical trials. CMR parametric imaging holds much promise as T1, T2 mapping and extracellular volume quantification allow us to monitor edema, inflammation and fibrosis, which are fundamental processes in RT-induced cardiotoxicity. Moreover, the association between serum biomarkers, genetic polymorphisms and the risk of developing cardiovascular disease after chest RT has been demonstrated, providing a platform for an integrative screening approach for cardiotoxicity. The present review summarizes contemporary evidence of RT-induced cardiac injury obtained from multimodality imaging—echocardiography, cardiovascular computed tomography, CMR and nuclear cardiology. Moreover, it identifies gaps in our current knowledge and highlights future perspectives to screen for RT-induced cardiotoxicity.
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Affiliation(s)
- Tomaž Podlesnikar
- Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Department of Cardiac Surgery, University Medical Centre Maribor, Maribor, Slovenia
- *Correspondence: Tomaž Podlesnikar,
| | - Boštjan Berlot
- Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Jure Dolenc
- Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Katja Goričar
- Pharmacogenetics Laboratory, Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tanja Marinko
- Department of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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15
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Applying global longitudinal strain in assessing cardiac dysfunction after radiotherapy among breast cancer patients: a systemic review and meta-analysis. Clin Transl Imaging 2022. [DOI: 10.1007/s40336-022-00493-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Myocardial injury detected by T1 and T2 mapping on CMR predicts subsequent cancer therapy-related cardiac dysfunction in patients with breast cancer treated by epirubicin-based chemotherapy or left-sided RT. Eur Radiol 2021; 32:1853-1865. [PMID: 34536111 PMCID: PMC8831341 DOI: 10.1007/s00330-021-08260-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 08/03/2021] [Accepted: 08/11/2021] [Indexed: 11/19/2022]
Abstract
Objectives Cancer therapy-related cardiac dysfunction (CTRCD) is a relevant clinical problem and needs early prediction. This study aimed to analyze myocardial injury using serial laboratory and cardiac magnetic resonance imaging (CMR) parameters after epirubicin-based chemotherapy compared with left-sided radiotherapy and to study their value for early prediction of CTRCD. Methods Sixty-six consecutive women (53 ± 13 years) including n = 39 with epirubicin-based chemotherapy and n = 27 with left-sided radiotherapy were prospectively studied by 3 T CMR including left ventricular (LV) mass and volumes for ejection fraction (LVEF), as well as feature-tracking with global longitudinal strain (GLS) and T1/T2 mapping. CMR was performed at baseline, at therapy completion (follow-up 1, FU1), and after 13 ± 2 months (FU2). CTRCD was defined as LVEF decline of at least 10% to < 55% or a > 15% GLS change at FU2. Results T1 and T2 increased at FU1 after epirubicin-based chemotherapy, but not after left-sided radiotherapy. CTRCD occurred in 20% of patients after epirubicin-based chemotherapy and in 4% after left-sided radiotherapy. T1 at FU1 was the best single parameter to predict CTRCD with an area under the curve (AUC) of 0.712 (CI 0.587–0.816, p = 0.005) with excellent sensitivity (100%, 66–100%), but low specificity (44%, 31–58%). Combined use of increased T1 and LVEF ≤ 60% at FU1 improved AUC to 0.810 (0.695–0.896) resulting in good sensitivity (78%, 44–95%) and specificity (84%, 72–92%). Conclusion Only epirubicin-based chemotherapy, but not left-sided radiotherapy, resulted in increased T1/T2 myocardial relaxation times as a marker of myocardial injury. Combined use of CMR parameters may allow an early prediction of subsequent CTCRD. Key Points • Myocardial T1 and T2 relaxation times increased at FU1 after epirubicin-based chemotherapy, but not after left-sided radiotherapy. • Cancer therapy–related cardiac dysfunction (CTRCD) occurred in 20% of patients after epirubicin-based chemotherapy and in 4% after left-sided radiotherapy. • Combined use of increased T1 and reduced LVEF had an AUC of 0.810 (0.695–0.896) to predict CTRCD with good sensitivity (78%, 44–95%) and specificity (84%, 72–92%). Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-08260-7.
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17
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Tuohinen SS, Skyttä T, Huhtala H, Poutanen T, Virtanen V, Kellokumpu-Lehtinen PL, Raatikainen P. 3-Year Follow-Up of Radiation-Associated Changes in Diastolic Function by Speckle Tracking Echocardiography. JACC: CARDIOONCOLOGY 2021; 3:277-289. [PMID: 34396335 PMCID: PMC8352342 DOI: 10.1016/j.jaccao.2021.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 03/21/2021] [Accepted: 03/21/2021] [Indexed: 01/21/2023]
Abstract
Background Radiation therapy (RT) results in myocardial changes consisting of diffuse fibrosis, which may result in changes in diastolic function. Objectives The aim of this study was to explore RT-associated changes in left ventricular (LV) diastolic function. Methods Sixty chemotherapy-naive patients with left-sided, early-stage breast cancer were studied with speckle tracking echocardiography at 3 time points: prior to, immediately after, and 3 years after RT. Global and regional early diastolic strain rate (SRe) were quantified, as were parameters of systolic function. Results Regional changes in SRe, particularly the apical and anteroseptal segments, were observed over time and were more evident than global changes. The apical SRe declined from a median of 1.24 (interquartile range: 1.01 to 1.39) s-1 at baseline to 1.02 (interquartile range: 0.79 to 1.15) s-1 at 3 years of follow-up (p < 0.001). This decline was associated with the left ventricular maximal radiation dose (β = 0.36, p = 0.007). The global SRe was <1.00 s-1 (SRedep) in 11 (18.3%) patients at baseline, 21 (35%) patients (p = 0.013) post-RT, and 17 (28.3%) patients (p = 0.051) at 3 years. SRedep post-RT was independently associated with baseline cardiac abnormalities (odds ratio: 0.26; 95% confidence interval: 0.08 to 0.84; p = 0.025); SRedep at 3 years of follow-up was associated with the baseline Charlson comorbidity index (odds ratio: 2.36; 95% confidence interval: 1.17 to 4.77; p = 0.017). Diastolic function abnormalities were evident even in patients with preserved global longitudinal strain at 3 years. Conclusions RT resulted in changes in the SRe in the apical and anteroseptal segments over 3 years of follow-up. Changes in SRe apical segments were present even in patients with preserved systolic function and were independently associated with RT dose and cardiovascular comorbidities.
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Key Words
- CI, confidence interval
- DLVmax, maximal left ventricular radiation dose
- GLS, global longitudinal strain
- IQR, interquartile range
- LAVI, left atrial volume indexed to body surface area
- LV, left ventricular
- LVEF, left ventricular ejection fraction
- RT, radiotherapy
- SR, strain rate
- SRe, early diastolic strain rate
- SReapex, apical early diastolic strain rate
- SRedep, global early diastolic strain rate <1 s-1
- SRs, systolic strain rate
- breast cancer
- diastolic strain rate
- radiotherapy
- speckle tracking echocardiography
- ΔGLS15, relative decline of more than 15% in global longitudinal strain
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Affiliation(s)
- Suvi Sirkku Tuohinen
- Heart and Lung Center, Helsinki University Central Hospital, Helsinki University, Helsinki, Finland.,Heart Hospital, Tampere University Hospital, University of Tampere, Tampere, Finland
| | - Tanja Skyttä
- Department of Oncology, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Tuija Poutanen
- Center for Child Health Research, Tampere, Finland.,Department of Pediatrics, Faculty of Medicine and Heath Technology, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Vesa Virtanen
- Heart Hospital, Tampere University Hospital, University of Tampere, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Pirkko-Liisa Kellokumpu-Lehtinen
- Department of Oncology, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Pekka Raatikainen
- Heart and Lung Center, Helsinki University Central Hospital, Helsinki University, Helsinki, Finland
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18
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De Sanctis V, Alfò M, Vitiello C, Vullo G, Facondo G, Marinelli L, Burocchi S, Gallo G, Valeriani M, Campanella B, Scalabrino G, Russo I, Salerno G, Cardelli P, Osti M, De Biase L. Markers of Cardiotoxicity in Early Breast Cancer Patients Treated With a Hypofractionated Schedule: A Prospective Study. Clin Breast Cancer 2021; 21:e141-e149. [DOI: 10.1016/j.clbc.2020.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 09/01/2020] [Accepted: 09/04/2020] [Indexed: 12/25/2022]
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19
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Clasen SC, Shou H, Freedman G, Plastaras JP, Taunk NK, Kevin Teo BK, Smith AM, Demissei BG, Ky B. Early Cardiac Effects of Contemporary Radiation Therapy in Patients With Breast Cancer. Int J Radiat Oncol Biol Phys 2021; 109:1301-1310. [PMID: 33340602 DOI: 10.1016/j.ijrobp.2020.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/02/2020] [Accepted: 12/07/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE To characterize the early changes in echocardiographically derived measures of cardiac function with contemporary radiation therapy (RT) in breast cancer and to determine the associations with radiation dose-volume metrics, including mean heart dose (MHD). METHODS AND MATERIALS In a prospective longitudinal cohort study of 86 patients with breast cancer treated with photon or proton thoracic RT, clinical and echocardiographic data were assessed at 3 time points: within 4 weeks before RT initiation (T0), within 3 days before 6 weeks after the end of RT (T1), and 5 to 9 months after RT completion (T2). Associations between MHD and echocardiographically derived measures of cardiac function were assessed using generalized estimating equations to define the acute (T0 to T1) and subacute (T0 to T2) changes in cardiac function. RESULTS The median estimates of MHD were 139 cGy (interquartile range, 99-249 cGy). In evaluating the acute changes in left ventricular ejection fraction (LVEF) from T0 to T1, and accounting for the time from RT, age, race, preexisting cardiovascular disease, and an interaction term with anthracycline or trastuzumab exposure and MHD, there was a modest decrease in LVEF of borderline significance (0.22%; 95% confidence interval [CI], -0.44% to 0.01%; P = .06) per 30-day interval for every 100 cGy increase of MHD. Similarly, there was a modest worsening in longitudinal strain (0.19%; 95% CI, -0.01% to 0.39%; P = .06) per 30-day interval for each 100 cGy increase in MHD. We did not find significant associations between MHD and changes in circumferential strain or diastolic function. CONCLUSIONS With modern radiation planning techniques, there are modest subclinical changes in measures of cardiac function in the short-term. Longer-term follow-up studies are needed to determine whether these early changes are associated with the development of overt cardiac disease.
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Affiliation(s)
- Suparna C Clasen
- Krannert Institute of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Haochang Shou
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gary Freedman
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John P Plastaras
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neil K Taunk
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Boon-Keng Kevin Teo
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda M Smith
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Biniyam G Demissei
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bonnie Ky
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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20
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Trivedi SJ, Tang S, Byth K, Stefani L, Lo Q, Otton J, Jameson M, Tran D, Batumalai V, Holloway L, Delaney GP, Koh ES, Thomas L. Segmental Cardiac Radiation Dose Determines Magnitude of Regional Cardiac Dysfunction. J Am Heart Assoc 2021; 10:e019476. [PMID: 33749308 PMCID: PMC8174310 DOI: 10.1161/jaha.120.019476] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Subclinical left ventricular dysfunction detected by 2‐dimensional global longitudinal strain post breast radiotherapy has been described in patients with breast cancer. We hypothesized that left ventricular dysfunction postradiotherapy may be site specific, based on differential segmental radiotherapy dose received. Methods and Results Transthoracic echocardiograms were performed at baseline, 6 weeks, and 12 months postradiotherapy on 61 chemotherapy‐naïve women with left‐sided breast cancer undergoing tangential breast radiotherapy. Radiation received within basal, mid, and apical regions for the 6 left ventricular walls was quantified from the radiotherapy treatment planning system. Anterior, anteroseptal, and anterolateral walls received the highest radiation doses, while inferolateral and inferior walls received the lowest. There was a progressive increase in the radiation dose received from basal to apical regions. At 6 weeks, the most significant percentage deterioration in strain was seen in the apical region, with greatest reductions in the anterior wall followed by the anteroseptal and anterolateral walls, with a similar pattern persisting at 12 months. There was a within‐patient dose–response association between the segment‐specific percentage deterioration in strain at 6 weeks and 12 months and the radiation dose received. Conclusions Radiotherapy for left‐sided breast cancer causes differential segmental dysfunction, with myocardial segments that receive the highest radiation dose demonstrating greatest strain impairment. Percentage deterioration in strain observed 6 weeks postradiotherapy persisted at 12 months and demonstrated a dose–response relationship with radiotherapy dose received. Radiotherapy‐induced subclinical cardiac dysfunction is of importance because it could be additive to chemotherapy‐related cardiotoxicity in patients with breast cancer. Long‐term outcomes in patients with asymptomatic strain reduction require further investigation.
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Affiliation(s)
- Siddharth J Trivedi
- Department of Cardiology Westmead Hospital Sydney NSW Australia.,Westmead Clinical School University of Sydney NSW Australia
| | - Simon Tang
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Central Coast Cancer Therapy Centre Gosford NSW Australia
| | - Karen Byth
- Research and Education Network Western Sydney Local Health DistrictWestmead Hospital Sydney NSW Australia.,NHMRC Clinical Trials CentreUniversity of Sydney NSW Australia
| | - Luke Stefani
- Department of Cardiology Westmead Hospital Sydney NSW Australia
| | - Queenie Lo
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Department of Cardiology St George Hospital Sydney NSW Australia
| | - James Otton
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Department of Cardiology Liverpool Hospital Sydney NSW Australia
| | - Michael Jameson
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Cancer Therapy Centre Liverpool Hospital Sydney NSW Australia
| | - David Tran
- Department of Cardiology Liverpool Hospital Sydney NSW Australia
| | - Vikneswary Batumalai
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Cancer Therapy Centre Liverpool Hospital Sydney NSW Australia
| | - Lois Holloway
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Cancer Therapy Centre Liverpool Hospital Sydney NSW Australia
| | - Geoff P Delaney
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Cancer Therapy Centre Liverpool Hospital Sydney NSW Australia
| | - Eng-Siew Koh
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Cancer Therapy Centre Liverpool Hospital Sydney NSW Australia
| | - Liza Thomas
- Department of Cardiology Westmead Hospital Sydney NSW Australia.,Westmead Clinical School University of Sydney NSW Australia.,South Western Sydney Clinical School University of New South Wales Sydney NSW Australia
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21
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Loap P, Kirova Y. Evaluating cardiac substructure radiation exposure in breast rotational intensity modulated radiation therapy: Effects of cancer laterality, fractionation and deep inspiration breath-hold. Cancer Radiother 2020; 25:13-20. [PMID: 33288407 DOI: 10.1016/j.canrad.2020.05.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/10/2020] [Accepted: 05/13/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Rotational intensity-modulated radiation therapy currently has a growing role in breast cancer radiation therapy, since this radiation technique reduces cardiac radiation exposure while homogeneously covering target volumes. This study aims to evaluate radiation exposure of cardiac substructures across a broad spectrum of breast cancer cases differing by cancer laterality, fractionation regimen and addition of deep-inspiration breath hold. MATERIALS AND METHODS Cardiac substructures were delineated following guidelines endorsed by the European Society for Radiotherapy and Oncology (ESTRO) for forty-four breast cancer patients having undergone conserving surgery and adjuvant rotational intensity-modulated radiation therapy. Target volumes consisted of the whole breast with a boost, axillary and internal mammary nodes. Patients were treated using free-breathing technique for left-sided or right-sided, normofractionated or hypofractionated helical tomotherapy or volumetric modulated arc therapy, or using deep-inspiration breath hold for left-sided normofractionated volumetric modulated arc therapy. Mean and maximum doses to cardiac substructures were retrieved. Correlations were performed between mean- and maximum radiation doses to cardiac substructures. RESULTS Left-sided and right-sided irradiations were associated with different cardiac substructure exposure patterns despite comparable mean heart dose: 7.21Gy for left-sided normofractionated regimen, 6.28Gy for right-sided normofractionated regimen. Deep-inspiration breath hold reduced mean doses to almost all cardiac substructures for left-sided irradiation, but did not decrease maximum doses to coronary arteries. Correlations between mean- and maximum doses to cardiac substructures were usually moderate, but stronger for right-sided irradiation. CONCLUSION Despite comparable mean heart dose, cardiac substructure radiation exposure patterns with rotational intensity-modulated radiation therapy strongly depend on the breast side, which could trigger clinically different long-term cardiotoxicity events. Deep-inspiration breath hold improves cardiac substructure dosimetry. Mean- and maximum heart dose could probably not be used as surrogate markers for precise cardiac substructure evaluation. In a near future, clinical practice and cardiotoxicity studies could possibly gain by considering cardiac substructure in a more systematic manner, possibly relying on cardiac autosegmentation algorithms.
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Affiliation(s)
- P Loap
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France.
| | - Y Kirova
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
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22
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Kirova Y, Tallet A, Aznar MC, Loap P, Bouali A, Bourgier C. Radio-induced cardiotoxicity: From physiopathology and risk factors to adaptation of radiotherapy treatment planning and recommended cardiac follow-up. Cancer Radiother 2020; 24:576-585. [PMID: 32830054 DOI: 10.1016/j.canrad.2020.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 12/25/2022]
Abstract
Cancer and cardiovascular disease (CVD) are the leading cause of mortality worldwide, and breast cancer (BC) the most common malignancy affecting women worldwide. Radiotherapy is an important component of BC treatment and participates in CVD occurrence. It seems, therefore, crucial to gather both radiation oncology and cardiology medical fields to improve the follow-up quality of our BC patients. This review aims at updating our knowledge regarding cardiotoxicities risk factors, and consequently, doses constraints in case of 3D-conformal and IMRT treatment planning. Then we will develop how to reduce cardiac exposure and what kind of cardiac follow-up we could recommend to our breast cancer patients.
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Affiliation(s)
- Y Kirova
- Department of radiation oncology, institut Curie, 75005 Paris, France
| | - A Tallet
- Department of radiation oncology, institut Paoli-Calmette, Marseille, France
| | - M C Aznar
- Division of cancer sciences, faculty of biology, medicine and health, the university of Manchester, The Christie NHS Foundation Trust, Manchester, and Nuffield department of population health, university of Oxford, Oxford, UK
| | - P Loap
- Department of radiation oncology, institut Curie, 75005 Paris, France
| | - A Bouali
- Cardiology department, Lyon Sud Hospital, Hospices civils de Lyon, Lyon, France
| | - C Bourgier
- Fédération universitaire d'oncologie radiothérapie, ICM, institut régional du cancer Montpellier, rue Croix-Verte, 34298 Montpellier cedex 05, France; IRCM, institut de recherche en cancérologie de Montpellier, inserm U1194, université Montpellier, avenue des Apothicaires, 34298 Montpellier cedex 05, France.
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23
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Breast size and dose to cardiac substructures in adjuvant three-dimensional conformal radiotherapy compared to tangential intensity modulated radiotherapy. Radiol Oncol 2020; 54:470-479. [PMID: 32990650 PMCID: PMC7585338 DOI: 10.2478/raon-2020-0050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/10/2020] [Indexed: 02/06/2023] Open
Abstract
Background The aim of the study was to quantify planned doses to the heart and specific cardiac substructures in free-breathing adjuvant three-dimensional radiation therapy (3D-CRT) and tangential intensity modulated radiotherapy (t-IMRT) for left-sided node-negative breast cancer, and to assess the differences in planned doses to organs at risk according to patients’ individual anatomy, including breast volume. Patients and methods In the study, the whole heart and cardiac substructures were delineated for 60 patients using cardiac atlas. For each patient, 3D-CRT and t-IMRT plans were generated. The prescribed dose was 42.72 Gy in 16 fractions. Patients were divided into groups with small, medium, and large clinical target volume (CTV). Calculated dose distributions were compared amongst the two techniques and the three different groups of CTV. Results Mean absorbed dose to the whole heart (MWHD) (1.9 vs. 2.1 Gy, P < 0.005), left anterior descending coronary artery mean dose (8.2 vs. 8.4 Gy, P < 0.005) and left ventricle (LV) mean dose (3.0 vs. 3.2, P < 0.005) were all significantly lower with 3D-CRT technique compared to t-IMRT. Apical (8.5 vs. 9.0, P < 0.005) and anterior LV walls (5.0 vs. 5.4 Gy, P < 0.005) received the highest mean dose (Dmean). MWHD and LV-Dmean increased with increasing CTV size regardless of the technique. Low MWHD values (< 2.5 Gy) were achieved in 44 (73.3%) and 41 (68.3%) patients for 3D-CRT and t-IMRT techniques, correspondingly. Conclusions Our study confirms a considerable range of the planned doses within the heart for adjuvant 3D-CRT or t-IMRT in node-negative breast cancer. We observed differences in heart dosimetric metrics between the three groups of CTV size, regardless of the radiotherapy planning technique.
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24
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Investigation of Association Between Cardiac Dose Distribution and Strain/Tissue Doppler Echocardiographic Indices During 1-Year Post-Mastectomy Radiation Therapy Follow-Up in Breast Cancer Patients. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2020. [DOI: 10.1007/s40944-020-00424-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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25
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Walker V, Lairez O, Fondard O, Jimenez G, Camilleri J, Panh L, Broggio D, Bernier MO, Laurier D, Ferrières J, Jacob S. Myocardial deformation after radiotherapy: a layer-specific and territorial longitudinal strain analysis in a cohort of left-sided breast cancer patients (BACCARAT study). Radiat Oncol 2020; 15:201. [PMID: 32819449 PMCID: PMC7439550 DOI: 10.1186/s13014-020-01635-y] [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: 06/23/2020] [Accepted: 08/04/2020] [Indexed: 02/08/2023] Open
Abstract
Background Radiotherapy for breast cancer (BC) and its resulting cardiac exposure are associated with subclinical left ventricular dysfunction characterized by early decrease of global longitudinal strain (LS) measurement based on 2D speckle-tracking echocardiography. Recent software allows multi-layer and segmental analysis of strain, which may be of interest to quantify and locate the impact of cardiac exposure on myocardial function and potentially increase the early detection of radiation-induced cardiotoxicity. The aim of the study was to evaluate whether decrease in LS 6 months after radiotherapy is layer-specific and if it varies according to the left ventricular regional level and the coronary arterial territories. Methods LS was measured at baseline before radiotherapy and 6 months post-radiotherapy. The LS was obtained for each myocardial layer (endocardial, mid-myocardial, epicardial), left ventricular regional level (basal, mid, apical) and coronary artery territory (left anterior descending artery (LAD), circumflex artery, right coronary artery). Results The study included 64 left-sided BC patients. Mean age was 58 years, mean doses to the heart, the left ventricle and the LAD were respectively 3.0, 6.7 and 16.4 Gy. The absolute decrease of LS was significant for the three layers (endocardial: − 20.0 ± 3.2% to − 18.8 ± 3.8%; mid-myocardial: − 16.0 ± 2.7% to − 15.0 ± 3.1%; epicardial: − 12.3 ± 2.5% to − 11.4 ± 2.8%, all p = 0.02), but only the relative decrease of LS in the endocardial layer was close to be significant (− 4.7%, p = 0.05). More precisely, the LS of the endocardial layer was significantly decreased for the most exposed parts of the left ventricle corresponding to the apical level (− 26.3 ± 6.0% vs. -24.2 ± 7.1%, p = 0.03) and LAD territory (− 22.8 ± 4.0% vs. -21.4 ± 4.8%, p = 0.03). Conclusion Six months post-radiotherapy, LS decreased predominantly in the endocardial layer of the most exposed part of the left ventricle. For precise evaluation of radiotherapy-induced cardiotoxicity and early left ventricular dysfunction, the endocardial layer-based LS might be the most sensitive parameter. Trial registration ClinicalTrials.gov: NCT02605512, Registered 6 November 2015 - Retrospectively registered.
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Affiliation(s)
- Valentin Walker
- Pôle Santé-Environnement (PSE-SANTE), Service de recherche sur les effets biologiques et sanitaires des rayonnements ionisants (SESANE), Laboratoire d'épidémiologie des rayonnements ionisants (LEPID), Institute for Radiological Protection and Nuclear Safety (IRSN), BP17, 92262, Fontenay-aux-Roses cedex, France
| | - Olivier Lairez
- Department of Cardiology, Rangueil University Hospital, 31059, Toulouse, France.,Cardiac Imaging Centre, Rangueil University Hospital, 31059, Toulouse, France.,Medical School of Rangueil, University Paul Sabatier, 31400, Toulouse, France
| | - Olivier Fondard
- Department of Cardiology, Clinique Pasteur, 31300, Toulouse, France
| | - Gaëlle Jimenez
- Department of Radiation Oncology (Oncorad), Clinique Pasteur, 31300, Toulouse, France
| | - Jérémy Camilleri
- Department of Radiation Oncology (Oncorad), Clinique Pasteur, 31300, Toulouse, France
| | - Loïc Panh
- Department of Cardiac Arrhythmia, Clinique Pasteur, 31300, Toulouse, France
| | - David Broggio
- Department of dosimetry, Institute for Radiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Marie-Odile Bernier
- Pôle Santé-Environnement (PSE-SANTE), Service de recherche sur les effets biologiques et sanitaires des rayonnements ionisants (SESANE), Laboratoire d'épidémiologie des rayonnements ionisants (LEPID), Institute for Radiological Protection and Nuclear Safety (IRSN), BP17, 92262, Fontenay-aux-Roses cedex, France
| | - Dominique Laurier
- Division of Health and Environment, Institute for Radiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Jean Ferrières
- Department of Cardiology, Rangueil University Hospital, 31059, Toulouse, France.,Medical School of Purpan, University Paul Sabatier, 31000, Toulouse, France.,INSERM, UMR1027, 31000, Toulouse, France
| | - Sophie Jacob
- Pôle Santé-Environnement (PSE-SANTE), Service de recherche sur les effets biologiques et sanitaires des rayonnements ionisants (SESANE), Laboratoire d'épidémiologie des rayonnements ionisants (LEPID), Institute for Radiological Protection and Nuclear Safety (IRSN), BP17, 92262, Fontenay-aux-Roses cedex, France.
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26
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Cardiac serum marker alterations after intraoperative radiotherapy with low-energy x-rays in early breast cancer as an indicator of possible cardiac toxicity. Strahlenther Onkol 2020; 197:39-47. [PMID: 32813034 PMCID: PMC7801302 DOI: 10.1007/s00066-020-01671-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/21/2020] [Indexed: 11/08/2022]
Abstract
Purpose To assess acute cardiac toxicity caused by intraoperative radiotherapy (IORT) with low-energy x‑rays for early breast cancer. Methods We prospectively analyzed pre- and postoperative troponin I and NT-proBNP in 94 women who underwent breast-conserving surgery between 2013 and 2017 at the Department of Gynecology and Obstetrics of the University Medical Center Mannheim, Germany. Thirty-nine women received IORT using low-energy x‑rays during breast-conserving surgery while 55 patients without IORT formed the control group. Demographic and surgical parameters as well as cardiac markers were evaluated. Results There were no significant differences concerning age and side of breast cancer between the groups. Furthermore, no significant difference between the troponin I assays of the IORT and control groups could be found (preoperatively: 0.017 ± 0.006 ng/ml vs. 0.018 ± 0.008 ng/ml; p = 0.5105; postoperatively: 0.019 ± 0.012 ng/ml vs. 0.018 ± 0.010 ng/ml; p = 0.6225). N‑terminal fragment of B‑type natriuretic peptide (NT-proBNP) was significantly higher in the control group 24 h after surgery (preoperatively: 158.154 ± 169.427 pg/ml vs. 162.109 ± 147.343 pg/ml; p = 0.56; postoperatively: 168.846 ± 160.227 pg/ml vs. 232.527 ± 188.957 pg/ml; p = 0.0279). Conclusion Troponin I levels as a marker of acute cardiac toxicity did not show any significant differences in patients who received IORT during breast-conserving surgery compared to those who did not. Electronic supplementary material The online version of this article (10.1007/s00066-020-01671-3) contains supplementary material, which is available to authorized users.
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27
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Sha X, Gong G, Han C, Qiu Q, Yin Y. Quantification of Myocardial Dosimetry and Glucose Metabolism Using a 17-Segment Model of the Left Ventricle in Esophageal Cancer Patients Receiving Radiotherapy. Front Oncol 2020; 10:1599. [PMID: 32850464 PMCID: PMC7431519 DOI: 10.3389/fonc.2020.01599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/23/2020] [Indexed: 12/04/2022] Open
Abstract
Objective Previous studies have shown that increased cardiac uptake of 18F-fluorodeoxyglucose (FDG) on positron emission tomography (PET) may be an indicator of myocardial injury after radiotherapy (RT). The primary objective of this study was to quantify cardiac subvolume dosimetry and 18F-FDG uptake on oncologic PET using a 17-segment model of the left ventricle (LV) and to identify dose limits related to changes in cardiac 18F-FDG uptake after RT. Methods Twenty-four esophageal cancer (EC) patients who underwent consecutive oncologic 18F-FDG PET/CT scans at baseline and post-RT were enrolled in this study. The radiation dose and the 18F-FDG uptake were quantitatively analyzed based on a 17-segment model. The 18F-FDG uptake and doses to the basal, middle and apical regions, and the changes in the 18F-FDG uptake for different dose ranges were analyzed. Results A heterogeneous dose distribution was observed, and the basal region received a higher median mean dose (18.36 Gy) than the middle and apical regions (5.30 and 2.21 Gy, respectively). Segments 1, 2, 3, and 4 received the highest doses, all of which were greater than 10 Gy. Three patterns were observed for the myocardial 18F-FDG uptake in relation to the radiation dose before and after RT: an increase (5 patients), a decrease (13 patients), and no change (6 patients). In a pairing analysis, the 18F-FDG uptake after RT decreased by 28.93 and 12.12% in the low-dose segments (0–10 Gy and 10–20 Gy, respectively) and increased by 7.24% in the high-dose segments (20–30 Gy). Conclusion The RT dose varies substantially within LV segments in patients receiving thoracic EC RT. Increased 18F-FDG uptake in the myocardium after RT was observed for doses above 20 Gy.
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Affiliation(s)
- Xue Sha
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Guanzhong Gong
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Chunlei Han
- Turku PET Centre, Turku University Hospital, Turku, Finland
| | - Qingtao Qiu
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Yong Yin
- Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
- *Correspondence: Yong Yin,
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28
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Abstract
OPINION STATEMENT Moderate-level evidence suggests that cardiac troponin and natriuretic peptides are useful for risk stratification and early identification of anthracycline cardiotoxicity; however, many of these studies used older chemotherapy regimens, and thus, the applicability to current anthracycline treatment regimens is uncertain. Further research is needed to determine optimal timing and thresholds for troponin and natriuretic peptides in anthracycline-treated patients and evaluate these and other promising biomarkers for anti-HER2 therapies, thoracic radiation, anti-VEGF therapy, and fluoropyrimidine therapy-related cardiotoxicity. Risk tools that combine cardiac risk factors, cancer treatment variables, biomarkers, and imaging parameters are most likely to accurately identify individuals at highest risk for cancer therapy cardiotoxicity. Clinical trials focusing cardioprotective strategies on high-risk individuals are more likely to result in clinically significant results compared with primary prevention cardioprotective approaches.
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Affiliation(s)
- Jenica N Upshaw
- Division of Cardiology, Tufts Medical Center, 800 Washington St, Box 5931, Boston, MA, 02111, USA.
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29
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Cardiac Monitoring for Thoracic Radiation Therapy: Survey of Practice Patterns in the United States. Am J Clin Oncol 2020; 43:249-256. [PMID: 31972567 DOI: 10.1097/coc.0000000000000666] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The American Society of Clinical Oncology (ASCO) 2017 guidelines on cardiac monitoring during cancer treatments identified patients receiving thoracic radiation (TRT) ≥30 Gy (heart in field) at increased risk for developing radiation-induced heart disease (RIHD). ASCO encouraged clinicians to actively screen and monitor for baseline modifiable cardiac risk factors and therapy-induced cardiotoxicity in this high-risk population. Coronary artery calcium (CAC) is an independent risk factor for adverse cardiac events that can be mitigated with preventative medical therapy. It is unclear whether radiation oncologists (ROs) are aware of ASCO guidelines or the implications of CAC observed on computed tomographic scans. We report on practice patterns, perceptions, and experiences of cardiac monitoring for patients receiving definitive TRT, excluding breast patients. MATERIALS AND METHODS A 28-question survey was emailed to United States ROs 3 times from September 2018 to January 2019. RESULTS There were 162 respondents from 42 states, 51% in academic practice. Most ROs (81%) were not aware of the ASCO guidelines. Only 24% agreed with the guidelines, only 27% believed symptomatic RIHD could manifest within 2 years of TRT, and 69% thought there was a lack of strong evidence for type and timing of cardiac monitoring tests. If CAC was evident on computed tomographic scans, 40% took no further action to inform the patient or referring doctor. CONCLUSIONS This survey highlights a critical gap in knowledge about cardiac monitoring and potentially life-saving opportunities for preventive cardiac medical management. Future studies focusing on timing and detection of RIHD may elucidate the utility of cardiac monitoring for TRT patients.
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Meehan J, Gray M, Martínez-Pérez C, Kay C, Pang LY, Fraser JA, Poole AV, Kunkler IH, Langdon SP, Argyle D, Turnbull AK. Precision Medicine and the Role of Biomarkers of Radiotherapy Response in Breast Cancer. Front Oncol 2020; 10:628. [PMID: 32391281 PMCID: PMC7193869 DOI: 10.3389/fonc.2020.00628] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/06/2020] [Indexed: 12/24/2022] Open
Abstract
Radiotherapy remains an important treatment modality in nearly two thirds of all cancers, including the primary curative or palliative treatment of breast cancer. Unfortunately, largely due to tumor heterogeneity, tumor radiotherapy response rates can vary significantly, even between patients diagnosed with the same tumor type. Although in recent years significant technological advances have been made in the way radiation can be precisely delivered to tumors, it is proving more difficult to personalize radiotherapy regimens based on cancer biology. Biomarkers that provide prognostic or predictive information regarding a tumor's intrinsic radiosensitivity or its response to treatment could prove valuable in helping to personalize radiation dosing, enabling clinicians to make decisions between different treatment options whilst avoiding radiation-induced toxicity in patients unlikely to gain therapeutic benefit. Studies have investigated numerous ways in which both patient and tumor radiosensitivities can be assessed. Tumor molecular profiling has been used to develop radiosensitivity gene signatures, while the assessment of specific intracellular or secreted proteins, including circulating tumor cells, exosomes and DNA, has been performed to identify prognostic or predictive biomarkers of radiation response. Finally, the investigation of biomarkers related to radiation-induced toxicity could provide another means by which radiotherapy could become personalized. In this review, we discuss studies that have used these methods to identify or develop prognostic/predictive signatures of radiosensitivity, and how such assays could be used in the future as a means of providing personalized radiotherapy.
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Affiliation(s)
- James Meehan
- Translational Oncology Research Group, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, United Kingdom
| | - Mark Gray
- Translational Oncology Research Group, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, United Kingdom.,The Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Carlos Martínez-Pérez
- Translational Oncology Research Group, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, United Kingdom.,Breast Cancer Now Edinburgh Research Team, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, United Kingdom
| | - Charlene Kay
- Translational Oncology Research Group, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, United Kingdom
| | - Lisa Y Pang
- The Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Jennifer A Fraser
- School of Applied Science, Sighthill Campus, Edinburgh Napier University, Edinburgh, United Kingdom
| | - Amy V Poole
- School of Applied Science, Sighthill Campus, Edinburgh Napier University, Edinburgh, United Kingdom
| | - Ian H Kunkler
- Cancer Research UK Edinburgh Centre and Division of Pathology Laboratories, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Simon P Langdon
- Cancer Research UK Edinburgh Centre and Division of Pathology Laboratories, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - David Argyle
- The Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Arran K Turnbull
- Translational Oncology Research Group, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, United Kingdom.,Breast Cancer Now Edinburgh Research Team, Institute of Genetics and Molecular Medicine, Western General Hospital, University of Edinburgh, Edinburgh, United Kingdom
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Role of Cardiovascular Biomarkers in the Risk Stratification, Monitoring, and Management of Patients with Cancer. Cardiol Clin 2020; 37:505-523. [PMID: 31587791 DOI: 10.1016/j.ccl.2019.07.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cardiovascular effects of cancer therapies are of concern. Prediction, diagnosis, and management of cardiotoxicity is a challenge. Cardiovascular biomarkers are being studied in relationship to cancer therapy, showing promise in detection and prevention of cardiotoxicity. We summarize the use of biomarkers in cardio-oncology and presents recommendations for their use. Troponins and natriuretic peptides are the most commonly used biomarkers. High-quality evidence supporting their use is lacking. Biomarkers can be incorporated into a detection strategy for cardiotoxicity. Large, well-powered studies are needed to delineate care strategies using biomarkers in the prediction and management of the cardiovascular effects of cancer therapy.
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Nack E, Koffer PP, Blumberg CS, Leonard KL, Huber KE, Fenton MA, Dizon DS, Wazer DE, Hepel JT. New Cardiac Abnormalities After Radiotherapy in Breast Cancer Patients Treated With Trastuzumab. Clin Breast Cancer 2019; 20:246-252. [PMID: 32067901 DOI: 10.1016/j.clbc.2019.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 11/18/2019] [Accepted: 12/09/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate cardiac imaging abnormalities after modern radiotherapy and trastuzumab in breast cancer patients. PATIENTS AND METHODS All patients treated with trastuzumab and radiotherapy for breast cancer between 2006 and 2014 with available cardiac imaging (echocardiogram or multigated acquisition scan) were retrospectively analyzed. Cardiac abnormalities included myocardial abnormalities (atrial or ventricular dilation, hypertrophy, hypokinesis, and impaired relaxation), decreased ejection fraction > 10%, and valvular abnormalities (thickening or stenosis of the valve leaflets). Breast laterality (left vs. right) and heart radiation dose volume parameters were analyzed for association with cardiac imaging abnormalities. RESULTS A total of 110 patients with 57 left- and 53 right-sided breast cancers were evaluated. Overall, 37 patients (33.6%) developed a new cardiac abnormality. Left-sided radiotherapy was associated with an increase in new cardiac abnormalities (relative risk [RR] = 2.51; 95% confidence interval [CI], 1.34-4.67; P = .002). Both myocardial and valvular abnormalities were associated with left-sided radiotherapy (myocardial: RR = 2.21; 95% CI, 1.06-4.60; P = .029; valvular: RR = 3.30; 95% CI, 0.98-10.9; P = .044). There was no significant difference in decreased ejection fraction between left- and right-sided radiotherapy (9.6% vs. 2.1%; P = .207). A mean heart dose > 2 Gy as well as volume of the heart receiving 20 Gy (V20), V30, and V40 correlated with cardiac abnormalities (mean heart dose > 2 Gy: RR = 2.00; P = .040). CONCLUSION New cardiac abnormalities, including myocardial and valvular dysfunction, are common after trastuzumab and radiotherapy. The incidence of new abnormalities correlates with tumor laterality and cardiac radiation dose exposure. Long-term follow-up is needed to understand the clinical significance of these early imaging abnormalities.
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Affiliation(s)
- Elana Nack
- Department of Radiation Oncology, Rhode Island Hospital, Providence, RI; Department of Radiation Oncology, Tufts Medical Center, Boston, MA.
| | - Paul P Koffer
- Department of Radiation Oncology, Rhode Island Hospital, Providence, RI
| | | | | | - Kathryn E Huber
- Department of Radiation Oncology, Tufts Medical Center, Boston, MA
| | - Mary Anne Fenton
- Department of Hematology Oncology, Rhode Island Hospital, Providence, RI
| | - Don S Dizon
- Department of Hematology Oncology, Rhode Island Hospital, Providence, RI
| | - David E Wazer
- Department of Radiation Oncology, Rhode Island Hospital, Providence, RI; Department of Radiation Oncology, Tufts Medical Center, Boston, MA
| | - Jaroslaw T Hepel
- Department of Radiation Oncology, Rhode Island Hospital, Providence, RI
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Palaskas N, Patel A, Yusuf SW. Radiation and cardiovascular disease. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S371. [PMID: 32016089 DOI: 10.21037/atm.2019.08.107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Nicolas Palaskas
- University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Desai MY, Jellis CL, Kotecha R, Johnston DR, Griffin BP. Radiation-Associated Cardiac Disease: A Practical Approach to Diagnosis and Management. JACC Cardiovasc Imaging 2019; 11:1132-1149. [PMID: 30092970 DOI: 10.1016/j.jcmg.2018.04.028] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 04/12/2018] [Accepted: 04/13/2018] [Indexed: 01/14/2023]
Abstract
Radiation-associated cardiac disease (RACD) results in complex clinical presentations, unique management issues, and increased morbidity and mortality. Patients typically present years or even decades after radiation exposure, with delayed-onset cardiac damage sustained from high cumulative doses. Multimodality imaging is crucial to determine the manifestations and severity of disease because symptoms are often nonspecific. Comprehensive screening using a coordinated approach may enable early detection. However, timing of intervention should be carefully considered in these patients because surgery is often complex and high-risk second surgeries should be minimized in the long-term. This review aims to provide treating physicians with a comprehensive and clinically focused overview of RACD, including clinical/imaging manifestations, multi-modality screening recommendations, and management options.
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Affiliation(s)
- Milind Y Desai
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | | | - Rupesh Kotecha
- Department of Radiation Oncology, Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Brian P Griffin
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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35
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Walker V, Lairez O, Fondard O, Pathak A, Pinel B, Chevelle C, Franck D, Jimenez G, Camilleri J, Panh L, Broggio D, Derreumaux S, Bernier MO, Laurier D, Ferrières J, Jacob S. Early detection of subclinical left ventricular dysfunction after breast cancer radiation therapy using speckle-tracking echocardiography: association between cardiac exposure and longitudinal strain reduction (BACCARAT study). Radiat Oncol 2019; 14:204. [PMID: 31727075 PMCID: PMC6854785 DOI: 10.1186/s13014-019-1408-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/28/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Breast cancer (BC) radiotherapy (RT) can induce cardiotoxicity, with adverse events often observed many years after BC RT. Subclinical left ventricular (LV) dysfunction can be detected early after BC RT with global longitudinal strain (GLS) measurement based on 2D speckle-tracking echocardiography. This 6-month follow-up analysis from the BACCARAT prospective study aimed to investigate the association between cardiac radiation doses and subclinical LV dysfunction based on GLS reduction. METHODS The patient study group consisted of 79 BC patients (64 left-sided BC, 15 right-sided BC) treated with RT without chemotherapy. Echocardiographic parameters, including GLS, were measured before RT and 6 months post-RT. The association between subclinical LV dysfunction, defined as GLS reduction > 10%, and radiation doses to whole heart and the LV were performed based on logistic regressions. Non-radiation factors associated with subclinical LV dysfunction including age, BMI, hypertension, hypercholesterolemia and endocrine therapy were considered for multivariate analyses. RESULTS A mean decrease of 6% in GLS was observed (- 15.1% ± 3.2% at 6 months vs. - 16.1% ± 2.7% before RT, p = 0.01). For left-sided patients, mean heart and LV doses were 3.1 ± 1.3 Gy and 6.7 ± 3.4 Gy respectively. For right-sided patients, mean heart dose was 0.7 ± 0.5 Gy and median LV dose was 0.1 Gy. Associations between GLS reduction > 10% (37 patients) and mean doses to the heart and the LV as well as the V20 were observed in univariate analysis (Odds Ratio = 1.37[1.01-1.86], p = 0.04 for Dmean Heart; OR = 1.14 [1.01-1.28], p = 0.03 for Dmean LV; OR = 1.08 [1.01-1.14], p = 0.02 for LV V20). In multivariate analysis, these associations did not remain significant after adjustment for non-radiation factors. Further exploratory analysis allowed identifying a subgroup of patients (LV V20 > 15%) for whom a significant association with subclinical LV dysfunction was found (adjusted OR = 3.97 [1.01-15.70], p = 0.048). CONCLUSIONS This analysis indicated that subclinical LV dysfunction defined as a GLS decrease > 10% is associated with cardiac doses, but adjustment for non-radiation factors such as endocrine therapy lead to no longer statistically significant relationships. However, LV dosimetry may be promising to identify high-risk subpopulations. Larger and longer follow-up studies are required to further investigate these associations. TRIAL REGISTRATION ClinicalTrials.gov: NCT02605512, Registered 6 November 2015 - Retrospectively registered.
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Affiliation(s)
- Valentin Walker
- Laboratory of Epidemiology (LEPID), PSE-SANTE, SESANE, Institute for Radiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Olivier Lairez
- Cardiac Imaging Center, Toulouse University Hospital, Toulouse, France
| | - Olivier Fondard
- Department of Cardiology, Clinique Pasteur, Toulouse, France
| | - Atul Pathak
- Department of Cardiology, Clinique Pasteur, Toulouse, France
| | - Baptiste Pinel
- Department of Radiation Oncology (Oncorad), Clinique Pasteur, Toulouse, France
| | - Christian Chevelle
- Department of Radiation Oncology (Oncorad), Clinique Pasteur, Toulouse, France
| | - Denis Franck
- Department of Radiation Oncology (Oncorad), Clinique Pasteur, Toulouse, France
| | - Gaëlle Jimenez
- Department of Radiation Oncology (Oncorad), Clinique Pasteur, Toulouse, France
| | - Jérémy Camilleri
- Department of Radiation Oncology (Oncorad), Clinique Pasteur, Toulouse, France
| | - Loïc Panh
- Department of Cardiac Arrhythmia, Clinique Pasteur, Toulouse, France
| | - David Broggio
- Department of Dosimetry, Institute for Radiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Sylvie Derreumaux
- Institute for Radiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Marie-Odile Bernier
- Laboratory of Epidemiology (LEPID), PSE-SANTE, SESANE, Institute for Radiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Dominique Laurier
- Institute for Radiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France
| | - Jean Ferrières
- Department of Cardiology, Toulouse University Hospital, Toulouse, France.,INSERM, UMR1027, Toulouse, France
| | - Sophie Jacob
- Laboratory of Epidemiology (LEPID), PSE-SANTE, SESANE, Institute for Radiological Protection and Nuclear Safety (IRSN), Fontenay-aux-Roses, France.
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Jimenez RB, Hickey S, DePauw N, Yeap BY, Batin E, Gadd MA, Specht M, Isakoff SJ, Smith BL, Liao EC, Colwell AS, Ho A, Januzzi JL, Passeri J, Neilan TG, Taghian AG, Lu HM, MacDonald SM. Phase II Study of Proton Beam Radiation Therapy for Patients With Breast Cancer Requiring Regional Nodal Irradiation. J Clin Oncol 2019; 37:2778-2785. [PMID: 31449469 PMCID: PMC7351324 DOI: 10.1200/jco.18.02366] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2019] [Indexed: 01/04/2023] Open
Abstract
PURPOSE To evaluate the safety and efficacy of proton beam radiation therapy (RT) for patients with breast cancer who require regional nodal irradiation. METHODS Patients with nonmetastatic breast cancer who required postoperative RT to the breast/chest wall and regional lymphatics and who were considered suboptimal candidates for conventional RT were eligible. The primary end point was the incidence of grade 3 or higher radiation pneumonitis (RP) or any grade 4 toxicity within 3 months of RT. Secondary end points were 5-year locoregional failure, overall survival, and acute and late toxicities per Common Terminology Criteria for Adverse Events (version 4.0). Strain echocardiography and cardiac biomarkers were obtained before and after RT to assess early cardiac changes. RESULTS Seventy patients completed RT between 2011 and 2016. Median follow-up was 55 months (range, 17 to 82 months). Of 69 evaluable patients, median age was 45 years (range, 24 to 70 years). Sixty-three patients (91%) had left-sided breast cancer, two had bilateral breast cancer, and five had right-sided breast cancer. Sixty-five (94%) had stage II to III breast cancer. Sixty-eight (99%) received systemic chemotherapy. Fifty (72%) underwent immediate reconstruction. Median dose to the chest wall/breast was 49.7 Gy (relative biological effectiveness) and to the internal mammary nodes, 48.8 Gy (relative biological effectiveness), which indicates comprehensive coverage. Among 62 surviving patients, the 5-year rates for locoregional failure and overall survival were 1.5% and 91%, respectively. One patient developed grade 2 RP, and none developed grade 3 RP. No grade 4 toxicities occurred. The unplanned surgical re-intervention rate at 5 years was 33%. No significant changes in echocardiography or cardiac biomarkers after RT were found. CONCLUSION Proton beam RT for breast cancer has low toxicity rates and similar rates of disease control compared with historical data of conventional RT. No early cardiac changes were observed, which paves the way for randomized studies to compare proton beam RT with standard RT.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Alice Ho
- Massachusetts General Hospital, Boston, MA
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Skyttä T, Tuohinen S, Luukkaala T, Virtanen V, Raatikainen P, Kellokumpu-Lehtinen PL. Adjuvant radiotherapy-induced cardiac changes among patients with early breast cancer: a three-year follow-up study . Acta Oncol 2019; 58:1250-1258. [PMID: 31219359 DOI: 10.1080/0284186x.2019.1630751] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: In this study, we evaluate the evolution of cardiac changes during a three-year follow-up after adjuvant breast radiotherapy (RT). Methods: Sixty patients with left-sided and 20 patients with right-sided early stage breast cancer without chemotherapy were included in this prospective study. Echocardiography and cardiac biomarkers were evaluated before, immediately after and 3 years after RT. Radiation doses to cardiac structures were calculated. Results: In echocardiography, left ventricle (LV) systolic measurements had impaired at 3 years compared to baseline: the mean global longitudinal strain (GLS) worsened from -18 ± 3 to -17 ± 3 (p = .015), LV ejection fraction from 62 ± 5% to 60 ± 4% (p = .003) and the stroke volume from 73 ± 16 mL to 69 ± 15 mL (p = .015). LV diastolic function was also negatively affected: the isovolumetric relaxation time was prolonged (p = .006) and the first peak of diastole decreased (p = .022). Likewise, left atrial (LA) measurements impaired. These changes in echocardiography were more prominent in left-sided than in right-sided patients. The concurrent aromatase inhibitor (AI) use was associated with GLS impairment. In all patients, the N-terminal pro-brain natriuretic peptide (proBNP) values were median (interquartile range) 74 (41-125) ng/L at baseline, 75 (41-125) ng/L at the end of RT and 96 (56-162) ng/L at 3 years (p < .001 from baseline to 3 years). However, proBNP did not increase in right-sided patients. Conclusion: During the 3-year follow-up after RT, negative subclinical changes in cardiac biomarkers and in LV systolic and diastolic function were observed. The measured changes were more pronounced in left-sided patients. In addition, AI use was associated with impaired cardiac systolic function.
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Affiliation(s)
- Tanja Skyttä
- Department of Oncology, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Suvi Tuohinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Heart Center, Tampere University Hospital, Tampere, Finland
- Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Tiina Luukkaala
- Research Innovation and Development Center, Tampere University Hospital and Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Vesa Virtanen
- Heart Center, Tampere University Hospital, Tampere, Finland
| | - Pekka Raatikainen
- Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Pirkko-Liisa Kellokumpu-Lehtinen
- Department of Oncology, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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van den Bogaard VA, van Luijk P, Hummel YM, van der Meer P, Schuit E, Boerman LM, Maass SW, Nauta JF, Steggink LC, Gietema JA, de Bock GH, Berendsen AJ, Smit WG, Sijtsema NM, Kierkels RG, Langendijk JA, Crijns AP, Maduro JH. Cardiac Function After Radiation Therapy for Breast Cancer. Int J Radiat Oncol Biol Phys 2019; 104:392-400. [DOI: 10.1016/j.ijrobp.2019.02.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 01/25/2019] [Accepted: 02/04/2019] [Indexed: 12/25/2022]
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Singh A, Voss WB, Lentz RW, Thomas JD, Akhter N. The Diagnostic and Prognostic Value of Echocardiographic Strain. JAMA Cardiol 2019; 4:580-588. [DOI: 10.1001/jamacardio.2019.1152] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Arushi Singh
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Robert W. Lentz
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - James D. Thomas
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Nausheen Akhter
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Yu AF, Ho AY, Braunstein LZ, Thor ME, Lee Chuy K, Eaton A, Mara E, Cahlon O, Dang CT, Oeffinger KC, Steingart RM, Liu JE. Assessment of Early Radiation-Induced Changes in Left Ventricular Function by Myocardial Strain Imaging After Breast Radiation Therapy. J Am Soc Echocardiogr 2019; 32:521-528. [PMID: 30826225 DOI: 10.1016/j.echo.2018.12.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Radiation therapy (RT)-induced cardiotoxicity is among the concerning sequelae of breast cancer (BCA) treatment, particularly in HER2-positive BCA patients who receive anthracyclines and trastuzumab-based therapy. The aim of this study was to assess for early RT-induced changes in echocardiographic and circulating biomarkers of left ventricular (LV) function and evaluate their association with radiation dose to the heart among patients with HER2-positive BCA treated with contemporary RT. METHODS A total of 47 women with HER2-positive BCA who were treated with an anthracycline, trastuzumab, and RT to the breast and/or chest wall ± regional lymph nodes were included in this study. Two-dimensional echocardiography with speckle-tracking imaging was performed at baseline (prechemotherapy), prior to and after RT (pre-RT and post-RT), and 6 months post-RT. High-sensitivity troponin I (hsTnI) was measured pre-RT and post-RT. Associations between mean heart dose (MHD) and changes in LV function after RT were examined in multivariable linear regression models. RESULTS The MHD was 1.8 ± 1.5 Gy for patients receiving left-sided RT (n = 26) and 1.1 ± 1.3 Gy for patients receiving right-sided RT (n = 21). Pre-RT, post-RT, and 6-month post-RT echocardiograms were performed at median (interquartile range) of 49 days (27, 77) before and 54 days (25, 78) and 195 days (175, 226) after RT, respectively. Compared with pre-RT, a minimal decrease in LV ejection fraction was observed post-RT (61% ± 7% vs 59% ± 8%; P = .003) without any significant change in global longitudinal, circumferential, or radial strain or diastolic indices at the post-RT timepoint. Median (interquartile range) concentrations of hsTnI decreased from 5.7 pg/mL (3.0, 8.7) pre-RT to 3.7 pg/mL (2.0, 5.9) post-RT. There was no significant change in systolic or diastolic indices of LV function at 6 months post-RT compared with pre-RT. MHD was not associated with changes in echocardiographic parameters of LV function after RT. CONCLUSIONS Breast RT using contemporary techniques can be delivered without evidence of early subclinical LV dysfunction or injury as measured by echocardiography and hsTnI in patients treated with anthracyclines and trastuzumab. Future studies should focus on identifying alternative biomarkers to elucidate early RT-induced cardiovascular effects and further characterizing long-term cardiovascular outcomes associated with contemporary breast RT.
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Affiliation(s)
- Anthony F Yu
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York.
| | - Alice Y Ho
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria E Thor
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katherine Lee Chuy
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne Eaton
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota
| | - Elton Mara
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Chau T Dang
- Weill Cornell Medical College, New York, New York; Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Richard M Steingart
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
| | - Jennifer E Liu
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, New York, New York
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Methods of diagnosis in cardio-oncology. КЛИНИЧЕСКАЯ ПРАКТИКА 2018. [DOI: 10.17816/clinpract09150-62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Early diagnosis and advances in treatment have led to improved survival of patients with cancer, but have also increased morbidity and mortality due to treatment side effects. Cardiovascular diseases (CVDs) are one of the most frequent of these side effects. As a result of the direct effects of radiation therapy and chemotherapy on heart and vessels сan be: acceleration of atherosclerosis, damage of cardiomyocytes and endothelium, and arterial and venous thrombosis. The direct effect of the cancer treatment on the heart is called cardiotoxicity. Early diagnosis and identification of patients at high risk of cardiotoxicity is the first step towards successful prevention of CVD in cancer patients without compromising cancer care, which ultimately leads to a reduction in mortality. Echocardiography is the method of choice for the detection of myocardial dysfunction during and after cancer therapy. New methods of imaging like three-dimensional echocardiography, speckle-tracking echocardiography, cardiac magnetic resonance show a higher sensitivity in detecting of early myocardial dysfunction during cancer therapy. This review outlines the main diagnostic algorithms and approaches used in cardiooncology.
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Demissei BG, Freedman G, Feigenberg SJ, Plastaras JP, Maity A, Smith AM, McDonald C, Sheline K, Simone CB, Lin LL, Carver JR, Liu P, Zhang L, Bekelman JE, Ky B. Early Changes in Cardiovascular Biomarkers with Contemporary Thoracic Radiation Therapy for Breast Cancer, Lung Cancer, and Lymphoma. Int J Radiat Oncol Biol Phys 2018; 103:851-860. [PMID: 30445173 DOI: 10.1016/j.ijrobp.2018.11.013] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/11/2018] [Accepted: 11/06/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE We characterized the early changes in cardiovascular biomarkers with contemporary thoracic radiation therapy (RT) and evaluated their associations with radiation dose-volume metrics including mean heart dose (MHD), V5, and V30. METHODS AND MATERIALS In a prospective longitudinal study of 87 patients with breast cancer, lung cancer, or mediastinal lymphoma treated with photon or proton thoracic RT, blood samples were obtained pre-RT and after completion of RT (median, 20 days; interquartile range [IQR], 1-35). High-sensitivity cardiac troponin T, N-terminal pro-B-type natriuretic peptide, placental growth factor (PIGF), and growth differentiation factor 15 (GDF-15) were measured. Associations between MHD, V5 and V30, and biomarker levels and associations between echocardiography-derived measures of cardiac function and biomarker levels were assessed in multivariable linear regression models. Analyses were performed according to the following subgroups: (1) breast cancer alone and (2) lung cancer and lymphoma combined. RESULTS The median (IQR) estimates of MHD ranged from 1.3 Gy (0.9-2.4) in breast cancer (n = 60) to 6.8 Gy (5.4-10.2) in mediastinal lymphoma (n = 14) and 8.4 Gy (6.7-16.1) in lung cancer (n = 13) patients (P < .001). There were no significant increases in biomarker levels from pre-RT to post-RT in breast cancer. In lung cancer/lymphoma, PIGF increased from a median (IQR) of 20 ng/L (16-26) to 22 ng/L (16-30) (P = .005), and GDF-15 increased from 1171 ng/L (755-2493) to 1887 ng/L (903-3763) (P = .006). MHD, V5, and V30 were significantly associated with post-RT PIGF and GDF-15 levels in multivariable models. Changes in biomarkers were not significantly associated with changes in echocardiography-derived measures of cardiac function. CONCLUSION Contemporary thoracic RT induces acute abnormalities in vascular and inflammatory biomarkers that are associated with radiation dose-volume metrics, particularly in lung cancer and mediastinal lymphoma. Long-term follow-up studies are needed to determine the impact of these changes on the development of overt cardiac disease.
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Affiliation(s)
- Biniyam G Demissei
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gary Freedman
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven J Feigenberg
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John P Plastaras
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Maity
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda M Smith
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Caitlin McDonald
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karyn Sheline
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charles B Simone
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland
| | - Lilie L Lin
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joseph R Carver
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter Liu
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Liyong Zhang
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Justin E Bekelman
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bonnie Ky
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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Tang S, Otton J, Holloway L, Delaney GP, Liney G, George A, Jameson M, Tran D, Batumalai V, Thomas L, Koh ES. Quantification of cardiac subvolume dosimetry using a 17 segment model of the left ventricle in breast cancer patients receiving tangential beam radiotherapy. Radiother Oncol 2018; 132:257-265. [PMID: 30446318 DOI: 10.1016/j.radonc.2018.09.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 09/23/2018] [Accepted: 09/27/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE Subacute changes following breast radiotherapy have been demonstrated in discrete areas of the left ventricle (LV), with recent guidelines being developed to help determine dose to subvolumes of the LV. This study aims to determine doses to the 17 segments of the LV as per the American Heart Association (AHA) and other cardiac subvolumes, and to correlate mean heart (MHD) dose with various subvolume dosimetric indices. These results may direct focus to specific left ventricular segments in studies of radiation-related heart disease incorporating surveillance imaging, help to determine more precise dose response relationships, and potentially aid prediction of late radiation effects. METHODS AND MATERIALS The heart and cardiac subvolumes of 29 patients treated with tangential radiotherapy for left breast cancer were contoured. Delineation of cardiac subvolumes (cardiac chambers, cardiac valves and the 17 segments of the LV) was undertaken using a novel contouring method on planning CT data reformatted into the cardiac axis. Individual segments were then combined to determine doses to the basal, mid and apical left ventricular regions, and the anterior, septal, inferior and lateral ventricular walls. Radiotherapy doses (including maximum, mean, D1cc, V25) were determined. Correlation analyses were performed between MHD and various substructure dosimetric indices. RESULTS Twenty five patients received tangential breast free breathing radiotherapy alone, and four patients received regional nodal irradiation including the internal mammary chain with deep inspiration breath hold (DIBH). For patients receiving breast only radiation, the median mean heart radiation dose was 2.62 Gy (range 1.52-3.90 Gy), and a heterogeneous dose distribution to the LV was noted, with the apical region receiving the highest median mean dose (14.99 Gy) compared with the mid and basal regions (3.10 Gy and 1.51 Gy respectively). The anterior LV wall received the highest median mean dose (9.21 Gy) with the remaining walls receiving similar mean doses (range 1.79-3.05 Gy). The anterior LV apical segment (segment 13) and apex (segment 17) received the highest individual median mean segment doses (26.73 Gy and 30.02 Gy respectively). Apical segments received the highest median mean doses (segments 13, 14, 15, 16), followed by the mid anterior (segment 7) and anteroseptal (segment 8) segments. Segments receiving the highest doses remained unchanged between the DIBH cohort and free breathing cohort. MHD showed a high correlation with the anterior wall r = 0.71, p < 0.05 and entire left ventricle r = 0.82, p < 0.05, but correlations varied from weak to high when MHD was correlated with segments receiving highest doses (range r = 0.43-0.76), p < 0.05. CONCLUSIONS In the setting of breast cancer radiotherapy, there are substantial RT dose variations within specific LV segments, with mid and apical anterior ventricular segments (segments 7, 13) and the apical region of the LV (segments 13, 14, 15, 16, 17) being consistently exposed to the highest radiation doses. Determining segmental and regional RT doses to the left ventricle may help guide focus in diagnostic cardiology in the post radiotherapy setting.
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Affiliation(s)
- Simon Tang
- Ingham Institute of Applied Medical Research, Liverpool Hospital, Australia; University of New South Wales, Australia; Cancer Therapy Centre, Liverpool Hospital, Australia.
| | - James Otton
- University of New South Wales, Australia; Department of Cardiology, Liverpool Hospital, Australia
| | - Lois Holloway
- Ingham Institute of Applied Medical Research, Liverpool Hospital, Australia; University of New South Wales, Australia; Cancer Therapy Centre, Liverpool Hospital, Australia; University of Sydney, Australia
| | - Geoffrey P Delaney
- Ingham Institute of Applied Medical Research, Liverpool Hospital, Australia; University of New South Wales, Australia; Cancer Therapy Centre, Liverpool Hospital, Australia
| | - Gary Liney
- Ingham Institute of Applied Medical Research, Liverpool Hospital, Australia; University of New South Wales, Australia; Cancer Therapy Centre, Liverpool Hospital, Australia
| | - Armia George
- Cancer Therapy Centre, Liverpool Hospital, Australia
| | - Michael Jameson
- Ingham Institute of Applied Medical Research, Liverpool Hospital, Australia; University of New South Wales, Australia; Cancer Therapy Centre, Liverpool Hospital, Australia
| | | | - Vikneswary Batumalai
- Ingham Institute of Applied Medical Research, Liverpool Hospital, Australia; Cancer Therapy Centre, Liverpool Hospital, Australia
| | - Liza Thomas
- University of New South Wales, Australia; University of Sydney, Australia; Department of Cardiology, Westmead Hospital, Australia
| | - Eng-Siew Koh
- Ingham Institute of Applied Medical Research, Liverpool Hospital, Australia; University of New South Wales, Australia; Cancer Therapy Centre, Liverpool Hospital, Australia
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44
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Trivedi SJ, Choudhary P, Lo Q, Sritharan HP, Iyer A, Batumalai V, Delaney GP, Thomas L. Persistent reduction in global longitudinal strain in the longer term after radiation therapy in patients with breast cancer. Radiother Oncol 2018; 132:148-154. [PMID: 30414755 DOI: 10.1016/j.radonc.2018.10.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/17/2018] [Accepted: 10/22/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND More than 80% of breast cancer patients receive radiotherapy (RT). However, RT can lead to cardiotoxicity, which usually develops insidiously over years, making diagnosis difficult. It is also unknown whether early identification of at-risk patients might improve long-term outcome. We have previously described subclinical alterations, detected by two-dimensional speckle tracking strain echocardiography, in left ventricular (LV) function immediately following RT in breast cancer. HYPOTHESIS Subclinical myocardial alterations in LV function consequent to RT cardiotoxicity, observed early, persist at 12 months. METHODS 40 chemotherapy naive women with left-sided breast cancer, treated with surgery and adjuvant breast RT, were prospectively recruited from two tertiary hospitals. Transthoracic echocardiography was performed at baseline (pre-RT), 6 weeks post-RT, and 12 months post-RT. RESULTS An increase in LV end diastolic and end systolic volumes was seen from baseline, consistent with persistent LV remodelling; however, due to the increase in both systolic and diastolic volumes over time, no change in LV ejection fraction (EF) was observed. Global longitudinal strain (GLS) and S' velocity remained significantly lower at 12 months post-RT. GLS dropped by >10% in 16 patients and by >20% in 4 patients compared to baseline. CONCLUSIONS Subclinical cardiac dysfunction using strain analysis, evident early, persists one year after RT, despite unchanged conventional indices such as LVEF. Persistent GLS reduction may be of particular importance in breast cancer patients receiving concomitant chemotherapy. Longer term prospective studies are required to determine if reductions in strain post-RT are associated with future adverse cardiovascular events.
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Affiliation(s)
- Siddharth J Trivedi
- Department of Cardiology, Westmead Hospital, Sydney, Australia; Westmead Clinical School, University of Sydney, Australia
| | | | - Queenie Lo
- South West Clinical School, University of New South Wales, Sydney, Australia; Department of Cardiology, St George Hospital, Sydney, Australia
| | | | - Arvind Iyer
- South West Clinical School, University of New South Wales, Sydney, Australia; Department of Cardiology, Macquarie University Hospital, Sydney, Australia
| | - Vikneswary Batumalai
- South West Clinical School, University of New South Wales, Sydney, Australia; Cancer Therapy Centre, Liverpool Hospital, Sydney, Australia; Ingham Institute of Applied Medical Research, Sydney, Australia
| | - Geoff P Delaney
- South West Clinical School, University of New South Wales, Sydney, Australia; Cancer Therapy Centre, Liverpool Hospital, Sydney, Australia; Ingham Institute of Applied Medical Research, Sydney, Australia
| | - Liza Thomas
- Department of Cardiology, Westmead Hospital, Sydney, Australia; Westmead Clinical School, University of Sydney, Australia; South West Clinical School, University of New South Wales, Sydney, Australia.
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45
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Niska JR, Thorpe CS, Allen SM, Daniels TB, Rule WG, Schild SE, Vargas CE, Mookadam F. Radiation and the heart: systematic review of dosimetry and cardiac endpoints. Expert Rev Cardiovasc Ther 2018; 16:931-950. [DOI: 10.1080/14779072.2018.1538785] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Joshua R. Niska
- Mayo Clinic - Department of Radiation Oncology, Phoenix, AZ, USA
| | | | - Sorcha M. Allen
- Mayo Clinic - Department of Cardio-Oncology, Scottsdale, AZ, USA
| | | | - William G. Rule
- Mayo Clinic - Department of Radiation Oncology, Phoenix, AZ, USA
| | - Steven E. Schild
- Mayo Clinic - Department of Radiation Oncology, Phoenix, AZ, USA
| | - Carlos E. Vargas
- Mayo Clinic - Department of Radiation Oncology, Phoenix, AZ, USA
| | - Farouk Mookadam
- Mayo Clinic - Department of Cardio-Oncology, Scottsdale, AZ, USA
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46
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Walker V, Crijns A, Langendijk J, Spoor D, Vliegenthart R, Combs SE, Mayinger M, Eraso A, Guedea F, Fiuza M, Constantino S, Tamarat R, Laurier D, Ferrières J, Mousseaux E, Cardis E, Jacob S. Early Detection of Cardiovascular Changes After Radiotherapy for Breast Cancer: Protocol for a European Multicenter Prospective Cohort Study (MEDIRAD EARLY HEART Study). JMIR Res Protoc 2018; 7:e178. [PMID: 30274965 PMCID: PMC6242210 DOI: 10.2196/resprot.9906] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 03/30/2018] [Accepted: 04/17/2018] [Indexed: 12/25/2022] Open
Abstract
Background Breast cancer is the most common cancer among women, and radiotherapy plays a major role in its treatment. However, breast cancer radiotherapy can lead to incidental irradiation of the heart, resulting in an increased risk for a variety of heart diseases arising many years after radiotherapy. Therefore, identifying breast cancer patients at the highest risk for radiation-induced cardiac complications is crucial for developing strategies for primary and secondary prevention, which may contribute to healthy aging. There is still a need for precise knowledge on the relationship between radiation dose to specific cardiac structures and early subclinical cardiac changes and their occurrence over time that could finally lead to cardiac complications. Objective The MEDIRAD EARLY HEART study aims to identify and validate new cardiac imaging and circulating biomarkers of radiation-induced cardiovascular changes arising within first 2 years of breast cancer radiotherapy and to develop risk models integrating these biomarkers combined with precise dose metrics of cardiac structures based on three-dimensional dosimetry. Methods The EARLY HEART study is a multicenter, prospective cohort study in which 250 women treated for breast cancer and followed for 2 years after radiotherapy will be included. Women treated with radiotherapy without chemotherapy for a unilateral breast cancer and aged 40-75 years meet the inclusion criteria. Baseline and follow-up data include cardiac measurements based on two-dimensional speckle-tracking echocardiography, computed tomography coronary angiography, cardiac magnetic resonance imaging, and a wide panel of circulating biomarkers of cardiac injury. The absorbed dose will be evaluated globally for the heart and different substructures. Furthermore, the dose-response relationship will allow modeling the radiation-induced occurrence and evolution of subclinical cardiac lesions and biomarkers to develop prediction models. Results This study details the protocol of the MEDIRAD EARLY HEART study and presents the main limits and advantages of this international project. The inclusion of patients began in 2017. Preliminary results are expected to be published in 2019, and complete analysis should be published in 2021. Conclusions The MEDIRAD EARLY HEART study will allow identifying the main cardiac imaging and blood-based determinants of radiation-induced cardiac injuries to better propose primary and secondary preventive measures in order to contribute to enhanced patient care and quality of life. Trial Registration ClinicalTrials.gov NCT03297346; https://clinicaltrials.gov/ct2/show/NCT03297346 (Archived by WebCite at http://www.webcitation.org/72KS7MIUU) Registered Report Identifier RR1-10.2196/9906
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Affiliation(s)
- Valentin Walker
- Pôle Santé-Environnement (PSE-SANTE), Service de recherche sur les effets biologiques et sanitaires des rayonnements ionisants (SESANE), Laboratoire d'épidémiologie des rayonnements ionisants (LEPID), Institut de Radioprotection et de Sûreté Nucléaire (IRSN), Fontenay-aux-Roses, France
| | - Anne Crijns
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Johannes Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Daan Spoor
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Rozemarijn Vliegenthart
- Center for Medical Imaging, Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Stephanie E Combs
- Department of Radiation Oncology, Technische Universität München (TUM), München, Germany.,Department of Radiation Sciences (DRS), Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München (HMGU), München, Germany.,Deutsches Konsortium für Translationale Krebsforschung (DKTK), Partner Site Munich, München, Germany
| | - Michael Mayinger
- Department of Radiation Oncology, Technische Universität München (TUM), München, Germany
| | - Arantxa Eraso
- Department of Radiation Oncology, Institut Català d'Oncologia, Girona, Spain
| | - Ferran Guedea
- Department of Radiation Oncology, Institut Català d'Oncologia, L'Hospitalet del Llobregat, Spain
| | - Manuela Fiuza
- Department of Cardiology, Centro Cardiovascular da Universidade de Lisboa, Lisbon, Portugal
| | - Susana Constantino
- Laboratory of Angiogenesis, Centro Cardiovascular da Universidade de Lisboa, Lisbon, Portugal
| | - Radia Tamarat
- Pôle Santé-Environnement (PSE-SANTE), Institut de Radioprotection et de Sûreté Nucléaire (IRSN), Fontenay-aux-Roses, France
| | - Dominique Laurier
- Pôle Santé-Environnement (PSE-SANTE), Service de recherche sur les effets biologiques et sanitaires des rayonnements ionisants (SESANE), Institut de Radioprotection et de Sûreté Nucléaire (IRSN), Fontenay-aux-Roses, France
| | - Jean Ferrières
- Department of Cardiology B and Epidemiology, University Hospital, Toulouse, France.,Unite Mixte de Recherche (UMR) 1027, The Institut national de la santé et de la recherche médicale (INSERM), Toulouse, France
| | - Elie Mousseaux
- Department of Radiology, Hôpital Européen Georges Pompidou, Paris Descartes University, Paris, France
| | - Elisabeth Cardis
- Institute for Global Health (ISGlobal), Radiation Programme, Barcelona Biomedical Research Park (PRBB), Barcelona, Spain.,Pompeu Fabra University (UPF), Barcelona, Spain.,Consorcio Centro de Investigación Biomédica en Red Epidemiologia y Salud Pública (CIBERESP), Madrid, Spain
| | - Sophie Jacob
- Pôle Santé-Environnement (PSE-SANTE), Service de recherche sur les effets biologiques et sanitaires des rayonnements ionisants (SESANE), Laboratoire d'épidémiologie des rayonnements ionisants (LEPID), Institut de Radioprotection et de Sûreté Nucléaire (IRSN), Fontenay-aux-Roses, France
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Brownlee Z, Garg R, Listo M, Zavitsanos P, Wazer DE, Huber KE. Late complications of radiation therapy for breast cancer: evolution in techniques and risk over time. Gland Surg 2018; 7:371-378. [PMID: 30175054 DOI: 10.21037/gs.2018.01.05] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Radiation therapy in combination with surgery, chemotherapy, and endocrine therapy as indicated, has led to excellent local and distant control of early stage breast cancers. With the majority of these patients surviving long term, mitigating the probability and severity of late toxicities is vital. Radiation to the breast, with or without additional fields for nodal coverage, has the potential to negatively impact long term cosmetic outcome of the treated breast as well as cause rare, but severe, complications due to incidental dosage to the heart, lungs and contralateral breast. The long-term clinical side-effects of breast radiation have been studied extensively. This review aims to discuss the risk of developing late complications following breast radiation and how modern techniques can be used to diminish these risks.
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Affiliation(s)
- Zachary Brownlee
- Department of Radiation Oncology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
| | - Rashi Garg
- Department of Radiation Oncology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
| | - Matthew Listo
- Department of Radiation Oncology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
| | - Peter Zavitsanos
- Department of Radiation Oncology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
| | - David E Wazer
- Department of Radiation Oncology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA.,Department of Radiation Oncology, Rhode Island Hospital and Brown University School of Medicine, Providence, RI, USA
| | - Kathryn E Huber
- Department of Radiation Oncology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
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Menezes KM, Wang H, Hada M, Saganti PB. Radiation Matters of the Heart: A Mini Review. Front Cardiovasc Med 2018; 5:83. [PMID: 30038908 PMCID: PMC6046516 DOI: 10.3389/fcvm.2018.00083] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 06/12/2018] [Indexed: 12/12/2022] Open
Abstract
Radiation Therapy (RT) has been critical in cancer treatment regimens to date. However, it has been shown that ionizing radiation is also associated with increased risk of damage to healthy tissues. At high radiation doses, varied effects including inactivation of cells in treated tissue and associated functional impairment are seen. These range from direct damage to the heart; particularly, diffuse fibrosis of the pericardium and myocardium, adhesion of the pericardium, injury to the blood vessels and stenosis. Cardiac damage is mostly a late responding end-point, occurring anywhere between 1 and 10 years after radiation procedures. Cardiovascular disease following radiotherapy was more common with radiation treatments used before the late 1980s. Modern RT regimens with more focused radiation beams, allow tumors to be targeted more precisely and shield the heart and other healthy tissues for minimizing the radiation damage to normal cells. In this review, we discuss radiation therapeutic doses used and post-radiation damage to the heart muscle from published studies. We also emphasize the need for early detection of cardiotoxicity and the need for more cardio-protection approaches where feasible.
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Affiliation(s)
- Kareena M Menezes
- Radiation Institute for Science and Engineering, A Texas A&M Chancellor's Research Initiative, Prairie View A&M University, Prairie View, TX, United States
| | - Huichen Wang
- Radiation Institute for Science and Engineering, A Texas A&M Chancellor's Research Initiative, Prairie View A&M University, Prairie View, TX, United States
| | - Megumi Hada
- Radiation Institute for Science and Engineering, A Texas A&M Chancellor's Research Initiative, Prairie View A&M University, Prairie View, TX, United States
| | - Premkumar B Saganti
- Radiation Institute for Science and Engineering, A Texas A&M Chancellor's Research Initiative, Prairie View A&M University, Prairie View, TX, United States
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49
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Zhu Q, Kirova YM, Cao L, Arsene-Henry A, Chen J. Cardiotoxicity associated with radiotherapy in breast cancer: A question-based review with current literatures. Cancer Treat Rev 2018; 68:9-15. [DOI: 10.1016/j.ctrv.2018.03.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 03/07/2018] [Accepted: 03/08/2018] [Indexed: 12/25/2022]
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50
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Tan LL, Lyon AR. Role of Biomarkers in Prediction of Cardiotoxicity During Cancer Treatment. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:55. [PMID: 29923056 PMCID: PMC6008350 DOI: 10.1007/s11936-018-0641-z] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Purpose of review As cancer survivor rates improve with early screening and modern treatment options, cardiotoxicity is becoming an increasing problem. It is imperative for physicians to recognize adverse events early so that appropriate measures can be taken before advanced and permanent cardiac dysfunction ensues. In this review, we will evaluate the literature surrounding current cardiac biomarkers in the detection of cardiotoxicity during cancer treatment as well as discuss the role of emerging novel biomarkers. Recent findings Troponin and brain natriuretic peptides show promise in the detection of subclinical cardiotoxicity during cancer treatment. In addition to identifying late complications among cancer survivors, they have the potential to predict patients who are at risk of developing cardiotoxicity prior to the initiation of cancer therapy. However, there are also conflicting data due to varying study design. Summary Although biomarkers are an attractive option in the detection of cardiotoxicity among cancer patients, current recommendations surrounding its role are based on expert consensus opinion. Further research with appropriately designed prospective trials is required to guide optimal clinical practice.
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Affiliation(s)
- Li-Ling Tan
- Cardio-Oncology Service, Department of Cardiology, Royal Brompton Hospital, London, SW3 6NP, UK
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Alexander R Lyon
- Cardio-Oncology Service, Department of Cardiology, Royal Brompton Hospital, London, SW3 6NP, UK.
- National Heart and Lung Institute, Imperial College London, London, UK.
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