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Meattini I, Becherini C, Caini S, Coles CE, Cortes J, Curigliano G, de Azambuja E, Isacke CM, Harbeck N, Kaidar-Person O, Marangoni E, Offersen BV, Rugo HS, Salvestrini V, Visani L, Morandi A, Lambertini M, Poortmans P, Livi L. International multidisciplinary consensus on the integration of radiotherapy with new systemic treatments for breast cancer: European Society for Radiotherapy and Oncology (ESTRO)-endorsed recommendations. Lancet Oncol 2024; 25:e73-e83. [PMID: 38301705 DOI: 10.1016/s1470-2045(23)00534-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/29/2023] [Accepted: 10/12/2023] [Indexed: 02/03/2024]
Abstract
Novel systemic therapies for breast cancer are being rapidly implemented into clinical practice. These drugs often have different mechanisms of action and side-effect profiles compared with traditional chemotherapy. Underpinning practice-changing clinical trials focused on the systemic therapies under investigation, thus there are sparse data available on radiotherapy. Integration of these new systemic therapies with radiotherapy is therefore challenging. Given this rapid, transformative change in breast cancer multimodal management, the multidisciplinary community must unite to ensure optimal, safe, and equitable treatment for all patients. The aim of this collaborative group of radiation, clinical, and medical oncologists, basic and translational scientists, and patient advocates was to: scope, synthesise, and summarise the literature on integrating novel drugs with radiotherapy for breast cancer; produce consensus statements on drug-radiotherapy integration, where specific evidence is lacking; and make best-practice recommendations for recording of radiotherapy data and quality assurance for subsequent studies testing novel drugs.
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Affiliation(s)
- Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Carlotta Becherini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Saverio Caini
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network, Florence, Italy
| | | | - Javier Cortes
- International Breast Cancer Center, Pangaea Oncology, Quironsalud Group and Medical Scientia Innovation Research, Barcelona, Spain; Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
| | - Giuseppe Curigliano
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Evandro de Azambuja
- Institut Jules Bordet and l'Université Libre de Bruxelles, Brussels, Belgium
| | - Clare M Isacke
- Breast Cancer Now Research Centre, The Institute of Cancer Research, London, UK
| | - Nadia Harbeck
- Breast Center, Department of Gynecology and Obstetrics and CCCMunich, LMU University Hospital, Munich, Germany
| | - Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel; The School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; GROW-School for Oncology and Reproduction, Maastricht University, Maastricht, Netherlands
| | - Elisabetta Marangoni
- Laboratory of Preclinical Investigation, Translational Research Department, Institut Curie, Paris, France
| | - Birgitte V Offersen
- Department of Experimental Clinical Oncology, Danish Centre for Particle Therapy, Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Hope S Rugo
- Department of Medicine, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA, USA
| | - Viola Salvestrini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Luca Visani
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Andrea Morandi
- Department of Experimental and Clinical Biomedical Sciences "M Serio", University of Florence, Florence, Italy
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy; Department of Medical Oncology, UOC Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences "M Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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Preoperative Radio(Chemo)Therapy in Breast Cancer: Time to Switch the Perspective? Curr Oncol 2022; 29:9767-9787. [PMID: 36547182 PMCID: PMC9777182 DOI: 10.3390/curroncol29120768] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/02/2022] [Accepted: 12/05/2022] [Indexed: 12/14/2022] Open
Abstract
AIM Radiation therapy represents, together with surgery and systemic treatment, the triad on which the current management of patients with breast cancer is based, achieving high control and survival rates. In recent years we have witnessed a (r)evolution in the conception of breast cancer treatment. The classic scheme of surgery followed by systemic treatment and radiotherapy is being subverted and it is becoming more and more frequent to propose the primary administration of systemic treatment before surgery, seeking to maximize its effect and favoring not only the performance of more conservative surgeries but also, in selected cases, increasing the rates of disease-free survival and overall survival. Radiotherapy is also evolving toward a change in perspective: considering preoperative primary administration of radiotherapy may be useful in selected groups. Advances in radiobiological knowledge, together with technological improvements that are constantly being incorporated into clinical practice, support the administration of increasingly reliable, precise, and effective radiotherapy, as well as its safe combination with antitumor drugs or immunotherapy in the primary preoperative context. In this paper, we present a narrative review of the usefulness of preoperative radiotherapy for breast cancer patients and the possibilities for its combination with other therapies.
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Dreyfuss AD, Velalopoulou A, Avgousti H, Bell BI, Verginadis II. Preclinical models of radiation-induced cardiac toxicity: Potential mechanisms and biomarkers. Front Oncol 2022; 12:920867. [PMID: 36313656 PMCID: PMC9596809 DOI: 10.3389/fonc.2022.920867] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 09/12/2022] [Indexed: 12/24/2022] Open
Abstract
Radiation therapy (RT) is an important modality in cancer treatment with >50% of cancer patients undergoing RT for curative or palliative intent. In patients with breast, lung, and esophageal cancer, as well as mediastinal malignancies, incidental RT dose to heart or vascular structures has been linked to the development of Radiation-Induced Heart Disease (RIHD) which manifests as ischemic heart disease, cardiomyopathy, cardiac dysfunction, and heart failure. Despite the remarkable progress in the delivery of radiotherapy treatment, off-target cardiac toxicities are unavoidable. One of the best-studied pathological consequences of incidental exposure of the heart to RT is collagen deposition and fibrosis, leading to the development of radiation-induced myocardial fibrosis (RIMF). However, the pathogenesis of RIMF is still largely unknown. Moreover, there are no available clinical approaches to reverse RIMF once it occurs and it continues to impair the quality of life of long-term cancer survivors. Hence, there is an increasing need for more clinically relevant preclinical models to elucidate the molecular and cellular mechanisms involved in the development of RIMF. This review offers an insight into the existing preclinical models to study RIHD and the suggested mechanisms of RIMF, as well as available multi-modality treatments and outcomes. Moreover, we summarize the valuable detection methods of RIHD/RIMF, and the clinical use of sensitive radiographic and circulating biomarkers.
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Meattini I, Livi L, Lorito N, Becherini C, Bacci M, Visani L, Fozza A, Belgioia L, Loi M, Mangoni M, Lambertini M, Morandi A. Integrating radiation therapy with targeted treatments for breast cancer: from bench to bedside. Cancer Treat Rev 2022; 108:102417. [PMID: 35623219 DOI: 10.1016/j.ctrv.2022.102417] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/14/2022] [Accepted: 05/17/2022] [Indexed: 11/02/2022]
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5
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Bachir B, Anouti S, Abi Jaoude J, Kayali M, Tfayli A, de Azambuja E, Poortmans P, Zeidan YH. Evaluation of Cardiotoxicity in HER-2-Positive Breast Cancer Patients Treated With Radiation Therapy and Trastuzumab. Int J Radiat Oncol Biol Phys 2022; 113:135-142. [PMID: 34986381 DOI: 10.1016/j.ijrobp.2021.12.159] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE Trastuzumab is associated with cardiac dysfunction in patients with human epidermal growth factor receptor 2 (HER-2)-positive breast cancer. The current study examines the effect of radiation therapy (RT) on cardiotoxicity in this patient population. METHODS AND MATERIALS The Herceptin Adjuvant (HERA) trial is a phase 3 prospective, randomized clinical trial that established the efficacy of trastuzumab in HER-2-positive breast cancer. The current study is a retrospective analysis of 3321 trial patients treated with trastuzumab, with or without RT. Cardiac function was closely monitored over a median follow-up period of 11 years. The primary endpoint of the current study was to determine the effect of RT on left ventricular ejection fraction (LVEF) and the occurrence of cardiovascular events. RESULTS Patients were divided into 3 groups: 1270 patients received trastuzumab and left-sided RT (group 1); 1271 patients received trastuzumab and right-sided RT (group 2); and 780 patients received trastuzumab with no RT (group 3). The incidence of decline in LVEF documented by echocardiography was 9.18%, 8.99%, and 8.80%, respectively, with no significant differences among the 3 groups (P = .073). The incidence of cardiovascular events was low in all groups, with the lowest incidence noted in group 3 (0.62%) followed by group 2 (0.92%) and group 1 (1.08%) (P = .619). Univariate and multivariate competing-risks regression showed that left-sided and right-sided RT delivery did not significantly increase the risk of LVEF decline or cardiovascular events. CONCLUSIONS Our analysis of the HERA trial suggests that RT does not significantly increase the risk of cardiotoxicity in HER-2-positive breast cancer patients treated with trastuzumab. Continued monitoring of patients is needed to investigate late effects of contemporary treatments for breast cancer patients.
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Affiliation(s)
- Bachir Bachir
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Sirine Anouti
- American University of Beirut, Faculty of Health Sciences, Beirut, Lebanon
| | | | - Majd Kayali
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Arafat Tfayli
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Evandro de Azambuja
- Institut Jules Bordet and l'Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Philip Poortmans
- Iridium Netwerk, Wilrijk-Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
| | - Youssef H Zeidan
- Lynn Cancer Institute, Baptist Health South Florida, Boca Raton, FL.
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Fourati N, Trigui R, Charfeddine S, Dhouib F, Kridis WB, Abid L, Khanfir A, Mnejja W, Daoud J. [Concomitant radiotherapy and trastuzumab: Rational and clinical implications]. Bull Cancer 2021; 108:501-512. [PMID: 33745737 DOI: 10.1016/j.bulcan.2020.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 12/01/2020] [Accepted: 12/18/2020] [Indexed: 11/25/2022]
Abstract
The HER2 receptor (Human Epidermal Growth Receptor 2) is a transmembrane receptor with tyrosine kinase activity that is over-expressed in 25-30 % of breast carcinomas. Its activation is associated with an exaggeration of cell proliferation with an increase in repair capacity resulting in increased radioresistance. On cardiac tissues, HER2 receptor activation plays a cardio-protective role. Trastuzumab, the first anti-HER2 drug used to treat patients with breast cancer overexpressing HER2 receptor , inhibits the cascade of reactions resulting in the proliferation of tumor cells, thus restoring cellular radiosensitivity. However, the combination of Trastuzumab with radiation therapy also removes HER2 receptor cardio-protective role on myocardial cells which increases the risk of cardiotoxicity. Thus, the concomitant association of these two modalities has long been a subject of controversy. Recent advances in radiation therapy technology and early detection of cardiac injury may limit the cardiotoxicity of this combination. Through this review, we developed the biological basis and the benefit-risk of concomitant combination of radiotherapy and Trastuzumab in adjuvant treatment of breast cancers overexpressing HER2 and we discuss the modalities of its optimization.
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Affiliation(s)
- Nejla Fourati
- Université de Sfax, CHU d'Habib-Bourguiba, faculté de médecine, service de radiothérapie carcinologique, Sfax, Tunisie.
| | - Rim Trigui
- Université de Sfax, CHU d'Habib-Bourguiba, faculté de médecine, service de radiothérapie carcinologique, Sfax, Tunisie
| | - Selma Charfeddine
- Université de Sfax, CHU d'Hedi-Chaker, faculté de médecine, service de cardiologie, Sfax, Tunisie
| | - Fatma Dhouib
- Université de Sfax, CHU d'Habib-Bourguiba, faculté de médecine, service de radiothérapie carcinologique, Sfax, Tunisie
| | - Wala Ben Kridis
- Université de Sfax, CHU d'Habib-Bourguiba, faculté de médecine, service d'oncologie médicale, Sfax, Tunisie
| | - Leila Abid
- Université de Sfax, CHU d'Hedi-Chaker, faculté de médecine, service de cardiologie, Sfax, Tunisie
| | - Afef Khanfir
- Université de Sfax, CHU d'Habib-Bourguiba, faculté de médecine, service d'oncologie médicale, Sfax, Tunisie
| | - Wafa Mnejja
- Université de Sfax, CHU d'Habib-Bourguiba, faculté de médecine, service de radiothérapie carcinologique, Sfax, Tunisie
| | - Jamel Daoud
- Université de Sfax, CHU d'Habib-Bourguiba, faculté de médecine, service de radiothérapie carcinologique, Sfax, Tunisie
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Andersen MM, Ayala-Peacock D, Bowers J, Kooken BW, D'Agostino RB, Jordan JH, Vasu S, Thomas A, Klepin HD, Brown DR, Hundley WG. Effect at One Year of Adjuvant Trastuzumab for HER2+ Breast Cancer Combined with Radiation or an Anthracycline on Left Ventricular Ejection Fraction. Am J Cardiol 2020; 125:1906-1912. [PMID: 32331711 DOI: 10.1016/j.amjcard.2020.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 11/30/2022]
Abstract
To determine the impact of radiation therapy (XRT) in addition to trastuzumab (TZB) adjuvant chemotherapy for HER2+ breast cancer on left ventricular systolic function, we assessed demographics, oncologic treatment history including XRT exposure, and serial measurements of left ventricular ejection fraction (LVEF) in 135 consecutively identified women receiving TZB for treatment of adjuvant breast cancer. Longitudinal mixed effects models were fit to identify baseline to treatment changes in LVEF among those receiving TZB with or without concomitant anthracycline or XRT. Women averaged 53 ± 3 years in age, 77% were white, 62% patients had 1 or more cardiovascular risk factors at baseline, and mean duration of TZB was 11 ± 5 months. Seventy-seven women were treated with XRT and received between 4000 and 5500 cGy of radiation. The LVEF declined by an average of 3.4% after 1 year for those in the study. Relative to baseline upon completion of adjuvant TZB, LVEF remained reduced for those receiving anthracycline with or without XRT (p=0.002 for both), or XRT alone (p=0.002), but not in those without these therapies. Amongst patients treated only with XRT and TZB, LVEF declined 3.1% on average in those with left-sided disease and 6.9% on average in those with right-sided disease (p= 0.06, p= 0.008 respectively). Among women receiving TZB for adjuvant treatment of HER-2 positive breast cancer, the administration of XRT, anthracycline, or the combination of the 2 is associated with a persistent post-treatment as opposed to a temporary treatment related decline in LVEF.
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Affiliation(s)
- Mousumi M Andersen
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest University Health Sciences, Winston-Salem, NC 27103
| | - Diandra Ayala-Peacock
- Department of Radiation Oncology, Vanderbilt Ingram Cancer Center, Nashville, TN 37232
| | - Jessie Bowers
- Penn State Heart and Vascular Institute, Penn State College of Medicine, Hershey, PA 17033
| | - Banks W Kooken
- Department of Internal Medicine, Radiation Oncology and Radiology, Wake Forest University Health Sciences, Winston-Salem, NC 27103
| | - Ralph B D'Agostino
- Department of Public Health Sciences, Wake Forest University Health Sciences, Winston-Salem, NC 27103
| | - Jennifer H Jordan
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest University Health Sciences, Winston-Salem, NC 27103; Department of Internal Medicine (Cardiology Division), Pauley Heart Center, VCU Health Sciences, Richmond, VA 23298
| | - Sujethra Vasu
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest University Health Sciences, Winston-Salem, NC 27103
| | - Alexandra Thomas
- Department of Internal Medicine, Section on Hematology and Oncology Section, Wake Forest University Health Sciences, Winston-Salem, NC 27103
| | - Heidi D Klepin
- Department of Internal Medicine, Section on Hematology and Oncology Section, Wake Forest University Health Sciences, Winston-Salem, NC 27103
| | - Doris R Brown
- Department of Internal Medicine, Radiation Oncology and Radiology, Wake Forest University Health Sciences, Winston-Salem, NC 27103
| | - W Gregory Hundley
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest University Health Sciences, Winston-Salem, NC 27103; Department of Internal Medicine (Cardiology Division), Pauley Heart Center, VCU Health Sciences, Richmond, VA 23298.
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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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Radiobiological models in prediction of radiation cardiotoxicity. Rep Pract Oncol Radiother 2019; 25:46-49. [PMID: 31889920 DOI: 10.1016/j.rpor.2019.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 12/04/2019] [Indexed: 12/16/2022] Open
Abstract
Coronary disease induced by previous radiotherapy is the most common cause of death among patients treated with radiotherapy for cancer. Risk factors that may affect the frequency and intensity of radiotherapy's cardiac toxicity are primarily the radiation dose and the volume of the heart exposed to radiation. The prolonged survival time of patients after radiotherapy, but also the intensive development of modern radiotherapy techniques results in the necessity of precise estimation of both tumor control probability, and the risk of normal tissue damage, thus the models describing the probability of complications in normal tissues have also been developed. The response from the cardiovascular system to high-dose radiation is known and associated with a pro-inflammatory response. However, the effect of low doses may be completely different because it induces an anti-inflammatory response. Also, there is no unambiguous answer to the question of whether RICD is a deterministic effect. Moreover, there is a lack of literature data on the use of known radiobiological models to assess the risk of cardiovascular complications. The models described are general and concerns any healthy tissue. Therefore, when planning treatment for patients, particular attention should be paid to the dose and area of the heart to be irradiated.
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Wright J, Blitzblau R. Cardiac Morbidity and Radiation Therapy for Breast Cancer. Int J Radiat Oncol Biol Phys 2019; 100:283-286. [PMID: 29353643 DOI: 10.1016/j.ijrobp.2017.06.2443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 06/19/2017] [Indexed: 12/17/2022]
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Evaluation of radiation-induced cardiac toxicity in breast cancer patients treated with Trastuzumab-based chemotherapy. Breast Cancer Res Treat 2018; 174:179-185. [DOI: 10.1007/s10549-018-5053-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 11/16/2018] [Indexed: 01/30/2023]
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12
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Wöckel A, Festl J, Stüber T, Brust K, Krockenberger M, Heuschmann PU, Jírů-Hillmann S, Albert US, Budach W, Follmann M, Janni W, Kopp I, Kreienberg R, Kühn T, Langer T, Nothacker M, Scharl A, Schreer I, Link H, Engel J, Fehm T, Weis J, Welt A, Steckelberg A, Feyer P, König K, Hahne A, Baumgartner T, Kreipe HH, Knoefel WT, Denkinger M, Brucker S, Lüftner D, Kubisch C, Gerlach C, Lebeau A, Siedentopf F, Petersen C, Bartsch HH, Schulz-Wendtland R, Hahn M, Hanf V, Müller-Schimpfle M, Henscher U, Roncarati R, Katalinic A, Heitmann C, Honegger C, Paradies K, Bjelic-Radisic V, Degenhardt F, Wenz F, Rick O, Hölzel D, Zaiss M, Kemper G, Budach V, Denkert C, Gerber B, Tesch H, Hirsmüller S, Sinn HP, Dunst J, Münstedt K, Bick U, Fallenberg E, Tholen R, Hung R, Baumann F, Beckmann MW, Blohmer J, Fasching P, Lux MP, Harbeck N, Hadji P, Hauner H, Heywang-Köbrunner S, Huober J, Hübner J, Jackisch C, Loibl S, Lück HJ, von Minckwitz G, Möbus V, Müller V, Nöthlings U, Schmidt M, Schmutzler R, Schneeweiss A, Schütz F, Stickeler E, Thomssen C, Untch M, Wesselmann S, Bücker A, Buck A, Stangl S. Interdisciplinary Screening, Diagnosis, Therapy and Follow-up of Breast Cancer. Guideline of the DGGG and the DKG (S3-Level, AWMF Registry Number 032/045OL, December 2017) - Part 2 with Recommendations for the Therapy of Primary, Recurrent and Advanced Breast Cancer. Geburtshilfe Frauenheilkd 2018; 78:1056-1088. [PMID: 30581198 PMCID: PMC6261741 DOI: 10.1055/a-0646-4630] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 06/20/2018] [Indexed: 12/29/2022] Open
Abstract
Purpose The aim of this official guideline coordinated and published by the German Society for Gynecology and Obstetrics (DGGG) and the German Cancer Society (DKG) was to optimize the screening, diagnosis, therapy and follow-up care of breast cancer. Method The process of updating the S3 guideline published in 2012 was based on the adaptation of identified source guidelines. They were combined with reviews of evidence compiled using PICO (Patients/Interventions/Control/Outcome) questions and with the results of a systematic search of literature databases followed by the selection and evaluation of the identified literature. The interdisciplinary working groups took the identified materials as their starting point and used them to develop suggestions for recommendations and statements, which were then modified and graded in a structured consensus process procedure. Recommendations Part 2 of this short version of the guideline presents recommendations for the therapy of primary, recurrent and metastatic breast cancer. Loco-regional therapies are de-escalated in the current guideline. In addition to reducing the safety margins for surgical procedures, the guideline also recommends reducing the radicality of axillary surgery. The choice and extent of systemic therapy depends on the respective tumor biology. New substances are becoming available, particularly to treat metastatic breast cancer.
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Affiliation(s)
- Achim Wöckel
- Universitätsfrauenklinik Würzburg, Universität Würzburg, Würzburg, Germany
| | - Jasmin Festl
- Universitätsfrauenklinik Würzburg, Universität Würzburg, Würzburg, Germany
| | - Tanja Stüber
- Universitätsfrauenklinik Würzburg, Universität Würzburg, Würzburg, Germany
| | - Katharina Brust
- Universitätsfrauenklinik Würzburg, Universität Würzburg, Würzburg, Germany
| | | | - Peter U. Heuschmann
- Institut für Klinische Epidemiologie und Biometrie (IKE-B), Universität Würzburg, Würzburg, Germany
| | - Steffi Jírů-Hillmann
- Institut für Klinische Epidemiologie und Biometrie (IKE-B), Universität Würzburg, Würzburg, Germany
| | | | - Wilfried Budach
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | | | | | - Ina Kopp
- AWMF-Institut für Medizinisches Wissensmanagement, Marburg, Germany
| | | | - Thorsten Kühn
- Frauenklinik, Klinikum Esslingen, Esslingen, Germany
| | - Thomas Langer
- Office des Leitlinienprogrammes Onkologie, Berlin, Germany
| | - Monika Nothacker
- AWMF-Institut für Medizinisches Wissensmanagement, Marburg, Germany
| | - Anton Scharl
- Frauenklinik, Klinikum St. Marien Amberg, Amberg, Germany
| | | | - Hartmut Link
- Praxis für Hämatologie und Onkologie, Kaiserslautern, Germany
| | - Jutta Engel
- Tumorregister München, Institut für medizinische Informationsverarbeitung, Biometrie und Epidemiologie, Ludwig-Maximilians-Universität München, München, Germany
| | - Tanja Fehm
- Universitätsfrauenklinik Düsseldorf, Düsseldorf, Germany
| | - Joachim Weis
- Stiftungsprofessur Selbsthilfeforschung, Tumorzentrum/CCC Freiburg, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Anja Welt
- Innere Klinik (Tumorforschung), Westdeutsches Tumorzentrum, Universitätsklinikum Essen, Essen, Germany
| | | | - Petra Feyer
- Klinik für Strahlentherapie und Radioonkologie, Vivantes Klinikum, Neukölln Berlin, Germany
| | - Klaus König
- Berufsverband der Frauenärzte, Steinbach, Germany
| | | | | | - Hans H. Kreipe
- Institut für Pathologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Wolfram Trudo Knoefel
- Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Michael Denkinger
- AGAPLESION Bethesda Klinik, Geriatrie der Universität Ulm, Ulm, Germany
| | - Sara Brucker
- Universitätsfrauenklinik Tübingen, Tübingen, Germany
| | - Diana Lüftner
- Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie, Campus Benjamin Franklin, Universitätsklinikum Charité, Berlin, Germany
| | - Christian Kubisch
- Institut für Humangenetik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Christina Gerlach
- III. Medizinische Klinik und Poliklinik, uct, Interdisziplinäre Abteilung für Palliativmedizin, Universitätsmedizin der Johannes Gutenberg Universität, Mainz, Germany
| | - Annette Lebeau
- Institut für Pathologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Cordula Petersen
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Markus Hahn
- Universitätsfrauenklinik Tübingen, Tübingen, Germany
| | - Volker Hanf
- Frauenklinik Nathanstift, Klinikum Fürth, Fürth, Germany
| | | | | | - Renza Roncarati
- Frauenselbsthilfe nach Krebs – Bundesverband e. V., Bonn, Germany
| | - Alexander Katalinic
- Institut für Sozialmedizin und Epidemiologie, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Christoph Heitmann
- Ästhetisch plastische und rekonstruktive Chirurgie, Camparihaus München, München, Germany
| | | | - Kerstin Paradies
- Konferenz Onkologischer Kranken- und Kinderkrankenpflege, Hamburg, Germany
| | - Vesna Bjelic-Radisic
- Universitätsfrauenklinik, Abteilung für Gynäkologie, Medizinische Universität Graz, Graz, Austria
| | - Friedrich Degenhardt
- Klinik für Frauenheilkunde und Geburtshilfe, Medizinische Hochschule Hannover, Hannover, Germany
| | - Frederik Wenz
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Mannheim, Mannheim, Germany
| | - Oliver Rick
- Klinik Reinhardshöhe Bad Wildungen, Bad Wildungen, Germany
| | - Dieter Hölzel
- Tumorregister München, Institut für medizinische Informationsverarbeitung, Biometrie und Epidemiologie, Ludwig-Maximilians-Universität München, München, Germany
| | - Matthias Zaiss
- Praxis für interdisziplinäre Onkologie & Hämatologie, Freiburg, Germany
| | | | - Volker Budach
- Klinik für Radioonkologie und Strahlentherapie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Carsten Denkert
- Institut für Pathologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Bernd Gerber
- Universitätsfrauenklinik am Klinikum Südstadt, Rostock, Germany
| | - Hans Tesch
- Centrum für Hämatologie und Onkologie Bethanien, Frankfurt, Germany
| | | | - Hans-Peter Sinn
- Pathologisches Institut, Universität Heidelberg, Heidelberg, Germany
| | - Jürgen Dunst
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Karsten Münstedt
- Frauenklinik Offenburg, Ortenau Klinikum Offenburg-Gengenbach, Offenburg, Germany
| | - Ulrich Bick
- Klinik für Radiologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Eva Fallenberg
- Klinik für Radiologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Reina Tholen
- Deutscher Verband für Physiotherapie, Referat Bildung und Wissenschaft, Köln, Germany
| | - Roswita Hung
- Frauenselbsthilfe nach Krebs, Wolfsburg, Germany
| | - Freerk Baumann
- Centrum für Integrierte Onkologie Köln, Uniklinik Köln, Köln, Germany
| | - Matthias W. Beckmann
- Frauenklinik, Universitätsklinikum Erlangen, CCC Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Jens Blohmer
- Klinik für Gynäkologie incl. Brustzentrum, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Fasching
- Frauenklinik, Universitätsklinikum Erlangen, CCC Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Michael P. Lux
- Frauenklinik, Universitätsklinikum Erlangen, CCC Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Nadia Harbeck
- Brustzentrum, Frauenklinik, Universität München (LMU), München, Germany
| | - Peyman Hadji
- Klinik für Gynäkologie und Geburtshilfe, Krankenhaus Nordwest, Frankfurt, Germany
| | - Hans Hauner
- Lehrstuhl für Ernährungsmedizin, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | | | | | - Jutta Hübner
- Klinik für Innere Medizin II, Universitätsklinikum Jena, Jena, Germany
| | - Christian Jackisch
- Klinik für Gynäkologie und Geburtshilfe, Sana Klinikum Offenbach, Offenbach, Germany
| | | | | | | | - Volker Möbus
- Klinik für Gynäkologie und Geburtshilfe, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Volkmar Müller
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ute Nöthlings
- Institut für Ernährungs- und Lebensmittelwissenschaften, Rheinische Friedrich-Wilhelms Universität Bonn, Bonn, Germany
| | - Marcus Schmidt
- Klinik und Poliklinik für Geburtshilfe und Frauengesundheit, Universitätsmedizin der Johannes Gutenberg-Universität Mai, Germany nz, Mainz
| | - Rita Schmutzler
- Zentrum Familiärer Brust- und Eierstockkrebs, Universitätsklinikum Köln, Köln, Germany
| | - Andreas Schneeweiss
- Nationales Centrum für Tumorerkrankungen, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Florian Schütz
- Nationales Centrum für Tumorerkrankungen, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Elmar Stickeler
- Klinik für Gynäkologie und Geburtsmedizin, Uniklinik RWTH Aachen, Aachen, Germany
| | | | - Michael Untch
- Klinik für Geburtshilfe und Gynäkologie, Helios Klinikum Berlin-Buch, Berlin, Germany
| | | | - Arno Bücker
- Klinik für Diagnostische und Interventionelle Radiologie am UKS, Universität des Saarlandes, Homburg, Germany
| | - Andreas Buck
- Nuklearmedizinische Klinik und Poliklinik des Universitätsklinikums Würzburg, Würzburg, Germany
| | - Stephanie Stangl
- Institut für Klinische Epidemiologie und Biometrie (IKE-B), Universität Würzburg, Würzburg, Germany
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13
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Mignot F, Ajgal Z, Xu H, Geraud A, Chen JY, Mégnin-Chanet F, Kirova Y. Concurrent administration of anti-HER2 therapy and radiotherapy: Systematic review. Radiother Oncol 2017; 124:190-199. [DOI: 10.1016/j.radonc.2017.07.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 06/22/2017] [Accepted: 07/04/2017] [Indexed: 12/18/2022]
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14
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Bian SX, Korah MP, Whitaker TR, Ji L, Groshen S, Chung E. No Acute Changes in LVEF Observed With Concurrent Trastuzumab and Breast Radiation With Low Heart Doses. Clin Breast Cancer 2017; 17:510-515. [PMID: 28412326 DOI: 10.1016/j.clbc.2017.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 02/28/2017] [Accepted: 03/15/2017] [Indexed: 12/24/2022]
Abstract
INTRODUCTION/BACKGROUND Treatment for HER2-postitive breast cancer often includes trastuzumab, breast/chest wall (CW) radiation (RT), and anthracyclines, all of which have cardiac toxicity. We aimed to evaluate the relationship between heart dose and acute left ventricular ejection fraction (LVEF) changes in patients who received concurrent trastuzumab and breast/CW RT with and without anthracycline use. PATIENTS AND METHODS We retrospectively reviewed all nonmetastatic breast cancer patients from 2008 to 2015 who received concurrent trastuzumab and breast/CW RT. Baseline LVEF was compared with the LVEF closest to treatment completion as well as with the lowest post-treatment LVEF. LVEF changes were correlated with laterality, heart dosimetric parameters, and doxorubicin use. RESULTS Eighty-eight patients were included in our analysis. The median follow-up was 45 months. Forty-one patients were right-sided and 47 left-sided. Thirty-one patients received doxorubicin, 16 right-sided and 15 left-sided. Mean heart dose was 1.10 Gy and 3.63 Gy for right- and left-sided patients, respectively (P < .001). In the entire cohort, a significant LVEF decrease of 3.0% was observed pre- and post-treatment. There was a significant effect of doxorubicin (P = .013) and a nonsignificant effect of RT laterality (P = .088) on LVEF change. The test of interaction between doxorubicin and laterality was not significant (P = .90). No significant association was found between LVEF change and heart dosimetric parameters, including percent volume of heart receiving 5 Gy (V5), 10 Gy (V10), 20 Gy (V20), and 45 Gy (V45), and maximum dose. Similar results were found when baseline LVEF was compared with the lowest post-treatment LVEF. CONCLUSION With cardiac doses < 4 Gy, declines in LVEF were not related to tumor laterality or heart dosimetric parameters. Statistically significant LVEF decreases were mainly attributed to doxorubicin.
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Affiliation(s)
- Shelly X Bian
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA.
| | - Mariam P Korah
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Taylor R Whitaker
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Lingyun Ji
- Department of Biostatistics, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Susan Groshen
- Department of Biostatistics, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - Eugene Chung
- Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, CA
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15
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Kirova YM, Fourquet A. Concurrent Use of Radiation Therapy and Targeted Molecules in the Breast Cancer Treatment. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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16
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Yavas G, Gultekin M, Yildiz O, Seyrek M, Demirkol S, Toy H, Sargon MF, Ozkayar O, Uner A, Yildiz F, Akyol F. Assessment of concomitant versus sequential trastuzumab on radiation-induced cardiovascular toxicity. Hum Exp Toxicol 2016; 36:1121-1130. [PMID: 27932539 DOI: 10.1177/0960327116680276] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
There are limited data regarding effect of trastuzumab on radiation-induced cardiovascular toxicity when used sequentially or concomitantly. This experimental study aims to investigate effect of trastuzumab on radiation-induced cardiovascular toxicity with respect to the treatment sequence. One hundred and eight female Wistar albino rats were divided into six groups (G): G1 was control, G2 was trastuzumab, and G3 was radiotherapy (RT); G4 and G6 were sequential RT and trastuzumab; and G5 was concomitant RT and trastuzumab groups, respectively. Rats were killed at 6th h, 21st and 70th days after RT; thoracic aorta and heart samples were obtained. Transthoracic echocardiography and functional studies evaluating relaxation of thoracic aorta were performed. Subendothelial edema scores of thoracic aorta samples at 21st and 70th days were higher in RT groups (G3, G4, G5, and G6) ( p < 0.001). There was a deterioration of relaxation responses of thoracic aorta samples in RT groups ( p < 0.001). Cardiac fibrosis (CF) scores revealed detrimental effect of RT beginning from 6th h and trastuzumab from 21st day. RT groups showed further deterioration of CF at 70th day. Ejection fraction, left ventricular mass, and fractional shortening were significantly decreased in G4, G5, and G6. Trastuzumab may increase pathological damage in cardiovascular structures when used with RT regardless of timing.
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Affiliation(s)
- G Yavas
- 1 Department of Radiation Oncology, Selcuk University, Konya, Turkey
| | - M Gultekin
- 2 Department of Radiation Oncology, Hacettepe University, Ankara, Turkey
| | - O Yildiz
- 3 Department of Pharmacology, Gulhane Military Medical Academy, Ankara, Turkey
| | - M Seyrek
- 3 Department of Pharmacology, Gulhane Military Medical Academy, Ankara, Turkey
| | - S Demirkol
- 4 Department of Cardiology, Gulhane Military Medical Academy, Ankara, Turkey
| | - H Toy
- 5 Department of Pathology, Necmettin Erbakan University, Konya, Turkey
| | - M F Sargon
- 6 Department of Anatomy, Hacettepe University, Ankara, Turkey
| | - O Ozkayar
- 7 Department of Pathology, Hacettepe University, Ankara, Turkey
| | - A Uner
- 7 Department of Pathology, Hacettepe University, Ankara, Turkey
| | - F Yildiz
- 2 Department of Radiation Oncology, Hacettepe University, Ankara, Turkey
| | - F Akyol
- 2 Department of Radiation Oncology, Hacettepe University, Ankara, Turkey
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17
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Cao L, Cai G, Chang C, Yang ZZ, Feng Y, Yu XL, Ma JL, Wu J, Guo XM, Chen JY. Early cardiac toxicity following adjuvant radiotherapy of left-sided breast cancer with or without concurrent trastuzumab. Oncotarget 2016; 7:1042-54. [PMID: 26460956 PMCID: PMC4808050 DOI: 10.18632/oncotarget.6053] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 09/23/2015] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To evaluate the influence of concurrent trastuzumab on the cardiotoxicity in patients receiving left-sided adjuvant radiotherapy. MATERIALS AND METHODS Medical records of stage I-III left-sided breast cancer patients, including 64 receiving concurrent trastuzumab with radiotherapy and 73 receiving radiotherapy alone were retrospectively reviewed. All of the patients had normal LVEF after adjuvant chemotherapy. Information of doses volume to cardiac structures was collected. Cardiac events were assessed according to CTC 2.0. RESULTS Median follow-up of LVEF and clinical assessment of cardiac function from the initiation of radiotherapy was 6.7 months (range 3-60.9) and 26 months (range 6.4-60.9), respectively. Grade 1 LVEF dysfunction occurred in 5 (7.8%) and 3 (4.1%) patients of the concurrent-trastuzumab and radiotherapy alone cohort, respectively. Trastuzumab was the only significant factor influencing absolute LVEF decrease in univariate analysis. In multivariate analysis of concurrent-trastuzumab cohort, IMC radiotherapy and start trastuzumab during radiotherapy were independent risk factors. For concurrent cohort, mean heart dose, as well as D10-D30, D50-D55, V5-V20 of the heart and D30-D45, D65-D75, V6-V15 of the LV were significantly higher in patients developing LVEF dysfunction. CONCLUSIONS Concurrent trastuzumab and left-sided radiotherapy is well tolerated in terms of cardiotoxicity in patients with normal baseline cardiac function after adjuvant chemotherapy. However, increases in mean dose and low-dose volume of cardiac structures are associated with a higher risk of acute LVEF dysfunction.
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Affiliation(s)
- Lu Cao
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Gang Cai
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Cai Chang
- Department of Ultrasound, Fudan University Shanghai Cancer Center, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhao-Zhi Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Yan Feng
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Xiao-Li Yu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Jin-Li Ma
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Jiong Wu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Xiao-Mao Guo
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
| | - Jia-Yi Chen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Shanghai Medical College, Fudan University, Shanghai, China
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18
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Nitsche M, Pahl R, Huber K, Eilf K, Dunst J. Cardiac Toxicity after Radiotherapy for Breast Cancer: Myths and Facts. Breast Care (Basel) 2015. [PMID: 26195942 DOI: 10.1159/000376560] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Radiotherapy is an important component in the multidisciplinary treatment of breast cancer. In recent years, the cardiac risks of radiation have been discussed several times. This problem has long been known and resolved from the radiotherapeutic point of view. The current data is briefly described here.
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Affiliation(s)
- Mirko Nitsche
- Zentrum für Strahlentherapie und Radioonkologie, Bremen/Westerstede, Germany ; Klinik für Strahlentherapie, Karl-Lennert-Krebscentrum, Universität Kiel, Germany
| | - René Pahl
- Klinik für Strahlentherapie, Karl-Lennert-Krebscentrum, Universität Kiel, Germany
| | - Karen Huber
- Klinik für Strahlentherapie, Karl-Lennert-Krebscentrum, Universität Kiel, Germany
| | - Kirsten Eilf
- Klinik für Strahlentherapie, Karl-Lennert-Krebscentrum, Universität Kiel, Germany
| | - Juergen Dunst
- Klinik für Strahlentherapie, Karl-Lennert-Krebscentrum, Universität Kiel, Germany
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19
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Cao L, Cai G, Chang C, Miao AY, Yu XL, Yang ZZ, Ma JL, Zhang Q, Wu J, Guo XM, Chen JY. Diastolic Dysfunction Occurs Early in HER2-Positive Breast Cancer Patients Treated Concurrently With Radiation Therapy and Trastuzumab. Oncologist 2015; 20:605-14. [PMID: 25933931 DOI: 10.1634/theoncologist.2014-0299] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 01/15/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Left ventricular ejection fraction (LVEF) is used routinely to monitor cardiac dysfunction associated with breast cancer treatment. In this study the prevalence of early left ventricular diastolic dysfunction (LVDD) and its relationship to the dose-volume of the heart irradiated were evaluated in HER2-positive breast cancer patients undergoing concurrent trastuzumab and adjuvant radiotherapy (RT). MATERIALS AND METHODS Data from 40 breast cancer patients treated with concurrent trastuzumab and left-sided adjuvant RT between September 2011 and October 2012 were collected prospectively. For comparison, 32 patients treated with concurrent trastuzumab and right-sided adjuvant RT and 71 patients treated with left-sided RT alone were collected retrospectively. Echocardiography was obtained before RT, immediately following RT, and 3 and 6 months after RT. Doses to the heart and left ventricle (LV) were quantified. RESULTS Prior to RT with concurrent trastuzumab, 11 of 29 (left) and 8 of 25 (right) patients with normal baseline left ventricular diastolic function (LVDF) developed LVDD. In patients receiving left-sided RT alone, 12 of 61 patients with normal baseline LVDF developed LVDD. Dmean, D15-D40, D60-D70, and V3-V10 of the LV were significantly higher in patients who developed LVDD after concurrent trastuzumab and left-sided RT. In contrast, only two patients developed grade 1 LVEF decrease after both concurrent treatment and left-sided RT alone. CONCLUSION Changes in LVDF compared with LVEF are more sensitive for early detection of cardiotoxicity. The dose-volume of the heart contributes significantly to the risk of LVDD in patients with left-sided breast cancer treated concurrently with trastuzumab. IMPLICATIONS FOR PRACTICE Abnormalities in diastolic function are more sensitive than changes in the left ventricular ejection fraction for detecting acute cardiotoxicity and are related to the dose-volume of the heart irradiated in patients with left-sided breast cancer receiving radiotherapy concurrently with trastuzumab. This result highlights the importance of decreasing the dose-volume of heart irradiated as a protective strategy in the treatment setting of concurrent trastuzumab and radiotherapy. Diastolic dysfunction may serve as a more sensitive tool for the early detection of cardiac damage and should be incorporated as a routine parameter in the functional monitoring of cardiotoxicity.
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Affiliation(s)
- Lu Cao
- Departments of Radiation Oncology, Ultrasound, and Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China; Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Gang Cai
- Departments of Radiation Oncology, Ultrasound, and Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China; Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Cai Chang
- Departments of Radiation Oncology, Ultrasound, and Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China; Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Ai-Yu Miao
- Departments of Radiation Oncology, Ultrasound, and Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China; Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Xiao-Li Yu
- Departments of Radiation Oncology, Ultrasound, and Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China; Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Zhao-Zhi Yang
- Departments of Radiation Oncology, Ultrasound, and Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China; Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Jin-Li Ma
- Departments of Radiation Oncology, Ultrasound, and Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China; Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Qian Zhang
- Departments of Radiation Oncology, Ultrasound, and Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China; Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Jiong Wu
- Departments of Radiation Oncology, Ultrasound, and Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China; Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Xiao-Mao Guo
- Departments of Radiation Oncology, Ultrasound, and Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China; Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Jia-Yi Chen
- Departments of Radiation Oncology, Ultrasound, and Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China; Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China; Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
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20
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Ulas A, Kos T, Avci N, Cubukcu E, Olmez OF, Bulut N, Degirmenci M. Patients with HER2-positive early breast cancer receiving adjuvant trastuzumab: clinicopathological features, efficacy, and factors affecting survival. Asian Pac J Cancer Prev 2015; 16:1643-9. [PMID: 25743846 DOI: 10.7314/apjcp.2015.16.4.1643] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of the present study was to evaluate clinicopathological characteristics of our early stage breast cancer patients who are epidermal growth factor receptor 2 (HER2) overexpressed/ amplified (HER2+), the efficacy of trastuzumab treatment and survival results. MATERIALS AND METHODS Patients with HER2- positive early stage breast cancer receiving adjuvant trastuzumab were investigated retrospectively. Clinicopathological features of 210 patients and treatment outcome were analysed. To evaluate survival rates, the Kaplan-Meier method was used. Univariate and multivariate analyses were conducted with the Cox regression model. RESULTS Mean age of the patients was 51.8, 71.9% being postmenopausal. Some 37.6% of patients were node negative, and 31% had T1 tumor size and 52.4% were positive for estrogen receptor. Of 210 patients, 89.5% completed planned 52 weeks adjuvant trastuzumab treatment. The median follow up was 27.5 months (6.0-86.0 ). Relapse free survival (RFS) was 68.0 months (95% CI: 62.1-74.0) and overall survival (OS) was 74.8 months (95% CI: 69.5-80.1). The 3 year OS for all patients was 92.0% and RFS was 79.6%. During follow up, relapse was detected at the rate of 14.3%. Trastuzumab associated cardiotoxicity was found at the rate of 3.3%. In univariate analyses, larger tumor size and grade III were significantly associated (p<0.05) with RFS. Multivariate analyses of covariates displaying p<0.05 identified grade III as an independent prognostic factor. CONCLUSIONS In the present study, it was established that trastuzumab had a satisfactory safety profile and treatment efficacy as in other clinical studies and that among clinicopathological factors evaluated, only being grade 3 had a significant effect on RFS. The occurrence of relapse with adjuvant trastuzumab makes it necessary to identify molecular predictors, which will define this group better and help explain resistance to anti HER2 based therapies.
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Affiliation(s)
- Arife Ulas
- Department of Medical Oncology, Ankara Ataturk Training and Research Hospital, Ankara, Turkey E-mail :
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Concurrent administration of trastuzumab with locoregional breast radiotherapy: long-term results of a prospective study. Breast Cancer Res Treat 2014; 148:345-53. [DOI: 10.1007/s10549-014-3166-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 08/18/2014] [Indexed: 10/24/2022]
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22
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[Towards an integrated approach to cardiovascular toxicities related to the treatments of breast cancer]. Bull Cancer 2014; 101:730-40. [PMID: 25091656 DOI: 10.1684/bdc.2014.1926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There is an increasing number of therapeutic options in breast cancer management. While prognosis improves, the cardiac toxicity related to treatments remains a significant issue. This toxicity has several clinical presentations and can be explained by complex and diverse molecular mechanisms. Systemic treatments (anthracyclines, inhibitors of HER2 signaling pathway, hormone therapy, antiangiogenic agents) and radiotherapy have their own cardiac toxicity. However, the toxicities associated with these treatments may potentiate together and the existence of pre-existing cardiovascular risk factors should be taken into account. The assessment of cardiac hazard evolves toward a multifactorial approach. Several possibilities exist to minimize the incidence of cardiac complications. Those include pharmacological and technological innovations, but also a more accurate selection of patients and a growing involvement of practitioners in the field of cardiac toxicity, which is prerequisite for an early management of cardiac events.
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Cardiotoxicity of concomitant radiotherapy and trastuzumab for early breast cancer. Radiol Oncol 2014; 48:105-12. [PMID: 24991199 PMCID: PMC4078028 DOI: 10.2478/raon-2013-0040] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 04/12/2013] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Trastuzumab therapy given in combination with one of several chemotherapy regimens is currently considered the standard of care for the treatment of early-stage, human epidermal growth factor receptor-2 (HER2) -positive breast cancer. The treatment with trastuzumab is due to a significant impact on the survival part of the standard adjuvant treatment of patients with HER2-positive breast cancer. Patients treated with postoperative breast or chest wall irradiation receive trastuzumab concomitant with radiotherapy. In a small proportion of patients trastuzumab causes cardiotoxicity. Preclinical findings indicate a radiosensibilizing effect of trastuzumab in breast cancer cells, but it is not yet clear whether it radiosensibilizes cells of healthy tissues too. CONCLUSIONS Special attention is required when left breast or left thoracic wall is irradiated in patient receiving trastuzumab, because long-term effects of the concurrent treatment with trastuzumab and radiotherapy are not yet known. In an era where more patients are surviving a diagnosis of breast cancer, better understanding and earlier detection of therapy-induced cardiac toxicity will be of paramount importance.
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Abstract
The overexpression of the Human Epidermal Growth Factor Receptor 2 (HER2) is observed in 15% of breast cancers and associated with poor prognosis in terms of overall survival. Trastuzumab is an anti-HER2 targeted therapy, leading to a specific inhibition of the molecular mechanisms triggered by this receptor. In an adjuvant setting, trastuzumab and radiotherapy have each proved their oncologic efficacy in the management of the breast tumours presenting this molecular profile. However, both treatments expose to an increased risk of toxicities, particularly cardiovascular ones. Moreover, the radiosensitizing effect of trastuzumab has been proved in vitro and in vivo. Hence, in clinical practice, the benefit/risk ratio of a concurrent treatment remains to be defined. This literature review has for purposes to describe the rationale making conceivable the administration of trastuzumab concurrently with locoregional breast radiotherapy, and to remind the results of the clinical studies having assessed this therapeutic association.
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Cutaneous and cardiac toxicity of concurrent trastuzumab and adjuvant breast radiotherapy: a single institution series. Med Oncol 2014; 31:891. [DOI: 10.1007/s12032-014-0891-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 02/11/2014] [Indexed: 12/15/2022]
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Nalbantov G, Kietselaer B, Vandecasteele K, Oberije C, Berbee M, Troost E, Dingemans AM, van Baardwijk A, Smits K, Dekker A, Bussink J, De Ruysscher D, Lievens Y, Lambin P. Cardiac comorbidity is an independent risk factor for radiation-induced lung toxicity in lung cancer patients. Radiother Oncol 2013; 109:100-6. [PMID: 24044794 DOI: 10.1016/j.radonc.2013.08.035] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 08/21/2013] [Accepted: 08/25/2013] [Indexed: 12/25/2022]
Abstract
PURPOSE To test the hypothesis that cardiac comorbidity before the start of radiotherapy (RT) is associated with an increased risk of radiation-induced lung toxicity (RILT) in lung cancer patients. MATERIAL AND METHODS A retrospective analysis was performed of a prospective cohort of 259 patients with locoregional lung cancer treated with definitive radio(chemo)therapy between 2007 and 2011 (ClinicalTrials.gov Identifiers: NCT00572325 and NCT00573040). We defined RILT as dyspnea CTCv.3.0 grade ≥2 within 6 months after RT, and cardiac comorbidity as a recorded treatment of a cardiac pathology at a cardiology department. Univariate and multivariate analyses, as well as external validation, were performed. The model-performance measure was the area under the receiver operating characteristic curve (AUC). RESULTS Prior to RT, 75/259 (28.9%) patients had cardiac comorbidity, 44% of whom (33/75) developed RILT. The odds ratio of developing RILT for patients with cardiac comorbidity was 2.58 (p<0.01). The cross-validated AUC of a model with cardiac comorbidity, tumor location, forced expiratory volume in 1s, sequential chemotherapy and pretreatment dyspnea score was 0.72 (p<0.001) on the training set, and 0.67 (p<0.001) on the validation set. CONCLUSION Cardiac comorbidity is an important risk factor for developing RILT after definite radio(chemo)therapy of lung cancer patients.
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Affiliation(s)
- Georgi Nalbantov
- Department of Radiation Oncology (Maastro Clinic), GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands.
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Jacob J, Belin L, Gobillion A, Daveau-Bergerault C, Dendale R, Beuzeboc P, Campana F, Bollet MA, Fourquet A, Kirova Y. Étude prospective monocentrique de la toxicité et de l’efficacité du trastuzumab concomitant à la radiothérapie. Cancer Radiother 2013; 17:183-90. [DOI: 10.1016/j.canrad.2012.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2012] [Revised: 12/14/2012] [Accepted: 12/26/2012] [Indexed: 10/27/2022]
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Kreienberg R, Albert US, Follmann M, Kopp IB, Kühn T, Wöckel A. Interdisciplinary GoR level III Guidelines for the Diagnosis, Therapy and Follow-up Care of Breast Cancer: Short version - AWMF Registry No.: 032-045OL AWMF-Register-Nummer: 032-045OL - Kurzversion 3.0, Juli 2012. Geburtshilfe Frauenheilkd 2013; 73:556-583. [PMID: 24771925 PMCID: PMC3963234 DOI: 10.1055/s-0032-1328689] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
| | - U.-S. Albert
- Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Klinik
für Gynäkologie, Gynäkologische Endokrinologie und Onkologie,
Marburg
| | - M. Follmann
- Deutsche Krebsgesellschaft e. V., Bereich Leitlinien,
Berlin
| | - I. B. Kopp
- AWMF-Institut für Medizinisches Wissensmanagement, c/o
Philipps-Universität, Marburg
| | - T. Kühn
- Klinikum Esslingen, Klinik für Frauenheilkunde und Geburtshilfe,
Esslingen
| | - A. Wöckel
- Universitätsklinikum Ulm, Klinik für Frauenheilkunde und Geburtshilfe,
Ulm
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Fourquet A, Kirova Y. Radiation therapy after breast-conserving surgery. BREAST CANCER MANAGEMENT 2012. [DOI: 10.2217/bmt.12.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Whole-breast irradiation in combination with breast-conserving surgery is a recognized standard alternative to mastectomy for the local treatment of early breast cancer. This article will review the evidence on the relationship of local control in the treated breast and survival, the indications of a boost dose to the tumor bed and the need for breast irradiation in ductal carcinoma in situ. Novel, shorter fractionation schemes allow the constraints of daily treatment courses over several weeks to be reduced, and recent technical improvements in treatment delivery will improve the results of treatment – in terms of local control and reduction of toxicity, and long-term sequelae. Research should focus on identifying molecular markers of radiation sensitivity and designing specific, targeted modulators of the radiation response in breast cancer.
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Affiliation(s)
- Alain Fourquet
- Departement de Radiotherapie, Institut Curie, 26 rue d’Ulm, Paris, France
| | - Youlia Kirova
- Departement de Radiotherapie, Institut Curie, 26 rue d’Ulm, Paris, France
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Tarantini L, Cioffi G, Gori S, Tuccia F, Boccardi L, Bovelli D, Lestuzzi C, Maurea N, Oliva S, Russo G, Faggiano P. Trastuzumab Adjuvant Chemotherapy and Cardiotoxicity in Real-World Women With Breast Cancer. J Card Fail 2012; 18:113-9. [DOI: 10.1016/j.cardfail.2011.10.015] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 10/14/2011] [Accepted: 10/19/2011] [Indexed: 01/11/2023]
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Niyazi M, Maihoefer C, Krause M, Rödel C, Budach W, Belka C. Radiotherapy and "new" drugs-new side effects? Radiat Oncol 2011; 6:177. [PMID: 22188921 PMCID: PMC3266653 DOI: 10.1186/1748-717x-6-177] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 12/21/2011] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Targeted drugs have augmented the cancer treatment armamentarium. Based on the molecular specificity, it was initially believed that these drugs had significantly less side effects. However, currently it is accepted that all of these agents have their specific side effects. Based on the given multimodal approach, special emphasis has to be placed on putative interactions of conventional cytostatic drugs, targeted agents and other modalities. The interaction of targeted drugs with radiation harbours special risks, since the awareness for interactions and even synergistic toxicities is lacking. At present, only limited is data available regarding combinations of targeted drugs and radiotherapy. This review gives an overview on the current knowledge on such combined treatments. MATERIALS AND METHODS Using the following MESH headings and combinations of these terms pubmed database was searched: Radiotherapy AND cetuximab/trastuzumab/panitumumab/nimotuzumab, bevacizumab, sunitinib/sorafenib/lapatinib/gefitinib/erlotinib/sirolimus, thalidomide/lenalidomide as well as erythropoietin. For citation crosscheck the ISI web of science database was used employing the same search terms. RESULTS Several classes of targeted substances may be distinguished: Small molecules including kinase inhibitors and specific inhibitors, antibodies, and anti-angiogenic agents. Combination of these agents with radiotherapy may lead to specific toxicities or negatively influence the efficacy of RT. Though there is only little information on the interaction of molecular targeted radiation and radiotherapy in clinical settings, several critical incidents are reported. CONCLUSIONS The addition of molecular targeted drugs to conventional radiotherapy outside of approved regimens or clinical trials warrants a careful consideration especially when used in conjunction in hypo-fractionated regimens. Clinical trials are urgently needed in order to address the open question in regard to efficacy, early and late toxicity.
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Affiliation(s)
- Maximilian Niyazi
- Department of Radiation Oncology, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 München, Germany
| | - Cornelius Maihoefer
- Department of Radiation Oncology, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 München, Germany
| | - Mechthild Krause
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Claus Rödel
- Klinik für Strahlentherapie und Onkologie, Johann Wolfgang Goethe Universität Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Wilfried Budach
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Heinrich Heine Universität Düsseldorf, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Claus Belka
- Department of Radiation Oncology, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377 München, Germany
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Toxicité cardiaque de la radiothérapie. Cancer Radiother 2011; 15:495-503. [DOI: 10.1016/j.canrad.2011.06.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Accepted: 06/16/2011] [Indexed: 11/20/2022]
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Yavas G, Yildiz F, Guler S, Sargon M, Yildiz D, Yolcu T, Tuncer M, Akyol F. Concomitant trastuzumab with thoracic radiotherapy: a morphological and functional study. Ann Oncol 2011; 22:1120-1126. [DOI: 10.1093/annonc/mdq590] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Palmieri C, Shah D, Krell J, Gojis O, Hogben K, Riddle P, Ahmad R, Tat T, Fox K, Porter A, Mahmoud S, Kirschke S, Shousha S, Gudi M, Coombes RC, Leonard R, Cleator S. Management and outcome of HER2-positive early breast cancer treated with or without trastuzumab in the adjuvant trastuzumab era. Clin Breast Cancer 2011; 11:93-102. [PMID: 21569995 DOI: 10.1016/j.clbc.2011.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2010] [Revised: 09/21/2010] [Accepted: 09/24/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND Adjuvant trastuzumab (AT) is known to significantly improve survival of women with HER2(+) early breast cancer. This study explores the use and nonuse of AT in early breast cancer, as well as the efficacy in a neoadjuvant and adjuvant population, within a routine clinical setting. PATIENTS AND METHODS Histopathology reports of invasive breast cancer resected at Imperial College Healthcare NHS Trust (ICHT) between January 2006 and December 2008 were reviewed. HER2(+) patients were identified and their case notes reviewed. In addition, patients who received AT at our center but underwent surgery elsewhere were included in the efficacy and safety analyses. RESULTS The local HER2(+) rate was 13.1%, with 54.5% of these patients receiving AT. A total of 128 patients received AT (85 local and 43 referrals from elsewhere). Neoadjuvant chemotherapy (CT) followed by postoperative AT was associated with a significantly increased risk of recurrence compared with adjuvant CT and then AT (hazard ratio [HR] 18.6 [95% CI, 1.8-152.2]; P = .013). The proportion of patients who were disease free at 3 years from primary therapy was 96.4% (95% CI, 89.8%-100%) for adjuvant therapy, compared with 72.0% (95% CI, 56.5%-91.6%) for neoadjuvant therapy. AT was omitted in 49 HER2(+) patients; the main reason for AT omission was clinical judgment that the breast cancer was low risk. Patients treated with AT had a significantly decreased risk of recurrence (HR 0.27 [95% CI, 0.08-0.97]; P = .04) compared with the untreated patients. The majority of untreated relapses were in patients in whom there was an original intent to use AT. The proportion alive at 3 years for adjuvant CT, neoadjuvant CT, and untreated AT was 100%, 74.5%, and 92.7% respectively. CONCLUSION The overall efficacy and safety of AT in our routine clinical setting is comparable to the large randomized trials. HER2(+) patients who underwent neoadjuvant CT had a significantly increased risk of disease recurrence compared with patients treated with adjuvant CT followed by trastuzumab. Untreated patients had an increased risk of recurrence.
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Affiliation(s)
- Carlo Palmieri
- Cancer Research UK Laboratories, Division of Cancer, Imperial College London, UK.
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Valli MC. Controversies in loco-regional treatment: post-mastectomy radiation for pT2-pT3N0 breast cancer arguments in favour. Crit Rev Oncol Hematol 2010; 84 Suppl 1:e70-4. [PMID: 21134765 DOI: 10.1016/j.critrevonc.2010.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Revised: 10/21/2010] [Accepted: 11/03/2010] [Indexed: 11/16/2022] Open
Abstract
Post-mastectomy RT decreases the rate of locoregional recurrences of about 70% in all patients irrespective of age, tumor characteristics or systemic therapy. Post-mastectomy RT has to be proposed, moreover when locoregional lymph nodes are part of the PTV, if an optimal coverage of the PTV and a satisfactory sparing of the OAR could be obtained. Due to the results of meta-analysis, consensus conferences and randomized trials the long-term efficacy of RT in decreasing the risk of LRF is well established and the vast majority of women, treated with mastectomy, will benefit from it.
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Affiliation(s)
- Maria Carla Valli
- Radiation Oncology Department, Oncology Institute of Southern Switzerland, Switzerland.
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Belkacémi Y, Gligorov J, Chauvet MP, Tsoutsou PG, Boussen H, Bourgier C. [Radiotherapy and combined therapy in breast cancer: standards and innovations in the adjuvant setting]. J Gynecol Obstet Hum Reprod 2010; 39:F63-F69. [PMID: 21067872 DOI: 10.1016/j.jgyn.2010.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Due to the significant advances in the diagnosis and treatment of breast cancer seen in the last decades, increased survival rates and better outcomes of patients are being observed. The role of radiotherapy remains pivotal in the treatment of early breast cancer. In the adjuvant setting, whole breast irradiation remains the standard of care using a relatively well standardized radiation technique. The recent technology advances and 3D conformal radiotherapy allow for better volumes definition resulting to increased organ at risk--sparing and therefore treatment optimization. Sophisticated techniques and emerging options (such as accelerated partial breast irradiation) are not routinely used yet outside of a clinical trial. Moreover, new drugs and targeted therapies have recently been introduced to the clinical practice for treatment individualization according to the specific tumours' prognosis and/or prediction of the drugs' efficacy based on new biological tools. Regarding the synergistic effect of these molecules with ionizing radiation, rigorous prospective evaluation of combined therapy is important to ensure improved long-term benefit/risk ratio. In this review, the significant advances of radiotherapy and combined therapy in the new era of breast cancer management will be discussed.
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Affiliation(s)
- Y Belkacémi
- Service d'oncologie-radiothérapie, CHU Henri-Mondor, AP-HP et faculté de médecine-université de Paris XII, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France.
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Tomorrow's targeted therapies in breast cancer patients: What is the risk for increased radiation-induced cardiac toxicity? Crit Rev Oncol Hematol 2010; 76:186-95. [DOI: 10.1016/j.critrevonc.2010.01.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2009] [Revised: 01/01/2010] [Accepted: 01/15/2010] [Indexed: 12/21/2022] Open
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Tsoutsou PG, Belkacemi Y, Gligorov J, Kuten A, Boussen H, Bese N, Koukourakis MI. Optimal sequence of implied modalities in the adjuvant setting of breast cancer treatment: an update on issues to consider. Oncologist 2010; 15:1169-78. [PMID: 21041378 DOI: 10.1634/theoncologist.2010-0187] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The adjuvant setting of early breast cancer treatment is an evolving field where different modalities must be combined to improve outcomes; moreover, quality of life of breast cancer survivors emerges as a new important parameter to consider, thus implying a better understanding of toxicities of these modalities. We have conducted a review focusing on the latest literature of the past 3 years, trying to evaluate the existing data on the maximum acceptable delay of radiotherapy when given as sole adjuvant treatment after surgery and the optimal sequence of all these modalities with respect to each other. It becomes evident radiotherapy should be given as soon as possible and within a time frame of 6-20 weeks. Chemotherapy is given before radiotherapy and hormone therapy. However, radiotherapy should be started within 7 months after surgery in these cases. Hormone therapy with tamoxifen might be given safely concomitantly or sequentially with radiotherapy although solid data are still lacking. The concurrent administration of letrozole and radiotherapy seems to be safe, whereas data on trastuzumab can imply only that it is safe to use concurrently with radiotherapy. Randomized comparisons of hormone therapy and trastuzumab administration with radiotherapy need to be performed.
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Affiliation(s)
- Pelagia G Tsoutsou
- Radiation Oncology Department, University Hospital of Alexandroupolis, Dragana 68 100, Alexandroupolis, Greece.
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Caussa L, Kirova YM, Gault N, Pierga JY, Savignoni A, Campana F, Dendale R, Fourquet A, Bollet MA. The acute skin and heart toxicity of a concurrent association of trastuzumab and locoregional breast radiotherapy including internal mammary chain: a single-institution study. Eur J Cancer 2010; 47:65-73. [PMID: 20843680 DOI: 10.1016/j.ejca.2010.08.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Revised: 07/26/2010] [Accepted: 08/16/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND To evaluate the skin and heart toxicity of a concurrent adjuvant trastuzumab-radiotherapy for breast cancer (BC), especially in the case of internal mammary chain (IMC) irradiation. MATERIAL AND METHODS Prospective study of 106 patients treated between 06/2003 and 03/2007 by concurrent trastuzumab-radiotherapy for non-metastatic BC. Left ventricular ejection fractions (LVEF) was assessed at baseline, before and after radiotherapy and then every 4-6 months. All toxicities were evaluated using CTCAEV3. RESULTS Median age was 52 years (25-76). Chemotherapy with anthracycline was administered in 92% of patients. All patients received trastuzumab every three weeks (8 mg/kg followed by 6 mg/kg) for a median duration of 12 months (3-40). The IMC was irradiated in 83% of patients. There were: 87 grade 1, 14 grade 2 and 2 grade 3 skin reactions. There were 13 oesophagitis: 9 grade 1; 3 grade 2, and 1 grade 3. Out of 101 patients with assessments after 6 months, late telangiectasia grade 1 occurred in 5 patients, local pain grade 1 in 19 patients and grade 2 in 3 patients, fibrosis grade 1 in 16 patients. A reversible grade ≥2 left ventricular systolic dysfunction occurred in 6 patients. CONCLUSION In this prospective study of breast cancer patients treated with trastuzumab-radiotherapy with, in most cases, anthracycline-based chemotherapy and IMC irradiation, both the rate of abnormal LVEF after concurrent trastuzumab-radiotherapy and the skin toxicity were deemed acceptable. Further follow-up is needed.
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Affiliation(s)
- Lucas Caussa
- Department of Radiation Oncology, Institut Curie, 26, rue d'Ulm, 75248 Paris cedex 05, France
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Belkacémi Y, Fourquet A, Cutuli B, Bourgier C, Hery M, Ganem G, Marsiglia H, Namer M, Gligorov J, Azria D. Radiotherapy for invasive breast cancer: guidelines for clinical practice from the French expert review board of Nice/Saint-Paul de Vence. Crit Rev Oncol Hematol 2010; 79:91-102. [PMID: 20615725 DOI: 10.1016/j.critrevonc.2010.06.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Revised: 05/21/2010] [Accepted: 06/10/2010] [Indexed: 11/18/2022] Open
Abstract
PURPOSE While new strategies for the treatment of invasive breast cancer (BC) are emerging, radiotherapy (RT) modalities are still under debate. The French expert review board of Nice-Saint-Paul de Vence was asked firstly to conduct a qualitative evidence-based systematic review and then to establish clinical practice guidelines for the use of post operative RT in invasive BC. METHODS AND MATERIALS A search to identify eligible studies was undertaken using the Medline® database. All phase III randomized trials and systematic reviews evaluating the role and modalities of RT in invasive BC were included, together with some noncontrolled studies if no randomized trials were identified. The quality and clinical relevance of the studies were evaluated to determine the level of evidence. RESULTS The maximum delay between surgery and RT should ≤8 weeks when chemotherapy (CT) is not indicated. This should not exceed 24 weeks when adjuvant CT is administered. Whole breast RT delivering 50 Gy in 25 fractions followed by a boost of 10-16 Gy remains the standard of care after conservative surgery (CS). In the elderly population, for certain cases presenting comorbidities associated with a limited life expectancy, RT indication (even hypofractioned) and boost delivery may be unnecessary in the light of an unfavourable risk/benefit ratio. RT technique and indications should not vary in case of neoadjuvant CT followed by CS. After total mastectomy, RT should be indicated in N+ and in N- patients with high risk of local recurrence. The experts recommend to initiate tamoxifen at the end of RT, while aromatase inhibitors could be administered either concomitantly or sequentially with RT. There is no consistent data to delay (or suspend) trastuzumab administration during RT. As for all patients, in case of concurrent RT-trastuzumab administration, reduction of cardiac tissues exposure is highly recommended. After breast reconstruction, RT should be delivered as after standard CS without boost. CONCLUSION Due to significant variations in practice in the treatment of patients with BC, our group aimed to provide guidelines for clinical practice. The systematic review of the literature formed the basis of our evidence-based recommendations; however expert agreements were necessary on those subjects that are still under debate. Our group will update these guidelines every 4 years, taking in consideration new advances in technology, new drugs administration, biologic tools and innovative therapeutic options.
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Affiliation(s)
- Y Belkacémi
- AP-HP, CHU Henri Mondor, Créteil, Université de Paris XII, France.
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Erven K, Jurcut R, Weltens C, Giusca S, Ector J, Wildiers H, Van den Bogaert W, Voigt JU. Acute radiation effects on cardiac function detected by strain rate imaging in breast cancer patients. Int J Radiat Oncol Biol Phys 2010; 79:1444-51. [PMID: 20605341 DOI: 10.1016/j.ijrobp.2010.01.004] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Revised: 12/23/2009] [Accepted: 01/06/2010] [Indexed: 01/09/2023]
Abstract
PURPOSE To investigate the occurrence of early radiation-induced changes in regional cardiac function using strain rate imaging (SRI) by tissue Doppler echocardiography. METHODS AND MATERIALS We included 20 left-sided and 10 right-sided breast cancer patients receiving radiotherapy (RT) to the breast or chest wall. Standard echocardiography and SRI were performed before RT (baseline), immediately after RT (post-RT), and at 2 months follow-up (FUP) after RT. Regional strain (S) and strain rate (SR) values were obtained from all 18 left ventricular (LV) segments. Data were compared to the regional radiation dose. RESULTS A reduction in S was observed post-RT and at FUP in left-sided patients (S(post-RT): -17.6 ± 1.5%, and S(FUP): -17.4 ± 2.3%, vs. S(baseline): -19.5 ± 2.1%, p < 0.001) but not in right-sided patients. Within the left-sided patient group, S and SR were significantly reduced after RT in apical LV segments (S(post-RT): -15.3 ± 2.5%, and S(FUP): -14.3 ± 3.7%, vs. S(baseline): -19.3 ± 3.0%, p < 0.01; and SR(post-RT): -1.06 ± 0.15 s(-1), and SR(FUP): -1.16 ± 0.28 s(-1), vs. SR(baseline): -1.29 ± 0.27 s(-1), p = 0.01), but not in mid- or basal segments. Furthermore, we observed that segments exposed to more than 3 Gy showed a significant decrease in S after RT (S(post-RT): -16.1 ± 1.6%, and S(FUP): -15.8 ± 3.4%, vs. S(baseline): -18.9 ± 2.6%, p < 0.001). This could not be observed in segments receiving less than 3 Gy. CONCLUSIONS SRI shows a dose-related regional decrease in myocardial function after RT. It might be a useful tool in the evaluation of modern RT techniques, with respect to cardiac toxicity.
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Affiliation(s)
- Katrien Erven
- Department of Radiotherapy, University Hospital Gasthuisberg, Leuven, Belgium.
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Belkacémi Y, Gligorov J. Concurrent trastuzumab – Internal mammary irradiation for HER2 positive breast cancer: “It hurts to be on the cutting edge”. Radiother Oncol 2010; 94:119-20; author reply 120-1. [DOI: 10.1016/j.radonc.2009.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Accepted: 04/10/2009] [Indexed: 10/20/2022]
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In response to Dr Belkacemi et al. Radiother Oncol 2010. [DOI: 10.1016/j.radonc.2009.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Bese NS, Umay C, Serdengecti S, Kepil N, Sut N, Altug T, Ober A. The impact of trastuzumab on radiation-induced pulmonary fibrosis: results of an experimental study. Med Oncol 2009; 27:1415-9. [PMID: 20041318 DOI: 10.1007/s12032-009-9395-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Accepted: 12/15/2009] [Indexed: 11/30/2022]
Abstract
There are no data regarding the late toxicity of trastuzumab (T) administration with radiotherapy (RT). In this experimental study, we aimed to asses if concurrent or sequential administration of T has any impact for the development of radiation-induced pulmonary fibrosis in rats. Fifty-four female Wistar-albino rats were divided into 6 groups. First group of rats (Group 1; concurrent T) had irradiation to whole thoracic region concurrently with T. Second group (Group 2: sequential T-RT) received thoracic irradiation, 1 week after T. Third group (Group 3: sequential RT-T) had thoracic irradiation first and they had T injection 1 week after RT. Fourth group (Group 4: T only) had only T application. Fifth group (Group 5: RT) had only RT. The last group (Group 6: sham) of rats were observed without any application. A single dose of 12 Gy was given to both lungs with an anterior field at 2 cm depth. T dose which was equivalent to 6 mg/kg adult dose was calculated for each rat, and injected by the tail vein. As an end point the extent of pulmonary fibrosis for each field was graded on a scale from 0 (normal lung or minimal fibrous thickening) to 4 (total fibrous obliteration of the field) at histopathological examination. The mean value of fibrosis scores were 1.44, 1.77, 1.75 and 1.62 for Group 1, 2, 3 and 5, respectively, without any statistically significant differences among them (P>0.05). The mean value of fibrosis scores for Group 4 and 6 were 0.25 and 0.33, respectively (P>0.05). When the mean value of fibrosis scores of the groups which had RT with or without T, compared with the observation and the T only groups, the difference was significant (P<0.05) (one-way ANOVA and Tukey HSD post hoc tests) As a conclusion: addition of T to thoracic irradiation either sequentially or concomitantly did not increase radiation-induced pulmonary fibrosis in rats.
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Affiliation(s)
- N S Bese
- Department of Radiation Oncology, Cerrahpasa Medical School, Istanbul University, 34098, Cerrahpasa, Istanbul, Turkey.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2009. [DOI: 10.1002/pds.1651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Can cutaneous telangiectasiae as late normal-tissue injury predict cardiovascular disease in women receiving radiotherapy for breast cancer? Br J Cancer 2009; 101:403-9. [PMID: 19603028 PMCID: PMC2720242 DOI: 10.1038/sj.bjc.6605182] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: Overall, ∼5% of patients show late normal-tissue damage after radiotherapy with a smaller number having a risk of radiation-induced heart disease. Although the data are conflicting, large studies have shown increased risks of cardiovascular disease (CVD) for irradiated patients compared with non-irradiated ones, or for those treated to the left breast or chest wall compared with those treated to the right. Cutaneous telangiectasiae as late normal-tissue injury have so far only been regarded as a cosmetic burden. Methods: The relationship between late normal-tissue radiation injury phenotypes in 149 irradiated breast cancer patients and the presence of cardiovascular disease were examined. Results: A statistically significant association between the presence of skin telangiectasiae and the long-term risk of CVD was shown in these patients (P=0.017; Fisher's exact test). Interpretation: This association may represent initial evidence that telangiectasiae can be used as a marker of future radiation-induced cardiac complications. It could also suggest a common biological pathway for the development of both telangiectasiae and CVD on the basis of a genetically predisposed endothelium. To our knowledge this is the first reported study looking at this association.
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