Effect of Dose to the Heart and Cardiac Substructures on Cardiac Toxicity after Breast Cancer Radiation

PURPOSE/OBJECTIVE(S)

Pre-existing cardiovascular disease, chemotherapy, and higher mean heart dose are known risk factors for cardiac toxicity after breast radiation therapy. However, the relationship between cardiac substructure radiation exposure and toxicity is not well understood. We hypothesized that mean heart dose is a surrogate for global cardiac radiation exposure but that more specific dosimetric thresholds for the heart and its substructures could be identified, which could be used to guide radiation planning for breast cancer patients in the future.

MATERIALS/METHODS

In this cohort study, all breast cancer patients who received curative intent breast or chest wall radiotherapy at a single high-volume institution in 2014 and 2017 were included (n = 841). Baseline characteristics included hormone therapy, chemotherapy, menopausal status, diabetes, dyslipidemia, pre-existing cardiac toxicity, and age at diagnosis. Outcomes included any cardiac toxicity, arrhythmia, cardiomyopathy, ischemia, valvular, pericardial disease, and death. The heart and substructures, including left ventricle, right ventricle, left atrium, right atrium, aortic valve, pulmonic valve, mitral valve, tricuspid valve, and left anterior descending artery, were delineated on the simulation CT for each patient. Dosimetric variables, including mean dose, max dose, and V1, 2, 3, 4, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, and 70 Gy for the heart and substructures (in cc) were extracted. For each dosimetric variable, multivariable logistic regression was performed using baseline covariates in addition to the single dosimetric variable. Patients with missing data values were excluded. Results were combined and False Discovery Rate p-value correction was performed.

RESULTS

Multiple cardiac substructure dosimetric variables were associated with increased risk of mortality on multivariable analysis (p < 0.05). For left atrium and right atrium, V2, 3, 4, and 5 Gy were all significant. For right ventricle, mean dose, V1, 2, 3, 4, 5, 10, 15, 20, 25, 30, and 35 Gy were significant. For mitral valve, mean dose, max dose, V3, 4, and 5 Gy were significant. For tricuspid valve, mean dose was significant. For aortic valve, max dose, mean dose, V4, and V5 Gy were significant. For the whole heart, V1, 2, 3, 4, 5, 10, 15, 20, 25, 30, and 35 Gy were significant.

CONCLUSION

We have identified multiple dosimetric variables for the heart and its substructures which were associated with increased risk of mortality after breast cancer radiation. In fact, for certain structures, there were multiple exposure thresholds which showed increased risk of toxicity, highlighting the complex relationship between substructure dose and outcomes. Further study into these relationships will identify the most critical cardiac substructure constraints that could be used in radiation treatment planning.

TCTP protects from apoptotic cell death by antagonizing bax function

Translationally controlled tumor protein (TCTP) is a potential target for cancer therapy. It functions as a growth regulating protein implicated in the TSC1-TSC2 -mTOR pathway or a guanine nucleotide dissociation inhibitor for the elongation factors EF1A and EF1Bbeta. Accumulating evidence indicates that TCTP also functions as an antiapoptotic protein, through a hitherto unknown mechanism. In keeping with this, we show here that loss of tctp expression in mice leads to increased spontaneous apoptosis during embryogenesis and causes lethality between E6.5 and E9.5. To gain further mechanistic insights into this apoptotic function, we solved and refined the crystal structure of human TCTP at 2.0 A resolution. We found a structural similarity between the H2-H3 helices of TCTP and the H5-H6 helices of Bax, which have been previously implicated in regulating the mitochondrial membrane permeability during apoptosis. By site-directed mutagenesis we establish the relevance of the H2-H3 helices in TCTP's antiapoptotic function. Finally, we show that TCTP antagonizes apoptosis by inserting into the mitochondrial membrane and inhibiting Bax dimerization. Together, these data therefore further confirm the antiapoptotic role of TCTP in vivo and provide new mechanistic insights into this key function of TCTP.

NMR in the SPINE Structural Proteomics project

This paper describes the developments, role and contributions of the NMR spectroscopy groups in the Structural Proteomics In Europe (SPINE) consortium. Focusing on the development of high-throughput (HTP) pipelines for NMR structure determinations of proteins, all aspects from sample preparation, data acquisition, data processing, data analysis to structure determination have been improved with respect to sensitivity, automation, speed, robustness and validation. Specific highlights are protonless (13)C-direct detection methods and inferential structure determinations (ISD). In addition to technological improvements, these methods have been applied to deliver over 60 NMR structures of proteins, among which are five that failed to crystallize. The inclusion of NMR spectroscopy in structural proteomics pipelines improves the success rate for protein structure determinations.

Pregnancy and alpha-1 antitrypsin deficiency

A 29 year old patient with alpha-1 antitrypsin deficiency and bullous emphysema became pregnant against the advice of her physicians. Despite a mid-trimester pneumothorax requiring the insertion of a chest tube, she went on to deliver a healthy child under epidural anaesthesia using a midforceps technique. Vaginal delivery is not necessarily contra-indicated in multiparous patients with bullous emphysema.

Incidence of Legionnaires' disease in a district general hospital

In order to assess the incidence of Legionnaires' disease in a district general hospital, 90 consecutive patients with pneumonia seen over a 3-year period were investigated. Only 2 patients were found to have Legionnaires' disease, indicating that it is not a frequent cause of pneumonia in the Bristol area.

Colorimetric enzymatic determination of serum total carbon dioxide, as applied to the Vickers Multichannel 300 discrete analyzer

Phosphoenolpyruvate carbosylase (EC 4.1.1.31) has been used in developing a simple, inexpensive colorimetric assay for serum total carbon dioxide in an open system. The oxaloacetate formed by the action of the enzyme on bicarbonate and phosphoenolpyruvate is measured by use of the diazonium salt of Fast Violet B. Interferences from billirubin, pyruvate, and drugs are negligible. Acetoacetate interference is significant only in highly ketotic samples, and a serum blank corrects for it. Serum protein interference is equivalent to 3.3 plus or minus 1.25 mmol of CO2 per liter and hence is sufficiently constant to be corrected for by use of a serum standard or serum blank. The method has been applied to the Vickers M-300 and D-300 systems and within-batch standard deviations of plus or minus 0.1 to plus or minus 0.6 mmol/liter have been observed. Excellent correlation with orthodox techniques has been obtained.