Download Cardiotoxicity of radiotherapy and chemotherapy

Cardiotoxicity of radiotherapy
for malignancy
RTOW
SATURDAY, MARCH 5, 2016
ERIKA SWANSON, MD
RADIATION ONCOLOGIST
COLUMBIA ST. MARY’S
Objectives
 Understand cardiac anatomy
 Learn pathophysiology of
cardiotoxicity
 Discuss different malignancies
associated with high risk of RT related
cardiotoxicity

Review dosimetry and DVH data
 Learn strategies to limit cardiac dose
 Brief introduction to Cardio-oncology
program/Survivorship
Why should we care?
 Cancer and heart disease are the leading causes of
morbidity and morality in US
 Modern treatment has improved survival for cancer
patients
 Long-term cancer survivors are expected to increase
by 30% in the next decade
 18 million by 2022 in US alone
Curigliano CA Cancer J Clin 2016
Cardiac anatomy
Cardiac anatomy
Pulmonary trunk
Right auricle
Aorta
Left
atrium
Descending
aorta
Conus arteriosus
Right atrium
ophagus
Aortic bulb
Left
ventricle
Left
atrium
Conus arteriosus
Right atrium
Left
ventricle
Left
atrium
Right ventricle
Left ventr
Right atrium
Esophagus
Left atriu
LAD
How’re you doing??
Cardiac Physiology
 Dr. Nand will be covering this next lecture
Pathophysiology
 Endothelial dysfunction is felt to be the precipitating
factor in most cardiac sequelae
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Impaired function
Stimulation of growth factors
Fibrosis
Small vessel occlusion and eventual cell death
Jaworski JACC, 2013
Overview of RT cardiotoxicity
Acute effects (<6 mos)
Late effects (3 – 30 years)
 Pericarditis
 Chronic pericarditis
 Coronary artery disease
 Valvular disease
 Cardiomyopathy
 Conduction
abnormalities
Acute Pericarditis Symptoms
 Chest pain
 Fever (+/-)
 sharp, worse with coughing or inspiration
 May be reduced by standing up or sitting forward
 Usually worsened by lying flat
Pathology
Risk factors for developing RT cardiotoxicity
 Radiation dose
 Dose per fraction
 Volume of heart irradiated
 Concominant administration of cardiotoxic drugs
 Younger age
 CV risk factors (smoking, hypertension, high chol)
Radiation therapy in breast cancer
 Stage I long term overall survival ~95%
 1 in 8 women diagnosed with breast cancer
 RT is standard of care after breast conserving
surgery

Reduces LR by ~60%  improve OS
 PMRT indicated for N+, T3, positive margins
 Reduces LRR by ~50-60%  improve OS (4-5%)
EBCTCG meta-analysis
Lancet 2000
EBCTCG
Lancet 2000
Left breast tangents
Left breast tangent DVH
Mean dose: 329 cGy
Max dose: 5088 cGy
V5: 17%
Dose Limitations
 Whole heart dose
 V16Gy < 5%
 V8Gy < 100%
 Mean < 320 cGy
Want to hear more?
Radiotherapy for early stage Hodgkin Lymphoma
 Long term survival approaches 90-95%
 RT is often used in combination with 2-4 cycles of
ABVD
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Some may give more chemo and omit RT
RT always indicated for bulky disease
Hodgkin Lymphoma
Aleman, Blood 2007
Hodgkin Lymphoma
Jaworski, JACC 2013
Stage IIB Unfavorable HL IMRT
Stage II HL DVH
Mean dose: 2326 cGy
Max dose: 3968 cGy
V5: 98%
Esophageal Cancer and RT
 Survival is ~30% at 3 years
 Radiation is used with concurrent chemotherapy
 Definitive for squamous cell carcinoma
 Neo-adjuvant for adenocarcinoma
 Most common cardiotoxicities seen are pericarditis
and decreased left ventricular ejection fraction
Esophageal Cancer
IMRT DVH Esophageal Cancer
Mean dose: 2669 cGy
Max dose: 5316 cGy
V5: 100%
Lung cancer
 Survival for stage III NSCLC is ~20% at 5 yrs
 RTOG 0617 (74 Gy vs 60Gy)
 OS worse in the high dose arm
 MVA: Volume of heart receiving >5Gy and >30Gy were
independent predictors of overall survival
Stage IIIA NSCLC
Stage IIIA NSCLC DVH
Mean dose: 1084 cGy
Max dose: 6711 cGy
V5: 54%
Strategies to limit the dose to heart
 Patient set up
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Prone position (insert prone dosimetry)
Breath hold
Respiratory gating
 Treatment strategy
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Omit RT when possible
Reduce RT dose
Limit RT field
Don’t deliver RT with concurrent cardiotoxic drugs
 Technique
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IMRT
Block the heart
Protons
Prone breast tangents
Prone breast tangent DVH
Mean dose: 148cGy
Max dose: 2543 cGy
V5: 2%
Protons for HL
Hoppe, IJROBP 2011
Survivorship
 There are no formal guidelines for following patients
after thoracic radiation

Consider cardiac perfusion and/or calcium scoring by CT for
those with doses >35 Gy to the coronary arteries, starting 5
years after RT or after age 30-35
 Cardio-oncology program
 Discipline developed in response to combined decision making
necessary to optimize care for cancer patients
You made it!