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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 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 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 Prone position (insert prone dosimetry) Breath hold Respiratory gating Treatment strategy Omit RT when possible Reduce RT dose Limit RT field Don’t deliver RT with concurrent cardiotoxic drugs Technique 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!
