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Case Report

Isolated Left Main Coronary Artery Stenosis afterThoracic Radiation Therapy: To Operate or Not to Operate

Hindawi Publishing CorporationCase Reports in MedicineVolume 2013, Article ID 834164, 5 pageshttp://dx.doi.org/10.1155/2013/834164

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Case Report



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Case Report


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Late cardiotoxicity after treatment for Hodgkin lymphoma

Berthe M. P. Aleman,1 Alexandra W. van den Belt-Dusebout,2 Marie L. De Bruin,2 Mars B. van ’t Veer,3

Margreet H. A. Baaijens,4 Jan Paul de Boer,5 Augustinus A. M. Hart,1 Willem J. Klokman,2 Marianne A. Kuenen,2

Gabey M. Ouwens,2 Harry Bartelink,1 and Flora E. van Leeuwen2

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Cardiac Effects of Radiotherapy

Asymptomatic Cardiac DiseaseFollowing Mediastinal Irradiation

G)%')-&)%15(4;()*("$+(.;HH(899I>J8@JBC=JIE=J?(

Table 2. Valvular Disease Following Irradiation

Echocardiographic Finding

Years Following Irradiation

p Value*All Patients

n 5 2942–10

n 5 8911–20

n 5 132>20

n 5 73

Aortic regurgitationTrace (%) 27 (9) 9 (10) 13 (10) 5 (7) 0.71Mild (%) 62 (21) 3 (3.4) 26 (20) 33 (45) , 0.0001Moderate or severe (%) 15 (5.1) 1 (1.1) 3 (2.3) 11 (15) , 0.0001

Mitral regurgitationTrace (%) 87 (30) 27 (30) 44 (33) 16 (22) 0.21Mild (%) 105 (36) 21 (24) 49 (37) 35 (48) 0.005Moderate or severe (%) 10 (3.4) 2 (2.3) 5 (3.8) 3 (4.1) 0.71

Tricuspid regurgitation

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Risk of Is che mic Heart Disease in Women after Radiotherapy for Breast Cancer

W"&U6(XH()*("$+(YZ.[(89:I>IFD@::BC(?D=E??D(

Moreover, every year, tens

-

nosis of ductal carcinoma in situ. The overall

5-year survival rate for these two diagnostic

groups combined is approximately 90%, and in

-

-

diation to the heart from radiotherapy for breast

cancer are typically about 1 or 2 Gy for disease of

the right breast. For disease of the left breast, the

doses are usually higher but vary widely, and for

-

tance of the heart to the thoracic wall is small

-

Among the 2168 women in this study, the

mean dose to the heart ranged from 0.03 Gy to

27.72 Gy, with an overall average of the mean

doses of 4.9 Gy. The risk of a major coronary

event increased linearly with the mean dose to

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Increase per gray, 7.4% (95% CI, 2.9–14.5)

P<0.001

local:shear stress:

NFkB-mediated inflammatoryresponse

systemic:

LDL accumulation in intima: oxidation→ enzymatic modification →

proinflammatory lipids

adhesion molecule expression

leukocyte adhesion → migration intosubendothelium

monocyte→ macrophages→ foamcells

endothelial cells and macrophages releaseinflammatory cytokines, oxygen and nitrogen

radicals, proteases

plaque formation

symptomatic coronary artery disease

innate immunity reaction to oxidised LDL: expression of e.g. IL-6, c-reactive protein, serum amyloid A, fibrinogen

circulatingendothelial cells

⊥pathogenesis of coronary artery disease – possible interactions with radiation effects

CRITICAL REVIEW

RADIATION-INDUCED CARDIOVASCULAR DISEASES: IS THE

EPIDEMIOLOGIC EVIDENCE COMPATIBLE WITH THE

RADIOBIOLOGIC DATA?

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Supradiaphragmatic Hodgkin Lymphoma

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Inform treating cardiologist and inform patient

Determine patients’ pacing-dependency

If ICD, Inform if anti-tachycardia therapy can be switched of by magnet

If CIED check-up > 3 months ago, plan check-up prior to start of

radiotherapy

Photon beam energy <10MV

Estimate dose on CIED (seed rawing for indication)

Minimize dose on CIED with treatment plan optimisation

Extra CIED check after last RT fraction by pacemaker

technologist (at 1, 3 and 6 months)

DOSE

0-10 Gy

YES

DOSE > 10

Gy

NO

HIGH RISK

In exceptional cases a decision to

start RT can be made

safety measures which are atleast

those used for intermediate risk

patients

ECG-monitoring during every

fraction

CIED checked within 24 hours by

pacemaker technician

INTERMEDIATE RISK

See LOW RISK plus:

Crashcart present during RT

Weekly check-up CIED

Possibility of external pacing

Trained staff with cardiology

expertise can be present within 10

minutes

(if not, patients should be referred to

another institute)

LOW RISK

Audiovisual monitoring of

patient

In case ICD: program

tachycardia therapy off or use

magnet

Letter to cardiologist

ICDs: weekly check-ups

Pacing independent patient and

Dose on CIED <2 Gy

Reconsider

radiotherapy or

CIED relocation

Patient with CIED and indicated radiotherapyWhen the tumour is

within this zone it is

likely that the CIED

dose is*:

>10Gy

2-10Gy

<2Gy

Figure 1 Flow diagram of Dutch guidelines. *Estimation of dose in case of a pectoral placed CIED.

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