Elsevier

Radiotherapy and Oncology

Volume 101, Issue 2, November 2011, Pages 316-321
Radiotherapy and Oncology

Morbidity of mediastinal irradiation
Dosimetric predictors of asymptomatic heart valvular dysfunction following mediastinal irradiation for Hodgkin’s lymphoma

https://doi.org/10.1016/j.radonc.2011.08.040Get rights and content

Abstract

Purpose

To identify dose–heart-volume constraints that correlate with the risk of developing asymptomatic valvular defects (VD) in Hodgkin’s lymphoma (HL) patients treated with three-dimensional radiotherapy (RT).

Patients and methods

Fifty-six patients undergoing cytotoxic chemotherapy (CHT) and involved-field radiation treatment for HL were retrospectively analyzed. Electro-echocardiography was performed before CHT, after CHT, and after RT. For the entire heart, for right and left ventricle (RV, LV), right and left atrium (RA, LA) percentage of volume exceeding 5–30 Gy in increment of 5 Gy (Vx), and dosimetric parameters were calculated using 1.6 Gy fraction as reference. To evaluate clinical and dosimetric factors possibly associated with VD, univariate and multivariate logistic regression analyses were performed.

Results

At a median follow up of 70.5 months, 32.1% of patients developed VD (regurgitation and/or stenosis): 25.0% developed mitral, 5.4% developed aortic, and 14.3% tricuspid VD. In particular the percentage of LA exceeding 25 Gy (LA-V25) and the percentage of LV exceeding 30 Gy (LV-V30) correlated with mitral and aortic VD with an odds ratio (OR) of 5.7 (LA-V25 > 63.0% vs. LA-V25  63.0%) and OR of 4.4 (LV-V30 > 25% vs. LV-V30  25%), respectively. RV-V30 correlated with tricuspid VD (OR = 7.2, RV-V30 > 65% vs. RV-V30  65%).

Conclusion

LA-V25, LV- and RV-V30 prove to be predictors of asymptomatic alteration of valve functionality.

Section snippets

Patient section

Data on 63 consecutive patients with Hodgkin’s disease undergoing post-chemotherapy supradiaphragmatic involved-field radiation therapy at the Department of Radiotherapy of the University “Federico II” of Naples between 2002 and 2008 were reviewed. Selection criteria included a minimum of a 30 months interval from HL therapy, the availability of cardiac evaluation with electrocardiography and echocardiography before chemotherapy (CHT), after CHT, and, periodically, after radiation therapy (RT)

Results

A total of 63 patients were analyzed in this study. Seven patients (11.1%) showed pre-existing cardiac abnormalities at the basal echocardiography and were consequently excluded from further evaluation. Demographic, disease and treatment characteristics of the remaining 56 patients are shown in Table 1. No electrocardiography abnormalities were detected in these patients.

At a median follow-up of 70.5 months (range, 36–110) after the end of radiation treatment, 18 out of 56 patients (32.1%)

Discussion

Hodgkin’s lymphoma survivors treated with mediastinal radiotherapy are particularly at risk of cardiovascular disease like myocardial infarction, angina pectoris, congestive heart failure, and valvular disorders. Despite the predominant role of radiation therapy on long-term cardiac effects [7], little information is available to date on preclinical heart disease following thoracic irradiation and dose–volume correlations. In the spectrum of cardiac pathology, asymptomatic valvular dysfunction

Conclusions

We have identified the cardiac chambers as critical target volumes for the development of asymptomatic heart valve defects in HL patients treated with sequential chemo-radiotherapy. We have also determined three dose–volume predictors of the risk of developing VD: LA-V25 = 63%, LV-V30 = 25%, and RV-V30 = 62% (dose fraction of 1.6 Gy). Although it is not possible to exclude that lower doses of radiation may be responsible of some valvular damage, the inclusion of these parameters in the treatment plan

Conflict of interest

The authors declare no conflict of interest.

References (35)

Cited by (42)

  • Long-term consequences of radiation therapy

    2022, Cardio-Oncology Practice Manual: A Companion to Braunwald's Heart Disease
  • Past, Present, and Future of Radiation-Induced Cardiotoxicity: Refinements in Targeting, Surveillance, and Risk Stratification

    2021, JACC: CardioOncology
    Citation Excerpt :

    In studies of patients with childhood cancers, LV doses correlated with heart failure (24) and increased left atrial volumes on cardiac magnetic resonance imaging (CMRI) (26). Other studies have found that doses to the ventricles correlate with outcomes such as decreased LV ejection fraction, valvular defects, acute coronary syndrome, and/or survival (19,20,22,27). In lung cancer, doses to the base of heart and its structures (atria and proximal great vessels) have repeatedly been found to correlate with cardiac outcomes and survival.

View all citing articles on Scopus
View full text