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Afternoon Report
Chad Rieck, MD
© 2014 Virginia Mason
Mechanism of Radiation Injury
2
© 2014 Virginia Mason 3
Radiation Injury to Thorax
• Dermatologic
– Radiation dermatitis
• Lung
– Radiation Fibrosis
– Radiation induced Lung Tumor
• Lymph
– Secondary tumors
© 2014 Virginia Mason 4
Radiation Injury to Thorax
• Cardiac
– Pericarditis
– Valvular Fibrosis
– Valvular Regurgitation
– Accelerated CAD
– Constrictive Cardiac Dysfunction
– Restrictive Cardiac Dysfunction
– Fibrosis of conduction system
© 2014 Virginia Mason
Risk Factors
5
• Dose (total dose, dose per fraction)
• Concomitant cardiotoxic drugs (anthracyclines)
• Age (younger is worse)
• Female sex
• Time of radiation exposure
– Modern radiation includes less radiation
• Follow up studies only 5-10 years old though
• Focus only on mortality rates
• Location of radiation
– Left sided breast cancer relative risk 1.32
• Other health conditions
– Diabetes relative risk 3.23
• Heart health prior to RTX
– CAD prior to radiation relative risk 6.67
© 2014 Virginia Mason 6
• CAD
– Radiation induces cascade of events causing
atherosclerosis
• Valvular Disease
– Fibrotic changes with or without calcification
– Left side valve disease more common
• Heart failure
– Myocardial fibrosis leads to diastolic dysfunction
• Arrhythmia
– Fibrosis of cells in the conduction system
Consequences
© 2014 Virginia Mason 7
Risk for each type of malignancy
• 15-50% of Hodgkin’s Lymphoma
– Worse with concomitant cardiotoxic
medications
• 25% pericardial effusion for esophageal
cancer
• Breast cancer
– 7.4% per gray. Average dose is 4.9 Gy
• 5-40% of all patients get valvular disease
© 2014 Virginia Mason
Breast Cancer
8
© 2014 Virginia Mason
Breast Cancer
9
© 2014 Virginia Mason
Breast Cancer
10
© 2014 Virginia Mason
Esophageal malignancy
11
© 2014 Virginia Mason
Esophageal malignancy
12
© 2014 Virginia Mason 13
© 2014 Virginia Mason 14
Wellness

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Chad noon conference

  • 2. © 2014 Virginia Mason Mechanism of Radiation Injury 2
  • 3. © 2014 Virginia Mason 3 Radiation Injury to Thorax • Dermatologic – Radiation dermatitis • Lung – Radiation Fibrosis – Radiation induced Lung Tumor • Lymph – Secondary tumors
  • 4. © 2014 Virginia Mason 4 Radiation Injury to Thorax • Cardiac – Pericarditis – Valvular Fibrosis – Valvular Regurgitation – Accelerated CAD – Constrictive Cardiac Dysfunction – Restrictive Cardiac Dysfunction – Fibrosis of conduction system
  • 5. © 2014 Virginia Mason Risk Factors 5 • Dose (total dose, dose per fraction) • Concomitant cardiotoxic drugs (anthracyclines) • Age (younger is worse) • Female sex • Time of radiation exposure – Modern radiation includes less radiation • Follow up studies only 5-10 years old though • Focus only on mortality rates • Location of radiation – Left sided breast cancer relative risk 1.32 • Other health conditions – Diabetes relative risk 3.23 • Heart health prior to RTX – CAD prior to radiation relative risk 6.67
  • 6. © 2014 Virginia Mason 6 • CAD – Radiation induces cascade of events causing atherosclerosis • Valvular Disease – Fibrotic changes with or without calcification – Left side valve disease more common • Heart failure – Myocardial fibrosis leads to diastolic dysfunction • Arrhythmia – Fibrosis of cells in the conduction system Consequences
  • 7. © 2014 Virginia Mason 7 Risk for each type of malignancy • 15-50% of Hodgkin’s Lymphoma – Worse with concomitant cardiotoxic medications • 25% pericardial effusion for esophageal cancer • Breast cancer – 7.4% per gray. Average dose is 4.9 Gy • 5-40% of all patients get valvular disease
  • 8. © 2014 Virginia Mason Breast Cancer 8
  • 9. © 2014 Virginia Mason Breast Cancer 9
  • 10. © 2014 Virginia Mason Breast Cancer 10
  • 11. © 2014 Virginia Mason Esophageal malignancy 11
  • 12. © 2014 Virginia Mason Esophageal malignancy 12
  • 13. © 2014 Virginia Mason 13
  • 14. © 2014 Virginia Mason 14 Wellness

Editor's Notes

  1. Constrictive = pericardial fibrosis Restrictive = myocardial fibrosis
  2. A history of ischemic heart disease before cancer therapy was associated with an increased risk of a cardiac event after treatment for breast cancer (ratio 6.67, p<0.001). Other factors associated with a significantly increased risk included other circulatory disease, diabetes, or a left-sided breast cancer (risk ratios 1.88, 3.23, and 1.32, respectively).
  3. The absolute increase in risk of a major coronary event or death from ischemic heart disease is small. In the case control study comparing women given RT who had a major coronary event with those did not have a coronary event [11], the authors calculated that the risk that a 50-year-old women with no other coronary risk factors would die of ischemic heart disease prior to age 80 years would increase from 1.9 to 2.4 percent if she received a mean dose of radiation of 3 Gy to her heart; the risk of having at least one major coronary event would increase from 4.5 to 5.4 percent. If the mean dose to the heart were 10 Gy, the risk of dying would increase from 1.9 to 3.4 percent, and the risk of having at least one acute coronary event would increase from 4.5 to 7.7 percent. Data suggest that the cardiac risk associated with breast cancer radiation is higher for smokers than for nonsmokers, though still low for both groups. In a patient data meta-analysis including approximately 41,000 breast cancer patients randomly assigned to receive or not receive adjuvant radiation in 75 trials, those receiving radiation had an increased cardiac mortality (relative risk [RR] 1.3, 95% CI 1.15-1.46) [24]. The risk of radiation-associated cardiac mortality was higher for smokers, translating to an absolute increase of 1.0 percent, versus 0.3 percent for nonsmokers.