This document discusses radiation-induced heart disease (RIHD) from radiotherapy for cancers near the heart. It covers: 1) Types of cancer treatment that can expose the heart to radiation like breast and lung cancer. 2) Manifestations of RIHD like coronary artery disease and arrhythmias. 3) Studies like one by Sarah Darby that showed increased heart risks proportional to mean heart dose. 4) Techniques to reduce heart exposure like deep inspiration breath hold, prone positioning, and proton beam therapy.

1. WH-WORDS ABOUT RIHD
DR KANHU CHARAN PATRO
MD,DNB(RADIATION ONCOLOGY),MBA,FICRO,FAROI,PDCR,CEPC
HOD,RADIATION ONCOLOGY
Mahatma Gandhi Cancer Hospital And Research Institute, Visakhapatnam
drkcpatro@gmail.com /M+91-9160470564

2. Slow my flow
• Introduction
• Sarah Darby article
• Burden
• Etiopathogenesis
• Parts
• Prevention
• Screening
• Conclusion

3. Introduction

4. Radiation exposure to heart
during thoracic RT
Lymphoma
Breast
Lung
Esophagus
Thymomas

6. Disease manifestations
CORONARY ARTERY DISEASE (CAD)
PERICARDITIS
VALVULAR DYSFUNCTION
ARRHYTHMIA
HEART FAILURE

9. Sarah C Darby

13. Conclusion
• The overall average of the mean doses to the whole heart was 4.9 Gy (range, 0.03 to
27.72).
• Rates of major coronary events increased linearly with the mean dose to the heart by
7.4% per Gray (95% confidence interval, 2.9 to 14.5; P.0001
• With no apparent threshold. The increase started within the first 5 years after
radiotherapy and continued into the third decade after radiotherapy.
• The proportional increase in the rate of major coronary events per gray was similar in
women with and women without cardiac risk factors at the time of radiotherapy
• Exposure of the heart to ionizing radiation during radiotherapy for breast cancer increases
the subsequent rate of ischemic heart disease.
• The increase is proportional to the mean dose to the heart, begins within a few years after
exposure, and continues for at least 20 years.
• Women with preexisting cardiac risk factors have greater absolute increases in risk from
radiotherapy than other women

15. Kathryn Banfill/Journal of Thoracic
Oncology/2020
POST HOC ANALYSIS

18. Post hoc analysis
• The original article revealed that the volume of heart receiving greater
than or equal to 5 Gy (V5) or greater than or equal to 30 Gy (V30)
was associated with worse overall survival.
• A secondary analysis of RTOG 0617 published 2 years later reported
that heart volume of heart receiving greater than or equal to 40 Gy
was the dose parameter most strongly associated with survival
• Zhang et al.performed a systematic review of studies published
before January 2018. They included 18 studies of patients with
NSCLC
• Heart V30 was associated with decreased overall survival in two
studies and MHD was associated with post radiotherapy cardiac
events in two studies

20. Hallmarks of RIHD
Fibrosis and calcification of the
aortic root and the aortomitral
curtain that can lead to
progressive stenosis of the aortic
and mitral valves;
Ostial coronary stenosis;
myocardial atrophy and
widespread pericardial
adhesions and thickening
ultimately leading to intractable
and inoperable pericardial
constriction

21. Etiopathogenesis

26. POST RT PERFUSION DEFECT

27. Manifestations

28. QUANTEC DATA
• Qualitative Analyses of Normal Tissue Effects in the Clinic
• QUANTEC recommended that the volume of heart receiving greater than
or equal to 30 Gy (V30) should be kept below 46%
• MHD less than 15 Gy
• First time that the risk of MACE (defined as MI, coronary
revascularization, or death from IHD) in breast cancer survivors increases
in a linear relationship to cardiac radiation dose, even at low-dose levels.
• The rate of MACE increased by 7.4% per one gray increase in MHD in
this cohort of patients

29. Contouring and planning implementations
Frances Duane ET AL /GREEN/2017

30. Constraint Recommendations

31. Screening recommendations
COG
ESMO
ASCO

32. ICOS RECCOMENDATIONS

37. DIBH
APBI
IMRT
DIBH
+
IMRT

38. Cardiac sparing techniques

39. DIBH - DEEP INSPIRATORY BREATHHOLD

43. Prone breast radiation

47. Proton breast RT

48. Cardiac and lung
dose comparison

49. Electron chest wall RT

50. Planning technique
• 10 left-sided postmastectomy patients with very challenging anatomy were
selected for this dosimetry study.
• The enface electron fields were designed from a single isocenter and gantry
angle with different energy beams using different cutouts that matched on
the skin.
• Smaller energy was used in the central thin chest wall part and higher
energy in the medial internal mammary nodes (IMN) area, superior part of
the thick chest wall, and/or Axilla area.
• The electron fields were matched to the photon supra-clavicular field in the
superior region.
• Daily field junctions were used to feather the match lines between all the
fields.
• Electron field dose calculations were done with Monte Carlo

52. The electron chest wall
irradiation technique using
electron Monte Carlo dose
algorithm can provide
adequate dose coverage to
the chest wall, IMNs and/or
Axilla nodes while achieving
heart sparing with acceptable
ipsilateral lung dose, minimal
contralateral lung and breast
dose.

53. APBI-INTERSTITIAL BRACHY

54. Intraoperative

55. 3DCRT AND IMRT

56. Balloon based brachy

57. Comparison of the current available APBI techniques

59. Cardiac sparing with APBI

60. RECOMMENDATIONS FOR BREAST APBI

61. APBI
1. MC-APBI for left-sided BC
demonstrate that MC-APBI delivers a
low dose to both the heart and LAD.
2. Especially in women with favorable
anatomic and pathologic features,
MC-APBI is a safe, convenient, and
effective mode of radiation delivery

62. Conclusion
Thoracic radiotherapy is known to cause a variety of cardiac damage through the
inflammatory pathways.
Who typically have multiple comorbidities, are at higher risk of cardiac events and
early mortality after thoracic radiotherapy
Evaluation with echocardiography, electrophysiological, or cardiac perfusion
studies are currently not part of the routine assessment of patients with beast and
lung cancer
There is a need for high-quality prospective research to investigate advanced
radiotherapy technologies such as MR-guided radiotherapy and PBT

63. WISH YOU A GOOD HEART