CARDIOTOXICIDAD POR RADIOTERAPIA: TÉCNICAS DE IRRADIACIÓN Y DE PROTECCIÓN CARDÍACA #COH18

Toxicidad cardiovascular secundaria a tratamientos onco-hematológicos: mecanismos y estrategias de prevención en onco-hematología
CARDIOTOXICIDAD POR RADIOTERAPIA:
TÉCNICAS DE IRRADIACIÓN Y DE
PROTECCIÓN CARDÍACA
Dra. Meritxell Arenas Prat, MD, PhD
Radiation Oncology Department,
Hospital Universitari Sant Joan de Reus
University Rovira i Virgili, Spain
17/01/2018

• Benefits of radiotherapy (RT)
• Volumes of RT and Organs at risk (OAR) / Constraints
• Cardiotoxicity
• RT techniques to reduce radiation dose to the heart
• Methods of respiratory control
• Cost-effective
• Conclusions

• RT globally cures 40% cancer patients with other
oncological treatments. 16% → exclusive
treatment.
• Cancer localizations where the heart radiation
dose received could produce cardiotoxicity are:
breast cancer (BC), lung, esophagus, Hodgkin
lymphomas, some hepatic and gastric cancer.
Benefits of RT

• BC is the most common cancer to affect women in
Europe and this implies the 30% of treatments in a
Radiation Oncology department.
Benefits of RT

Reduces recurrence 31% to
15.4% (N- (7287 pts)) and
63.7% to 42.5% (N+ (1050 pts))
• 10 year gain 15,7% (N-) and
21,2% (N+)
Reduces breast cancer
mortality of 20.5% to 17.2%
(N-) and 51.3% to 42.8% (N+)
• 15 year gain 3.3% (N-)
and 8.5% (N+)
RT → ↓ LR and ↑OS (after BCS and mastectomy)

4004 patients
Randomized
between RT IMC
and Medial SC
nodes or no RT.

Volumes of RT

90%
81%
48%
Most IMN in first 3-4
intercostal spaces

OAR and CONSTRAINTS (Our Department)
Total volume of both lungs taken together V20<30%
Ipsilateral lung V20<20-25%, mean dose <15Gy
Contralateral lung V10<10% mean dose <5Gy
Heart Mean Heart Dose 3 Gy (right BC), 5 Gy (left BC)
V20<10%, V25<10%, V45<30%, V50<20%
Contralateral breast V10<10% mean dose <5Gy
Humerus and ribcage maximum dose 50Gy
Brachyal plexus maximum dose 60Gy
Thyroid maximum dose 45Gy
Spinal cord maximum dose 46Gy
Other: QUANTEC

LEFT ANTERIOR DESCENDING ARTERY

• Epidemiological studies have shown cardiac mortality and
morbidity of breast irradiation.
• A significant linear correlation between mean heart dose and rate
of major coronary events (MCE), increase of 3- 7.4% per Gy.
Cardiotoxicity
Darby et al. NEJM 2013
McGale, Darby et al. Radioth Oncol 2011

• The heart is one of the most radiosensitive organ.
• No threshold of mean heart dose and MCE. Risks below 2Gy
could not be estimated.
• These studies have used older RT techniques. New RT
techniques ↓ cardiac dose and probably cardiac morbidity and
mortality.
Cardiotoxicity
Courtesy by P. Poortmans

• The risk begins within five years of RT and continues into
the third decade after RT.
• The risk is even greater in women with cardiac risk factors
(smoking, obesity, hypertension, cholesterol) and is
exacerbated with other therapies (anthracyclines,
trastuzumab, pertuzumab).
• RT can produce: myocardial infarction, congestive heart
failure, pericarditis, arrhythmias, angina, or valve
dysfunction.
Cardiotoxicity
Taylor CW, Kirby AM. Clin Oncol 2015

Cardiotoxicity

• ↑ ROS → inflammation → accelerated atherosclerosis.
Cardiotoxicity

• Optimisation of beam angles
• The use of multileaf collimator shielding
• Prone position
• Intensity-modulated RT (IMRT) and Arc RT Techniques (VMAT)
• Proton beam therapy (PBT)
• Partial beast irradiation
• Respiratory control → Deep inspiration (breath-hold and
gating techniques)
RT techniques to reduce
radiation dose to the heart

The value of the prone technique for cardiac protection is
less clear than other techniques; decreased cardiac doses for
large breasted women but increased cardiac doses for women
with smaller breast volume.

• IMRT/VMAT: represents a proven technique to provide
cardiac protection.
• Proton therapy: limited data available and high costs.
• Partial breast irradiation can be offered to women with early
stage BC based on consensus guidelines currently published.
Courtesy by P. Poortmans

• Abdominal compression
• Breath-Hold Gating Techniques
• Voluntary Deep Inspiration Breath Hold (vDIBH)
• Active breathing control (ABC)
• Free-Breathing Gating Techniques
• Real Time Position Management (RPM)
• BrainLab Exactracgating
• Others: AlignRT, VisionRT Ldt …
• Tumor tracking → Cyberknife
Respiratory Control
✓ Gating: turn radiation on/off at a specific breathing phase
✓ Tracking: synchronize beam motion with breathing motion

• DIBH expands the lungs and increase the separation
between the chest wall and heart.
Respiratory Control

• Respiratory control techniques are estimated to reduce
cardiac mortality by 4.7% compared with free breathing
techniques in left sided patients.
Respiratory Control

WORKFLOW
PATIENT SELECTION
At least 75% of patients with left-sided
BC may benefit from the DIBH.
PATIENT COMPLIANCE / TRAINING
TREATMENT VERIFICATION
• 5 mm margin around the LAD
• Heart shadow
• Optimal treatment verification image
(TVI) protocol for the DIBH technique
is an area for future research to
ensure both the reproducibility of the
pt position

PATIENT
SELECTION

Cost Respiratory Control
• 365 pts economic study (197 without respiratory gating (RG) and 168 with RG).
• The use of RG induced a cost increase of 996 euros for BC with breath-hold
techniques and 1510 euros for synchronized gating techniques.
Remonnay R, Morelle M, Giraud P, Carrère MO.
The cost of respiration-gated radiotherapy in the
framework of a clinical research programme
“STIC”. Cancer Radiother. 2009 Jul;13(4):281-90

Cost Respiratory Control (Spain)

Cost Heart Failure (Spain)

Cost-effective
The low cost of control respiratory techniques justify
their implementation

• These technologies must be accessible to all RT
services and it must be necessary to reinforce the human
and material resources necessary for its implementation.
International recomendations
Chauvet B, Mahe MA, Maingon P, Mazeron JJ, Mornex F, Societe francaise de radiotherapie o, et al. Livre blanc de la
radiothérapie en France 2013. Douze objectifs pour améliorer un des traitements majeurs du cancer. Cancer
radiotherapie : journal de la Societe francaise de radiotherapie oncologique. 2013;17 Suppl 1:S2-72. Livre blanc de la
radiotherapie en France 2013. Douze objectifs pour ameliorer un des traitements majeurs du cancer.

• As local control and SV for pt with cancer are now excellent,
the minimization of treatment related toxicity is now a priority.
• Increased efforts to minimize cardiac dose in cancer RT may
be beneficial to patients.
• The choice of method is up to the cancer center and will be
largely based on the pre-existing equipment in the
department.
• In clinical practice select those ptes benefit most (left BC, risk
factors, young …). Biomarkers could help us.
CONCLUSIONS

• The implementation of cardio-oncology units are
necessary for prevention and treatment of cardiotoxicity
of oncological treatments.
CONCLUSIONS
Individualized radiotherapy treatment are CRUCIAL

Gracias!
meritxell.arenas@gmail.com
marenas@grupsagessa.com
Acknowledgements:
Philip Poortmans
Marta Bonet
Frederick Barlett
Ovidio Hernández
Teresa López
Ángel Montero
Sebastià Sabater
Víctor Hernández
.....

CARDIOTOXICIDAD POR RADIOTERAPIA: TÉCNICAS DE IRRADIACIÓN Y DE PROTECCIÓN CARDÍACA #COH18

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CARDIOTOXICIDAD POR RADIOTERAPIA: TÉCNICAS DE IRRADIACIÓN Y DE PROTECCIÓN CARDÍACA #COH18