Late cardiac effects of mediastinal radiotherapy in patients with Hodgkin's disease

Abstract

Twenty-eight patients younger than age 40 years, treated for Hodgkin's disease with mediastinal irradiation, were examined no less than 5 years after the irradiation in order to evaluate the frequency of cardiac abnormalities. Twelve patients (43%) had had some pericardial event after radiation: a diagnosed pericarditis, remarkably increased heart volume, or a conspicuous change of cardiac silhouette, suggesting pericardial fluid. On evaluation, 50% of the patients complained of symptoms, and 13 patients had to stop the exercise test on a low level because of chest pain, dyspnea, or general fatigue. In 13 patients some of the following abnormalities in the electrocardiogram (ECG) was found: right bundle branch block (four), first-degree atrioventricular block (four), abnormal P terminal force (five), or a low voltage (two). In ten patients (38%) an increase of the pericardial fluid was seen in the echocardiogram, and in nine patients the right ventricle wall thickness had increased. In two patients a severe coronary artery disease was found. One died suddenly after an acute myocardial infarction (AMI), and the other had a large anterior AMI. Two patients with chronic pericardial fluid underwent partial pericardectomy. Two cases of mild pulmonary valve stenosis, one pulmonary subvalvular stenosis and two aortic valve deformities were discovered. Eight patients went through cardiac catheterization, and in all but one case the pressures were slightly elevated suggesting diminished diastolic compliance. In summary, 19 of 28 patients had some abnormal cardiac findings, but only three of them were serious ones.

Late cardiopulmonary toxicity after treatment for Hodgkin's disease

“…The linear accelerator of 25 MV used, gives a lower dose to the heart than 'Co or 8 MV LinAc as described in other studies (Brosius et al, 1981;Carmel & Kaplan, 1976;Cosset et al, 1984;La Monte et al, 1986;Larson et al, 1976;McReynolds et al, 1976;Pohjola-Sintonen et al, 1987;Watchie et al, 1987;Zarrabi et al, 1984); 1.8 Gy to a maximum of 2 Gy per fraction, five fractions per week, the two fields being treated every day, all these precautions are probably important to reduce late sequelae. Nevertheless, our follow-up is still too short to conclude.…”

“…Findings include acute but transient decreases in PFTs over the first 6 months with return to pretreatment values by 8-12 months (DoPico et al, 1979;Evans et al, 1974;Smith et al, 1989). Nevertheless Zuccali et al (1981), or Pohjola (1987 reported a significant decrease in vital capacity and inspiratory capacity in 30% of the patients, sometimes severe, more than 12 months after treatment. The follow-up of the patients in our series lasted more than 2 years and can explain our low sequelae level.…”

“…Generally, a 25% incidence of findings including ST segment depression, T wave changes, minor QRS abnormalities and occasional silent myocardial infarction are reported (Brosius et al, 1981;LaMonte et al, 1986;Larson et al, 1976;McReynolds et al, 1976;Pohjola-Sintonen et al, 1987;Watchie et al, 1987;Zarrabi et al, 1984). Watchie et al (1987) found a 13% incidence of complete or incomplete right bundle branch blocks.…”

“…Pohjola et al (1987) reported an incidence of 38% of pericardial effusion more than 5 years after mediastinal irradiation. Gottdiener et al (1983) gave 36%.…”

“…More recent data suggest a dramatic decrease in these sequelae over the past decade as a result of refined treatment techniques (Carmel & Kaplan, 1976;Morgan et al, 1985;Smith et al, 1989). However, sequelae are still too frequent in the recent literature (Cosset et al, 1984;Cossett et al, 1988;LaMonte et al, 1986;Pohjola-Sintonen et al, 1987;Zarrabi et al, 1984;Zucali et al, 1981 Irradiation was applied to all patients in the same institution from a 25 MV photon beam from a linear accelerator (Sagittaire CGR) with two opposed mantle fields as defined by KAPLAN (Kaplan, 1980 Forty-five Xenon 133 ventilation/perfusion scintigraphies were performed with the technique described by LACOSTE (Lacoste et al, 1980 (MET). MET was determined with the maximal theoretical heart rate given by the following formula: 220 -age of the patient (Astrand, 1952;Astrad & Rodahl, 1970).…”