Severe left main coronary stenosis in a young female patient, 6 years after mediastinal radiation therapy for non-Hodgkin lymphoma: assessment by coronary angiography and intravascular ultrasound

Abstract

Sirs:Due to advances in chemo-and radiotherapy over the last decades, a considerable amount of patients with malignant Hodgkin and non-Hodgkin lymphomas become long-term survivors [1][2][3]. However, cardiovascular complications, especially in patients who undergo mediastinal radiotherapy with potential exposure of cardiac structures, represent a significant cause of long-term mortality [4,5]. Data on cardiac morbidity show that a diverse cardiac pathology can be found in this patient cohort, including conduction abnormalities, valvular, pericardial and coronary artery disease (CAD) [4][5][6][7]. Hereby, the microvascular pathology is characterized by a decrease in capillary density [8], causing chronic myocardial ischemia and fibrosis in experimental models. Macrovascular disease on the other hand, usually occurs through an accelerated development of age-related atherosclerosis and frequently involves ostial lesions of the left main and of the right coronary artery, resulting in an increased risk for non-fatal myocardial infarction or sudden cardiac death [9].A 34-year-old woman with stable angina and suspected CAD was referred to our institution for coronary angiography in December 2010. None of the established atherogenic risk factors were present. A history of primary mediastinal diffuse large B-cell non-Hodgkin lymphoma was present, which was diagnosed in 2003, and was treated with 6 courses of rituximab added to cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) chemotherapy at that time. Due to tumor relapse after R-CHOP treatment, autologous stem cell transplantation was performed in 2004, followed by mediastinal radiotherapy. Complete remission of the disease was noted thereafter. At the time of presentation in our department in December 2010, the patient exhibited typical angina and dyspnoea on exertion, and an ambulatory stress-ECG exhibited inducible ST segment depression of 0.3 mV in the leads V3-V6. Laboratory findings including parameters for renal function, serum electrolytes, C-reactive protein, N-terminal prohormone of brain natriuretic peptide (NT-proBNP) and high-sensitive troponin T were within the normal range. Furthermore, echocardiography showed no valve disorders and no conduction abnormalities were seen in the ECG.Left ventricular (LV)-angiography during cardiac catheterization showed normal left-ventricular function. Coronary angiography revealed a severe ostial stenosis of the left main coronary artery, which remained after the intracoronary administration of 0.4 mg nitroglycerin (Fig. 1a). Coronary atherosclerosis was also observed in the mid circumflex coronary vessel without causing flow-limiting stenosis. No other significant lesions were observed (Fig. 1a-c). In order to verify the extent and localization of the observed left main lesion, intravascular ultrasound (IVUS) was subsequently performed (iLab Ultrasound Imaging System, Boston Scientific, MA, USA), exhibiting the presence of a large fibrotic plaque in the ostium of the left main coronary artery (Fig. 2a, ...

Definition of the margin of major coronary artery bifurcations during radiotherapy with electrocardiograph-gated 4D-CT

“…The findings of Fuzellier et al [14] indicated that the risk of radiation-induced CAD should be considered when the mediastinal radiation dose is greater than or equal to 30 Gy. Coronary artery bifurcations and proximal segments that are located in the irradiation field become preferential sites for lesion formation, whereas distal segments are usually unaffected [15]. The coronary artery is a late-responding organ; as a result of the complexity in delineation and inadequate knowledge of motion, it is not considered a routine organ at risk (OAR) during radiotherapy planning [16].…”

Isolated Left Main Coronary Artery Stenosis after Thoracic Radiation Therapy: To Operate or Not to Operate

“…One study found that 16% of isolated coronary ostial stenosis was secondary to radiation therapy [6]. Isolated ostial stenosis of the left main coronary artery following radiation therapy has been reported in eight other cases in the literature [7–14] (Table 1). These patients were young to middle-aged females (mean age 40 years, range 26–51 years), with no or few traditional risk factors for CAD.…”