Symptomatic cardiac toxicity is predicted by dosimetric and patient factors rather than changes in 18F-FDG PET determination of myocardial activity after chemoradiotherapy for esophageal cancer

Abstract

Purpose To determine factors associated with symptomatic cardiac toxicity in patients with esophageal cancer treated with chemoradiotherapy. Material and Methods We retrospectively evaluated 102 patients treated with chemoradiotherapy for locally advanced esophageal cancer. Our primary endpoint was symptomatic cardiac toxicity. Radiation dosimetry, patient demographic factors, and myocardial changes seen on 18F-FDG PET were correlated with subsequent cardiac toxicity. Cardiac toxicity measured by RTOG and CTCAE v3.0 criteria was identified by chart review. Results During the follow up period, 12 patients were identified with treatment related cardiac toxicity, 6 of which were symptomatic. The mean heart V20 (79.7% vs. 67.2%, p=0.05), V30 (75.8% vs. 61.9%, p=0.04), and V40 (69.2% vs. 53.8%, p=0.03) were significantly higher in patients with symptomatic cardiac toxicity than those without. We found the threshold for symptomatic cardiac toxicity to be a V20, V30 and V40 above 70%, 65% and 60%, respectively. There was no correlation between change myocardial SUV on PET and cardiac toxicity, however, a greater proportion of women suffered symptomatic cardiac toxicity compared to men (p=0.005). Conclusions A correlation did not exist between percent change in myocardial SUV and cardiac toxicity. Patients with symptomatic cardiac toxicity received significantly greater mean V20, 30 and 40 values to the heart compared to asymptomatic patients. These data need validation in a larger independent data set.

Is cardiac toxicity a relevant issue in the radiation treatment of esophageal cancer?

“…3D functional cardiac imaging was used to evaluate cardiac toxicity in five papers [10][11][12][13][14]. Treatment details and patient numbers are again listed and marked as the last five papers in Table 1.…”

“…Konski et al evaluated 74 esophageal cancer patients using FDG-PET [12]. The FDG uptake declined, especially in the lateral myocardial wall, shortly after treatment.…”

“…Not only treatment related factors were significant related to cardiac toxicity, older age and female sex gave a significantly higher risk in two [3,7] and one [12] of the reviewed papers. However, patient numbers are low and these non-treatment related risk factors should be confirmed in larger patient groups.…”

Early detection of radiation-induced heart disease using 99mTc-MIBI SPECT gated myocardial perfusion imaging in patients with oesophageal cancer during radiotherapy

“…Additionally, the heart is a mobile structure, and its location may vary both in interfraction and intrafraction relative to the planned CT scan [41]; as a result, the regional dose distribution may be influenced and the segmental location of the two SPECT polar maps may not match very well. All studies of this type suffer from this same limitation.…”

Radiation Therapy

“…In the treatment of esophageal cancer using definitive regimen of 60 Gy with concurrent chemoradiotherapy, investigators from Japan reported that the optimal V20 threshold to predict symptomatic radiation pneumonitis (grade 2) was 30.5 % [22]. Konski and colleagues proposed thresholds for symptomatic cardiac toxicities (pericardial effusion, myocardial infarction, and sick sinus syndrome) for whole-heart V20 of 70 %, V30 of 65 %, and V40 of 60 % [23]. Wei and colleagues performed an analysis of pericardial effusion risk from DVH parameters among patients treated with definitive chemoradiotherapy [24].…”