Ischemic heart disease after mantlefield irradiation for Hodgkin's disease in long-term follow-up
Introduction
Patients treated for Hodgkin's disease have an excess mortality risk even when the risk of recurrent disease is negligible [26]. One of the major causes of the excess mortality is cardiac disease [3], [8], [13], [17], [19], [20], [26]. With increased control rates and the availability of a variety of therapeutic options, it has become extremely important to be aware of the various complications associated with radiotherapy. It is well known that cardiac events such as pericardial effusions and acute and constructive pericarditis can be related to the applied radiotherapy technique, that is, to the proportion of the dose delivered to the heart by the anterior portal, the total dose, and the daily fraction dose [2], [5], [6], [7], [9], [14], [17], [19], [31], [32]. For myocardial infarction and coronary artery disease it is as yet unclear whether and to what extent the applied radiotherapy technique influences the likelihood of occurrence of these events. Somewhat conflicting data regarding the benefit of a low cardiac fraction dose and a low total dose have been reported [1], [13], [15], [16], [24], [25], [27], [28], [33], [34], [35], [36].
In most institutes the daily fraction dose for a mantlefield irradiation is prescribed to the midplane in the patient in the center of the field. As of the mid sixties, in the Daniel den Hoed Cancer Center (DDHCC) the daily fraction dose (2.0 Gy) has been prescribed midplane in the area with the smallest patient diameter, usually the neck [10]. Due to the large diameter of the inferior part of the mediastinum, this type of dose prescription leads to a relatively low fraction dose to the heart. Because of the potential importance of the fraction size for the development of cardiac complications, we have retrospectively analyzed the medical records of patients, treated initially with radiotherapy alone, for the development of symptomatic ischemic cardiac events.
Section snippets
Patients
We have retrospectively reviewed the medical records of patients treated for Hodgkin's disease in our department in the period 1965–1980. The endpoint of the study was the occurrence of symptomatic ischemic heart disease (WHO-ICD code 410–414). The censor date of the study was 1993. For those patients with symptoms mentioned in the records that could potentially be of cardiac origin, but which could not be diagnosed, the general practitioner and/or medical specialists were consulted; these
Results
Thirty-one patients (12%) developed an ischemic event after the start of radiotherapy. An overview of the observed lesions is given in Table 2. Seven of these patients had invasive therapy for the cardiac lesion: four patients had coronary artery bypass surgery, two patients had a percutaneous transluminal angioplasty and one patient had a pacemaker implantation. For 11 of the 31 patients, a coronary angiography had been made. For all these patients stenoses in one or more large coronary
Discussion and conclusions
Differences in patient populations, in selected subgroups of cardiac lesions in the analyses, and in follow-up periods often hamper an exact comparison with published data on the incidence of cardiac events. In the present study, the choice of the subgroup of ischemic heart disease was based on the number of patients involved, on the reliability of the diagnosis in the study population and in the general Dutch population, and on the existing subgroup division used for the general population.
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Present address: Arnhems Radiotherapeutisch Instituut (ARTI), Arnhem, The Netherlands.