Radiotherapy as administered from the 1980s onward is associated with an increased risk of cardiovascular disease. Irradiated breast cancer patients should be advised to refrain from smoking to reduce their risk for cardiovascular disease.

We assessed cardiovascular disease (CVD) incidence in 1474 survivors of Hodgkin lymphoma (HL) younger than 41 years at treatment . Multivariable Cox regression and competing risk analyses were used to quantify treatment effects on CVD risk. After a median follow-up of 18.7 years, risks of myocardial infarction (MI) and congestive heart failure (CHF) were strongly increased compared with the general population (standardized incidence ratios [SIRs] ‫؍‬ 3.6 and 4.9, respectively), resulting in 35.7 excess cases of MI and 25.6 excess cases of CHF per 10 000 patients/year. SIRs of all CVDs combined remained increased for at least 25 years and were more strongly elevated in younger patients. Mediastinal radiotherapy significantly increased the risks of MI, angina pectoris, CHF, and valvular disorders (2-to 7-fold). Anthracyclines significantly added to the elevated risks of CHF and valvular disorders from mediastinal RT (hazard ratios [HRs] were 2.81 and 2.10, respectively). The 25-year cumulative incidence of CHF after mediastinal radiotherapy and anthracyclines in competing risk analyses was 7.9%. In conclu IntroductionOver the past decades, survival of patients treated for Hodgkin lymphoma (HL) has improved dramatically, as a result of the development of multiagent chemotherapy (CT), more accurate radiotherapy (RT), and enhanced possibilities to reduce treatment complications. 1 Unfortunately, the improved prognosis of HL has been accompanied by long-term toxicity, such as elevated risks of second primary malignancies, 2-9 cardiovascular disease (CVD), 2,3,[8][9][10] and infections. 2,8,9 Increased mortality of cardiac disease after mediastinal radiotherapy for HL has been reported in several studies. 2,3,[8][9][10] Dose-dependent anthracycline-induced cardiotoxicity has been observed in survivors of malignancies other than HL, who were usually treated with higher anthracycline doses. 11,12 It is not known, therefore, whether anthracyclines add to the increased risk of CVD from mediastinal RT for survivors of HL. This is an important clinical question because most patients with HL now receive anthracycline-containing chemotherapy. Although a few studies reported on nonfatal cardiac events, comparisons with the general population were usually not made, because in most countries CVD incidence rates are not available. [13][14][15][16][17][18] The purpose of our study was to assess the long-term risk of various CVDs in a cohort of 1474 five-year survivors of HL treated between 1965 and 1995.Unique features of this study include long and near complete follow-up and the availability of complete treatment data, including radiation fields and chemotherapeutic agents. In addition, we compared the incidence of various CVDs with population-based reference rates from the general population, we accounted for competing risk of death from any cause, and we incorporated cardiac risk factors in the analyses. Patients and methods Data collection proceduresWe included all 5-year survivors of HL diagnosed before age 41 years (n ϭ 148...

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Reduction of radiation volume appears to decrease the risk for BC after HL. In addition, shorter duration of intact ovarian function after irradiation is associated with a significant reduction of the risk for BC.

Cardiac metastaseswith induction chemotherapy, with a poor response. Radiotherapy was initiated in order to reduce dysphagia. After 10.8-Gy radiotherapy was stopped because of increasing dyspnea arising from the narrowed left major bronchus (produced by local progression of the tumor), the placement of a bronchial stent was necessitated. At the same time, a second stent was placed in the esophagus to relieve the dysphagia. Palliative radiotherapy was given in fi ve daily fractions of 4 Gy, with marked alleviation of the dysphagia.In December 2006 he developed atypical chest pain. CT of the chest at that time showed regression of the esophageal tumor; but, surprisingly, cardiac metastasis was seen (Fig. 2). On echocardiography left ventricular function appeared normal. A dense hyperechogenic mass was seen in the myocardium, with a small amount of pericardial effusion. Palliative radiotherapy was delivered with anteriorposterior opposing fi elds. Radiation portals encompassed the CM with a margin of 1.5 cm to make sure that, with cardiac motion, the target volume remained in the portal. In order to shorten the treatment period, we prescribed a total dose of 20 Gy, in daily fractions of 4 Gy. Three weeks after the initiation of the palliative radiotherapy his symptoms were alleviated. Unfortunately we could not confi rm this subjective relief with chest CT, because the patient died of aspiration pneumonia 10 weeks after the initiation of the palliative radiotherapy. No autopsy was performed. Discussion and review of the literature EpidemiologyAlthough cardiac metastases (CM) are much more common than primary cardiac tumors, the diagnosis of CM antemortem is seldom made, because more than 90% are clinically silent. About 75% of primary cardiac tumors are benign and 25% are malignant (4% primary malignancy and 96% CM). According to the literature, CM have been found in 1.5%-20% of autopsies of cancer patients and in 0.2%-6.5% of subjects in unselected autopsy series. Abstract We report a case of esophageal cancer with symptomatic metastases to the heart; the patient was treated with short-course radiotherapy with good symptomatic relief. We reviewed the current literature regarding the epidemiology, clinical presentation, diagnostic tools, treatment modalities, and the prognosis of cardiac metastases. In this report we summarize the most recent autopsy studies (published between 1975 and 2007), in which we found an autopsy incidence of cardiac metastases of 2.3% among the general population, while the incidence among autopsies of cancer patients was 7.1%. Therefore, we share the opinion with others that there has been an increase in the incidence of cardiac metastases among cancer patients diagnosed after 1970, in comparison with the reported incidences in older series before 1970 (7.1% vs 3.8%; Kruskal-Wallis rank test; P = 0.039). Special attention was given to the role of radiotherapy in the management of cardiac metastases.

Purpose Previous reports suggest that radiation therapy for breast cancer (BC) can cause ischemic heart disease, with the radiation-related risk increasing linearly with mean whole heart dose (MWHD). This study aimed to validate these findings in younger BC patients and to investigate additional risk factors for radiation-related myocardial infarction (MI). Methods and Materials A nested case-control study was conducted within a cohort of BC survivors treated during 1970 to 2009. Cases were 183 patients with MI as their first heart disease after BC. One control per case was selected and matched on age and BC diagnosis date. Information on treatment and cardiovascular risk factors was abstracted from medical and radiation charts. Cardiac doses were estimated for each woman by reconstructing her regimen using modern 3-dimensional computed tomography planning on a typical patient computed tomography scan. Results Median age at BC of cases and controls was 50.2 years (interquartile range, 45.7-54.7). Median time to MI was 13.6 years (interquartile range, 9.9-18.1). Median MWHD was 8.9 Gy (range, 0.3-35.2 Gy). MI rate increased linearly with increasing MWHD (excess rate ratio [ERR] per Gy, 6.4%; 95% confidence interval, 1.3%-16.0%). Patients receiving ≥20 Gy MWHD had a 3.4-fold (95% confidence interval, 1.5-7.6) higher MI rate than unirradiated patients. ERRs were higher for younger women, with borderline significance (ERR <45years , 24.2%/Gy; ERR ≥50years , 2.5%/Gy; P interaction = .054). Whole heart dose-volume parameters did not modify the dose-response relationship significantly. Conclusions MI rate after radiation for BC increases linearly with MWHD. Reductions in MWHD are expected to contribute to better cardiovascular health of BC survivors.

Young patients with BC irradiated with breast tangentials experience increased risk of CBC, especially in those with a positive family history of BC. This finding should be taken into account when advising breast radiation with tangential fields to young patients with BC. Adjuvant chemotherapy seemed to reduce the risk of CBC during the first 5 years after treatment only.

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