Exposure of the heart in lung cancer radiation therapy: A systematic review of heart doses published during 2013 to 2020

Kearney, Maeve; Keys, Maeve; Faivre-Finn, Corinne; Wang, Zhe; Aznar, Marianne C.; Duane, F.

doi:10.1016/j.radonc.2022.05.007

Cited by 13 publications

(12 citation statements)

References 49 publications

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“…This study adds to existing literature showing that increasing MHD ( 9 , 13 , 14 , 18 ), heart V30Gy ( 19 ), heart V50Gy ( 9 ) and heart V5Gy ( 12 ) are all associated with worse overall survival in patients having curative radiotherapy for lung cancer. Moreover, we show that mean lung dose is significantly associated with survival, demonstrating that lung dose remains important in addition to heart dose.…”

Section: Discussionsupporting

confidence: 54%

Heart dose and cardiac comorbidities influence death with a cardiac cause following hypofractionated radiotherapy for lung cancer

et al. 2022

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BackgroundThere is increasing evidence of cardiac toxicity of thoracic radiotherapy however, it is difficult to draw conclusions on cardiac dose constraints due to the heterogeneity of published studies. Moreover, few studies record data on cause of death. The aim of this paper is to investigate the relationship between conventional cardiac dosimetric parameters and death with cardiac causes using data from the UK national cause of death registry.MethodsData on cancer diagnosis, treatment and cause of death following radical lung cancer radiotherapy were obtained from Public Health England for all patients treated at the Christie NHS Foundation Trust between 1/1/10 and 31/12/16. Individuals with metastatic disease and those who received multiple courses of thoracic radiotherapy where excluded. All patients who received > 45Gy in 20 fractions were included. Cardiac cause of death was defined as the following ICD-10 codes on death certificate: I20-I25; I30-I32; I34-I37; I40-I52. Cardiac V5Gy, V30Gy, V50Gy and mean heart dose (MHD) were extracted. Cumulative incidence of death with cardiac causes were plotted for each cardiac dosimetric parameter. Multi-variable Fine and Gray competing risk analysis was used to model predictors for cardiac death with non-cardiac death as a competing risk.ResultsCardiac dosimetric parameters were available for 967 individuals, 110 died with a cardiac cause (11.4%). Patients with a cardiac comorbidity had an increased risk of death with a cardiac cause compared with those without a cardiac comorbidity (2-year cumulative incidence 21.3% v 6.2%, p<0.001). In patients with a pre-existing cardiac comorbidity, heart V30Gy ≥ 15% was associated with higher cumulative incidence of death with a cardiac cause compared to patients with heart V30Gy <15% (2-year rate 25.8% v 17.3%, p=0.05). In patients without a cardiac comorbidity, after adjusting for tumour and cardiac risk factors, MHD (aHR 1.07, 1.01-1.13, p=0.021), heart V5Gy (aHR 1.01, 1-1.13, p=0.05) and heart V30Gy (aHR 1.04, 1-1.07, p=0.039) were associated with cardiac death.ConclusionThe effect of cardiac radiation dose on cardiac-related death following thoracic radiotherapy is different in patients with and without cardiac comorbidities. Therefore patients’ cardiovascular risk factors should be identified and managed alongside radiotherapy for lung cancer.

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Section: Discussionsupporting

confidence: 54%

Heart dose and cardiac comorbidities influence death with a cardiac cause following hypofractionated radiotherapy for lung cancer

et al. 2022

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“…Additionally, inclusion of cardiac substructures as OARs has previously been shown to improve cardiac sparing [ 55 ], and there are plans to incorporate our automatic segmentation tool with existing RT planning software for this purpose. Finally, while improved cardiac risk models are an important step to further understanding and mitigating negative side-effects of radiotherapy, these should be considered alongside methods to limit heart dose [ 56 , 57 ], and therefore additional research on the emerging radiotherapy and planning techniques with consideration of cardiac substructures is warranted.…”

Section: Discussionmentioning

confidence: 99%

Open-source, fully-automated hybrid cardiac substructure segmentation: development and optimisation

et al. 2023

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Radiotherapy for thoracic and breast tumours is associated with a range of cardiotoxicities. Emerging evidence suggests cardiac substructure doses may be more predictive of specific outcomes, however, quantitative data necessary to develop clinical planning constraints is lacking. Retrospective analysis of patient data is required, which relies on accurate segmentation of cardiac substructures. In this study, a novel model was designed to deliver reliable, accurate, and anatomically consistent segmentation of 18 cardiac substructures on computed tomography (CT) scans. Thirty manually contoured CT scans were included. The proposed multi-stage method leverages deep learning (DL), multi-atlas mapping, and geometric modelling to automatically segment the whole heart, cardiac chambers, great vessels, heart valves, coronary arteries, and conduction nodes. Segmentation performance was evaluated using the Dice similarity coefficient (DSC), mean distance to agreement (MDA), Hausdorff distance (HD), and volume ratio. Performance was reliable, with no errors observed and acceptable variation in accuracy between cases, including in challenging cases with imaging artefacts and atypical patient anatomy. The median DSC range was 0.81–0.93 for whole heart and cardiac chambers, 0.43–0.76 for great vessels and conduction nodes, and 0.22–0.53 for heart valves. For all structures the median MDA was below 6 mm, median HD ranged 7.7–19.7 mm, and median volume ratio was close to one (0.95–1.49) for all structures except the left main coronary artery (2.07). The fully automatic algorithm takes between 9 and 23 min per case. The proposed fully-automatic method accurately delineates cardiac substructures on radiotherapy planning CT scans. Robust and anatomically consistent segmentations, particularly for smaller structures, represents a major advantage of the proposed segmentation approach. The open-source software will facilitate more precise evaluation of cardiac doses and risks from available clinical datasets. Graphical abstract

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“…This suggests that if IMRT is not ready by the start of the initial planning, treatment may be initiated with 3DCRT. In addition, focusing on the heart, the MHD was similar between IMRT and 3DCRT in the present study, in agreement with the findings from previous studies 8 …”

Section: Discussionmentioning

confidence: 99%

“…In addition, focusing on the heart, the MHD was similar between IMRT and 3DCRT in the present study, in agreement with the findings from previous studies. 8 The hybrid technique demonstrated favorable dose characteristics; however, its high MU value is a notable concern. A shorter irradiation time is preferable when considering respiratory motion management such as breath-hold, and a lower MU value is required to minimize low-dose exposure.…”

Section: Initial Plan Extension On the Initial Ct Imagesmentioning

confidence: 99%

“…The latest cardio‐oncology guidelines define a mean heart dose (MHD) of ≥25 Gy as very high risk, <25 Gy but >15 Gy as high risk, <15 Gy but >5 Gy as moderate risk, and <5 Gy as low risk 7 . A literature review conducted from 2013 to 2020 reported an average cardiac dose of 10.3 Gy 8 . Although there are cases in which cardiac dose reduction is difficult owing to the anatomical location of the lesion, it is important to reduce the cardiac dose to the maximum feasible extent.…”

Section: Introductionmentioning

confidence: 99%

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Dosimetric comparison of five different radiotherapy treatment planning approaches for locally advanced non‐small cell lung cancer with sequential plan changes

Saito,

Komiyama,

Marino

et al. 2023

Thoracic Cancer

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BackgroundThe purpose of this study was to compare the dosimetric characteristics of five different treatment planning techniques for locally advanced non‐small cell lung cancer (LA‐NSCLC) with sequential plan changes.MethodsA total of 13 stage III NSCLC patients were enrolled in this study. These patients had both computed tomography (CT) images for initial and boost treatment plans. The latter CT images were taken if tumor shrinkage was observed after 2 weeks of treatment. The prescription dose was 60 Gy/30 Fr (initial: 40 Gy/20 Fr, and boost: 20 Gy/10 Fr). Five techniques (forward‐planed 3‐dimensional conformal radiotherapy [F‐3DCRT] on both CT images, inverse‐planned 3DCRT [I‐3DCRT] on both CT images, volumetric modulated arc therapy [VMAT] on both CT images, F‐3DCRT on initial CT plus VMAT on boost CT [bVMAT], and hybrid of fixed intensity‐modulated radiotherapy [IMRT] beams and VMAT beams on both CT images [hybrid]) were recalculated for all patients. The accumulated doses between initial and boost plans were compared among all treatment techniques.ResultsThe conformity indexes (CI) of the planning target volume (PTV) of the five planning techniques were 0.34 ± 0.10, 0.57 ± 0.10, 0.86 ± 0.08, 0.61 ± 0.12, and 0.83 ± 0.11 for F‐3DCRT, I‐3DCRT, VMAT, bVMAT, and hybrid, respectively. In the same manner, lung volumes receiving >20 Gy (V20Gy) were 21.05 ± 10.56%, 20.86 ± 6.45, 19.50 ± 7.38%, 19.98 ± 10.04%, and 17.74 ± 7.86%. There was significant improvement about CI and V20Gy for hybrid compared with F‐3DCRT (p < 0.05).ConclusionThe IMRT/VMAT hybrid technique for LA‐NSCLC patients improved target CI and reduced lung doses. Furthermore, if IMRT was not available initially, starting with 3DCRT might be beneficial as demonstrated in the bVMAT procedure of this study.

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Exposure of the heart in lung cancer radiation therapy: A systematic review of heart doses published during 2013 to 2020

Cited by 13 publications

References 49 publications

Heart dose and cardiac comorbidities influence death with a cardiac cause following hypofractionated radiotherapy for lung cancer

Heart dose and cardiac comorbidities influence death with a cardiac cause following hypofractionated radiotherapy for lung cancer

Open-source, fully-automated hybrid cardiac substructure segmentation: development and optimisation

Dosimetric comparison of five different radiotherapy treatment planning approaches for locally advanced non‐small cell lung cancer with sequential plan changes

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