Radyasyon İle İlişkili Aortik Hastalıklar
Özet
Radyoterapi (RT), meme kanseri, Hodgkin lenfoma ve diğer torasik maligniteler için yaygın kullanılan bir tedavi yöntemidir, ancak uzun vadede radyasyon ilişkili kalp hastalıkları (RİKH) riskini artırır. RİKH, genellikle 10-15 yıllık bir sessiz dönem sonrasında ortaya çıkar ve perikardiyal, miyokardiyal, vasküler, valvüler sorunlar ve iletim bozuklukları gibi kardiyovasküler komplikasyonlara neden olabilir. Radyasyonun kalp dokularına etkisi nedeniyle bu hastaların uzun dönem izlenmesi önemlidir ve ek olarak uygulanan kemoterapi, kardiyak komplikasyon riskini artırabilir.
Radyasyon hasarı, aort duvarında nekroz, fibroz hiperplazi ve lenfosit infiltrasyonu gibi akut değişikliklere neden olabilir. Kronik aşamada aort duvarı kalınlaşır ve mikrokalsifikasyonlar gelişebilir. RİKH risk faktörleri arasında yüksek radyasyon dozu, genç yaş, eş zamanlı kemoterapi ve kardiyovasküler hastalık öyküsü bulunur. RİKH tanısı koymak genellikle zordur ve ekokardiyografi, BT, MRI veya biyopsi gibi yöntemler gerektirebilir. Porselen aorta, aorttaki yaygın kalsifikasyonla tanımlanır ve bu, cerrahi tekniklerde değişiklik gerektirebilir. Bu durum, artmış inme riski ve yüksek morbidite-mortalite ile ilişkilidir.
Radyasyon ilişkili kalp hastalıklarının (RİKH) önlenmesine, tedavisinden daha fazla önem verilmelidir ve bunun ilk adımı, radyoterapinin sadece gerekli hastalara ve yeterli dozda uygulanmasıdır.
Radiotherapy (RT) is a commonly used treatment method for breast cancer, Hodgkin's lymphoma, and other thoracic malignancies, but it increases the risk of radiation-induced heart diseases (RIHD) in the long term. RIHD typically emerges after a silent period of 10-15 years and can lead to cardiovascular complications such as pericardial, myocardial, vascular, valvular issues, and conduction abnormalities. Due to the effects of radiation on heart tissues, long-term monitoring of these patients is crucial, and chemotherapy can further increase the risk of cardiac complications.
Radiation damage can cause acute changes in the aortic wall, such as necrosis, fibrous hyperplasia, and lymphocyte infiltration. In the chronic stage, the aortic wall thickens, and microcalcifications can develop. Risk factors for RIHD include high radiation dose, young age, concurrent chemotherapy, and a history of cardiovascular disease. Diagnosing RIHD is often difficult and may require methods such as echocardiography, CT, MRI, or biopsy. Porcelain aorta is characterized by widespread calcification in the aorta, which may necessitate changes in surgical techniques. This condition is associated with an increased risk of stroke and high morbidity-mortality.
Prevention of radiation-induced heart diseases (RIHD) should be prioritized over treatment, and the first step in prevention is ensuring radiotherapy is administered only to necessary patients and at an adequate dose.
Referanslar
R. Madan, R. Benson, D.N. Sharma, et al. Radiation induced heart disease: Pathogenesis, management and review literatüre. Journal of the Egyptian National Cancer Institute (2015) 27, 187–193
Effects of radiotherapy and surgery in early breast cancer. An overview of the randomized trials. Early Breast Cancer Trialists’ Collaborative Group. New Engand Journal of Medicine 1995;333(22):1444–55.
Clarke M, Collins R, Darby S, et al. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. The Lancet 2005;366:2087–106.
Ivo Steiner. Pathology of radiation induced heart disease. Reports of Practical Oncology and Radiotherapy. 25 (2020) 178–181
Hudson REB. Cardiovascular pathology. Vol. 2. London: E. Arnold; 1965:1612–1614.
Patrizio Lancellotti, Vuyisile T. Nkomo, Luigi P. Badano et al. Expert Consensus for Multi-Modality Imaging Evaluation of Cardiovascular Complications of Radiotherapy in Adults: A Report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography EACVI/ASE Expert Consensus Statement
Otto CM, Bonow RO, ed. Valvular Heart Disease: A Companion to Braunwald’s Heart Disease. 4th ed. Philadelphia, PA: Elsevier/Saunders; 2014.
Makkar RR, Jilaihawi H, Mack M, et al. Stratification of outcomes after transcatheter aortic valve replacement according to surgical inoperability for technical versus clinical reasons. Journal American College of Cardiology. 2014;63:901–911. doi: 10.1016/j.jacc.2013.08.1641.
Bapat VN, Attia RQ, Thomas M. Distribution of calcium in the ascend- ing aorta in patients undergoing transcatheter aortic valve implantation and its relevance to the transaortic approach. JACC Cardiovascular Interventions. 2012;5:470–476. doi: 10.1016/j.jcin.2012.03.006.
Kempfert J, Van Linden A, Linke A, et al. Transapical aortic valve implantation: therapy of choice for patients with aortic stenosis and porcelain aorta? The Annals of Thoracic Surgery. 2010;90:1457–1461. doi: 10.1016/j.athoracsur.2010.06.080.
Faggiano P, Frattini S, Zilioli V, et al. Prevalence of comorbidities and associated cardiac diseases in patients with valve aortic stenosis: potential implications for the decision-making process. International Journal of Cardiology. 2012;159:94–99. doi: 10.1016/j.ijcard.2011.02.026.
Fukuda I, Daitoku K, Minakawa M, Fukuda W. Shaggy and calcified aorta: surgical implications. General Thoracic and Cardiovascular Surgery. 2013;61:301– 313. doi: 10.1007/s11748-013-0203-y.
Gillinov AM, Lytle BW, Hoang V, et al. The atherosclerotic aorta at aortic valve replacement: surgical strategies and results. The Journal of Thoracic and Cardiovascular Surgery. 2000;120:957–963. doi: 10.1067/ mtc.2000.110191.
Buz S, Pasic M, Unbehaun A, Drews T, et al. Trans-apical aortic valve implantation in patients with severe calcification of the ascending aorta. Europan Journal of Cardiothoracic Surgery. 2011;40:463–468. doi: 10.1016/j.ejcts.2010.11.075.
Eisen A, Tenenbaum A, Koren-Morag N, et al. Calcification of the thoracic aorta as detected by spiral computed tomography among stable angina pectoris patients: association with cardiovascular events and death. Circulation. 2008;118:1328–1334. doi: 10.1161/ CIRCULATIONAHA.107.712141.
Budoff MJ, Nasir K, Katz R, et al.Thoracic aortic calcification and coronary heart disease events: the Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis. 2011;215:196–202. doi: 10.1016/j.atherosclerosis.2010.11.017.
Urbanski PP, Raad M, Wagner M, et al. Cardiac surgery in patients with a porcelain aorta in the era of transcatheter valve implantation. Europan Journal of Cardiothoracic Surgery. 2013;44:48–53. doi: 10.1093/ ejcts/ezs695.
Svensson LG, Sun J, Cruz HA, Shahian DM. Endarterectomyforcalcified porcelain aorta associated with aortic valve stenosis. The Annals of Thoracic Surgery. 1996;61:149–152. doi: 10.1016/0003-4975(95)00984-1.
Bucerius J, Gummert JF, Borger MA, et al. Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. The Annals of Thoracic Surgery. 2003;75:472–478.
Karohl C, D’Marco Gascón L, Raggi P. Noninvasive imaging for assessment of calcification in chronic kidney disease. Nature Reviews Nephrology. 2011;7:567–577. doi: 10.1038/nrneph.2011.11
Coblentz C, Martin L, Tuttle R. Calcified ascending aorta after radiation therapy. AJR American Journal of Roentgenology 1986;147:477–478. doi: 10.2214/ ajr.147.3.477.
Mesurolle B, Qanadli SD, Merad M, et al. Unusual radiologic findings in the thorax after radiation therapy. Radiographics. 2000;20:67–81. doi: 10.1148/radiographics. 20.1.g00ja1167.
Desai MY, Karunakaravel K, Wu W, et al. Pulmonary fibrosis on multidetector computed tomography and mortality in patients with radiation-associated cardiac disease undergoing cardiac surgery. Journal of Thoracic and Cardiovascular Surgery. 2014;148:475–81.e3. doi: 10.1016/j.jtcvs.2013.08.087.
Yamada M, Naito K, Kasagi F,et al. Prevalence of atherosclerosis in relation to atomic bomb radiation exposure: an RERF Adult Health Study. International Journal of Radiation Biology. 2005;81:821–826. doi: 10.1080/09553000600555504.
Carver JR, Shapiro CL, Ng A, Jacobs L, et al; ASCO Cancer Survivorship Expert Panel. American Society of Clinical Oncology clinical evidence review on the ongoing care of adult cancer survivors: cardiac and pulmonary late effects. Journal of Clinical Oncology. 2007;25:3991–4008. doi: 10.1200/JCO.2007.10.9777.
Referanslar
R. Madan, R. Benson, D.N. Sharma, et al. Radiation induced heart disease: Pathogenesis, management and review literatüre. Journal of the Egyptian National Cancer Institute (2015) 27, 187–193
Effects of radiotherapy and surgery in early breast cancer. An overview of the randomized trials. Early Breast Cancer Trialists’ Collaborative Group. New Engand Journal of Medicine 1995;333(22):1444–55.
Clarke M, Collins R, Darby S, et al. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. The Lancet 2005;366:2087–106.
Ivo Steiner. Pathology of radiation induced heart disease. Reports of Practical Oncology and Radiotherapy. 25 (2020) 178–181
Hudson REB. Cardiovascular pathology. Vol. 2. London: E. Arnold; 1965:1612–1614.
Patrizio Lancellotti, Vuyisile T. Nkomo, Luigi P. Badano et al. Expert Consensus for Multi-Modality Imaging Evaluation of Cardiovascular Complications of Radiotherapy in Adults: A Report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography EACVI/ASE Expert Consensus Statement
Otto CM, Bonow RO, ed. Valvular Heart Disease: A Companion to Braunwald’s Heart Disease. 4th ed. Philadelphia, PA: Elsevier/Saunders; 2014.
Makkar RR, Jilaihawi H, Mack M, et al. Stratification of outcomes after transcatheter aortic valve replacement according to surgical inoperability for technical versus clinical reasons. Journal American College of Cardiology. 2014;63:901–911. doi: 10.1016/j.jacc.2013.08.1641.
Bapat VN, Attia RQ, Thomas M. Distribution of calcium in the ascend- ing aorta in patients undergoing transcatheter aortic valve implantation and its relevance to the transaortic approach. JACC Cardiovascular Interventions. 2012;5:470–476. doi: 10.1016/j.jcin.2012.03.006.
Kempfert J, Van Linden A, Linke A, et al. Transapical aortic valve implantation: therapy of choice for patients with aortic stenosis and porcelain aorta? The Annals of Thoracic Surgery. 2010;90:1457–1461. doi: 10.1016/j.athoracsur.2010.06.080.
Faggiano P, Frattini S, Zilioli V, et al. Prevalence of comorbidities and associated cardiac diseases in patients with valve aortic stenosis: potential implications for the decision-making process. International Journal of Cardiology. 2012;159:94–99. doi: 10.1016/j.ijcard.2011.02.026.
Fukuda I, Daitoku K, Minakawa M, Fukuda W. Shaggy and calcified aorta: surgical implications. General Thoracic and Cardiovascular Surgery. 2013;61:301– 313. doi: 10.1007/s11748-013-0203-y.
Gillinov AM, Lytle BW, Hoang V, et al. The atherosclerotic aorta at aortic valve replacement: surgical strategies and results. The Journal of Thoracic and Cardiovascular Surgery. 2000;120:957–963. doi: 10.1067/ mtc.2000.110191.
Buz S, Pasic M, Unbehaun A, Drews T, et al. Trans-apical aortic valve implantation in patients with severe calcification of the ascending aorta. Europan Journal of Cardiothoracic Surgery. 2011;40:463–468. doi: 10.1016/j.ejcts.2010.11.075.
Eisen A, Tenenbaum A, Koren-Morag N, et al. Calcification of the thoracic aorta as detected by spiral computed tomography among stable angina pectoris patients: association with cardiovascular events and death. Circulation. 2008;118:1328–1334. doi: 10.1161/ CIRCULATIONAHA.107.712141.
Budoff MJ, Nasir K, Katz R, et al.Thoracic aortic calcification and coronary heart disease events: the Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis. 2011;215:196–202. doi: 10.1016/j.atherosclerosis.2010.11.017.
Urbanski PP, Raad M, Wagner M, et al. Cardiac surgery in patients with a porcelain aorta in the era of transcatheter valve implantation. Europan Journal of Cardiothoracic Surgery. 2013;44:48–53. doi: 10.1093/ ejcts/ezs695.
Svensson LG, Sun J, Cruz HA, Shahian DM. Endarterectomyforcalcified porcelain aorta associated with aortic valve stenosis. The Annals of Thoracic Surgery. 1996;61:149–152. doi: 10.1016/0003-4975(95)00984-1.
Bucerius J, Gummert JF, Borger MA, et al. Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients. The Annals of Thoracic Surgery. 2003;75:472–478.
Karohl C, D’Marco Gascón L, Raggi P. Noninvasive imaging for assessment of calcification in chronic kidney disease. Nature Reviews Nephrology. 2011;7:567–577. doi: 10.1038/nrneph.2011.11
Coblentz C, Martin L, Tuttle R. Calcified ascending aorta after radiation therapy. AJR American Journal of Roentgenology 1986;147:477–478. doi: 10.2214/ ajr.147.3.477.
Mesurolle B, Qanadli SD, Merad M, et al. Unusual radiologic findings in the thorax after radiation therapy. Radiographics. 2000;20:67–81. doi: 10.1148/radiographics. 20.1.g00ja1167.
Desai MY, Karunakaravel K, Wu W, et al. Pulmonary fibrosis on multidetector computed tomography and mortality in patients with radiation-associated cardiac disease undergoing cardiac surgery. Journal of Thoracic and Cardiovascular Surgery. 2014;148:475–81.e3. doi: 10.1016/j.jtcvs.2013.08.087.
Yamada M, Naito K, Kasagi F,et al. Prevalence of atherosclerosis in relation to atomic bomb radiation exposure: an RERF Adult Health Study. International Journal of Radiation Biology. 2005;81:821–826. doi: 10.1080/09553000600555504.
Carver JR, Shapiro CL, Ng A, Jacobs L, et al; ASCO Cancer Survivorship Expert Panel. American Society of Clinical Oncology clinical evidence review on the ongoing care of adult cancer survivors: cardiac and pulmonary late effects. Journal of Clinical Oncology. 2007;25:3991–4008. doi: 10.1200/JCO.2007.10.9777.
