Identification and management of severe multiple radiation-induced heart disease: case reports from locally advanced esophageal cancer patient

Abstract

E sophageal cancer (EC) is one of the leading causes of cancer-related mortality worldwide. It is a highly malignant tumor with a high local recurrence and distant metastasis. Notably, about half of the world’s EC patients occur in China. Smoking, drinking liquor alcohol and eating hot food are the top three risk factors for EC in China. Radiation therapy (RT) plays a pivotal role in the treatment of locally advanced EC patients, and radiation-induced heart diseases (RIHD) has become a clinically concerned problem, which may involve any structure of heart, including coronary heart disease (CHD), atrial fibrillation (AF), valvular heart disease (VHD), pericardial effusion (PE), heart failure (HF), thromboembolic disease (TED) and atrioventricular block (AVB), sick sinus syndrome (SSS), and etc; some of which may occur after 10−15 years or even more decades. 3] Herein, we report some cases with severe multiple RIHD after traditional RT and intensity modulated radiotherapy (IMRT) in different ages. To the best of our knowledge, few investigators have focused on relevant similar cases. Five patients with upper (n = 2) or middle (n = 3) thoracic locally advanced esophageal squamous cell carcinoma who received radiotherapy, combined surgery (n = 4) or concurrent chemotherapy (n = 1) between 1990 and 2018 were retrospectively analyzed. Baseline characteristics and risk factors for cardiovascular disease (CVD) are shown in Table 1. All patients had no clear CVD clinical symptoms prior-RT, but there were some risk factors in three cases. Case 2 had been smoking average 40 cigarettes and drinking 150−250 mL liquor alcohol per day for 27 years prior to RT. Cases 4 & 5 had hypertension and Case 4 had mild diabetes mellitus and did not take hypoglycemic drugs. EC management and identification of RIHD are presented in Table 2 and Figure1−5. We can’t get more details because RT for Cases 1–3 was respectively performed 30, 24 and 20 years ago. Their treatment regiments were similar as follows: Cobalt-60 RT (60 Gy in fractions 5−7 weeks followed surgery). Case 4 was treated with postoperative IMRT in 2014. Due to the patient with advanced age, Case 5 was only treated by chemoradiotherapy, which consisted of Tegio 40 mg/day for the first 14 days, and IMRT at 2 Gy/day for five days per week (total dose: 60 Gy) in 2018. Clinical target volume was defined by referring to EC position plus 1−2 cm. RIHD was mainly detected and evaluated by electrocardiogram (ECG), dynamic ECG (DCG), ultrasonic echocardiography (UCG), CT angiography (CTA), coronary angiography (CAG) and N-terminal pro Btype natriuretic peptide. They were diagnosed with CHD (n = 5), AF (n = 4), VHD (n = 3), PE (n = 5), HF (n = 5), TED (n = 2) and third-degree AVB (n = 1), and SSS (n = 2). RIHD management and prognosis of RIHD are showed in Table 3. With the continuous progress of esophageal cancer radiotherapy (ECRT) technology, the survival rate of EC patients has been significantly improved. However, RT in the locally advanced stage EC inevitably leads to heart injury. RT mainly results in the Journal of Geriatric Cardiology