International Journal of Radiation Oncology*Biology*Physics
Clinical investigationNormal tissueThe utility of 18F-fluorodeoxyglucose positron emission tomography for early diagnosis of radiation-induced myocardial damage
Introduction
Positron emission tomography (PET) using 18F-fluorodeoxyglucose (FDG) is considered to be useful for evaluating tumor extension or detecting recurrence in patients with esophageal cancer. Therefore, FDG-PET is a promising noninvasive method for follow-up after chemoradiotherapy for esophageal cancer. Some patients have shown focal increased FDG uptake in the basal myocardium after completion of chemoradiotherapy. We suspected that these findings indicate myocardial damage induced by radiotherapy.
Before the 1960s, the myocardium was considered to be a relatively radiation-resistant organ, although pericardiac effusion without symptoms after irradiation for the mediastinum often occurred. Recently, however, there have been many reports of patients with radiation-induced myocardial damage in the late phase (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16). There have also been reports of occasional heart-related deaths in patients with esophageal cancer after radiotherapy (17, 18). Significant impairment of the left ventricular ejection fraction after radiotherapy for the mediastinum has also been reported (19). In addition, ischemic changes in the irradiated myocardium have been observed in some studies on myocardial perfusion imaging (7, 8, 9).
In the present study, we evaluated patients who showed focal increased FDG uptake in the basal myocardium after radiotherapy for esophageal cancer. To our knowledge, although we reported a case of radiation-induced cardiomyopathy (20), there are no other reports of those FDG-PET findings that suggest radiation-induced myocardial damage. To clarify the clinical significance of these findings, we investigated the relationship with dose distribution in the myocardium and compared the findings of heart ultrasound (US), magnetic resonance imaging (MRI), and myocardial single-photon emission computed tomography (SPECT).
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Patients
Between August 2004 and July 2005, a total 64 patients (60 males and 4 females; median age, 66 years; range, 45 to 86 years) were enrolled in the present study with follow-up study for cancer. All patients had primary or postoperative recurrent thoracic esophageal cancer and had undergone irradiation to the mediastinum in our institution. Sixty-three patients had been proven to have squamous cell carcinoma, and one patient had been proven to have adenocarcinoma. The characteristics of all
Results
In the present study, 13 (20.3%) of the 64 patients showed high FDG uptake in the base of the left ventricular myocardium corresponding to the irradiated fields in comparison with FDG uptake in the myocardium outside the irradiated fields. The distribution of high FDG uptake is very characteristic and not consistent with the vascular territory of coronal arteries. That is, the high FDG uptake was seen in the basal portions of the anterior wall, posterior wall, lateral wall, and interventricular
Discussion
In the present study, 13 (20.3%) of the 64 patients who underwent irradiation for esophageal cancer showed high FDG uptake in the basal myocardium. The regions of high FDG uptake corresponded to the irradiated field but not to any coronary artery vascular territories. It is unlikely that these findings are a result of regional ischemia due to stenosis or occlusion of coronary arteries. Therefore, in this study, we explored the possibility of myocardial damage induced by radiation.
Myocardial
Conclusions
Focal increased FDG uptake in the basal myocardium is sometimes seen in patients with esophageal cancer after radiotherapy. This finding might indicate radiation-induced myocardial damage. Cardiac function and symptom of the patients with those focal increased FDG uptake should be followed to prevent cardiac impairment or death as a result of radiation therapy.
References (22)
- et al.
Radiation heart diseaseAnalysis of 16 young (aged 15 to 33 years) necropsy patients who received over 3,500 rads to the heart
Am J Med
(1981) - et al.
Mortality from myocardial infarction following postlumpectomy radiotherapy for breast cancer: A population-based study in Ontario, Canada
Int J Radiat Oncol Biol Phys
(1999) - et al.
Radiation-induced heart disease in rats
Int J Radiat Oncol Biol Phys
(1985) - et al.
Cardiac perfusion changes in patients treated for breast cancer with radiation therapy and Doxorubicin: Preliminary results
Int J Radiat Oncol Biol Phys
(2001) - et al.
Cardiac doses in postoperative irradiation
Radiother Oncol
(1992) - et al.
Morbidity of ischemic heart disease in early breast cancer 15–20 years after adjuvant radiotherapy
Int J Radiat Oncol Biol Phys
(1994) The Skinner lecture: A cost-benefit analysis postoperative radiotherapy in the treatment of early breast cancer
Clin Oncol
(1991)- et al.
Cardiac risk after mediastinal irradiation for Hodgkin’s disease
Radiother Oncol
(1998) - et al.
The significance of cardiac doses received during chemoradiation of oesophageal and gastro-oesophageal junctional cancers
Clin Oncol
(2003) - et al.
Cardiovascular mortality in a randomized trial of adjuvant radiation therapy versus surgery alone in primary breast cancer
Int J Radiat Oncol Biol Phys
(1992)
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2020, Advances in Radiation OncologyCitation Excerpt :Therefore, we should consider additional care for long-term survivors who have received mediastinal RT for esophageal cancer. Past studies showed that nuclear medicine imaging such as I-123b-methyl iodophenyl pentadecanoic acid (BMIPP) was useful for detecting RT-induced myocardial damage.13-18 Late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) enables visualization of the myocardial scar in patients with ischemic and nonischemic myocardial diseases,19,20 and it has higher spatial resolution than that of scintigraphy.21