Radiation induced pericarditis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.
Overview
The survival rate in Hodgkin lymphoma, Non-Hodgkin's lymphoma and breast carcinomas has significantly improved with use of radiation therapy. However, radiation therapy to thoracic and mediastinal cancers have also led to the development of pericarditis, coronary artery disease, cardiomyopathy, conduction abnormalities in heart and valvular heart diseases which account for significant morbidity and mortality. The incidence is higher with doses greater than 40 Gy (4000 rad).
Historical Perspective
Classification
Based on the presentation and onset of symptoms, the radiation-induced pericardial disease may be classified as:[1]
- Acute pericarditis
- Delayed pericarditis
- Pancarditis
- Constrictive pericarditis
- Pericardial effusion
Pathophysiology
Radiation therapy disrupts endothelial cells of the microvasculature of the pericardium and leads to repeated episodes of ischemia. The final result is the formation of fibrosis and fibrinous exudates that are ultimately replaced by fibroblasts and collagen fibers [2][3][4][5].
Radiation-induced pericarditis depends on:
- Total dose of radiation
- Amount of cardiac silhouette exposed
- Nature of the radiation source
- Duration and fractionation of therapy
In a retrospective study, 27.7% of the patients developed pericardial effusion after median time period of 5.3 months following radiotherapy for esophageal carcinoma with radiation dose ranging between 3 to 50Gy. It was concluded that high dose-volume of the irradiated pericardium and heart increased the risk of developing pericarditis[6].
Causes
Differentiating Radiation-induced Pericarditis from other Diseases
Epidemiology and Demographics
Pericardial changes are the most common cardiac complications of radiation therapy[3]. Incidence of radiation induced pericarditis has significantly decreased with the use of lower doses and newer radiotherapy techniques [7][8][9]. In a study, incidence decreased from 20% to 2.5% with the changes in methods of RT administration[7]
In as study among pediatric population with various cancers, radiation therapy with ≥15 GY increased the risk of developing pericarditis by two to six times[10]
Risk Factors
Screening
Natural History, Complications, and Prognosis
Diagnosis
Diagnostic Study of Choice
There are no established criteria for radiation induced pericarditis.
History and Symptoms
- Acute pericarditis: Acute pericarditis is a rare complication of radiation therapy. It presents with nonspecific pericarditis symptoms such as chest pain and fever shortly after radiation therapy[1][3].
- Delayed pericarditis: Delayed pericarditis occurs from months to years after exposure to radiation [11][12]. It usually presents with pericardial chest pain, dyspnea, and orthopnea. Protein-rich exudate may accumulate in the pericardial sac leading to pericardial effusion. Rapid accumulation may result in the development of cardiac tamponade presenting with clinical signs and symptoms of hypotension, distant heat sounds, and justended jugular veins. Dyspnea, orthopnea, chest pain with clinical signs of distant heart sounds, hypotension, and distended jugular veins might serve as pointers for diagnosis[3][11].
Physical Examination
Patients may present with fever
Vitals
Pulse
Rate
Blood Pressure
Neck
- Jugular venous distension with a prominent Y descent and Kussmaul's sign
Heart
- Ewart's sign may be present. This includes a pericardial knock
- Pericardial rub(heard best while leaning forwards) and distant heart sounds
Abdomen
Extremities
Laboratory Findings
Electrocardiogram
Non-specific ST and T wave changes or ST segment elevation in all leads may be noted.
X-ray
Echocardiography or Ultrasound
CT scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Pericardiocentesis
- Radiation induced pericardial effusion can be confused with malignant pericarditis and hypothyroidism (secondary to mediastinal irradiation) induced pericarditis.
- Pericardiocentesis can be used to differentiate them with fluid analysis for malignant cells and thyroid function tests.
- For more information on pericardiocentesis, click here.
Treatment
Medical Therapy
Surgery
- Pericarditis with large effusion can be drained either percutaneously or surgically
- Those with recurrent pericardial effusion can be treated with pericardiotomy(pericardial window) or by surgical stripping.
- Pericardiectomy is recommended for patients who develop constrictive pericarditis. However, the perioperative mortality rate is higher in postradiation constrictive pericarditis compared to that of idiopathic constrictive pericarditis[13].
Primary Prevention
Secondary Prevention
References
- ↑ 1.0 1.1 Yusuf SW, Sami S, Daher IN (2011). "Radiation-induced heart disease: a clinical update". Cardiol Res Pract. 2011: 317659. doi:10.4061/2011/317659. PMC 3051159. PMID 21403872.
- ↑ Fajardo LF (1989). "The unique physiology of endothelial cells and its implications in radiobiology". Front Radiat Ther Oncol. 23: 96–112. doi:10.1159/000416574. PMID 2697671.
- ↑ 3.0 3.1 3.2 3.3 Yusuf SW, Venkatesulu BP, Mahadevan LS, Krishnan S (2017). "Radiation-Induced Cardiovascular Disease: A Clinical Perspective". Front Cardiovasc Med. 4: 66. doi:10.3389/fcvm.2017.00066. PMC 5662579. PMID 29124057.
- ↑ Taunk NK, Haffty BG, Kostis JB, Goyal S (2015). "Radiation-induced heart disease: pathologic abnormalities and putative mechanisms". Front Oncol. 5: 39. doi:10.3389/fonc.2015.00039. PMC 4332338. PMID 25741474.
- ↑ Hooning MJ, Aleman BM, van Rosmalen AJ, Kuenen MA, Klijn JG, van Leeuwen FE (2006). "Cause-specific mortality in long-term survivors of breast cancer: A 25-year follow-up study". Int J Radiat Oncol Biol Phys. 64 (4): 1081–91. doi:10.1016/j.ijrobp.2005.10.022. PMID 16446057.
- ↑ Wei X, Liu HH, Tucker SL, Wang S, Mohan R, Cox JD; et al. (2008). "Risk factors for pericardial effusion in inoperable esophageal cancer patients treated with definitive chemoradiation therapy". Int J Radiat Oncol Biol Phys. 70 (3): 707–14. doi:10.1016/j.ijrobp.2007.10.056. PMID 18191334.
- ↑ 7.0 7.1 Carmel RJ, Kaplan HS (1976). "Mantle irradiation in Hodgkin's disease. An analysis of technique, tumor eradication, and complications". Cancer. 37 (6): 2813–25. doi:10.1002/1097-0142(197606)37:6<2813::aid-cncr2820370637>3.0.co;2-s. PMID 949701.
- ↑ Maisch B, Ristić AD (2003). "Practical aspects of the management of pericardial disease". Heart. 89 (9): 1096–103. PMC 1767862. PMID 12923044.
- ↑ Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y; et al. (2004). "Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology". Eur Heart J. 25 (7): 587–610. doi:10.1016/j.ehj.2004.02.002. PMID 15120056.
- ↑ Mulrooney DA, Yeazel MW, Kawashima T, Mertens AC, Mitby P, Stovall M; et al. (2009). "Cardiac outcomes in a cohort of adult survivors of childhood and adolescent cancer: retrospective analysis of the Childhood Cancer Survivor Study cohort". BMJ. 339: b4606. doi:10.1136/bmj.b4606. PMID 19996459.
- ↑ 11.0 11.1 Morton DL, Glancy DL, Joseph WL, Adkins PC (1973). "Management of patients with radiation-induced pericarditis with effusion: a note on the development of aortic regurgitation in two of them". Chest. 64 (3): 291–7. doi:10.1378/chest.64.3.291. PMID 4127171.
- ↑ Applefeld MM, Cole JF, Pollock SH, Sutton FJ, Slawson RG, Singleton RT; et al. (1981). "The late appearance of chronic pericardial disease in patients treated by radiotherapy for Hodgkin's disease". Ann Intern Med. 94 (3): 338–41. doi:10.7326/0003-4819-94-3-338. PMID 7224379.
- ↑ Bertog SC, Thambidorai SK, Parakh K, Schoenhagen P, Ozduran V, Houghtaling PL; et al. (2004). "Constrictive pericarditis: etiology and cause-specific survival after pericardiectomy". J Am Coll Cardiol. 43 (8): 1445–52. doi:10.1016/j.jacc.2003.11.048. PMID 15093882.