Radiation-Induced Coronary Artery Disease

CHEST VOLUME

I NUMBER

71

5 I

Radiation-Induced

Coronary

in

Artery

clinical

formed

in

and

the

has shown that the mals can be damaged radiation.’ prior

jury

to cardiac

to

of

exudative of the has

The

appearing of radiotherapy. a benign

#{243}onstriction.LS high

rabbit.3 the

In

the

capillary

it has

lesion

is mediated cells,

microcirculation

a large

group

been

patients

California

(San

Francisco)

has

sion is clearly dose-dependent of tolerance to radiation can cardium.’ of

the

It is expected heart

pericarditis

of

Ordinarily,

in

therapy.L4.S

In

with

printed) disease six

died

and 1)

Hodgkin’s with

an

extensive

that

(in been with

dissevere myo-

.

as this, one connection

atherosclerosis

very

is tempted between

ionizing

this First,

in general.

to establish radiation is not apone should is capable

Several

expert-

monkeys, dogs, rats, mice, birds, etc) performed precisely to prove such a varying degrees of success;6 for instance,

of

Study

of

radio-

Hodgkin’s disease the University of shown

that

the

le-

a large field

of

volume radiation,

in 16 fractions in an incidence

over of

5 percent.’

hearts

being artery

injury

muscle.3

severe

radiation-induced

disease show no more atherosclerosis pected for the corresponding age.4 least ten reports have been published more are coronary

ments have point,

have

underwent

when the

of 4,000 rads will result

about

of

he

and that the limits be defined for the peri-

that,

is included

the administration a four-week period

for at

treatment later,

radiation

to prove

These coronary

in compromise

who

therapy of the mediastinum at Stanford University and

for

be

able

ar-

dispropor-

vessels.

factors

But

of causing

pa-

that

through

resulting

other

and coronary artery disease. propriate scientific methodology.

white

established

or

the re-

lesions

the

(Fig

In cases such cause-and-effect

risk

young

coronary

as family history, hypertenetc. A dramatic example was boy who received 4,000 rads

months

infarct

of

whom

a

volume fibrosis.

Zealand

for

those

the

individuals

of cardiac

of

a

of the

atherosclerosis

cardial

or pen-

to a large myocardial

mantle

coronary

is

in some

New

rabbit,

endothelial

within

tamponade

the

me-

usually

addition,

in

lungs, lesion

myocardial

reproduced

myocardial

of the

and

the

to

Sixteen

in

many

by

the

range

unexpected

condition lacked

in-

ease.

are

old)

totally

artery disease, such sion, hyperlipidemia, that of a 14-year-old

radio-

Although

doses of radiation may develop diffuse

pericardilal well

In

often

common

course,

to cardiac

to the

patients

cases

years

was

tionate

of

to the

of

most

initiation

ceiving of the Both

a limit

disease

per-

believed

35

of ages is frequently

the

atherosclerosis

other

to

1970s

other mamdoses of ioniz-

was

pericarditis have

early

possibility

neoplasms

breast.

cardial

been

and

the

imposes

progressed

heart

the

what

studies,

tissues

of cases

lesion

to

those

and

work

and

heart of man by therapeutic

malignant

diastinum,

majority

1960s

Contrary

many

year

experimental

late

The (15

terial

within

spontaneous

observed.

Disease Extensive

developed

which

tients

therapy

1977

atherosclerosis

EDITORIALS

ing

MAY,

of

describing seemingly these

FIGURE

than that exSince 1957, at (and three 16 patients related to

individuals,

1.

Transverse

section

of left

anterior

coronary

artery

boy who died with large, acute, anteroseptal myocardial infarct. Sixteen months earlier, he had received 4,000 rads to mantle for Hodgkin’s disease. Notice marked eccentric myointimal proliferation (and atheromatosis) which at this point has reduced lumen to less than one-fourth of its expected diameter (hematoxylin-eosm, original magnification from

with radio-

coronary

X

563

15-year-old

27).

coronary

atherosclerosis

coronary

arterial

bits receiving to the heart lipids

sclerosis,

of

produced

type

human

rabbits

seen

in

did

by

man, the

ated

human seems There

not

has

not

other

resulting of tumors of these

mentally

of the

patients there

been of

and

sclerosis.

expression is

United States, radiation-induced very

that

individuals diet and

and

that

rich

but

coronary

it may lipids

in

the

and

be

at risk. Therefore, radiotherapy alone may

be

other

pressed in areas subjected cal injury, such as irradiation.

when

planning

but not

the

relationship

tion

is still

questionable;

of coronary and

ship

exists,

the

of

appears

to be

overall

incidence

in patients disease

low.

was

reduced

a dose

neoplasm

of 3,000

of the In

to

the

by shielding rads;9 however,

otherwise possibility

the

EDITORIALS

majority

would

kill

of producing of

cases,

the

5

the

radiation-induced

in

Pathology

with

the

ir-

comM.D.#{176} Calif

University

School

Department,

LF,

VA

beof the

Gold

Lee

Cancer GD, of

the

development

Res

4:325-334,

Conomy

JP,

consequences

Dose

and

Am treat-

effusion

asso-

Hodgkin’s

disease.

KE:

Arch CL,

of radiation-induced

29:244-257,

Cohn

1973

Morphology

Pathol

Roberts

of

radia-

86:512-519, WC:

irradiation

1968

Coronary

for

heart

Hodgkin’s

disease.

1976 A:

Rupture

36:904-913,

synergism

a

Invest

JR.

60:39-45,

LF,

for

Pathogenesis

mediastinal

Med

et al:

North

pericardial

disease.

RA,

7 Amromin

8

JR: Lab

heart after

J,

disease:

Clin

1975

Stewart

McReynolds

heart Radiol

technique

Stewart

LF,

Fajardo

aspects.

K, Ruckdeschel

fibrosis.

Fajardo

Radiation-induced

mantle

35:795-802,

J

LF:

radiation-related

Fajardo

tion.

apex not

thereby against

a lesion

factors

Cancer

Am 6

disease

patient,

1971 R, Brace

disease

Hodgkin’s

to the heart, of therapy

9:511-531, Byhardt

myocardial

relation-

cardiac one should

to is

F. Fajardo,

Dr. Fajardo, 94304

experimental

tion-induced

disease

for the

3 4

to radia-

heart

mantle

patients

microcirculation

Stanford

Fajardo

and

ciated

in

University

JR,

Clinical

ment

radiis that heart

coronary

At Stanford

a tumor adjacent a valuable form that

such

requests: Palo Alto

1 Stewart

ex-

if the

technique

REFERENCES

because

of radiation-induced

irradiated

fail to treat compromising

564

incidence very

Reprint Hospital,

of physi-

disease

even

the those

secondary

of Pathology,

addi-

radiotherapy artery

Professor

of Medicine.

athero-

coronary arterial disease be an important consideration of

the

Never-

Stanford, eAssociate

speculate sufficient

form

that benefit

Luis

one may are not

which,

feasible.

fibrosis

whom

portions of of disease,

promised.

2

a course

myocardial in

be

not

susvein results.

distal free

the

of irradi-

some

diffuse

will

was

satisfactory

to realize

probably

radiation

the

of

Now, should one try to prevent the possible ation-induced coronary disease? The answer one should try to prevent radiation-induced in general, should

with

number

factors

to

it is important

(see radia-

saphenous

the are

should

of

reported

associates in whom

by

with

bypass

type

case

disease

treated

bypass

artery

as if it were

Iqbal and a patient artery

was

artery

of bypass

neces-

predispose to is preferentially

effect

who

different be pos-

This

in the

cholesterol.

population

to the

surgically

exemplified

coronary

theless,

con-

for

disease

does

should be of coronary

is not it should

atherosclerosis.

been

and

coronary

experi-

that,

has

disease

what

hearts hearts,4

If the angiogram shows that the major coronary arteries

be ruled may

possible

in

in relation

there

how-

in whom both

the

coronary

tion-induced

the number of cases of possible coronary artery disease is appar-

or independently, and whose

disease particular

to approach

neck;8

radiation

it is

common

small

ated that

sible

pected

to the penpericardio-

artery

of the heart, the distribution

disease in irradiated that in nonirradiated

after

cannot

coronary

artery from

deficits, and

that

irradiation Since

in this issue of Chest by page 664). They describe

development of atherosclerosis severity of spontaneous athero-

a diet

a diet

event

approach

arteries.

individuals

of atherosclerosis,

have

tionally sclerosis

head

are

clinically,

Furthermore,

Such

in irradi-

coronary

is a suggestion,

to premature increase the

to

than

atherosclerosis

Therefore,

tribute or may

appear

in neurologic

spontaneous

out.8

the

develop after the treatment?

not deathero-

administration

should

arteries

most

(again)

heart.

re-

and confined treatable by

or pericardiectomy.

In

spontaneous

sometimes

ever,

cause

centesis

of

to occur, particularly in the carotid vesare reports of carotid artery narrow-

radiotherapy

after

heart disease will be mild cardium and, therefore,

in rab-

atherosclerosis did typical coronary

atherosclerosis

This sels.

ently

to

produced

alone.

Secondly,

sary

the

experimentally

radiation

full

If

diet, I know,

the

similar been

(2,500 rads in five fractions) with high concentrations

cholesterol.7

the abnormal As far as

ing,

has

radiation and a diet

and

ceive velop.

quite

disease

Gildenhom

major

HC,

x-irradiation of

of

vessels

after

radia-

1975 Solomon

and

coronary

RD,

et

cholesterol-fat

J

lesions.

artery

al:

feeding

The on

Atheroscier

1964 Kellermeyer of

RW:

therapeutic

Delayed

cerebrovascular

radiation.

Cancer

36:1702-

1708, 1975 9

Cannel

RC,

Kaplan

HS:

Mantle

irradiation

disease:

An

analysis

of

technique,

tumor

complications.

Cancer

37:2813-2825,

in

Hodgkin’s

irradiation

and

1976

CHEST, 71: 5, MAY, 1977