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Radiation elevated tricuspid regurgitant jet velocity in childhood cancer survivors
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The risk for elevated tricuspid regurgitant jet velocity was increased in a cohort of childhood cancer survivors who had received radiation, according to recent results.
Gregory T. Armstrong, MD, MSCE, of the department of epidemiology and cancer control at St. Jude Children’s Research Hospital, and colleagues conducted the study to determine the presence of pulmonary hypertension in a cohort of 498 adult survivors of childhood cancer. The researchers also aimed to examine links between radiation and cardiac function, lung function and exercise capacity in this population.
Gregory T. Armstrong
The median age of survivors was 38 years (range, 20 to 59 years). The primary cancer diagnosis was performed at a median age of 27.3 years (range, 12.2 to 46 years).
The researchers defined abnormal tricuspid regurgitant jet velocity as more than 2.8 m/s by Doppler echocardiography. They observed increased tricuspid regurgitant jet velocity in 25.2% of patients who had experienced radiation directed at the chest. Among those who had received more than 30 Gy of radiation, the rate of tricuspid regurgitant jet velocity was 30.8%, according to the findings.
Multivariate analysis results indicated that elevated tricuspid regurgitant jet velocity was linked to an increasing radiation dose. Compared with no radiation, a dose of 1 Gy to 19.9 Gy yielded an OR of 2.09 (95% CI, 0.63-6.96) for tricuspid regurgitant jet velocity; for 20 Gy to 29.9 Gy, the OR was 3.46 (95% CI, 1.59-7.54); for a dose of ≥30 Gy, the OR was 4.54 (95% CI, 1.77-11.64). Increased tricuspid regurgitant jet velocity also was associated with BMI >40 kg/m2 (OR=3.89; 95% CI, 1.46-10.39) and aortic valve regurgitation (OR=5.85; 95% CI, 2.05-16.74).
Survivors with tricuspid regurgitant jet velocity >2.8 m/s were more than five times as likely to have severe functional limitations on a 6-minute walk than those with a velocity below that threshold (OR=5.2; 95% CI, 2.5-11), according to researchers.
“A substantial number of adult survivors of childhood cancer who received chest-directed [radiation therapy] have an increased [tricuspid regurgitant jet velocity] and may have pulmonary hypertension as a result of both direct lung injury and cardiac dysfunction,” Armstrong and colleagues concluded.
Perspective
Back to TopBirte H. Wistinghausen, MD
The improvement in cure rates of children with cancer has been a remarkable success story. However, with improving cure rates, more or more of these patients reach adulthood, and that has led to increasing awareness of the long-term effects of therapy.
Armstrong and colleagues report on a 498-patient cohort of survivors of childhood cancer who received chest-directed radiation therapy and/or anthracyclines and had an echocardiogram with tricuspid regurgitant jet velocity (TRV) measured. They found a 25.2% incidence of increased TRV in survivors who received chest-directed radiation therapy. The incidence rose to 30.8% in patients who had received more than 30.8 Gy.
Increased TRV can be a sign of pulmonary hypertension, and the authors also report that survivors with a TRV greater than 2.8 m/s (n=69) had severe functional limitation of a 6-minute walk. The majority of the survivors were between the ages of 26 and 45 years at the time of evaluation, a relatively young age to have major functional limitations.
Efforts have been made to reduce radiation exposure of children. Chest radiation therapy is still used in Hodgkin’s disease, as well as stage IV Wilms’ tumors. Reducing radiation doses in Hodgkin’s disease has been a long-time goal because of the known long-term toxicities, such as the increased risk of breast cancers in females and the increased risk for cardiopulmonary late effects. Pulmonary hypertension had not been previously reported. This report raises pulmonary hypertension as an additional possible late effect. The true incidence will have to be further studied and confirmed by cardiac catheterization, but Doppler echocardiography is a widely available and noninvasive modality for screening and should be obtained in these patients at regular intervals.
The Children’s Oncology Group has a list of institutions with formal late effects clinic and long-term follow-up guidelines available on its website, and they are great resources. As more children with cancer survive and reach adulthood, it is important to keep monitoring these patients for late effects as they transition their care to adult providers. At the same time, it is important to fund further research into limited late effects without compromising cure.
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