CARDIAC RISK AFTER MEDIASTINAL IRRADIATION FOR HODGKINS-DISEASE

Purpose: To evaluate the risk of cardiac lesions after conventionally fractionated irradiation (Rt) of the mediastine with or without chemot herapy (Ct) in patients with Hodgkin's disease (HD) and to relate them to known cardiovascular risk factors. Patients and methods: Between 1 964 and 1992, 352 (total group) patients with KD were treated with cur ative intention using Rt with or without Ct including the mediastine a nd had a follow-up of at least 1 year. More than 96% of the patients h ad a complete follow-up. One hundred forty-four patients (64% of the l iving patients, heart study group) have regular follow-up in our depar tment and had a special heart examination including rest and exercise EGG, echocardiography and myocardial perfusion scintigraphy (112 patie nts). Doses per fraction in the anterior heart region were between 1.3 and 2.1 Gy. Total doses were between 30.0 and 42.0 Gy in 93% of cases . The mean length of follow-up was 11.2 years (range 1.0-31.5 years). Other cardiovascular risk factors evaluated were body mass index, bloo d pressure, smoking history, diabetes mellitus, hypercholesterolemia a nd history of coronary artery disease before Rt. Results: In the total group, the risk of fatal cardiac ischemic events and/or of sudden une xpected death was significantly higher than expected with a relative r isk of 4.2 for myocardial infarction and 6.7 for myocardial infarction or sudden death. In female patients and in patients without other car diovascular risk factors, the risk of fatal or non-fatal ischemic card iac events was not significantly different from the expected value. In the subgroup with no cardiovascular risk factors and treatment withou t Ct, there was no ischemic or other major cardiac event. Echocardiogr aphy showed valvular thickenings in a large amount of the patients (th e cumulative risk after 30-year follow-up was above 60%) but mostly wi thout hemodynamic disturbance. In patients without hypertension and wi thout coronary artery disease, findings of perfusion scintigraphy and echocardiographic evaluation of systolic and diastolic function were n ormal. Treatment with Ct was not a significant risk factor for cardiac events but the number of patients whose treatment included adriamycin and with a follow-up exceeding 10 years is to low for a definitive ev aluation. Conclusions: In patients without the usual cardiovascular ri sk factors (smoking, hypertension, obesity, hypercholesterolemia, diab etes mellitus) the risk of serious cardiac lesions after conventionall y fractionated irradiation of the mediastinum with an intermediate tot al dose between 30 and 40 Gy is low. Also the cardiac risk of the comb ination of this irradiation with Ct including adriamycin with a total dose between 200 and 300 mg/m(2) seems low but further long-term obser vation is necessary. (C) 1998 Elsevier Science Ireland Ltd.