Past, Present, and Future of Radiation-Induced Cardiotoxicity: Refinements in Targeting, Surveillance, and Risk Stratification

Abstract

Radiation therapy is an important component of cancer therapy for many malignancies. With improvements in cardiac-sparing techniques, radiation-induced cardiac dysfunction has decreased but remains a continued concern. In this review, we provide an overview of the evolution of radiotherapy techniques in thoracic cancers and associated reductions in cardiac risk. We also highlight data demonstrating that in some cases radiation doses to specific cardiac substructures correlate with cardiac toxicities and/or survival beyond mean heart dose alone. Advanced cardiac imaging, cardiovascular risk assessment, and potentially even biomarkers can help guide post-radiotherapy patient care. In addition, treatment of ventricular arrhythmias with the use of ablative radiotherapy may inform knowledge of radiation-induced cardiac dysfunction. Future efforts should explore further personalization of radiotherapy to minimize cardiac dysfunction by coupling knowledge derived from enhanced dosimetry to cardiac substructures, post-radiation regional dysfunction seen on advanced cardiac imaging, and more complete cardiac toxicity data.

Keywords: CAC, coronary artery calcium; CAD, coronary artery disease; CMRI, cardiac magnetic resonance imaging; CT, computed tomography; HL, Hodgkin lymphoma; LAD, left anterior descending artery; LV, left ventricular; MHD, mean heart dose; NSCLC, non–small cell lung cancer; RICD, radiation-induced cardiovascular disease; RT, radiation therapy; SBRT, stereotactic body radiation therapy; breast cancer; cancer survivorship; childhood cancer; esophageal cancer; imaging; lung cancer; lymphoma; radiation physics.