Radiation-Associated Pericardial Disease
Purpose of Review
This review highlights the literature related to pericardial injury following radiation for oncologic diseases.
Radiation-associated pericardial disease can have devastating consequences. Unfortunately, there is considerably less evidence regarding pericardial syndromes following thoracic radiation as compared to other cardiovascular outcomes. Pericardial complications of radiation may arise acutely or have an insidious onset several decades after treatment. Transthoracic echocardiography is the screening imaging modality of choice, while cardiac magnetic resonance imaging further characterizes the pericardium and guides treatment decision-making. Cardiac CT can be useful for assessing pericardial calcification. Ongoing efforts to lessen inadvertent cardiac injury are directed towards the revision of radiation techniques and protocols.
As survival of mediastinal and thoracic malignancies continues to improve, radiation-associated pericardial disease is increasingly relevant. Though advances in radiation oncology demonstrate promise in curtailing cardiotoxicity, the long-term effects pertaining to pericardial complications remain to be seen.
KeywordsPericardial disease Radiation Pericardial effusion Constrictive pericarditis
Dr. Desai is supported by the Haslam Family Endowed Chair in Cardiovascular Medicine.
Compliance with Ethical Standards
Conflict of Interest
Natalie Szpakowski and Milind Y. Desai declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 4.Gaya AM, Ashford RF. Cardiac complications of radiation therapy. Clin Oncol (R Coll Radiol). 2005;17(3):153–9.Google Scholar
- 16.Reshko LB, Kalman NS, Hugo GD, Weiss E Jr. Cardiac radiation dose distribution and cardiotoxicity in early-stage non-small cell lung cancer treated with stereotactic body radiation therapy. Int J Radiat Oncol Biol Phys. 2017;99(2):E492.Google Scholar
- 18.Lancellotti P, Nkomo VT, Badano LP, Bergler-Klein J, Bogaert J, Davin L, et al. Expert consensus for multi-modality imaging evaluation of cardiovascular complications of radiotherapy in adults: a report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. J Am Soc Echocardiogr. 2013;26(9):1013–32.PubMedGoogle Scholar
- 19.Hancock SL, Donaldson SS, Hoppe RT. Cardiac disease following treatment of Hodgkin's disease in children and adolescents. J Clin Oncol Off J Am Soc Clin Oncol. 1993;11(7):1208–15.Google Scholar
- 30.Adler Y, Charron P, Imazio M, Badano L, Baron-Esquivias G, Bogaert J, et al. 2015 ESC guidelines for the diagnosis and management of pericardial diseases: the task force for the diagnosis and management of pericardial diseases of the European Society of Cardiology (ESC) endorsed by: the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2015;36(42):2921–64.PubMedGoogle Scholar
- 33.Desai MY, Jellis CL, Kotecha R, Johnston DR, Griffin BP. Radiation-associated cardiac disease: a practical approach to diagnosis and management. J Am Coll Cardiol Img. 2018;11(8):1132–49.Google Scholar
- 39.Cremer PC, Tariq MU, Karwa A, Alraies MC, Benatti R, Schuster A, et al. Quantitative assessment of pericardial delayed hyperenhancement predicts clinical improvement in patients with constrictive pericarditis treated with anti-inflammatory therapy. Circ Cardiovasc Imaging. 2015;8(5):e003125.PubMedGoogle Scholar
- 40.Feng D, Glockner J, Kim K, Martinez M, Syed IS, Araoz P, et al. Cardiac magnetic resonance imaging pericardial late gadolinium enhancement and elevated inflammatory markers can predict the reversibility of constrictive pericarditis after antiinflammatory medical therapy. Circulation. 2011;124(17):1830–7.PubMedGoogle Scholar
- 48.•• George TJ, Arnaoutakis GJ, Beaty CA, Kilic A, Baumgartner WA, Conte JV. Contemporary etiologies, risk factors, and outcomes after pericardiectomy. Ann Thorac Surg. 2012;94(2):445–51 This study showed high mortality following pericardiectomy for radiation-related pericarditis. PubMedPubMedCentralGoogle Scholar
- 49.•• Wu W, Masri A, Popovic ZB, Smedira NG, Lytle BW, Marwick TH, et al. Long-term survival of patients with radiation heart disease undergoing cardiac surgery. Circulation. 2013;127(14):1476–84 This important study illustrated the poor outcomes of patients with radiation heart disease. PubMedGoogle Scholar
- 50.Zamorano JL, Lancellotti P, Rodriguez Munoz D, Aboyans V, Asteggiano R, Galderisi M, et al. 2016 ESC position paper on cancer treatments and cardiovascular toxicity developed under the auspices of the ESC committee for practice guidelines: the task force for cancer treatments and cardiovascular toxicity of the European Society of Cardiology (ESC). Eur Heart J. 2016;37(36):2768–801.PubMedGoogle Scholar
- 53.• Maraldo MV, Brodin NP, Vogelius IR, Aznar MC, Munck AF, Rosenschold P, et al. Risk of developing cardiovascular disease after involved node radiotherapy versus mantle field for Hodgkin lymphoma. Int J Radiat Oncol Biol Phys. 2012;83(4):1232–7 This study suggested less cardiotoxicity was associated with involved-node therapy in Hodgkin lymphoma. PubMedGoogle Scholar
- 54.Gyenes G, Gagliardi G, Lax I, Fornander T, Rutqvist LE. Evaluation of irradiated heart volumes in stage I breast cancer patients treated with postoperative adjuvant radiotherapy. J Clin Oncol Off J Am Soc Clin Oncol. 1997;15(4):1348–53.Google Scholar
- 56.• Mulliez T, Speleers B, Madani I, De Gersem W, Veldeman L, De Neve W. Whole breast radiotherapy in prone and supine position: is there a place for multi-beam IMRT? Radiat Oncol. 2013;8:151 This study suggested cardiotoxicity could be reduced with prone positioning in breast cancer patients. PubMedPubMedCentralGoogle Scholar