gms | German Medical Science

27th German Cancer Congress Berlin 2006

German Cancer Society (Frankfurt/M.)

22. - 26.03.2006, Berlin

Late cardiac toxicity in Hodgkin's disease survivors after mediastinal radiotherapy: investigation using cardiac MRI

Meeting Abstract

  • corresponding author presenting/speaker Dirk Vordermark - Univ.-Klinik f. Strahlentherapie, Würzburg, Deutschland
  • Ines Seufert - Univ.-Klinik f. Strahlentherapie, Würzburg
  • Franz Schwab - Univ.-Klinik f. Strahlentherapie, Würzburg
  • Oliver Kölbl - Univ.-Klinik f. Strahlentherapie, Würzburg
  • Margret Kung - Med. Univ.-Klinik und Poliklinik II, Würzburg
  • W. Machann - Univ.-Institut f. Röntgendiagnostik, Würzburg
  • Michael Flentje - Univ.-Klinik f. Strahlentherapie, Würzburg
  • Christine Angermann - Med. Univ.-Klinik und Poliklinik II, Würzburg
  • Meinrad Beer - Univ.-Institut f. Röntgendiagnostik, Würzburg

27. Deutscher Krebskongress. Berlin, 22.-26.03.2006. Düsseldorf, Köln: German Medical Science; 2006. DocPO110

The electronic version of this article is the complete one and can be found online at:

Published: March 20, 2006

© 2006 Vordermark et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.



Background: Late cardiac changes are well recognized as a major toxicity after treatment of Hodgkin´s disease. However, the long-term dose-effect relationship for specific cardiac structures in mediastinal radiotherapy has rarely been investigated. The clinical introduction of cardiac magnetic resonance imaging (MRI) permits excellent quantification of cardiac function and identification of localized myocardial defects.

Patients and methods: Fifty-five long-term survivors of Hodgkin´s disease treated with mediastinal radiotherapy alone (60%) or in combination with chemotherapy (40%) between 1978 and 1985 were studied (Ann Arbor stages I/II/III in 24/51/25%, mean age at time of treatment 25 years, range 6 to 49 years). The 3-D radiation dose to the following cardiac structures was reconstructed: left (LV) and right ventricle (RV), left (LA) and right atrium (RA), right (RCA) and left anterior descending (LAD) and left circumflex (LCX) coronary arteries. The long-term survivors were invited for cardiac MRI as part of extensive cardiologic tests. The MRI protocol consisted of an axial t2-weighted haste sequence, an axial t1-weigted TSE sequence, a SSFP-CINE sequence in short and long axis orientation, a multislice SSFP perfusion sequence and finally an IR-late enhancement sequence in axial as well in the short and long heart axis orientation.

Results: Of the 55 survivors, 47% were treated with anterior mantle field alone (MF, cobalt-60), 33% with anterior mantle field and rotational boost to the mediastinum (MF+ROT), 13% with anterior mantle field and dorsal boost (MF+DORS). Mean ± SD total mediastinal doses for MF+ROT (41.7±3.5 Gy) and for MF+DORS (42.7±7.4) were significantly higher than for MF (36.7±5.2 Gy). The relative overdosage to right heart structures with anterior MF (median maximal dose to RV 129%, to RCA 127%) was siginificantly reduced to 117% and 112%, respectively, in MF+ROT.

Of 13 patients so far invited for cardiac MRI, 10 investigations (77%) could be performed. The following abnormalities were detected: myocardial perfusion deficits (60%), myocardial delayed enhancement (50%), valvular stenosis or insufficiency (20%), pericardial effusion (20%). The ejection fraction ranged from 49% to 66% and was below 55% in 20% of patients.

Conclusions: In patients irradiated with anterior mantle-field techniques, high doses to anterior heart portions were only partly compensated by boost treatment from non-anterior angles. As the threshold doses for coronary artery disease, cardiomyopathy, pericarditis and valvular changes are assumed to be 30 to 40 Gy, cardiac toxicity must be anticipated in these patients. Early results of our ongoing cardiac MRI study suggest a high prevalence of myocardial, pericardial and valvular defects but mostly normal systolic function. The localization of cardiac changes will be correlated with the 3-D radiotherapy dose distribution.