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Cardiac toxicity of Thoracic radiotherapy tweetorial from our recent paper in @JTOonline. Multidisciplinary effort from @MeredithGiulia1 @finn_corinne @FeiSun10 @MarianneAznar @Al_McWilliam MSchmitt, KFranks, MCVozenin ( @OncoUNILCHUV) #CardioOnc #radonc https://authors.elsevier.com/a/1cST-5Xq2QKeZe
RTOG0617 was the first trial to raise the possibility of cardiac toxicity in patients with lung cancer. There's been a lot of research since then so what do we know now? @JeffBradleyMD https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(14)71207-0/fulltext
Radiation induced heart disease (RIHD) is a result of acute endothelial damage and cytokine activation leading to chromic inflammation and fibrin deposition
Inflammation affects heart substructures in different ways. Patients may have pericarditis/pericardial adhesions, valve stenosis/regurgitation, coronary artery narrowing. This can be studied in animal models eg. mice and zebrafish
1/3 of patients with lung cancer have cardiac comorbidities that increase the incidence of cardiac events, independent of radiotherapy. Other patients have cardiac risk factors such as hypertension, hyperlipidaemia or diabetes
Risk of cardiac events can be assessed with Q-risk/Framingham but imaging gives more info on baseline cardiac function. Recent paper by @AzadehAbravan @RT_physics shows vascular calcifications on RTP correlate with cardiac comorbidities and survival http://tinyurl.com/269nvj5j
If heart dose is important what dose parameter should we use? Should we use a different parameter in patients with cardiac comorbidities? Or avoid certain substructures? We don't know!
What can we do for patients? Address cardiac risk factors: 
cholesterol; improve diabetic control; exercise; smoking cessation. Monitor for cardiac complications and manage with #CardioOnc input
cholesterol; improve diabetic control; exercise; smoking cessation. Monitor for cardiac complications and manage with #CardioOnc input
Protons may reduce cardiac and integral body dose to prevent cardiac toxicity and lymphopenia after thoracic RT and studies are ongoing. What can we avoid and in whom? What other research is important?
We need prospective trials such as ACCOLADE and CLARIFY. Also consistent use of validated cardiac contouring atlases to assess cardiac dose with recording of comorbidities & cardiac outcomes. Then implement cardiac sparing RT and comorbidity management to improve patients' lives
