Date, Hiroshi

Kanemitsu, Hideo

Matsuo, Yukinori

Minatoya, Kenji

Mizowaki, Takashi

Nakagawa, Yasuaki

Nakajima, Daisuke

Sato, Genki Edward

JTO Clinical and Research Reports

English

PubMed

Kyoto University Research Information Repository

RIGHT:URL:CITATION:AUTHOR(S):ISSUE DATE:TITLE:Safe Delivery of PostoperativeRadiotherapy for ThymicCarcinoma Located on the OutflowGraft of a Left Ventricular AssistDeviceSato, Genki Edward; Matsuo, Yukinori; Kanemitsu,Hideo; Minatoya, Kenji; Nakajima, Daisuke; Date,Hiroshi; Nakagawa, Yasuaki; Mizowaki, TakashiSato, Genki Edward ...[et al]. Safe Delivery of Postoperative Radiotherapy for ThymicCarcinoma Located on the Outflow Graft of a Left Ventricular Assist Device. JTO Clinicaland Research Reports 2021, 2(1): 100101.2021-01http://hdl.handle.net/2433/276408© 2020 The Authors. Published by Elsevier Inc. on behalf of theInternational Association for the Study of Lung Cancer.; This is an openaccess article under the CC BY-NC-ND license.CASE REPORTSafe Delivery of Postoperative Radiotherapy forThymic Carcinoma Located on the Outflow Graftof a Left Ventricular Assist DeviceGenki Edward Sato, MD,a,b Yukinori Matsuo, MD, PhD,a,* Hideo Kanemitsu, MD, PhD,cKenji Minatoya, MD, PhD,c Daisuke Nakajima, MD, PhD,d Hiroshi Date, MD, PhD,dYasuaki Nakagawa, MD, PhD,e Takashi Mizowaki, MD, PhDaaDepartment of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Sakyo-ku,Kyoto, JapanbDepartment of Radiation Oncology, Shiga General Hospital, Moriyama City, Shiga, JapancDepartment of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, JapandDepartment of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, JapaneDepartment of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, JapanReceived 25 February 2020; revised 11 September 2020; accepted 16 September 2020Available online - 05 October 2020IntroductionImplantation of a left ventricular assist device (LVAD)improves survival rates for patients with severe heartfailure.1 Because cancer incidence increases with age,2there is a risk of developing cancer subsequent to theimplantation surgery. Therefore, safe treatment of can-cer in patients with LVAD is an important concern forthoracic oncologists. Several reports have assessed thefeasibility of treatments for cancers distant from theLVAD graft site.3–5 However, treatment of cancersdirectly involving the LVAD graft has not beenaddressed. Here, we report the first case of post-operative radiotherapy (PORT) for thymic squamous cellcarcinoma located on the outflow graft of an LVAD.Case ReportA 69-year-old man, implanted with a cardiacresynchronization therapy defibrillator (CRT-D) forarterial fibrillation 8 years ago, exhibited dilated-phasehypertrophic cardiomyopathy and was fitted with anLVAD as a bridge to the transplant 4 years ago. Duringfollow-up, he was diagnosed with a thymus tumor on theoutflow graft of the LVAD by computed tomography (CT)(Fig. 1A–C). The clinical diagnosis of the tumor wasthymoma, and he underwent surgery for total resectionby a median sternotomy. The tumor was resected with asufficient safety margin to the naked eye, and theintraoperative frozen section confirmed malignant thy-moma and tumor-free resection lines. However, the finalpathologic diagnosis was thymic squamous cell carci-noma with a microscopically positive margin (R1resection), which was classified as pT1aN0M0 stage Iaccording to the guidelines of the Union for InternationalCancer Control version 8. As the surgical margin waspositive at the outflow graft of the LVAD, PORT wasindicated. This decision was made by a multidisciplinarythoracic oncology team, including thoracic surgeons,pulmonologists, diagnostic radiologists, and radiationoncologists. Written informed consent was obtainedfrom the patient.A total dose of 66 Gy in 33 fractions with 6-MVphotons was administered: 50 Gy in 25 fractions forthe tumor bed and an additional 16 Gy in eight fractionsat the surgical margin (Fig. 2A and B). The LVADcontroller and CRT-D were placed outside the radiationfield. Maximum doses were calculated as 68.3, 0.00, and0.99 Gy for the graft, LVAD pump, and CRT-D, respec-tively. PORT was completed without device errors; the*Corresponding author.Disclosure: The authors declare no conflict of interest.Address for correspondence: Yukinori Matsuo, MD, PhD, Department ofRadiation Oncology and Image-Applied Therapy, Graduate School ofMedicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto606-8507, Japan. E-mail: ymatsuo@kuhp.kyoto-u.ac.jpCite this article as: Sato GE, et al. Safe Delivery of PostoperativeRadiotherapy for Thymic Carcinoma Located on the Outflow Graft ofa Left Ventricular Assist Device. JTO Clin Res Rep 2:100101ª 2020 The Authors. Published by Elsevier Inc. on behalf of theInternational Association for the Study of Lung Cancer. This is anopen access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).ISSN: 2666-3643https://doi.org/10.1016/j.jtocrr.2020.100101JTO Clinical and Research Reports Vol. 2 No. 1: 100101A Self-archived copy inKyoto University Research Information Repositoryhttps://repository.kulib.kyoto-u.ac.jpsettings of the LVAD and CRT-D were confirmed to beunchanged. Both warfarin and aspirin were used asantithrombotic therapy in peri- and post-PORT periodswith a target international normalized ratio of 2 to 2.5.After the completion of PORT, the graft and anastomoticregion were assessed by CT every few months. In the 13-month follow-up period, no evidence of cancer recur-rence and no radiological change in the graft or anasto-motic region were observed (Fig. 3A and B). However,the patient suddenly died at 18 months after PORT.LVAD was checked, and no problems were noted. Anautopsy and a clinicopathologic conference were con-ducted to ascertain the cause of death. No macroscopicthrombosis or hemorrhage was observed in any of theorgans, including the thorax. Microscopic examinationaround the graft and anastomotic region revealed onlyfibrosis without recurrence of malignancy, owing to thesurgery and PORT for thymic carcinoma. The autopsydid not suggest any cause of death. Ultimately, it wasconcluded that no association existed between the deathof the patient and PORT.DiscussionSeveral studies have reported that electrical devicessuch as LVADs should be placed outside the radiationfield during PORT and that lower-energy photon beams(10 MV) should be used to prevent device errorsinduced by the photons and photoneutrons generated bythe linear accelerator.5 On the basis of this recommen-dation, we successfully performed PORT without anyinduced device errors.The effect of PORT on the stability of devicegrafts and anastomotic regions was previously un-tested in humans. The material of the outflow graftis Dacron, reported to be tolerant of radiotherapy;80-Gy irradiation did not affect the nature of theFigure 1. Diagnostic CT images before the surgery. (A) Axial view of CT (white arrow, thymic carcinoma). (B) Axial view of CTrevealing the graft and anastomotic region (white arrow). (C) Reconstructed image of CT (green object, thymic carcinoma onthe outflow graft of the LVAD; white arrow, the anastomotic region between the outflow graft and ascending aorta). CT,computed tomography; LVAD, left ventricular assist device.Figure 2. Dose distribution of PORT in (A) axial view and (B) coronal view. PORT, postoperative radiotherapy.2 Sato et al JTO Clinical and Research Reports Vol. 2 No. 1A Self-archived copy inKyoto University Research Information Repositoryhttps://repository.kulib.kyoto-u.ac.jpDacron tube.6 Regarding irradiation to the anasto-motic regions, a study in canines revealed that PORTfor the anastomotic region of an abdominal aorticgraft was feasible; the patency rate of the grafts was100%, and no disunion, rupture, or aneurysm wasobserved.7 However, minor thrombosis in theluminal surface was noted in one case, suggestingthe irradiated graft and anastomotic regions shouldbe closely monitored. In our study, the graft andanastomotic region of the LVAD were inevitablyincluded in the radiation field owing to the locationof the tumor. As thrombosis in the graft andextravasation from the anastomotic region are lethalevents, these regions were closely monitored by CTfor early detection and confirmed to be stable.Standard antithrombotic therapy could be givenduring that period. On the basis of the results of theautopsy and the clinicopathologic conference, PORTfor the graft and anastomotic region was confirmedto be feasible in this case. Although it is difficult tocome to a definitive conclusion regarding the safetyof PORT, our study reveals that definitive cancertreatment by PORT may be feasible even if the tu-mor is located on the graft or anastomotic region.DeclarationsEthics Approval and Consent to ParticipateThis study followed all dictates of the HelsinkiDeclaration.Consent for PublicationWritten consent was obtained from the patient forpublication of this report and any accompanying images.AcknowledgmentsThe English in this document has been checked byEditage (https://www.editage.jp/). Dr. Sato contributedto writing—original draft of the manuscript, Dr. Matsuocontributed to supervision of the manuscript. Drs.Kanemitsu, Minatoya, Nakajima, Date, Nakagawa, andMizowaki contributed to writing—review and editing ofthe manuscript.References1. Kirklin JK, Pagani FD, Kormos RL, et al. Eighth annualINTERMACS report: special focus on framing the impact ofadverse events. J Heart Lung Transplant. 2017;36:1080–1086.2. Thakkar JP, McCarthy BJ, Villano JL. Age-specific cancerincidence rates increase through the oldest age groups.Am J Med Sci. 2014;348:65–70.3. Spano G, Stutz E, Elicin O, et al. Is it safe to irradiate thenewest generation of ventricular assist devices? A casereport and systematic literature review. Artif Organs.2020;44:449–456.4. Loyaga-Rendon RY, Inampudi C, Tallaj JA, Acharya D,Pamboukian SV. Cancer in end-stage heart failure patientssupported by left ventricular assist devices. ASAIO J.2014;60:609–612.5. Emerson LY, Deek MP, Almendral J, Jabbour SK. Radiationtherapy in patients with left ventricular assist device: acase report and literature review. Pract Radiat Oncol.2016;6:e145–e147.6. Seydel HG, Loomus MG, Krohmer JS, MacLean CJ. Theeffect of irradiation in the therapeutic dose range onvascular-graft material. Radiology. 1983;146:815–816.7. Shu C, Guo Y, Zhou X, Wan H, Yan J, Yuan L. Effect ofpostoperative fractionated radiotherapy on canine ePTFEgraft neointima and anastomotic stoma healing: a pre-liminary experimental study. Asian J Surg. 2011;34:121–127.Figure 3. Follow-up CT images at 13 months after the initiation of PORT. (A) No evidence of cancer recurrence was observed.A soft tissue mass can be noted in the tumor bed. This mass revealed no change in size from immediately after the surgeryuntil this CT, leading to its diagnosis as a postoperative scar. (B) No significant change was noted around the graft or anas-tomotic region. CT, computed tomography; PORT, postoperative radiotherapy.January 2021 Safe Delivery of RT in Outflow Graft of LVAD 3A Self-archived copy inKyoto University Research Information Repositoryhttps://repository.kulib.kyoto-u.ac.jp

Safe Delivery of Postoperative Radiotherapy for Thymic Carcinoma Located on the Outflow Graft of a Left Ventricular Assist Device

http://dx.doi.org/10.1016/j.jtocrr.2020.100101

Safe Delivery of Postoperative Radiotherapy for Thymic Carcinoma Located on the Outflow Graft of a Left Ventricular Assist Device

Abstract

Similar works

Full text

Available Versions

Kyoto University Research Information Repository