title: Cardiac Function After Multimodal Breast Cancer Therapy Assessed With Functional Magnetic Resonance Imaging and Echocardiography Imaging.
abstract: OBJECTIVE
  Breast intensity modulated radiation therapy (IMRT) reduces high-dose heart volumes but increases low-dose volumes. We prospectively assessed heart changes after 3D conformal RT (3DCRT) and IMRT for left-sided breast cancer. Heart dose was analyzed individually, 3DCRT patients were moderately exposed, and IMRT was performed only in patients with unacceptably high heart doses upon 3DCRT planning.
  
  
  METHODS
  In 49 patients (38 patients received 3DCRT; 11 patients received IMRT; and 20 patients received neoadjuvant or adjuvant chemotherapy) magnetic resonance imaging (MRI) and echocardiography were performed before and at 6, 12, and 24 months after treatment.
  
  
  RESULTS
  Mean heart dose for IMRT was 12.9 ± 3.9 Gy versus 4.5 ± 2.4 Gy for 3DCRT. Heart volumes receiving >40 Gy were 2.6% (3DCRT) versus 1.3% (IMRT); doses were >50 Gy only with 3DCRT. Temporary ejection fraction (EF) decrease was observed on MRI after 6 months (63%-59%, P=.005) resolving at 24 months. Only 3 patients had pronounced largely transient changes of EF and left ventricular enddiastolic diameter (LVEDD). Mitral (M) and tricuspid (T) annular plane systolic excursion (MAPSE and TAPSE) were reduced over the whole cohort (still within normal range). After 24 months left ventricular remodeling index decreased in patients receiving chemotherapy (0.80 vs 0.70, P=.028). Neither wall motion abnormalities nor late enhancements were found. On echocardiography, in addition to EF findings that were similar to those on MRI, global strain was unchanged over the whole cohort at 24 months after a transient decrease at 6 and 12 months. Longitudinal strain decreased in the whole cohort after 24 months in some segments, whereas it increased in others.
  
  
  CONCLUSIONS
  Until 24 months after risk-adapted modern multimodal adjuvant therapy, only subclinical cardiac changes were observed in both 3DCRT patients with inclusion of small to moderate amounts of heart volume in RT tangents and in the patients treated with IMRT and reduced high-dose heart exposure.
authors.affiliation: First Medical Department, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany; German Center for Cardiovascular Research, Mannheim, Germany. Electronic address: felix.heggemann@umm.de.
authors.forename: Felix
authors.initials: F
authors.lastname: Heggemann
authors.affiliation: Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.
authors.forename: Hanna
authors.initials: H
authors.lastname: Grotz
authors.affiliation: Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.
authors.forename: Grit
authors.initials: G
authors.lastname: Welzel
authors.affiliation: First Medical Department, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany; German Center for Cardiovascular Research, Mannheim, Germany.
authors.forename: Christina
authors.initials: C
authors.lastname: Dösch
authors.affiliation: Institute of Diagnostic Radiology and Nuclear Medicine, University Medical Center Mannheim University of Heidelberg, Mannheim, Germany.
authors.forename: Jan
authors.initials: J
authors.lastname: Hansmann
authors.affiliation: Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.
authors.forename: Uta
authors.initials: U
authors.lastname: Kraus-Tiefenbacher
authors.affiliation: German Center for Cardiovascular Research, Mannheim, Germany; Institute of Diagnostic Radiology and Nuclear Medicine, University Medical Center Mannheim University of Heidelberg, Mannheim, Germany.
authors.forename: Ulrike
authors.initials: U
authors.lastname: Attenberger
authors.affiliation: German Center for Cardiovascular Research, Mannheim, Germany; Institute of Diagnostic Radiology and Nuclear Medicine, University Medical Center Mannheim University of Heidelberg, Mannheim, Germany.
authors.forename: Stephan Oswald
authors.initials: SO
authors.lastname: Schönberg
authors.affiliation: First Medical Department, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany; German Center for Cardiovascular Research, Mannheim, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Borggrefe
authors.affiliation: Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.
authors.forename: Frederik
authors.initials: F
authors.lastname: Wenz
authors.affiliation: First Medical Department, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany; German Center for Cardiovascular Research, Mannheim, Germany.
authors.forename: Theano
authors.initials: T
authors.lastname: Papavassiliu
authors.affiliation: Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.
authors.forename: Frank
authors.initials: F
authors.lastname: Lohr
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D066126:Cardiotoxicity / Q000453:epidemiology / Q000209:etiology; D017024:Chemotherapy, Adjuvant; D004452:Echocardiography; D005260:Female; D006321:Heart / Q000187:drug effects / Q000502:physiology / Q000528:radiation effects*; D006801:Humans; D008279:Magnetic Resonance Imaging; D008408:Mastectomy; D008875:Middle Aged; D058958:Organs at Risk / Q000528:radiation effects; D011446:Prospective Studies; D011829:Radiation Dosage; D011879:Radiotherapy Dosage; D018714:Radiotherapy, Adjuvant; D020266:Radiotherapy, Conformal / Q000379:methods*; D050397:Radiotherapy, Intensity-Modulated / Q000379:methods; D013318:Stroke Volume / Q000187:drug effects / Q000502:physiology / Q000528:radiation effects; D000069584:Unilateral Breast Neoplasms / Q000188:drug therapy / Q000532:radiotherapy*; D016277:Ventricular Function, Left / Q000187:drug effects / Q000502:physiology / Q000528:radiation effects