Transesophageal Echocardiography and Radiation-induced Damages.

The long-term sequelae of mantle therapy include, especially lung and cardiac disease but also involve the vessels and the organs in the neck and thorax (such as thyroid, aorta, and esophagus). We presented the case of 66-year-old female admitted for congestive heart failure in radiation-induced heart disease. The patient had undergone to massive radiotherapy 42 years ago for Hodgkin's disease (type 1A). Transesophageal echocardiography was performed unsuccessfully with difficulty because of the rigidity and impedance of esophageal walls. Our case is an extraordinary report of radiotherapy's latency effect as a result of dramatic changes in the structure of mediastinum, in particular in the esophagus, causing unavailability of a transesophageal echocardiogram.

INTRODUCTION

Radiation therapy for Hodgkin's lymphoma treatment has evolved dramatically in the last century.

It was realized that radiation works very well for Hodgkin's disease. Medical researchers also realized that treating only small areas originally involved by lymphoma with radiation was not good enough,[12] if radiation had to be used as the only treatment.

A large area covering all lymph node areas in the upper or lower half of the body had to be treated. This became known as extended field radiation therapy (EFRT). When the upper half of the body was being treated, the EFRT field was called the “mantle field.”[3]

A high-dose radiation exposure on the thorax is mainly used in the context of adjuvant radiotherapy after conservative or radical breast surgery, adjuvant or exclusive radiotherapy of lung and esophageal cancer, and as a complement to systemic treatment in lymphoma. Irradiation of the heart increases the risk of the so-called “radiation-induced” heart disease (RIHD).[4]

The incidence of RIHD is 10–30% by 5–10 years posttreatment;[5] the prevalence of RIHD, in the setting of the modern protocols of delivering adjuvant radiotherapy, reduction in doses, and field radiation size, is still poorly defined.[6]

CASE REPORT

We describe the case of a 66-year-old female with a history of Hodgkin's lymphoma (type 1A) treated with mantle radiotherapy in 1973.

She was admitted for congestive heart failure in radiation-induced heart disease. A cardiac computed tomography angiography (64 Dual-Source, CareDose, and electrocardiogram pulsing MinDose) showed calcified ascending aorta and pericardium calcification narrowing the right ventricle, bronchiectasis and fibrosis of the lungs, and esophagus [Figure 1a and b].

Figure 1

(a) Multidetector computed tomography short-axis view of the calcification in the ascending aorta and the nearest thickened pericardium, (b) multidetector computed tomography long-axis view of the thickened wall of the esophagus

A cardiac magnetic resonance imaging (1.5 T) revealed normal left ventricle size (VTS 17 ml, VTSI 10 ml/m2), with ejection fraction of 0.87, stroke volume (SV) of 70 ml, SV index 39 ml/m2, aortic regurgitation and stenosis with aortic valve peak velocity of 163 cm/s and a mild thickness of pericardium (3 mm) and esophagus [Figure 2].

Figure 2

Magnetic cardiac imaging (magnetic resonance imaging), axial image demonstrating circumferential thickening of the pericardium (>3 mm), normal volume of the heart, and calcification of the ascending aorta

A transthoracic echocardiography was performed and documented normal EF, aortic regurgitation and aortic stenosis with effective orifice area of 0.78 cmq [Figure 3a and b], calcified mitral annulus, signs of constrictive pericarditis (pericardial calcifications, augmented thickness, and Doppler signs of constriction – high filling pressure in the left and right ventricle, annulus paradoxes, and diastolic flow reversal in expiration in the suprahepatic veins), and of myocardial damage (low-tissue Doppler velocities at the mitral annulus level [Figure 3c], significant pulmonary hypertension [Figure 3d]). Therefore, we wanted to observe better heart and the signs of constrictive pericarditis, so we performed a transesophageal echocardiogram (TEE). Surprisingly, we were unable to visualize the cardiac structures because of high and completely acoustic impedance and interfaces [Figure 4]. The acoustic shadowing due to the interface of two different structures with a high level of impedance showed the suboptimal image and no resolution of cardiac structures. The resultant images were echodense with the lack of signal in the sector beyond the structure [Video 1].

Figure 3

(a) Transthoracic echocardiography view of aortic regurgitation, (b) transthoracic echocardiography showing aortic valve stenosis, (c) transthoracic echocardiography demonstrating the myocardial damage by low-tissue Doppler velocities at the mitral annulus level, (d) transthoracic echocardiography showing pulmonary hypertension

Figure 4

Transesophageal echocardiography failure: The completely impedance to visualize the cardiac structure

DISCUSSION

Radiation therapy uses high-energy rays (or particles) to destroy cancer cells. To treat Hodgkin's disease, a carefully focused beam of radiation is delivered from a machine outside of the body.[67] If the Hodgkin's disease was in the upper body, radiation was given to the mantle field, which included lymph node areas in the neck, chest, and under the arms.[8] The side effects of radiation depend on where the radiation is aimed. They could be short- or long-term effects. The long-term sequelae of mantle therapy include, especially the lung and cardiac disease but also involve the vessels and the organs in the neck and thorax (such as thyroid, aorta, and esophagus).[910]

In our case report, the significant thickness of esophagus [Figure 1b] caused the acoustic impedance due to the inability of TEE to view correctly and complete cardiac structure. Any degree of vision or level of depth of the probe did not capture defined images.

CONCLUSION

The short- and long-term sequelae of mantle field radiation were not predictable and quantifiable and included, especially heart and thoracic structure labeling radiation-induced heart disease. In the literature, the descriptions of unavailable TEE in a patient with a history of radiation therapy have been few, all of them have pointed out to the RIHD or other radiation-induced effects. Our case report emphasized the failure of the TEE, in particular, the impedance of radiation-induced thickness of the esophagus hence the unavailability to collect good quality images during the examination.

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Conflicts of interest

There are no conflicts of interest.