Context The majority of patients with Hodgkin lymphoma are young and highly
curable. This necessitates concern for prevention, diagnosis, and optimal
management of potential treatment-related complications.
Objective To identify and quantify the incidence of and factors contributing to
long-term cardiac and vascular complications after radiation therapy for Hodgkin
Design and Setting Retrospective study comparing patients treated from 1962 to 1998 at
a university–based referral center with a matched general population.
Patients Four hundred fifteen consecutive patients who fulfilled the inclusion
criteria of a minimum 2-year follow-up (median, 11.2 years) and whose radiation
fields included the heart or carotid or subclavian arteries.
Main Outcome Measures Multivariable analyses of potential risk factors and observed-to-expected
ratios for cardiac valve surgery, coronary artery bypass graft surgery, percutaneous
coronary intervention, or both based on Surveillance, Epidemiology, and End
Results (SEER) and National Hospital Discharge Survey (NHDS) data.
Results Forty-two patients (10.4%) developed coronary artery disease at a median
of 9 years after treatment, 30 patients (7.4%) developed carotid and/or subclavian
artery disease at a median of 17 years after treatment, and 25 patients (6.2%)
developed clinically significant valvular dysfunction at a median of 22 years.
The most common valve lesion was aortic stenosis, which occurred in 14 valves.
The observed-to-expected ratio for valve surgery was 8.42 (95% confidence
interval [CI], 3.20-13.65) and the observed-to-expected ratio for coronary
artery bypass graft surgery or percutaneous coronary intervention was 1.63
(95% CI, 0.98-2.28). At least 1 cardiac risk factor was present in all patients
who developed coronary artery disease. The only treatment-related factor associated
with the development of coronary artery disease was utilization of a radiation
technique that resulted in a higher total dose to a portion of the heart (relative
risk, 7.8; 95% CI, 1.1-53.2; P = .04) . No specific
treatment-related factor was associated with carotid or subclavian artery
disease or valvular dysfunction. Freedom from any cardiovascular morbidity
was 88% at 15 years and 84% at 20 years.
Conclusions Among patients treated with radiation therapy for Hodgkin lymphoma,
there are statistically higher than expected rates of valve surgery and coronary
revascularization procedures over the next 10 to 20 years. Coronary vascular
disease is associated with higher radiation doses and traditional coronary
heart disease risk factors. Noncoronary vascular disease and clinically important
valvular dysfunction are less well understood complications at 15 to 20 years
after radiation, requiring surveillance and further study.