Andersons pediatric cardiology 1691
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Introduction
Overthepastseveraldecadestherehavebeensignificantimprovementsinthe
careofpatientsdiagnosedwithcancer,particularlyinthepediatricagerange.
Therearemorethan15.5millionsurvivorsofcancerintheUnitedStates,1and
inpediatricsspecifically,cancerisdiagnosedin15,700patientsyoungerthan20
yearseachyear(Table62.1).Withcurrent5-yearsurvivalforalltypesat80%,
thisyieldsapproximately450,000survivorsofpediatriccancer.2Oneunintended
consequenceofthesuccessesoftherapyisagrowingpopulationofpatientsat
riskforcancertreatment–relatedcardiotoxicity(CTC),andcardiovascular
diseasehasemergedasaleadingcauseofbothmorbidityandmortalityinthis
population.3Survivorsarefivetosixtimesmorelikelythansiblingcontrolsto
developcardiovasculardiseaseofalletiologies,including:symptomaticheart
failurefrombothsystolicanddiastolicdysfunction;asymptomaticventricular
dysfunction;valvardisease;coronarydisease;arrhythmias;autonomic
dysfunction;vascularchanges;andpericardialdisease.4,5
Table62.1
DistributionofCasesofChildhoodandAdolescentCancersinthe
UnitedStatesWithCommon,PotentiallyCardiotoxicTreatment
Exposures
LEUKEMIA
Acutelymphocytic
leukemia
Acutemyeloid
leukemia
LYMPHOMA
Hodgkin
lymphoma
Non-Hodgkin
lymphoma
Centralnervous
systemc
Neuroblastoma
Retinoblastoma
Wilmstumor
Bonetumorsd
Children
(0–14y)
Adolescents
(15–19y)
Cumulative
AnthracyclineDosea
PotentialThoracicRadiation
ExposureScenarios
26%
8%
Lowb
Craniospinalphotonradiation
5%
4%
High
–
4%
15%
Loworhighb
Sitedependent
6%
8%
Loworhighb
Sitedependent
21%
10%
–
Craniospinalphotonradiation
7%
3%
5%
4%
–
–
–
7%
Lowb
–
Lowb
High
Sitedependent
–
Selectmetastaticpatients
Selectmetastaticpatients
Softtissuesarcoma 7%
Germcelltumors
3%
Carcinomaand
4%
melanoma
7%
12%
20%
Highe
–
–
Selectmetastaticpatients
–
Sitedependent
aHigh(cumulative≥250mg/m2)andlowdose(<250mg/m2)appliestodoxorubicinordoxorubicin
equivalentofotheranthracyclines.
bAnthracyclinesincludedonlyinselecthighandintermediateriskregimens,notalltreatment
protocols.
cIncludesependymoma,astrocytoma,andmedulloblastoma.
d
IncludesosteosarcomaandEwingsarcoma.
eAnthracyclinesincludedonlyinselecthighriskregimens,notalltreatmentprotocols.
Treatmentishighlyvariablebasedondiagnosis,patientage,diseasestage,siteofdisease,and
severalotherfactors.Representedinthistablearegeneraltrendsonly.
ModifiedfromWardE,DeSantisC,RobbinsA,etal.Childhoodandadolescentcancerstatistics,
2014.CACancerJClin.2014;64(2):83–103;andHowladerN,NooneAM,KrapchoM,etal.
SEERcancerstatisticsreview,1975–2009(vintage2009populations),NationalCancerInstitute.
Bethesda,MD, />
DevelopmentofCancerTherapy–Related
Cardiotoxicity
ThefirstevidenceforCTCwasreportedshortlyaftertheintroductionof
anthracyclinechemotherapyinthelate1960sand1970s.6,7Earlyeffortswere
focusedonmanagementofsymptomaticheartfailureinsurvivorsbutquickly
shiftedtoprevention.Therehassincebeenrecognitionthatalmostall
chemotherapeuticagentsposesomecardiovascularrisk.Clinicalexperience
showsthattherearethreetypesofanthracycline-associatedcancertreatment–
relatedcardiotoxicities:acuteoccurswithinthefirstweekoftreatmentasa
transientdepressionofventricularsystolicfunctionandisusuallyreversibleon
discontinuationoftherapy(Fig.62.1;Videos62.1and62.2);early-onsetchronic
progressivedevelopslessthan1yearaftercompletionoftreatmentasdilated
and/orrestrictivecardiomyopathyandcanbeprogressive;andlate-onsetchronic
progressive,whichissimilartoearly-onsetprogressivebutmanifestsmorethan
1yearaftertreatmentiscompleted(Video62.3).5Thisschemedoesnot
incorporatetheotherpossiblenegativecardiovascularoutcomes,nordoesit
necessarilyapplytootherdrugsortreatmentmodalities.
