대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Adriamycin Induced Cardiac Toxicity

Radiologic Findings

Chest radiograph on 2001 shows no diagnostic abnormality. Chest radiograph on March 19th shows increased size of cardiac silluette and findings of pulmonary edema, which have rapidlly improved on follow up chest radiograph. Chest CT scans also show global enlargement of cardiac chambers and small amount of pericardial effusion. Echocardiography demonstrated decreased left ventricular ejection fraction (25%)with severe LV dysfuction, dilated left ventricle and both atria.
The pateint underwent mastectomy due to breast cancer. She had been treated adjuvant chemotherapy including adriamycin four cycles. Total accumulative dose of adriamycin was 360 mg per square meter of body surface area.

Brief Review

The anthracycline derivatives, particularly doxorubicin (Adriamycin), are powerful antineoplastic agents that, when given in high doses (more than 550 mg/m2 for doxorubicin), may produce fatal heart failure. Adriamycin cardiotoxicity causes characteristic histologic changes on endomyocardial biopsy, with vacuolar degeneration and myofibrillar loss. Potential mechanisms of cardiotoxicity include free radical formation, release of histamines and catecholamines, and effects on mitochondrial function and nucleic acid synthesis.
The incidence of heart failure is related not only to the dose of the drug but also to the presence or absence of several risk factors (cardiac irradiation, age >70 years, underlying heart disease, hypertension, treatment with cyclophosphamide); at any dose, patients with these risk factors have an eight- to tenfold greater frequency of developing heart failure than do patients lacking them.
Between 5 and 10% of patients receiving at least 500 mg per square meter of body surface area develop overt heart failure, but more than half of patients receiving multiple courses have 10% decline in resting ejection fraction. The dysfunction may continue to progress, with 63% of pediatric patients who have received at least 500 mg per square meter having some cardiac dysfunction detected after 10 years. Some patients with congestive heart failure, even those with severe depression of left ventricular function, have demonstrated recovery of cardiac function with aggressive management with ACE inhibitors and diuretics. Cardiomegaly is the hallmark of dilated myocardiopathy. Although all cardiac chambers may be affected, the left ventricle usually is the most dilated with decreased ventricular ejection fraction.

References

1. Stevenson LW. Diseases of the myocardium. In Bennett JC, Plum F. Cecil textbook of medicine. 20th ed. Philadelphia: W.B. Saunders company, 1996:327-336.
2. Joshua Wynne; Eugene Braunwald. The Cardiomyopathies and Myocarditides. In Isselbacher, et al. Harrison's Principles of internal medicine. 13th ed. McGraw-Hill Inc. 1994:1091

Keywords

Vascular, Vascular, Drug complication,