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Case report
Stereotactic magnetic resonance imaging-guided radiotherapy for intracardiac metastases: A case report
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Radiothérapie stéréotaxique guidée par IRM pour les métastases intracardiaques : rapport d’un cas
M. Michaleta,b,c,*, R. Tétreaud, J .- L. Pasquié e,f,g,h, O. Chabrei, D. Azriaa, b,c
a Institut du cancer de Montpellier, 208, avenue des Apothicaires, 34298 Montpellier, France
b Fédération universitaire d’oncologie radiothérapie d’Occitanie Méditerranée (FOROM), 208, avenue des Apothicaires, 34298 Montpellier, France
” Inserm, U1194 IRCM, 208, avenue des Apothicaires, 34298 Montpellier, France
d Service d’imagerie médicale, institut du cancer de Montpellier, 208, avenue des Apothicaires, 34298 Montpellier, France e Service de cardiologie, CHU de Montpellier, 371, avenue du Doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France
f CNRS, UMR9214, Montpellier, France
% Inserm, U1046 Phymedexp, Montpellier, France
h Université de Montpellier, Montpellier, France
i Service d’endocrinologie-diabétologie, CHU de Grenoble-Alpes, boulevard de la Chantourne, 38043 Grenoble cedex 9, France
ARTICLE INFO
Article history:
Received 21 June 2023
Accepted 23 June 2023
Keywords: MR-guided radiotherapy Adrenocortical carcinoma Cardiac metastases
ABSTRACT
Adrenocortical carcinoma is a malignant tumor with a poor prognosis and a frequent metastatic exten- sion. In very rare cases, a cardiac metastatic disease may occur, and surgical resection is essential for its management. MR-guided stereotactic radiotherapy is an attractive radiotherapy modality for the treatment of mobile thoracic tumors, enabling the target to be monitored continuously during irradia- tion, while the dosimetric plan can be adapted daily if necessary. We report here the case of a patient with intracardiac metastasis secondary to malignant adrenocortical carcinoma, treated with magnetic resonance imaging-guided stereotactic radiotherapy.
@ 2024 Société française de radiothérapie oncologique (SFRO). Published by Elsevier Masson SAS. All
rights reserved.
RÉSUMÉ
Le corticosurrénalome est une tumeur maligne de pronostic défavorable avec une extension métasta- tique fréquente. Dans de très rares cas, il est possible d’observer une atteinte métastatique cardiaque, dont la prise en charge repose avant tout sur la resection chirurgicale. La radiothérapie stéréotaxique guidée par IRM est une modalité intéressante pour le traitement des tumeurs thoraciques mobiles, per- mettant de suivre la cible de façon continue pendant l’irradiation, tout en adaptant quotidiennement le plan dosimétrique selon le besoin. Nous rapportons ici le cas d’une patiente atteinte d’une métastase intracardiaque secondaire à un corticosurrénalome malin, traitée par irradiation stéréotaxique guidée par IRM.
@ 2024 Société française de radiothérapie oncologique (SFRO). Publié par Elsevier Masson SAS. Tous droits réservés.
Mots clés : Radiothérapie guidée par IRM Carcinome corticosurrenalien Métastases cardiaques
1. Introduction
Adrenocortical carcinoma is a rare endocrine malignancy aris- ing from the adrenal gland. Adrenocortical carcinoma can secrete different cortical hormones (causing hypercorticism, hyperandro- genism, or primary aldosteronism), leading to different morbidity
* Corresponding author. Institut du cancer de Montpellier, 208, avenue des Apoth- icaires, 34298 Montpellier, France.
E-mail address: morgan.michalet@icm.unicancer.fr (M. Michalet).
[1]. The prognosis is bad, with most of cases metastatic or locally advanced at time of diagnosis [2]. Surgery is the cornerstone of localized diseases treatment, whereas chemotherapy is used for metastatic diseases (mitotane for indolent diseases or more aggres- sive platinum-based regimens for others) [3].
Cardiac tumors are rare and most of them are benign [4]. Among malign tumors, metastatic tumors are 100 to 1000-fold more com- mon than primary cardiac tumors [5]. Treatment of cardiac tumors is classically based on surgical resection. Radiation therapy is a limited option due to limited heart constraint doses, even in old literature on this topic [6].
Magnetic resonance imaging (MRI)-guided radiotherapy is an interesting option for such treatment, thanks to three advantages in comparison to “standard” radiotherapy. It offers a good contrast for cardiac tumors using MR images contrast and the possibility to follow the target during irradiation with continuous cine-MR images. Moreover, it is possible to daily adapt the plan to take into account the possible volume modifications [7,8]. We present in this article the case of a patient treated in our institution with MRI- guided radiation for an intracardiac metastasis from a primitive adrenocortical carcinoma.
2. Case presentation
A 65-year-old female patient was addressed in our department; she had a history of adrenocortical carcinoma with a first treat- ment 10 years before, which consisted of a left adrenalectomy. She later developed local recurrence treated by partial diaphrag- matic resection 7 years later and hepatic metastases treated with chemoembolization. Six years after this, she was diagnosed with an asymptomatic cardiac metastasis located in the right ventri- cle. A close follow-up was proposed, and the patient had been treated with radiofrequency for pulmonary metastases 5 years and 2 years before admission in our department. The cardiac mass did not progress since first radiofrequency treatment.
One month following the second radiofrequency treatment, the patient presented with electrocardiogram modifications, without clinical symptoms. A cardiac MRI was performed and found a 41-mm heterogeneous right ventricular mass, probably with septoapical myocardial origin, with intralesional necrotic- haemorrhagic changes, confirming the progression of this cardiac metastasis (Fig. 1). The CT-scan did not find any other progression
| Volumes | |
| Gross tumor volume (GTV) | 44.21 cm3 |
| Planning target volume (PTV) | 63.64 cm3 |
| Dose constraints | |
| Heart valves | <0.5 cm3 at 23 Gy, Dmax 38 Gy |
| Heart excluding PTV | < 15 cm3 at 32 Gy, Dmax 38 Gy |
| Large bowel | Dmax < 32 Gy |
| Stomach | Dmax < 32 Gy |
Dmax: maximum dose.
except this cardiac lesion. The case was discussed in multidisci- plinary staff meeting. The surgical resection was contraindicated due to technical impossibility. The patient was proposed for a radio- therapy.
Clinically, the patient was asymptomatic, with a performance status of 0. The cardiac report was good, with a left ventricular ejec- tion fraction of 61% on echocardiography and no kinetic troubles.
We discussed this case in our department and proposed a stereotactic MR-guided radiotherapy. We chose to use the MRIdian (Viewray®), which is a MR-linear accelerator (6-MV linear acceler- ator combined with a 0.35-T MR-imaging device). We prescribed 30 Gy in five fractions every other day, over two weeks, with nor- malization on D50%, ensuring a target coverage (planning target volume [PTV]) of 95% within the 95% isodose. PTV was built with a 3-mm isotropic expansion from GTV, which was delineated using MRIdian simulation images, as well as a 1.5-T diagnostic MRI after registration.
Volumes and dose constraints used are presented in Table 1. A 98.1% target coverage was obtained for the PTV V95%. The dose distribution is shown in Fig. 2.
A cardiological assessment with electrocardiogram and echocardiography was proposed before, during treatment (after the third fraction) and after the last fraction. A continuous elec- trocardiogram monitoring was performed during irradiation using an amagnetic scopus. The treatment was well tolerated with no evidence of cardiac dysfunction during and after treatment, and no other toxicity.
A close follow-up was performed with a clinical assessment at 1, 3 and 6 months and a CT-scan assessment at 3 and 6 months after treatment. We observed a progressive partial response as
Isodose Lines
Rx Dose = 30.00 Gy
| Dose (Gy) | Rx (%) |
|---|---|
| 31.50 | 105.0 |
| 28.50 | 95.0 |
| 20.00 | 66.7 |
| 10.00 | 33.3 |
0
50 man
34 mm
38 mm
.
4
Fig. 3. CT-scan with iodin contrast product injection performed at 3 months (right) and 6 months (left) after treatment, showing a progressive partial response.
shown in Fig. 3. At 6 months post-treatment, the lesion mea- sured 31 x 34 mm compared to 36 x 41 mm before treatment. The other already known secondary pulmonary lesions were stable. The patient was asymptomatic and the cardiological evaluation was perfectly stable.
3. Discussion
As cardiac metastases are rare situations, only few data are avail- able concerning the use of radiotherapy in this situation. On the other hand, some data are emerging concerning the use of stereo- tactic radiotherapy for refractory ventricular tachycardia [9,10]. MR-guided radiotherapy is an interesting option for the treatment of cardiac masses. Corradini et al. described their experience of MRI- guided radiotherapy for primary cardiac sarcomas [11] All patients were irradiated in a salvage situation after surgery with a prescrip- tion of 30 to 35 Gy in five fractions. All patients completed the treatment with a good tolerance.
Other authors described their experience for the treatment of intracardiac and pericardial metastases using MRI-guided radiation [12]. They treated five patients with a median dose of 40 Gy in five fractions. After a median follow-up of 4.7 months, all patients pre- sented a stable disease, partial or complete response. One patient presented with an atrial fibrillation 6 months after treatment.
Due to the larger lesion size than those described in the two previous articles, we chose to deliver a dose of 30 Gy in five fractions for this patient. We obtained a good partial response, with no other progressive lesion and no toxicity observed after a follow-up of 6
months. This result is encouraging, and we hope to obtain a better response in the following months along with a good quality of life.
4. Conclusion
MRI-guided radiotherapy appears to be a potential good option for inoperable cardiac tumors. A longer follow-up is required to assess late toxicity and survival outcomes.
Disclosure of interests
The authors have not declared their activi- ties/relationships/interests.
References
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