Effect of Adjuvant Chemotherapy on Left Ventricular Remodeling in Women with Newly Diagnosed Primary Breast Cancer: A Pilot Prospective Longitudinal Cardiac Magnetic Resonance Imaging Study.

PURPOSE: The aim of this study was to assess the left ventricular (LV) remodeling response to chemotherapy in low-cardiac-risk women with newly diagnosed nonmetastatic breast cancer. Cardiotoxic effects of chemotherapy are an increasing concern. To effectively interpret cardiac imaging studies performed for screening purposes in patients undergoing cancer therapy it is necessary to understand the normal changes in structure and function that may occur. METHODS: Twenty women without preexisting cardiovascular disease, of a mean age of 50 years, newly diagnosed with nonmetastatic breast cancer and treated with anthracycline or trastuzumab, were prospectively enrolled and evaluated at four time points (at baseline, during chemotherapy, 2 weeks after chemotherapy, and 6 months after chemotherapy) using cardiac magnetic resonance imaging, blood samples, and a clinical questionnaire. RESULTS: Over a 6-month period, the left ventricular ejection fraction (%) decreased (64.15±5.30 to 60.41±5.77, P<0.002) and the LV end-diastolic (mm) and end-systolic (mm) volumes increased (124.73±20.25 to 132.21±19.33, P<0.04 and 45.16±11.88 to 52.57±11.65, P<0.00, respectively). The LV mass (g) did not change (73.06±11.51 to 69.21±15.3, P=0.08), but the LV mass to LVEDV ratio (g/mm) decreased (0.594±0.098 to 0.530±0.124, P<0.04). CONCLUSIONS: In low-cardiac-risk women with nonmetastatic breast cancer, the increased LV volume and a mildly decreased left ventricular ejection fraction during and after chemotherapy do not seem to be associated with laboratory or clinical evidence of increased risk for heart failure.

Severe and resistant hypertension in an older woman with claudication.

Coarctation of the aorta is an uncommon cause of treatment-resistant hypertension in adults. It is typically detected and treated in infancy or childhood with surgical or endovascular procedures. Most cases of recurrence of coarctation after repair occur in childhood or early adulthood; recurrence in older persons (>70 years) has rarely been reported. A 73-year-old woman was referred to us for the management of treatment-resistant hypertension accompanied by symptoms of claudication and headaches, which had resulted in multiple emergency room visits. Of note, 58 years earlier, a graft from the left subclavian artery had been used to bypass an aortic coarctation. During a hospitalization for severe hypertension accompanied by acute kidney injury and heart failure, diagnostic angiography revealed a complete thrombotic occlusion of the left subclavian-artery-to-descending-aorta bypass graft and a tight coarctation in the descending thoracic aorta. Balloon angioplasty and stenting across the coarctation was only transiently effective; subsequently, an ascending-to-descending graft was placed distal to the coarctation, and within a few days, the blood pressure levels and claudication improved markedly. This case demonstrates that hypertension specialists should suspect the possibility of recurrence of a coarctation in older patients who present with resistant hypertension and have a remote history of coarctation repair. Although such late recurrences are not common, as illustrated in our patient, surgical intervention may contribute to significant improvement in blood pressure control and prevent future complications.

Apical hypertrophic cardiomyopathy associated with chronic hypertension: diagnostic and management implications.

Apical hypertrophic cardiomyopathy (HCM) is a rare variant of HCM in the non-Japanese population (1% to 2%). Diagnostic dilemma occurs when this type of HCM is newly discovered in a patient previously diagnosed with left ventricular hypertrophy (LVH) secondary to hypertension. We describe an atypical presentation of an apical HCM in the setting of chronic hypertension (HTN) and review the literature of this rare variant of HCM. Our patient presented with chest pain and was found to have apical HCM with inducible apical ischemia and an abnormal blood pressure response to exercise. Multimodality imaging approach is proposed to evaluate the LVH when both apical HCM and hypertension are present given the impact of an accurate diagnosis on prognosis and management.

Effect of in utero exposure of iodinated intravenous contrast on neonatal thyroid function.

PURPOSE: Administration of radioactive iodine to a pregnant woman for thyroid ablation has been shown to affect neonatal thyroid levels. Thus, there is a theoretical risk in affecting a neonate's thyroid level upon birth with prior administration of intravenous contrast containing iodine to a pregnant woman during a computed tomographic scan. However, there is no literature to support this theoretical risk. This study attempted to determine if there is any effect on a newborn's thyroid levels after exposure to this type of contrast material in utero. MATERIALS AND METHODS: The medical charts of 96 pregnant women during the years 2004 through 2009 on whom computed tomographic scans were performed were reviewed. A total of 29 charts were excluded secondary to missing neonatal records, missed abortions, and intrauterine fetal demise. The rest were subdivided into those who received intravenous (IV) ± oral contrast material and those who did not. The medical records of the newborns of these patients were also reviewed. The subject group consisted of 61 pregnant women who received IV ± oral contrast and their 64 neonates. The control group consisted of 6 pregnant patients who did not receive IV contrast and their 6 neonates. RESULTS: Of the 64 neonates in the subject group, only one neonate was found to have a low thyroxine level with a normal thyroid stimulating hormone level. This infant was severely premature, being born at the 25th week of gestation, and developed respiratory distress syndrome and sepsis, which were potential confounding factors. All of the 6 neonates in the control group had normal thyroid levels. CONCLUSION: This study concludes that there is no significant adverse clinical risk of thyroid function abnormalities to the fetus after IV iodinated contrast material to their mothers.

Head and neck cancers: post-therapy changes in muscles with FDG PET-CT.

BACKGROUND: FDG PET-CT plays a critical role in the management of head and neck cancer patients. After therapy, many patterns of altered physiologic FDG uptake have been recognized. In our institution, we noticed patterns of head and neck muscle uptake that were unique in the post-therapy scans of head and neck cancer patients. MATERIALS AND METHODS: A total of 32 patients with head and neck cancers who had both pretherapy and posttherapy FDG PET-CT scans were retrospectively analyzed. Regional anatomic muscle groups that had increased PET uptake on either pretherapy or post-therapy scans were identified. RESULTS: On the pretherapy scans, the majority of patients (24/32 patients) did not have increased PET activity in the predefined muscle groups. On the post-therapy scans, the majority of patients (25/32 patients) demonstrated increased uptake in at least 1 head and neck muscle group, with an average of 3 muscle groups per patient. The muscle groups with the greatest frequencies were the prevertebral (50%), the accessory neck (47%), the posterior paravertebral (47%), and the scalene muscles (38%). Relative to pretherapy scans, the mean intensity of the post-therapy elevations corresponded to greater SUVs. CONCLUSION: FDG PET-CT scan commonly depicts an elevated FDG muscle uptake in all regional anatomic muscle groups in the post-therapy head and neck cancer patient. This uptake should be considered as a consequence of treatment and perhaps changes in altered biomechanics, and not be confused with residual or recurrent neoplastic activity.