Faculty of Medicine, University of Queensland, Brisbane, Australia; Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia.
Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Int J Radiat Oncol Biol Phys. 2024 Aug 1;119(5):1437-1454. doi: 10.1016/j.ijrobp.2024.03.044. Epub 2024 Apr 5.
The purpose of this review is to summarize the literature on carotid artery stenosis (CAS) and ischemic stroke (IS) in patients with head and neck cancer (HNC) treated with radiation therapy (RT) to guide assessment, screening, and management strategies. Patients treated with RT for HNC are at an elevated risk of developing CAS, with published meta-analyses demonstrating that CAS >50% occurs in approximately 25% of patients. Previous research suggests a 10-year cumulative incidence of stroke between 5.7% and 12.5%. Cardiovascular disease (CVD) risk prediction tools such as Qstroke, QRISK-2, and Framingham risk score perform poorly for predicting IS for patients with HNC who received RT. Duplex ultrasound is the most common imaging modality to assess CAS, but controversy remains as to the utility of screening asymptomatic individuals. Only 3 of the 5 major HNC survivorship guidelines acknowledge RT as a risk factor for CAS or IS, while only 1 makes a specific recommendation on screening for CAS (American Head and Neck Society). Within the general population, only 1 CVD guideline discusses RT as a risk factor for CAS (Society for Vascular Surgery). Clinicians involved in the care of patients with HNC treated with RT should be aware of the increased risk of CAS and IS and the challenges in risk prediction. Although there is a lack of evidence to make firm recommendations, HNC survivorship recommendations should ensure HNC survivors and primary care providers are informed of these risks and the importance of assessment and management of CVD risk factors. Future studies are required to refine risk prediction models in patients with HNC and to determine those most likely to benefit from targeted screening and initiation of early preventative strategies.
本文旨在综述头颈部癌症（HNC）患者接受放射治疗（RT）后颈动脉狭窄（CAS）和缺血性脑卒中（IS）的文献，以指导评估、筛查和管理策略。接受 RT 治疗的 HNC 患者发生 CAS 的风险升高，已发表的荟萃分析表明，约 25%的患者 CAS >50%。先前的研究表明，脑卒中的 10 年累积发生率为 5.7%至 12.5%。用于预测接受 RT 的 HNC 患者 IS 风险的心血管疾病（CVD）风险预测工具（如 Qstroke、QRISK-2 和Framingham 风险评分）效果不佳。双功能超声是评估 CAS 的最常用影像学方法，但对于无症状个体筛查的效用仍存在争议。在 5 项主要的 HNC 生存指南中，只有 3 项承认 RT 是 CAS 或 IS 的危险因素，而只有 1 项对 CAS 筛查提出了具体建议（美国头颈学会）。在普通人群中，只有 1 项 CVD 指南将 RT 视为 CAS 的危险因素（血管外科学会）。参与 RT 治疗的 HNC 患者治疗的临床医生应意识到 CAS 和 IS 的风险增加，以及风险预测的挑战。尽管缺乏确凿证据来制定明确建议，但 HNC 生存指南应确保 HNC 幸存者和初级保健提供者了解这些风险，以及评估和管理 CVD 风险因素的重要性。需要进一步研究以完善 HNC 患者的风险预测模型，并确定最有可能受益于针对性筛查和早期预防策略的患者。
