Cumulative Radiation Exposure and Lifetime Cancer Risk in Patients With Tetralogy of Fallot Requiring Early Intervention

Jeannette R Wong-Siegel; Andrew C Glatz; Courtney McCracken; Choonsik Lee; Cari M Kitahara; Lene H S Veiga; Yun Zhang; Bryan H Goldstein; Christopher J Petit; Athar M Qureshi; George T Nicholson 3rd; Mark A Law; Jeffery Meadows; Shabana Shahanavaz; Michael L O'Byrne; Sarosh P Batlivala; Joelle Pettus; Asaad Beshish; Christopher E Mascio; Jennifer C Romano; Kathyrn O Stack; Ivor Asztalos; Tacy E Downing; Jeffrey D Zampi

doi:10.1016/j.jacadv.2024.101239

Cumulative Radiation Exposure and Lifetime Cancer Risk in Patients With Tetralogy of Fallot Requiring Early Intervention

JACC Adv. 2024 Sep 6;3(10):101239. doi: 10.1016/j.jacadv.2024.101239. eCollection 2024 Oct.

Authors

Jeannette R Wong-Siegel¹, Andrew C Glatz¹, Courtney McCracken², Choonsik Lee³, Cari M Kitahara³, Lene H S Veiga³, Yun Zhang⁴, Bryan H Goldstein⁵, Christopher J Petit⁴, Athar M Qureshi⁶, George T Nicholson 3rd⁷, Mark A Law⁸, Jeffery Meadows⁹, Shabana Shahanavaz¹⁰, Michael L O'Byrne¹¹, Sarosh P Batlivala¹⁰, Joelle Pettus¹², Asaad Beshish¹², Christopher E Mascio¹³, Jennifer C Romano¹⁴, Kathyrn O Stack¹¹, Ivor Asztalos¹¹, Tacy E Downing¹⁵, Jeffrey D Zampi¹⁴

Affiliations

¹ The Heart Center, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, USA.
² Center for Research and Evaluation, Kaiser Permanente, Atlanta, Georgia, USA.
³ Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institute of Health, Rockville, Maryland, USA.
⁴ New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Vagelos College of Physicians & Surgeons, New York, New York, USA.
⁵ Heart Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
⁶ The Lillie Frank Abercrombie Division of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.
⁷ Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt University Medical Center, Nashville, Tennessee, USA.
⁸ Children's of Alabama, University of Alabama at Birmingham, Birmingham, Alabama, USA.
⁹ Department of Pediatrics, University of California San Francisco, San Francisco, California, USA.
¹⁰ Heart Institute, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
¹¹ The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
¹² Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA.
¹³ West Virginia University Medicine Children's Hospital, Morgantown, West Virginia, USA.
¹⁴ C.S. Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, Michigan, USA.
¹⁵ Division of Cardiology, Children's National Hospital, Washington, DC, USA.

Abstract

Background: Neonates with tetralogy of Fallot and symptomatic cyanosis (sTOF) require early intervention, utilizing either a staged repair (SR) or primary repair (PR) approach. They are exposed to several sources of low-dose ionizing radiation, which may contribute to increased cancer risk.

Objectives: The purpose of this study was to compare cumulative radiation exposure and associated lifetime attributable risk (LAR) of cancer between treatment strategies in sTOF.

Methods: Neonates with sTOF who underwent SR or PR from 2012 to 2017 were retrospectively reviewed from the Congenital Cardiac Research Collaborative. Radiation exposure from all radiologic studies prior to 18 months of age was converted to organ-equivalent doses and projected LAR of cancer incidence using the National Cancer Institute dosimetry tools.

Results: There were 242 neonates from 8 centers, including patients with 146 SR and 96 PR. Cumulative total effective dose was significantly higher for SR (median 8.3 mSv, IQR: 3.0-17.4 mSv) than PR (2.1 mSv, IQR: 0.8-8.5 mSv; P < 0.001). Cumulative organ-level doses were significantly higher in SR compared to PR. Regardless of treatment strategy, LARs were higher in females compared to males. Among organs with median exposure >1 mGy in females, the LAR was highest for breast in SR (mean 1.9/1,000 patients). The highest proportion of cancers attributable to radiation exposure was projected for thyroid cancer in females undergoing SR (7.3%).

Conclusions: Cumulative radiation exposure and LARs were higher among those undergoing SR compared to PR. This will be an important factor to consider in determining the preferred neonatal treatment strategy and should substantiate efforts to reduce radiation exposure in this vulnerable population.

Keywords: cancer; congenital heart disease; outcomes; radiation exposure; staged repair.