Journal Reading III

Carotid stenosis prevalence after

radiotherapy in nasopharyngeal carcinoma:
A meta-analysis

Presenter: dr. Giovano Andika Pradana

Supervisor: Dr. dr. Irwan Ramli, Sp.Rad(K)Onk.Rad
Overview
1 Background

2 Methods

3 Result

4 Discussion

5 Conclusion

6 Critical Appraisal
1 Background

Optic Brachial
neuropathy plexus injury
Chemoradiation 5-year survival Increasing late
effective for NPC >50% toxicity
Brain
necrosis
1 Background

Asymptomatic Postradiation NPC

population population
Aim Examine the effects of
radiation therapy for NPC
on carotid stenosis risk
4,2% 30%
Examine effects on various
carotid regions: CCA, ICA,
ECA, carotid bulb
 2 Methods

Elligibility criteria
• Case control and
observational studies
• Examine extra-cranial
carotid artery (ECCA)
stenosis
• Compare post-radiation
NPC patients with non-
irradiated patients
• Exclusion: case series,
review article
Quality assessment,
Search strategy Data collection
statistical analysis
• Nov 5th 2017 • Two reviewers collect • Studies were scored
• Medline, EMBASE, Web data using Newcastle-Ottawa
of Science, Cochrane • Data recorded: age, sex, scale
• Filter: human subjects, comorbidity, RT dose, • Meta-analysis
English language time interval, CVA performed with Review
• Publication date or Manager 5.3 using RR
status not restricted to compare
dichotomous variables

[‘‘carotid stenosis” OR ‘‘plaque” OR ‘‘atherosclerosis” OR ‘‘occlusion”] AND [‘‘Nasopharyngeal Carcinoma” OR

‘‘Nasopharyngeal Neo- plasm” OR ‘‘Nasopharyngeal Tumor” OR ‘‘Nasopharyngeal Cancer”]
3
2 Methods
Result
3 Result
3 Result
3 Result
3 Result
3 Result
3 Result
3 Result
3 Result
3 Result
4
3 Discussion
Result

• Mixed blessing of radiotherapy: tumor control and survival versus long-term side
effects
• No large-scale study has yet analyzed carotid stenosis rates in NPC patients after
receiving RT.
• Increase in incidence of carotid stenosis in post-radiation NPC patients
• RR 4,17 (95%CI 2,44 to 7,10; p<0,05)
• Different blood vessels may receive different radiation dose:
• Significant difference: CCA, ECA, carotid bulb, CCA/ICA, CCA/ICA/carotid bulb
• No significant difference: ICA
• Increase in incidence of significant carotid stenosis (>50%)
• RR 8,72 (95%CI 3,53 to 21,55)
• No significant difference in CCA and carotid bulb
4 Discussion

Intimal proliferation,
necrosis of media,
fibrosis of adventitia

Collagen
Inflammation
overproduction

Damage in Stiffening and

Extracelullar
endothelial and thickening of matrix remodelling
vasa vasorum arteries
4 Discussion
4 Discussion

Study limitation:
• Based on observational data from case-control dan cross-sectional studies
• Interstudy variations:
• Control: 3 studies use non-irradiated NPC patients, 7 studies use healthy
subjects, 2 studies use stroke patients
• Matching
• Imaging for carotid stenosis evaluation: 10 studies use US, 1 study uses
MR angiography, 1 study uses CT angiography
• RT technique: 1 study uses IMRT, 11 other use 2D, 3D, or not stated
• Other variations: age at treatment, radiation dose, time elapsed before
the first carotid stenosis examination
5
4 Conclusion
Discussion

There is a strong association between

radiation therapy and carotid stenosis.

NPC patients who undergo radiation therapy

should be thoroughly screened after
treatment

Further study required for more precise

analysis
5
6 Conclusion
Critical Appraisal

Patient Intervention Comparison Outcome

• NPC • Radiation • Non- • Carotid
patients therapy irradiated stenosis
patients
6 Critical Appraisal

Is it unlikely that important, relevant studies were missed?

• Probably, there is lack of unpublished studies and articles in language other
than English included in analysis

Were the criteria used to select articles for inclusion appropriate?

• Yes, study design and PICO were clearly specified in eligibility criteria

Were the included studies sufficiently valid for the type of question asked?
• Yes, the studies included were scored using Newcastle-Ottawa scale

Were the results similar from study to study?

• Yes, the results were similar, but there was heterogeneity
Thank You