117 Summarized discussion and future perspectives. We found a linear dose response relationship between mean radiation dose to the segments of the left ventricle and their ECV values. These results suggest that (co) irradiation of the heart causes direct damage to the myocardium [3]. In chapter 6 we compared the same two groups of patients and evaluated the combined results of CT, MRI, quality of life (QoL) questionnaires, blood biomarkers for cardiac damage and echocardiography. In this pilot study, we hypothesized that myocardial fibrosis plays a central role in cardiac toxicity leading to atrial fibrillation, conduction changes and decreased role functioning. Due to the limited number of patients however, these results need to be verified in a larger preferably prospective cohort study. Results are further explored in the discussion section hereafter [4]. Chapter 7 reports on the results of a prospective longitudinal study monitoring cardiac blood biomarkers during and after (neoadjuvant) (chemo)radiotherapy for EC. In this study, an association was found between the rise of these biomarkers during treatment and radiation dose parameters to the heart and lungs. During follow up, these markers were mainly associated with clinical events and overall survival, but no significant relationships were found with radiation dose distribution parameters. We feel however that these biomarkers can further help unravelling mechanisms behind cardiac toxicity in future clinical trials. In the meanwhile, they have been incorporated in some clinical trials [5]. In this summarizing chapter, a number of subjects will be further explored in more detail. 8
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