119 Summarized discussion and future perspectives. The different cardiac syndromes The most common reported cardiac toxicities are pericardial effusion, atrial fibrillation and ischemic events. Pericardial Effusion(PE): In the third chapter we developed an NTCP model for pericardial effusion. We found a significant dose response relationship between the mean heart dose (MHD) and pericardial effusion (PE) with an odds ratio of 1.09 per Gray. This is in line with other papers published in the literature on PE in EC patients. PE is an objective endpoint but often asymptomatic and thus, the reported incidences are highly dependent on the amount of routine CT scans or echocardiography’s performed during follow up. In most papers reporting on PE, as well as in our own study, the prescribed target dose was relatively high and patients were treated with relatively outdated techniques. In our population, the MHD was 26.4 [13.3-37.5] Gy resulting in 69 patients (32%) with PE during follow up. Nowadays, the prescribed dose is lower, and constraints on the heart dose are generally more strict [8,9]. This is most likely the reason that lower incidence rates are reported in recent clinical trials [7,10,11]. Haddad et al reported on the clinical consequences of pericardial effusion during follow up and outcome of oncologic patients with pericardial effusion as seen on echocardiography. Thirteen percent of patients with PE (217/1645) were symptomatic and needed drainage. The majority (98%) of the patients were drained percutaneously (212/217) with a 99% success rate and low (2%) (serious) complication rate requiring extra interventions. It should be noted however, that out of the patients who were drained percutaneously, only 33 patients (16%) were treated with mediastinal radiotherapy less than one year before presentation. Overall survival of these patients was not significantly different from patients not treated with prior radiotherapy [12]. In summary, at present, symptomatic PE is a rare complication and when it occurs, the majority of the patients doesn’t need treatment. Treatment of pericardial effusion itself is relatively safe and effective. Atrial fibrillation(AF) Atrial fibrillation is another well-known complication after multimodality treatment for EC cancer[1,13]. In the paper of Cai et all, AF accounted for 24% (22/91) of all 8
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