122 Chapter 8 adaptive treatments as well as a reduction of the clinical target volume itself are probably better options to reduce the radiation dose to the left atrium. Figure 1, dose distribution of an esophageal cancer patient comparing a proton and a photon dose distribution and its relation to the dose of the atria It is worthwhile to prevent AF, as AF is a clinically relevant adverse event. Patients with AF are at a higher risk of developing stroke and generally need anticoagulants. Moreover, AF may cause or enhance heart failure, and patients require hospitalization more frequently and have worse overall survival rates [21]. In summary, AF is a frequently occurring complication after chemoradiotherapy (and surgical resection) for EC. AF is most likely related to the radiation dose to the atria which causes fibrosis. Due to the close proximity of the oesophagus to the atria of the heart it is unlikely that treatment plan modification by newer radiotherapy techniques will reduce the risk of AF. Therefore, these new technologies should be combined with margin reduction, in order to reduce the risk of AF. Ischaemic events Although ischemic events have been reported after (c)RT for EC, it is not a frequently occurring complication in the studies performed in this thesis. However, myocardial infarction might be underreported because of the risk of sudden death and therefore might not have been recognized as a coronary event. In our retrospective cohort, we only found 4 patients (2%) presenting with a myocardial infarction, whereas, in the CROSS SECT study, we did not find a
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