123 Summarized discussion and future perspectives. difference in coronary calcifications either. The number of coronary calcifications (CAC scores), which is a known predictor for cardiovascular events, was similar in the irradiated patient group as compared to the patients treated with surgery as single treatment modality. Moreover, we did not find a relationship between CAC scores and radiation dose volume parameters of the (subregions) of the heart. A major limitation of this study was its cross-sectional study design. First, we did not have reliable information on baseline CAC scores. Second, as we only analysed EC survivors, patients with cardiovascular risk factors, with consequently higher CAC scores, might have died sooner after treatment. Moreover, irradiated patients were treated with the CROSS regimen, with a relatively low prescribed dose of 41.4 Gy. However, in a more recent paper by Cai et al, the authors reported that 19% of the cardiac complications after definitive CRT for EC were attributed to ischemic events [11]. In a larger population (n=716 patients), combining their data with another institute, they analysed risk factors for the combined endpoint coronary events and heart failure. In this analysis they found that multivariable prediction models including the dose to coronary arteries instead of the dose to the heart performed significantly better with a higher AUC [22]. This is in line with the results obtained in studies on breast cancer in which the dose to the left ventricle (next to the LAD) and dose to the LAD were better predictors for ischaemic coronary events, than the mean dose to the heart [23]. Figure 2, dose distribution of an esophageal cancer versus a breast cancer patient and its relation to the dose of the coronary arteries (LAD) Looking at the dose distributions in oesophageal and breast cancer patients (figure 2), the lower numbers of coronary events in oesophageal cancer patients as compared to breast cancer patients might partly (next to the worse overall survival 8
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