19 Review on cardiac toxicity Introduction Increasing numbers of patients with esophageal cancer are currently being treated with curatively intended combined modality strategies such as chemoradiation, either in the neoadjuvant setting followed by surgery or as definitive treatment. Due to improved outcome, resulting from the addition of chemotherapy to radiotherapy, more patients are surviving treatment of esophageal cancer. Therefore, more patients are at risk for treatment-related toxicity, which is becoming a major concern. Little data is available on cardiac morbidity and mortality following radiation treatment of esophageal cancer. This may be explained by the fact that cardiac toxicity has traditionally been regarded as a late (or very late) side effect. Given the relatively low incidence of esophageal cancer and previously low cure rates after treatment, data on radiation-induced cardiac toxicity has remained scarce. Radiation-induced cardiac toxicity in other cancers, such as breast cancer and Hodgkin’s lymphoma, has been studied more extensively due to larger numbers of patients and better survival. In these patient groups, higher rates of cardiac death have been found during long-term follow up [1]. However, in esophageal cancer, cardiac doses are generally markedly higher due to the location of the target area close to the heart and/or to the higher total dose. Currently, no clear guidelines exist on how to distribute the radiation dose between the different organs at risk in radiotherapy treatment planning of esophageal cancer, in particular the relation between the dose to the lungs and to the heart. This question becomes even more relevant with the clinical introduction of new radiation delivery techniques like intensity modulated radiotherapy (IMRT) and proton therapy. We therefore reviewed the current evidence on types and incidence of radiation induced cardiac toxicity and the possibly association with dose-volume parameters after multimodality treatment for esophageal cancer. 2
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