24 Chapter 2 reduced below 26.1 Gy, the risk for PCE decreased from 73% to 13% at 18 months after treatment. The strongest prognostic factor was a V30 pericardium of >46%. Shirai et al. retrospectively analyzed 43 esophageal cancer patients.[7] In total, 35% of the patients developed non-malignant PE, including 4 patients (13%) with grade ≥2, which required medical intervention. In the univariate analysis, most cardiac and one lung parameter (V50 lung) were significantly associated with the development of PE. In de multivariate analysis, older age and the cardiac V50 were the only significant prognostic factors for PE. The left ventricular ejection fraction was studied in two papers [8,9], with relatively low patient numbers. Treatment details are listed in table 1. A small decline(4-5%) in ejection fraction was found after treatment in both papers. However, no significant association was found between dose distribution and a reduction in ejection fraction. 3D functional cardiac imaging was used to evaluate cardiac toxicity in five papers. [10–14] Treatment details and patient numbers are again listed and marked as the last five papers in table 1. Gayed et al. compared 26 irradiated to 25 non-irradiated esophageal cancer patients from a prospective database[11]. Cardiac risk factors, including demographics were comparable in the two groups. In this cohort, gated myocardial perfusion scans were routinely performed preoperatively and blinded for former treatment. Perfusion abnormalities and wall ischemia were increasingly seen in the irradiated group, but functional parameters (left ventricular ejection fraction, end diastolic and systolic) did not differ significantly. Most perfusion defects were found in the higher dose areas (>45 Gy), 70% vs. 25%. However, the mean heart dose was not statistically higher in the patients with abnormal perfusion scans. In another study from the same investigators, the clinical implications of these perfusion abnormalities in 24 lung and 16 esophageal cancer patients were investigated [10]. Although new perfusion defects were seen in about 1/3 of the patients, no significant relationship was found with symptomatic cardiac complications after a rather short median follow up of 10.9 months. Konski et al. evaluated 74 esophageal cancer patients using FDG-PET.[12] The FDG uptake declined, especially in the lateral myocardial wall, shortly after treatment. A significant association was found between the V20, V30 and V40 of the heart and symptomatic cardiac toxicity. The V40 was 69.2% vs. 53.8% among patients with
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