Clinical Trial Summary
Rationale: Radiation-induced cardiac and pulmonary toxicity after treatment for
intra-thoracic tumors is a clinically relevant problem, which may jeopardize the benefit of
(neo-adjuvant) (chemo) radiotherapy. Although cure rates are rising since the introduction of
neo-adjuvant chemoradiation (neo-CRT) as current standard treatment for esophageal cancer
(EC), recent studies showed that there is a substantial risk of non-cancer treatment-related
death in these patients. Furthermore, this risk is underestimated as the cause of death of
many patients remains unknown, since the distinction between tumor related and non-cancer
related death can be difficult.
Cardiac and pulmonary toxicity and its interaction as seen in pre-clinical studies might
explain for these unknown deaths as suggested in several clinical studies. Clinical imaging
studies performed shortly after treatment showed changes in different cardiac function
parameters, all related to radiation dose parameters. Systematic imaging studies analysing
subclinical toxicities at longer follow up have never been performed, most probably because
of poor survival rates. However, identification of the magnitude of (subclinical)
cardiopulmonary toxicity, by performing several cardiopulmonary function tests, is essential
in this patient group as this toxicity is most likely the cause of the increased mortality
after thoracic radiotherapy. For future perspectives, these results can be used to select the
best diagnostic methods for a prospective cohort study to develop prediction tools for
cardiopulmonary toxicity..
Objective: The main objective of this study is to determine the most suitable diagnostic test
to identify cardiopulmonary (dys)function in EC survivors treated with neo-CRT followed by
surgical resection. Furthermore, we want to estimate the difference in cardiopulmonary
(dys)function in EC survivors treated with neo-CRT followed by surgical resection compared to
EC survivors who were treated with surgical resection alone.
Study design: Cross-sectional pilot study
Study population: 40 EC patients who were treated with curative intent by esophageal
resection with or without neo-CRT
Intervention (if applicable): Not applicable.
Main study parameters/endpoints: As this is an exploratory pilot study to determine the most
suitable diagnostic tests for future studies, there will be several endpoints related to
(sub)clinical cardiopulmonary dysfunction.
Signs of myocardial ischemia, systolic or diastolic dysfunction, rhythm and valve disorders,
pericardial effusion and fibrosis, myocardial fibrosis, focal wall motion disorders and
coronary calcifications will be analyzed. The cardiopulmonary (dys)function in EC survivors
treated with neo-CRT followed by surgical resection will be compared to cardiopulmonary
(dys)function in EC survivors treated with surgical resection alone.
Nature and extent of the burden and risks associated with participation, benefit and group
relatedness: Several tests will be performed at one time point, 5-10 years after given
treatment. If the findings of the test indicate cardiovascular complications, the patient
will be referred to the cardiologist for further analysis and/or preventive measures. As one
of the tests, cardiac MRI, including gadolinium (Dotarem 0.2 mmol/kg) enhancement will be
performed. Potential side effects of gadolinium include brief headache, nausea (feeling sick)
and dizziness for a brief time following the injection. Allergic reactions are rare.
Furthermore, a cardiac CT scan will be performed with a total radiation exposure of 0.6 mSv
(less than a third of the annual background radiation dose), the risks will be minimal.
