Cardiac CT reveals high prevalence of coronary artery disease in esophageal cancer eligible for radiotherapy
DOI:
https://doi.org/10.2340/1651-226X.2025.42563Keywords:
esophageal cancer, radiation therapy, cardiovascular complications, myocardial perfusion, intensity-modulated radiation therapy, proton beam therapyAbstract
Background: Assessment of cardiac disease before cancer therapy is crucial, as advancements in cancer treatment have led to prolonged survival and an increase in cardiovascular complications. Specifically, esophageal cancer and heart disease share common risk factors, such as smoking and obesity. Radiation therapy (RT) for esophageal cancer is associated with elevated cardiac radiation exposure. This study aimed to assess the prevalence of coronary artery disease (CAD) in patients with esophageal cancer who were eligible for RT.
Methods: We examined the prevalence of coronary artery stenosis, abnormal myocardial perfusion, and late enhancement using pre-RT cardiac computed tomography (CT) data of 41 patients with thoracic esophageal cancer who were referred for RT between January 2017 and June 2023 and had no history of ischemic heart disease.
Results: The median age of the 41 patients was 71 years, with 40 patients being male. Cardiac CT identified significant coronary stenosis (≥50% luminal narrowing) in 18 patients (44%), among whom 9 (50%) had severe stenosis, multivessel disease, or myocardial ischemia. Significant stenosis was most frequently observed in the left anterior descending artery (16/18). Late enhancement, indicating myocardial infarction, was observed in seven patients (17%).
Interpretation: Patients with esophageal cancer without a history of ischemic heart disease had a high prevalence (44%) of CAD, with half of them having severe stenosis, multivessel disease, or myocardial ischemia. Given the high prevalence of coronary stenosis, pre-treatment cardiac evaluation is crucial for patients with esophageal cancer. Incorporating cardiac CT findings into radiotherapy planning is recommended to optimize patient care.
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Wang J, Wei C, Tucker SL, Myles B, Palmer M, Hofstetter WL, et al. Predictors of postoperative complications after trimodality therapy for esophageal cancer. Int J Radiat Oncol Biol Phys. 2013;86(5):885–91.
https://doi.org/10.1016/j.ijrobp.2013.04.006 DOI: https://doi.org/10.1016/j.ijrobp.2013.04.006
Lin SH, Zhang N, Godby J, Wang J, Marsh GD, Liao Z, et al. Radiation modality use and cardiopulmonary mortality risk in elderly patients with esophageal cancer. Cancer. 2016;122(6):917–28.
https://doi.org/10.1002/cncr.29857 DOI: https://doi.org/10.1002/cncr.29857
Lin SH, Wang L, Myles B, Thall PF, Hofstetter WL, Swisher SG, et al. Propensity score-based comparison of long-term outcomes with 3-dimensional conformal radiotherapy vs intensity-modulated radiotherapy for esophageal cancer. Int J Radiat Oncol Biol Phys. 2012;84(5):1078–85.
https://doi.org/10.1016/j.ijrobp.2012.02.015 DOI: https://doi.org/10.1016/j.ijrobp.2012.02.015
He L, Chapple A, Liao Z, Komaki R, Thall PF, Lin SH. Bayesian regression analyses of radiation modality effects on pericardial and pleural effusion and survival in esophageal cancer. Radiother Oncol. 2016;121(1):70–4.
https://doi.org/10.1016/j.radonc.2016.08.005 DOI: https://doi.org/10.1016/j.radonc.2016.08.005
Xi M, Xu C, Liao Z, Chang JY, Gomez DR, Jeter M, et al. Comparative outcomes after definitive chemoradiotherapy using proton beam therapy versus intensity modulated radiation therapy for esophageal cancer: a retrospective, single-institutional analysis. Int J Radiat Oncol Biol Phys. 2017;99(3):667–76.
https://doi.org/10.1016/j.ijrobp.2017.06.2450 DOI: https://doi.org/10.1016/j.ijrobp.2017.06.2450
Wang X, Palaskas NL, Yusuf SW, Abe JI, Lopez-Mattei J, Banchs J, et al. Incidence and onset of severe cardiac events after radiotherapy for esophageal cancer. J Thorac Oncol. 2020;15(10):1682–90.
https://doi.org/10.1016/j.jtho.2020.06.014 DOI: https://doi.org/10.1016/j.jtho.2020.06.014
van den Bogaard VA, Ta BD, van der Schaaf A, Bouma AB, Middag AM, Bantema-Joppe EJ, et al. Validation and modification of a prediction model for acute cardiac events in patients with breast cancer treated with radiotherapy based on three-dimensional dose distributions to cardiac substructures. J Clin Oncol. 2017;35(11):1171–8.
https://doi.org/10.1200/JCO.2016.69.8480 DOI: https://doi.org/10.1200/JCO.2016.69.8480
Banfill K, Giuliani M, Aznar M, Franks K, McWilliam A, Schmitt M, et al. Cardiac toxicity of thoracic radiotherapy: existing evidence and future directions. J Thorac Oncol. 2021;16(2):216–27.
https://doi.org/10.1016/j.jtho.2020.11.002 DOI: https://doi.org/10.1016/j.jtho.2020.11.002
Frandsen J, Boothe D, Gaffney DK, Wilson BD, Lloyd S. Increased risk of death due to heart disease after radiotherapy for esophageal cancer. J Gastrointest Oncol. 2015;6(5):516–23.
Pao TH, Chang WL, Chiang NJ, Lin CY, Lai WW, Tseng YL, et al. Pericardial effusion after definitive concurrent chemotherapy and intensity modulated radiotherapy for esophageal cancer. Radiat Oncol. 2020;15(1):48.
https://doi.org/10.1186/s13014-020-01498-3 DOI: https://doi.org/10.1186/s13014-020-01498-3
Darby SC, Ewertz M, McGale P, Bennet AM, Blom-Goldman U, Bronnum D, et al. Risk of ischemic heart disease in women after radiotherapy for breast cancer. N Engl J Med. 2013;368(11):987–98.
https://doi.org/10.1056/NEJMoa1209825 DOI: https://doi.org/10.1056/NEJMoa1209825
Minsky BD, Pajak TF, Ginsberg RJ, Pisansky TM, Martenson J, Komaki R, et al. INT 0123 (Radiation Therapy Oncology Group 94-05) phase III trial of combined-modality therapy for esophageal cancer: high-dose versus standard-dose radiation therapy. J Clin Oncol. 2002;20(5):1167–74.
https://doi.org/10.1200/JCO.2002.20.5.1167 DOI: https://doi.org/10.1200/JCO.2002.20.5.1167
Bradley JD, Paulus R, Komaki R, Masters G, Blumenschein G, Schild S, et al. Standard-dose versus high-dose conformal radiotherapy with concurrent and consolidation carboplatin plus paclitaxel with or without cetuximab for patients with stage IIIA or IIIB non-small-cell lung cancer (RTOG 0617): a randomised, two-by-two factorial phase 3 study. Lancet Oncol. 2015;16(2):187–99.
https://doi.org/10.1016/S1470-2045(14)71207-0 DOI: https://doi.org/10.1016/S1470-2045(14)71207-0
Kamimura D, Cain LR, Mentz RJ, White WB, Blaha MJ, DeFilippis AP, et al. Cigarette smoking and incident heart failure: insights from the Jackson heart study. Circulation. 2018;137(24):2572–82.
https://doi.org/10.1161/CIRCULATIONAHA.117.031912 DOI: https://doi.org/10.1161/CIRCULATIONAHA.117.031912
Guenancia C, Lefebvre A, Cardinale D, Yu AF, Ladoire S, Ghiringhelli F, et al. Obesity as a risk factor for anthracyclines and trastuzumab cardiotoxicity in breast cancer: a systematic review and meta-analysis. J Clin Oncol. 2016;34(26):3157–65.
https://doi.org/10.1200/JCO.2016.67.4846 DOI: https://doi.org/10.1200/JCO.2016.67.4846
Ishikura S, Nihei K, Ohtsu A, Boku N, Hironaka S, Mera K, et al. Long-term toxicity after definitive chemoradiotherapy for squamous cell carcinoma of the thoracic esophagus. J Clin Oncol. 2003;21(14):2697–702.
https://doi.org/10.1200/JCO.2003.03.055 DOI: https://doi.org/10.1200/JCO.2003.03.055
Morota M, Gomi K, Kozuka T, Chin K, Matsuura M, Oguchi M, et al. Late toxicity after definitive concurrent chemoradiotherapy for thoracic esophageal carcinoma. Int J Radiat Oncol Biol Phys. 2009;75(1):122–8.
https://doi.org/10.1016/j.ijrobp.2008.10.075 DOI: https://doi.org/10.1016/j.ijrobp.2008.10.075
Wright CD, Kucharczuk JC, O’Brien SM, Grab JD, Allen MS, Society of Thoracic Surgeons General Thoracic Surgery D. Predictors of major morbidity and mortality after esophagectomy for esophageal cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database risk adjustment model. J Thorac Cardiovasc Surg. 2009;137(3):587–95; discussion 96.
https://doi.org/10.1016/j.jtcvs.2008.11.042 DOI: https://doi.org/10.1016/j.jtcvs.2008.11.042
Takada A, Ichikawa Y, Nakamura S, Toyomasu Y, Kawamura T, Nanpei Y, et al. Preliminary results of reduced myocardial blood flow in the subacute phase after radiation therapy for thoracic esophageal cancer: a quantitative analysis with stress dynamic myocardial computed tomography perfusion imaging. Radiother Oncol. 2022;177:191–6.
https://doi.org/10.1016/j.radonc.2022.11.002 DOI: https://doi.org/10.1016/j.radonc.2022.11.002
Bittencourt MS, Hulten E, Polonsky TS, Hoffman U, Nasir K, Abbara S, et al. European Society of cardiology-recommended coronary artery disease consortium pretest probability scores more accurately predict obstructive coronary disease and cardiovascular events than the diamond and forrester score: the partners registry. Circulation. 2016;134(3):201–11.
https://doi.org/10.1161/CIRCULATIONAHA.116.023396 DOI: https://doi.org/10.1161/CIRCULATIONAHA.116.023396
Nazir MS, Murphy T, Poku N, Wheen P, Nowbar AN, Andres MS, et al. Clinical utility and prognostic value of coronary computed tomography angiography in patients with cancer. Am J Cardiol. 2023;207:448–54.
https://doi.org/10.1016/j.amjcard.2023.08.121 DOI: https://doi.org/10.1016/j.amjcard.2023.08.121
Nakamura S, Kitagawa K, Goto Y, Omori T, Kurita T, Yamada A, et al. Incremental prognostic value of myocardial blood flow quantified with stress dynamic computed tomography perfusion imaging. JACC Cardiovasc Imaging. 2019;12(7 Pt 2):1379–87.
https://doi.org/10.1016/j.jcmg.2018.05.021 DOI: https://doi.org/10.1016/j.jcmg.2018.05.021
Nakamura S, Kitagawa K, Goto Y, Takafuji M, Nakamori S, Kurita T, et al. Prognostic value of stress dynamic computed tomography perfusion with computed tomography delayed enhancement. JACC Cardiovasc Imaging. 2020;13(8):1721–34.
https://doi.org/10.1016/j.jcmg.2019.12.017 DOI: https://doi.org/10.1016/j.jcmg.2019.12.017
Klein LW, Weintraub WS, Agarwal JB, Schneider RM, Seelaus PA, Katz RI, et al. Prognostic significance of severe narrowing of the proximal portion of the left anterior descending coronary artery. American Journal of Cardiology. 1986;58(1):42-6.
https://doi.org/10.1016/0002-9149(86)90238-9 DOI: https://doi.org/10.1016/0002-9149(86)90238-9
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Copyright (c) 2025 Akinori Takada, Satoshi Nakamura, Yutaka Toyomasu, Takamitsu Mase, Tomoko Kawamura, Suguru Araki, Yoshitaka Suzuki, Masaki Ohi, Hajime Sakuma, Yoshihito Nomoto, Kakuya Kitagawa
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