Resectable Esophageal Cancer Therapy-Related Cardiac Dysfunction: A Review of Mechanisms and Predictive Tools

Esophageal cancer (EC), a highly lethal malignancy with over 445 000 deaths globally in 2022, ranks among the leading causes of cancer mortality globally. As survival improves in EC, cancer therapy-related cardiac dysfunction (CTRCD) has emerged as an important cause of morbidity and mortality. Contemporary treatment strategies involving surgery, fluoropyrimidine-based chemotherapy, immune checkpoint inhibitors, and thoracic radiotherapy expose patients to distinct and overlapping mechanisms of cardiovascular injury. The increasing use of perioperative regimens such as fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) and immunochemotherapy (d-FLOT) approaches further underscores the importance of cardiovascular surveillance. Current evidence suggests that whole-heart dosimetric parameters alone may inadequately predict cardiovascular risk, whereas cardiac substructure-specific assessment and multimodal surveillance may facilitate earlier detection of subclinical injury and more individualized management. However, existing evidence remains largely retrospective, and standardized thresholds for biomarkers, imaging parameters, and surveillance intervals are lacking. Cardio-oncology has become essential in mitigating these risks through early detection and preventive strategies. In this review, we summarize current evidence on the mechanisms, incidence, and predictors of CTRCD in EC. By integrating biochemical, imaging, dosimetric, and predictive modeling approaches, clinicians may better balance oncologic efficacy with cardiovascular safety, reduce long-term cardiac morbidity, and improve overall outcomes in patients undergoing contemporary multimodality treatment for esophageal cancer.