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Background Cardiovascular and pro-atherogenic side-effects of chemoradiotherapy for non-small cell lung cancer (NSCLC) remain a major concern given the growing burden of cancer therapy-related cardiovascular disease. Atherosclerotic plaque burden can be measured using calcium scoring while plaque activity can be assessed using [18F] fluorodeoxyglucose ([18F]FDG) positron emission tomography (PET).Objectives To investigate the impact of chemoradiotherapy on aortic atherosclerotic burden and disease activity in patients with advanced NSCLC undergoing repeated [18F] FDG PET and computed tomography (CT) scans.Methods All [18F] FDG PET-CT scans of patients with stage 3B NSCLC from the American College of Radiology Imaging Network (ACRIN 6668) trial were retrieved from the Cancer Imaging Archive. Volumes of interest for the aorta, left ventricle and major non-cardiac organs were manually delineated. Calcium scores, mean standard uptake values (SUVmean) and target-to-background ratios (TBRmean) were quantified, and comparisons before and after treatment scans performed.Results Twenty-six patients (mean 60±9 years, body-mass index 25±5 kg/m2) met the inclusion criteria, with 23 having aortic atherosclerosis as evidenced by the presence of aortic calcification. Pre- and post-treatment scans were performed approximately 14 weeks apart. After chemoradiotherapy, aortic calcium score increased by 10% in calcified plaques (p<0.05) and aortic [18F] FDGTBRmean uptake increased by 4% (p=0.02) (figure 1). There were no changes in [18F] FDG uptake in other organs (figure 2).Conclusion Chemoradiotherapy has adverse effects on the vasculature, possibly through increased inflammation resulting in accelerated atherosclerotic disease. This increased cardiovascular risk in lung cancer survivors highlight the need for aggressive risk factor modification at the earliest opportunity. In cancer survivors who have undergone cancer treatment, which of the following best reflects an appropriate cardio-oncology management strategy based on current evidence of therapy related vascular effects?A. Routine cardiovascular assessment only when cardiac symptoms developB. Cardiovascular risk should only be assessed years after completion of therapyC. Aggressive modification of cardiovascular risk factors should be implemented earlyD. Vascular inflammation detected on FDG PET imaging does not translate into clinical riskE. Cancer therapy related cardiovascular effects are limited to myocardial dysfunctionAbstract 35 Figure 2A and B shows changes in [18F] FDG uptake before and after chemoradiotherapy. C shows the change in calcium score after treatment. *p<0.05. TBRmean = Tissue to background ratio relative to aortic blood poolAbstract 35 Figure 1Graphical abstract. NSCLC: Non-small cell lung cancer, PET: Positron Emission Tomography, CT: Computed Tomography, [18F]FDG: [18F]Fluorodeoxyglucose, CT: Computed Tomography, CT Ca score: Computed Tomography calcium scoreAnswer is C.