Nonrandomized comparison between definitive chemoradiotherapy and radical surgery in patients with T(2-3)N(any) M(0) squamous cell carcinoma of the esophagus

Predictive factors of esophageal stenosis associated with tumor regression in radiation therapy for locally advanced esophageal cancer

The purpose of this retrospective study was to clarify the predictive factors correlated with esophageal stenosis within three months after radiation therapy for locally advanced esophageal cancer. We enrolled 47 patients with advanced esophageal cancer with T2-4 and stage II-III who were treated with definitive radiation therapy and achieving complete response of primary lesion at Kyushu University Hospital between January 1998 and December 2005. Esophagography was performed for all patients before treatment and within three months after completion of the radiation therapy, the esophageal stenotic ratio was evaluated. The stenotic ratio was used to define four levels of stenosis: stenosis level 1, stenotic ratio of 0-25%; 2, 25-50%; 3,50-75%; 4,75-100%. We then estimated the correlation between the esophageal stenosis level after radiation therapy and each of numerous factors. The numbers and total percentages of patients at each stenosis level were as follows: level 1: n = 14 (30%); level 2: 8 (17%); level 3: 14 (30%); and level 4: 11 (23%). Esophageal stenosis in the case of full circumference involvement tended to be more severe and more frequent. Increases in wall thickness tended to be associated with increases in esophageal stenosis severity and frequency. The extent of involved circumference and wall thickness of tumor region were significantly correlated with esophageal stenosis associated with tumor regression in radiation therapy (p = 0.0006, p = 0.005). For predicting the possibility of esophageal stenosis with tumor regression within three months in radiation therapy, the extent of involved circumference and esophageal wall thickness of the tumor region may be useful.

Optimal timing of endoscopic evaluation of the primary site of esophageal cancer after chemoradiotherapy or radiotherapy: a retrospective analysis

BACKGROUND

Although use of gastrointestinal endoscopy for response evaluation in patients with esophageal cancer undergoing chemoradiotherapy or radiotherapy (CRT/RT) treatment is widely accepted, optimal timing for evaluation has not been sufficiently investigated. Here, we investigated optimal timing of primary site response evaluation in esophageal cancer patients treated with CRT/RT.

PATIENTS AND METHODS

This study examined esophageal cancer patients who underwent CRT/RT between September 2002 and December 2004. Time to complete response (CR) at the primary site was assessed in patients designated as CR at the primary site, while progression-free survival at the primary site (PFSp) was assessed in patients designated as incomplete response at the primary site.

RESULTS

Eighty-three patients were enrolled in this study. Median total RT dose was 60 Gy (range, 50-60 Gy), and median RT duration was 53 days (range, 35-74 days). Mean time to CR at the primary site was 97 days (range, 52-201 days). In four patients, although initial examination of biopsy specimens found evidence of viable cancer cells within 75 days of treatment initiation, subsequent examination found no such evidence, and the patients were thus designated as CR. Median PFSp was 149 days (range, 67-399 days), and PFSp rate at 90 days was 97%. Median interval between the previous examination and initial primary progressive disease was 37 days.

CONCLUSION

Recommended time of first response evaluation for esophageal cancer following initiation of CRT/RT was found to be between 75 and 90 days. Subsequent evaluation should be carried out approximately one month following non-CR/non-progressive disease declassification.

Replacement of cisplatin with nedaplatin in a definitive 5-fluorouracil/cisplatin-based chemoradiotherapy in Japanese patients with esophageal squamous cell carcinoma

OBJECTIVE

The effects of replacing cisplatin (CDDP) with cis-diammineglycolatoplatinum (nedaplatin, NDP), a second-generation platinum complex, on the pharmacokinetics of 5-fluorouracil (5-FU) were investigated in Japanese patients with esophageal squamous cell carcinoma, who were treated with a definitive 5-FU/CDDP-based chemoradiotherapy.

METHODS

Fifty-six patients were enrolled, 49 treated with CDDP and 7 treated with NDP. A course consisted of continuous infusion of 5-FU at 400 mg/m(2)/day for days 1-5 and 8-12, infusion of CDDP or NDP at 40 mg/m(2)/day on days 1 and 8, and radiation at 2 Gy/day on days 1 to 5, 8 to 12, and 15 to 19, with a second course repeated after a 2-week interval. Plasma concentrations of 5-FU were determined by high performance liquid chromatography at 5 PM on days 3, 10, 38 and 45, and at 5 AM on days 4, 11, 39 and 46.

RESULTS AND CONCLUSIONS

The circadian rhythm in plasma concentrations of 5-FU observed in the case of CDDP was altered when NDP was used instead. The clinical response can be predicted by monitoring plasma concentrations of 5-FU in the CDDP group, but not in the NDP group.

Prospective comparison of surgery alone and chemoradiotherapy with selective surgery in resectable squamous cell carcinoma of the esophagus

PURPOSE

Esophagectomy remains the mainstay treatment for esophageal cancer, although retrospective studies have suggested that chemoradiotherapy (CRT) is as effective as surgery. To determine whether CRT can substitute for surgery as the primary treatment modality, we performed a prospective direct comparison of outcomes after treatment in patients with resectable esophageal cancer who had received CRT and those who had undergone surgery.

METHODS AND MATERIALS

Eligible patients had resectable T1-3N0-1M0 thoracic esophageal cancer. After the surgeon explained the treatments in detail, the patients selected either CRT (CRT group) or surgery (OP group). The CRT course consisted of two cycles of cisplatin and fluorouracil with split-course concurrent radiotherapy of 60Gy in 30 fractions. Patients with progressive disease during CRT and/or with persistent or recurrent disease after CRT underwent salvage resection.

RESULTS

Of 99 eligible patients with squamous cell carcinoma registered between January 2001 and December 2005, 51 selected CRT and 48 selected surgery. Of the patients in the CRT group, 13 (25.5%) underwent esophagectomy as salvage therapy. The 3- and 5-year survival rates were 78.3% and 75.7%, respectively, in the CRT group compared with 56.9% and 50.9%, respectively, in the OP group (p = 0.0169). Patients in the OP group had significantly more metastatic recurrence than those in the CRT group.

CONCLUSIONS

Treatment outcomes among patients with resectable thoracic esophageal squamous cell carcinoma were comparable or superior after CRT (with salvage therapy if needed) to outcomes after surgery alone.

Pharmacokinetics and pharmacogenomics in esophageal cancer chemoradiotherapy

Esophageal cancer is one of the most lethal malignancies. Surgical resection of the tumor from the primary site has been the standard treatment, especially for localized squamous cell carcinoma, but considerable clinical efforts during the last decade have resulted in novel courses of treatment. These options include chemoradiotherapy, consisting of a continuous infusion of 5-fluorouracil (5-FU), cisplatin (CDDP), and concurrent radiation. Given the substantial inter- and/or intra-individual variation in clinical outcome, future improvements will likely require the incorporation of a novel anticancer drug, pharmacokinetically guided administration of CDDP or 5-FU, and identification of potential responders by patient genetic profiling prior to treatment. In this review, the latest information on incidence, risk factors, biomarkers, therapeutic strategies, and the pharmacokinetically guided or genotype-guided administration of CDDP and 5-FU is summarized for future individualization of esophageal cancer treatment.

Retrospective review of surgery and definitive chemoradiotherapy in patients with squamous cell carcinoma of the thoracic esophagus aged 75 years or older

OBJECTIVE

The aim of this study was to review the treatment outcomes of surgery and definitive chemoradiotherapy (CRT) in elderly patients with squamous cell carcinoma of the thoracic esophagus.

METHODS

A total of 64 patients aged 75 or older were retrospectively reviewed; 40 were treated with surgery and 24 with CRT. The CRT group included eight patients with unresectable disease and four patients medically unfit for surgery. Surgery included esophagectomy with lymphadenectomy and CRT consisted of 60-70 Gy of radiation concurrent with 5-fluorouracil alone or combined with cisplatin. Short- and long-term outcomes and survival of each modality were assessed.

RESULTS

In the surgery group, 33 patients (82.5%) had co-morbid conditions. Complete resection rate was 90.0%. An overall post-operative complication rate was 65.0% and in-hospital mortality was seen in three patients (7.5%). In the CRT group, complete response rate was 41.7%. Leukopenia was most common Grade 3 hematological toxicity. Treatment-related deaths caused by acute toxicities occurred in three patients (12.5%), whereas those caused by late toxicities in four (16.7%). For cStage I disease in the surgery group, the overall 1-, 3- and 5-year survival rate were 90.9%, 63.6% and 54.5%, respectively, with a median survival time of 78.7 months. For cStages II-IV, the median survival time of the surgery and the CRT group was 18.7 and 12.8 months, respectively.

CONCLUSIONS

The short- and long-term outcomes of surgery for the elderly seemed acceptable; however, definitive CRT may be a promising treatment modality. Further investigation may alter the sphere of influence in the field of esophageal cancer treatment in the elderly.

Salvage esophagectomy after high-dose chemoradiotherapy for esophageal squamous cell carcinoma

OBJECTIVE

Chemoradiotherapy is a popular definitive therapy for esophageal carcinoma among many patients and oncologists. Although the complete response rates are high and short-term survival is favorable after chemoradiotherapy, persistent or recurrent locoregional disease is frequent. Salvage surgery is the sole curative intent treatment option for this course of the disease. The present study evaluates the safety and value of salvage esophagectomy for locoregional failure after high-dose definitive chemoradiotherapy for esophageal squamous cell carcinoma.

METHODS

We reviewed 59 consecutive patients with thoracic esophageal squamous cell carcinoma who underwent salvage esophagectomy after definitive chemoradiotherapy. All patients received more than 60 Gy of radiation plus concurrent chemotherapy for curative intent. The data were compared with those of patients who received esophagectomy without preoperative therapy.

RESULTS

Postoperative morbidity and mortality rates were increased among patients who underwent salvage esophagectomy compared with those who underwent esophagectomy without preoperative therapy (mean hospital stay, 38 vs 33 days; anastomotic leak rates, 31% vs 25%; respiratory complication rates, 31% vs 20%; reintubation within 1 week, 2% vs 2%; hospital mortality rates, 8% vs 2%). Tracheobronchial necrosis and gastric conduit necrosis were highly lethal complications after salvage esophagectomy; 3-year postoperative survivals were 38% and 58%, respectively.

CONCLUSION

Patients who underwent salvage esophagectomy after definitive high-dose chemoradiotherapy had increased morbidity and mortality. Nevertheless, this is acceptable in view of the potential long-term survival after salvage esophagectomy. Such treatment should be considered for carefully selected patients at specialized centers.

Role of salvage esophagectomy after definitive chemoradiotherapy

Chemoradiotherapy has become a popular definitive therapy among many patients and oncologists for potentially resectable esophageal carcinoma. Although the complete response rates are high and short-term survival is favorable after chemoradiotherapy, persistent or recurrent locoregional disease is quite frequent. Salvage surgery is the sole curative intent treatment option for this course. As experience with definitive chemoradiotherapy grows, the number of salvage surgeries may increase. Selected articles about salvage esophagectomy after definitive chemoradiotherapy for esophageal carcinoma are reviewed. The number of salvage surgeries was significantly lower than the number of expected candidates. To identify candidates for salvage surgery, patients undergoing definitive chemoradiotherapy should be followed up carefully. Salvage esophagectomy is difficult when dissecting fibrotic masses from irradiated tissues. Patients who underwent salvage esophagectomy had increased morbidity and mortality. Pulmonary complications such as pneumonia and acute respiratory distress syndrome were common. The anastomotic leak rate was significantly increased because of the effects of the radiation administered to the tissues used as conduits. The most significant factor associated with long-term survival appeared to be complete resection. However, precise evaluation of resectability before operation was difficult. Nevertheless, increased morbidity and mortality will be acceptable in exchange for potential long-term survival after salvage esophagectomy. Such treatment should be considered for carefully selected patients at specialized centers.

VEGF G-1154A is predictive of severe acute toxicities during chemoradiotherapy for esophageal squamous cell carcinoma in Japanese patients

This study was conducted to evaluate the association between systemic exposure to 5-fluorouracil (5-FU) and genetic polymorphisms of vascular endothelial growth factor (VEGF) with clinical outcomes to a 5-FU/cisplatin-based chemoradiotherapy in Japanese patients with esophageal squamous cell carcinoma (ESCC). Forty-nine patients with ESCC (I/II/III/IVa = 11/9/17/7, with 5 postoperative recurrences) were enrolled into this study. One course of treatment consisted of protracted venous infusions of 5-FU (400 mg/m2/24 hr for day 1-5 and 8-12) and cisplatin (40 mg/m2/3 hr on day 1 and 8), and radiation (2 Gy/day on day 1-5, 8-12, and 15-19); a second course was repeated after a 2 week interval. A total of eight measurements of the plasma concentration of 5-FU were made per patient to evaluate its systemic exposure as area under the concentration time curve for 480 hours (AUC480h), and VEGF genotypes of T-1498C, G-1154A, C-634G, C-7T, C936T, and G1612A were evaluated. The mean value of AUC480h in the patients with a complete response was 58.7 +/- 16.8 mg*h/L, which was higher than that in the others, 49.0 +/- 10.9 mg*h/L (P = 0.029), whereas no such association was found for severe acute toxicities. VEGF genotype was not associated with the clinical response, whereas VEGF G-1154A resulted in severe acute leukopenia (P = 0.042) and severe acute cheilitis (P = 0.025). In conclusion, VEGF G-1154A was a predictor of severe acute toxicities during 5-FU/cisplatin-based chemoradiotherapy in Japanese ESCC patients, whereas the AUC480h value of 5-FU was predictive of the clinical response.

REG I enhances chemo- and radiosensitivity in squamous cell esophageal cancer cells

Identification of reliable markers of chemo- and radiosensitivity and the key molecules that enhance the susceptibility of squamous esophageal cancer cells to anticancer treatments would be highly desirable. To test whether regenerating gene (REG) I expression enhances chemo- and radiosensitivity in esophageal squamous cell carcinoma cells, we used MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide) assays to compare the chemo- and radiosensitivities of untransfected TE-5 and TE-9 cells with those of cells stably transfected with REG Ialpha and Ibeta. We then used flow cytometry to determine whether REG I expression alters cell cycle progression. No REG I mRNA or protein were detected in untransfected TE-5 and TE-9 cells. Transfection with REG Ialpha and Ibeta led to strong expression of both REG I mRNA and protein in TE-5 and TE-9 cells, which in turn led to significant increases in both chemo- and radiosensitivity. Cell cycle progression was unaffected by REG I expression. REG I thus appears to enhance the chemo- and radiosensitivity of squamous esophageal cancer cells, which suggests that it may be a useful target for improved and more individualized treatments for patients with esophageal squamous cell carcinoma.

Elective nodal irradiation (ENI) in definitive chemoradiotherapy (CRT) for squamous cell carcinoma of the thoracic esophagus

BACKGROUND AND PURPOSE

There are some reports indicating that prophylactic three-field lymph node dissection for esophageal cancer can lead to improved survival. But the benefit of ENI in CRT for thoracic esophageal cancer remains controversial. The purpose of the present study is to retrospectively evaluate the efficacy of elective nodal irradiation (ENI) in definitive chemoradiotherapy (CRT) for thoracic esophageal cancer.

MATERIALS AND METHODS

Patients with squamous cell carcinoma (SCC) of the thoracic esophagus newly diagnosed between February 1999 and April 2001 in our institution was recruited from our database. Definitive chemoradiotherapy consisted of two cycles of cisplatin/5FU repeated every 5 weeks, with concurrent radiation therapy of 60 Gy in 30 fractions. Up to 40 Gy radiation therapy was delivered to the cervical, periesophageal, mediastinal and perigastric lymph nodes as ENI.

RESULTS

One hundred two patients were included in this analysis, and their characteristics were as follows: median age, 65 years; male/female, 85/17; T1/T2/T3/T4, 16/11/61/14; N0/N1, 48/54; M0/M1, 84/18. The median follow-up period for the surviving patients was 41 months. Sixty patients achieved complete response (CR). After achieving CR, only one (1.0%; 95% CI, 0-5.3%) patient experienced elective nodal failure without any other site of recurrence.

CONCLUSION

In CRT for esophageal SCC, ENI is effective for preventing regional nodal failure. Further evaluation of whether ENI leads to an improved overall survival is needed.

Tumor staging of advanced esophageal cancer: combination of double-contrast esophagography and contrast-enhanced CT

OBJECTIVE

The objective of this study was to compare the diagnostic accuracy of tumor staging in patients with advanced esophageal cancer based on contrast-enhanced CT findings alone with that based on a combination of CT and double-contrast esophagography and to evaluate the relevance of tumor stage to survival rate.

MATERIALS AND METHODS

In 94 patients who underwent surgery as the primary treatment for esophageal cancer and had a diagnosis of postoperative T stage 3 (pT3) or pT4 disease based on pathologic examination, T stage was evaluated using CT alone and using a combination of CT and double-contrast esophagography. The diagnostic criterion for T4 disease using CT alone was tumor strongly displacing or deforming adjacent organs. The diagnostic criterion for T4 disease using the combined method was tumor displacing or deforming adjacent organs in the direction that corresponded to the direction of the location of the tumor or the deepest ulcer as diagnosed by barium esophagography. Concordance of T staging based on imaging with postoperative T staging based on pathology results, the gold standard, and survival rate were assessed for CT alone and for the combined method.

RESULTS

The concordance rate with postoperative T staging pathology results was 78% for CT alone and 84% for CT and double-contrast esophagography combined, with a significant difference between the two diagnostic methods. For patients with a diagnosis of T3 and those with a diagnosis of T4 using CT alone, the 3-year survival rate was 42% and 26%, respectively, with no significant difference between the two. For patients with a diagnosis of T3 and those with a diagnosis of T4 using the combined method, the 3-year survival rate was 42% and 21%, respectively, with a significant difference between the two.

CONCLUSION

The diagnostic performance of contrast-enhanced CT and double-contrast esophagography combined in staging advanced esophageal tumors is better than that of CT alone and thus has potential for estimating prognosis.

Scoring system for predicting response to chemoradiotherapy, including 5-Fluorouracil and platinum, for patients with esophageal cancer

We have retrospectively evaluated clinical data before therapy to enable reliable prediction of the response of esophageal cancer to chemoradiotherapy (CRT). We analyzed 108 patients who received 5-fluorouracil and platinum combined with 60 Gy radiation for esophageal cancer. Factors significantly related to response were extracted by use of logistic regression analysis, and a response score (RS) was prepared by combining these factors. By multivariate analysis, nutritional status, T stage, M stage, and alkaline phosphatase were selected as significant factors that contributed independently to the response of esophageal cancer to CRT (P < 0.05). The odds ratios of the four selected factors was approximated and scored. The group with a high RS was found to include patients with complete response with a significantly higher frequency than the group with a low score (72.7% vs. 14.8%, P < 0.001). The RS is suggested to be an appropriate scoring system with which to predict response for these patients.

A single institutional non-randomized retrospective comparison between definitive chemoradiotherapy and radical surgery in 82 Japanese patients with resectable esophageal squamous cell carcinoma

This retrospective study was conducted to compare the treatment results between radical surgery and definitive chemoradiotherapy for resectable squamous cell carcinoma of the esophagus. Between June 2000 and May 2005, 82 consecutive patients were selected for this study in which 33 were treated with chemoradiotherapy and 49 with surgery. The patients in the chemoradiotherapy (CRT) group received 2-4 cycles of 5-fluorouracil (1000 mg/m(2)/day, day 1-4, continuous) combined with cisplatin (75 mg/m(2), day 1, bolus) plus 50.4 Gy of radiation, while those in the surgery group were treated by an esophagectomy with radical node dissection. Eighteen surgical patients received postoperative chemotherapy. The baseline clinical TNM stage was similar between the two groups. With a median follow-up period of 36 months (range: 23-84 months) with 47 survivors (57%), the 3-year overall survival rates (P = 0.22) and disease-free survival rates (P = 0.16) were 48% and 44% in the chemoradiotherapy group versus 65% and 59% in the surgery group, and lacked statistical significance. This non-randomized study on patients with resectable squamous cell carcinoma of the esophagus showed that chemoradiotherapy could result in survival comparable with conventional surgery in spite of selection bias of patients. There is a trend toward improved survival with surgery versus definitive CRT.

A retrospective study of second-line chemotherapy for unresectable or recurrent squamous cell carcinoma of the esophagus refractory to chemotherapy with 5-fluorouracil plus platinum

BACKGROUND

In Japan, chemotherapeutic agents that have been approved for the treatment of esophageal cancer include cisplatin, nedaplatin, 5-fluorouracil, vindesine, and docetaxel. We retrospectively investigated the efficacy and toxicity of a combination of nedaplatin plus vindesine, or docetaxel alone, for patients with unresectable or recurrent squamous cell carcinoma of the esophagus refractory to prior chemotherapy with 5-fluorouracil plus platinum.

METHODS

Nedaplatin was administered at 90 mg/m(2) intravenously on day 1, and vindesine was administered at 3 mg/m(2) intravenously on days 1 and 8 every 28 days. Docetaxel 60 mg/m(2) or 70 mg/m(2) was administered intravenously every 21 days. We analyzed the response rate, overall survival time, progression-free survival time, and toxicity in 24 patients treated with nedaplatin plus vindesine and 28 patients treated with docetaxel.

RESULTS

In patients treated with nedaplatin plus vindesine, the response rate of the 13 patients with measurable lesions was 8% (1/13), the median progression-free survival time was 1.8 months, and the median survival time was 5.5 months. In patients treated with docetaxel, the response rate of the 17 patients with measurable lesions was 18% (3/17), the median progression-free survival time was 2.1 months, and the median survival time was 5.1 months. The most frequent toxicity was neutropenia (grade 4; 13% in the group with nedaplatin plus vindesine and 50% in the docetaxel group), and febrile neutropenia (grade 3; 4% and 18%, respectively).

CONCLUSION

The efficacy of the two regimens for unresectable or recurrent squamous cell carcinoma of the esophagus refractory to chemotherapy with 5-fluorouracil plus platinum was unsatisfactory. New, more effective therapies are needed.

Treatment of double carcinoma of the esophagus and lung

We report four cases of double carcinoma of the esophagus and the lung. Case 1: a patient with synchronous double carcinoma of the esophagus and the lung underwent chemoradiotherapy (CRT) because of respiratory dysfunction. Case 2: a patient who was diagnosed with esophageal carcinoma after the surgery for lung carcinoma underwent CRT because of respiratory dysfunction. Case 3: a patient with synchronous double carcinoma underwent a two-stage operation. Case 4: a patient with synchronous double carcinoma underwent CRT at another hospital. To further treat the patients, we chose a two-stage operation. CRT is believed to be a feasible treatment in inoperable patients because patients 1 and 2 are alive 28 and 21 months after CRT, respectively. A two-stage operation is considered a suitably safe surgical procedure because no fatal postoperative complications occurred in cases 3 and 4.

REG Ialpha is a reliable marker of chemoradiosensitivity in squamous cell esophageal cancer patients

BACKGROUND

A reliable marker of chemoradiosensitivity that would enable appropriate and individualized treatment of thoracic squamous cell esophageal cancer has long been sought. We investigated whether regenerating gene (REG) Ialpha is such a marker.

METHODS

We assessed expression of REG Ialpha in untreated endoscopic biopsy specimens and examined the correlation between REG Ialpha expression and the clinical responses to definitive chemoradiotherapy and prognosis. We also examined the relationship between REG Ialpha expression in the resected tumor and the prognosis of patients who received esophagectomy for thoracic squamous cell esophageal cancer.

RESULTS

Among the 42 patients treated with definitive chemoradiotherapy, 8 of the 23 REG I-positive patients (35%) showed complete responses to chemoradiotherapy, while only one of the 19 REG I-negative patients did so. The survival rate among the REG I-positive patients was significantly better than among the REG I-negative patients. For the 76 patients treated surgically, there was no significant difference in the survival rates among the REG I-positive and REG I-negative patients.

CONCLUSIONS

REG Ialpha expression in squamous cell esophageal carcinoma may be a reliable marker of chemoradiosensitivity. We anticipate that it will enable us to provide more appropriate and individualized treatment to patients of advanced esophageal squamous cell carcinoma.

A retrospective study of definitive chemoradiotherapy for elderly patients with esophageal cancer

OBJECTIVE

The efficacy and safety of definitive chemoradiotherapy (CRT) for elderly patients with esophageal cancer have not been fully elucidated yet. We conducted a retrospective comparison of the outcomes of CRT between elderly and nonelderly patients with Stage II-III (non-T4) esophageal cancer.

METHODS

There were 33 elderly (aged over 71) patients and 145 nonelderly (aged under 70) patients who fulfilled the selection criteria. The treatment consisted of the continuous infusion of fluorouracil (5-FU) and the intravenous infusion of cisplatin (CDDP) combined with 60 Gy of radiation.

RESULTS

Although the CR rate was almost identical between the 2 groups (63.6% vs. 63.4%, respectively), the recurrence rate after CR was higher in the elderly patients group than in the nonelderly patients group (47.6% vs. 33.7%, P = 0.32). The elderly patient group showed a significantly inferior survival in comparison to the nonelderly patient group with a median survival time (14.7 months vs. 35.1 months, P = 0.01). Discontinuations at the end of CRT were more frequent in the elderly patient group than in the nonelderly patients (57.6% vs. 17.3%, P = 0.01). In addition, over Grade 3 hematologic adverse events were more frequently observed in elderly patients than in nonelderly patients. There were no obvious differences in patients who died of causes other than primary disease.

CONCLUSION

This retrospective analysis revealed a significantly inferior efficacy even in selected elderly patients. Although improving the dose intensity of CRT should be desirable even in elderly patients, it seems to be difficult because of more substantial toxicity in elderly patients.

Salvage esophagectomy following definitive chemoradiotherapy

OBJECTIVES

To evaluate the outcome of salvage surgery following definitive chemoradiotherapy (CRT) for locally advanced esophageal cancer.

METHODS

We reviewed patients undergoing salvage esophagectomy from August 2000 through April 2006 at the National Cancer Center Hospital East, following 5-fluorouracil and cisplatinum chemotherapy with concurrent radiotherapy over 50 Gy. Clinicopathological backgrounds, complications, and survival were analyzed.

RESULTS

Forty-six patients (42 men, all with squamous cell carcinoma) underwent salvage surgery after full-dose concurrent chemoradiotherapy. The median age was 61 years (range, 43-72). Thirteen patients had a relapse after complete response; 26 patients partial response; 4 patients progressive disease; 3 patients NC to CRT. Salvage surgery consisted of transthoracic esophagectomy, three-field node dissection, and reconstruction with the colon or stomach with vascular restoration. Operation time ranged from 257 to 602 min. Postoperative complications were pneumonia in 5; anastmotic leakage in 10; wound infection in 3; anastomotic stenosis in 2; recurrent nerve palsy in 4; pyothorax in 2; multiple organ failure in 1; myocardial infarction in 1; trachea necrosis in 1. There were four 30-day operative deaths and three more hospital deaths. The median survival time from salvage surgery was 12 months and that from CRT was 22 months. The 3-year survival rate was 17%. Three patients are surviving more than 3 years and their diseases were pathological NO.

CONCLUSION

Mobidity and mortality rates were high among patients undergoing salvage esophagectomy. However, there are some long-term survivors, and highly selected patients should be indicated for salvage surgery.

Salvage oesophagectomy after local failure of definitive chemoradiotherapy

BACKGROUND

Definitive chemoradiotherapy (CRT) is one treatment option for locally advanced oesophageal carcinoma. CRT typically consists of high-dose (50-66 Gy) external beam radiotherapy concurrent with 5-fluorouracil and cisplatin. When definitive CRT fails to achieve local control, salvage oesophagectomy is frequently the only treatment available that can offer a chance of long-term survival.

METHODS

Online databases were searched for publications relating to salvage oesophagectomy and definitive CRT. Nine series containing a total of 105 patients were reviewed. Demographics, indications for surgery, type of resection, complications and outcome data were extracted.

RESULTS

Each centre performed one to three salvage resections per year comprising 1.7-4.1 per cent of the oesophagectomy workload. The overall anastomotic leak rate was 17.1 per cent. The in-hospital mortality rate was 11.4 per cent. Five-year survival rates of 25-35 per cent were achieved. Prognostic factors for increased survival were R0 resection (P = 0.006) and longer interval between CRT and recurrence (P = 0.002).

CONCLUSION

Salvage resection after CRT is feasible for selected patients but is a formidable undertaking. Restaging investigations after CRT for potentially resectable tumours in fit candidates should include endoscopy and positron emission tomography-computed tomography. Salvage oesophagectomy is carried out with the goal of cure and it should be attempted only if an R0 resection is technically possible.

Temporal change in brain natriuretic Peptide after radiotherapy for thoracic esophageal cancer

PURPOSE

To investigate the relationships of plasma levels of brain natriuretic peptide (BNP) with abnormal (18)F-fluorodeoxyglucose (FDG) accumulation in the myocardium corresponding to irradiated fields and temporal changes in BNP, which is used as an index of heart remodeling, after radiotherapy for the mediastinum.

MATERIALS AND METHODS

Brain natriuretic peptide concentrations were measured before and after radiotherapy for thoracic esophageal cancer, and the change in BNP concentration after radiotherapy was investigated. Moreover, FDG accumulation in the myocardium was investigated in patients who had undergone FDG positron emission tomography less than 14 days before or after measurement of BNP concentration, and the Mann-Whitney U test was used to detect significant difference between BNP concentrations in patients with and without abnormal FDG accumulation corresponding to the irradiated field.

RESULTS

There was significant difference between the levels of BNP in patients without abnormal FDG accumulation in the irradiated myocardium and in patients with abnormal FDG accumulation (p < 0.001). The levels of BNP in the 9-24 months after radiotherapy group and in the >24 months after radiotherapy group were significantly higher than the levels in the before radiotherapy group, immediately after radiotherapy group, 1-2 months after radiotherapy group, and control group.

CONCLUSIONS

The level of BNP was significantly increased more than 9 months after the start of radiotherapy and was significantly higher in patients who had high FDG accumulation corresponding to the irradiated field. The results of this study indicate that BNP concentration might be an early indicator of radiation-induced myocardial damage.

Preoperative mapping of lymphatic drainage from the tumor using ferumoxide-enhanced magnetic resonance imaging in clinical submucosal thoracic squamous cell esophageal cancer

BACKGROUND

In thoracic esophageal cancer, lymph node metastases distribute widely from the neck to the abdominal area as a result of a complex periesophageal lymphatic network. The aim of the present study was to evaluate the potential clinical utility of a new method of mapping lymphatic drainage from tumors using ferumoxide-enhanced magnetic resonance imaging (MRI).

METHODS

Twenty-three patients with clinical submucosal thoracic squamous cell esophageal cancer were examined. Ferumoxides were injected endoscopically into the peritumoral submucosal layer, after which their appearance in the lymph nodes in the neck, superior mediastinum, and abdomen was evaluated using MRI.

RESULTS

Flux of ferumoxides from tumors was detected in all 23 patients. Among the 20 patients with middle and lower thoracic esophageal cancers, there was no lymphatic drainage to the neck in 5 (25%) patients, none to the neck and superior mediastinum in 4 (20%), and none to the abdomen in 2 (10%), which could enable the extent of lymph node dissection to be reduced. We diagnosed clinical negative lymph node metastasis (N0) in 17 patients; the remaining 6 patients were diagnosed with clinical lymph node metastasis. Two patients (12%) diagnosed clinical N0, showed pathologic lymph node metastasis. Ferumoxide-enhanced MRI detected an influx of contrast agent into the metastatic node in both patients.

CONCLUSIONS

Ferumoxide-enhanced MRI lymphatic mapping enables detection of the direction and area of lymphatic flux. It thus has the potential to improve our ability to gauge the appropriate extent of treatment in clinical submucosal squamous cell esophageal cancer.

Favorable genetic polymorphisms predictive of clinical outcome of chemoradiotherapy for stage II/III esophageal squamous cell carcinoma in Japanese

OBJECTIVES

This study was performed to find the genetic factors predictive of clinical outcome to a 5-fluorouracil (5-FU)/cisplatin (CDDP)-based chemoradiotherapy (CRT) in Japanese patients with locally advanced esophageal squamous cell carcinoma (ESCC).

MATERIALS AND METHODS

Thirty-one patients with stage I-IVa ESCC (I/II/III/IVa = 7/7/14/3) were enrolled in this study. One course of treatment consisted of protracted venous infusions (PVIs) of 5-FU (400 mg/m2/24 hours for days 1-5 and 8-12), CDDP (40 mg/m2/3 hours on days 1 and 8) and radiation (2 Gy/d on days 1-5, 8-12, and 15-19), and a 2nd course was successively repeated after a 2-week interval. A total of 8 measurements of the plasma concentration of 5-FU were made using high performance liquid chromatography. Genetic polymorphisms examined herein included those in the genes coding thymidylate synthase (TS), glutathione S-transferase P1 (GSTP1), multidrug resistant transporter MDR1/P-glycoprotein, and intercellular adhesion molecule-1, and in a circadian rhythm-relating gene, CLOCK.

RESULTS

The CR rate depended on stage (P = 0.001), but the analysis was not sufficiently powered to reach a level of statistical significance for the 2-year survival rate (P = 0.061). For stage II/III patients, to have 2 or 3 polymorphisms of 3R/3R of 5'-TSER, a 6 bp of 3'-TSUTR, and GSTP1-Ile105Val resulted in an extensively longer survival (P = 0.020), although no difference was found between 2 groups, with respect to the plasma concentrations of 5-FU and clinicopathologic characteristics.

CONCLUSIONS

The prognostic index may allow predictions of the clinical outcome of a 5-FU/CDDP-based CRT in stage II/III ESCC patients.

Risk factors for enlargement of cardiac silhouette on chest radiography after radiotherapy for esophageal cancer

PURPOSE

To evaluate the incidence and risk factors of enlargement of cardiac silhouette on chest radiographs after radiotherapy for esophageal cancer.

MATERIALS AND METHODS

We analyzed 67 patients with esophageal cancer who received external beam radiation therapy with a total dose of >or=50 Gy and were followed for >or=6 months. Sixteen patients received radiation alone, and the remaining 51 received chemoradiotherapy. The difference between the cardiothoracic ratio (CTR) on the pretreatment chest radiograph and that on the posttreatment radiograph with maximum cardiac silhouette for each patient was used for the analysis.

RESULTS

The average maximum increase in CTR for the entire group was 4.5%, which was statistically significant. Only the area of the cardiac silhouette in the initial radiation field was a significant risk factor for enlargement of the cardiac silhouette. Pericardial effusions were observed in all patients who underwent computed tomography with severe enlargement of the cardiac silhouette.

CONCLUSION

The CTR value significantly increased after radiotherapy for esophageal cancer. Radiation-induced pericardial effusion may be the main cause of enlargement of the cardiac silhouette. The irradiated cardiac area was the only significant risk factor for enlargement of the cardiac silhouette; the use of chemotherapy was not.

Postoperative gastrointestinal dysfunction after 2-field versus 3-field lymph node dissection in patients with esophageal cancer

PURPOSE

Using an instrument we developed to assess postoperative dysfunction objectively (Surg Today 2005;35:535-42), we compared postoperative dysfunction after 2 - field versus 3 - field lymph node dissection retrospectively, in patents undergoing esophageal cancer surgery.

METHODS

Subjects were selected randomly from among patients who had undergone radical surgery for squamous cell carcinoma of the thoracic esophagus followed by reconstruction with a gastric tube and a cervical anastomosis. Patients rated 32 items related to postoperative dysfunction according to a 5-grade scale. Postoperative gastrointestinal dysfunction was evaluated on the basis of the total score and the scores for seven symptom categories: decreased physical activity, symptoms of reflux, dumping-like syndrome, nausea and vomiting, passage dysfunction, pain, and diarrhea or soft feces.

RESULTS

We studied 42 patients, 22 of whom underwent 2-field lymph node dissection and 20 of whom underwent 3-field dissection. The total gastrointestinal dysfunction score was significantly higher in the 3-field group than in the 2-field group (78.4 +/- 14.1 points vs 67.9 +/- 16.9 points, P = 0.038). When we analyzed the data according to the symptom categories, the 3-field group had higher scores for decreased physical activity, symptoms of reflux, dumping-like syndrome, nausea and vomiting, and passage dysfunction.

CONCLUSION

Three-field lymph node dissection was associated with greater postoperative gastrointestinal dysfunction than 2-field lymph node dissection. Thus, the preoperative identification of those patients with esophageal cancer who are most likely to benefit from concurrent cervical lymph node dissection is essential.

Long-term results of chemoradiotherapy for locally advanced esophageal cancer, using daily low-dose 5-fluorouracil and cis-diammine-dichloro-platinum (CDDP)

BACKGROUND

We evaluated the efficacy and toxicity of radiation combined with daily, low-dose protracted chemotherapy for locally advanced esophageal cancer.

METHODS

We analyzed data for 68 patients with locally advanced esophageal cancer, including 18 surgical candidates. Standard fractionation (total dose range, 60 to 70 Gy) was used for radiotherapy. The chemotherapy consisted of a daily 5-fluorouracil dose of 250 mg/m2, with a cis-diammine-dichloro-platinum dose of 3 mg/m2 administered on radiotherapy days.

RESULTS

Sixty-four patients (94%) received at least 60 Gy. Grade 3 acute hematological toxicity was observed in 13 (19%) patients; there was no grade 4 hematological toxicity. Complete response, partial response, no change, and progressive disease were obtained in 22, 35, 7, and 4 patients, respectively. Minimum follow-up for surviving patients was 45 months. Locoregional progression-free rates at 3 and 5 years were 47% and 47%. Four patients died of late cardiac toxicity; the primary site for all 4 patients was the middle thoracic esophagus. Overall survival rates at 2, 3, and 5 years were 40%, 32%, and 20%. The 3- and 5-year survival rates in patients with T2-3M0 disease were 43% and 27%, and the rates were 24% and 15% in patients with T4/M1.

CONCLUSION

Given the large proportion of patients in this study with inoperable disease (roughly three quarters), our treatment seemed to provide equivalent efficacy and less hematological toxicity than standard-dose chemoradiotherapy.

Dose escalation study of docetaxel and nedaplatin in patients with relapsed or refractory squamous cell carcinoma of the esophagus pretreated using cisplatin, 5-fluorouracil, and radiation

BACKGROUND

Definitive chemoradiation with cisplatin (CDDP) and 5-fluorouracil (5FU) has been playing an important role in the treatment of esophageal cancer, but some patients are not curable or have recurrent lesions. However, few chemotherapeutic regimens are available for such patients. Docetaxel and nedaplatin are active for esophageal cancer. We conducted a dose-escalation study of docetaxel and nedaplatin as second line-chemotherapy after definitive chemoradiation in patients with relapsed or refractory squamous cell carcinoma of the esophagus after chemoradiation.

METHODS

Nedaplatin was administered on day 1 and docetaxel was administered on days 1 and 15, every 4 weeks. Dose escalation was based on the dose-limiting toxicity (DLT) observed during the first cycle.

RESULTS

Twelve patients were enrolled. At a docetaxel dose of 30 mg/m(2) and a nedaplatin dose of 80 mg/m(2), one grade 4 neutropenia occurred and caused one treatment break longer than 2 weeks, but there were few DLTs. At doses of 35 and 80 mg/m(2), respectively, two grade 4 neutropenias and one grade 2 thrombopenia occurred and caused three treatment breaks longer than 2 weeks. Therefore, the maximum tolerated dose was established at this dose level. Two grade 3 anorexias and one grade 3 nausea occurred, but other non-hematological toxicities were generally mild. Responses were seen in one-fourth of the 12 patients, including one complete remission.

CONCLUSION

The recommended doses of docetaxel and nedaplatin were 30 and 80 mg/m(2), respectively. This combination could be a potential second-line treatment for this target population.

REG I expression predicts long-term survival among locally advanced thoracic squamous cell esophageal cancer patients treated with neoadjuvant chemoradiotherapy followed by esophagectomy

BACKGROUND

The prognosis for patients with locally advanced thoracic esophageal cancer is extremely unfavorable. We have been administering neoadjuvant chemoradiotherapy (CRT) followed by esophagectomy to these patients and studying whether REG I expression in untreated endoscopic biopsy specimens is predictive of patient responsiveness to CRT and/or survival after treatment.

METHODS

Between 1992 and 2003, 47 patients with T4 (direct invasion of adjacent organs) thoracic esophageal cancers were administered neoadjuvant CRT followed by esophagectomy. REG I expression was assessed in untreated endoscopic biopsy specimens and correlated with clinical and histological responses and survival in 37 patients who had also undergone curative surgery.

RESULTS

Among the 37 cases that received CRT followed by surgery, the therapeutic response rate for neoadjuvant CRT was 68%, and a complete histological response in resected specimens from the primary lesion was achieved in 8 (22%) patients. These clinical and histological responses to neoadjuvant CRT did not significantly correlate with survival, however. By contrast, 9 patients were judged REG-positive based on analysis of their untreated endoscopic biopsy specimens, and their cumulative survival rate was significantly higher than that of the 28 REG-negative patients (P = 0.0073). Univariate analysis showed REG I expression to be a prognostic factor (P = 0.0386) that increased the risk of death 8.4-fold.

CONCLUSIONS

Evaluation of REG I expression in untreated endoscopic biopsy specimens may provide a basis for new treatments of locally advanced thoracic squamous cell esophageal cancers.

Predictive factors of survival in patients treated with definitive chemoradiotherapy for squamous cell esophageal carcinoma

AIM

The aim of the study was to evaluate the predictive factors of survival in patients with locally advanced squamous cell esophageal carcinoma (LASCOC) treated with definitive chemoradiotherapy (CRT) regimen based on the 5FU/CDDP combination.

METHODS

All patients with LASCOC treated with a definitive CRT using the 5FU/CDDP combination between 1994 and 2000 were retrospectively included. Clinical complete response (CCR) to CRT was assessed by esophageal endoscopy and CT-scan 2 mo after CRT completion. Prognostic factors of survival were assessed using univariate and multivariate analysis by the Cox regression model.

RESULTS

A total of 116 patients were included in the study. A CCR to CRT was observed in 86/116 (74.1%). The median survival was 20 mo (range 2-114) and the 5-year survival was 9.4%. Median survival of responder patients to CRT was 25 mo (range 3-114) as compared to 9 mo (range 2-81) in non-responder patients (P < 0.001). In univariate analysis, survival was associated with CCR (P < 0.001), WHO performance status < 2 (P = 0.01), tumour length < 6 cm (P = 0.045) and weight loss < 10% was in limit of significance (P = 0.053). In multivariate analysis, survival was dependant to CCR (P < 0.0001), weight loss < 10% (P = 0.034) and WHO performance < 2 (P = 0.046).

CONCLUSION

Our results suggest that survival in patients with LASCOC treated with definitive CRT was correlated to CCR, weight loss and WHO performance status.

Factors affecting the prognosis of patients with esophageal cancer undergoing salvage surgery after definitive chemoradiotherapy

BACKGROUND AND OBJECTIVES

Although salvage surgery after definitive chemoradiotherapy (CRT) is common, the safety and indication has not yet been established.

METHODS

We retrospectively compared the mortality and morbidity of 24 patients who underwent salvage surgery with those of historical controls treated with neoadjuvant CRT followed by planned esophagectomy during the same period, and analyzed the prognostic factor of salvage surgery.

RESULTS

Preoperative serum albumin (3.7 vs. 4.1 g/dl, P = 0.0157) and lymphocyte count (763 vs. 964/mm(3), P = 0.0111) in the salvage group were significantly lower than those in the neoadjuvant group. A significant difference was also observed in operation time (567 vs. 474 min, P = 0.0381), C-reactive protein (CRP) on postoperative day 1 (11.2 vs. 8.7 mg/dl, P = 0.0021), and postoperative systemic inflammatory response syndrome (SIRS) duration (3.5 vs. 2.9 days, P = 0.0486). There were three hospital deaths in the salvage group, whereas no patient died in the neoadjuvant group. Multivariate analysis showed curability (R0 vs. R1 + R2) to be the strongest prognostic factor of salvage surgery (P = 0.0064). R1 + R2 operation was more frequently performed in the salvage group (33% vs. 13%), and the reason for all cases was unresectable T4, which had been underestimated preoperatively.

CONCLUSIONS

Salvage surgery is a highly invasive and morbid operation, which is performed on immunocompromised hosts. The indication must be carefully considered, with care taken to avoid non-curative surgery.

Treatment results of chemoradiotherapy for clinical stage I (T1N0M0) esophageal carcinoma

PURPOSE

In 1991, we started a clinical prospective trial for operable esophageal carcinoma, foreseeing organ preservation, to assess the treatment results after definitive chemoradiotherapy (CRT) for clinical Stage I (T1N0M0) esophageal cancer.

PATIENTS AND METHODS

Between 1992 and 2003, 63 patients were enrolled in this study. Tumor depth was mucosal cancer (T1a) in 23 and submucosal cancer (T1b) in 40. CRT consisted of 55-66 Gy/50-60 fractions (median, 59.4 Gy); from 1 to 3 cycles (median, 2) of concurrent chemotherapy (Cisplatin and 5-fluorouracil), followed by high-dose-rate intraluminal brachytherapy 10-12 Gy/2-3 fractions.

RESULTS

The 5-year overall and cause-specific and disease-free survival rates were 66.4%, 76.3%, and 63.7%, respectively. The 5-year cause-specific survival rates for T1a and T1b cancer patients were 85.2% and 70.0%, respectively (p = 0.06). The 5-year disease-free survival rates for T1a and T1b were 84.4% and 50.5%, respectively (p < 0.01). Esophageal fistula as a late toxicity occurred in 2 patients (G4: 1; G5: 1), and esophageal stricture requiring a liquid diet occurred in 2 patients. Pericardial effusion was observed in 3 patients.

CONCLUSION

We confirmed that patients with T1N0M0 esophageal carcinoma had their esophagus preserved in 89.2% of cases after definitive CRT, and the survival rates were equivalent to those of previous reports of surgery.

Outcome and Treatment Strategy for Mid- and Lower-Thoracic Esophageal Cancer Recurring Locally in the Lymph Nodes of the Neck

The aim of the present study was to assess the outcome of treatment for patients with recurrent mid- and lower-thoracic esophageal cancers in whom recurrence was localized to the lymph nodes of the neck, and to determine the best strategy for further treatment. Between 1989 and 2001, 270 patients with mid- and lower-thoracic esophageal cancer underwent curative esophagectomy; 90 of those patients had a cancer recurrence. Our focus was on lymph node recurrence, especially when the recurrent cancers were localized to the lymph nodes in the neck. The outcomes of those patients and the efficacy of the strategies used to treat the recurrent cancers were determined. In 43 patients (48%), recurrent cancer initially appeared in the lymph nodes. Among the 43 patients, 15 (35%) had localized neck recurrence. The time between tumor recurrence and death among the 15 patients with localized neck recurrence was significantly longer than among the 28 patients with other recurrence patterns. In addition, 15 patients underwent lymph node resection, while 28 patients were treated non-surgically. The time between tumor recurrence and death was significantly longer in patients treated surgically. Of the 15 patients in whom recurrence affected the neck lymph nodes only, 10 (67%) were treated surgically; their 2-year survival rate after recurrence was 45%. The outcomes of recurrent esophageal cancers localized to the lymph nodes of the neck were better than those seen with other recurrence patterns, and salvage resection followed by chemoradiation therapy would seem to be indicated for those patients.

Photodynamic therapy as salvage treatment for local failures after definitive chemoradiotherapy for esophageal cancer

BACKGROUND

Although definitive chemoradiotherapy for esophageal cancer shows a high response rate, persistent or recurrent locoregional disease remains a major problem. Salvage esophagectomy is the only curative intent treatment option; however, it carries higher morbidity and mortality rates than primary esophagectomy. Response to second-line chemotherapy is quite dismal.

METHODS

From December 2002 to November 2003, we applied salvage photodynamic therapy to 13 patients with local failures after completion of chemoradiotherapy, 4 patients had local recurrence after achieving a complete response, and 9 had a persistent tumor after chemoradiotherapy. The decision to treat was based on patients' refusal of salvage surgery or chemotherapy. After the intravenous administration of 2 mg/kg of Photofrin, photoradiation treatment with an excimer dye laser was performed for 48 hours and 72 hours after the injection. Written informed consent was obtained from all patients.

RESULTS

Eight patients (62%) achieved a complete response. After a median follow-up period of 12 months after photodynamic therapy, 6 patients were still free of disease, and the overall survival rate at 1 year was 68.4%. There were no treatment-related deaths.

CONCLUSIONS

Our results show that salvage photodynamic therapy could be a promising curative intent treatment option with low morbidity and mortality rates.

Circadian Variability of Pharmacokinetics of 5-Fluorouracil and CLOCK T3111C Genetic Polymorphism in Patients With Esophageal Carcinoma

The variations of plasma concentrations of 5-fluorouracil (5-FU) were investigated in 30 esophageal cancer patients treated with repetitive protracted venous infusion (PVI) of 5-FU-based chemoradiotherapy, and in an attempt to find a new possible candidate that explains their variations, CLOCK T3111C genetic polymorphism was examined. The patients have received 2 courses of chemoradiotherapy consisting of 2 cycles of 5-day PVI of 5-FU (400 mg/m/d) with cisplatin and concurrent radiation. The plasma concentrations of 5-FU were determined at 5 PM on day 3 and 5 AM on day 4 after the beginning of each 5-FU infusion. The CLOCK T3111C genotype was determined by polymerase chain reaction-restricted fragment length polymorphism (PCR-RFLP) and by direct sequencing. Plasma concentrations were measured in 239 samples. In the first course, the plasma concentrations of 5-FU at 5 AM were significantly lower than those at 5 PM in the first cycle, whereas a similar tendency was observed in the second cycle, although not significantly (Wilcoxon signed-rank test). The plasma concentrations of 5-FU at 5 PM and 5 AM in the second cycle were both significantly higher than those in the first cycle, and their coefficient of variation in the former was also significantly smaller than that in the latter. These phenomena in the first course were also observed in the second one. These results revealed the elevation of plasma drug concentration and its reduced circadian variation during repetitive PVI of 5-FU. In 5-FU-based chemotherapy, its administration schedule should be made in consideration of these phenomena. The CLOCK T3111C genotype did not have a significant impact on the variation of the plasma concentrations of 5-FU in this study population. Further studies are needed to clarify the mechanism of these phenomena and to identify an easy-to-assess marker of circadian rhythms for use in individualizing delivery of 5-FU.

Reduced tumor vessel density and high expression of glucose transporter 1 suggest tumor hypoxia of squamous cell carcinoma of the esophagus surviving after radiotherapy

BACKGROUND

Squamous cell carcinoma of the esophagus (ESCC) is radiosensitive; however, surgeons frequently encounter ESCC that survives radiotherapy to grow more rapidly and invasively. This alteration of tumor behavior may result from tumor hypoxia induced by radiotherapy.

METHODS

Forty-four patients with advanced (T3 and T4) ESCC, who underwent radiotherapy before operation, either with 40 Gy for preoperative treatment or 60 Gy or more for radical treatment, and 44 patients without preoperative therapy were subjected to retrospective immunohistochemical study. CD34 for tumor vessels, glucose transporter 1 (GLUT1) which was induced by hypoxia, MIB-1 for proliferating activity, and p53 were stained for surgical samples from ESCC patients. Tumor tissue at the invading front was the focus of evaluation. Macroscopic morphologic differences of ESCC were also evaluated.

RESULTS

Loss of esophageal wall thickness and deep ulceration were morphologic characteristics of ESCC after radiotherapy. Tumor vessel density was reduced and GLUT1 expression was greater in the ESCC after radiotherapy than in those without treatment. Tumor vessel density was similar for both preoperative and radical radiotherapy samples, while GLUT1 expression tended to be greater in the latter than in the former. The expression of MIB-1 and p53 did not show any significant difference between ESCC with or without radiotherapy.

CONCLUSIONS

Reduced vessel density and increased GLUT1 expression suggested tumor hypoxia for ESCC occurred after radiotherapy. Tumor hypoxia would induce ulcerative and invasive growth, which is a great obstacle to clinical treatment of residual or relapse ESCC after radiotherapy.