Long-term toxicity after definitive chemoradiotherapy for squamous cell carcinoma of the thoracic esophagus

Associations between vascular endothelial growth factor polymorphisms and response to 5-FU-based pharmaceutical therapy in esophageal squamous cell carcinoma: A meta-analysis

BACKGROUND AND AIMS

Vascular endothelial growth factor (VEGF) gene polymorphisms are associated with the response to pharmaceutical therapy in many cancers. This study aimed to investigate the effects of VEGF gene polymorphisms in esophageal squamous cell carcinoma patients receiving pharmaceutical therapy.

METHODS

This literature-based meta-analysis was performed with keywords related to VEGF gene polymorphisms and clinical response in esophageal squamous carcinoma patients receiving pharmaceutical therapy (including 5-FU, cisplatin, oxaliplatin, and calcium folinate). After a series of bias grading analyses and DerSimonian-Laird method analysis, odds ratios and 95% confidence intervals were calculated to examine the potential relationships. Sensitivity and subgroup analyses were subsequently performed to determine the major causes of heterogeneity.

RESULTS

Heterogeneity was dramatically reduced after the removal of one study from the analysis (I2 = 37%, P = 0.19). The remaining studies involved 5-FU-based treatment. The presence of VEGF G-1154A and VEGF-634C/G was found to be correlated with patient response to 5-FU/CDDP-based treatment, whereas VEGF-2549I/D was correlated with response to 5-FU/oxaliplatin-based treatment, and VEGF-936C/T was associated with both 5-FU/CDDP- and 5-FU/oxaliplatin-based treatment response.

CONCLUSION

VEGF gene polymorphisms affect the response of esophageal squamous carcinoma patients receiving pharmaceutical therapy, especially 5-FU-based treatments.

Case Report: Esophageal cancer under comprehensive treatment strategy-application and clinical outcome analysis of combined immunotherapy, targeted therapy, and low-dose radiotherapy

Current evidence for the combined use of immunotherapy, low-dose chemoradiotherapy, and epidermal growth factor receptor-targeted therapy for the treatment of advanced esophageal squamous cell carcinoma is lacking. We report the case of a 73-year-old woman with squamous cell carcinoma of upper middle thoracic esophagus. After undergoing concurrent chemoradiotherapy combined with immunotherapy and anti-angiogenic targeted therapy, the patient achieved a progression-free survival of 17 months. To date, the patient has achieved 35 months of overall survival, which continues to extend, with a good quality of life. Immunotherapy combined with low-dose concurrent chemoradiotherapy is a promising option for elderly patients with advanced esophageal cancer who are intolerant to standard treatments. The addition of an epidermal growth factor receptor monoclonal antibody as a radiosensitizer improves therapeutic efficacy. The combination of sintilimab and anlotinib has the potential to treat recurrent and metastatic esophageal cancer. Tailoring treatment strategies for specific patient groups is essential in personalized medicine.

Cardiac CT reveals high prevalence of coronary artery disease in esophageal cancer eligible for radiotherapy

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.

Is prophylactic lymph node dissection efficacious in salvage esophagectomy after definitive chemoradiotherapy?

BACKGROUND

Salvage esophagectomy for esophageal cancer after definitive chemoradiotherapy (dCRT) is a high-risk surgery, and radical lymph node dissection (RLND) can cause severe complications. However, the significance of RLND in salvage surgery remains unclear.

METHODS

This study included 55 patients who underwent curative-intent salvage esophagectomy after dCRT for esophageal squamous cell carcinoma. We evaluated the prognostic impact of lymph node dissection of each station using efficacy indexes (EIs) and compared the outcomes between RLND and limited lymph node dissection (LLND).

RESULTS

Nine (16.4%) patients underwent RLND and 46 (83.6%) underwent LLND. Patients who underwent RLND had greater operative blood loss and a greater number of resected lymph nodes compared to patients who underwent LLND (P = 0.053 and 0.002, respectively). However, the incidence of postoperative complications was not significantly different between the groups. The EIs of the cervical and mediastinal lymph nodes were zero because no patients with involved nodes at these stations remained alive at 5 years. In contrast, perigastric lymph nodes had relatively high EIs. Overall and cancer-specific survival did not differ significantly between patients who underwent RLND and those who underwent LLND (P = 0.475 and 0.808, respectively).

CONCLUSIONS

The EIs of the cervical and mediastinal lymph nodes were zero, and RLND did not improve survival. Depending on tumor status, LLND may be sufficient for salvage esophagectomy.

Definitive-dose adjuvant radiotherapy following endoscopic submucosal dissection for superficial esophageal cancer

BACKGROUND

Prophylactic chemoradiation therapy (CRT) using 40-41.4 Gy post-endoscopic submucosal dissection (ESD) for clinical T1N0M0 esophageal cancer reportedly yields favorable outcomes. However, it cannot completely prevent locoregional lymph node (LN) metastases. We retrospectively analyzed outcomes and adverse events associated with our dose-escalated treatment regimen (definitive-dose radiotherapy [RT] of 50-61.2 Gy, with/without chemotherapy) for these patients, and predictors of progression-free survival (PFS) and overall survival (OS).

METHODS

Between 2006 and 2018, 44 consecutive patients (42 men and 2 women; median age, 70 years) who underwent definitive-dose RT post-ESD and had a pathological depth of the muscularis mucosa with lymphovascular invasion (LVI) or the upper-middle submucosal third at our institution were included. We excluded patients who could not obtain a margin-free resection by ESD. If feasible, systemic chemotherapy with 5-fluorouracil plus high- or low-dose cisplatin or nedaplatin was administered concurrently.

RESULTS

Five-year PFS, OS, and disease-specific survival rates were 78.8%, 88.4%, and 97.7%, respectively. Six metachronous esophagus (14%), two locoregional LN within the irradiated area with a prophylactic dose of 41.4 Gy (5%), and two locoregional LN plus liver (5%) recurrences occurred. No LN recurrence occurred within the definitive dose of ≥ 50 Gy in the irradiated area. Metachronous esophageal recurrence involved areas receiving ≥ 50 Gy. Univariate and multivariate analyses revealed that age was an independent prognostic factor for both PFS and OS.

CONCLUSIONS

Definitive-dose RT/CRT post-ESD could provide favorable locoregional LN control and PFS/OS regardless of patient characteristics, including pathological findings and chemotherapy regimen/course, except for age. These results need to be interpreted carefully given several limitations, therefore, definitive-dose RT/CRT should be conducted with caution in clinical practice until high-quality prospective clinical trials evaluating the effectiveness and safety.

Dose to cardiac substructures and cardiovascular events in esophageal cancer patients treated with definitive radiotherapy

INTRODUCTION

While there is a growing amount of data on the cardiac toxicity of radiotherapy (RT) in relation to its impact on cardiac sub-structures (CSS), there are only few studies addressing this issue in patients followed for esophageal cancer (ESOC). We aimed to evaluate the association between independent parameters of dose received by CSS and major cardiac events (MACEs) in this population.

MATERIALS AND METHODS

We retrospectively analyzed 122 patients treated with exclusive RT or chemo-RT for ESOC. Heart and CSS i.e. right atrium, left atrium (LA), right ventricle, left ventricle and myocardium, have been automatically segmented, and dose volume histogram were extracted. Cardiac events were collected focusing on the occurrence of MACEs of grade 3 or higher (G3+) and grade 4 or higher (G4+) according to the CTCAE v5.0.

RESULTS

With a median follow-up of 21.9 months and in a population of high to very high cardiovascular risk (95.5%), 21 (17.2%) and 9 (7.4%) patients had G3 + and G4 + MACEs with a respective median time to event of 13.05 and 9.8 months. After multivariate analysis and among all heart and CSS-based dosimetric features, only the volume of LA receiving 15 Gy or more (V15LA) remained significantly associated with the G3 + and G4 + MACEs. The use of volumetric modulated arctherapy significantly reduced V15LA compared with 3D conformal RT.

CONCLUSION

In a cohort of ESOC patients treated with exclusive RT, incidence of MACEs was associated with V15LA, underlining the importance of CSS. These high cardiovascular (CV) risk patients should benefit from standard CV assessment and strict control of their risk factors.

Cardio-oncology concerns in radiotherapy: Heart and cardiac substructure toxicities from modern delivery techniques

Cardio-oncology is lately gaining more attention due to radiation-induced cardiac events reported by a very large number of studies. In view of this, the current overview of the literature aimed to encompass all studies from the past 15 years to assess changes in cardiac dose due to treatment evolution, as well as the changes in treatment planning customs to incorporate not only the heart as a whole but also cardiac substructures. Modern treatment techniques, particularly proton therapy, offers superior cardiac sparing compared to more established radiotherapy, for all evaluated tumor sites. Intensity modulation, particularly coupled with respiratory gating shows significant improvement in dose-volume parameters pertaining to the heart. While past studies considered mean heart dose as the only reference for cardiac toxicities, recommendations for the other cardiac substructures to be dosimetrically assessed during planning are becoming more common.

Clinical outcomes and prognostic factors of volumetric modulated arc therapy (VMAT) of esophageal cancer

Background

The objective was to evaluate the efficacy and safety of radiotherapy and the prognostic factors in patients with esophageal cancer who received definitive radiotherapy, using volumetric modulated arc therapy (VMAT).

Materials and methods

Forty-seven patients who received definitive radiotherapy using VMAT between September 2017 and December 2020 were enrolled. Prescription doses were 60 Gy in 30 fractions to the planning target volume (PTV) primary and 48 Gy in 30 fractions to the PTV subclinical. Overall survival (OS), progression free survival (PFS), and toxicity were analyzed, and univariate and multivariate analyses were used to investigate the prognostic factors.

Results

Median follow up time was 10 months. Most of the patients had an advanced disease stage (stage I, 12.8%; II, 8.5%; III, 27.7%; IV, 51.0%) patients (38.3%) had a T4 tumor. The median survival time was 14 months (range: 0-56 months). The 2-year OS and PFS were 31.3% and 20.4%, respectively. Acute adverse events (≥ Grade 3) were observed in 25 patients (53.2%), and the most frequent types were dysphagia, hematological toxicities including leukopenia, and febrile neutropenia in 14 (29.8%), 10 (21%), and 10 (21%) patients, respectively. Late adverse events (Grade 3 or higher) were observed in eight patients (17.0%), and the most frequent types were pneumonitis in four patients (8.5%), and Grade 5 in one patient (2.1%; esophageal fistula). In multivariate analysis, neutrophil-to-lymphocyte ratio (NLR) > 3 (p = 0.026) was significantly associated with poor survival.

Conclusion

Definitive radiotherapy of 60Gy with VMAT is feasible and safe for patients with esophageal cancer. Pre-treatment NLR >3 was an independent prognostic factor for OS.

Radiation-associated cardiovascular disease in patients with cancer: current insights from a cardio-oncologist

Radiation-associated cardiovascular disease (RACD), a complex disease characterized with pericarditis, myocardial damage, valvular heart diseases, heart failure, vasculopathy and ischemic heart disease, has a generally poor prognosis. While RACD may be acute, it often manifests in the late years or even decades following radiation exposure to the chest. With an increasing number of cancer survivors, RACD is likely to become an important issue in cardio-oncology. This review discusses pre-radiation therapy (RT) preparation, peri-RT patient management and long follow-up planning post-RT from a cardiology perspective. Additionally, a novel technique of stereotactic radiotherapy, which has been applied for the treatment of intractable cardiac arrhythmias, is presented. Appropriate patient examination and management during and after RT are essential to support patients undergoing cancer treatment to improve long life expectancy. A multidisciplinary team is needed to determine how to manage patients who receive RT to reduce RACD, to detect early phases of RACD and to provide the best treatment for RACD. Recent studies increasingly report advances in diagnosis using new equipment that has the potential to detect early phases of RACD, along with growing evidence for the optimal treatment for RACD. This review provides an overview of recent studies and guidelines to report on the latest findings, and to identify unresolved issues surrounding RACD that require validation in future studies.

Knowledge domains and emerging trends in radiotherapy in oesophageal cancer from 2004 to 2023: a bibliometric analysis and visualization study

Esophageal cancer (EC) is a malignant tumour with high morbidity and mortality rates. Recent studies have shown that much progress has been made in the research of radiotherapy in EC. This study aims to provide a comprehensive overview of the knowledge structure and research hotspots of radiotherapy in EC through bibliometrics. Publications related to radiotherapy in EC from 2014 to 2023 were searched on the web of science core collection database. VOSviewers, CiteSpace and R package 'bibliometrix' were used to conduct this bibliometric analysis. In total, 4258 articles from 76 countries led by China and the USA were included. The Chinese Academy of Medical Sciences-Peking Union Medical College has the highest number of publications. International Journal of Radiation Oncology Biology Physics is the most popular journal and also the most co-cited journal in this field. These publications come from 21 972 authors among which Liao Zhongxing had published the most papers and Cooper JS was co-cited most often. Neoadjuvant chemoradiotherapy and strategies based on it are the main topics in this research field. 'IMRT' and 'immunotherapy' are the primary keywords of emerging research hotspots. This is a bibliometric study that comprehensively summarizes the research trends and developments of radiotherapy in EC. This information identifies recent research frontiers and hot directions, which will provide a reference for scholars studying radiotherapy in EC.

Recent progress in chemoradiotherapy for oesophageal squamous cell carcinoma

Oesophageal squamous cell carcinoma is a common malignancy worldwide. Definitive chemoradiotherapy is the standard treatment for patients with resectable stage oesophageal squamous cell carcinoma who cannot undergo surgery, as well as those with locally advanced unresectable oesophageal squamous cell carcinoma. However, it has several disadvantages such as poor survival, radiation-related toxicities and severe and lethal complications related to salvage treatment for residual or recurrent disease. Numerous clinical trials on chemoradiotherapy have been conducted to confirm the optimal combination of irradiation and chemotherapy. For advanced disease, multimodal treatment strategies including salvage surgery are essential. Palliative chemoradiotherapy is also crucial for dysphagia in locally advanced oesophageal squamous cell carcinoma with or without metastatic lesions. Recently, the synergistic mechanism of radiotherapy combined with immunotherapy has been reported. Early phase clinical trials suggest that a combination of immunotherapy and chemoradiotherapy can improve clinical outcomes with manageable side effects, but further investigations are needed. Here, we reviewed the existing clinical data and current development of chemoradiotherapy combined with immunotherapy in patients with oesophageal squamous cell carcinoma.

Dose Evaluation in 2-Phase Method for Advanced Esophageal Cancer by Hybrid Irradiation Techniques

Purpose

In concurrent chemoradiotherapy for advanced esophageal cancer, a 2-phase method consisting of initial irradiation of a wide elective nodal region and boost irradiation of the primary lesion is commonly employed. Although dose escalation to the primary lesion may be required to achieve higher local control rates, the radiation dose to critical organs must not exceed dose constraints. To achieve an optimum balance of dose prescription and dose reduction to surrounding organs, such as the lungs and heart, we compared hybrid dose distributions and investigated the best combination of the following recent irradiation techniques: volumetric modulation arc therapy (VMAT), proton broad-beam irradiation, and intensity-modulated proton beam therapy (IMPT).

Materials and Methods

Forty-five patients with advanced esophageal cancer whose primary lesions were located in the middle- or lower-thoracic region were studied. Radiotherapy plans for the initial and boost irradiation in the 2-phase method were calculated using VMAT, proton broad-beam irradiation, and IMPT calculation codes, and the dose-volume histogram indices of the lungs and heart for the accumulated plans were compared.

Results

In plans using boost proton irradiation with a prescribed dose of 60 Gy(RBE), all dose-volume histogram indices were significantly below the tolerance limits. Initial and boost irradiation with VMAT resulted in the median dose of V30 Gy(RBE)(heart) of 27.4% and an achievement rate below the tolerance limit of 57.8% (26 cases). In simulations of dose escalation up to 70 Gy(RBE), initial and boost IMPT resulted in the highest achievement rate, satisfying all dose constraints in 95.6% (43 cases).

Conclusion

Applying VMAT to both initial and boost irradiation is not recommended because of the increased risk of the cardiac dose exceeding the tolerance limit. IMPT may allow dose escalation of up to 70 Gy(RBE) without radiation risks to the lungs and heart in the treatment of advanced esophageal cancer.

Involved-field irradiation or elective-nodal irradiation in neoadjuvant chemo-radiotherapy for locally-advanced esophageal cancer: comprehensive analysis for dosimetry, treatment-related complications, impact on lymphocyte, patterns of failure and survival

Purpose

To compare the differences between involved-field irradiation (IFI) and elective nodal irradiation (ENI) in selecting the optimal target area for neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced esophageal squamous cell carcinoma (LA-ESCC).

Materials and methods

We retrospectively analyzed 267 patients with LA-ESCC, of whom 165 underwent ENI and 102 underwent IFI. Dosimetry, treatment-related complications, pathological responses, recurrence/metastasis patterns, and survival were compared between the two groups.

Results

The median follow-up duration was 27.9 months. The R0 resection rates in the IFI and ENI groups were 95.1% and 92.7%, respectively (p=0.441), while the pathological complete response (pCR) rates were 42.2% and 34.5%, respectively (p=0.12). The ENI group received higher radiation doses to the heart (HV30:23.9% vs. 18%, p=0.033) and lungs (LV30:7.7% vs. 4.9%, p<0.001) than the IFI group. Consequently, the ENI group showed a higher incidence of grade 2 or higher radiation pneumonitis (30.3% vs. 17.6%, p=0.004) and pericardial effusion (26.7% vs. 11.8%, p=0.021) than the IFI group. Post-operation fistulas were observed in 3 (2.9%) and 17 cases (10.3%) in the IFI and ENI groups, respectively (p=0.026). In the multivariate analysis, smoking, positive lymph node involvement (pN+), and anastomotic fistula were independent predictors of overall survival (OS). The pN+ patients exhibited a greater propensity for recurrence compared to pN- patients, especially in the first year of follow-up (6.67% vs. 0.56%, p=0.003).

Conclusion

The ENI group had a higher incidence of radiation-induced adverse events compared to the IFI group, likely due to the higher radiation doses to normal tissues. Considering the similar disease-free survival (DFS) and OS rates in the two groups, IFI may be suitable for nCRT in patients with LA-ESCC, although further prospective studies are warranted.

Development and validation of a nomogram to predict cardiac death after radiotherapy for esophageal cancer

Background

Patients frequently die from cardiac causes after radiotherapy for esophageal cancer. Early detection of cardiac death risk in these patients is crucial to improve clinical decision-making and prognosis. Thus, we modeled the risk of cardiac death after irradiation for esophageal cancer.

Methods

A retrospective analysis of 37,599 esophageal cancer cases treated with radiotherapy in the SEER database between 2000 and 2018 was performed. The selected cases were randomly assigned to the model development group (n = 26,320) and model validation group (n = 11,279) at a ratio of 7:3. We identified the risk factors most commonly associated with cardiac death by least absolute shrinkage and selection operator regression analysis (LASSO). The endpoints for model development and validation were 5- and 10-year survival rates. The net clinical benefit of the models was evaluated by decision curve analysis (DCA) and concordance index (C-index). The performance of the models was further assessed by creating a receiver operating characteristic curve (ROC) and calculating the area under the curve (AUC). Kaplan-Meier (K-M) survival analysis was performed on the probability of death. Patients were classified according to death probability thresholds. Five- and ten-year survival rates for the two groups were shown using K-M curves.

Results

The major risk factors for cardiac death were age, surgery, year of diagnosis, sequence of surgery and radiotherapy, chemotherapy and a number of tumors, which were used to create the nomogram. The C-indexes of the nomograms were 0.708 and 0.679 for the development and validation groups, respectively. DCA showed the good net clinical benefit of nomograms in predicting 5- and 10-year risk of cardiac death. The model exhibited moderate predictive power for 5- and 10-year cardiac mortality (AUC: 0.833 and 0.854, respectively), and for the development and validation cohorts (AUC: 0.76 and 0.813, respectively).

Conclusions

Our nomogram may assist clinicians in making clinical decisions about patients undergoing radiotherapy for esophageal cancer based on early detection of cardiac death risk.

Investigation of the efficacy of the change ratio of brain natriuretic peptide for predicting the cardiac effects of chemoradiotherapy on esophageal cancer

The aim of this study was to investigate the effectiveness of brain natriuretic peptide (BNP) as a predictor of radiological effects on the heart. A total of 41 patients with esophageal cancer who underwent chemoradiotherapy (CRT) were retrospectively investigated. The BNP levels were measured on the first day of CRT (pre-CRT) and the last day of CRT (post-CRT), and the median concentration of BNP and dosimetric parameters of the heart were calculated. The change ratio of BNP was calculated as follows: [(BNP post-CRT) - (BNP pre-CRT)]/(BNP pre-CRT). The comparison of BNP pre-CRT with post-CRT was performed using a Wilcoxon signed-rank test. The relationship between dosimetric parameters and change ratio was analyzed using Spearman's correlation coefficient. The median levels of BNP of pre-CRT and post-CRT were 10 and 22 pg/ml, respectively, and the difference was statistically significant (P<0.0001). Significant correlations (all P<0.05) were observed between the change ratio and mean dose, V5, V10, V20, and V30. Of the cohort, 14 patients developed acute-to-subacute cardiac events, such as pericardial effusion, cardiomegaly, acute exacerbation of chronic heart failure, and a decreased ejection fraction. The change ratios of BNP, V5, V10, V20, and V30 were significantly higher in patients who experienced cardiac events compared with those who did not. The results of this study showed that BNP measurement, particularly the change ratio of BNP pre- and post-CRT, may be a useful cardiac event predictor in addition to dosimetric parameters.

Planning strategies for robust carbon-ion scanning radiotherapy for stage I esophageal cancer: a retrospective study

This study aimed to establish a treatment planning strategy with carbon-ion scanning radiotherapy (CIRTs) for stage I esophageal cancer. The clinical data of seven patients treated with CIRTs were used. The setup error and interfractional and intrafractional motion error were analyzed using in-room computed tomography (CT) images for each treatment day. Finally, the planning target volume (PTV) margin was identified according to the accuracy of the treatment system. To ensure robustness against the positional displacements of the target and organs at risk (OAR), the replacement areas were placed as a contour adjacent to the tumor or OAR on the CT-image. The CT values of these areas were replaced by those of the target or OAR. Further, the dose distributions were optimized. Moreover, the variations in the target coverage from the initial plan for each treatment day (ΔV95%) were evaluated. By contrast, the risk of OAR was not evaluated in this study. The setup error was within 1.0 mm. The interfractional and intrafractional target motion errors were 2.8 and 5.0 mm, respectively. The PTV margins were 6.5 and 6.8 mm in the axial and depth directions, respectively. The robustness to target and OAR displacement was evaluated. The results showed that the target coverage with replacement could suppress decreased target coverage more than that without replacement. The PTV determination and replacement methods used in this study improved the target coverage in CIRTs for stage I esophageal cancer. Despite the need for a clinical follow-up, this method may help to improve clinical outcomes.

Late Toxicity and Health-Related Quality of Life Following Definitive Chemoradiotherapy for Esophageal Cancer: A Systematic Review and Meta-analysis

PURPOSE

Definitive chemoradiotherapy (dCRT) is a treatment option with curative intent for patients with esophageal cancer that could result in late toxicities and affect health-related quality of life (HRQoL). This study aimed to review the literature and perform a meta-analysis to investigate the effect of dCRT on late toxicities and HRQoL in esophageal cancer.

METHODS AND MATERIALS

A systematic search was performed in MEDLINE, EMBASE, and PsychINFO. Prospective phase II and III clinical trials, population-based studies, and retrospective chart reviews investigating late toxicity or HRQoL after dCRT (≥50 Gy) were included. The HRQoL outcomes were analyzed using linear mixed-effect models with restricted cubic spline transformation. Any HRQoL changes of ≥10 points were considered clinically relevant. The risk of toxicities was calculated using the number of events and the total study population.

RESULTS

Among 41 included studies, 10 assessed HRQoL and 31 late toxicity. Global health status remained stable over time and improved after 36 months compared with baseline (mean change, +11). Several tumor-specific symptoms, including dysphagia, eating restrictions, and pain, improved after 6 months compared with baseline. Compared with baseline, dyspnea worsened after 6 months (mean change, +16 points). The risk of any late toxicity was 48% (95% CI, 33%-64%). Late toxicity risk of any grade for the esophagus was 17% (95% CI, 12%-21%), pulmonary 21% (95% CI, 11%-31%), cardiac 12% (95% CI, 6%-17%), and any other organ 24% (95% CI, 2%-45%).

CONCLUSIONS

Global health status remained stable over time, and tumor-specific symptoms improved within 6 months after dCRT compared with baseline, with the exception of dyspnea. In addition, substantial risks of late toxicity were observed.

Assessment of Treatment Plan Quality between Flattening Filter and Flattening Filter Free Photon Beam for Carcinoma of the Esophagus with IMRT Technique

Background

As compared to the flattened photon beam, removing the flattening filter (FF) from the head of a gantry decreases the average energy of the photon beam and increases the dose rate, leading to an impact on the quality of treatment plans.

Objective

This study aimed to compare the quality of intensity-modulated radiation therapy (IMRT) treatment plans for esophageal cancer with and without a flattened filter photon beam.

Material and Methods

In this analytical study, 12 patients, who had already been treated with a 6X FF photon beam, were treated based on new IMRT methods using a 6X the flattening filter-free (FFF) photon beam. Both 6X FF IMRT and 6X FFF IMRT plans used identical beam parameters and planning objectives. All plans were evaluated with planning indices and doses for organs at risk (OARs).

Results

Insignificant dose variation was for HI, CI, D_98%, and V_95% between FF and FFF photon beam IMRT plans. FF-based IMRT plan delivered a 15.51 % and 11.27% higher mean dose to both lungs and heart than the FFF plan, respectively. The integral dose (ID) for the heart and lungs was 11.21% and 15.51%, respectively, less in the IMRT plan with an FFF photon beam.

Conclusion

In contrast to the FF photon beam, a filtered photon beam-oriented IMRT plan provides significant OAR sparing without losing the quality of the treatment plan. High monitor units (MUs), low ID, and Beam on Time (BOT) are major highlights of the IMRT plan with FFF beam.

Gene Signatures for Latent Radiation-Induced Lung Injury Post X-ray Exposure in Mouse

Objective

To investigate the X-ray-specific sensitive genes and potential signaling pathways involved in the latent period of radiation-induced lung injury (RILI) in mouse models.

Method

Mice were randomized into groups for whole thoracic irradiation with a single fraction of 20 Gy X-ray or 12.5 Gy carbon heavy ion. Lungs were harvested 3 weeks after the irradiation, whole RNA was extracted and detected with the genome-wide transcriptional microarrays. Differentially expressed genes (DEGs) were calculated for each group and the X-ray-specific sensitive genes were determined, followed by the gene enrichment analysis of those DEGs exploring the potentially relevant signaling pathways and biological processes in latent RILI.

Results

Three weeks after irradiation, gene expression levels varied between groups. 76 up-regulated DEGs were determined with mice in the X-ray group and gene ontology enrichment analysis for biological process (GO-BP) obtained several processes which were associated with radiation reaction, mitotic, immune cell chemotaxis or metastasis, immune factors, p53 apoptosis, and tissue remodeling. KEGG signaling pathway enrichment analysis showed that those 76 up-regulated DEGs were enriched in p53, IL-17, FoXO, melanoma, and non-small-cell lung cancer signaling pathways. By comparing the DEGs in X-ray and heavy ion groups, X-ray-specific sensitive genes were determined, the top 10 genes were Adamts9, Aacs, Col6a2, Fdps, Mdk, Mcam, Stbd1, Lbh, Ak3, and Emid1. The expression level of the top 10 genes was found to be significantly higher in the X-ray group than in the control and heavy ion groups.

Conclusion

Our research determined the X-ray-specific sensitive gene set in mice lungs after exposure to radiation. The gene set could be used as a genetic marker to suggest the latency of RILI. The enrichment analysis results suggested that the relevant signaling pathways were potentially involved in the development of RILI. Further validation of those genes and signaling pathways is needed to confirm these findings.

Long‑term prognosis and comprehensive endoscopic treatment strategy for esophageal cancer, including salvage endoscopic treatment after chemoradiation therapy

Endoscopic submucosal dissection (ESD) is the first treatment option for superficial squamous cell carcinoma of the esophagus (SSCE). Salvage endoscopic treatment for recurrent advanced esophageal cancer after chemoradiotherapy (CRT) has been reported. However, there are few reports on long-term prognosis after salvage endoscopic treatment in Japan. The present study investigated long-term treatment results after conventional ESD for SSCE and after salvage endoscopic treatment for locally recurrent lesions after CRT. Outcomes of esophageal ESD were retrospectively investigated at Nagasaki University Hospital and long-term prognosis after salvage endoscopic treatment for locally recurrence lesions after CRT was examined. The en-bloc curative resection rate was 89.5% (606/676) for conventional ESD. The 5-year cause-specific survival rate (CSS) was 98.5%. A total of 77 patients underwent salvage endoscopic treatment [ESD or photodynamic therapy (PDT)] for locally recurrent lesions after CRT. The 3-year CSS was 81.3 and 77.1% for salvage ESD and salvage PDT, respectively. SSCE management using ESD yielded high en-bloc curative resection and survival rates. Overall, establishing salvage endoscopic treatment made long-term control of the underlying disease possible, while also maintaining the quality of life for patients with recurrent advanced esophageal cancer deeper than patients with T1b who underwent CRT and patients with recurrence after additional CRT following ESD.

Network Pharmacology and in vitro Experimental Verification on Intervention of Quercetin, Present in Chinese Medicine Yishen Qutong Granules, on Esophageal Cancer

OBJECTIVE

To explore the potential mechanism of Yishen Qutong Granules (YSQTG) for the treatment of esophageal cancer using network pharmacology and experimental research.

METHODS

The effective components and molecular mechanism of YSQTG in treating esophageal cancer were expounded based on network pharmacology and molecular docking. The key compound was identified by high-performance liquid chromatography and mass spectrometry (HPLC-MS) to verify the malignant phenotype of the key compounds in the treatment of esophageal cancer. Then, the interaction proteins of key compounds were screened by pull-down assay combined with mass spectrometry. RNA-seq was used to screen the differential genes in the treatment of esophageal cancer by key compounds, and the potential mechanism of key compounds on the main therapeutic targets was verified.

RESULTS

Totally 76 effective compounds of YSQTG were found, as well as 309 related targets, and 102 drug and disease interaction targets. The drug-compound-target network of YSQTG was constructed, suggesting that quercetin, luteolin, wogonin, kaempferol and baicalein may be the most important compounds, while quercetin had higher degree value and degree centrality, which might be the key compound in YSQTG. The HPLC-MS results also showed the stable presence of quercetin in YSQTG. By establishing a protein interaction network, the main therapeutic targets of YSQTG in treating esophageal cancer were Jun proto-oncogene, interleukin-6, tumor necrosis factor, and RELA proto-oncogene. The results of cell function experiments in vitro showed that quercetin could inhibit proliferation, invasion, and clonal formation of esophageal carcinoma cells. Quercetin mainly affected the biological processes of esophageal cancer cells, such as proliferation, cell cycle, and cell metastasis. A total of 357 quercetin interacting proteins were screened, and 531 genes were significantly changed. Further pathway enrichment analysis showed that quercetin mainly affects the metabolic pathway, MAPK signaling pathway, and nuclear factor kappa B (NF- κ B) signaling pathway, etc. Quercetin, the key compound of YSQTG, had stronger binding activity by molecular docking. Pull-down assay confirmed that NF- κ B was a quercetin-specific interaction protein, and quercetin could significantly reduce the protein level of NF- κ B, the main therapeutic target.

CONCLUSION

YSQTG can be multi-component, multi-target, multi-channel treatment of esophageal cancer, it is a potential drug for the treatment of esophageal cancer.

Combination of photodynamic therapy and endoscopic mucosal resection for recurrent esophageal squamous cell carcinoma after chemoradiotherapy

Photodynamic therapy (PDT) was developed for residual or recurrent esophageal cancer after radiotherapy. Here, we report a case of successful treatment of highly elevated esophageal squamous cell carcinoma (ESCC) that recurred after definitive chemoradiotherapy (dCRT) using PDT combined with endoscopic resection (ER). An 86-year-old man was found to have an ESCC in the mid-thoracic esophagus. One year and two months after dCRT, a local recurrence was seen. The recurrent ESCC had a highly elevated component. The ESCC was estimated to have invaded the deep submucosa at the highly elevated component. PDT was selected as a treatment option since no lymph node or distant metastases were found. However, there was concern that the laser would not be able to penetrate deep into the ESCC due to its high elevated component. Therefore, ER was performed to remove the highly elevated component, and PDT was performed later. However, after the ER, the circumference of the recurrent ESCC was found to be approximately half the circumference, and post-PDT stenosis was also a concern due to the wide circumference of the ESCC. Therefore, we limited the area of laser irradiation in one session of PDT. Four sessions of PDT were needed over 13 months, but a local complete response was achieved without adverse events.

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

BACKGROUND AND PURPOSE

Late adverse cardiac events after radiation therapy (RT) for thoracic malignancies are known, but the underlying mechanisms are poorly understood. This study aimed to determine the radiation dose that can cause MBF alterations in the subacute phase after RT for thoracic esophageal cancer using stress dynamic myocardial computed tomography perfusion imaging (CTP).

MATERIALS AND METHODS

Twenty-five patients with esophageal cancer scheduled for RT were prospectively enrolled. The quantitative analysis of MBF by CTP was performed before and 3 months after RT. The mean radiation dose and hyperemic MBF in 15 segments of the left ventricular (LV) myocardium were determined. ΔMBF was calculated in each segment as MBFafter RT - MBFbeforeRT. The myocardial segments were classified into the following 5 groups according to the mean radiation dose: group A, <10 Gy; B1, 10-15 Gy; B2, 15-20 Gy; C, 20-30 Gy; and D, >30 Gy.

RESULTS

The final cohort included 22 patients who completed pre- and post-RT CTP. A one-way analysis of variance revealed a significant difference (p=0.005) in ΔMBF among the five groups of LV segments classified by the mean radiation dose. ΔMBF was significantly lower in group C (-7.7 ± 28.9 mL/min/100 g, p=0.020) and group D (-8.4 ± 34.8 mL/min/100 g, p=0.004) in comparison to ΔMBF in group A (4.9 ± 26.1 mL/min/100 g).

CONCLUSIONS

This study using CTP early after RT demonstrated a significant reduction of the MBF in the LV segments with ≥20 Gy of radiation. The results might provide important insights into preventing radiotherapy-induced cardiac events.

Pirfenidone for the prevention of radiation-induced lung injury in patients with locally advanced oesophageal squamous cell carcinoma: a protocol for a randomised controlled trial

INTRODUCTION

Radiation-induced lung injury (RILI) is one of the most clinically-challenging toxicities and dose-limiting factors during and/or after thoracic radiation therapy for oesophageal squamous cell carcinoma (ESCC). With limited effective protective drugs against RILI, the main strategy to reduce the injury is strict adherence to dose-volume restrictions of normal lungs. RILI can manifest as acute radiation pneumonitis with cellular injury, cytokine release and cytokine recruitment to inflammatory infiltrate, and subsequent chronic radiation pulmonary fibrosis. Pirfenidone inhibits the production of inflammatory cytokines, scavenges-free radicals and reduces hydroxyproline and collagen formation. Hence, pirfenidone might be a promising drug for RILI prevention. This study aims to evaluate the efficacy and safety of pirfenidone in preventing RILI in patients with locally advanced ESCC receiving chemoradiotherapy.

METHODS AND ANALYSIS

This study is designed as a randomised, placebo-controlled, double-blinded, single-centre phase 2 trial and will explore whether the addition of pirfenidone during concurrent chemoradiation therapy (CCRT) could prevent RILI in patients with locally advanced ESCC unsuitable for surgery. Eligible participants will be randomised at 1:1 to pirfenidone and placebo groups. The primary endpoint is the incidence of grade >2 RILI. Secondary endpoints include the incidence of any grade other than grade >2 RILI, time to RILI occurrence, changes in pulmonary function after CCRT, completion rate of CCRT, disease-free survival and overall survival. The follow-up period will be 1 year. In case the results meet the primary endpoint of this trial, a phase 3 multicentre trial with a larger sample size will be required to substantiate the evidence of the benefit of pirfenidone in RILI prevention.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of Fujian Union Hospital (No. 2021YF001-02). The findings of the trial will be disseminated through peer-reviewed journals, and national and international conference presentations.

TRIAL REGISTRATION NUMBER

ChiCTR2100043032.

Endoscopic debulking resection with additive chemoradiotherapy: Optimal management of advanced inoperable esophageal squamous cell carcinoma

BACKGROUND

There is no remedial strategy other than definitive chemoradiotherapy for patients with advanced esophageal squamous cell carcinoma (ESCC) who are not eligible to undergo surgical treatment.

AIM

To introduce a novel therapy called endoscopic debulking resection (EdR) followed by additive chemoradiotherapy (CRT) and evaluate its efficacy and safety.

METHODS

Advanced, inoperable ESCC patients between 1 January 2015 and 30 December 2019 were investigated retrospectively. Patients who received EdR followed by CRT were deemed the EdR + CRT group and those without CRT were deemed the EdR group. Overall survival (OS), progression-free survival (PFS), and adverse events were evaluated.

RESULTS

A total of 41 patients were enrolled. At a median follow-up of 36 mo (range: 1-83), the estimated 1-, 2-, and 3-year cumulative OS rates of patients who underwent EdR plus additive CRT were 92.6%, 85.2%, and 79.5%, respectively, which were higher than those of patients who underwent EdR alone (1-year OS, 83.3%; 2-year OS, 58.3%; 3-year OS, 50%; P = 0.05). The estimated 2-year cumulative PFS rate after EdR + CRT was 85.7%, while it was 61.5% after EdR (P = 0.043). According to the univariate and multivariate Cox regression analyses, early clinical stage (stage ≤ IIB) and additive CRT were potential protective factors for cumulative OS. No severe adverse events were observed during the EdR procedure, and only mild to moderate myelosuppression and radiation pneumonia were observed in patients who underwent additive CRT after EdR.

CONCLUSION

EdR plus CRT is an alternative strategy for selective advanced inoperable ESCC patients.

Proton Beam Therapy for Esophageal Cancer

Simple Summary

Early-stage esophageal cancer is managed surgically, with the addition of radiotherapy for locally advanced disease. Current photon-based radiotherapy results in a high treatment-related complications, due to proximal organ involvement. The anatomic location of the esophagus raises challenges due to the anatomical changes associated with diaphragmatic motion, weight loss, tumor changes, and set-up variability. These propelled the interest in proton beam therapy (PBT), which theoretically offers a reduction in the radiation exposure to healthy neighboring tissues with improvements in the therapeutic ratio. In this review, we present the role of PBT for esophageal cancer, including treatment planning, early clinical comparisons with photon-based techniques, ongoing trials, current challenges, toxicities, and issues of equity and health services.

Abstract

Early-stage esophageal cancer is often primarily managed surgically, with the addition of radiotherapy for locally advanced disease. However, current photon-based radiotherapy regimens and surgery results in a high incidence of treatment-related cardiac and pulmonary complications due to the involvement of proximal organs at risk. In addition, the anatomic location of the esophagus raises challenges for radiotherapy due to the anatomical changes associated with diaphragmatic motion, weight loss, tumor changes, and set-up variability. These challenges propelled the interest in proton beam therapy (PBT), which theoretically offers a reduction in the radiation exposure to healthy neighboring tissues with improvements in the therapeutic ratio. Several dosimetric studies support the potential advantages of PBT for esophageal cancer treatment however, translation of these results to improved clinical outcomes remains unclear with limited clinical data, especially in large populations. Studies on the effect on quality of life are likewise lacking. Here, we review the existing and emerging role of PBT for esophageal cancer, including treatment planning, early clinical comparisons of PBT with photon-based techniques, recently concluded and ongoing clinical trials, challenges and toxicities, effects on quality of life, and global inequities in the treatment of esophageal cancer.

Treatment outcomes of 156 patients with cervical esophageal cancers treated with definitive radiation therapy- A single-institution experience of a rare cancer

Purpose

Esophageal cancer is the most prevalent malignant tumor. The incidence of cervical esophageal cancer is low and there are insufficient data on the efficacy of radical radiotherapy. The purpose of this study was to clarify the efficacy with radical IFI radiotherapy, to analyze the pattern of initial lymph node metastasis and recurrence under the new lymph node zoning of esophageal cancer.

Methods

We reviewed cervical esophageal cancer treated with radical radiotherapy. The inclusion criteria were diagnosis of esophageal cancer by pathology; receiving radical radiotherapy or chemoradiotherapy; tumor location in accordance with definition of cervical esophageal cancer. Three dimensional radiotherapy was used. The target area was IFI.

Results

156 patients entered the final analysis. The proportion of no failure was 42.31%, local esophageal failure was 30.13%, in-field lymph node metastasis was 10.26%, out-field lymph node metastasis was 1.28% and distant organ metastasis was 23.72%, second primary tumor was 2.56%. The median OS and DFS was 49.0 months (35.27-62.73) and 31.0 months (14.47-47.53). The results of initial LN metastasis pattern analysis showed the supraclavicular and upper mediastinum were the main sites of cervical esophageal cancer metastasis. In patients with recurrent LN, the results showed that the cervical, supraclavicle, upper mediastinum and abdomen were the main sites of recurrence.

Conclusion

Our study is a retrospective study of a large sample of radical radiotherapy for cervical esophageal cancer. Failure in irradiation field is the main failure pattern. Concurrent radiotherapy and chemotherapy under IFI radiation is a considerable treatment option for cervical esophageal cancer.

A Single-Arm Confirmatory Study of Definitive Chemoradiotherapy Including Salvage Treatment for Clinical Stage II/III Esophageal Squamous Cell Carcinoma (JCOG0909 Study)

PURPOSE

Definitive chemoradiotherapy (CRT) is the standard treatment for patients with locally advanced esophageal cancer (EC) who refuse surgery as the initial therapy. However, poor survival, a high incidence of late toxicities, and severe complications after salvage surgery remain issues to be resolved. This single- arm multicenter trial (Trial name XXXX) aimed to confirm the efficacy of CRT modifications, including salvage treatment, for reducing CRT-related toxicities and facilitating salvage treatment for improved survival.

METHODS AND MATERIALS

Patients with clinical stage II/III EC (UICC 6th, non-T4) were eligible. Chemotherapy comprised cisplatin (75 mg/m2 on days 1and 29) and 5- fluorouracil (1,000 mg/m2/d on days 1-4 and 29-32). Radiotherapy was administered at a total dose of 50.4 Gy. Good responders received 1-2 additional cycles of chemotherapy. For residual or recurrent disease, salvage endoscopic resection (ER) or salvage surgery was performed based on specific criteria. The primary endpoint was the 3-year overall survival (OS). The calculated sample size was 95 patients, with a one-sided alpha of 5% and a power of 80%. The expected and threshold 3-year OS were 55% and 42%, respectively.

RESULTS

Overall, 96 patients were enrolled, and 94 were included in the efficacy analysis. A complete response was achieved in 55 patients (59%). Salvage ER and salvage surgery were performed in 5 (5%) and 25 patients (27%), respectively. R0 resection by salvage surgery was achieved in 19 patients (76%). Five patients (20%) showed grade 3 or 4 early operative complications, and 9 patients (9.6%) showed grade 3 late toxicities during the long-term follow-up. The 3-year OS was 74.2% (90% CI, 65.9%-80.8%).

CONCLUSION

The combination of definitive CRT and salvage treatment has lower CRT- related toxicities and yields good OS, thus making it a promising novel treatment option for patients with locally advanced EC.

Association of volumetric-modulated arc therapy with radiation pneumonitis in thoracic esophageal cancer

The lung volume receiving low-dose irradiation has been reported to increase in volumetric-modulated arc radiotherapy (VMAT) compared with three-dimensional conformal radiotherapy (3DCRT) for thoracic esophageal cancer, which raises concerns regarding radiation pneumonitis (RP) risk. This single institutional retrospective cohort study aimed to explore whether VMAT for thoracic esophageal cancer was associated with RP. Our study included 161 patients with thoracic esophageal cancer, of whom 142 were definitively treated with 3DCRT and 39 were treated with VMAT between 2008 and 2018. Radiotherapy details, dose-volume metrics, reported RP risk factors and RP incidence were collected. The RP risk factors were assessed via multivariate analysis. Dose-volume analysis showed that VMAT delivered more conformal dose distributions to the target volume (P < 0.001) and reduced V30 Gy of heart (57% vs 41%, P < 0.001) but increased V5 Gy (54% vs 41%, P < 0.001) and V20 Gy (20% vs 17%, P = 0.01) of lungs compared with 3DCRT. However, the 1-year incidence rates of RP did not differ between the two techniques (11.3% in 3DCRT vs 7.7% in VMAT, P = 0.53). The multivariate analysis suggested that the presence of interstitial lung disease (ILD) (P = 0.01) and V20 Gy of lungs ≥20% (P = 0.008) were associated with RP. Conclusively, VMAT increased the lung volume receiving low to middle doses irradiation, although this might not be associated with RP. Further studies are needed to investigate the effect of using VMAT for delivering conformal dose distributions on RP.

Association between unintentional splenic radiation and lymphopenia and high neutrophil/lymphocyte ratio after radiotherapy in patients with esophageal cancer

Background

Unintentional irradiation of the spleen may reduce absolute lymphocyte count (ALC), which can affect tumor immunity. Therefore, in the present study, we evaluated spleen dose-volume parameters associated with ALC and neutrophil/lymphocyte ratio (NLR) in patients with esophageal cancer.

Methods

This retrospective study evaluated patients who were diagnosed with stage I–IV esophageal cancer and who received radiotherapy at Nihon University Itabashi Hospital between January 2015 and March 2020. Spleen V5, V10, V20, and V30 and mean spleen dose, which are dose-volume histogram parameters correlated with ALC and NLR, were analyzed.

Results

In total, 89 esophageal cancer patients with a median age of 72 years (range, 51–92 years) were included in this research. Results showed that spleen V5, V10, and V20 and mean splenic dose were significantly correlated with a low ALC. Meanwhile, a significant association was observed between spleen V5 and V10 and a high NLR (P<0.05). In the linear regression analysis, spleen V5 and V10 were remarkably associated with a low ALC (P=0.006 and 0.008). Further, a correlation was noted between spleen V5 and a high NLR (P=0.019). Spleen V5 and V10 were remarkably associated with greater than grade 3 lymphopenia (P=0.024 and P=0.031).

Conclusions

A correlation was observed between the irradiated volume of the spleen and ALC and NLR in patients with esophageal cancer. Furthermore, the spleen should be regarded as a high-risk organ, and the use of techniques in reducing spleen V5, V10 for the preservation of tumor immunity may be beneficial.

Retrospective analysis of neoadjuvant chemotherapy followed by surgery versus definitive chemoradiotherapy with proton beam for locally advanced esophageal squamous cell carcinoma

BACKGROUND

This is the first study to compare the long-term outcomes between neoadjuvant chemotherapy + surgery and definitive chemoradiotherapy with proton beam therapy for locally advanced esophageal squamous cell carcinoma.

METHODS

We reviewed patients with clinical stage IB-III esophageal squamous cell carcinoma (UICC 7th edition) who underwent neoadjuvant chemotherapy + surgery or definitive chemoradiotherapy with proton beam therapy (2009-2017). Overall survival, progression-free survival, and recurrence or regrowth rates were compared between the two treatment groups. Subgroup analyses of overall survival according to baseline characteristics were also performed.

RESULTS

Forty-three patients received neoadjuvant chemotherapy + surgery (median follow-up 47.4 months) and 60 received definitive chemoradiotherapy with proton beam therapy (median follow-up 51.5 months). Baseline characteristics were similar between the groups except for sex, tumor location, and cT classification. The neoadjuvant chemotherapy + surgery and definitive chemoradiotherapy with proton beam therapy groups had similar 3-year overall survival rates (73.1% and 61.7%, respectively, hazard ratio: 0.88, 95% confidence interval 0.49-1.58, p = 0.66), 3-year progression-free survival rates (46.5% and 45%, respectively, hazard ratio: 1.03, 95% confidence interval 0.62-1.70, p = 0.92), and recurrence or regrowth rates (53.5% vs. 50.0%, p = 0.84). In the subgroup analysis, favorable survival was observed after definitive chemoradiotherapy with proton beam therapy for cT1-2 disease (hazard ratio 2.58, 95% confidence interval 0.84-7.99) and after neoadjuvant chemotherapy + surgery for cT3 or higher disease (hazard ratio 0.32, 95% confidence interval 0.15-0.67, p-for-interaction = 0.002).

CONCLUSIONS

Long-term outcomes were comparable between the treatments. The choice of the treatment according to cT classification might affect survival.

Cytomegalovirus reactivation in esophageal cancer patients receiving chemoradiotherapy: A retrospective analysis

Background

Although rare, cytomegalovirus (CMV) reactivation can be lethal in patients with cancer. However, the criteria for the prevention of cytomegalovirus reactivation during cancer treatment are unclear. This study aimed to identify factors associated with CMV reactivation in patients with esophageal cancer who were receiving chemoradiotherapy.

Methods

This retrospective study included esophageal cancer patients receiving definitive or palliative chemoradiotherapy during April 2013–March 2020. Patients with fever during chemoradiotherapy underwent a systemic work‐up to detect the primary focus of infection, and CMV antigenemia was assessed in cases of unidentifiable infection.

Results

Among 132 patients (80.3% male, median age 69 years [range, 39–86 years]), 124 received 5‐fluorouracil plus cisplatin and 8 received oxaliplatin–5‐fluorouracil–levofolinate chemotherapy. Overall, 19 patients had CMV reactivation, 37 had other infections, and 76 had no identified infection (groups 1, 2, and 3, respectively). Median minimum lymphocyte counts were 81.0/µl (interquartile range: 52.0–144.0/µl), 120.0/µl (81.0–162.5/µl), and 185.5/µl (120.5–328.0/µl) in groups 1, 2, and 3, respectively, with counts being significantly lower in groups 1 and 2 than in group 3 (p < 0.001). In multiple logistic regression analysis, the minimum lymphocyte count was associated with CMV reactivation (odds ratio 0.983, 95% confidence interval: 0.973–0.994, p = 0.002).

Conclusion

CMV reactivation is not rare in patients with esophageal cancer who were receiving chemoradiotherapy and is associated with the minimum lymphocyte counts. CMV reactivation should be considered during differential diagnosis for patients with a severe decline in lymphocyte counts when receiving chemoradiotherapy.

Long-term outcomes of an esophagus-preserving chemoradiotherapy strategy for patients with endoscopically unresectable stage I thoracic esophageal squamous cell carcinoma

•

Endoscopically unresectable stage I esophageal cancer is usually treated by surgery.

•

Operable stage I esophageal carcinomas were treated with our multimodal approach.

•

Based on interim appraisal, most patients were treated with chemoradiotherapy.

•

Although local recurrences were common, half of them were rescued without surgery.

•

We observed favorable long-term survival and esophagus preservation rates.

Background and purpose

To assess the long-term outcomes of a multimodal approach for maximum esophagus preservation in operable patients with endoscopically unresectable stage I thoracic esophageal squamous cell carcinoma (ESCC).

Materials and methods

The medical records of patients with stage I thoracic ESCC treated with our protocol between 1992 and 2005 were retrospectively reviewed. Our protocol consisted of neoadjuvant concurrent chemoradiotherapy, followed by either additional definitive chemoradiotherapy for good responders (CRT group) or surgery for moderate or poor responders (CRT-S group) after an interim appraisal.

Results

A total of 51 patients were analysed. The median age of the patients was 67 years. The median follow-up period was 124.8 months. After the interim assessment, 49 and 2 cases were assigned to the CRT and CRT-S groups, respectively. In the intent-to-treat analyses, overall survival (OS), disease-free survival (DFS), cumulative incidence for death from esophageal cancer, and that for loss of esophageal function were 78.9%, 53.5%, 10.5%, and 20.4% at 5 years, and 55.2%, 27.8%, 18.2%, and 22.9% at 10 years, respectively. Grade 3 late toxicities occurred with the following incidences: esophageal stenosis in 1 case, esophageal ulcer in 1 case, and pericardial effusion in 2 cases. No grade 4 or higher toxicities were observed.

Conclusion

Long-term survival and esophagus preservation outcomes were favorable, with acceptable toxicities. Our results suggest that CCRT is an alternative treatment for majority of operable patients with endoscopically unresectable stage I thoracic ESCC in combination with salvage therapy.

Definitive chemoradiotherapy versus esophagectomy in patients with clinical T1bN0M0 esophageal squamous cell carcinoma: A retrospective study

BACKGROUND AND PURPOSE

This study aimed to determine the equivalence between definitive chemoradiotherapy (DCRT) and radical esophagectomy in clinical T1bN0M0 esophageal squamous cell carcinoma (ESCC).

MATERIALS AND METHODS

Among 282 patients with cT1bN0M0 ESCC, 238 underwent radical esophagectomy and 44 underwent DCRT. Both treatments were retrospectively compared overall survival (OS), progression-free survival (PFS), and complications.

RESULTS

The DCRT group exhibited poorer patient characteristics than the surgery group, especially with mean age (73 vs. 63 years), Eastern Cooperative Oncology Group (ECOG) status, and Charlson Comorbidity Index (p < 0.001, each). The median follow-up duration was 49.5 (range, 0.4-97.0) and 45.5 months (range, 5.0-112.0) in the surgery and DCRT groups, respectively. In the DCRT group, clinical complete response was achieved in 43 patients (97.7%) at 1 month after treatment. The 5-year OS rates were 75.8% and 68.8% (p = 0.135) and the 5-year PFS were 63.8% and 57.8% (p = 0.637) for the surgery and DCRT groups, respectively. Local recurrence rates were identical between the two groups (11.4% and 11.4%), but the distant metastasis rate was lower in the DCRT group (n = 1, 2.27% vs. n = 29, 12.15%). Grade 3-4 hematologic toxicities were observed in 11 patients (25%) of the DCRT group, and 56 patients (23.5%) in the surgery group showed grade 3-5 surgical complications, including mortality (n = 5).

CONCLUSION

Based on the non-inferior survival rates, recurrence patterns, and complication rates without critical surgical mortality, DCRT was comparable to esophagectomy for cT1bN0 esophageal squamous cell carcinoma.

Dosimetric Comparison Between Carbon-ion Radiotherapy and Photon Radiotherapy for Stage I Esophageal Cancer

BACKGROUND/AIM

The present study aimed to compare the radiation dose distribution of carbon-ion radiotherapy (CIRT) for stage I esophageal cancer with three-dimensional conformal radiotherapy (3DCRT) and volumetric modulated arc therapy (VMAT).

PATIENTS AND METHODS

Fifteen patients with cT1bN0M0 esophageal cancer who received 3DCRT at Kanagawa Cancer Center between January 2014 and April 2019 were enrolled. The dose-volume histogram parameters of the target volume and normal organs planned with CIRT, 3DCRT, and VMAT were evaluated.

RESULTS

The homogeneity index for the target volume of CIRT was significantly lower than that of 3DCRT and VMAT. In addition, the radiation dose of CIRT to the heart, lungs, spinal cord, and skin was significantly lower than that of 3DCRT and VMAT.

CONCLUSION

Favorable dose distributions with CIRT were demonstrated compared with 3DCRT and VMAT for esophageal cancer.

Salvage Esophagectomy

Salvage esophagectomy is an option for patients with recurrent or persistent esophageal cancer after definitive chemoradiation therapy or those who undergo active surveillance after induction chemoradiation therapy. Salvage resection is associated with higher rates of morbidity compared with planned esophagectomy but offers patients with locally advanced disease a chance at improved long-term survival. Salvage resection should be preferentially performed in a multidisciplinary setting by high-volume and experienced surgeons. Technical considerations, such as prior radiation dosage, radiation field, and choice of conduit, should be taken into account.

Ten-Year Outcome of Neoadjuvant Chemoradiotherapy Plus Surgery for Esophageal Cancer: The Randomized Controlled CROSS Trial

PURPOSE

Preoperative chemoradiotherapy according to the chemoradiotherapy for esophageal cancer followed by surgery study (CROSS) has become a standard of care for patients with locally advanced resectable esophageal or junctional cancer. We aimed to assess long-term outcome of this regimen.

METHODS

From 2004 through 2008, we randomly assigned 366 patients to either five weekly cycles of carboplatin and paclitaxel with concurrent radiotherapy (41.4 Gy in 23 fractions, 5 days per week) followed by surgery, or surgery alone. Follow-up data were collected through 2018. Cox regression analyses were performed to compare overall survival, cause-specific survival, and risks of locoregional and distant relapse. The effect of neoadjuvant chemoradiotherapy beyond 5 years of follow-up was tested with time-dependent Cox regression and landmark analyses.

RESULTS

The median follow-up was 147 months (interquartile range, 134-157). Patients receiving neoadjuvant chemoradiotherapy had better overall survival (hazard ratio [HR], 0.70; 95% CI, 0.55 to 0.89). The effect of neoadjuvant chemoradiotherapy on overall survival was not time-dependent (P value for interaction, P = .73), and landmark analyses suggested a stable effect on overall survival up to 10 years of follow-up. The absolute 10-year overall survival benefit was 13% (38% v 25%). Neoadjuvant chemoradiotherapy reduced risk of death from esophageal cancer (HR, 0.60; 95% CI, 0.46 to 0.80). Death from other causes was similar between study arms (HR, 1.17; 95% CI, 0.68 to 1.99). Although a clear effect on isolated locoregional (HR, 0.40; 95% CI, 0.21 to 0.72) and synchronous locoregional plus distant relapse (HR, 0.43; 95% CI, 0.26 to 0.72) persisted, isolated distant relapse was comparable (HR, 0.76; 95% CI, 0.52 to 1.13).

CONCLUSION

The overall survival benefit of patients with locally advanced resectable esophageal or junctional cancer who receive preoperative chemoradiotherapy according to CROSS persists for at least 10 years.

Definitive radiotherapy for secondary esophageal cancer after allogeneic hematopoietic stem cell transplantation

The reports for secondary esophageal cancer treated by radiotherapy or chemoradiotherapy is few, however they potentially yield a cure for esophageal cancer. We report a case of definitive radiotherapy for a patient with secondary locally advanced unresectable esophageal cancer after hematopoietic stem cell transplantation for acute myeloid leukemia. Definitive radiotherapy for the current patient was completed with acceptable toxicity despite the poor general condition with long-term chronic graft-versus-host disease. Radiotherapy may be the definitive treatment for this population unfit for concurrent chemotherapy or surgery.

Review of clinical results of charged-particle therapy for esophageal cancer

Esophageal cancer is one of the common causes of cancer-related death. The treatment for esophageal cancer, particularly unresectable cases, is a difficult problem. Reports about charged-particle therapy including proton beam therapy and carbon-ion radiotherapy for esophageal cancer have increased. The objective of this study was to review the clinical results of charged-particle therapy for esophageal cancer. Charged-particle therapy was used with an expectation of increasing overall survival with reducing toxicities because charged-particle therapy can reduce the irradiated dose for normal tissues around the target tumor due to its characteristics, hence the name Bragg peak. Proton beam therapy showed a superior distribution of irradiation dose over X-ray therapy including intensity-modulated radiotherapy in silico, but clinical results were not the same. Some reports suggested that proton beam therapy may reduce acute and late toxicities, particularly in the heart and lung, during and after treatment, although it cannot lead to a higher overall survival than that in X-ray therapy. On the other hand, there are a few reports about carbon-ion radiotherapy for esophageal cancer. The special feature of carbon-ion radiotherapy is that hypofractionated radiotherapy is possible as compared to that in X-ray therapy or proton beam therapy. However, the true clinical impact of proton beam therapy or carbon-ion radiotherapy remains unclear because there are no prospective clinical trials comparing charged-particle therapy to X-ray therapy. In view of charged-particle therapy may become one of the treatment choices for esophageal cancer, further studies are needed.

Doses of intensity-modulated radiotherapy and its association with cardiac disease in esophageal cancer patients

Background

No clear guidelines or available studies exist regarding the effects of intensity-modulated radiotherapy (IMRT) of esophageal cancer (EC) on the cardiovascular system. We therefore analyzed a wide range of cardiac vascular dosimetric parameters and clinical characteristics to assess the prognostic factors for EC patients treated with IMRT.

Methods

A total of 112 patients receiving IMRT at the Qianfoshan Hospital between July 2012 and May 2017 were retrospectively reviewed. The dose per fraction was 1.8-2.0 Gy, and the total dose range was 54-66 Gy. Kaplan-Meier analysis was used to estimate death due to heart disease. Univariate and multivariate logistic regression models were calculated to test for associations between patient characteristics and dose-volume histogram (DVH) parameters. A t-test and chi-squared or Fisher's exact test was used to analyze the comparisons.

Results

The maximum and mean doses received by the heart were 57.34±13.51 and 24.83±11.40 Gy, respectively. Among the parameters examined, which included the maximum dose received by the heart, the mean dose received by the right and left ventricle (RV and LV), and the maximum dose received by the right atrium (RA), the mean dose received by the RV predicted survival and was included in our multivariate analysis. The results indicated that patients with basic heart disease who were undergoing concurrent radiochemotherapy were more likely to have cardiac disease.

Conclusions

This is first study to examine the prognosis of cardiovascular vessels exposed to various radiation doses during the treatment of EC, the findings of which suggest that limiting radiation exposure may be an important measure in IMRT application. These findings of this study may provide theoretical support for prediction of radiation-induced heart disease (RIHD). Furthermore, to curb the risk of RIHD, the modality of chemotherapy also needs to be attentively monitored and managed.

Proton beam radiotherapy for esophagus cancer: state of the art

The majority of esophageal cancer patients are diagnosed with locoregionally confined disease, which is often amenable to curative intent therapy. Chemoradiotherapy (CRT) improves overall survival (OS) in stage II and III esophagus cancer in the neoadjuvant and definitive settings. Due to the close proximity of organs at risk (OARs), including lungs, heart, stomach, bowel, kidneys, and spinal cord, esophageal CRT can result in profound acute and late toxicities. Acute toxicities can include esophagitis, nausea, vomiting, fatigue, and cytopenias. Late complications may also occur months or years after completion of thoracic radiotherapy, including significant cardiac, pulmonary, liver, kidney, or bowel toxicities, which can be life-threatening or fatal. Photon-based radiotherapy exposes OARs to significant doses of radiation, whereas proton beam therapy (PBT) has unique physical properties, as it lacks an exit dose. This allows PBT to deliver, a more conformal dose to the target and minimize the volume of OARs exposed to radiation. This dosimetric advantage may portend an increased therapeutic ratio of CRT for esophagus cancer. The objective of this review is to discuss the evolution of photon and proton-based radiotherapy techniques, rationale, dosimetric and clinical studies comparing outcomes of photon- and proton-based techniques, ongoing prospective trials, and future directions of PBT as a means of reducing toxicity and improving oncologic outcomes for patients with esophagus cancer.

Chemoradiotherapy with extended nodal irradiation and/or erlotinib in locally advanced oesophageal squamous cell cancer: long-term update of a randomised phase 3 trial

Background

To report the long-term outcomes of a phase III trial designed to test two hypotheses: (1) elective nodal irradiation (ENI) is superior to conventional field irradiation (CFI), and (2) chemoradiotherapy plus erlotinib is superior to chemoradiotherapy in locally advanced oesophageal squamous cell cancer (ESCC).

Methods

Patients with locally advanced ESCC were randomly assigned (1:1:1:1 ratio) to one of the four groups: A: radiotherapy adoption of ENI with two cycles of concurrent TP chemotherapy (paclitaxel and cisplatin) plus erlotinib; B: radiotherapy adoption of ENI with two cycles of concurrent TP; C: radiotherapy adoption of CFI with two cycles of concurrent TP plus erlotinib and D: radiotherapy adoption of CFI with two cycles of concurrent TP. A total of 60 Gy of radiation doses was delivered over 30 fractions. We explored the impact of epidermal growth factor receptor (EGFR) expression on the efficacy of erlotinib plus chemoradiotherapy.

Results

A total of 352 patients (88 assigned to each treatment group) were enrolled. The 5-year survival rates were 44.9%, 34.8%, 33.8% and 19.6% in groups A, B, C and D, respectively (P = 0.013). ENI significantly improved OS compared with standard CFI (median, 38.5 vs 22.6 months; HR, 0.74; P = 0.018). The addition of erlotinib significantly improved OS (median, 39.4 vs 27.4 months; HR, 0.75; P = 0.025). Patients with overexpressing EGFR treated with erlotinib had a better OS and PFS than those without erlotinib.

Conclusions

Concurrent chemoradiotherapy with ENI and/or erlotinib improved long-term survival in locally advanced ESCC.

Clinical trial registration

Trial registration: NCT00686114.

Quantification of Myocardial Dosimetry and Glucose Metabolism Using a 17-Segment Model of the Left Ventricle in Esophageal Cancer Patients Receiving Radiotherapy

OBJECTIVE

Previous studies have shown that increased cardiac uptake of 18F-fluorodeoxyglucose (FDG) on positron emission tomography (PET) may be an indicator of myocardial injury after radiotherapy (RT). The primary objective of this study was to quantify cardiac subvolume dosimetry and 18F-FDG uptake on oncologic PET using a 17-segment model of the left ventricle (LV) and to identify dose limits related to changes in cardiac 18F-FDG uptake after RT.

METHODS

Twenty-four esophageal cancer (EC) patients who underwent consecutive oncologic 18F-FDG PET/CT scans at baseline and post-RT were enrolled in this study. The radiation dose and the 18F-FDG uptake were quantitatively analyzed based on a 17-segment model. The 18F-FDG uptake and doses to the basal, middle and apical regions, and the changes in the 18F-FDG uptake for different dose ranges were analyzed.

RESULTS

A heterogeneous dose distribution was observed, and the basal region received a higher median mean dose (18.36 Gy) than the middle and apical regions (5.30 and 2.21 Gy, respectively). Segments 1, 2, 3, and 4 received the highest doses, all of which were greater than 10 Gy. Three patterns were observed for the myocardial 18F-FDG uptake in relation to the radiation dose before and after RT: an increase (5 patients), a decrease (13 patients), and no change (6 patients). In a pairing analysis, the 18F-FDG uptake after RT decreased by 28.93 and 12.12% in the low-dose segments (0-10 Gy and 10-20 Gy, respectively) and increased by 7.24% in the high-dose segments (20-30 Gy).

CONCLUSION

The RT dose varies substantially within LV segments in patients receiving thoracic EC RT. Increased 18F-FDG uptake in the myocardium after RT was observed for doses above 20 Gy.

Cardiotoxicity of radiation therapy in esophageal cancer

With a development of radiotherapeutic techniques, availability of radiotherapy data on cardiotoxicity, and slowly improving esophageal cancer outcomes, an increasing emphasis is placed on the heart protection in radiation treated esophageal cancer patients. Radiation induced heart complications encompass mainly pericardial disease, cardiomyopathy, coronary artery atherosclerosis, valvular heart disease, and arrhythmias. The most frequent toxicity is pericardial effusion which is usually asymptomatic in the majority of patients. The use of modern radiotherapy techniques is expected to reduce the risk of cardiotoxicity, although this expectation has to be confirmed by clinical data.

Analysis of cardiac toxicity after definitive chemoradiotherapy for esophageal cancer using a biological dose-volume histogram

This study aimed to evaluate the relationship between cardiac toxicity after definitive chemoradiotherapy (CRT) for esophageal cancer and the dose-volume histogram (DVH) of organs at risk (OARs) [using biological effective dose (BED)]. We analyzed the data of 83 patients with esophageal cancer treated using definitive CRT between 2001 and 2016. Furthermore, we evaluated pericardial effusion (PE) as a measure of cardiac toxicity. The median total irradiation dose was 60 (50.4-71) Gy. Symptomatic PE was observed in 12 (14%) patients. The heart and pericardium V5-V100-BED were significantly higher in patients with symptomatic PE than in those without symptomatic PE (heart: V5-V95-BED, P < 0.001; V100-BED, P = 0.0053, and pericardium: V5-V40-BED, V55-V95-BED, P < 0.001; V45-50-BED, V100-BED, P < 0.05, respectively). Receiver operating characteristic curve analysis showed that the dose-volume parameter of the pericardium and the heart that was most strongly associated with an adverse cardiac event was V80-BED, and the mean dose and the cut-off value were 27.38% and 61.7 Gy-BED, respectively. Multivariate analysis showed that the pericardium V80-BED and the mean heart dose-BED were risk factors for symptomatic PE (P < 0.001, respectively). We revealed the relationship between the irradiated dose of the OARs and symptomatic PE using a BED-based dose-volume histogram. Pericardium V80-BED and mean heart dose-BED were the most relevant risk factors for symptomatic PE.

Comparison of involved field radiotherapy and elective nodal irradiation in combination with concurrent chemotherapy for T1bN0M0 esophageal cancer

BACKGROUND

The optimal radiation field of chemoradiation therapy (CRT) for stage I esophageal squamous cell carcinoma (ESCC) is unknown. This retrospective study compared efficacy and safety of two CRT modalities, involved field irradiation (IFI) and elective nodal irradiation (ENI), when treating patients with clinical stage I (T1bN0M0) ESCC.

METHODS

Patients had received 60 Gy CRT concurrently with 5-FU and cisplatin between January 2000 and December 2012. The clinical target volume of IFI was limited to the primary tumor plus a 2-cm craniocaudal margin; that of ENI covered the primary tumor plus the field of regional lymph nodes.

RESULTS

One hundred and ninety-five patients were selected (IFI group, 78; ENI group, 117). The 5-year overall, cause-specific and progression-free survival rates were 90.5%, 91.6% and 77.6% in the IFI group, and 72.5%, 88.3%, 57.9% in the ENI group, respectively. Of recurrent patients (n = 16 in the IF and n = 33 in the ENI groups) after achieving complete remission, 12 (75%) in the IFI group received definitive salvage therapy, 11 (33%) patients did in the ENI group. More patients died of diseases other than esophageal cancer in the ENI group (n = 29, 25%) than in the IFI group (n = 3, 3.8%). Multivariate analysis identified ENI (HR 3.63 [1.78-7.38], p < 0.001), age ≥ 70 (HR 2.65 [1.53-4.58], p < 0.001) and PS = 1 (HR 2.36 [1.33-4.18], p = 0.003) as poor prognostic factors for OS.

CONCLUSIONS

IF irradiation would be better than ENI for the patients with stage I ESCC who received definitive chemoradiotherapy.