Relationship between the radiologic features of esophageal cancer and the local control by radiation therapy

MR imaging characteristics of different pathologic subtypes of esophageal carcinoma

OBJECTIVES

To describe the specific MRI characteristics of different pathologic subtypes of esophageal carcinoma (EC) METHODS: This prospective study included EC patients who underwent esophageal MRI and esophagectomy between April 2015 and October 2021. Pathomorphological characteristics of EC such as localized type (LT), ulcerative type (UT), protruding type (PT), and infiltrative type (IT) were assessed by two radiologists relying on the imaging characteristics of tumor, especially the specific imaging findings on the continuity of the mucosa overlying the tumor, the opposing mucosa, mucosa linear thickening, and transmural growth pattern. Intraclass correlation coefficients (ICC) were calculated for the consistency between two readers. The associations of imaging characteristics with different pathologic subtypes were assessed using multilogistic regression model (MLR).

RESULTS

A total of 201 patients were identified on histopathology with a high inter-reader agreement (ICC = 0.991). LT showed intact mucosa overlying the tumor. IT showed transmural growth pattern extending from the mucosa to the adventitia and a "sandwich" appearance. The remaining normal mucosa on the opposing side was linear and nodular in UT. PT showed correlation with T1 staging and grade 1; IT showed correlation with T3 staging and grades 2-3. Four MLR models showed high predictive performance on the test set with AUCs of 0.94 (LT), 0.87 (PT), 0.96 (IT), and 0.97 (UT), respectively, and the predictors that contributed most to the models matched the four specific characteristics.

CONCLUSIONS

Different pathologic subtypes of EC displayed specific MR imaging characteristics, which could help predict T staging and the degree of pathological differentiation.

CLINICAL RELEVANCE STATEMENT

Different pathologic subtypes of esophageal carcinoma displayed specific MR imaging characteristics, which correspond to differences in the degree of differentiation, T staging, and sensitivity to radiotherapy, and could also be one of the predictive factors of cause-specific survival and local progression-free rates.

KEY POINTS

Different types of EC had different characteristics on MR images. A total of 91/95 (96%) LTEC showed intact mucosa over the tumor, while masses or nodules are specific to PTEC; 21/27 (78%) ITEC showed a "sandwich" sign; and 33/35 (60%) UTEC showed linear and nodular opposing mucosa. In the association of tumor type with degree of differentiation and T staging, PTEC was predominantly associated with T1 and grade 1, and ITEC was associated with T3 and grades 2-3, while LTEC and UECT were likewise primarily linked with T2-3 and grades 2-3.

Does protruding type 1 esophageal cancer really have a good response to radiation therapy?-a retrospective observational study

BACKGROUND

It is now well-established that esophageal cancer can be more accurately classified macroscopically on the basis of endoscopic rather than esophagographic findings. Thus far, no studies have reported correlations between responses to radiation therapy (RT) and endoscopically-determined macroscopic type of locally advanced esophageal cancer. In this retrospective study, we therefore aimed to determine such correlations in patients who had undergone at least two follow-up endoscopies.

METHODS

Our study cohort comprised 30 patients who had received radiotherapy for locally advanced squamous cell carcinoma (SCC) of the esophagus from January 2012 to November 2017 at our hospital. The lesions had been classified endoscopically into one of the five types specified by the Guidelines for Clinical and Pathologic Studies on Carcinoma of the Esophagus of the Japanese Society for Esophageal Disease. All patients had received radiotherapy and 27 had received chemotherapy. In accordance with those guidelines, responses to treatment were evaluated endoscopically, a median of 74 days after initiating radiotherapy. Follow-up endoscopy had been performed at least twice in 18/30 patients.

RESULTS

The primary complete response (CR) rate was significantly higher in patients with type 1 disease (protruding) than in those with the other types (χ2 test, P=0.041). The only correlation revealed by logistic regression analysis was between CR rate and macroscopically classified type 1 disease (P=0.05). Disease-specific survival (DSS) did not differ between macroscopically classified types (P=0.31). Patients with clinical T2 disease and ≤ stage IIIA had better outcomes than those with other stages (P=0.041 and 0.025, respectively).

CONCLUSIONS

Macroscopic classification of esophageal carcinoma by endoscopy accurately identifies a group with a higher primary CR rate to chemoradiotherapy (CRT): those with type 1 disease (protruding). However, median DSS did not differ between patients with type 1 disease and those with other types.

Role of barium esophagography in patients with locally advanced esophageal cancer: evaluation of response to neoadjuvant chemoradiotherapy

Purpose. This retrospective study examined the usefulness of barium esophagography, focusing on the luminal stenosis, in the response evaluation of neoadjuvant chemoradiotherapy (NACRT) in patients with esophageal cancer. Materials and Methods. Thirty-four patients with primary advanced esophageal cancer (≥T2) who were treated with NACRT before surgical resection were analyzed. All patients underwent barium esophagography before and after NACRT. The tumor length, volume, and percent esophageal stenosis (PES) before and after NACRT were measured. These values and their changes were compared between histopathologic responders (n = 22) and nonresponders (n = 12). Results. Posttreatment tumor length and PES in responders (4.5 cm ± 1.1 and 33.0% ± 18.5) were significantly smaller than those in nonresponders (5.8 cm ± 1.9 and 48.0% ± 12.9) (P = 0.018). Regarding posttherapeutic changes, the decrease in PES in responders (31.5% ± 13.9) was significantly greater than that in nonresponders (14.4% ± 10.7) (P < 0.001). The best decrease in PES cutoff with which to differentiate between responders and nonresponders was 18.8%, which yielded a sensitivity of 91% and a specificity of 75%. Conclusions. Decrease in PES is a good parameter to differentiate responders from nonresponders for NACRT. Barium esophagography is useful in response evaluation to NACRT in patients with locally advanced esophageal cancer.

Late-course accelerated hyperfractionated radiotherapy for localized esophageal carcinoma

PURPOSE

To evaluate the long-term survival results and patterns of failure for localized carcinoma of the esophagus receiving late-course accelerated hyperfractionated (LCAF) radiotherapy (RT).

METHODS AND MATERIALS

We studied 201 patients with histologically confirmed squamous cell carcinoma of the esophagus who were treated with LCAF RT between August 1994 and January 2000. The design of the radiation fields was based on the diagnosis by computed tomography and barium examination. All patients received conventionally fractionated RT at 1.8 Gy/d, five fractions weekly for the first two-thirds of treatment to a dose of about 41.4 Gy in 23 fractions within 4-5 weeks. This was followed by LCAF RT using reduced fields, 1.5 Gy/fraction twice daily with a 6-h interval between fractions, to a dose of about 27 Gy within 9 days. Thus, the total dose was 68.4 Gy in 41 fractions within 44 days.

RESULTS

The incidence of Grade 3-5 acute radiation-induced bronchitis was 4.0% (8 cases), 3.0% (6 cases), and 0%, respectively. The incidence of Grade 3-5 acute radiation-induced esophagitis was 14.9% (30 cases), 0.5% (1 case), and 0%. Ten patients (5%) died of late complications. The 1-year, 3-year, and 5-year overall survival rate was 73%, 34%, and 26%, respectively. The 1-year, 3-year, and 5-year local control rate was 77%, 58%, and 56%, respectively. The main site of first failure was locoregional failure and distant metastasis (including lymph node metastasis from regional recurrence). Of 201 patients, 77 (38.4%) had local disease alone or with distant metastasis as the first failure, and 70 patients (34.9%) had distant metastasis and/or lymph node metastasis alone or with local failure as the first failure.

CONCLUSION

The LCAF regimen offers similar local control and survival to standard chemotherapy plus RT, such as was delivered in the Radiation Therapy Oncology Group studies 85-01 and 94-05.

Relationships between radiosensitivity and microvascular density in esophageal carcinoma: significance of hypoxic fraction

PURPOSE

The prognosis and the radiosensitivity of macroscopically infiltrative type of esophageal carcinoma are worse than those of the localized type of esophageal carcinoma treated with irradiation. The aim of this study was to investigate the cause of differences in radiosensitivity and prognosis of esophageal carcinoma according to macroscopic type from the viewpoint of tumor angiogenesis.

METHODS AND MATERIALS

A total of 40 surgically resected esophageal carcinoma tissues with good material remaining were selected at random from macroscopically localized type (n = 20) and infiltrative type (n = 20) of esophageal carcinoma. The highest intratumoral microvascular density (h-MVD), average intratumoral microvascular density (a-MVD), Ki67 labeling index, and expression of vascular endothelial growth factor (VEGF) in each section were estimated.

RESULTS

h-MVD was significantly (p = 0.0006) greater in the infiltrative type than in the localized type, whereas a-MVD (p = 0.0014) and Ki67 labeling index (p = 0.022) were significantly lower in the infiltrative type than in the localized type. The expression level of VEGF was significantly (p < 0.0001) higher in the infiltrative type.

CONCLUSIONS

The generally underdeveloped vascular densities with low proliferation activities (suggesting increase of hypoxic fraction) seemed to be one of the reasons for unfavorable radiosensitivities of infiltrative type of esophageal carcinoma. The infiltrative type of esophageal carcinoma shows a high level of VEGF expression and high activity of tumor angiogenesis. The locally enhanced neovascularization, which occurs frequently in hematogenous metastasis seemed to be one of the reasons for the unfavorable prognosis of the infiltrative type of esophageal carcinoma.

Chemoradiation in conservation therapy for esophageal cancer

Irradiation alone can be highly beneficial for patients with advanced or metastatic esophageal cancer, but external beam irradiation alone is now usually reserved for patients only requiring palliation. Higher cure rates are achieved with irradiation delivered with radiosensitizing chemotherapy based on clinical trials performed over the last decade. Chemoradiation programs based on the modest success with infusional 5-FU, cisplatin, and 50 Gy are justified for either palliative or curative treatment as long as the toxicity is acceptable. One challenge is to increase the incidence of pathologic complete response rates without incurring unacceptable acute toxicity, which is the major dose-limiting factor in current trials. Newer methods that may ameliorate acute injury are different dose schedules for chemoradiation and different methods of dose delivery. Infusional administration of chemotherapy and new dose planning and delivery systems for irradiation (conformal irradiation) are currently under study. Organ preservation for larger numbers of patients may be possible if any of these methods hold up to the early indications of success.

Combined modality therapy for esophageal cancer

Whereas many patients with esophageal carcinoma present with what appears to be localized disease, cure rates with surgical resection alone remain low. Although surgical resection, where feasible, affords patients the best chance of cure, the primary tumor has often invaded local tissues or structures, and occult micrometastases often exist at the time of presentation. In an effort to improve treatment results, various combinations of surgery, radiotherapy, and chemotherapy have been used. The results of combined modality therapy are reviewed in this article. The importance of accurate pretreatment staging is discussed, and ongoing prospective randomized trials are reviewed.

Late esophageal toxicity using a combination of external beam radiation, intraluminal brachytherapy and 5-fluorouracil infusion in carcinoma of the esophagus

One hundred patients with potentially curable squamous cell carcinoma of the esophagus were treated using a combination of external beam radiation, medium-dose intraluminal brachytherapy (ILBT), and 5-fluorouracil infusion (as a radiosensitizer) from January 1990 to December 1993. The main objective was to determine late toxicity and optimization of the dose of intraluminal radiation. All patients had external radiation of 50 Gy over 5 1/2 weeks, followed by ILBT of 20 Gy for 50 patients (group 1) and 15 Gy for a subsequent 50 patients (group 2), using a dose rate of 315-330 cGy/h with the prescription at 1 cm off axis. The 5-fluorouracil infusion was 500 mg/m2 administered 12 h prior to ILBT. The treatment-related complications among groups 1 and 2 were strictures 24% vs. 8% (p = 0.029), ulceration 30% vs. 28% (p = 0.8), and tracheoesophageal fistulae 12% for both groups. The overall survival for groups 1 and 2 was 8% and 23% at 5 years. The development of life-threatening complications is a major concern and extreme caution is urged before selecting patients for a combination of ILBT and 5-fluorouracil treatment.

Mismatched clinicopathological response after concurrent chemoradiotherapy for thoracic esophageal cancer

We have been treating patients with operable thoracic esophageal cancer according to our own protocol. It includes the initial concurrent chemoradiotherapy (CRT) followed by continuous CRT or surgery. Patients with good response to initial chemoradiotherapy were allowed to continue chemoradiotherapy, whereas the others were treated with surgery. However, there were two cases which showed discrepancies in the clinicopathological response. Both patients received initial chemoradiotherapy, including two courses of cisplatin (100-120 mg), 5-fluorouracil (750-1000 mg for 4 days) and radiation (44-50 Gy). On completion of the initial chemoradiotherapy, all diagnostic imaging modalities including barium swallow, esophagoscopy, endoscopic ultrasonography and thoracic computed tomography strongly implicated residual tumor with a reduction rate of 40-50%. The patients underwent radical esophagectomy 15-20 days after initial chemoradiotherapy. Pathological specimens only revealed thickening of the esophageal wall due to inflammatory change without residual carcinoma. These facts suggest the current limitations of diagnostic images in evaluating the response to chemoradiotherapy.

Comparison between chemoradiation protocol intended for organ preservation and conventional surgery for clinical T1-T2 esophageal carcinoma

PURPOSE

This retrospective study was designed to compare treatment results of the chemoradiation protocol with conventional surgery for thoracic T1-T2 esophageal squamous cell carcinoma.

METHODS AND MATERIALS

Sixty-six patients with esophageal carcinoma, clinically diagnosed as T1 (tumor invading lamina propria or submucosa) or T2 (tumor invading muscularis propria) were treated for 12 consecutive years, from July 1986 to January 1998. The conventional surgery group included 30 patients who underwent esophagectomy with regional lymph node dissection. Twenty-one of them received postoperative radiotherapy. Thirty-six patients were assigned to the chemoradiation protocol, consisting of neoadjuvant chemoradiotherapy (44 Gy; CDDP: 60 mg/m2, day 1, bolus; 5-FU: 400 mg/m2, day 1-4, continuous), followed by either definitive radiotherapy with high-dose-rate intraluminal brachytherapy (total 70 Gy) for responders or surgery for nonresponders as in the conventional surgery group. Surgical candidates in both groups received intraoperative radiotherapy for abdominal lymphatics since 1991.

RESULTS

In the protocol group, 4 patients underwent radical surgery after neoadjuvant chemoradiotherapy, and the remaining 32 underwent definitive chemoradiotherapy. Local control rates at 1 and 3 years were 85% and 70% in the T1/protocol group versus 91% and 80% in the T1/surgery group, and 83% and 83% in the T2/protocol group versus 94% and 80% in the T2/surgery group, respectively. There was no statistical significance. Overall 1- and 3-year survival rates were 100% and 83% in the T1/protocol group versus 82% and 72% in the T1/surgery group (p = 0.36), and 100% and 51% in the T2/protocol group, versus 95% and 68% in the T2/surgery group p = 0.61), respectively. There was no treatment-related mortality in either group. The rates of esophageal conservation were 92% in the T1/protocol group and 58% in the T2/protocol group.

CONCLUSION

The chemoradiation protocol can result in comparable survival with conventional surgery for patients with T1-T2 esophageal carcinoma. A randomized trial between definitive chemoradiotherapy and surgery is required.

A phase II trial of four courses of preoperative chemotherapy in squamous or anaplastic carcinoma of the oesophagus

We have reported the results of a previous Phase II trial of two courses of neoadjuvant mitomycin (6 mg/m2), ifosfamide (3 g/m2) and cisplatin (50 mg/m2) (MIC) in squamous or anaplastic carcinoma of the oesophagus. In this current study, we have investigated whether there was any clinical benefit in extending the preoperative treatment to four courses for patients who responded after two courses. Response was assessed by barium swallow, which was compared with previous barium swallows performed prior to any treatment and after the second course of MIC. Of an initial 43 patients, 27 (63%) were assessed as responders after two courses of MIC. Twenty of these 27 patients were entered into the study with a view to receiving two further courses of MIC prior to surgery. Seventeen completed four courses. Five patients were complete responders after two courses and remained complete responders after four courses. Twelve patients were partial responders after two courses; six of these became complete responders after four courses, five remained partial responders, and one showed progression. Haematological toxicity and alopecia were increased after extending the number of courses beyond two. On pathological assessment, three patients with a complete response after four courses, and one with a complete response after three courses, had microscopic clearance of tumour. Extension beyond two courses of neoadjuvant MIC gives an improvement in response, as judged by barium assessment, but increases toxicity, cost of treatment and delay before surgery. Although the numbers are small, the results suggest that a worthwhile improvement in the radiological response of squamous or anaplastic oesophageal tumours may be gained by proceeding beyond two courses of MIC. A randomized trial, with larger numbers of patients, is needed to show whether there is any improvement in radiological and pathological response rates and in survival to be gained by the extension of treatment beyond two courses.

The management of patients with advanced cancer (II)

In this second article in the series, obstruction of hollow viscera in patients with advanced malignant disease is discussed. The obstruction of such structures can be associated with the development of painful and incapacitating symptoms, often in patients who have a limited life expectancy. This obstruction may be caused by the primary tumour, compression from adjacent tumour-draining lymph nodes, the presence of metastases distant from the site of the primary tumour or to adhesions within the abdominal compartment (usually as a result of previous surgery). The organs most often affected are the oesophagus, the intestine (small and large), the biliary tree and the genito-urinary tract. Obstruction of each of these organs and its management is discussed in more detail below.

Radical radiotherapy for medically inoperable non-small cell lung cancer in clinical stage I: a retrospective analysis of 149 patients

PURPOSE

In order to obtain the standard treatment results of medically inoperable non-small cell lung cancer (NSCLC) in Stage I in the post-CT scan era, a retrospective analysis of patients who were treated by radical radiotherapy was performed.

METHODS AND MATERIALS

149 cases treated between 1980 and 1989 were accumulated from ten large hospitals in Japan. All patients received a total dose of 55-75 Gy (mean 64.7 Gy) with conventional fractionation. For evaluation of treatment results, complete response (CR) rate, median survival period and long-termed survival rates were used.

RESULTS

The median survival of the all cases was 27.2 months and the actuarial 3- and 5-year survival rates were 34.2% and 22.2%, respectively. CR was obtained in 57 cases (38%). The CR rate was strongly correlated with the long-term survival (5-year survival rate in CR group: 35.1% compared with PR + NC group: 14.1% (P < 0.0001)). The size of tumor was also of prognostic importance. In 116 patients who died within 5 years after treatment, 66 patients (57%) died of local tumor regrowth.

CONCLUSION

Although the medically inoperable NSCLC patients in Stage I should be offered curative radiation therapy, development of some new steps to increase the CR rate and local control rate is urgently needed.

Preoperative high-dose radiation and chemotherapy in adenocarcinoma of the esophagus and esophagogastric junction

BACKGROUND

Esophageal adenocarcinoma (EA) incidence is rising. Defining optimal management is essential because median survival after surgery alone is only approximately 12 months. High-dose radiation (> 5000 cGy) and chemotherapy (HDRCT) preoperatively for patients with EA has not been fully investigated. We evaluated tumor response, resectability, and survival following HDRCT in patients with localized EA.

METHODS

Thirty patients with American Joint Committee on Cancer (AJCC) clinical stage I or II EA were prospectively treated with HDRCT. The treatment consisted of 60 Gy radiation at 2 Gy per fraction with concurrent infusional 5-fluorouracil (5-FU) and a bolus of mitomycin C followed by esophagogastrectomy. The range of follow-up was 7 to 69 months, with a median of 31 months.

RESULTS

Twenty of 30 patients (67%) received full-course HDRCT. Severe esophagitis precluded full-dose radiation in 10 patients. Three patients developed neutropenia and fever requiring admission to a hospital. Two patients died preoperatively of treatment-related complications. Nine patients were not explored. Eighteen patients were resected with curative intent; the remaining three had metastatic disease at laparotomy. Seven of 18 resected patients (39%), or 7/30 (23%) of all patients treated, had a pathologic complete response. There was one operative death. Overall local control was seen in 25/30 patients (83%). Median overall survivals for resected and for all patients were 23 and 13 months, respectively.

CONCLUSIONS

Preoperative HDRCT in patients with EA results in encouraging local tumor response and local control. Overall survival, however, may not be improved, and the treatment-related mortality of 10% is higher than reported with surgery alone or with preoperative chemotherapy.

Prognostic factors in radiation-treated esophageal carcinoma

Prognostic factors in esophageal carcinoma treated with irradiation were examined. The prognosis of 111 patients without metastasis who had received more than 60 Gy was analyzed. Significant associations were found between survival rates and tumor length, stage, radioresponse of the primary tumor and the s.c. X-P classification based on barium contrast radiography; superficial type (tumor limited to the surface of the esophageal wall), tumorous type (solid mass without ulceration), Ul-A type (tumor with shallow ulceration with regular margin), Ul-B type (tumor with deep ulceration or irregular ulcer margin), and funneled type (tumor invading the esophageal wall in a scirrhous pattern). In multiple regression analysis, the X-P classification had the strongest correlation with survival and the survival rates of patients with the superficial type, the tumorous type and the s.c. Ul-A type were significantly higher than those of patients with the other tumor types (p < 0.001).

Surgical therapy of oesophageal carcinoma

During the past 10 years, postoperative mortality associated with surgical treatment of oesophageal carcinoma has been reduced by one-half. However, it appears that all efforts to improve long-term survival with extensive excisional procedures and adjuvant chemotherapy and radiotherapy have failed. Fifty-six of 100 patients presenting to the surgeon with an oesophageal carcinoma have resectable disease. Recent studies suggest that seven of them will die from postoperative complications and 49 patients will be discharged from the hospital after an average of 3 weeks. Of these patients, 27 will survive the first, 12 the second, and ten the fifth year. Although it may be possible to further reduce postoperative complications and mortality, the chances of improving the long-term prognosis of patients with oesophageal carcinoma seem small.

The prognostic significance of number of positive nodes in cervical carcinoma stages IB, IIA, and IIB

Radical hysterectomy and bilateral pelvic lymphadenectomy were done on 875 patients diagnosed with cervical carcinoma Stages IB (484 patients), IIA (96 patients), and IIB (295 patients). The number of positive nodes was 0 in 620 patients (N0), one in 98 patients (N1), two to three in 80 patients (N2), four to 18 in 45 patients (N4), and unresectable in 32 patients. Cumulative 5-year survival rates were 89%, 81%, 63%, 41%, and 23%, respectively. Significant survival reduction rates (P less than 0.05) from N0 to N1 were insignificant in Stage IB patients (92% versus 91%), in those patients without parametrial invasion (92% versus 90%), and in those with parametrial invasion (76% versus 72%). Survival reduction rates (P less than 0.01) from N1 to N2 resulted from a reduction in IB patients without parametrial invasion (100%-71%, P less than 0.01). Survival reduction rates (P less than 0.05) from N2 to N4 resulted from a reduction in Stage IIB patients with parametrial invasion (60%-29%, P less than 0.05). These figures suggest that the number of positive nodes is a more indicative prognostic factor than the existence of nodal metastasis, and that the 5-year survival rates of those patients with one positive node can be improved up to the level of those without nodal metastasis.

5-year results of postoperative extended-field irradiation on 76 patients with nodal metastases from cervical carcinoma stages IB to IIIB

Extended-field irradiation was administered after radical surgery to 76 patients with nodal metastases from cervical carcinoma Stages IB (37 patients), IIA (six patients), IIB (29 patients), and IIIB (four patients). The first recurrent sites of disease were distant organs via hematogenous routes of 12 patients and in the pelvic fields of eight patients. The 5-year disease-free survival rates were 95% for 27 patients with one positive node, 64% for 37 patients with multiple positive nodes, and 44% for 12 patients with unresectable nodes; 72% in total. Poor disease-free survival rates were associated with Stage IIB (60%), more than 30 mm invasion depths (44%), small cell cancer (0%), adenocarcinoma (57%), adenosquamous carcinoma (50%), and premenopause (60%). In 52 patients with nonkeratinizing large cell carcinoma, the disease-free survival rates were significantly different between Stage IB and IIB (87% versus 47%, P less than 0.05). This dissimilarity was caused by significant differences between Stage IB and IIB patients with less than 30 mm invasion depths (90% versus 53%, P less than 0.05), with parametrial extension (100% versus 39%, P less than 0.005), and with unresectable nodes (100% versus 0%, P less than 0.05). These results indicate that postoperative extended-field irradiation can control distant spread via lymphatic routes with significant improvement of patient survival, and that the number of positive nodes, tumor cell types, depth of tumor invasion, and clinical stages are important prognostic factors subsequent to this combined therapy.

The effect of radiotherapy on dysphagia and survival in patients with esophageal cancer

A group of 127 patients with esophageal cancer treated with radiotherapy at different dose levels was retrospectively analysed. It was found that 70.5% of the patients showed improvement of dysphagia and that 54% remained palliated with respect to food passage until their death. The two major prognostic variables with respect to the palliative effect on dysphagia as well as survival were the passage score and the radiation dose. Patients with severe dysphagia (PASS 0 or 1) had a median actuarial DFI and SURV of 3.7 and 6.4 months, respectively, in contrast to 16.0 and 8.7 months for patients who were able to use (semi)solid food (PASS 2 and 3). The median actuarial DFI and SURV of patients treated with a relatively low dose (less than 50 Gy in 5 weeks) were 2.5 and 4.8 months, respectively, compared to 10.1 and 8.3 months, respectively, for patients treated with a relatively high dose.