1
|
Arnstadt B, Allescher HD. [Palliative endoscopy]. Chirurg 2021; 93:310-322. [PMID: 34137905 DOI: 10.1007/s00104-021-01426-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/07/2022]
Abstract
Endoscopy is the leading method in the diagnostics of gastrointestinal malignancies. With the increasing incidences of various tumor entities, a palliative treatment situation is already present in many patients despite an increasing number of screening strategies. Palliative endoscopy can make an essential contribution to alleviation of tumor-related symptoms, such as dysphagia, malnutrition, cholestasis, ileus and pain. Various approaches can be offered to safeguard the nutrition, e.g. percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ), for maintenance of the gastrointestinal passage (stents) and secretion drainage or to drain congested hollow organs. Furthermore, in cases of inaccessibility or impassability of stenoses due to tumors, endosonographically assisted punctures offer the possibility to guarantee new drainage options or continuities by stent placement. In all interventions possible contraindications and complications must be taken into account.
Collapse
Affiliation(s)
- Benno Arnstadt
- Gastroenterologie, Hepatologie, Stoffwechsel, Nephrologie, Klinikum Garmisch-Partenkirchen GmbH, Garmisch-Partenkirchen, Deutschland.
| | - Hans-Dieter Allescher
- Gastroenterologie, Hepatologie, Stoffwechsel, Nephrologie, Klinikum Garmisch-Partenkirchen GmbH, Garmisch-Partenkirchen, Deutschland
| |
Collapse
|
2
|
Hipp J, Nagavci B, Schmoor C, Meerpohl J, Hoeppner J, Schmucker C. Post-Neoadjuvant Surveillance and Surgery as Needed Compared with Post-Neoadjuvant Surgery on Principle in Multimodal Treatment for Esophageal Cancer: A Scoping Review. Cancers (Basel) 2021; 13:cancers13030429. [PMID: 33561090 PMCID: PMC7865772 DOI: 10.3390/cancers13030429] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 12/11/2022] Open
Abstract
Simple Summary A substantial fraction of patients with esophageal cancer show post-neoadjuvant pathological complete response (pCR). Principal esophagectomy after neoadjuvant treatment is the standard of care for all patients, including those with pCR. Surveillance and surgery as needed may be a treatment alternative for these patients. We performed a scoping review and described all relevant clinical studies addressing these two treatment approaches. We identified three completed randomized controlled trials (RCTs) including 468 participants, three planned/ongoing RCTs with a planned sample size of 752 participants, one non-randomized controlled study with 53 participants, ten retrospective cohort studies (2228 participants) and one survey on patients’ preferences (100 participants). The current scoping review reveals that although surveillance and surgery as needed has been investigated within different study designs, the available study pool show methodological limitations and clinical results are heterogeneous. A thoroughly planned RCT considering these limitations will be of great importance to provide these patients with the best treatment. Abstract Background: A substantial fraction of patients with esophageal cancer show post-neoadjuvant pathological complete response (pCR). Principal esophagectomy after neoadjuvant treatment is the standard of care for all patients, although surveillance and surgery as needed in case of local recurrence may be a treatment alternative for patients with complete response (CR). Methods: We performed a scoping review to describe key characteristics of relevant clinical studies including adults with non-metastatic esophageal cancer receiving multimodal treatment. Until September 2020, relevant studies were identified through systematic searches in the bibliographic databases Medline, Web of Science, Cochrane Library, Science Direct, ClinicalTrials, the German study register, and the WHO registry platform. Results: In total, three completed randomized controlled trials (RCTs, with 468 participants), three planned/ongoing RCTs (with a planned sample size of 752 participants), one non-randomized controlled study (NRS, with 53 participants), ten retrospective cohort studies (with 2228 participants), and one survey on patients’ preferences (with 100 participants) were identified. All studies applied neoadjuvant chemoradiation protocols. None of the studies examined neoadjuvant chemotherapeutic protocols. Studies investigated patient populations with esophageal squamous cell carcinoma, adenocarcinoma, and mixed cohorts. Important outcomes reported were overall, disease-free and local recurrence-free survival. Limitations of the currently available study pool include heterogeneous chemoradiation protocols, a lack of modern neoadjuvant treatment protocols in RCTs, short follow-up times, the use of heterogeneous diagnostic methods, and different definitions of clinical CR. Conclusion: Although post-neoadjuvant surveillance and surgery as needed compared with post-neoadjuvant surgery on principle has been investigated within different study designs, the currently available results are based on a wide variation of diagnostic tools to identify patients with pCR, short follow-up times, small sample sizes, and variations in therapeutic procedures. A thoroughly planned RCT considering the limitations in the currently available literature will be of great importance to provide patients with CR with the best and less harmful treatment.
Collapse
Affiliation(s)
- Julian Hipp
- Center of Surgery, Department of General and Visceral Surgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany;
| | - Blin Nagavci
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany; (B.N.); (J.M.)
| | - Claudia Schmoor
- Clinical Trials Unit, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany;
| | - Joerg Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany; (B.N.); (J.M.)
- Cochrane Germany, Cochrane Germany Foundation, 79110 Freiburg, Germany
| | - Jens Hoeppner
- Department of Surgery, University Medical Center Schleswig-Holstein, UKSH Campus Lübeck, 23538 Lübeck, Germany;
| | - Christine Schmucker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany; (B.N.); (J.M.)
- Correspondence: ; Tel.: +49(0)761-203-6695
| |
Collapse
|
3
|
Starr B, Davis S, Ayala-Peacock D, Blackstock WA, Levine EA. Reassessment of the Role of Enteral Tube Feedings for Patients with Esophageal Cancer. Am Surg 2020. [DOI: 10.1177/000313481408000822] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Nutrition is important for patients with esophageal cancer because dysphagia can be exacerbated by chemoradiotherapy. Some centers suggest routine enteral tube placement (TF) to facilitate nutrition. This investigation was to evaluate the use of TF access for patients undergoing multi-modality therapy for esophageal carcinoma. This retrospective study analyzed 113 patients who underwent esophagectomy and 97 patients who underwent definition chemoradiotherapy for esophageal cancer between 2001 and 2013. Throughout this time period, a strategy for selective tube placement was used. Nutrition was assessed through absolute lymphocyte counts, protein, and albumin levels. A total of 28 (30%) patients during preoperative chemoradiotherapy and 31 (32%) of those undergoing definitive chemoradiation received TFs. There were 16 Dobhoff tubes, 28 gastrostomy tubes, and 15 jejunostomies. Tubes were maintained an average of 3.9 months with 20 (34%) of these patients reporting tube-related complications. At the time of surgery, there was no statistical difference in any of the nutritional assessments between those patients who received TF and those who did not. Both groups experienced similar total postoperative complication rates (64% vs 65%) and similar median length of hospital stay (12 to 13 days). Chemoradiotherapy resulted in decreased nutritional parameters; however, there was no difference in the degree of reduction between those who underwent TF and those who did not. The data show that routine placement of enteral access is not necessary for esophageal carcinoma. In fact, the risks of placing enteral access may outweigh the benefits. Administration of TF should be restricted to select patients during chemoradiotherapy or before esophagectomy.
Collapse
Affiliation(s)
- Brett Starr
- From the Surgical Oncology Service, Departments of General Surgery and Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Stephanie Davis
- From the Surgical Oncology Service, Departments of General Surgery and Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Diandra Ayala-Peacock
- From the Surgical Oncology Service, Departments of General Surgery and Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - William A. Blackstock
- From the Surgical Oncology Service, Departments of General Surgery and Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Edward A. Levine
- From the Surgical Oncology Service, Departments of General Surgery and Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| |
Collapse
|
4
|
Park MI. Chemoradiotherapy for Esophageal Cancer. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2019. [DOI: 10.7704/kjhugr.2019.19.3.161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
|
5
|
Forootan M, Tabatabaeifar M, Fatemi M, Darvishi M. Efficacy of Chemoradiotherapy on Health-Related Quality of Life in Esophageal Cancer Patients with Dysphagia. Mater Sociomed 2019; 31:246-252. [PMID: 32082087 PMCID: PMC7007622 DOI: 10.5455/msm.2019.31.246-252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction: Esophageal cancer is diagnosed with more than 480,000 patients per year and this disease became the eighth most common cancer worldwide. Aim: In this study, we tried to investigate the role of chemoradiotherapy in decreasing the severity of dysphagia and increasing the quality of life (QOL) in patients with esophageal cancer. Methods: Patients were diagnosed with esophageal cancer, which were proven by pathological studies. Also, all of these patients had no primary surgeries for their esophageal cancer. For determining the cancer staging, the endoscopy, sonography, abdominal and pelvic computed tomography scans were assessed. Results: In this study, 81% of patients showed responsiveness to the chemoradiotherapy and their dysphagia significantly was getting improved after treatment in comparison to the initial date (P<0.01). Also, the pain score significantly decreased after chemoradiotherapy. However, the analysis failed to show any significant difference between before and after treatment in 19% of patients who had high degrees of dysphagia and they were the candidate for surgery and stent putting. On the other hand, we demonstrated that there is no correlation between sex, age, tumor type and location with the recovery rate of dysphagia. In addition, we showed that none of the patients showed the recurrence of dysphagia during the study (1.5 years). Conclusion: Chemoradiotherapy could be a novel treatment for patients with inoperable esophageal cancer to reduce the severity of dysphagia and increasing the QOL of these individuals.
Collapse
Affiliation(s)
- Mojgan Forootan
- Department of Gastroenterology, Gastrointestinal and Liver Diseases Research Center (RCGLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Morteza Tabatabaeifar
- Department of Gastroenterology, Gastrointestinal and Liver Diseases Research Center (RCGLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Fatemi
- Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Darvishi
- Infectious Diseases and Tropical Medicine Research Center (IDTMRC), Department of Aerospace and Subaquatic Medicine, AJA University of Medical Sciences, Tehran, Iran, Iran
| |
Collapse
|
6
|
Kawamoto T, Nihei K, Sasai K, Karasawa K. Palliative radiotherapy and chemoradiotherapy in stage IVA/B esophageal cancer patients with dysphagia. Int J Clin Oncol 2018; 23:1076-1083. [PMID: 30066207 DOI: 10.1007/s10147-018-1324-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/27/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Palliative therapeutic strategies in esophageal squamous cell carcinoma (ESCC) patients with dysphagia remain controversial. Only few studies have assessed therapeutic effect factors related to improvement in dysphagia score and nutrition-support-free survival (NSFS). OBJECTIVE The present study assessed the efficacy and therapeutic effect factors related to the use of palliative radiotherapy (RT) and chemoradiotherapy (CRT) in ESCC patients with dysphagia. METHODS We retrospectively evaluated 70 patients with stage IVA/B ESCC. Patients received RT of 30 Gy in 10 fractions or concurrent CRT using 5-fluorouracil plus cisplatin of 40 Gy in 20 fractions. The change in the dysphagia score from before to after treatment was assessed, and NSFS was evaluated. RESULTS The median follow-up duration was 6 months (range 1-41 months). The overall rate of improvement in the dysphagia score was 60%. The median NSFS was 7.5 months. Craniocaudal tumor length < 6 cm, tumor circumference < 3/4, and CRT of 40 Gy in 20 fractions were associated with a significant improvement in the dysphagia score (p = 0.0036, p = 0.0069, and p = 0.03, respectively). NSFS was significantly longer with CRT than with RT (p = 0.048). CONCLUSION Palliative RT and CRT are effective treatment options for ESCC patients with dysphagia. Craniocaudal tumor length < 6 cm, tumor circumference < 3/4, and CRT of 40 Gy in 20 fractions may improve dysphagia. CRT of 40 Gy in 20 fractions may improve NSFS.
Collapse
Affiliation(s)
- Terufumi Kawamoto
- Division of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 18-22-3 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan. .,Department of Radiation Oncology, Graduate School of Medicine, Juntendo University, Tokyo, Japan.
| | - Keiji Nihei
- Division of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 18-22-3 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Keisuke Sasai
- Department of Radiation Oncology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Katsuyuki Karasawa
- Division of Radiation Oncology, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 18-22-3 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| |
Collapse
|
7
|
Sakaguchi M, Maebayashi T, Aizawa T, Ishibashi N, Saito T. Clinical results of multimodality therapy for esophageal cancer with distant metastasis. J Thorac Dis 2018; 10:1500-1510. [PMID: 29707300 DOI: 10.21037/jtd.2018.03.45] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background The purpose of this study is to evaluate outcomes in upfront local response and survival of patients with esophageal cancer and distant metastasis. Methods This retrospective study included 34 patients (25 males) aged 42-92 years (median, 70 years) with a histological diagnosis of esophageal squamous cell cancer with distant metastasis. Staging was performed according to the UICC's TNM (6th edition) classification of malignant tumor. Results The median survival time (MST) was 5 months. The 1-year overall survival (OS) was 20.6%. Improved OS was associated with receipt of surgery [hazard ratio (HR), 3.857; 95% CI, 1.142-13.024; P=0.030] on both univariate and multivariate analyses, and the MST was 11 months. The overall objective local response rate was 82%. Ten patients had complete response (CR), 18 had partial response (PR). The overall symptom response was 88% patients. Six had CR, 24 had PR. There was no significant difference in the objective and symptom response between ≤50 and >50 Gy. Concurrent chemoradiotherapy (CCRT) with 50 Gy gave results of objective and symptom responses comparable to those of 60 Gy, which has been reported previously. Conclusions CCRT with 50 Gy gave results comparable to those of 60 Gy, which has been reported previously, and the toxicity was acceptable. Our findings showed that a multimodality therapy that includes surgery may improve survival in only a select group.
Collapse
Affiliation(s)
- Masakuni Sakaguchi
- Department of Radiology, Nihon University School of Medicine, Tokyo, Japan
| | - Toshiya Maebayashi
- Department of Radiology, Nihon University School of Medicine, Tokyo, Japan
| | - Takuya Aizawa
- Department of Radiology, Nihon University School of Medicine, Tokyo, Japan
| | - Naoya Ishibashi
- Department of Radiology, Nihon University School of Medicine, Tokyo, Japan
| | | |
Collapse
|
8
|
Boniface MM, Wani SB, Schefter TE, Koo PJ, Meguid C, Leong S, Kaplan JB, Wingrove LJ, McCarter MD. Multidisciplinary management for esophageal and gastric cancer. Cancer Manag Res 2016; 8:39-44. [PMID: 27217796 PMCID: PMC4853141 DOI: 10.2147/cmar.s101169] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The management of esophageal and gastric cancer is complex and involves multiple specialists in an effort to optimize patient outcomes. Utilizing a multidisciplinary team approach starting from the initial staging evaluation ensures that all members are in agreement with the plan of care. Treatment selection for esophageal and gastric cancer often involves a combination of chemotherapy, radiation, surgery, and palliative interventions (endoscopic and surgical), and direct communication between specialists in these fields is needed to ensure appropriate clinical decision making. At the University of Colorado, the Esophageal and Gastric Multidisciplinary Clinic was created to bring together all experts involved in treating these diseases at a weekly conference in order to provide patients with coordinated, individualized, and patient-centered care. This review details the essential elements and benefits of building a multidisciplinary program focused on treating esophageal and gastric cancer patients.
Collapse
Affiliation(s)
- Megan M Boniface
- Section of Surgical Oncology, Division of GI, Tumor and Endocrine Surgery, Department of Surgery, University of Colorado Denver, Aurora, CO, USA
| | - Sachin B Wani
- Division of Gastroenterology and Hepatology, Department of Therapeutic and Interventional Endoscopy, University of Colorado Denver, Aurora, CO, USA
| | - Tracey E Schefter
- Department of Radiation Oncology, University of Colorado Denver, Aurora, CO, USA
| | - Phillip J Koo
- Division of Radiology-Nuclear Medicine, Department of Radiology, University of Colorado Denver, Aurora, CO, USA
| | - Cheryl Meguid
- Section of Surgical Oncology, Division of GI, Tumor and Endocrine Surgery, Department of Surgery, University of Colorado Denver, Aurora, CO, USA
| | - Stephen Leong
- Division of Medical Oncology, University of Colorado Denver, Aurora, CO, USA
| | - Jeffrey B Kaplan
- Department of Pathology, University of Colorado Denver, Aurora, CO, USA
| | - Lisa J Wingrove
- Department of Food and Nutrition Services, University of Colorado Hospital Cancer Center, Aurora, CO, USA
| | - Martin D McCarter
- Section of Surgical Oncology, Division of GI, Tumor and Endocrine Surgery, Department of Surgery, University of Colorado Denver, Aurora, CO, USA
| |
Collapse
|
9
|
|
10
|
Hingorani M, Dixit S, Johnson M, Plested V, Alty K, Colley P, Beavis AW, Roy R, Maraveyas A. Palliative Radiotherapy in the Presence of Well-Controlled Metastatic Disease after Initial Chemotherapy May Prolong Survival in Patients with Metastatic Esophageal and Gastric Cancer. Cancer Res Treat 2015; 47:706-17. [PMID: 25687854 PMCID: PMC4614191 DOI: 10.4143/crt.2014.174] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 09/13/2014] [Indexed: 11/21/2022] Open
Abstract
Purpose We report the outcomes of patients treated with palliative radiotherapy (pRT) to the primary tumour in the context of well-controlled metastatic disease after initial chemotherapy. Materials and Methods Clinical records of 132 patients with metastatic esophago-gastric (OG) cancer treated with palliative chemotherapy (pCT) between January 2009 and June 2013 were reviewed. Ninetyseven patients had responding or stable disease after 3 months of chemotherapy, of whom 53 patients received pRT to the primary tumour after initial chemotherapy in the presence of well-controlled metastatic disease (group A, pCT-RT). The remaining 44 patients were treated with pCT alone (group B, pCT). Treatment-related outcomes were assessed in above groups including time to local progression (TTLP), progression-free and overall survival. Results The median overall survival for patients treated with pRT after initial chemotherapy (group A) was 23.3 months (95% confidence interval [CI], 17.70 to 28.89 months) and significantly higher than the 14 months (95% CI, 10.91 to 17.08 months) in patients treated with pCT alone (group B) (p < 0.001). The use of pCT-RT was an independent predictor of OS in multivariate analysis. Local recurrence was observed in 12/53 of patients (23%) in group A compared to 16/44 (36%) in group B. The median TTLP was significantly higher in patients after pCT-RT at 17.3 months (5.23 months to 44.50 months) compared to 8.3 months (range, 4.10 to 25.23 months) in patients treated with pCT alone (p=0.006). Conclusion The possibility of pRT influencing systemic disease in advanced OG cancer has not been reported, and results from the present study present strong arguments for investigation of this therapeutic strategy in a randomized trial.
Collapse
Affiliation(s)
- Mohan Hingorani
- Department of Clinical Oncology, Castle Hill Hospital, Hull and East Yorkshire, NHS Trust, Hull, UK
| | - Sanjay Dixit
- Department of Clinical Oncology, Castle Hill Hospital, Hull and East Yorkshire, NHS Trust, Hull, UK
| | | | - Victoria Plested
- Department of Clinical Oncology, St. James Institute of Oncology, Leeds Teaching Hospital, NHS Trust, Leeds, UK
| | - Kevin Alty
- Department of Clinical Oncology, Castle Hill Hospital, Hull and East Yorkshire, NHS Trust, Hull, UK
| | - Peter Colley
- Department of Clinical Oncology, Castle Hill Hospital, Hull and East Yorkshire, NHS Trust, Hull, UK
| | - Andrew W Beavis
- Department of Clinical Oncology, Castle Hill Hospital, Hull and East Yorkshire, NHS Trust, Hull, UK.,Faculty of Science and Engineering, University of Hull, Hull, UK.,Faculty of Health and Well-Being, University of Sheffield-Hallam, Sheffield, UK
| | - Rajarshi Roy
- Department of Clinical Oncology, Castle Hill Hospital, Hull and East Yorkshire, NHS Trust, Hull, UK
| | - Anthony Maraveyas
- Department of Clinical Oncology, Castle Hill Hospital, Hull and East Yorkshire, NHS Trust, Hull, UK
| |
Collapse
|
11
|
Jalaj S, Lee SY, McGaw C, John BK, Li Z, Awad ZT, Scolapio JS, Munoz JC. Proton radiotherapy dose perturbations caused by esophageal stents of varying material composition are negligible in an experimental model. Endosc Int Open 2015; 3:E46-50. [PMID: 26134771 PMCID: PMC4423262 DOI: 10.1055/s-0034-1390709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 09/08/2014] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Self-expanding metal and plastic esophageal stents (SEMS and SEPS, respectively) are used in conjunction with chemoradiation for palliation of malignant dysphagia. To date, the dosimetric effects of stents undergoing proton radiotherapy are not known. STUDY AIM To investigate the proton radiotherapy dose perturbations caused by esophageal stents of varying designs and materials undergoing external beam treatment for esophageal cancer. PATIENTS AND METHODS Simulated clinical protocol. Solid acrylic phantom was used to mimic the esophageal tissue environment. Stents made of nitinol, stainless steel and polyester were tested. Proton beam dose of 2 Gy-E was delivered to each stent in a single anterior to posterior field. Film and image based evidence of dose perturbation were main outcomes measured. RESULTS Only the stainless steel and plastic stents demonstrated slight overall dose attenuations (- 0.5 % and - 0.4 %, respectively). All the nitinol-based stents demonstrated minimal overall dose perturbations ranging from 0.0 % to 1.2 %. Negligible dose perturbations were observed on each of the stent surfaces proximal to the radiation source, ranging from - 0.8 % (stainless steel stent) to 1.0 % (nitinol stent). Negligible dose effects were also observed on the distal surfaces of each stent ranging from - 0.5 % (plastic and stainless steel stents) to 1.0 % (nitinol stent). CONCLUSION Proton radiotherapy dose perturbations caused by stents of varying designs and material composition are negligible. Negligible dose perturbation is in keeping with the inherent advantage of proton therapy over traditional radiotherapy composed of photons - given its relative large mass, protons have little side scatter.
Collapse
Affiliation(s)
- Sujai Jalaj
- Division of Gastroenterology, Department of Medicine, University of Florida, Jacksonville College of Medicine, Jacksonville, Florida, United States,Corresponding author Sujai Jalaj, MD Division of Gastroenterology, Department of MedicineUniversity of Florida, Jacksonville College of Medicine655 West 8th Street, B0138-C290Jacksonville, FL 32209+1–904–244–2165
| | - Sang Yeob Lee
- Department of Radiation Oncology, University of Florida, Proton Therapy Institute, Jacksonville, Florida, United States
| | - Camille McGaw
- Division of Gastroenterology, Department of Medicine, University of Florida, Jacksonville College of Medicine, Jacksonville, Florida, United States
| | - Bijo K John
- Division of Gastroenterology, Department of Medicine, University of Florida, Jacksonville College of Medicine, Jacksonville, Florida, United States
| | - Zuofeng Li
- Department of Radiation Oncology, University of Florida, Proton Therapy Institute, Jacksonville, Florida, United States
| | - Ziad T Awad
- Department of Surgery, University of Florida, Jacksonville College of Medicine, Jacksonville, Florida, United States
| | - James S Scolapio
- Division of Gastroenterology, Department of Medicine, University of Florida, Jacksonville College of Medicine, Jacksonville, Florida, United States
| | - Juan C Munoz
- Division of Gastroenterology, Department of Medicine, University of Florida, Jacksonville College of Medicine, Jacksonville, Florida, United States
| |
Collapse
|
12
|
Abstract
Oesophageal carcinoma is one of the most virulent malignant diseases and a major cause of cancer-related deaths worldwide. Diagnosis and accuracy of pretreatment staging have substantially improved throughout the past three decades. Therapy is challenging and the optimal approach is still debated. Oesophagectomy is considered to be the procedure of choice in patients with operable oesophageal cancer. Endoscopic measures and limited surgical procedures provide an alternative in patients with early carcinomas confined to the oesophageal mucosa. Chemotherapy and radiotherapy or concurrent chemoradiotherapy are also frequently applied, either as definitive treatment or as neoadjuvant therapy within multimodal approaches. The question of whether multimodal treatment offers improved results has been the focus of many studies since the 1990s. Although results are discordant and even some meta-analyses remain inconclusive, it is now widely accepted that multimodal therapy leads to a modest survival benefit. The role of minimally invasive oesophagectomy is not yet defined. Endoscopic stent insertion, radiotherapy and other palliative measures provide relief of tumour-related symptoms in advanced, unresectable tumour stages.
Collapse
|
13
|
Freeman RK, Ascioti AJ, Mahidhara RJ. Palliative therapy for patients with unresectable esophageal carcinoma. Surg Clin North Am 2012; 92:1337-51. [PMID: 23026285 DOI: 10.1016/j.suc.2012.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Most patients diagnosed with carcinoma of the esophagus do not undergo therapy with curative intent. The focus of treatment for these patients is to maximize their progression-free survival and palliate the most common sequelae of their disease: dysphagia, malnutrition, pain, and intraluminal tumor bleeding. This article discusses the available treatment options for palliation of patients with unresectable esophageal cancer.
Collapse
Affiliation(s)
- Richard K Freeman
- Department of Thoracic and Cardiovascular Surgery, St Vincent Hospital, Indianapolis, IN 46260, USA.
| | | | | |
Collapse
|
14
|
Tanaka H, Hayashi S, Ohtakara K, Hoshi H. Palliative radiotherapy for patients with tracheobronchial and esophageal compression due to intrathoracic malignant tumors. Asia Pac J Clin Oncol 2012; 8:e82-8. [PMID: 22897905 DOI: 10.1111/j.1743-7563.2012.01530.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To evaluate palliative outcomes of patients with extrinsic malignant tracheobronchial or esophageal stenosis treated with radiation. Mediastinal or hilar lymphadenopathy surrounding the tracheobronchi or esophagus may cause compression, presenting as dyspnea and dysphagia respectively. Treatment is important for symptom relief and maintaining patients' quality of life. METHODS Dyspnea and dysphagia were assessed using the Hugh-Jones score and a modified dysphagia scale, respectively. A total of 13 patients (median age, 60 years) with dyspnea received palliative radiotherapy. The primary organs were lung (n = 6), colorectum (n = 5), hypopharynx (n = 1) and uterine cervix (n = 1). Three patients received concurrent chemotherapy. The median time-adjusted biological effective dose (BED) was 33.0 Gy(10) . Ten patients (median age, 61) with dysphagia received palliative radiotherapy. The primary organs were lung (n = 7), esophagus (n = 2) and hypopharynx (n = 1). Three patients received concurrent chemotherapy. The median time-adjusted BED was 32.1 Gy(10) . RESULTS Palliation of dyspnea and dysphagia occurred in seven (54%) and five (50%) patients, respectively. Patients treated with doses over 35 Gy(10) had greater score improvements than those treated with less than 35 Gy(10) in both groups. Patients who received concurrent chemoradiotherapy had greater score improvements than those treated with radiotherapy alone. Dyspnea patients with pretreatment scores of 2 (n = 5) had greater score improvements than those with scores of 3 or more (n = 8). CONCLUSION External beam radiotherapy should be considered for patients with tracheobronchial or esophageal stenosis before their symptoms worsen. The prescription dose should be over 35 Gy(10) .
Collapse
Affiliation(s)
- Hidekazu Tanaka
- Department of Radiology, Gifu University Hospital, Gifu 501-1194, Japan.
| | | | | | | |
Collapse
|
15
|
Grandinetti A. Multimodal Treatment: Early and Long-term Results and Recurrences. Updates Surg 2012. [DOI: 10.1007/978-88-470-2330-7_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
16
|
Ikeda E, Kojima T, Kaneko K, Minashi K, Onozawa M, Nihei K, Fuse N, Yano T, Yoshino T, Tahara M, Doi T, Ohtsu A. Efficacy of concurrent chemoradiotherapy as a palliative treatment in stage IVB esophageal cancer patients with dysphagia. Jpn J Clin Oncol 2011; 41:964-72. [PMID: 21742654 DOI: 10.1093/jjco/hyr088] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To retrospectively assess the efficacy and safety of palliative chemoradiotherapy in Stage IVB esophageal cancer patients with dysphagia due to the primary lesion. METHODS Forty patients with dysphagia caused by metastatic esophageal cancer, which had been treated between January 2004 and June 2009, were retrospectively investigated. The treatment consisted of two courses of chemotherapy (5-fluorouracil and cisplatin) and concurrent irradiation of 40 Gy in 20 fractions to the esophageal primary tumor. The grade of dysphagia was evaluated; nutrition-support-free survival was evaluated using the status of nutritional support of patients. Response to treatment, overall survival, progression-free survival and toxicities were also evaluated. RESULTS Dysphagia score improved in 75% of the patients. Seventeen of the 20 patients (85%) who had required nutritional support at baseline improved their oral intake to no longer need the support, in a median time of 43 days. The median nutrition-support-free survival was 301 days in the 20 patients who had had adequate oral intake before the treatment. Disease control rate of the primary lesion was 95%, including 12 patients (30%) who achieved a complete response. The overall response rate was 55%. The median survival was 308 days, and the 1-year-survival rate was 45.0%. The median progression-free survival was 139 days. Toxicities were generally well tolerated. Major toxicities (Grade 3 or 4) involved hemoglobin (23%), leukocytes (15%), neutrophils (20%), anorexia (10%), nausea (3%), esophageal perforation (5%) and febrile neutropenia (3%). Two patients (5%) died within 30 days of terminating radiotherapy. CONCLUSIONS Palliative chemoradiotherapy using 5-fluorouracil plus cisplatin combined with concurrent 40 Gy irradiation effectively improved the symptom of dysphagia in Stage IVB esophageal cancer with acceptable toxicity and favorable survival.
Collapse
Affiliation(s)
- Eiji Ikeda
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba 277-8577, Japan
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Chen YK, Schefter TE, Newman F. Esophageal cancer patients undergoing external beam radiation after placement of self-expandable metal stents: is there a risk of radiation dose enhancement? Gastrointest Endosc 2011; 73:1109-14. [PMID: 21628012 DOI: 10.1016/j.gie.2011.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Accepted: 02/02/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Self-expandable metal stents (SEMSs) are used for palliation of malignant dysphagia. It is not known whether dose adjustments are required when there is a stent in the radiation field. OBJECTIVE To measure the effects of esophageal stents of various designs and materials on radiation dose to the tissue adjacent to the stent in the radiation field to determine whether there should be any dose adjustment. DESIGN Simulated clinical protocol. SETTING Linear accelerator radiation treatment center. PATIENTS Solid Water phantoms were used to mimic the tissue environment of the human esophagus as well as stents of various designs and materials and controls. INTERVENTIONS Radiation beams composed of photons (x-rays) delivered in split dosing with energies of 6, 10, and 15 million volts. MAIN OUTCOME MEASUREMENTS Film and image-based evidence of dose enhancement; Monte Carlo calculations. RESULTS Dose enhancement from single beams was seen only on the anterior surface, particularly in the stainless steel Z-stent (3.5%-7.8%) and the nonmetal Polyflex stent (5.5%-8.8%); less dose enhancement was seen on the anterior surface of the Alimaxx and Ultraflex nitinol stents (2%-2.5%). A negligible dose effect was seen on the posterior wall of all the stents tested. Monte Carlo calculation results were roughly similar to actual dosimeter measurements. LIMITATIONS Simulated clinical protocol. CONCLUSIONS This tissue-mimicking model reveals that radiation dose enhancement is a function of stent design and material, and the dose reduction is unnecessary as long as multiple fields are used.
Collapse
Affiliation(s)
- Yang K Chen
- Division of Gastroenterology and Hepatology, University of Colorado Denver, Aurora, Colorado 80045-2541, USA
| | | | | |
Collapse
|
18
|
Bae SH, Park W, Choi DH, Nam H, Kang WK, Park YS, Park JO, Chun HK, Lee WY, Yun SH, Kim HC. Palliative radiotherapy in patients with a symptomatic pelvic mass of metastatic colorectal cancer. Radiat Oncol 2011; 6:52. [PMID: 21600018 PMCID: PMC3130661 DOI: 10.1186/1748-717x-6-52] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Accepted: 05/21/2011] [Indexed: 12/17/2022] Open
Abstract
Background To evaluate the palliative role of radiotherapy (RT) and define the effectiveness of chemotherapy combined with palliative RT (CCRT) in patients with a symptomatic pelvic mass of metastatic colorectal cancer. Methods From August 1995 to December 2007, 80 patients with a symptomatic pelvic mass of metastatic colorectal cancer were treated with palliative RT at Samsung Medical Center. Initial presenting symptoms were pain (68 cases), bleeding (18 cases), and obstruction (nine cases). The pelvic mass originated from rectal cancer in 58 patients (73%) and from colon cancer in 22 patients (27%). Initially 72 patients (90%) were treated with surgery, including 64 complete local excisions; 77% in colon cancer and 81% in rectal cancer. The total RT dose ranged 8-60 Gy (median: 36 Gy) with 1.8-8 Gy per fraction. When the α/β for the tumor was assumed to be 10 Gy for the biologically equivalent dose (BED), the median RT dose was 46.8 Gy10 (14.4-78). Twenty one patients (26%) were treated with CCRT. Symptom palliation was assessed one month after the completion of RT. Results Symptom palliation was achieved in 80% of the cases. During the median follow-up period of five months (1-44 months), 45% of the cases experienced reappearance of symptoms; the median symptom control duration was five months. Median survival after RT was six months. On univariate analysis, the only significant prognostic factor for symptom control duration was BED ≥40 Gy10 (p < 0.05), and CCRT was a marginally significant factor (p = 0.0644). On multivariate analysis, BED and CCRT were significant prognostic factors for symptom control duration (p < 0.05). Conclusions RT was an effective palliation method in patients with a symptomatic pelvic mass of metastatic colorectal cancer. For improvement of symptom control rate and duration, a BED ≥ 40 Gy10 is recommended when possible. Considering the low morbidity and improved symptom palliation, CCRT might be considered in patients with good performance status.
Collapse
Affiliation(s)
- Sun Hyun Bae
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Lu JJ. Esophageal Cancer. Radiat Oncol 2008. [DOI: 10.1007/978-3-540-77385-6_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
20
|
Bedenne L, Michel P, Bouché O, Milan C, Mariette C, Conroy T, Pezet D, Roullet B, Seitz JF, Herr JP, Paillot B, Arveux P, Bonnetain F, Binquet C. Chemoradiation Followed by Surgery Compared With Chemoradiation Alone in Squamous Cancer of the Esophagus: FFCD 9102. J Clin Oncol 2007; 25:1160-8. [PMID: 17401004 DOI: 10.1200/jco.2005.04.7118] [Citation(s) in RCA: 846] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose Uncontrolled studies suggest that chemoradiation has similar efficacy as surgery for esophageal cancer. Therefore, a randomized trial was carried out to compare, in responders only, chemoradiation alone with chemoradiation followed by surgery in patients with locally advanced tumors. Patients and Methods Eligible patients had operable T3N0-1M0 thoracic esophageal cancer. Patients received two cycles of fluorouracil (FU) and cisplatin (days 1 to 5 and 22 to 26) and either conventional (46 Gy in 4.5 weeks) or split-course (15 Gy, days 1 to 5 and 22 to 26) concomitant radiotherapy. Patients with response and no contraindication to either treatment were randomly assigned to surgery (arm A) or continuation of chemoradiation (arm B; three cycles of FU/cisplatin and either conventional [20 Gy] or split-course [15 Gy] radiotherapy). Chemoradiation was considered equivalent to surgery if the difference in 2-year survival rate was less than 10%. Results Of 444 eligible patients, 259 were randomly assigned; 230 patients (88.8%) had epidermoid cancer, and 29 (11.2%) had glandular carcinoma. Two-year survival rate was 34% in arm A versus 40% in arm B (hazard ratio for arm B v arm A = 0.90; adjusted P = .44). Median survival time was 17.7 months in arm A compared with 19.3 months in arm B. Two-year local control rate was 66.4% in arm A compared with 57.0% in arm B, and stents were less required in the surgery arm (5% in arm A v 32% in arm B; P < .001). The 3-month mortality rate was 9.3% in arm A compared with 0.8% in arm B (P = .002). Cumulative hospital stay was 68 days in arm A compared with 52 days in arm B (P = .02). Conclusion Our data suggest that, in patients with locally advanced thoracic esophageal cancers, especially epidermoid, who respond to chemoradiation, there is no benefit for the addition of surgery after chemoradiation compared with the continuation of additional chemoradiation.
Collapse
|
21
|
Hung AY, Canning CA, Patel KM, Holland JM, Kachnic LA. Radiation therapy for gastrointestinal cancer. Hematol Oncol Clin North Am 2006; 20:287-320. [PMID: 16730296 DOI: 10.1016/j.hoc.2006.01.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This article has reviewed the current role of radiation in the treatment of gastrointestinal malignancies and discussed the data supporting its use. Radiation treatment in this setting continues to evolve with the increasing implementation of more conformal delivery techniques. Further scientific investigation is needed to establish the optimal role of radiation and to better define its integration with novel systemic and biologic modalities.
Collapse
Affiliation(s)
- Arthur Y Hung
- Department of Radiation Oncology, Oregon Health & Science University, Portland, OR 97239-3098, USA.
| | | | | | | | | |
Collapse
|
22
|
Blackstock AW, Farmer MR, Lovato J, Mishra G, Melin SA, Oaks T, Aklilu M, Clark PB, Levine EA. A prospective evaluation of the impact of 18-F-fluoro-deoxy-D-glucose positron emission tomography staging on survival for patients with locally advanced esophageal cancer. Int J Radiat Oncol Biol Phys 2005; 64:455-60. [PMID: 16213103 DOI: 10.1016/j.ijrobp.2005.07.959] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2005] [Revised: 07/15/2005] [Accepted: 07/16/2005] [Indexed: 12/16/2022]
Abstract
PURPOSE To determine the impact of 18-F-fluoro-deoxy-D-glucose positron emission tomography (FDG-PET) in the staging and prognosis of patients with locally advanced esophageal cancer (LAEC). METHODS AND MATERIALS Between January 2000 and October 2004, all patients with LAEC evaluated in the Department of Radiation Oncology were considered for enrollment into a Phase II trial of preoperative chemoradiation. Entry required a staging whole-body FDG-PET scan. RESULTS One hundred ten consecutive patients were evaluated; 38 were ineligible for reasons including treatment elsewhere, prior malignancy, or refusal of treatment. After conventional staging (clinical examination, endoscopic ultrasound, and chest/abdominal computerized tomography), 33 patients were ineligible because of metastatic disease or poor performance status. Of the remaining 39 patients, 23 were confirmed to have LAEC after FDG-PET staging and were treated in the Phase II trial (Cohort I). Sixteen patients, however, had FDG-PET findings consistent with occult metastatic disease and were deemed ineligible for the trial but were treated with curative intent (Cohort II). The 2-year survival rate for the 23 patients in Cohort I was 64%, compared with 17% (p=0.003) for patients in Cohort II (FDG-PET positive). CONCLUSIONS More than one-third of patients determined to have LAEC with conventional staging were upstaged with the use of FDG-PET. Despite comparable therapy, upstaging with FDG-PET predicts poor 2-year survival.
Collapse
Affiliation(s)
- A William Blackstock
- Department of Radiation Oncology, Wake Forest University School of Medicine, Winston Salem, NC 27157, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Azar R. Palliation of patients with esophageal cancer and metal stents. Gastrointest Endosc 2004; 60:861-2; author reply 862. [PMID: 15557981 DOI: 10.1016/s0016-5107(04)02022-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
|
24
|
Guillem P, Fabre S, Mariette C, Triboulet JP. Surgery after induction chemoradiotherapy for oesophageal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2003; 29:158-65. [PMID: 12633559 DOI: 10.1053/ejso.2002.1335] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
AIM We discuss the role of surgery after induction chemoradiotherapy, when a complete response is apparent. METHODS We enrolled 247 consecutive patients who underwent chemoradiotherapy and oesophagectomy for cancer. Patients were classified in two groups as to whether they had chemoradiotherapy (n = 60) or not (n = 187) before surgery. RESULTS The 5-year survival rate of patients with complete response was 54% and was significantly higher than that of the other group (P = 0.018). Of the 60 patients responding, 34 (56.7%) were found to have a complete pathological tumour response (pT0). The overall sensitivity and specificity of the post-chemoradiotherapy restaging were 60.7% and 86.4%. CONCLUSIONS Complete response after induction chemoradiotherapy is not a reliable tool in the management of oesophageal cancer. We need to improve postchemoradiotherapy restaging to be sure that chemoradiotherapy will provide the same long-term survival rates as surgery.
Collapse
Affiliation(s)
- P Guillem
- Department of Digestive and General Surgery, University Hospital, 59037, Lille, France
| | | | | | | |
Collapse
|
25
|
Jatoi A, Thomas CR. Esophageal cancer and the esophagus: challenges and potential strategies for selective cytoprotection of the tumor-bearing organ during cancer treatment. Semin Radiat Oncol 2002; 12:62-7. [PMID: 11917287 DOI: 10.1053/srao.2002.31376] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Esophageal cancer is treated optimally with a combined-modality approach according to most clinical investigators. Cytotoxic chemotherapy and ionizing radiotherapy, given in a concomitant schedule, has yielded superior survival rates compared with radiotherapy alone. However, mucosal toxicity from such treatment may compromise quality of life and may mandate an unscheduled break in therapy in some patients who do not respond readily to standard treatments such as antacids; combinations of viscous xylocaine, aluminum hydroxide-magnesium carbonate, and diphenhydramine hydrochloride; oral liquid morphine sulfate, hydrocodone bitartrate, or acetaminophen. Hence, a number of alternative strategies that are designed to either prevent or limit toxicity to normal tissues without diminishing the antitumor effect are being tested. These include the use of conformal radiotherapy treatment planning techniques, amifostine (Ethyol, WR-2721), gene therapy via intratumoral injection of manganese superoxide dismutase-plasmid/liposome, glutamine, melatonin, omega-3-polyunsaturated fatty acids, transforming growth factor, flavonoid compounds, probucol, and keratinizing growth factor. An ongoing phase 2 trial by the North Central Cancer Treatment Group (NCCTG) may help clarify a role for cytoprotectants in patients receiving combined-modality therapy for esophageal cancer.
Collapse
Affiliation(s)
- Aminah Jatoi
- Department of Oncology, Mayo Comprehensive Cancer Center, Mayo Clinic Foundation, Rochester, MN, USA
| | | |
Collapse
|
26
|
Caroli-Bosc FX, Van Laethem JL, Michel P, Gay F, Hendlisz A, Forget F, Bleiberg H. A weekly 24-h infusion of high-dose 5-fluorouracil (5-FU)+leucovorin and bi-weekly cisplatin (CDDP) was active and well tolerated in patients with non-colon digestive carcinomas. Eur J Cancer 2001; 37:1828-32. [PMID: 11576835 DOI: 10.1016/s0959-8049(01)00180-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In patients with non-colon digestive carcinomas, various schedules and doses of 5-fluorouracil (5-FU) and leucovorin combined with cisplatin (CDDP) have been used extensively. The present study explored the toxicity and activity of a weekly 24-h infusion of high dose 5-FU modulated by high dose leucovorin with bi-weekly CDDP. 59 patients with measurable disease were treated with a weekly infusion of high dose 5-FU (2 or 2.6 g/m2)+leucovorin 500 mg/m2 for 6 weeks and a bi-weekly dose of CDDP (50 mg/m2). All patients had metastatic or locoregionally advanced disease and had a performance status < or =3. All patients were evaluable for toxicity and 58 for response. Toxicity was different according to the schedule of 5-FU. Serious adverse events occurred most frequently when 5-FU was given at a dose of 2.6 g/m2 with a high incidence of grade 3/4 neutropenia (16%) and febrile neutropenia (13%), and led to dose reductions in both CDDP and 5-FU in 13 patients (34%). For patients who started 5-FU at a dose of 2 g/m2, no reduction in 5-FU was required, and only 4 patients required a dose reduction of CDDP (19%). Grade 3/4 neutropenia was seen in 10% of patients of this group and only 1 patient required hospitalisation for febrile neutropenia. Other grade 3/4 toxicities were rare in both groups. Renal toxicity was infrequent and mild and did not require dose adjustments. The overall response rate was 33%; 19 patients achieved a partial responses (PR). No patient had a complete response (CR). The median duration of response was 5.7 months (range 2-24 months) and the median survival was 7.9 months ( range: 1-30, 95% confidence interval (CI): 7-9). The combination of weekly 24-h infusion of high dose 5-FU with leucovorin and bi-weekly cisplatin seems a well-tolerated and active treatment in non-colon digestive carcinomas. A dose of 2 g/m2 of 5-FU seems to be recommended.
Collapse
Affiliation(s)
- F X Caroli-Bosc
- Gastroenterology Department, Institut Jules Bordet, Rue Héger-Bordet, 1-1000, Brussels, Belgium.
| | | | | | | | | | | | | |
Collapse
|
27
|
Abstract
BACKGROUND Oesophageal cancer carries a poor prognosis. The 5-year survival rate following resection ranges from 10 to 35 per cent. Recent evidence suggests that the addition of non-surgical treatments to surgery may improve resection rates, reduce the risk of recurrence and improve survival. This review examines the role of preoperative chemoradiotherapy (CRT) in oesophageal cancer. METHODS A Medline-based literature review (1980-2000) was performed using the key words 'neoadjuvant or preoperative' and 'chemoradiotherapy or radiochemotherapy'. Additional literature was obtained from original papers and published meeting abstracts. RESULTS Forty-six non-randomized and six randomized trials of preoperative CRT were found. Resection rates, pathological complete response (pCR), treatment-related mortality rates and relapse patterns are documented. Improved 5-year survival rates approaching 60 per cent may be achieved following pCR. Three of the six randomized trials show a benefit in either overall survival or disease-free survival compared with surgery alone. Treatment-related toxicity can be significant. CONCLUSION Preoperative CRT may improve survival. Emerging evidence suggests that CRT alone can achieve similar survival rates to surgery alone. New imaging modalities may help to select which patients require surgery. Larger randomized trials of preoperative CRT or chemotherapy are needed to define optimal regimens and produce higher pCR rates with acceptable toxicity.
Collapse
Affiliation(s)
- J I Geh
- Queen Elizabeth Hospital, Birmingham, Cookridge Hospital, Leeds and Mount Vernon Hospital, Northwood, UK
| | | | | |
Collapse
|
28
|
Abstract
The taxanes, paclitaxel and docetaxel, are novel antimitotic agents that are under extensive investigation in clinical trials. Both taxanes have demonstrated significant activity against many solid tumors as single agents and in combination with other chemotherapeutic agents. In addition, taxanes arrest cells at the G2/M phase of the cell cycle, which is the most radiosensitive phase. These properties are exploited in clinical trials combining this taxane with radiation therapy. Most studies included patients with non-small cell lung cancer (NSCLC) and cancers of the head and neck and there are a few studies with concurrent taxane/RT in esophageal, gastric, pancreatic, brain and breast cancer. Information concerning the tolerability and possible utility of docetaxel is also becoming available. This manuscript will review some of the more prominent trials of the taxanes in combination with radiation therapy for solid tumors.
Collapse
Affiliation(s)
- H Choy
- Center for Radiation Oncology, B902 TVC, Vanderbilt University Medical Center, 22nd Ave at Pierce, Nashville, TN 37232-5671, USA
| |
Collapse
|
29
|
Bedford JL, Viviers L, Guzel Z, Childs PJ, Webb S, Tait DM. A quantitative treatment planning study evaluating the potential of dose escalation in conformal radiotherapy of the oesophagus. Radiother Oncol 2000; 57:183-93. [PMID: 11054522 DOI: 10.1016/s0167-8140(00)00258-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND PURPOSE This study aims to evaluate the reduction in radiation dose to normal thoracic structures through the use of conformal radiotherapy techniques in the treatment of oesophageal cancer, and to quantify the resultant potential for dose escalation. MATERIALS AND METHODS Three different CT-derived treatment plans were created and compared for each of ten patients. A two-phase treatment with conventional straight-edged fields and standard blocks (CV2), a two-phase conformal plan (CF2), and a three-phase conformal plan where the third phase was delivered to the gross tumour only (CF3), were considered for each patient. Escalated dose levels were determined for techniques CF2 and CF3, which by virtue of the conformal field shaping, did not increase the mean lung dose. The resulting increase in tumour control probability (TCP) was estimated. RESULTS A two-phase conformal technique (CF2) reduced the volume of lung irradiated to 18 Gy from 19.7+/-11.8 (1 SD) to 17.1+/-12.3% (P=0.004), and reduced the normal tissue complication probability (NTCP) from 2.4+/-4.0 to 0.7+/-1.6% (P=0.02) for a standard prescribed dose of 55 Gy. Consequently, technique CF2 permitted a target dose of 59.1+/-3.2 Gy without increasing the mean lung dose. Technique CF3 facilitated a prescribed dose of 60.7+/-4.3 Gy to the target, the additional 5 Gy increasing the TCP from 53. 1+/-5.5 to 68.9+/-4.1%. When the spinal cord tolerance was raised from 45 to 48 Gy, technique CF3 allowed 63.6+/-4.l Gy to be delivered to the target, thereby increasing the TCP to 78.1+/-3.2%. CONCLUSIONS Conformal radiotherapy techniques offer the potential for a 5-10 Gy escalation in dose delivered to the oesophagus, without increasing the mean lung dose. This is expected to increase local tumour control by 15-25%.
Collapse
Affiliation(s)
- J L Bedford
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Trust, Downs Road, Sutton, Surrey SM2 5PT, UK
| | | | | | | | | | | |
Collapse
|
30
|
Hayter CR, Huff-Winters C, Paszat L, Youssef YM, Shelley WE, Schulze K. A prospective trial of short-course radiotherapy plus chemotherapy for palliation of dysphagia from advanced esophageal cancer. Radiother Oncol 2000; 56:329-33. [PMID: 10974382 DOI: 10.1016/s0167-8140(00)00225-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE Between 1994 and 1997, 22 patients with dysphagia from advanced incurable esophageal cancer were enrolled in a phase I/II prospective study to assess the palliative benefit and toxicity of a short course of radiotherapy with chemotherapy. METHODS The study population included 17 men and five women with a median age of 69 (range 43-84). Patients were treated with 30 Gy in ten fractions to the mediastinum with a concurrent single course of chemotherapy (5-FU, 1000 mg/m(2), days 1-4 and mitomycin-C 10 mg/m(2), day 1). Swallowing ability was recorded each day on a self-administered diary card using the five point dysphagia index of the MRC (UK). The median baseline MRC swallowing score was 4 (cannot swallow solids). RESULTS Treatment was generally well tolerated, but seven (32%) patients had transient worsening of dysphagia scores immediately following treatment because of esophagitis; fifteen (68%) achieved a complete response (score 1: no difficulty on swallowing) with a median time to normalization of swallowing of 5 weeks. For these patients, the median dysphagia-free interval from time of onset of improvement was 11 weeks (range 1-131 weeks) and 11 (73%) remained dysphagia-free until death. The remaining patients had no or marginal improvement. Univariate analysis showed no difference between responders and non-responders with respect to age, gender, or histology. Median survival for the entire study population was 20 weeks (range 3-135 weeks). CONCLUSIONS This prospective trial shows that a short course of radiotherapy plus chemotherapy may produce complete relief of swallowing difficulties in a substantial proportion of patients with acceptable toxicity.
Collapse
Affiliation(s)
- C R Hayter
- The Radiation Oncology Research Unit, Department of Oncology, Queen's University, Kingston Regional Cancer Centre, Kingston, ON, Canada
| | | | | | | | | | | |
Collapse
|
31
|
Wilson KS, Lim JT. Regarding Chan et al. IJROBP 1999;45:265-270. Int J Radiat Oncol Biol Phys 2000; 47:539-40. [PMID: 10847790 DOI: 10.1016/s0360-3016(99)00490-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
32
|
Wilson KS, Lim JT. Primary chemo-radiotherapy and selective oesophagectomy for oesophageal cancer: goal of cure with organ preservation. Radiother Oncol 2000; 54:129-34. [PMID: 10699475 DOI: 10.1016/s0167-8140(99)00174-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE The role of definitive chemo-radiotherapy in squamous cell oesophageal carcinoma has been established by the Radiation Therapy Oncology Group (RTOG). We have studied a modification of the RTOG chemo-radiotherapy protocol in patients with any histologic type of oesophageal carcinoma. We planned oesophagectomy for patients with post-treatment positive endoscopic biopsy or <75% regression on CAT scan, or with resectable local recurrence. Study end-points were histologic response, toxicity, oesophagectomy and survival rates after primary chemo-radiotherapy. METHODS Consecutive patients with any T or N status, M0, disease encompassable in radical radiotherapy ports, no prior surgical excision, and fit for chemo-radiotherapy, were eligible. Treatment plan was three cycles of cisplatin/5-fluorouracil chemotherapy and radical external radiation therapy (50 Gy in 25 fractions) starting with cycle 2. Selective oesophagectomy was performed in patients with post-treatment positive biopsy or <75% regression on CT scan, or with localized recurrence. RESULTS From 1993-1996, 32 patients were treated. Post-treatment complete histologic response rate was 77% (95% confidence limits 58-90%). Grade 3 or 4 toxicities occurred in 31 and 3 patients, respectively. Minimum follow-up time was 12 months. Median disease-specific survival time was 16.1 months for all patients, and was not significantly different according to histologic type (17 squamous, 12 adenocarcinoma). Oesophagectomy was performed in six of 15 surviving and five of 17 deceased patients. CONCLUSION It is possible to cure oesophageal cancer with chemo-radiotherapy and selective oesophagectomy, and achieve organ preservation in the majority of long term survivors.
Collapse
Affiliation(s)
- K S Wilson
- Division of Medical Oncology, British Columbia Cancer Agency, Vancouver Island Cancer Center, 1900 Fort Street, Victoria, Canada
| | | |
Collapse
|
33
|
Kos X, Trotteur G, Dondelinger RF. Delayed esophageal hemorrhage caused by a metal stent: treatment with embolization. Cardiovasc Intervent Radiol 1998; 21:428-30. [PMID: 9853152 DOI: 10.1007/s002709900293] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
We report a case of life-threatening esophageal hemorrhage after metal stent implantation successfully treated by arterial embolization. An 85-year-old woman was admitted in shock secondary to massive hematemesis and melena. Recent medical history revealed esophageal cancer treated 8 weeks previously by endoesophageal radiotherapy (40 Gy) and endoscopic placement of a covered Wall-stent prosthesis. Selective arteriography of the fifth posterior right intercostal artery showed massive contrast extravasation in the esophagus. Embolization was performed with 150-250-micron polyvinyl alcohol particles. Follow-up at 5 months was uneventful. Arteriography and embolization are advised when severe hemorrhage occurs after esophageal implantation of metal stents.
Collapse
Affiliation(s)
- X Kos
- Department of Medical Imaging, University Hospital Sart Tilman, Liège, Belgium
| | | | | |
Collapse
|
34
|
Blazeby JM, Alderson D. Review: chemotherapy, irradiation and their roles in the management of oesophageal cancer. J Gastroenterol Hepatol 1997; 12:612-9. [PMID: 9304515 DOI: 10.1111/j.1440-1746.1997.tb00494.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The role of multimodality therapy in the treatment of oesophageal cancer has been extensively investigated in many longitudinal studies and randomized trials. Despite some promising results, no clear beneficial evidence has consistently been produced. At present it cannot be routinely recommended outside the context of controlled clinical trials.
Collapse
Affiliation(s)
- J M Blazeby
- University Department of Surgery, Bristol Royal Infirmary, UK
| | | |
Collapse
|
35
|
Abstract
The incidence of esophageal adenocarcinoma and adenocarcinoma of the gastric cardia has increased so substantially in the last two decades that adenocarcinoma now accounts for approximately one half of esophageal malignancies seen in the United States and Europe. The reasons for this histological change may be related to a parallel increase in the incidence of gastroesophageal reflux disease in the Western world and the subsequent development of Barrett's metaplasia. Controversies surrounding carcinoma of the esophagus that are currently the focus of study are the relationship of Barrett's esophagus to the development of adenocarcinoma; whether adenocarcinoma of the esophagus and cardia is the same disease; the correct way to stage the disease; the treatment of disease confined to the mucosa; the extent of surgical resection to cure disease beyond the mucosa; the role of adjuvant chemotherapy in the treatment of the disease; and the methods of palliating patients with incurable disease.
Collapse
Affiliation(s)
- T R DeMeester
- University of Southern California School of Medicine, Division of Cardiovascular and Thoracic Surgery, Los Angeles 90033-4612, USA
| |
Collapse
|
36
|
|
37
|
Affiliation(s)
- T C Kok
- Department of Medical Oncology, University Hospital Rotterdam Dijkzigt, The Netherlands
| |
Collapse
|
38
|
Feliu J, González Barón M, García Girón C, Espinosa E, Vicent JM, Gómez Navarro J, Berrocal A, Ordóñez A, Vilches Y, de Castro J, Díaz J. Phase II study of cisplatin, 5-fluorouracil, and leucovorin in inoperable squamous cell carcinoma of the esophagus. ONCOPAZ Cooperative Group, Spain. Am J Clin Oncol 1996; 19:577-80. [PMID: 8931675 DOI: 10.1097/00000421-199612000-00009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Cisplatin (P) and 5-fluorouracil (5FU) have demonstrated activity for the treatment of squamous cell carcinoma of the esophagus. Previous studies have shown that leucovorin (L) may potentiate the antitumoral activity of 5FU, so we tested the combination P-5FU-L in 31 patients with inoperable squamous cell esophageal carcinoma. Chemotherapy consisted of P 20 mg/m2 in 4 h, followed by L 200 mg/m2 in 2 h and 5FU 600 mg/m2 in 18 h. This schedule was repeated for 5 days every 4 weeks. The treatment plan included three courses of chemotherapy followed by radiotherapy. The overall response rate was 58% (95% CI = 39-76%), with one complete remission (3%), and 61% of patients reported an improvement in dysphagia. Gastrointestinal toxicity was the main side effect: grade 3-4 mucositis appeared in 19% of patients, grade 3-4 nausea/vomiting in 13%, and grade 3-4 diarrhea in 6.5%. There was one toxic death caused by neutropenia and sepsis. Nineteen patients received local radiotherapy after chemotherapy, which increased the overall response rate to 63% (5% complete responses). Dysphagia improved in 75% of them. The median survival for all patients was 11 months. This study shows that sequential therapy with P-5FU-L and radiotherapy achieves a high response rate as well as adequate symptomatic relief in patients with inoperable esophageal cancer. The results justify further evaluation of P-5FU-L in patients with earlier-stage disease.
Collapse
Affiliation(s)
- J Feliu
- Medical Oncology Service, La Paz Hospital, Madrid, Spain
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Affiliation(s)
- B S Tan
- Department of Radiology, United Medical School, Guy's Hospital, London, UK
| | | | | |
Collapse
|
40
|
Spiridonidis CH, Laufman LR, Jones JJ, Gray DJ, Cho CC, Young DC. A phase II evaluation of high dose cisplatin and etoposide in patients with advanced esophageal adenocarcinoma. Cancer 1996. [DOI: 10.1002/(sici)1097-0142(19961115)78:10<2070::aid-cncr6>3.0.co;2-s] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
41
|
Abstract
Many patient with esophageal cancer have advanced disease that in not amenable to curative treatment. For these individuals the relief of dysphagia is of utmost importance to the quality of their remaining survival time. This article reviews and compares the methods of palliation with focus on indications and contraindications, advantages as well as disadvantages of each technique, success rates, and complications. Tumor characteristics, the physician's experience, the institution's capabilities, cost, and patient preference will influence choice of palliation. Methods are often complementary rather than competitive.
Collapse
Affiliation(s)
- C E Reed
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston 29425, USA
| |
Collapse
|
42
|
Burmeister BH, Denham JW, O'Brien M, Jamieson GG, Gill PG, Devitt P, Yeoh E, Hamilton CS, Ackland SP, Lamb DS. Combined modality therapy for esophageal carcinoma: preliminary results from a large Australasian multicenter study. Int J Radiat Oncol Biol Phys 1995; 32:997-1006. [PMID: 7607974 DOI: 10.1016/0360-3016(94)00449-u] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE This report updates local control and survival experience and focuses on treatment toxicity in 294 patients with esophageal cancer who have been treated at six Australasian centers using three prospective unrandomized protocols that used concurrent radiation, cisplatin, and modest dose infusional fluorouracil. METHODS AND MATERIALS Protocol 1--"definitive" chemoradiation. One hundred and thirty-seven patients have been treated with "definitive" radiation to 60 Gy in 6 weeks plus two courses of cisplatin (80 mg/m2) and infusional fluorouracil (800 mg/m2/day over 4 days) during the first and fourth weeks of radiation. Protocol 2--"preoperative" chemoradiation and surgery. Seventy-eight patients received chemoradiation using the same chemotherapy, but 30-35 Gy in 3-4 weeks prior to surgery. Protocol 3--"palliative" chemoradiation. Seventy-nine patients deemed incurable were treated "palliatively" with the same chemoradiation protocol without surgery. Follow-up ranges from 6 months to 7 years (mean 22 months) in live patients. RESULTS Durable palliation of dysphagia in all three treatment groups has been reflected by encouraging 3-year survival expectations of 43.2 +/- 5% in definitively treated patients, 40.3 +/- 7.65% in surgically treated patients, and 8.5% +/- 3.9% in the palliatively treated patients. There are early indications that female patients have fared better than males. Toxicity levels were modest in all three groups. Following definitive treatment, severe myelotoxicity (World Health Organization grades 3 and 4) occurred in 19%, severe esophagitis (World Health Organization grade 3) in 11%, and moderate or severe benign stricture in 17%, depending upon age and sex of the patient (being worse in female patients). CONCLUSIONS These studies demonstrate that the concurrent addition of modest dose cisplatin and infusional dose fluorouracil to radiation in the definitive, preoperative, and palliative settings contribute to high rates of durable dysphagia-free survival, with overall survival comparable to (and possibly better than) the chemoradiation arm of the recently reported Intergroup Study, but at the cost of less morbidity.
Collapse
Affiliation(s)
- B H Burmeister
- Queensland Radium Institute, Mater Misericordiae Hospital, South Brisbane, Australia
| | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Algan O, Coia LR, Keller SM, Engstrom PF, Weiner LM, Schultheiss TE, Hanks GE. Management of adenocarcinoma of the esophagus with chemoradiation alone or chemoradiation followed by esophagectomy: results of sequential nonrandomized phase II studies. Int J Radiat Oncol Biol Phys 1995; 32:753-61. [PMID: 7790262 DOI: 10.1016/0360-3016(94)00592-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE The incidence of adenocarcinoma of the esophagus is increasing, but the optimal treatment for this disease is unknown. We evaluated the efficacy of chemoradiation and chemoradiation followed by esophagectomy as treatment for adenocarcinoma of the esophagus in sequential prospective nonrandomized phase II studies. METHODS AND MATERIALS Between May 1981 and June 1992, all previously untreated patients (N = 35) with potentially resectable adenocarcinoma of the esophagus (clinical Stage I or II) were treated with curative intent in sequential prospective Phase II studies. From May 1981 to August 1987, 11 patients (median age 66) were treated with concurrent chemotherapy [mitomycin C, and 5-fluorouracil (5-FU)] and radiotherapy to a median dose of 60 Gy (CRT group). From September 1987 to June 1992, 24 patients (median age 65) were treated with the same regimen of chemoradiation followed by planned esophagectomy (CRT+PE group). Of these, 12 patients (median age 62) actually underwent esophagectomy (CRT+E subgroup). RESULTS The median overall survival was 19 months for the CRT group and 15 months for the CRT+PE group. For the CRT+E subgroup, the median overall survival was 33 months. The 3-year actuarial overall survival for the CRT and the CRT+PE groups were 36 and 28% (p = 0.949). The subset of patients treated with chemoradiation followed by esophagectomy had a 3-year actuarial overall survival of 33% (p = 0.274). The 3-year actuarial freedom from local failure rates were similar: 62% in the CRT group vs. 58% in the CRT+PE group. Of the 12 patients who underwent esophagectomy (CRT+E group), 9 (75%) were free of local failure. Four of 12 (33%) patients had no pathologic evidence of malignancy in their surgical specimen. Six of 11 patients (55%) in the CRT group were free of local failure at the time of analysis. Two of five patients in this group who had local recurrence at 2 and 10 months underwent surgical salvage with subsequent survivals of 20 and 100 months, respectively. Treatment-related mortality was 0 out of 11 in the CRT group and 2 out of 24 in the CRT+PE group. Dysphagia relief was similar in the CRT group vs. the CRT+E subgroup; however, a greater percentage of patients treated with chemoradiation alone had normal long-term swallowing function when compared to those patients also undergoing esophagectomy (100% vs. 73%). CONCLUSION High-dose chemoradiation alone appears to provide similar survival and relief of dysphagia compared with high-dose chemoradiation followed by esophagectomy for patients with potentially resectable esophageal adenocarcinoma. Local failure may be higher in patients undergoing chemoradiation compared to chemoradiation followed by esophagectomy, but surgical salvage is possible, thus providing similar overall local control. However, because of the small number of patients in each group, these treatment modalities need to be further evaluated in a prospective randomized Phase III study.
Collapse
Affiliation(s)
- O Algan
- Fox Chase Cancer Center, Department of Radiation Oncology, Philadelphia, PA 19111, USA
| | | | | | | | | | | | | |
Collapse
|
44
|
Middleton G, Cunningham D. Current options in the management of gastrointestinal cancer. Ann Oncol 1995; 6 Suppl 1:17-25; discussion 25-6. [PMID: 8695539 DOI: 10.1093/annonc/6.suppl_1.s17] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Surgery is the standard approach for localized gastrointestinal malignancy both in the upper GI tract and for cancer of the large bowel. Adjuvant chemotherapy following curatively resected colorectal cancer, results in a definite survival advantage. The use of chemotherapy in an attempt to downstage inoperable gastric cancer to allow for subsequent radical resection has yielded promising results. Likewise improved survival rate in patients treated with adjuvant chemotherapy after resection, justify further exploration of perioperative chemotherapy in operable gastric cancer. In squamous oesophageal cancer, modem chemo-radiation regimens are superior to radiotherapy alone in localized disease. Some series demonstrate impressive survival rates in the absence of surgical intervention raising the question as to the precise role of surgery in a combined modality approach. Ongoing randomized trials will clarify the relative contributions of these treatment modalities in the management of this disease. In metastatic disease of both upper GI and colonic tumours maintenance of good quality of life should be the primary endpoint. Randomised trials of chemotherapy against best supportive care have provided strong justification for the use of chemotherapy in the management of advanced gastric, pancreatic and colorectal cancer.
Collapse
Affiliation(s)
- G Middleton
- Cancer Research Campaign, Institute of Cancer Research, Sutton, Surrey, U.K
| | | |
Collapse
|
45
|
Blazeby JM, Alderson D. The Modem Management of Patients with Oesophageal Cancer. PROGRESS IN PALLIATIVE CARE 1995. [DOI: 10.1080/09699260.1995.11746721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
46
|
Whittington R. Controversies in the management of adenocarcinoma of the esophagus and esophagogastric junction. Semin Radiat Oncol 1994. [DOI: 10.1016/s1053-4296(05)80065-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
47
|
|
48
|
Coia LR. Chemoradiation: A superior alternative for the primary management of esophageal carcinoma. Semin Radiat Oncol 1994. [DOI: 10.1016/s1053-4296(05)80063-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
49
|
|
50
|
Kavanagh BD, Montana GS, Crawford J, Wolfe WG, Anscher MS. Long-term results of combined modality therapy for esophageal cancer. ACTA ACUST UNITED AC 1993. [DOI: 10.1002/roi.2970010406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|