A randomized controlled trial of conventional fraction and late course accelerated hyperfraction three-dimensional conformal radiotherapy for esophageal cancer

[Dose-escalated radiotherapy in esophageal cancer: A review of the literature]

For non-operable, localized esophageal cancer, definitive concurrent chemoradiotherapy is the standard treatment. Currently, the radiation dose recommended is 50 to 50,4Gy. However, the optimal radiation dose remains controversial. Many studies have demonstrated that locoregional failure remains a common failure pattern, most likely to occur within the original gross tumor volume. Several retrospective studies have indicated that higher radiation dose may improve local control and survival while others failed to demonstrate improved oucomes. In three randomized trials (INT0123, ARTDECO, and CONCORDE), dose escalation did not improve locoregional control nor survival, establishing 50Gy as the standard chemoradiation dose for patients who will not undergo surgery. Here, we reviewed the results of dose escalation in the literature in the neoadjuvant and definitive settings.

Association of 3D-CRT and IMRT accelerated hyperfractionated radiotherapy with local control rate and 5-year survival in esophageal squamous cell carcinoma patients

OBJECTIVES

This retrospective study examined the relevance and prognostic factors of whole-course conformal radiotherapy (CRT) and late-course accelerated hyperfractionation radiotherapy (LCAFRT) for esophageal squamous cell carcinoma (ESCC).

METHODS

A total of 110 patients with ESCC received whole-course CRT and LCAFRT between May 2004 and January 2015. All patients received conventional CRT of 2 Gy per day, up to 30-40 Gy, followed by LCAFRT using reduced fields at 1.5 Gy/fraction twice a day, up to 24-39 Gy, for a total dose of 60-69 Gy.

RESULTS

The median follow-up was 85 months. The whole groups 1-, 3-, and 5-year survival rates were 81.8%, 46.4%, and 41.8%, respectively. The local control rates for the whole group at 1, 3, and 5 years were 82.7%, 70.0%, and 68.2%, respectively. There were no significant differences among survival rates and local control rates between the 3D-CRT and intensity-modulated radiotherapy (IMRT) groups. The main reactions to acute radiotherapy were acute radiation tracheitis, esophagitis, and pneumonia. The tumor location and TNM stage were independent prognostic factors for overall survival.

CONCLUSION

The results showed that whole-course CRT and LCAFRT for ESCC can improve survival and local control with a tolerable acute reaction compared to previous studies. Local recurrence and distant metastasis are the main failure modes of treatment.

ADVANCES IN KNOWLEDGE

Whole-course CRT and LCAFRT for ESCC can improve the survival and local control rate compared with previous studies from the 2DRT era. It might provide another treatment for patients with inoperable ESCC or refusing surgery.

Late-course accelerated Hyperfractionation vs. Conventional Fraction Radiotherapy under precise technology plus Concurrent Chemotherapy for Esophageal Squamous Cell Carcinoma: comparison of efficacy and side effects

Background: The accelerated reproliferation of esophageal squamous cell carcinoma (ESCC) after radiation contributes to conventional fraction radiotherapy (CFRT) failure. Late course accelerated hyperfractionated radiotherapy (LCAHFRT) can improve the long-term survival of esophageal cancer patients in China but is associated with a high rate of side effects due to the large exposure field of two-dimensional treatment and drug toxicity. Intensity-modulated radiotherapy (IMRT) can increase the tumor dose while decreasing the normal tissue dose. Therefore, we compared the outcomes and side effects of LCAHFIMRT plus concurrent chemotherapy (CT) and CFIMRT plus CT for ESCC.

Methods and Materials: Between 2013 and 2016, 114 eligible patients with ESCC were recruited and randomly assigned to receive LCAHFIMRT+CT (58 patients) or CFIMRT+CT (56 patients) by a linear accelerator (6-MV X-ray) under image guidance. Two cycles of CT with cisplatin and docetaxel were also administered.

Results: The complete response (CR) rates were 79.3% and 61.8% in the LCAHFIMRT+CT and CFIMRT+CT groups, respectively (P=0.041). The median duration of local control times was 31.0±1.9 months for the LCAHFIMRT+CT group and 24.0±3.3 months for the CFIMRT+CT groups,and the 1-, 2-, and 3-year local control rates were 86.2%, 63.8%, and 41.4% and 85.7%, 51.8%, and 32.1% for the LCAHFIMRT+CT and CFIMRT+CT groups (P=0.240), respectively. The median survival times were 34.0±1.1 months for the LCAHFIMRT+CT group and 28.0.0±3.7 months for the CFIMRT groups,and the 1-, 2-, and 3-year survival rates were 87.9%, 74.1%, and 44.8% and 87.5%, 60.7%, and 39.3% for the LCAHFIMRT+CT and CFIMRT+CT groups, respectively (P=0.405). The incidence of side effects was not significantly different between the two groups. Local recurrence and uncontrolled disease resulted in more deaths in the CFIMRT+CT group than in the LCAHFIMRT+CT group (58.9% vs. 39.7%) (P=0.040).

Conclusion: For ESCC patients, LCAHFRT delivered by image-guided intensity-modulated techniques Plus Concurrent Chemotherapy with cisplatin and docetaxel keeps safety and high CR rate, as well as local control and long-term survival rates.

Artesunate prevents knee intraarticular adhesion via PRKR-like ER kinase (PERK) signal pathway

Background

Intraarticular scar adhesion refers to a serious complication caused by knee surgery or trauma, leading to various sequelae (e.g., articular cartilage degeneration and knee joint stiffness). Artesunate (ART) has exhibited an effect to suppress fibroblast proliferation, whereas the exact mechanism remains unclear. This study aims to delve into the possible mechanism of ART in suppressing joint adhesion.

Methods

The effect of ART on reduced intraarticular adhesions was ascertained by histological staining and immunohistochemical analysis through vivo experiments. Cell Counting Kit-8 (CCK-8) assay, Western blot analysis, flow cytometry, and tunnel staining were used to detect the effect of ART in promoting fibroblast apoptosis and delve into its possible signaling pathway.

Results

The results of hematoxylin-eosin (HE) staining suggested that the number of fibroblasts decreased with the increase in ART concentration. The results of Masson staining were similar, with the increase in concentration, the collagen content decreased. Immunohistochemical results showed that the expression of endoplasmic reticulum stress (ERS) characteristic proteins 78 kDa glucose-regulated protein 78 (GRP78) and C/EBP homologous protein (CHOP) increased in a concentration-dependent manner. CCK-8 results suggested that ART could inhibit fibroblast viability in a concentration- and time-dependent manner. Results of flow cytometry, tunnel staining, and Western blot suggested the apoptosis of fibroblasts occurred after ART treatment. Cells with caspase inhibitors were treated, and apoptotic proteins cleaved-poly ADP-ribose polymerase (cleaved PARP) and cleaved-caspase 3 were detected; the results showed that the apoptotic effect of ART was reduced. The expressions of ERS-related protein CHOP and apoptosis-related protein Bax were upregulated, while the expression of Bcl-2 was downregulated, and the ratio of Bax/Bcl-2 increased in a concentration-dependent manner. Continuous detection of PRKR-like ER kinase (PERK) pathway-related proteins showed that the expression of p-PERK and phosphorylating eukaryotic initiation factor 2α (p-eIF2α) increased in a time-dependent and concentration-dependent manner. PERK pathway inhibitors could partially inhibit ART-mediated apoptosis through PERK pathway.

Conclusions

ART can promote fibroblast apoptosis through PERK pathway, a classical ERS pathway, and thus prevent fibrosis in the surgical area after joint surgery.

Accelerated Hyperfractionated Radiotherapy versus Conventional Fractionation Radiotherapy for Head and Neck Cancer: A Meta-Analysis of Randomized Controlled Trials

Objective

The benefits of accelerated hyperfractionated radiotherapy (HART) and conventional fractionation radiotherapy (CFRT) in the treatment of head and neck cancer (HNC) remain controversial. In this study, we analyzed the therapeutic effects of these two treatment regimens to explore whether HART can improve the overall survival (OS) rate and locoregional control (LRC) rate in patients with HNC.

Methods

The PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched for eligible studies. The OS rate and LRC rate were considered as the efficacy outcomes. I² was used to test the heterogeneity among studies with a cutoff value of 50%. Potential publication bias was assessed by funnel plots and Egger's test. We also performed a sensitivity analysis to assess the stability of the results. In this meta-analysis, all analyses were performed using R 3.5.3 software.

Results

Twelve qualified articles including a total of 2,935 patients were identified. HART had a significant beneficial effect on OS rate (HR = 0.80, 95% CI: 0.65–0.98). Compared with CFRT, HART demonstrated a significantly higher LRC rate (HR = 0.82, 95% CI: 0.71–0.96).

Conclusion

Our meta-analysis showed that HART can significantly improve OS and LRC compared with CFRT in patients with HNC.

REV7 confers radioresistance of esophagus squamous cell carcinoma by recruiting PRDX2

Radiotherapy has been widely used for the clinical management of esophageal squamous cell carcinoma. However, radioresistance remains a serious concern that prevents the efficacy of esophageal squamous cell carcinoma (ESCC) radiotherapy. REV7, the structural subunit of eukaryotic DNA polymerase ζ, has multiple functions in bypassing DNA damage and modulating mitotic arrest in human cell lines. However, the expression and molecular function of REV7 in ESCC progression remains unclear. In this study, we first examined the expression of REV7 in clinical ESCC samples, and we found higher expression of REV7 in ESCC tissues compared to matched adjacent or normal tissues. Knockdown of REV7 resulted in decreased colony formation and increased apoptosis in irradiated Eca‐109 and TE‐1 cells coupled with decreased tumor weight in a xenograft nude mouse model postirradiation. Conversely, overexpression of REV7 resulted in radioresistance in vitro and in vivo. Moreover, silencing of REV7 induced increased reactive oxygen species levels postirradiation. Proteomic analysis of REV7‐interacting proteins revealed that REV7 interacted with peroxiredoxin 2 (PRDX2), a well‐known antioxidant protein. Existence of REV7‐PRDX2 complex and its augmentation postirradiation were further validated by immunoprecipitation and immunofluorescence assays. REV7 knockdown significantly disrupted the presence of nuclear PRDX2 postirradiation, which resulted in oxidative stress. REV7‐PRDX2 complex also assembled onto DNA double‐strand breaks, whereas REV7 knockdown evidently increased double‐strand breaks that were unmerged by PRDX2. Taken together, the present study sheds light on REV7‐modulated radiosensitivity through interacting with PRDX2, which provides a novel target for ESCC radiotherapy.

The role of definitive chemoradiation in patients with non-metastatic oesophageal cancer

Definitive chemoradiation (dCRT) is a curative treatment option for patients with oesophageal cancer. It is effective in both adenocarcinoma and squamous cell carcinoma. However, locoregional control is less after dCRT compared to preoperative CRT (pCRT) followed by surgery. Also, overall survival is lower compared to pCRT followed by surgery, which can only partly be explained by a negative selection of patients. The optimal dose of radiotherapy remains to be determined, but dose escalation above 50.4Gy might be beneficial. Cisplatinum/5-FU is the most applied concurrent chemotherapy, but carboplatin/paclitaxel seems equally effective with less toxicity. The addition of 5-FU to a taxane and platinum seems promising. Accelerated fractionation and addition of cetuximab did not improve results. dCRT is a successful treatment for regional lymph node recurrences, but less so for recurrences at the anastomotic site. Re-irradiation after prior curative radiotherapy yields poor results. dCRT can be safely used in carefully selected elderly.

Altered fractionation radiotherapy with or without chemotherapy in the treatment of head and neck cancer: a network meta-analysis

Objectives

A Bayesian network meta-analysis (NMA) was conducted in patients with head and neck cancers (HNCs) to estimate the efficacy and safety of treatment with conventional fractionation radiotherapy (CF), conventional fractionation chemoradiotherapy (CF_CRT), hyperfractionated radiotherapy (HF), hyperfractionated chemoradiotherapy (HF_CRT), accelerated fractionation radiotherapy, accelerated fractionation chemoradiotherapy, accelerated hyperfractionated radiotherapy (HART) or accelerated hyperfractionated chemoradiotherapy (HACRT) to identify superior treatments to aid in clinical decisions.

Methods

PubMed, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for potentially eligible randomized controlled trials up to December 2016. Overall survival (OS), disease-free survival (DFS) and locoregional control (LRC) were considered efficacy outcomes, whereas acute toxicity and late toxicity on skin and mucosa were considered safety outcomes. The surface under the cumulative ranking curve (SUCRA) was calculated to rank each treatment in each index.

Results

Data from 72 trials with 21,868 participants were included in the analysis. Concerning OS, all treatments were associated with a significant advantage compared to CF alone, with HR effect sizes ranging from 0.64 to 0.83, and HACRT was significantly more effective than all the other treatments. The network comparisons of both HACRT vs HART and HF_CRT vs HF demonstrated a higher OS benefit, with an HR of 0.78 (95% credible interval [CrI]: 0.64–0.95) and 0.78 (95% CrI: 0.61–0.99), respectively. The results of SUCRA indicated that HACRT had the best ranking for OS and LRC, HF_CRT for DFS, HART for acute and late skin toxicity, CF_CRT for acute mucosal toxicity and HF_CRT for late mucosal toxicity.

Conclusion

The NMA results support the notion that HACRT is the preferable treatment modality for HNCs because it has better rankings in all three efficacy indexes, although it does present a high risk of acute mucosal toxicity.

A network meta-analysis of the treatments for esophageal squamous cell carcinoma in terms of survival

We aimed to compare treatments for patients with esophageal squamous cell carcinoma (SCC) in terms of survival. Medline, Web of Science, Scopus, the Cochrane Library and Embase were searched. Randomized controlled trials (RCT) that had compared esophageal SCC treatments were included. The hazard ratio (HR) with 95% credible interval (CrI) was used to summarize the effect measures in the Bayesian network meta-analysis. Out of 23,256 references, 43 RCTs with 34 treatments were included. Carboplatin and paclitaxel plus radiotherapy plus surgery (carbo-pacli + RT + S) compared with surgery alone decreased risk of death (HR = 0.49; 95% CrI: 0.26, 0.90). The HRs for carbo-pacli + RT + S versus surgery plus cisplatin and fluorouracil and surgery plus cisplatin and vindesine were 0.44 (0.22, 0.86) and 0.41 (0.20, 0.83), respectively. Among all treatments in network, carbo-pacli + RT + S ranked as first treatment. It seems carbo-pacli + RT + S was a better treatment among available treatments in network in terms of survival in patients with esophageal SCC.

Radiotherapy for esophageal carcinoma: dose, response and survival

Esophageal cancer (EC) is an extremely aggressive, lethal malignancy that is increasing in incidence worldwide. At present, definitive chemoradiotherapy is accepted as the standard treatment for locally advanced EC. The EC guidelines recommend a radiation dose of 50.4 Gy for definitive treatment, yet the outcomes for patients who have received standard-dose radiotherapy remain unsatisfactory. However, some studies indicate that a higher radiation dose could improve local tumor control, and may also confer survival benefits. Some studies, however, suggest that high-dose radiotherapy does not bring survival benefit. The available data show that most failures occurred in the gross target volume (especially in the primary tumor) after definitive chemoradiation. Based on those studies, we hypothesize that at least for some patients, more intense local therapy may lead to better local control and survival. The aim of this review is to evaluate the radiation dose, fractionation strategies, and predictive factors of response to therapy in functional imaging for definitive chemoradiotherapy in esophageal carcinoma, with an emphasis on seeking the predictive model of response to CRT and trying to individualize the radiation dose for EC patients.

Phase I study of concurrent selective lymph node late-course accelerated hyperfractionated radiotherapy and S-1 plus cisplatin for locally advanced oesophageal squamous cell carcinoma

OBJECTIVE

This Phase I study aimed to assess the safety and efficacy of concurrent selective lymph node (SLN) late-course accelerated hyperfractionated (LCAF) intensity-modulated radiotherapy (IMRT) and S-1 plus cisplatin (CDDP) for the locally advanced oesophageal squamous-cell carcinoma (ESCC).

METHODS

The total dose of SLN LCAF IMRT was 59.6 Gy/34 fractions in 5.4 weeks. The concurrent chemotherapy (CCRT) was administered as follows: CDDP 25 mg m(-2) on Days 1-3 and Days 22-24; S-1 was applied in a de-escalating dosage with a decrement of 10 mg m(-2) per day, from its full dose level of 80 mg m(-2), orally twice daily on Days 1-14 and Days 22-35. We inferred the maximum-tolerated dose (MTD), dose-limiting toxicities (DLTs) and recommended dose, according to adverse reaction during CCRT.

RESULTS

Totally, 15 patients with ESCC with T2-4N0-1M0-1a were enrolled in Dose Level 1 (80 mg m(-2)). In the initial five patients, two patients developed DLTs. As MTD was not reached, five additional patients were treated with the same dose level, and DLTs occurred in only one patient. Similar results were found in the last five patients. After CCRT, the objective response rates were 100% for primary tumours and 86.2% for metastatic lymph nodes, respectively. Totally, the observed Grade 3 toxicities during CCRT were leukopenia (20%), neutropenia (20%) and dermatitis (13.3%), and no Grade 4 toxicity occurred. The Kaplan-Meier-estimated overall and progression survival rates were 86.7% and 66.7% (1 year), 73.3% and 60% (2 years) and 73.3% and 60% (3 years).

CONCLUSION

The concurrent SLN LCAF IMRT and chemotherapy with S-1 and CDDP was well tolerated and showed promising efficacy. The dose of S-1 in this regimen was recommended with 80 mg m(-2) orally twice daily on Days 1-14 and Days 22-35.

ADVANCES IN KNOWLEDGE

CCRT with S-1 plus CDDP exhibited encouraging results with milder toxicities, high objective response rates and ideal overall survival time.

Downregulation of MDC1 and 53BP1 by short hairpin RNA enhances radiosensitivity in laryngeal carcinoma cells

DNA double-strand breaks (DSBs) induced by ionizing radiation (IR) are among the most cytotoxic types of DNA damage. The DNA damage response (DDR) may be a reason for the cancer cell resistance to radiotherapy using IR. Identified as critical upstream mediators of the phosphorylation of ataxia telangiectasia-mutated (ATM) pathway, mediator of DNA damage checkpoint 1 (MDC1) and p53-binding proteins 1 (53BP1) may affect the radiosensitivity of tumor cells. In the present study, we generated two HEP-2 cell lines with a stable knockdown of MDC1 or 53BP1 with short hairpin RNA (shRNA), respectively, and investigated the effect of MDC1 and 53BP1 on cell radiosensitivity, cell cycle distribution and the formation of cell foci. Downregulation of the two proteins reduced the number of clonogenic cells that treated with IR. Accumulation of G2/M phase cells was detected after the MDC1 and 53BP1 downregulation. These results indicated that the expression of MDC1 or 53BP1 limited tumor cell sensitivity to radiotherapy and may play an important role in the DNA repair progression. Furthermore, the MDC1 foci was identified and presented in the 53BP1-inhibited cells. By contrast, the 53BP1 foci was absent from the MDC1-inhibited cells. The results confirmed that the recruitment of 53BP1 into the foci occurred in an MDC1-dependent manner.

The optimal concentration of topical hydroxycamptothecin in preventing intraarticular scar adhesion

10-Hydroxycamptothecin could reduce intraarticular adhesion by inhibiting fibroblasts proliferation after knee surgery. However, the ideal concentration of hydroxycamptothecin have not been defined. This study was tried to verify the optimal concentration of 10-hydroxycamptothecin in preventing knee intraarticular adhesion. Sixty rabbits were randomly divided into five groups. Approximately 10 mm × 10 mm of the cortical bone was removed from both sides of the femoral condyle and the underneath cancellous bone was exposed. Various concentrations of hydroxycamptothecin (0.1 mg/ml, 0.5 mg/ml, 1.0 mg/ml, 2.0 mg/ml) or saline were applied to the decorticated areas for 10 minutes. After four weeks, the degree of inraarticular adhesion was assessed by macroscopic evaluation, biochemical analysis of hydroxyproline content and histological evaluation. The results demonstrated that the extent of knee inraarticular adhesion in 1.0 mg/ml group and 2.0 mg/ml hydroxycamptothecin group were significantly lower than those of 0.5 mg/ml group, 0.1 mg/ml hydroxycamptothecin group and control group. Moreover, there was no significant difference between 1.0 mg/ml group and 2.0 mg/ml hydroxycamptothecin group. In conclusion, topical application of 1.0 mg/ml hydroxycamptothecin may be the optimal concentration in reducing intraarticular adhesion after knee surgery in rabbits.

Repopulation of tumor cells during fractionated radiotherapy and detection methods (Review)

Repopulation of tumor cells during radiotherapy is believed to be a significant cause for treatment failure. The phenomenon of tumor repopulation during fractionated radiotherapy was found from clinical observations that identified that the local control rate decreased with a prolonged treatment time. A series of animal experiments with varied overall treatment time and fractionated doses were performed to demonstrate tumor cell repopulation during radiotherapy in various mouse xenograft models. However, conventional detection methods are challenging, as it is difficult to separate viable cells from those destined for apoptosis during fractionated radiotherapy. In essence, the mechanism of tumor repopulation involves the continuing proliferation of clonogenic tumor cells. In vivo imaging, tracking and targeting of the repopulation of these cells has been of clinical interest so as to administer a higher dose to the tumor repopulation regions. Currently, functional imaging methods, including 3'-deoxy-3'-¹⁸F-fluorothymidine positron emission tomography (¹⁸F-FLT PET), are showing promise in assessing the proliferation activity of tumors in vivo. This review mainly focuses on the phenomenon of tumor repopulation during radiotherapy and its conventional and novel detection methods, particularly on the feasibility of ¹⁸F-FLT PET for the detection of tumor-cell repopulation.

Elective lymph node irradiation late course accelerated hyper-fractionated radiotherapy plus concurrent cisplatin-based chemotherapy for esophageal squamous cell carcinoma: a phase II study

BACKGROUND

In this phase II study, we evaluated the efficacy, toxicity, and patterns of failure of elective lymph node irradiation (ENI) late course accelerated hyper-fractionated radiotherapy (LCAHRT) concurrently with cisplatin-based chemotherapy (CHT) for esophageal squamous cell carcinoma (ESCC).

METHODS

Patients with clinical stage II-IVa (T1-4N0-1M0 or M1a) ESCC were enrolled between 2004 and 2011. Radiation therapy (RT) comprised two courses: The first course of radiation covered the primary and metastatic regional tumors and high risk lymph nodal regions, given at 2 Gy per fraction for a dose of 40 Gy. In the second course, LCAHRT was delivered to the boost volume twice a day for an additional 19.6 Gy in 7 treatment days, using 1.4 Gy per fraction. Two cycles of CHT were given at the beginning of RT.

RESULTS

The median age and Karnofsky performance status were 63 years and 80, respectively. The American Joint Committee on Cancer stage was II in 14 (20.6%) patients, III in 32 (47.1%), and IVa in 22 (32.3%). With a median follow-up of 18.5 months, the overall survival at 1-, 3-, 5-year were 75.5%, 46.5%, 22.7% for whole group patients, versus 78.6%, 49.4%, 39.9% for patients with stage II-III. The patterns of first failure from local recurrence, regional failure, and distant metastasis were seen in 20.6%, 17.6%, and 19.1%, respectively. The most frequent acute high-grade (≥ 3) toxicities were esophagitis and leucopenia, occurred in 26.4% and 32.4%.

CONCLUSIONS

ENI LCAHRT concurrently with CHT was appeared to be an effective regimen for ESCC patient with a favorable and tolerated profile. Further observation with longer time and randomized phase III trial is currently underway.

TRIAL REGISTRATION

ChiCTR-TRC-09000568.

Definitive chemoradiotherapy for esophageal carcinoma

Radiation therapy plays an important role in the treatment of esophageal cancer. Radiation therapy may be combined with chemotherapy, used as a component of induction therapy, used in the adjuvant setting, or used for palliation of advanced disease. Chemotherapy is also occasionally used as a solitary treatment modality for patients with esophageal cancer. Current treatment protocols include multiple agents, and agents directed against specific molecular targets have been investigated in clinical trials. This article discusses future directions related to the selection of radiation treatment protocols, novel targeted chemotherapeutic agents, and the selection of patients for surgery.