Factors influencing outcome following radio-chemotherapy for oesophageal cancer. The Trans Tasman Radiation Oncology Group (TROG)

Development of a prognostic nomogram and risk stratification system for upper thoracic esophageal squamous cell carcinoma

Background

The study aimed to develop a nomogram model to predict overall survival (OS) and construct a risk stratification system of upper thoracic esophageal squamous cell carcinoma (ESCC).

Methods

Newly diagnosed 568 patients with upper ESCC at Fujian Medical University Cancer Hospital were taken as a training cohort, and additional 155 patients with upper ESCC from Sichuan Cancer Hospital Institute were used as a validation cohort. A nomogram was established using Cox proportional hazard regression to identify prognostic factors for OS. The predictive power of nomogram model was evaluated by using 4 indices: concordance statistics (C-index), time-dependent ROC (ROCt) curve, net reclassification index (NRI) and integrated discrimination improvement (IDI).

Results

In this study, multivariate analysis revealed that gender, clinical T stage, clinical N stage and primary gross tumor volume were independent prognostic factors for OS in the training cohort. The nomogram based on these factors presented favorable prognostic efficacy in the both training and validation cohorts, with concordance statistics (C-index) of 0.622, 0.713, and area under the curve (AUC) value of 0.709, 0.739, respectively, which appeared superior to those of the American Joint Committee on Cancer (AJCC) staging system. Additionally, net reclassification index (NRI) and integrated discrimination improvement (IDI) of the nomogram presented better discrimination ability to predict survival than those of AJCC staging. Furthermore, decision curve analysis (DCA) of the nomogram exhibited greater clinical performance than that of AJCC staging. Finally, the nomogram fairly distinguished the OS rates among low, moderate, and high risk groups, whereas the OS curves of clinical stage could not be well separated among clinical AJCC stage.

Conclusion

We built an effective nomogram model for predicting OS of upper ESCC, which may improve clinicians' abilities to predict individualized survival and facilitate to further stratify the management of patients at risk.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Primary gross tumor volume is prognostic and suggests treatment in upper esophageal cancer

Background

To aid clinicians strategizing treatment for upper esophageal squamous cell carcinoma (ESCC), this retrospective study investigated associations between primary gross tumor volume (GTVp) and prognosis in patients given surgical resection, radiotherapy, or both resection and radiotherapy.

Methods

The population comprised 568 patients with upper ESCC given definitive treatment, including 238, 216, and 114 who underwent surgery, radiotherapy, or combined radiotherapy and surgery. GTVp as a continuous variable was entered into the multivariate Cox model using penalized splines (P-splines) to determine the optimal cutoff value. Propensity score matching (PSM) was used to adjust imbalanced characteristics among the treatment groups.

Results

P-spline regression revealed a dependence of patient outcomes on GTVp, with 30 cm³ being an optimal cut-off for differences in overall and progression-free survival (OS, PFS). GTVp ≥30 cm³ was a negative independent prognostic factor for OS and PFS. PSM analyses confirmed the prognostic value of GTVp. For GTVp < 30 cm³, no significant survival differences were observed among the 3 treatments. For GTVp ≥30 cm³, the worst 5-year OS rate was experienced by those given surgery. The 5-year PFS rate of patients given combined radiotherapy and surgery was significantly better than that of patients given radiotherapy. The surgical complications of patients given the combined treatment were comparable to those who received surgery, but radiation side effects were significantly lower.

Conclusion

GTVp is prognostic for OS and PFS in upper ESCC. For patients with GTVp ≥30 cm³, radiotherapy plus surgery was more effective than either treatment alone.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08838-w.

Post-Neoadjuvant Surveillance and Surgery as Needed Compared with Post-Neoadjuvant Surgery on Principle in Multimodal Treatment for Esophageal Cancer: A Scoping Review

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.

Hypofractionated Radiotherapy in Combination With Chemotherapy Improves Outcome of Patients With Esophageal Carcinoma Tracheoesophageal Groove Lymph Node Metastasis

This study investigated the efficiency and safety of hypofractionated radiotherapy (HFR) combined with paclitaxel chemotherapy for the treatment of postsurgery tracheoesophageal groove lymph node (TGLN) metastasis in patients with esophageal cancer (EC). Fifty-three EC patients with TGLN metastasis after surgery admitted to the Yancheng Third People's Hospital from January 2013 to June 2015 were included in this study. They were randomly divided into the HFR group (n = 25) and conventional fractioned radiotherapy (CFR) group (n = 28) based on the random grouping method. Patients in the HFR group received treatment with radiation of 60 Gy (5 fractions per week, total 20 fractions) combined with paclitaxel chemotherapy at a dose of 50 mg once per week for 4 weeks. Patients in the CFR group received radiation of 60 Gy (5 fractions per week, total 30 fractions) combined with paclitaxel chemotherapy at a dose of 50 mg once per week for 6 weeks. The adverse events and treatment outcomes in these two groups were analyzed. It was found that there was no significant difference in the incidence of radiation esophagitis in the HFR group compared with that of the CFR group (grades 3-4, 44.0 vs. 25.0%; P = 0.149). There was no statistical difference in the incidence of radiation pneumonitis between these two groups (grades 3-4, 16.0 vs. 7.1%; P = 0.314). No statistical difference was noticed in complete response (CR), partial response (PR), and no response (NR) between these two groups. The median overall survival (OS) in the HRF group was significantly longer compared with that of the CRF group (24.2 months (95% CI, 16.2-32.1 months) vs. 11.8 months (95% CI, 9.2-14.4 months); P = 0.024). Our results indicated that the combination of HFR and chemotherapy improved the prognosis of EC patients with TGLN metastasis with no increased adverse events.

The current optimal multimodality treatments for oesophageal squamous-cell carcinoma: A systematic review and meta-analysis

BACKGROUND

Multimodality treatments including definitive chemoradiotherapy (dCRT) and neoadjuvant chemoradiotherapy (nCRT) or chemotherapy (nCT) followed by surgery (S) are frequently used to improve prognosis in locally advanced oesophageal squamous-cell carcinoma (LAESCC), while the optimal multimodality regimen has yet to be defined; therefore, this systematic review and meta-analysis aimed to find out the current best multimodality regimen for LAESCC.

METHODS

We conducted a systematic search of PubMed, Embase, Ovid and Cochrane Library databases for studies comparing nCRT + S with nCT + S or dCRT. The primary outcome was overall survival. The secondary outcomes were the rates of R0 resection, pathologic complete response (pCR), tumor-free lymph nodes (pN0) and postoperative recurrence.

RESULTS

Five studies comparing nCRT + S with nCT + S and fourteen studies comparing nCRT + S with dCRT were finally included. Meta-analysis showed that nCRT + S had higher rates of R0 resection (OR 1.84, 95% CI 1.03-3.29), pCR (OR: 2.90 95% CI 1.37-6.14) and pN0 (OR: 2.55 95% CI 1.54-4.24) with a significant survival advantage (HR 0.72; 95% CI 0.52-0.99) when compared with nCT + S in LAESCC. When nCRT + S was compared with dCRT, nCRT + S yielded a significant survival benefit (HR 0.65; 95% CI 0.56-0.76) and had a significantly lower rate of local recurrence (OR: 0.35 95% CI 0.22-0.57).

CONCLUSION

Current evidence suggests that CRT + S may be the optimal potential curative treatment mode for patients with LAESCC as long as they are suitable for this multimodality regimen.

Emerging therapeutic targets in esophageal adenocarcinoma

The incidence of gastro-esophageal disease and associated rate of esophageal adenocarcinoma (EAC) is rising at an exponential rate in the United States. However, research targeting EAC is lagging behind, and much research is needed in the field to identify ways to diagnose EAC early as well as to improve the rate of pathologic complete response (pCR) to systemic therapies. Esophagectomy with subsequent reconstruction is known to be a morbid procedure that significantly impacts a patient's quality of life. If indeed the pCR rate of patients can be improved and those patients destined to be pCR can be identified ahead of time, they may be able to avoid this life-altering procedure. While cancer-specific biological pathways have been thoroughly investigated in other solid malignancies, much remains unexplored in EAC. In this review, we will highlight some of the latest research in the field in regards with EAC, along with new therapeutic targets that are currently being explored. After reviewing conventional treatment and current changes in medical therapy for EAC, we will focus on unchartered grounds such as cancer stem cells, genetics and epigenetics, immunotherapy, and chemoradio-resistant pathways as we simultaneously propose some investigational possibilities that could be applicable to EAC.

High-dose versus conventional-dose irradiation in cisplatin-based definitive concurrent chemoradiotherapy for esophageal cancer: a systematic review and pooled analysis

We investigate whether high-dose (HD, ≥60 Gy) radiotherapy in definitive concurrent chemoradiotherapy (CCRT) based on cisplatin could yield benefits compared to conventional-dose (CD) CCRT. PubMed, Embase and Google Scholar were searched and data were pooled and analyzed for response rate, survival, failure patterns and toxicity. Results showed advantages in response rate, 5-year overall survival rate, local regional recurrence and distant failure rate compared to the CD arm with no difference in Grade ≥3 acute and late esophagitis, other toxicities were rare with moderate tolerance, subgroup analysis of squamous cell carcinoma also showed advantages for HD arm. We concluded that ≥60 Gy CCRT improved clinical outcomes compared to the CD arm, especially for esophageal squamous cell carcinoma. Our findings may provide a basis for future trials.

Paclitaxel and cisplatin combined with intensity-modulated radiotherapy for upper esophageal carcinoma

Purpose

This study was conducted to evaluate the effectiveness and safety of intensity-modulated radiotherapy (IMRT) and concurrent paclitaxel plus cisplatin (TP regimen) for upper esophageal carcinoma.

Methods

36 patients of upper esophageal carcinoma were retrospectively analyzed. Patients were treated with IMRT (median 60 Gy) combined with concurrent TP regimen chemotherapy. The Kaplan-Meier analysis was performed in statistical analysis. Toxicities were recorded according to the NCI CTC version 3.0.

Results

36 patients aged 43–73 years (median 57 years). The median follow-up period was 14.0 months. The 1-year and 2-year survival rates were 83.3% and 42.8% respectively. The median progression-free survival (PFS) time and overall survival (OS) time were 12.0 (95% CI: 7.8–16.2 months) and 18.0 months (95% CI: 9.9–26.1 months), respectively. Grade 3 neutropenia, radiation-induced esophagitis and radiodermatitis were observed in 5 (13.9%), 3 (8.3%) and 8 (22.2%) patients respectively. There were two treatment-related deaths due to esophageal perforation and hemorrhea.

Conclusions

For those patients with upper esophageal carcinoma, IMRT combined with concurrent TP regimen chemotherapy was an effective treatment. However, more attention should be paid to the occurrence of perforation and hemorrhea.

Dosimetric comparison of IMRT vs. 3D conformal radiotherapy in the treatment of cancer of the cervical esophagus

BACKGROUND AND PURPOSE

Radiotherapy planning for cervical esophageal cancer is challenging. We compared IMRT and 3D conformal radiotherapy (CRT) with respect to conformality of target coverage and normal tissue sparing.

MATERIALS AND METHODS

We selected five patients with cervical esophagus cancer, who represented the heterogeneity of clinical cases, treated to radical dose and planned with Pinnacle v6.2. Target doses for CRT plans were 50, 60, and 70Gy (single-phase IMRT 56, 63, and 70). We compared PTV coverage by the 95% isodose (PTV(95)), conformality ratio (CR), conformation number (CN), and maximum or mean doses (D(max), D(mean)) to normal structures.

RESULTS

Median PTV(95) for IMRT plans for PTV70, PTV63, and PTV56 were 97%, 99%, and 98% (CRT 91%, 98%, and 85%). IMRT plans demonstrated lower D(max) to the spinal cord and brainstem (42 and 36Gy) compared to CRT (46 and 39Gy). Median left parotid D(mean) was 35Gy (IMRT) vs. 53Gy (CRT). Median right parotid D(mean) was 35Gy (IMRT) vs. 36Gy (CRT). The median CR50/56Gy was 1.4 (CRT) vs. 1.2 (IMRT), CR70Gy 1.7 (CRT) vs. 1.1 (IMRT). CN50/56 and CN70 values were 0.80 and 0.85 (IMRT) vs. 0.56 and 0.5 (CRT).

CONCLUSIONS

IMRT provides superior target volume coverage and conformality, with decreased dose to normal structures.

Salvage oesophagectomy after local failure of definitive chemoradiotherapy

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Therapeutic strategies in oesophageal carcinoma: role of surgery and other modalities

Traditionally, surgery is considered the best treatment for oesophageal cancer in terms of locoregional control and long-term survival. However, survival 5 years after surgery alone is about 25%, and, therefore, a multidisciplinary approach that includes surgery, radiotherapy, and chemotherapy, alone or in combination, could prove necessary. The role of each of these treatments in the management of oesophageal cancer is under intensive research to define optimum therapeutic strategies. In this report we provide an update on treatment strategies for resectable oesophageal cancers on the basis of recent published work. Results of the latest randomised trials allow us to propose the following guidelines: surgery is the standard treatment, to be used alone for stages I and IIa, or possibly with neoadjuvant chemotherapy or chemoradiotherapy for stage IIb disease. For locally advanced cancers (stage III), neoadjuvant chemotherapy or chemoradiotherapy followed by surgery is appropriate for adenocarcinomas. Chemoradiotherapy alone should only be considered in patients with squamous-cell carcinomas who show a morphological response to chemoradiotherapy, and produces a similar overall survival to chemoradiotherapy followed by surgery, but with less post-treatment morbidity. Although the addition of surgery to chemotherapy or chemoradiotherapy could result in improved local control and survival, surgery should be done in experienced hospitals where operative mortality and morbidity are low. Moreover, surgery should be kept in mind as salvage treatment in patients with no morphological response or persistent tumour after definitive chemoradiotherapy.

Esophageal cancer located at the neck and upper thorax treated with concurrent chemoradiation: a single-institution experience

BACKGROUND

To characterize the treatment and outcome of patients with cervical and upper thoracic esophageal cancer, the authors retrospectively reviewed the 11-year experience from The University of Texas M. D. Anderson Cancer Center.

METHODS

Thirty-five patients with M0 cervical or upper thoracic esophageal cancer and treated with concurrent chemoradiotherapy were analyzed. Median radiation dose was 50.4 Gy (range, 24.5-64.8) Gy delivered with 1.8-Gy daily fractions over 5.5 weeks. Chemotherapy was 5-fluorouracil based. Response after treatment was evaluated on the basis of radiography, biopsy, or both. The survival rates were calculated by means of the Kaplan-Meier method.

RESULTS

The median follow-up for the surviving patients was 39 months. The actuarial 5-year overall survival (OS), cause-specific survival, disease-free survival, local relapse-free survival, and distant metastasis-free survival rates were 18.6%, 27.6%, 22.4%, 47.7%, and 57.0%, respectively. Patients who received a radiation dose of greater than or equal to 50 Gy had a higher complete response rate than those who received less than 50 Gy (79.2% versus 27.3%; p = 0.003). On multivariate analysis, radiation dose was the only protective factor associated with the rates of OS (p = 0.006), cause-specific survival (p = 0.003), and local relapse-free survival (p = 0.001); tumor stage was the only factor associated with rate of disease-free survival (p = 0.007).

CONCLUSION

Concurrent chemoradiotherapy is an effective treatment modality for patients with cervical and upper thoracic esophageal cancer. The authors' results suggest that a total radiation dose of 50 to 65 Gy with a concurrent chemotherapy regimen may improve local control and the OS rate in this rare type of esophageal cancer.

Chemoradiation Followed by Surgery Compared With Chemoradiation Alone in Squamous Cancer of the Esophagus: FFCD 9102

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.

Survival benefits from neoadjuvant chemoradiotherapy or chemotherapy in oesophageal carcinoma: a meta-analysis

BACKGROUND

Resectable oesophageal cancer is often treated with surgery alone or with preoperative (neoadjuvant) chemoradiotherapy or chemotherapy. We aimed to clarify the benefits of neoadjuvant chemoradiotherapy or chemotherapy versus surgery alone by a meta-analysis of randomised trial data.

METHODS

Eligible trials were identified first from earlier published meta-analyses and systematic reviews. We also used MEDLINE, Cancerlit, and EMBASE databases to identify additional studies and published abstracts from major scientific meetings since 1980. Only randomised studies with an analysis by an intention-to-treat principle were included, and searches were restricted to those databases citing articles in English. We used published hazard ratios if available or estimates from other survival data or survival curves. Treatment effects by type of tumour and treatment sequencing were also investigated.

FINDINGS

Ten randomised comparisons of neoadjuvant chemoradiotherapy versus surgery alone (n=1209) and eight of neoadjuvant chemotherapy versus surgery alone (n=1724) in patients with local operable oesophageal carcinoma were identified. The hazard ratio for all-cause mortality with neoadjuvant chemoradiotherapy versus surgery alone was 0.81 (95% CI 0.70-0.93; p=0.002), corresponding to a 13% absolute difference in survival at 2 years, with similar results for different histological tumour types: 0.84 (0.71-0.99; p=0.04) for squamous-cell carcinoma (SCC), and 0.75 (0.59-0.95; p=0.02) for adenocarcinoma. The hazard ratio for neoadjuvant chemotherapy was 0.90 (0.81-1.00; p=0.05), which indicates a 2-year absolute survival benefit of 7%. There was no significant effect on all-cause mortality of chemotherapy for patients with SCC (hazard ratio 0.88 [0.75-1.03]; p=0.12), although there was a significant benefit for those with adenocarcinoma (0.78 [0.64-0.95]; p=0.014).

INTERPRETATION

A significant survival benefit was evident for preoperative chemoradiotherapy and, to a lesser extent, for chemotherapy in patients with adenocarcinoma of the oesophagus. The findings provide an evidence-based framework for the use of neoadjuvant treatment in management decisions.

Systematic overview of preoperative (neoadjuvant) chemoradiotherapy trials in oesophageal cancer: evidence of a radiation and chemotherapy dose response

BACKGROUND AND PURPOSE

Numerous trials have shown that pathological complete response (pCR) following preoperative chemoradiotherapy (CRT) and surgery for oesophageal cancer is associated with improved survival. However, different radiotherapy doses and fractionations and chemotherapy drugs, doses and scheduling were used, which may account for the differences in observed pCR and survival rates. A dose-response relationship may exist between radiotherapy and chemotherapy dose and pCR.

PATIENTS AND METHODS

Trials using a single radiotherapy and chemotherapy regimen (5FU, cisplatin or mitomycin C-based) and providing information on patient numbers, age, resection and pCR rates were eligible. The endpoint used was pCR and the covariates analysed were prescribed radiotherapy dose, radiotherapy dosexdose per fraction, radiotherapy treatment time, prescribed chemotherapy (5FU, cisplatin and mitomycin C) dose and median age of patients within the trial. The model used was a multivariate logistic regression.

RESULTS

Twenty-six trials were included (1335 patients) in which 311 patients (24%) achieved pCR. The probability of pCR improved with increasing dose of radiotherapy (P=0.006), 5FU (P=0.003) and cisplatin (P=0.018). Increasing radiotherapy treatment time (P=0.035) and increasing median age (P=0.019) reduced the probability of pCR. The estimated alpha/beta ratio of oesophageal cancer was 4.9 Gy (95% confidence interval (CI) 1.5-17 Gy) and the estimated radiotherapy dose lost per day was 0.59 Gy (95% CI 0.18-0.99 Gy). One gram per square metre of 5FU was estimated to be equivalent to 1.9 Gy (95% CI 0.8-5.2 Gy) of radiation and 100mg/m2 of cisplatin was estimated to be equivalent to 7.2 Gy (95% CI 2.1-28 Gy). Mitomycin C dose did not appear to influence pCR rates (P=0.60).

CONCLUSIONS

There was evidence of a dose-response relationship between increasing protocol prescribed radiotherapy, 5FU and cisplatin dose and pCR. Additional significant factors were radiotherapy treatment time and median age of patients within the trial.

Feasibility of chemoradiation therapy with protracted infusion of5-fluorouracil for esophageal cancer patients not suitable for cisplatin

BACKGROUND

Chemoradiation therapy is the standard treatment for esophageal cancer in patients not fit for surgery. The regimen most commonly used includes cisplatin and 5-fluorouracil. Little data exists regarding alternative chemotherapy regimens in patients not suitable for cisplatin. We report on a regimen using protracted infusion 5-fluorouracil alone for both curative and palliative indications.

METHODS

Twenty-two patients with localized esophageal cancer suitable for curative chemoradiation therapy and 24 patients suitable for palliative therapy were enrolled. Chemotherapy consisted of 5-fluorouracil 225 mg/m(2) daily throughout the radiation therapy. The radiation dose was 56 to 60 Gy in 28 to 30 fractions (curative patients) and 30 to 35 Gy in 15 fractions (palliative patients).

RESULTS

The median age of the patients was 75 years. The regimen was tolerable. Significant grade 3 toxicities experienced were esophagitis (11%) and venous catheter toxicity (9%). The median survival was 17 months for curative patients and 9 months for palliative patients. The complete response rate was 86% endoscopically and 45% radiologically for curative patients. Relief of dysphagia was experienced in 67% of palliative patients. Quality of life was satisfactory in both groups.

CONCLUSIONS

This study showed that continuous-infusion 5-fluorouracil given concurrently with radiation therapy is a useful alternative to platinum-based chemoradiation therapy in patients with esophageal carcinoma.

[Radiotherapy and chemotherapy in the treatment of oesophageal carcinoma]

Surgery, chemotherapy and radiotherapy are the three major arms of treatment for cancer of the oesophagus, and combined modality therapy is required to treat advanced disease. Exclusive chemoradiotherapy is a feasible option for locoregionally advanced disease in responder patients. Elective surgery as a palliative procedure should not be regarded as a standard option in patients with metastatic or non-resectable oesophageal cancer. Surgery appears more and more as an adjuvant therapy in the curative treatment of oesophageal cancer, especially for advanced tumours.

Endoscopic response predicts for survival and organ preservation after primary chemoradiotherapy for esophageal cancer

PURPOSE

To determine the role of endoscopic surveillance in predicting organ preservation and survival after primary chemoradiotherapy (CRT) for esophageal cancer.

MATERIALS AND METHODS

Fifty-six consecutive patients with nonmetastatic esophageal cancer were treated with primary CRT between May 1993 and April 1999 with curative intent and subsequent surveillance with endoscopy and CT scans. Patients with residual disease on endoscopy and/or CT 6 weeks after CRT were considered for immediate esophagectomy. The remaining patients continued endoscopic surveillance and were considered for esophagectomy only when local relapse was detected. Five-year survival was estimated using the Kaplan-Meier method, and univariate and multivariate analyses were performed to identify significant factors associated with disease-specific survival.

RESULTS

With a median follow-up of 62 months, the 5-year overall and disease-specific survival was 30% (95% confidence interval [CI]: 17%-43%) and 37% (95% CI: 22%-50%), respectively. Fourteen of 24 (58%) patients who survived more than 2 years did not require an esophagectomy. On univariate analysis, favorable prognostic factors for disease-specific survival were female gender (p = 0.026), CT-defined N(0) status (p = 0.027), and negative endoscopy at 6 weeks after CRT (p < 0.0001). On multivariate analysis, N(0) status and negative endoscopy after CRT remained significant (p = 0.03 and p < 0.0001, respectively) for disease-specific survival. On multivariate analysis for overall survival, female gender and negative endoscopy were significant (p = 0.35 and p < 0.001, respectively). The hazard ratios for disease-specific survival with positive nodal status and positive endoscopy were 2.44 (95% CI: 1.14-5.3) and 5.18 (95% CI: 2.3-11.6), respectively.

CONCLUSIONS

Endoscopic response after primary CRT for esophageal cancer was the most significant predictive factor for overall and disease-specific survival. Regular endoscopic surveillance after CRT achieved survival rates comparable to other strategies and successfully preserved the esophagus in the majority of patients who survived more than 2 years.

Diagnosis and therapy for advanced esophageal cancer

PURPOSE OF REVIEW

The majority of esophageal cancers are advanced at presentation, rendering cure unlikely, especially by surgery alone. Consequently, much research effort has been directed towards studies of adjuvant chemotherapy and chemoradiation, particularly in defining the best regimens from the standpoint of efficacy and minimal toxicity and in an attempt to predict response.

RECENT FINDINGS

Overall results of adjuvant therapy have been conflicting, although a survival advantage has been documented in those demonstrating objective response to chemoradiation. In such circumstances, comparable survival has been demonstrated using chemoradiation alone, leading to the hypothesis that surgery may be best reserved for nonresponders. For those with stage IV disease or unfit for radical treatment, a variety of palliative modalities exist including stenting, laser photocoagulation, brachytherapy, and chemotherapy used singly or in combination, the latter providing encouraging improvement in survival over single-modality treatment.

SUMMARY

Current research is directed towards securing better results using newer chemotherapeutic agents such as taxanes and irinotecan and deploying molecular markers both to predict response to chemotherapy and to target its delivery to tumor sites.

Factors predictive of survival for esophageal carcinoma treated with preoperative radiotherapy with or without chemotherapy followed by surgery

PURPOSE

To evaluate parameters that may influence prognosis in patients treated with preoperative radiotherapy (RT) or chemoradiation.

METHODS AND MATERIALS

One hundred seventy-six patients with esophageal carcinoma received preoperative radiotherapy (45 patients) or chemoradiation (131 patients). Forty-three received no surgery (NS), 32 had exploratory surgery (ES), and 101 received definitive surgery (DS).

RESULTS

Five-year cause-specific survival and absolute survival rates were overall, 19% and 16%; NS group, 0% and 0%; ES group, 3% and 3%; DS group, 30% and 26%. On univariate analysis, definitive surgery (P < 0.0001), tumor size less than 5 cm (P < 0.0001), and chemotherapy (P = 0.0015) were significant predictors of improved cause-specific survival. Cause-specific survival was 51% for tumors </=3 cm (n = 33), 32% for 3.1 to 4 cm (n = 28), and 16% for 4.1 to 5 cm (n = 29). No patient with a tumor >/=6 cm (n = 86) survived. Multivariate analysis of the DS group showed complete or partial pathologic response (P = 0.0001), chemotherapy (P = 0.0026), and overall treatment time less than 3 months (P = 0.0405) significantly predicted improved cause-specific survival. Tumor <5 cm was marginally significant (P = 0.0515).

CONCLUSION

Patients who undergo preoperative chemoradiation and definitive surgery have improved survival.

Relapse patterns after chemo-radiation for carcinoma of the oesophagus

AIM

The detailed review of patterns of failure in this report was undertaken to identify the continuing obstacles to the successful management of oesophageal cancer, and to establish whether there is a case to compare definitive chemo-radiation (Def-CR) and surgery for patients with squamous cancer in a randomized controlled trial.

MATERIALS AND METHODS

First and subsequent sites of failure were reviewed in 274 patients treated with Def-CR using two cycles of cisplatin, infusional fluorouracil and 60 Gy; and 92 patients with limited chemo-radiation (CR), using one cycle and 35 Gy, followed by surgery (CR-Surg). All were treated on prospective non-randomized trials run by the Trans-Tasman Radiation Oncology Group between 1985 and 1999. Failure patterns were analysed using competing risks methodology, and pre-treatment variables predicting survival were identified by proportional hazards modelling.

RESULTS

Site, stage, performance status and gender were independently predictive of survival following Def-CR. Local failure was evident in 42.3% of patients, but distant failure in isolation occurred in an additional 18.1%. Lowest rates of local and distant failure at 5 years (29.9% and 26%) occurred in patients with squamous cancer (SCC) located in the upper-third, whose 5-year survival was also the most favourable (49.2%). Survival was least favourable in patients with adenocarcinoma (AC) in the lower two-thirds (18.1%) due to higher rates of local (51.5%) and distant (36.1%) failure. Local failure occurred in 31.5% of patients undergoing CR-Surg but distant failure in isolation was observed in a further 34.7%. Outcomes were least favourable in patients with AC of the lower-third in whom 57.7% failed distantly and 5-year survival was 3.8%. Response to pre-operative chemo-radiation was also strongly predictive of outcome. Patients with no residual cancer in the resection specimen had the lowest rates of local (0%) and distant (16.7%) failure and the best survival (64.9%). Survival in patients with residual cancer in nodes, however, was extremely poor (3.5%) with distant failure occurring in 66.7%.

CONCLUSION

The concurrent administration of chemotherapy with radiotherapy seems to have improved loco-regional control and has exposed distant failure as an obstacle to further improvements in outcome. Site, histological subtype, gender and response to chemo-radiation may predict biological differences in oesophageal cancer (OC) that influence outcome. A good case for a randomized comparison between Def-CR and CR-Surg in patients with SCC in the lower two-thirds exists.

Locally advanced esophageal cancer

Patients diagnosed with adenocarcinoma or squamous cell carcinoma of the esophagus should undergo computed tomography of the chest and abdomen and positron emission tomography to look for evidence of distant metastatic disease. In the absence of systemic metastases, locoregional staging should be performed with endoscopic ultrasonography and fine needle aspiration of accessible periesophageal lymph nodes and any detectable celiac lymph nodes. Patients found to have T3 tumors (transmural extension), T4 tumors (invasion of adjacent structures), or N1-M1a (lymph node-positive) disease do poorly when treated with surgery alone; 5-year survival is less than 20%. These patients should be considered for combined modality therapy. Patients with T4 disease are generally not deemed candidates for surgical resection; they may be considered for definitive chemoradiotherapy. Patients with T3 disease or lymph node-positive disease may be treated with neoadjuvant chemoradiotherapy followed by surgery or definitive chemoradiotherapy alone. Patients considered for trimodality therapy should be fully restaged before surgery to assess their response to neoadjuvant treatment. This should include repeat endoscopic ultrasound and fine needle aspiration of lymph nodes. Patients whose lymph node metastases do not completely respond to neoadjuvant therapy are unlikely to benefit from the addition of surgery. Patients with persistently positive celiac lymph nodes have a very poor prognosis and should not undergo surgery. Patients with persistent nodal disease who have good performance status may be considered for additional chemotherapy. Patients with locally advanced esophageal cancer who have poor performance status are not good candidates for combined modality therapy. These individuals are best managed with palliative intent. Particular attention should be given to alleviating the common problem of dysphagia, which causes significant morbidity.

Measurements of tumor tissue oxygen tension using a time-resolved luminescence-based optical oxylite probe: comparison with a paired survival assay

Recently, a system that measures tissue oxygen tension using time-resolved luminescence-based optical sensors has become available commercially (Oxford Optronix, Oxford, England). Two experiments were conducted using this system. First, the oxygen tension distribution was measured in two tumor lines: a spontaneous mouse fibrosarcoma, FSa-II, and a human squamous cell carcinoma xenograft, FaDu. The area in which the pO(2) was equal to or lower than 2.5 mmHg was defined as the hypoxic lesion, and the hypoxic cell fraction was taken as the fraction of these measurements in a tumor. The measured hypoxic cell fractions were compared with those determined by the paired cell survival assay for tumors of various sizes. Second, the tumor tissue pO(2) was measured continuously after administration of two different anesthetics to evaluate the effect of these drugs on tissue pO(2). Results indicated a good agreement between the hypoxic cell fractions measured by this system and those determined by the paired cell survival curve assay for tumors smaller than approximately 500 mm(3). For tumors larger than approximately 500 mm(3), the hypoxic cell fractions measured by the oxygen probe system were higher than those measured by the paired cell survival assay. This may suggest that the hypoxic cell fraction measured by the oxygen probes included both hypoxic and necrotic areas in large tumors where necrotic lesions occupied a significant portion of the tumor. Continuous measurements of pO(2) after anesthesia (Nembutal, or ketamine plus xylazine) showed a consistent rise in the pO(2) during the first 20-30 min of measurement. Subsequently, the pO(2) values became constant or continued to rise slowly. For comparison, the tumor cell survivals were assayed after a dose of 20 Gy given in air at 5, 20 and 60 min after anesthesia. The result showed a decrease in cell survival only in tumors irradiated 20 min after an injection of Nembutal.

Does histologic grade have a role in the management of head and neck cancers?

PURPOSE

High histologic grade is usually associated with a greater propensity to distant metastases (DM). Its role to predict DM in head and neck cancer is not yet defined. The aim of this study is to evaluate the role of histologic grade as an independent predictor of DM and to determine a subgroup of patients who may benefit from systemic chemotherapy.

PATIENTS AND METHODS

This is a retrospective study of 1,266 consecutive patients treated by definitive or postoperative radiotherapy between 1989 and 1997. All patients received at least 50 Gy. All stages and subsites of head/neck were included. DM rates were evaluated by the Kaplan-Meier method with a subsequent Cox analysis.

RESULTS

There is a strong correlation of grade with N stage (P <.000001). The metastases-free survival (MFS) was 98%, 90%, and 72% for grades 1, 2, and 3, respectively (P <.000001). In patients with N0 stage, MFS is always greater than 90%, whatever the grade. In the 222 N1 patients, MFS was more than 90% in grade 1 and 2 but dropped to 75% for grade 3 (P =.001). In patients with N2 and N3, MFS was 91%, 79%, and 59% for grades 1, 2, and 3, respectively (P =.008). The same conclusion is applicable when only patients with neck control are analyzed. In a Cox model, grade was an independent predictor of DM (P =.000001) as well as T stage (P =.003), N stage (P =.000001), and neck failure (P =.0003). Higher grade was also an independent predictor of survival (P =.02).

CONCLUSION

Patients with histologic grade 1 and grade 2 (except N3) are at low risk of DM. Patients with grade 2 and N3 or patients with grade 3 and N1 to N3 have a higher risk of distant metastases and should be considered for systemic treatment.

Localization of small esophageal cancers for radiation planning using endoscopic contrast injection: report on a series of eight cases

Recently, Barrett's esophagus and early adenocarcinomas have been detected increasingly frequently in routine follow-up of patients with gastroesophageal reflux. Although surgery is the treatment of choice, some patients are medically unfit for esophagectomy and, in this case, the only alternative curative therapy is radical chemoradiation therapy. In addition, some patients who present with symptoms have small tumors that cannot be localized accurately using routine imaging techniques. This report describes a series of eight patients with small esophageal cancers in whom the tumors were successfully localized following endoscopic injection of contrast, and treated with chemoradiation therapy. The treatment was successful in seven patients. This method of tumor localization demonstrated that conventional techniques are mostly unreliable when applied to very early cancers.

Localized squamous-cell cancer of the esophagus: retrospective analysis of three treatment schedules

BACKGROUND AND PURPOSE

A retrospective study comparing chemotherapy and radiation, esophagectomy alone versus preoperative radiochemotherapy and surgery in localized squamous-cell esophageal carcinoma.

MATERIALS AND METHODS

Between 1989 and 1995, 139 patients (40 stage I, 77 stage IIA and 22 stage IIB according to the UICC 78 TNM classification) were treated in two different institutions. They were divided into three groups according to the treatment proposed: E group (treatment by esophagectomy; n = 30), RCT+E group (treatment by preoperative radiochemotherapy and esophagectomy; n = 46), RCT group (treatment by radiochemotherapy; n = 63). Factors like age, tumor localization and stage were similar in all groups. An intention to treat analysis was made.

RESULTS

The E group showed no postoperative mortality, while in the RCT+E group, the surgery mortality was 12.8%. The mortality after RCT was 1.7%. After preoperative radiochemotherapy, a pathological complete response was observed in 25% of cases and the curative resection rate was higher (82% after RCT + E versus 60% after E). The 5-year survival difference between the three groups was not relevant (E group, 12.6%; RCT group, 25.8%; RCT + E group, 38.7%). The median survival was 29, 24 and 28.5 months, respectively. The event-free survival was identical for the E group and the RCT group. For patients treated by radiochemotherapy, local and/or distant relapses were significantly reduced by esophagectomy (relapses occurred in 51% of patients in the RCT + E group versus 75% in the RCT group, P = 0.017). Palliative care (dilatations, prosthesis, gastrostomy or jejunostomy) to improve dysphagia was necessary for 38% of patients treated by exclusive radiochemotherapy versus 11% of patients treated by surgery (P = 0.001).

CONCLUSIONS

Treatments by esophagectomy or radiochemotherapy were not significantly different. Preoperative radiochemotherapy and surgery lead to a higher survival rate than exclusive radiochemotherapy, however, with a high postoperative mortality rate. This study suggests the relevance of a prospective randomized trial to compare RCT+E and RCT alone.

Preoperative (neoadjuvant) chemoradiotherapy in oesophageal cancer

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.

A quantitative treatment planning study evaluating the potential of dose escalation in conformal radiotherapy of the oesophagus

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%.

Modern pathology: prognostic parameters in squamous cell carcinoma of the esophagus

In the present study the prognostic impact of new histological and molecular parameters were tested retrospectively in a series of 149 patients with esophageal squamous cell carcinoma (SCC) who underwent potentially curative resection therapy. In addition, the prognostic value of various molecular markers was investigated in a group of 38 patients with locally advanced esophageal SCC treated using combined therapy modalities. In the surgically treated carcinomas, the following morphological parameters proved to be prognostically significant in univariate survival analysis and multivariate survival analysis: pattern of invasion, inflammatory response, and lymph vessel invasion. In contrast, tumor grading according to the criteria of the WHO and tumor cell proliferation did not show significant prognostic impact. Concerning the prognostic influence of molecular parameters, strong expression of the proliferation regulating molecule p21WAF1 and weak expression of the apoptosis regulating molecule Bcl-XL were predictors of poor survival in univariate and multivariate survival analysis. No prognostic impact was shown in relation to the expression of p53 and the apoptosis regulating molecules Bcl-2 and Bax. In the multimodally treated esophageal cancer patients, strong expression of p21WAF1 and accumulation of p53 were predictors of poor survival, whereas expression of Bcl-2, Bax, and Bcl-XL had no prognostic significance. In conclusion, morphological and molecular parameters may provide important prognostic information for esophageal cancer patients.

Primary chemo-radiotherapy and selective oesophagectomy for oesophageal cancer: goal of cure with organ preservation

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.

Outcome of patients receiving radiation for cancer of the esophagus: results of the 1992-1994 Patterns of Care Study

PURPOSE

A Patterns of Care Study examined the records of patients with esophageal cancer (EC) treated with radiation in 1992 through 1994 to determine the national practice processes of care and outcomes and to compare the results with those of clinical trials.

PATIENTS AND METHODS

A national survey of 63 institutions was conducted using two-stage cluster sampling, and specific information was collected on 400 patients with squamous cell (62%) or adenocarcinoma (37%) of the thoracic esophagus who received radiation therapy (RT) as part of primary or adjuvant treatment. Patients were staged according to a modified 1983 American Joint Committee on Cancer staging system. Fifteen percent of patients had clinical stage (CS) I disease, 40% had CS II disease, and 30% had CS III disease. Twenty-six percent of patients underwent esophagectomy. Seventy-five percent of patients received chemotherapy; 84% of these received concurrent chemotherapy and radiation (CRT).

RESULTS

Significant variables for overall survival in multivariate analysis include the use of esophagectomy (risk ratio [RR] = 0.62), the use of chemotherapy (RR = 0.63), Karnofsky performance status (KPS) greater than 80 (RR = 0.61), CS I or II disease (RR = 0.66), and facility type (RR = 0.72). Age, sex, and histology were not significant. Preoperative CRT resulted in a nonsignificantly higher 2-year survival rate compared with definitive CRT alone (63% v 39%; P =.11), whereas 2-year survival by planned treatment rather than treatment given was 47.7% for preoperative CRT and 35.4% for definitive CRT (P =.23). Definitive CRT compared with definitive RT alone resulted in significantly higher 2-year survival (39% v 20.6%; P =.027) and lower 2-year local regional failure (30% v 57.9%; P =. 0031).

CONCLUSION

This study confirms the value of CRT in EC treatment. It indicates that the results obtained in practice settings nationwide are similar to those obtained in clinical trials and that KPS and the 1983 clinical staging system are useful prognostic indicators. The suggested value of esophagectomy and superiority of preoperative CRT over CRT alone in this study should be tested in a randomized trial.

Causes for increased myelosuppression with increasing age in patients with oesophageal cancer treated by chemoradiotherapy

The aim of this study was to identify why increasing myelosuppression accompanies increasing age in patients treated for oesophageal cancer by chemoradiation. Weekly neutrophil and platelet counts were obtained throughout treatment in 86 patients undergoing chemoradiation without surgery for oesophageal cancer. One or two cycles of cisplatin 80 mg/m2/day followed by 5-fluorouracil 800 mg/m2/day for 4-5 days were administered during the first and fourth or fifth week of radiotherapy using 2 Gy daily fractions. 44 of the patients underwent 5-fluorouracil pharmacokinetic studies. Multiple regression procedures were used to determine the strength of factors that contribute to initial and nadir neutrophil and platelet counts. The kinetics of myeloid response were evaluated from the rates of disappearance and re-appearance of neutrophils and platelets during treatment. Age, fluorouracil dose (or AUC), baseline body weight and neutrophil (or platelet) count were found to be powerfully and independently predictive of both first neutrophil and platelet nadir count. Baseline neutrophil and platelet counts were also found to correlate negatively with advancing age independently of other factors. The rate of descent of both indices, however, was independent of age, baseline count and fluorouracil dose suggesting that variations in the size of the myeloproliferative compartment prior to treatment were responsible for interpatient variations. In addition, the rate of recovery of both indices was not influenced by age amongst patients in whom data was assessable suggesting that proliferation of surviving marrow elements is not compromised by age. These data are compatible with the hypothesis that a progressive depletion of the myeloid stem cell compartment accompanies advancing age, and that this is responsible for increasing myelotoxicity.

What is the role of radiation-chemotherapy in the radical non-surgical management of carcinoma of the oesophagus? Upper GI Cancer Working Party of the UK Medical Research Council

The optimal radical non-surgical management of carcinoma of the oesophagus has yet to be determined. The combination of high-dose radiotherapy with chemotherapy is being explored, particularly in North America. The MRC Upper GI Working Party has debated the areas where there is scientific uncertainty and which clinical trials may be appropriate to undertake in the UK.

A combined modality approach to the management of oesophageal cancer

This study aims to update the experience of multimodality approaches in the management of oesophageal cancer that have been adopted in several Australian and New Zealand hospitals. Between 1984 and 1985, 92 patients received pre-operative radiotherapy (30-36 Gy over 3 weeks) and one of two chemotherapy regimes (one or two courses of i.v. cisplatin 80 mg/m2 plus a 4-5 day continuous i.v. of fluorouracil 5-800 mg/m2/day) concurrently prior to surgery. Eighty-two patients (89%) underwent resection as planned. Operative specimens were microscopically free of residual tumour in 18 patients. Eight patients (9%) had treatment-related deaths: seven from surgery and one due to pre-operative chemoradiation. The Kaplan-Meier 5-year cause-specific survival estimates were 32.9 +/- 7.8% for the 58 patients with squamous cancer and 0% for the 32 with adenocarcinoma. Complete pathological response to the pre-operative regime was more common in females and was associated with a survival advantage. Five-year cause-specific survival expectation in patients who experienced a complete pathological response was 71.5 +/- 12.4%, whereas it was only 15.9 +/- 5.6% in patients who had residual cancer in their surgical specimens. Although less toxic the pre-operative regime utilizing only one cycle of chemotherapy was no less efficacious either in producing a complete pathological response or in terms of survival expectation. This uncontrolled pilot study has produced encouraging long-term results, especially for patients with squamous carcinoma that experienced a complete response to pre-operative synchronous chemoradiotherapy. A randomized controlled study comparing surgery alone with (one cycle) chemoradiation followed by surgery is now underway.