Definitive chemoradiation therapy with docetaxel, cisplatin, and 5-fluorouracil (DCF-R) in advanced esophageal cancer: a phase 2 trial (KDOG 0501-P2). Int J Radiat Oncol Biol Phys. 2014;89:872-879. [PMID: 24867539 DOI: 10.1016/j.ijrobp.2014.03.030]

Pembrolizumab plus cisplatin and fluorouracil as induction chemotherapy followed by definitive chemoradiotherapy for patients with cT4 and/or supraclavicular lymph node metastasis (M1Lym) of esophageal squamous cell carcinoma

Definitive chemoradiotherapy (DCRT) is administered as standard treatment for patients with cT4 and/or M1Lym esophageal squamous cell carcinoma (ESCC); however, its long-term result is inadequate. Although several studies have reported that conversion surgery can improve the survival of these patients, none have identified significantly better long-term survival than that achieved by DCRT. Thus, enhancing DCRT seems important to improve the survival of these patients. A strategy of shrinking tumor volume before DCRT and providing consolidation chemotherapy for systemic control is expected to improve the survival of these patients. Pembrolizumab plus cisplatin and fluorouracil has demonstrated good local control and significant improvement in the survival of patients with advanced esophageal cancer. Based on these results, the following strategy is proposed: This protocol should be applied as induction for these patients; then, DCRT should be provided depending on the initial response; and finally, adjuvant chemotherapy with an immune checkpoint inhibitor should be given to all responders.

A Meta-Analysis and Review of Radiation Dose Escalation in Definitive Radiation Therapy between Squamous Cell Carcinoma and Adenocarcinoma of Esophageal Cancer

Esophageal cancer, ranked as the eighth most prevalent cancer globally, is characterized by a low survival rate and poor prognosis. Concurrent chemoradiation therapy (CCRT) is the standard therapy in the non-surgical treatment of localized carcinoma of the esophagus. Nevertheless, the radiation doses employed in CCRT remain notably lower compared to the curative definite chemoradiation therapy utilized in the management of other carcinomas. In order to increase the local control rates and enhance the treatment outcomes, several clinical trials have used high-dose radiation to analyze the effect of dose escalation. Despite the integration of technically advanced RT schemes such as intensity-modulated radiation therapy (IMRT), the results of these trials have failed to demonstrate a significant improvement in overall survival or local progression-free survival. In this review, we investigated previous clinical trials to determine the ineffectiveness of radiation dose escalation in the context of CCRT for esophageal cancer. We aim to clarify the factors contributing to the limited efficacy of escalated radiation doses in improving patient outcomes. Furthermore, we delve into recent research endeavors, exploring prospective radiation dose modifications being altered based on the histological characteristics of the carcinoma. The exploration of these recent studies not only sheds light on potential refinements to the existing treatment protocols but also seeks to identify novel approaches that may pave the way for more efficacious and personalized therapeutic strategies for esophageal cancer management.

Prognostic value of radiomic features in patients with esophageal cancer treated with chemoradiotherapy

BACKGROUND

The aim of the present study was to evaluate the prognostic value of radiomic features in patients who underwent chemoradiotherapy for esophageal cancer.

METHODS

In this retrospective study, two independent cohorts of esophageal cancer patients treated with chemoradiotherapy were included. Radiomics features of each patient were extracted from pre-treatment computed tomography (CT) images. Radiomic features were selected by employing univariate and multivariate analyses in the test cohort. Selected radiomic features were verified in the validation cohort. The endpoint of the present study was overall survival.

RESULTS

A total of 101 esophageal cancer patients were included in our study, with 71 patients in the test cohort and 30 patients in the validation cohort. Univariate analysis identified 158 radiomic features as prognostic factors for overall survival in the test cohort. A multivariate analysis revealed that root mean squared and Low-High-High (LHH) median were prognostic factors for overall survival with a hazard ratio of 2.23 (95% confidence interval [CI]: 1.16-4.70, P = 0.017) and 0.26 (95% CI: 0.13-0.54, P < 0.001), respectively. In the validation cohort, root mean squared high/LHH median low group had the most preferable prognosis with a median overall survival of 73.30 months (95% CI: 32.13-NA), whereas root mean squared low/LHH median low group had the poorest prognosis with a median overall survival of 9.72 months (95% CI: 2.50-NA), with a P value of < 0.001.

CONCLUSIONS

We identified two radiomic features that might be independent prognostic factors of overall survival of esophageal cancer patients treated with chemoradiotherapy.

The impact of radiation dose on the efficacy of definitive chemoradiotherapy in patients with locally advanced esophageal carcinoma: a systematic review and meta-analysis

To investigate the impact of radiation dose on the efficacy of definitive chemoradiotherapy(dCCRT) in patients with locally advanced esophageal carcinoma. PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Wanfang, and Chinese National Knowledge Infrastructure(CNKI) were searched for eligible studies. Studies that compared high-dose radiation(HD-RT) group with low-dose radiation(LD-RT) group using modern radiotherapy techniques for locally advanced esophageal carcinoma patients in dCCRT were identified. The hazard ratios (HR) for overall survival (OS), progression-free survival (PFS), and the odds ratios (OR) for clinical complete response (cCR), local-regional failure (LRF), distant metastasis (DM), and grade≥3 AEs. Meta-analysis was performed when relevant data were available. Eleven studies involving 1943 patients were included for analyses. The results showed that the HD-RT group had better OS (pooled HR 0.78 [0.70, 0.87], p < .00001), PFS (pooled HR 0.72 [0.55, 0.94], p = .01), cCR (OR 1.52 [1.13, 2.05], p = .005), and LRF (OR 0.60 [0.45, 0.80], p = .0004). In addition, there were no significant differences between the two groups in terms of DM (OR 1.43 [1.00, 2.04], p = .05), grade 3-5 radiation pneumonitis (OR 1.38 [0.71, 2.68], p = .35), grade 3-5 radiation esophagitis (OR 1.36 [0.88, 2.10], p = .17), grade 3-5 other esophageal toxicities(stenosis/fistula/hemorrhage) (OR 1.22 [0.75, 2.00], p = .43), and treatment-related death (OR 1.40 [0.73, 2.68], p = .31). High-dose radiotherapy in definitive CCRT for patients with locally advanced esophageal carcinoma is associated with improved PFS, OS, cCR, and LC with no increase of grade≥3AEs. Simultaneously, we await the preliminary and final results of several ongoing dose-escalation randomized trials. Furthermore, future studies should provide personalized radiotherapy doses for these patients.

Metachronous Squamous Cell Carcinoma of the Esophagus After Resolution of Previous Adenocarcinoma

Esophageal cancer is the sixth leading cause of cancer-related death worldwide. Metachronous malignancies refer to multiple independent primary cancers diagnosed at least 6 months apart. The incidence of metachronous esophageal cancers with different histologic subtypes is extremely rare. This case presents an unprecedented occurrence of esophageal adenocarcinoma, followed by metachronous squamous cell carcinoma.

High-dose versus standard-dose radiotherapy in concurrent chemoradiotherapy for inoperable esophageal cancer: a systematic review and meta-analysis

PURPOSE

The aim of this study was to evaluate the effectiveness and safety of high-dose (HD-RT) versus standard-dose radiotherapy (SD-RT) in concurrent chemoradiotherapy (CCRT) for inoperable esophageal cancer (EC) patients.

METHODS

A systematic search of the literature was conducted by screening PubMed, Web of Science, EMBASE and Cochrane Library databases before October 7, 2022 to collect controlled clinical studies of high-dose (≥ 60Gy) and standard-dose (50-50.4Gy) radiation in CCRT for EC. For statistical analysis, a fixed-effects model was used to synthesize HR and OR if there was no significant heterogeneity among studies; otherwise, a random-effects model was employed.

RESULTS

There were ten studies with 4625 patients included in the study, 3667 of whom (79.3%) were esophageal squamous cell carcinoma (ESCC). The HD-RT group had no significant benefits in overall survival (OS) (HR = 0.88, 95% confidence interval [CI] = 0.74-1.05, P = 0.16) and progression-free survival (HR = 0.84, 95%CI = 0.67-1.04, P = 0.12) in total EC patients, compared with SD-RT group. However, in ESCC subgroup analysis, compared with SD-RT group, a better OS was observed in the HD-RT group (HR = 0.78, 95%CI = 0.70-0.88, P < 0.0001).

CONCLUSION

Compared with the radiation dose of 50-50.4Gy, the increase of radiation dose (≥ 60Gy) did not achieve benefits in survival for inoperable EC patients receiving CCRT. However, in patients with ESCC, high dose (≥ 60Gy) of radiation probably improved OS.

Multimodal Treatment Strategies to Improve the Prognosis of Locally Advanced Thoracic Esophageal Squamous Cell Carcinoma: A Narrative Review

Esophageal cancer is the seventh most common malignancy and sixth most common cause of cancer-related death globally. Esophageal squamous cell carcinoma (ESCC) with aortic or tracheal invasion is considered unresectable, and has an extremely poor prognosis; its standard treatment is definitive chemoradiotherapy (dCRT). In recent years, induction chemotherapy (ICT) has been reported to yield high response rates for locally advanced ESCC, and the efficacy and safety of ICT followed by conversion surgery (CS) have been investigated. Multimodal treatment, combining surgery with induction chemoradiotherapy (ICRT) or ICT, is necessary to improve ESCC prognosis. CS is generally performed for locally advanced ECC after ICRT or ICT when tumor downstaging is achieved, although its prognostic benefit remains controversial. The Japan Clinical Oncology Group (JCOG) has conducted a three-arm phase III randomized controlled trial (JCOG1510) to confirm the superiority of DCF (docetaxel, cisplatin, and 5-fluorouracil) ICT, over conventional dCRT, among patients with initially unresectable ESCC. In recent years, researchers have reported favorable outcomes of induction therapy followed by CS and salvage surgery, after dCRT or systemic immunochemotherapy. In this review, we will describe the latest developments in the multimodal treatment including chemotherapy, CRT, surgery, and immunotherapy, which may improve oncological and survival outcomes for patients with cT4 ESCC.

[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.

Comparison of Concurrent Chemoradiotherapy with Radiotherapy Alone for Locally Advanced Esophageal Squamous Cell Cancer in Elderly Patients: A Randomized, Multicenter, Phase II Clinical Trial

This randomized, multicenter, phase II clinical trial was performed to compare the safety and efficacy of concurrent chemoradiotherapy using S-1 (CCRT) with radiotherapy alone (RT) for elderly patients with locally advanced esophageal squamous cell carcinoma (ESCC). All eligible patients were randomly assigned to the CCRT group or the RT group at a 1:1 ratio. The CCRT group received 50.4 Gy radiotherapy concurrent with S-1 and the RT group received 59.4 Gy radiotherapy alone. The primary endpoints were toxicity and the overall response rate (ORR), and the secondary endpoints were overall survival (OS) and progression-free survival (PFS). In total, 157 elderly patients with ESCC were recruited from December 2016 to March 2020. By June 2021, the median follow-up duration had reached 38 months. No grade 5 toxicities occurred in either group and the overall rate of severe toxicities (≥grade 3) was higher in the CCRT group (19.2% to 7.6%; p=0.037), particularly neutropenia (7.7% vs. 1.3%; p=0.06). The CCRT group presented a significantly higher ORR (83.3% vs. 68.4%; p=0.009) and prolonged PFS (25.7 months vs.13.9 months; p=0.026) than the RT group. The median OS was 27.3 months in the CCRT group and 19.1 months in the RT group (p=0.59). For patients older than 70 years with locally advanced ESCC, concurrent chemoradiotherapy with S-1 had tolerable adverse effects and improved ORR and PFS compared with radiotherapy alone.

Surgical strategies for treatment of clinical T4 esophageal cancer in Japan

Definitive chemoradiation (dCRT) is the mainstay treatment for cStage IVa esophageal squamous cell carcinoma (ESCC) with good performance status (PS), according to standard practice guidelines. Salvage surgery may incur operation complications and risk of mortality. According to the esophageal cancer practice guidelines outlined by the Japan Esophageal Society, when a tumor is residual and recurrent, chemotherapy and palliative symptomatic treatment is continued. However, salvage operation has been selected as a therapeutic option for recurrent or residual tumors after dCRT. There is weak evidence for not recommending surgery for cStage IVa ESCC exhibiting residual disease following dCRT. It has been reported that during salvage surgery the only prognostic factor that is thought to be performed is complete resection (R0), but at the same time, salvage esophagectomy increases the incidence of postoperative complications and mortality. The phase II chemoselection study by Yokota T et al. in Japan showed that multidisciplinary treatment initiated by induction therapy, in which docetaxel is added to cisplatin and 5-fluorouracil, resulted in a good prognosis in the short term. In this review, we discuss the surgical strategy and future of unresectable clinical T4 (cT4) ESCC.

Clinical Prognostic Factors for Patients With Esophageal Cancer Treated With Definitive Chemoradiotherapy

Background Treatment with definitive chemoradiotherapy (CRT) is the best option for patients with locally advanced esophageal tumors considered unresectable or for patients without clinical conditions to undergo surgical treatment. Technological advances in radiotherapy in the last decades have made treatment more accurate with less toxicity, and the association with more effective systemic treatment has been gradually improving survival rates. Aim Evaluate clinical prognostic factors for progression-free survival (PFS) and overall survival (OS) in patients with esophageal cancer treated with definitive radiotherapy (RT) and chemotherapy (ChT). Material and methods The clinical records of 60 patients treated from April 2011 until December 2019 with esophageal cancer considered unresectable and/or without clinical conditions for surgery, treated with definitive CRT, were analyzed. All patients had upper digestive endoscopy (UDE) with positive biopsy, neck, chest, and abdominal CT scan, and 18F-fluorodeoxyglucose positron-emission tomography (PET-CT). Patients were followed with physical examination and CTs every three months in the first and second years and every six months from the third year of follow-up. UDE was made every three to six months after the end of the treatment or in suspicion of tumor recurrence. PET-CT was also performed in the follow-up when clinically necessary. Local and regional failure (LRF) was defined as abnormalities in the image tests within the planning target volume (PTV) and/or positive biopsy on UDE. Any other failure was defined as a distant failure (DF). PFS was defined in the record of the first tumor recurrence site and OS in the death record from the date of the start of treatment. Results The median age of the patients was 66 years (range: 33 to 83 years) and 46 patients (76.7%) were male. Squamous cell carcinoma (SCC) was the most frequent histological type (85%). Most patients had tumors located in the mid-thoracic esophagus (53.3%) and stage III or IV (59.9%). All patients were treated using 3D (76.7%) or intensity-modulated radiotherapy (IMRT; 23.3%). The median total dose was 50.4Gy (41.4-50.4). All patients received platinum-based ChT concomitant with RT. The most common regimen used was carboplatin and paclitaxel, with a median of five cycles. With a median follow-up of 19 months, the median PFS and OS were 10 and 20 months, respectively. LRF and DF as the first site of failure were observed in 22 (36.6%) and 26 (43.3%) patients, respectively. In the univariate analysis, tumor length lower than 2.6 cm, gross tumor volume (GTV) volume lower than 28 cm³, clinical tumor stages T1 and T2, clinical node stage N0, clinical prognostic stage groups I and II, and complete response to treatment, were statistically significant factors for better PFS and OS. In the multivariate analysis, the presence of clinical nodal stage N0 was related to better PFS (p=0.02). Conclusion Node clinical status was the most important clinical factor for PFS. Despite all the technical progress observed in radiotherapy, treatments concomitant with platinum-based chemotherapy are associated with high levels of LRF and DF. New strategies in systemic therapy and radiotherapy are necessary for improving outcomes.

Concurrent chemoradiotherapy with S-1 compared with concurrent chemoradiotherapy with docetaxel and cisplatin for locally advanced esophageal squamous cell carcinoma

Background

This retrospective study was to assess and compare the toxicity and efficacy of concurrent chemoradiotherapy (CCRT) with S-1 or docetaxel and cisplatin in patients with locally advanced esophageal squamous cell carcinoma (ESCC).

Methods

Patients with locally advanced ESCC who received CCRT with S-1 (70 mg/m² twice daily on days 1–14, every 3 weeks for 2 cycles, S-1 group) or docetaxel (25 mg/m²) and cisplatin (25 mg/m²) on day 1 weekly (DP group) between 2014 and 2016 were retrospectively analyzed. Radiotherapy was delivered in 1.8–2.0 Gy per fraction to a total dose of 50–60 Gy. Treatment-related toxicities (Common Terminology Criteria for Adverse Events version 4.0), response rate, and survival outcomes were compared between groups.

Results

A total of 175 patients were included in this study (72 in the S-1 group and 103 in the DP group). Baseline characteristics were well balanced between the two groups. The incidence of grade 3–4 adverse events were significantly lower in the S-1 group than that of the DP group (22.2% vs. 45.6%, p = 0.002). In the DP group, elderly patients (> 60 years) had a significantly higher rate of grade 3–4 adverse events than younger patients (58.1% vs. 31.3%, p = 0.01). The objective overall response rate (complete response + partial response) was 68.1% in the S-1 group, and 73.8% the DP group (p = 0.497). The 3-year overall survival was 34.7% in the S-1 group, and 38.8% in the DP group (p = 0.422). The 3-year progression free survival in the DP group was higher than that in the S-1 group but without significant difference (33.0% vs. 25.0%, p = 0.275).

Conclusion

CCRT with S-1 is not inferior to CCRT with docetaxel and cisplatin and is better tolerated in in elderly patients with locally advanced ESCC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13014-021-01821-6.

Prognostic value of pre-treatment maximum standardized uptake value and CRP in radiotherapy of esophageal cancer

The aim of the present study was to evaluate the prognostic value of the pre-treatment maximum standardized uptake value (SUV_max) and CRP in patients who underwent chemoradiotherapy for esophageal squamous cell carcinoma. A retrospective review of 69 consecutive patients with esophageal cancer who underwent concurrent chemoradiotherapy between 2013 and 2016 was performed. The total radiotherapy doses were 50, 50.4 or 60 Gy. The endpoints of the present study were overall survival (OS) and disease-free survival (DFS). The median follow-up for censored cases was 45.7 months. In 56 patients, ¹⁸F-fluorodeoxyglucose positron emission tomography was performed within 1 month prior to chemoradiotherapy. Data on CRP within 1 month prior to chemoradiotherapy were available for all patients. In the group of SUV_max >12.85, the rates of 2-year OS and DFS were 49.0 and 35.7%, respectively. In the group of SUV_max ≤12.85, these values were 72.4 and 67.1%, respectively (P=0.048 and P=0.057, respectively). In the group of CRP ≥1 mg/dl, these percentages were 38.5 and 25.0%, respectively. In the group of CRP <1 mg/dl, these rates were 71.2 and 59.7%, respectively (P=0.013 and P<0.001, respectively). A multivariate analysis revealed that pre-treatment serum CRP levels remained an independent prognostic factor for both OS and DFS [OS: hazard ratio (HR), 0.25, P=001; DFS: HR, 0.28, P=0.005]. In conclusion, high SUV_max was associated with lower OS, while high CRP was associated with lower OS and DFS.

The efficacy and safety of definitive concurrent chemoradiotherapy for non-operable esophageal cancer

Objective

To report outcomes and toxicity in patients who received definitive concurrent chemoradiation (DCCRT) for non‐operable esophageal cancer (EC) in the modern era, and to identify markers of overall and disease‐free survival (OS/DFS).

Methods

We conducted a retrospective cohort study of patients with unresectable EC who received DCCRT at our institution between 1/2008 and 1/2019. Descriptive statistics were used to report disease‐control outcomes and CTCAE v4.0–5.0 toxicities. Univariable and multivariable Cox regression, and stepwise regression were used to identify associations with survival.

Results

At a median follow‐up of 19.5 months, 130 patients with adenocarcinoma (AC) (62%) or squamous cell carcinoma (SCC) (38%) were evaluable (Stage II‐III: 92%). Patients received carboplatin/paclitaxel (75%) or fluorouracil‐based (25%) concurrent chemotherapy. Median total RT dose was 50.4 Gy (range, 44.7–71.4 Gy) delivered in 28 fractions (24–35). Locoregional and distant recurrence occurred in 30% and 35% of AC, and 24% and 33% of SCC, respectively. Median OS and DFS were 22.9 and 10.7 months in AC, and 25.7 and 20.2 months in SCC, respectively. On stepwise regression, tumor stage, feeding tube during DCCRT, and change in primary tumor PET/CT SUVmax were significantly associated with OS and DFS. Most severe toxicities were acute grade 4 hematologic cytopenia (6%) and radiation dermatitis (1%). Most common acute grade 3 toxicities were hematologic cytopenia (35%), dysphagia (23%), and anorexia (19%).

Conclusions

Treatment of non‐operable EC with DCCRT has acceptable toxicity and can provide multi‐year disease control for some patients, even in AC. Continued follow‐up and investigation in large studies would be useful.

Dose escalation of 3D radiotherapy is effective for esophageal squamous cell carcinoma: a multicenter retrospective analysis (3JECROG R-03)

Background

To evaluate the impact of radiation dose escalation on overall survival (OS) in patients with non-metastatic esophageal squamous cell carcinoma (ESCC) treated with radical radiotherapy.

Methods

The clinical data of ESCC patients treated with three-dimensional (3D) radiotherapy alone or chemoradiotherapy were collected from multiple institutes and retrospectively analyzed. Patients who received radiation dose ≥40 Gy were included. Radiation dose as a continuous variable was entered into the Cox regression model by using penalized spline regression to allow for a nonlinear relationship between radiation dose and OS to be identified. Patients were stratified into five groups according to EQD₂. The Kaplan-Meier method was used to assess the OS in different dose groups. Univariate and multivariate analyses were performed to evaluate the factors associated with OS.

Results

A total of 2,469 patients were included from 10 institutes across China. The median follow-up time was 58.3 months [95% confidence interval (CI): 56.4–60.2 months]. The median OS and PFS time were 24.3 months (95% CI: 22.5–26.2 months) and 18.0 months (95% CI: 16.4–19.6 months), respectively. The risk of death decreased sharply with a dose up to 60 to 62 Gy, before increasing slightly after the dose was elevated beyond 62 Gy. Multivariate analysis indicated that the chance of death was significantly decreased in patients who received radiotherapy doses of 60–62 Gy [P=0.028, hazard ratio (HR) 0.85, 95% CI: 0.73–0.98)], compared with those who received radiotherapy doses of 40–60 Gy.

Conclusions

Our results reveal radiation dose is a significant prognostic factor of survival for ESCC patients. Higher radiation dose contributes to much more favorable survival outcomes for ESCC patients receiving radical radiotherapy by modern techniques, and 60 Gy or above might be the most optimal radiation dose.

The efficacy and safety of simultaneous integrated dose reduction in clinical target volume with intensity-modulated radiotherapy for patients with locally advanced esophageal squamous cell carcinoma

Background

Compelling research to explore the effectiveness of simultaneous integrated dose reduction in clinical target volume (CTV) with intensity-modulated radiotherapy (SIR-IMRT) for locally advanced esophageal squamous cell carcinoma (ESCC) are limited. This study aimed to compare the clinical efficacy and treatment-related toxicity between SIR-IMRT and conventional IMRT (C-IMRT) in the treatment of ESCC.

Methods

From March 2010 to September 2016, the clinical data of 257 patients with ESCC who received definitive IMRT in the Tianjin Medical University Cancer Institute and Hospital were collected and retrospectively analyzed. Among these patients, 137 patients received C-IMRT with a prescribed dose of 60 Gy in 30 fractions for planning target volume (PTV), while 120 patients received SIR-IMRT with a prescribed dose of 60 Gy in 30 fractions for the planning gross tumor volume (PGTV) and a prescribed dose of 54 Gy in 30 fractions for PTV. All of the patients received definitive IMRT with elective nodal irradiation. Locoregional control, survival, treatment toxicity and dose to organs at risk (OAR) were compared between the groups.

Results

Patients who received SIR-IMRT showed a similar locoregional failure rate compared to the C-IMRT group (27.5% versus 29.9%, P=0.668). The 1-, 2- and 3-year overall survival (OS) rates were 71.5%, 44.3%, 44.3% vs. 77.9%, 52.1%, 32.9% in the C-IMRT and SIR-IMRT groups, respectively (P=0.825). No significant differences were observed in PFS and LRRFS between the two groups (P=0.880 and P=0.216, respectively). The dose of lung V30 and the maximum dose of spinal cord in the C-IMRT group were significantly higher than those in the SIR-IMRT group (P=0.013, P=0.047). The incidence of acute radiation esophagitis was significantly lower in the SIR-IMRT group (P=0.046), although no statistical difference was observed in the incidence of acute severe adverse events between the two groups.

Conclusions

SIR-IMRT offers an effective and safe option for patients with unresectable ESCC who receive definitive RT. Further prospective and larger sample size studies are warranted to confirm our results.

T4 cervical esophageal cancer cured with modern chemoradiotherapy: A case report

BACKGROUND

T4 esophageal cancer portends a poor prognosis, particularly when it is complicated by a tracheoesophageal fistula (TEF) either resulting from disease or occurring as a complication of treatment. Patients with TEF that occurs during treatment are commonly treated with palliative intent because fistula-associated treatment complications such as aspiration pneumonia and mediastinitis are associated with high morbidity and mortality. To date, there is no clear evidence on the optimal treatment of T4 esophageal cancer, particularly when a TEF formation occurs.

CASE SUMMARY

A 67-year-old gentleman who presented with dysphagia and weight loss. Endoscopy and imaging revealed a T4N1M0 cervical esophageal squamous cell carcinoma. He received image-guided intensity-modulated radiation therapy, with concurrent weekly carboplatin (area under curve 2 mg/mL per minute) and paclitaxel (50 mg/m² of body surface area). One week after treatment initiation (16.2 Gy thus far), he developed cough on swallowing. A TEF was detected on image-guided radiation therapy using cone-beam computed tomography during the treatment course, for which a tracheal stent was inserted. After discussing the risks and morbidity of continuing treatment, he resumed chemoradiotherapy with an additional radiation dose of 45 Gy in 25 fractions. Three months after completion of chemoradiotherapy, he developed an esophageal stricture that required esophageal stenting and dilatation. The patient remains cancer-free at two year on follow-up. Complete response of esophageal cancer was evident on post-treatment endoscopy and computed tomography imaging, with successful closure of TEF.

CONCLUSION

This case highlights that successful curative treatment for esophageal cancer complicated by a TEF is possible using novel chemotherapeutic regimens and modern radiation technologies.

Definitive chemoradiotherapy for squamous cell carcinoma of the esophagus: outcomes for borderline-resectable disease

Definitive chemoradiotherapy (dCRT) is the standard treatment for unresectable esophageal cancer. Induction chemotherapy has been actively investigated for borderline-resectable and unresectable disease, but the superiority over dCRT has yet to be confirmed. The purpose of this study was to evaluate the outcome of dCRT with special interest in borderline-resectable disease. Patients with esophageal cancer treated with dCRT between January 2004 and November 2016 were included in this retrospective analysis. Chemotherapy consisted of two cycles of cisplatin (70-75 mg/m2) on day 1 and 5-fluorouracil (700-1000 mg/m2 per day) on days 1-4 or low-dose cisplatin (10 mg/m2 per day) and 5-fluorouracil (175 mg/m2 per day) for 20 days. Radiotherapy was given with a daily fraction of 1.8-2 Gy to a total dose of 50-70 Gy. A total of 104 patients were included: 34 were resectable, 35 were borderline-resectable and 35 were unresectable. Complete response was achieved in 44 patients (42%). Eighteen patients (17%) suffered Grade 2 or greater cardiopulmonary toxicity and seven patients (7%) suffered Grade 3 cardiopulmonary toxicity. At the time of this analysis, 59 patients were dead and 45 were censored. The 3-year overall survival proportions for resectable, borderline-resectable and unresectable patients were 64%, 46% and 21%, respectively. The overall survival for borderline-resectable patients with complete response and noncomplete response was significantly different (P < 0.001), with 3-year survival of 70% and 8%, respectively. The overall survival for complete response patients with borderline-resectable disease was encouraging. Further investigation to find a subgroup fit for esophagus-preserving treatment is warranted.

Do Higher Radiation Doses with Concurrent Chemotherapy in the Definitive Treatment of Esophageal Cancer Improve Outcomes? A Meta-Analysis and Systematic Review

Background: To investigate the effects and safety profile of radiation dose escalation utilizing computerized tomography (CT) based radiotherapy techniques (including 3-Dimensional conformal radiotherapy, intensity-modulated radiotherapy and proton therapy) in the definitive treatment of patients with esophageal carcinoma (EC) with definitive concurrent chemoradiotherapy (dCCRT). Methods: All relevant studies utilizing CT-based radiation planning, comparing high-dose (≥ 60 Gy) versus standard-dose (50.4 Gy) radiation for patients with EC were analyzed for this meta-analysis. Results: Eleven studies including 4946 patients met the inclusion criteria, with 96.5% of patients diagnosed with esophageal squamous cell carcinoma (ESCC). The high-dose group demonstrated a significant improvement in local-regional failure (LRF) (OR 2.199, 95% CI 1.487-3.253; P<0.001), two-year local-regional control (LRC) (OR 0.478, 95% CI 0.309-0.740; P=0.001), two-year overall survival (OS) (HR 0.744, 95% CI 0.657-0.843; P<0.001) and five-year OS (HR 0.683, 95% CI 0.561-0.831; P<0.001) rates relative to the standard-dose group. In addition, there was no difference in grade ≥ 3 radiation-related toxicities and treatment-related deaths between the groups. Conclusion: Under the premise of controlling the rate of toxicities, doses of ≥ 60 Gy in CT-based dCCRT of ESCC patients might improve locoregional control and ultimate survival compared to the standard-dose dCCRT. While our review supports a dose-escalation approach in these patients, multiple ongoing randomized trial initial and final reports are awaited to evaluate the effectiveness of this strategy.

A study of concurrent chemoradiotherapy with weekly docetaxel and cisplatin for advanced esophageal squamous cell carcinoma with T4 and/or M1 lymph node metastasis or locoregional recurrence

Background

The improvement of survival outcomes and the reduction of toxicities for esophageal squamous cell carcinoma (SCC) are still needed. We conducted a pilot study of concurrent chemoradiotherapy with weekly docetaxel and cisplatin for the treatment of esophageal SCC with T4 and/or M1 lymph node metastasis (LNM) or locoregional recurrence.

Methods

Fifty-four patients with advanced thoracic esophageal SCC having a stage T4 tumor or M1 LNM and/or locoregional recurrence were enrolled. Docetaxel and cisplatin were both administered weekly at a dose of 25 mg/m² 5–6 times in total concurrently with a specific dose of radiation. The primary endpoint was overall survival (OS), and the secondary endpoints were progression-free survival (PFS), locoregional control and treatment-related toxicities.

Results

From October 2015 to December 2016, concurrent treatment with full-cycle docetaxel and cisplatin and radiotherapy was administered to 41 of 54 patients (75.9%). A total of 51 patients (94.4%) completed the radiation schedules. Twenty-one patients (44.4%) achieved a complete response, and 21 (44.4%) achieved a partial response after chemoradiotherapy. The median survival time was 18.2 months, and the median PFS time was 11.5 months. The 1-year and 3-year OS, locoregional control and PFS rates were 70.4, 80.6, 50.0 and 36.4%, 64.3, 31.5%, respectively. Grade 3 toxicities included neutropenia (13.0%), anemia (3.7%), thrombocytopenia (1.9%), fatigue (20.4%), anorexia (13.0%), esophagitis (11.1%), and pneumonitis (5.6%). Grade 4 neutropenia occurred in 16.7% of patients. Four patients (7.4%) died from grade 5 toxicities. There were no significant differences in both survival and grade 3 and higher toxicities between the newly diagnosed group and recurrent group.

Conclusions

Concurrent chemoradiotherapy with weekly docetaxel and cisplatin is a well-tolerated and effective treatment regimen for esophageal SCC with T4 or M1 LNM and/or locoregional recurrence. Clinical trials with larger sample size and comparisons with conventional fluorouracil and cisplatin regimens are needed.

Induction chemoradiotherapy including docetaxel, cisplatin, and 5-fluorouracil for locally advanced esophageal cancer

BACKGROUND

Locally advanced esophageal cancer (EC) invading surrounding organs (T4b) is difficult to treat. In general, definitive chemoradiotherapy (d-CRT) has been chosen as treatment for such cases. However, the outcome has not been good. Recently, the effectiveness of d-CRT with docetaxel, cisplatin, and 5-fluorouracil (DCF-RT) has been reported. Furthermore, surgery after d-CRT has a better prognosis than d-CRT alone in some reports, although it has a high risk of surgical complications. This study investigated the effectiveness and safety of induction DCF-RT.

METHODS

The subjects were EC patients who underwent induction DCF-RT in Okayama University Hospital between January 2011 and December 2017. Their background characteristics, treatment details, histopathological factors, adverse events during CRT, postoperative complications, and overall survival (OS) were assessed.

RESULTS

A total of 16 cases were performed induction DCF-RT. In 10 cases, death occurred, with 9 cancer-related deaths, and 1 death due to other disease. For all cases, OS was 37.5% at 3 years. 12 cases underwent esophagectomy after DCF-RT. Their OS was 50% at 3 years. 13 patients (81.3%) had Grade 3 febrile neutropenia. In 7 cases (62.5%), fasting for the treatment of diarrhea was needed. Three patients (25%) developed anastomotic leakage. Some recurrent laryngeal nerve paralysis was observed in 6 cases (50%).

CONCLUSION

Although the rates of adverse events and surgical complications were slightly higher than in past reports, they were acceptable. It is useful to perform induction DCF-RT for T4b EC.

Recent progress in multidisciplinary treatment for patients with esophageal cancer

Esophageal cancer is one of the most aggressive gastrointestinal cancers. This review focuses on eight topics within the multidisciplinary approach for esophageal cancer. As esophagectomy is highly invasive and likely to impair quality of life, the development of less invasive strategies is expected. Endoscopic resection (ER) of early esophageal cancer is a less invasive treatment for early esophageal cancer. A recent phase II trial revealed that combined ER and chemoradiotherapy (CRT) is efficacious as an esophagus-preserving treatment for cT1bN0 squamous cell carcinoma (SCC). Esophagectomy and definitive CRT are equally effective for patients with clinical stage I SCC in terms of long-term outcome. For locally advanced resectable cancers, multidisciplinary treatment strategies have been established through several clinical trials of neoadjuvant or perioperative treatment. Minimally invasive esophagectomy may improve the outcomes of patients and CRT is a curative-intent alternative to esophagectomy. CRT with 50.4 Gy radiotherapy combined with salvage surgery is a promising option to preserve the esophagus. Induction chemotherapy followed by esophagectomy may improve the outcomes of patients with locally advanced unresectable tumors. Immune checkpoint inhibitors are effective for esophageal cancer, and their introduction to clinical practice is awaited.

Concurrent chemoradiotherapy with raltitrexed and nedaplatin regimen for esophageal squamous cell carcinoma

BACKGROUND

The aim of the study reported here was to evaluate the feasibility and safety of raltitrexed and nedaplatin with concurrent radiotherapy in patients with unresectable, locally advanced esophageal squamous cell carcinoma (ESCC).

METHODS

Eligible patients were adults with newly diagnosed untreated, unresectable esophageal cancer in stages I to IV with lymph node metastases or cervical esophageal cancer. Patients received nedaplatin 25 mg/m per day on day 1-3, raltitrexed 3 mg/m on days 1 repeated every 21 days for 2 cycles, and combined concurrent radiotherapy (2 Gy/fraction, total dose of 60 Gy).

RESULT

Thirty patients were included with squamous cell carcinoma. The median follow-up duration was 24 months. The overall response rate was 90%. The 1-year and 2-year overall survival rates for all patients were 70.4% and 55.7% with a median survival time of 30 months, and the median progression free survival was 20 month. The major toxicities were leukopenia and thrombopenia, with grade 3 to 4 leukopenia and thrombopenia were 50% and 30% of patients.

CONCLUSION

Concurrent chemoradiotherapy with raltitrexed and nedaplatin agents frequently caused myelosuppression but was highly active and suggested to be a promising treatment option for locally advanced ESCC.

Docetaxel, cisplatin, and 5-fluorouracil combination chemoradiotherapy for patients with cervical esophageal cancer: a single-center retrospective study

BACKGROUND

To evaluate the efficacy of docetaxel, cisplatin, and 5-fluorouracil as combination chemoradiotherapy (DCF-RT) for cervical esophageal cancer (CEC), we performed a retrospective analysis of CEC patients treated by DCF-RT at a single institution.

METHODS

We conducted a single-center retrospective study. Twenty-one patients with CEC who underwent DCF-RT between 1999 and 2017 at our institute were included in this study. Chemotherapy consisted of intravenous docetaxel at 50 mg/m² on day 1, intravenous CDDP at 60 mg/m² on day 1, and intravenous 5-FU at 600 mg/m² on days 1-4, repeated every 4 weeks for two cycles. Among the 21 patients, six were irradiated using three-dimensional conformal RT (3D- conformal RT) and 15 were treated using intensity-modulated RT (IMRT) consisting of 60 Gy in 30 fractions.

RESULTS

The median follow-up period was 49.6 months (range 4.6-97.6). The overall complete response (CR) and local CR rates were 61.9% and 81.0% for all patients, and 76.9% and 84.6% for patients without hypopharyngeal and/or thoracic esophageal invasion, respectively. The 3-year overall survival (OS), progression-free survival (PFS), and local failure-free survival (LFFS) rates were 79.6, 52.4, and 74.7%, respectively. Grade 3-4 leucopenia developed in 12 patients (70.6%), neutropenia developed in 13 patients (81.2%), and mucositis developed in 2 patients (9.5%). There were no treatment-related deaths.

CONCLUSIONS

The 3-year OS and LFFS of patients who underwent DCF-RT were higher than those in the previous studies. Although the high rate of myelosuppression requires careful management, DCF-RT is a safe and effective modality for CEC.

Treatment and clinical outcome of clinical T4 esophageal cancer: A systematic review

BACKGROUND

Survival of patients with cT4 esophageal cancer is dismal. Although the optimal treatment strategy remains to be established, two treatment options are available for cT4 esophageal cancers: definitive chemoradiation (dCRT) and induction treatment followed by conversion surgery (CS). However, little is known concerning the differences in clinical outcome between patients with T4 esophageal tumors treated with dCRT and those eventually treated with CS.

METHODS

A systematic search of the scientific literature on PubMed/MEDLINE was carried out using the keywords "T4 esophageal cancer," "invading (involving) adjacent organ," "definitive chemoradiation," "induction therapy," "salvage surgery," and "conversion surgery," obtaining 28 reports published up to July 2018.

RESULTS/CONCLUSION

We found that CS was superior to dCRT with respect to local disease control and short-term survival; however, CS was associated with relatively higher perioperative mortality and morbidity. Alternatively, although dCRT might often cause fistula formation, a clinical complete response to dCRT is likely to lead to a better prognosis. Recent advances in chemotherapeutic agents have led to triple induction chemotherapy, with docetaxel, cisplatin, and 5-fluorouracil (DCF), which has shown promise as an initial induction treatment for cT4 esophageal cancer. Indeed, this regimen could control both local and systemic disease, which enables curative resection without preoperative CRT. Moreover, some appropriate changes in perioperative management and intensive systemic chemotherapy might enhance patient outcome. Randomized controlled trials with a large sample size are needed to establish the standard treatment for cT4 esophageal cancer.

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.

Prognostic Factors of Salvage Esophagectomy for Residual or Recurrent Esophageal Squamous Cell Carcinoma After Definitive Chemoradiotherapy

BACKGROUND

The aim of this study was to confirm prognostic factors for salvage esophagectomy for remnant or recurrent esophageal squamous cell carcinoma after definitive chemoradiotherapy.

STUDY DESIGN

We retrospectively analyzed clinicopathological backgrounds of 50 patients who underwent salvage esophagectomy between April 2005 and January 2016. Salvage esophagectomy comprised 40 three-incision esophagectomies, two transhiatal esophagectomies and eight pharyngolaryngoesophagectomies. Independent prognostic factors for overall survival were assessed using Cox regression analysis of the factors.

RESULTS

Salvage esophagectomy remains a highly invasive surgery and correlated with a higher incidence of all morbidities of Clavien-Dindo classification (CDc) ≥II, severe morbidities of CDc ≥ IIIb, any pulmonary morbidities and chylorrhea, compared with those in patients without preoperative definitive chemoradiotherapy. Cox regression analysis suggested that R0 resection (hazard ratio [HR] 6.39; 95% confidence interval [CI] 2.03-9.68, P = 0.002), absence of severe complications (HR 4.97; 95% CI 1.70-14.81, P = 0.004) and early pStage (0-II) (HR 3.42; 95% CI 1.24-10.12, P = 0.018) were independent prognostic factors for salvage esophagectomy.

CONCLUSIONS

Salvage esophagectomy remains correlated with a high incidence of postoperative complications. Avoiding non-curative surgery and reducing the incidence of severe postoperative complications are important if patients are to receive prognostic benefit of this highly invasive surgery.

Definitive chemoradiotherapy with docetaxel, cisplatin, and 5-fluorouracil (DCF-R) for advanced cervical esophageal cancer

BACKGROUND

Recently, definitive chemoradiotherapy (dCRT) has become one of the essential treatment strategies for esophageal squamous cell carcinoma (ESCC) and has been especially gaining prevalence for cervical ESCC to preserve the larynx. Our department recently introduced dCRT concomitant with docetaxel, cisplatin, and 5-fluorouracil (DCF-R) for treating advanced cervical ESCC. This study aims to assess the safety and outcomes of DCF-R in patients with advanced cervical ESCC.

METHODS

We retrospectively assessed 11 patients with advanced cervical ESCC (clinical stage: II-IV, including T4b and/or M1 lymph node) who received DCF-R as the first-line treatment between December 2010 and February 2015.

RESULTS

Our patient cohort comprised 8 males and 3 females (median age 68 years; range 54-76 years). The pretreatment clinical stage included stage II (1), stage III (7), and stage IV (3) cases [including 3 patients with T4b (2 trachea and 1 thyroid) and 3 patients with M1 lymph node]. We attained complete response (CR) in 10 patients and stable disease in 1 patient. Of 10 patients with CR, 5 experienced recurrence and 5 continued exhibiting CR. Furthermore, grade 3 or more adverse events included leucopenia (91%), neutropenia (91%), febrile neutropenia (45%), and pharyngeal pain (55%). While the 2-year overall survival rate was 72%, the 2-year recurrent-free survival rate was 64%, respectively.

CONCLUSIONS

DCF-R treatment for advanced cervical esophageal cancer could be completed by the careful administration; although a strong blood toxicity might occur, this treatment may provide the chance to obtain favorable prognosis with larynx preservation.

Concurrent Chemoradiotherapy with Docetaxel, Cisplatin, and 5-fluorouracil Improves Survival of Patients with Advanced Esophageal Cancer Compared with Conventional Concurrent Chemoradiotherapy with Cisplatin and 5-fluorouracil

Purpose: To compare treatment outcomes and adverse events between concurrent chemoradiotherapy with docetaxel, cisplatin, and 5-fluorouracil (DCF-RT) and conventional concurrent chemoradiotherapy with cisplatin and 5-fluorouracil (CF-RT).

Methods and Materials: We retrospectively investigated treatment outcomes and adverse events in 121 patients with advanced esophageal cancer who underwent concurrent chemoradiotherapy with CF-RT (n = 83) or DCF-RT (n = 38). In the CF-RT group, patients were administered cisplatin (70 mg/m²) and 5-fluorouracil (700 mg/m²) for 5 days; in the DCF-RT group, patients were administered docetaxel (50 mg/m²), cisplatin (50 mg/m²), and 5-fluorouracil (500 mg/m²) for 5 days. The radiotherapy dose was 1.8-2 Gy per session, up to a total of 50-60 Gy.

Results: The complete response (CR) rate was 37.8% in the CF-RT group and 52.6% in the DCF-RT group. Overall survival (OS) rates at 2 and 3 years were 45.0% and 37.5%, respectively, in the CF-RT group and 62.9% and 56.7%, respectively, in the DCF-RT group, with a significant intergroup difference (p = 0.032). Progression-free survival rates at 2 and 3 years were 44.1% and 36.9%, respectively, in the CF-RT group and 45.0% and 45.0%, respectively, in the DCF-RT group (p = 0.10). Local control rates at 2 and 3 years were 59.1% and 54.6%, respectively, in the CF-RT group and 71.8% and 71.8%, respectively, in the DCF-RT group (p = 0.12). The incidence of Grade 3/4 leukopenia was 55.4% (n = 46) in the CF-RT group and 78.9% (n = 30) in the DCF-RT group, with a significant intergroup difference (p = 0.022). The incidence of Grade 3/4 neutropenia was 47.0% (n = 39) in the CF-RT group and 65.8% (n = 25) in the DCF-RT group, with a notable albeit not statistically significant difference between the groups (p = 0.054). There were no significant intergroup differences in anemia, thrombocytopenia, radiation-induced dermatitis, radiation esophagitis, or late adverse events.

Conclusions: Rates of OS and CR were improved after treatment with DCF-RT compared with CF-RT. Although DCF-RT-treated patients had higher rates of leukopenia, treatment safety was ensured through proper management of myelotoxicity. DCF-RT is a promising treatment regimen for advanced esophageal cancer.

The current status of multimodality treatment for unresectable locally advanced esophageal squamous cell carcinoma

A multimodality approach plays a key role in the treatment of patients with unresectable locally advanced esophageal squamous cell carcinoma (ESCC). Currently, definitive chemoradiotherapy (dCRT) using 5-fluorouracil (5-FU) plus cisplatin with radiotherapy is the standard treatment in this population. dCRT regimens using 5-FU plus leucovorin plus oxaliplatin (FOLFOX), and carboplatin plus paclitaxel have been investigated in prospective clinical trials. Anti-epidermal growth factor receptor (EGFR) antibody has been evaluated in combination with dCRT; however, this combination has not revealed any additive benefits. Induction chemotherapy using docetaxel plus 5-FU plus cisplatin has also been under investigation. Although long-term survival and cure have been observed in some patients by dCRT, most patients experience local failure or distant metastasis and eventually die from the disease. Salvage surgery is an important option if the residual or recurrent tumors after dCRT can be resectable, but is associated with high postoperative morbidity and mortality. Introduction of radiotherapy using a new technique with dose escalation is expected to improve efficacy without increasing radiation-related toxicities. Immunotherapy in combination with radiotherapy has also gathered attention. For the establishment of new and effective treatments in the field of unresectable locally advanced ESCC, a collaboration between clinical researchers and basic researchers is warranted.

A phase II trial of concurrent chemoradiotherapy with weekly paclitaxel and carboplatin in advanced oesophageal carcinoma

BACKGROUND

This study was performed to assess the efficacy and feasibility of definitive chemoradiotherapy consisting of weekly doses of combined paclitaxel and carboplatin concurrent with radiation therapy, followed by 2 cycles of consolidation chemotherapy for advanced esophageal carcinoma.

METHODS

Eligibility criteria included local, advanced, newly diagnosed and postoperative local regional lymph node metastasis; Eastern Cooperative Oncology Group (ECOG) score ≤ 2; and adequate organ function. Patients received concurrent chemoradiation therapy consisting of radiotherapy (50.4 Gy/28 Fx or 61.2 Gy/34 Fx) and concurrent paclitaxel (50 mg/m²) and carboplatin (area under the curve, AUC = 2) on days 1, 8, 15, 22 and 29. The two-cycle consolidation chemotherapy protocol was paclitaxel (175 mg/m²) plus carboplatin (AUC = 5) administered on days 57 and 85, after concurrent chemoradiotherapy.

RESULTS

Between August 2013 and February 2015, 65 patients with oesophageal carcinoma were enrolled in the study; 34 (52.3%) were newly diagnosed and 31 (47.6%) had postoperative local regional lymph node metastasis. The median overall survival time was 21.7 months (95% confidence interval [CI] 16.7-26.6), and the median progression-free survival time was 12.1 months (95% CI 9.0-15.3). A total of 96.9% (63/65) and 67.6% (44/65) patients completed ≥5 cycles and all 7 cycles of chemotherapy, respectively. A total of 93.8% (61/65) patients completed radiation therapy. The 1- and 2-year overall survival rates were 73.7 and 42.0%, respectively. The 1- and 2-year progression-free survival rates were 50.6 and 31.1%, respectively. Grade 3-4 toxicity during chemoradiotherapy included neutropenia (24.5%), thrombocytopenia (4.6%), fatigue (1.5%), anaemia (1.5%), radiation dermatitis (1.5%), pneumonitis (1.5%), oesophagitis (4.6%) and vomiting (1.5%).

CONCLUSIONS

In patients with locally advanced oesophageal cancer, the combination of weekly doses of paclitaxel and carboplatin was well tolerated and produced comparable results. A three-arm randomised phase III trial (NCT02459457) comparing paclitaxel in combination with cisplatin, carboplatin or 5-fluorouracil with concurrent radiotherapy is on-going at our hospital.

Treatment results of neoadjuvant chemoradiotherapy followed by radical esophagectomy in patients with initially inoperable thoracic esophageal cancer

PURPOSE

We evaluated the effectiveness of neoadjuvant chemoradiotherapy (CRT) followed by esophagectomy for cT4 esophageal cancer or lymph node metastases (LNM) invading adjacent structures.

MATERIALS AND METHODS

We retrospectively evaluated 42 consecutive patients with thoracic esophageal cancer who underwent CRT followed by esophagectomy between 2008 and 2013. All were initially considered to be unresectable because of cT4 (n = 32) disease or LN invasion (n = 10). Radiotherapy was administered at 41.4 Gy/23 fr with concurrent chemotherapy. At completion of CRT, restaging was performed using computed tomography (CT).

RESULTS

All cT4 tumors were downstaged, LNM invading to adjacent structures were considered to be released, and subtotal esophagectomy was performed. The median follow-up period was 42 months. The curative resection (R0) rate was 94% in cT4 group and 70% in LN invasion group. The 3-year overall survival (OS) and 3-year locoregional control (LRC) rates were 65-80% in the cT4 group and 50-67% in LN invasion group, respectively.

CONCLUSIONS

The cT4 group showed good rates of R0, OS, and LRC. Surgical resection should be an effective option when downstaging is achieved by CRT for patients with initially inoperable thoracic esophageal cancer.

Patterns of failure and clinical outcomes of definitive radiotherapy for cervical esophageal cancer

Purpose

Because of the scarcity of cervical esophageal cancer (CEC), data for this disease entity is limited. We aim to evaluate the outcomes, prognostic factors and failure patterns of CEC treated by contemporary radiotherapy (RT).

Methods

We retrospectively analyzed 86 CEC patients consecutively treated between 2007 and 2015 by definitive RT with or without concurrent chemotherapy. RT was mainly delivered with Intensity Modulated Irradiation Therapy (IMRT) or Volumetric-Modulated Arc Therapy (VMAT). Statistical analyses were performed on survival, prognostic factors and failure patterns.

Results

The median follow-up time was 19.4 months. The 3-year overall survival (OS), local regional failure free survival (LRFFS), distant metastatic free survival (DMFS), and progression free survival (PFS) were 53.6%, 57.9%, 81.5% and 41.5%, respectively. Independent predictors for poorer OS were N stage, hoarseness and recurrent laryngeal nerve lymph node (RLN) involvement, and predictors for LRFFS were N stage and EQD2 (equivalent dose in 2 Gy fraction) to gross tumor volume (GTV), with ≥ 66Gy achieving local control of 94.7%. Patients receiving elective nodal irradiation (ENI) had better nodal regional control than those receiving involved field irradiation (IFI). 31 (36%) patients had treatment failure and 15 (17.4%), 8 (9.3%) and 14 (16.2%) patients had local, regional, and distant failure, respectively. 86.7% (13/15) local failures were within GTV, and supraclavicular region (62.5%, 5/8) was the most common regional failure site. No severe toxicities were observed.

Conclusions

Our results seem to indicate that good locoregional control might be achieved for CEC with adequate radiation dose and treatment planning approaches.

Comparison of definitive chemoradiotherapy and radiotherapy alone in patients older than 75 years with locally advanced esophageal carcinoma: A retrospective cohort study

The aim of this study was to evaluate the efficacy and acute toxicity of definitive chemoradiotherapy (CRT) and radiotherapy (RT) alone as initial treatment in patients aged 75 years and older with locally advanced esophageal squamous cell carcinoma (ESCC) who are not eligible for surgery.Between February 2009 and February 2015, 122 patients older than 75 years with locally advanced ESCC were retrospectively reviewed, in whom 52 patients allocated to the CRT group were treated with at least 2 cycles of platinum and 5-fluorouracil, 70 patients allocated to the RT group were treated with RT alone, all patients were received a total radiation dose of 54-66 Gy, with 1.8 or 2-Gy/fraction. Response rate (RR), progression-free survival (PFS), overall survival (OS), and acute toxicities were compared between the 2 different treatment groups.In the CRT group, the median PFS and OS were 15.3 and 24.6 months, while 10.6 and 19.4 months in the RT group (P = .008 and P = .018). The 1-year survival rates of the 2 groups were 78.8% versus 64.3% (P = .081), and the 2-year survival rates were 48.1% and 30.0% (P = .042), respectively. The objective RR was 55.8% in the CRT group with 18 complete response (CR) and 18.6% in the RT group with 13 CR. Acute toxicity in the CRT group was higher than in the RT group, especially the grade 3 to 4 acute toxicities.Compared with RT alone, definitive CRT in the treatment of locally advanced ESCC can prolong the survival time in elderly patients. Definitive CRT should be considered the first-treatment choice for elderly patients like the younger patients who are not eligible for surgery.

Cocktail without hangover: in search for the optimal chemotherapy in the combined management of non-operable esophageal carcinomas

BACKGROUND

The worldwide incidence of esophageal cancer has greatly increased over the past few decades making it the sixth deadliest cancer. The disease is often detected in advanced stages when surgery is no longer an option. The standard treatment in these situations is combined chemoradiotherapy, by employing drug cocktails that lead to optimal treatment outcomes both from the perspective of tumor control and normal tissue toxicity.

METHODS

The aim of this work was to collate the existing trials and clinical studies reported on non-operable esophageal cancer and to analyze the results based on treatment outcomes after various drug combinations.

RESULTS

Of all drug combinations, cisplatin/5-FU is the most well established chemotherapy regimen for esophageal cancer as both neoadjuvant therapy, an alternative option to surgery, and for palliative purposes. Although this regimen is associated with the most toxicity, it also appears to have the best survival benefit and relief of symptoms.

CONCLUSIONS

More research is warranted to further increase the therapeutic ratio in non-operable esophageal cancers.

Value and application of trimodality therapy or definitive concurrent chemoradiotherapy in thoracic esophageal squamous cell carcinoma

BACKGROUND

Few large, prospective, randomized studies have investigated the value and optimal application of neoadjuvant chemoradiotherapy followed by surgery (trimodality therapy) or definitive concurrent chemoradiotherapy (CCRT) for patients with thoracic esophageal squamous cell carcinoma (TESCC).

METHODS

The authors analyzed data from patients with TESCC in the Taiwan Cancer Registry database. To compare their outcomes, patients with TESCC were enrolled and categorized into the following groups according to treatment modality: group 1, those who underwent surgery alone; group 2, those who received trimodality therapy; and group 3, those who received definitive CCRT. Group 1 was used as the control arm for investigating the risk of mortality after treatment.

RESULTS

In total, 3522 patients who had TESCC without distant metastasis were enrolled. Multivariate Cox regression analysis indicated that a Charlson comorbidity index score ≥3, American Joint Committee on Cancer stage ≥IIA, earlier year of diagnosis, alcohol consumption, cigarette smoking, and definitive CCRT were significant, independent predictors of a poor prognosis. After adjustment for confounders, adjusted hazard ratios and 95% confidence intervals (CIs) for overall mortality in patients with clinical stage I, IIA, IIB, IIIA, IIIB, and IIIC TESCC were 2.01 (95% CI, 0.44-6.18), 1.65 (95% CI, 0.99-2.70), 1.48 (95% CI, 0.91-2.42), 0.66 (95% CI, 1.08-1.14), 0.39 (95% CI, 0.26-0.57), and 0.44 (95% CI, 0.24-0.83), respectively, in group 2; and 2.06 (95% CI, 1.18-3.59), 2.65 (95% CI, 1.76-4.00), 2.25 (95% CI, 1.49-3.39), 1.34 (95% CI, 0.79-2.28), 0.82 (95% CI, 0.57-1.17), and 0.93 (95% CI, 0.51-1.71), respectively, in group 3.

CONCLUSIONS

Trimodality therapy may be beneficial for the survival of patients with advanced-stage (IIIA-IIIC) TESCC, and CCRT might be an alternative to surgery alone in these patients. Cancer 2017;123:3904-15. © 2017 American Cancer Society.

Elective nodal irradiation is not necessary in chemoradiotherapy for postoperative loco-regional recurrent esophageal cancer

Purpose

The purposes of the present study were to evaluate prognostic factors for patients with postoperative loco-regional recurrent esophageal cancer treated with chemoradiotherapy by multivariate analysis and to determine which irradiation is better, involved field irradiation or elective nodal irradiation, by matched-pair analysis.

Methods

We reviewed records for 80 patients with postoperative loco-regional recurrent esophageal cancer treated by chemoradiotherapy between 2000 and 2014. The median follow-up period was 62.0 months. Thirty-one cases were treated with elective nodal irradiation and were randomly matched by risk factors to 49 cases treated with involved field irradiation (1:1).

Results

Fifty-one patients had disease recurrence again, and irradiated-field failure was observed in 26 patients. The 5-year overall survival rate was 30.5% with a median survival period of 26.5 months. Grade 3 or higher late toxicity was observed in only one patient. In multivariate analysis, short disease-free interval and anastomotic recurrence were statistically significant unfavorable prognostic factors for overall survival (hazard ratios: 2.1 and 2.5, respectively). Matched-pair analysis including disease-free interval, pattern of recurrence and number of recurrent regions revealed that overall survival rate and irradiated-field control rate in patients treated with involved field irradiation were significantly better than those in patients treated with elective nodal irradiation (P = 0.016 and P = 0.014, respectively).

Conclusions

Short disease-free interval and anastomotic recurrence are unfavorable factors and elective nodal irradiation is not necessary in chemoradiotherapy for patients with postoperative loco-regional recurrent esophageal cancer.

Overview of different available chemotherapy regimens combined with radiotherapy for the neoadjuvant and definitive treatment of esophageal cancer

INTRODUCTION

Neoadjuvant chemoradiotherapy (CTRT) is the current standard of care for treatment of locally advanced cancer of the esophagus or gastroesophageal junction. Many efforts have been made over the last years to identify the best chemotherapy and radiotherapy combination regimen, but specific randomized trials addressing this issue are still lacking. Areas covered: A systematic review of the literature was performed searching in PubMed all published studies of combinations CTRT regimens for operable or unresectable esophageal cancer to describe activity and toxicity. Studies considered were prospective series or clinical phase II-III trials including at least 40 patients and published in English language. Expert commentary: Long-term results of CROSS trial have established RT combined with carboplatin plus paclitaxel chemotherapy as the preferred neoadjuvant treatment option for both squamous and adenocarcinoma of the esophagus. More effective multimodal treatment strategies integrating novel biological agents including immunotherapy and based on an extensive molecular tumor characterization are eagerly awaited.

Concurrent chemoradiotherapy with elective lymph node irradiation for esophageal cancer: a systemic review and pooled analysis of the literature

Concurrent chemoradiotherapy (CCRT) has been accepted as the standard non-surgical treatment for esophageal cancer. However, no consistent conclusions have been reached whether elective lymph node irradiation (ENI) should be delivered. Therefore, we performed a systematic review and pooled analysis to evaluate the value of CCRT with ENI. A literature search based on PubMed, Embase and Google Scholar was carried out and all of the studies were evaluated carefully regarding with survival outcomes, response rates, patterns of failure rates and acute/late toxicities. Twenty-two studies were identified based on the criteria: median overall survival time was 21.0 months; pooled response rates were 56.8% (CR) and 85.8% (CR+PR), respectively; residual disease rate, local-regional recurrence rate, distant failure rate and both (local-regional recurrence plus distant failure) rate was 28%, 21%, 11%, and 7%, respectively; hematologic toxicities were the most sever acute toxicities and esophagus-related toxicity was the most common radiation-related toxicity both in acute (15.7%) and late (6.2%) phase. In conclusion, ENI is feasible with acceptable toxicities in esophageal carcinoma and the efficacy should be verified in randomized trials.

Outcomes of definitive chemoradiation in patients with esophageal cancer

The incidence of esophageal cancer has risen dramatically in the Western world. Although surgical resection of esophageal tumors is considered the cornerstone of curative approaches in localized esophageal cancer, approximately 40% of patients who undergo chemoradiation followed by surgery will experience a recurrence. Additionally, surgical resection is not a viable option for many patients with locally advanced unresectable disease, poor general condition or whose condition deteriorated following chemoradiation. Several investigators have, therefore, attempted to evaluate the outcomes of definitive chemoradiation in patients with localized or locally advanced esophageal cancer. The outcomes of concurrent chemoradiation remain a matter of debate given the heterogenous study design and treatment regimens used in recent trials. Understanding the clinical benefit of chemoradiation is essential prior to recommending it as an alternative to surgery. In our review, we present the most recent studies evaluating the role of chemoradiation to better define the clinical outcomes of patients with special attention to overall survival.

Radiobiological evaluation of simultaneously dose-escalated versus non-escalated intensity-modulated radiation therapy for patients with upper thoracic esophageal cancer

OBJECTIVE

To compare the radiobiological response between simultaneously dose-escalated and non-escalated intensity-modulated radiation therapy (DE-IMRT and NE-IMRT) for patients with upper thoracic esophageal cancer (UTEC) using radiobiological evaluation.

METHODS

Computed tomography simulation data sets for 25 patients pathologically diagnosed with primary UTEC were used in this study. DE-IMRT plan with an escalated dose of 64.8 Gy/28 fractions to the gross tumor volume (GTV) and involved lymph nodes from 25 patients pathologically diagnosed with primary UTEC, was compared to an NE-IMRT plan of 50.4 Gy/28 fractions. Dose-volume metrics, tumor control probability (TCP), and normal tissue complication probability for the lung and spinal cord were compared. In addition, the risk of acute esophageal toxicity (AET) and late esophageal toxicity (LET) were also analyzed.

RESULTS

Compared with NE-IMRT plan, we found the DE-IMRT plan resulted in a 14.6 Gy dose escalation to the GTV. The tumor control was predicted to increase by 31.8%, 39.1%, and 40.9% for three independent TCP models. The predicted incidence of radiation pneumonitis was similar (3.9% versus 3.6%), and the estimated risk of radiation-induced spinal cord injury was extremely low (<0.13%) in both groups. Regarding the esophageal toxicities, the estimated grade ≥2 and grade ≥3 AET predicted by the Kwint model were increased by 2.5% and 3.8%. Grade ≥2 AET predicted using the Wijsman model was increased by 14.9%. The predicted incidence of LET was low (<0.51%) in both groups.

CONCLUSION

Radiobiological evaluation reveals that the DE-IMRT dosing strategy is feasible for patients with UTEC, with significant gains in tumor control and minor or clinically acceptable increases in radiation-induced toxicities.

Role of definitive chemoradiotherapy using docetaxel and 5-fluorouracil in patients with unresectable locally advanced esophageal squamous cell carcinoma: a phase II study

Definitive chemoradiotherapy (CRT) with docetaxel (DOC) and 5-fluorouracil (5-FU) is a unique regimen for esophageal cancer. In this prospective phase II study, antitumor effect and safety of CRT using DOC and 5-FU for inoperable locally advanced esophageal cancer were evaluated. DOC 7.5 mg/m² was infused on days 1, 8, 22, and 29. 5-FU 250 mg/m² /day was infused continuously on days 1-5, 8-12, 15-19, 22-26, 29-33, 36-40, and 43-45. Radiotherapy was given to 66 Gy in 33 fractions. Eleven patients with thoracic and five with cervical esophageal cancer were eligible. All patients had esophageal squamous cell carcinoma (ESCC). The response rate was 94%, with complete response in five patients (31%) and partial response in 10 (63%). Hematologic toxicity was mild; only one patient (6%) had Grade 1 leukopenia. Nonhematologic Grade 3 or higher adverse events were esophagitis (31%), anorexia (6%), and esophago-bronchial fistula (6%). No treatment-related deaths occurred. The median time to progression was 20 months and overall 3-year and 5-year survival were 44% and 31%, respectively. Definitive CRT using DOC and 5-FU could be performed safely, and it demonstrated a favorable antitumor effect for ESCC. This regimen might be indicated in patients in whom it is desirable to avoid myelosuppression and progression of renal impairment.

Chemoradiation therapy with docetaxel in elderly patients with stage II/III esophageal cancer: A phase 2 trial

PURPOSE

The most effective treatments in elderly patients with esophageal cancer remain a subject of debate. This multicenter phase 2 study was designed to evaluate the efficacy and toxicity of chemoradiation therapy (CRT) with docetaxel (DTX) in elderly patients with stage II/III (non-T4) esophageal cancer.

METHODS AND MATERIALS

Patients ≥70 years of age with clinical stage II/III esophageal cancer received DTX at a weekly dose of 10 mg/m2 during 6 consecutive weeks and concurrent radiation therapy (60 Gy in 30 fractions). The primary endpoint was the 2-year survival rate, and the required number of enrolled patients was 37.

RESULTS

Between July 2008 and January 2011, 16 patients were enrolled. The study was prematurely closed because of slow accrual. Characteristics of the patients were as follows: median age, 77 years (range, 73-81); performance status 0/1, 4/12; and clinical stage IIA/IIB/III, 3/4/9. Of the 16 patients, 14 (87.5%) completed the CRT. The 2-year survival rate was 62.5% (90% confidence interval [CI], 42.5-82.5). The median survival time was 27.7 months (95% CI, 23.3-32.2 months) and the median progression-free survival was 15.2 months (95% CI, 5.4-25.0 months). Seven patients achieved complete response, resulting in a complete response rate of 43.8% (95% CI, 19.8-70.1). Grade 3 or higher acute toxicities included esophagitis (31.3%), anorexia (12.5%), leukopenia (6.3%), neutropenia (6.3%), thrombocytopenia (6.3%), mucositis (6.3%), and infection (6.3%). Grade 3 or higher late toxicities included esophagitis (12.5%), pleural effusion (12.5%), pneumonitis (6.3%), and pericardial effusion (6.3%).

CONCLUSIONS

CRT with DTX might be a treatment option for elderly patients with stage II/III esophageal cancer, particularly for patients who are medically unfit for surgery or cisplatin-containing therapy. However, further improvements of this therapy are required to decrease the incidence of esophagitis.

Chemoradiotherapy for esophageal squamous cell cancer

Chemoradiotherapy has been clinically indicated for patients with resectable esophageal squamous cell carcinoma who refuse surgical resection and in locally advanced unresectable esophageal squamous cell carcinoma patients. Concurrent chemoradiotherapy prolongs survival than radiation therapy alone when given as definitive treatment. Therefore, chemoradiotherapy is recognized as the standard non-invasive treatment for patients with localized esophageal cancer who opt for non-surgical treatment. JCOG9906 showed promising outcomes for stage II/III ESCC patients. But there are some problems about chemoradiotherapy for esophageal squamous cell carcinoma. Late toxicities are sometimes lethal for patients who achieved complete response even after years. Salvage treatment for residual or recurrent disease is unestablished. Modified Radiation Therapy Oncology Group regimen at the dose of 50.4 Gy reduced late toxicities without reducing efficacy. Optimal timings and procedure of salvage surgery and endoscopic therapy is evaluated in JCOG0909. Strategy including salvage therapy after chemoradiotherapy should be considered at the time of starting the treatment. Targeted therapy has not shown adding effect for chemoradiotherapy for esophageal squamous cell carcinoma yet. New agents, such as immune checkpoint inhibitors, are expected to show synergistic effect with chemoradiotherapy for esophageal squamous cell carcinoma. Further investigation is needed.