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Zhou XL, Yu CH, Wang WW, Ji FZ, Xiong YZ, Zhu WG, Tong YS. Concurrent chemoradiotherapy with S-1 compared with concurrent chemoradiotherapy with docetaxel and cisplatin for locally advanced esophageal squamous cell carcinoma. Radiat Oncol 2021; 16:94. [PMID: 34039375 PMCID: PMC8157673 DOI: 10.1186/s13014-021-01821-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 05/19/2021] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Xi-Lei Zhou
- Department of Radiation Oncology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu, China
| | - Chang-Hua Yu
- Department of Radiation Oncology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu, China
| | - Wan-Wei Wang
- Department of Radiation Oncology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu, China
| | - Fu-Zhi Ji
- Department of Radiation Oncology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu, China
| | - Yao-Zu Xiong
- Department of Radiation Oncology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu, China
| | - Wei-Guo Zhu
- Department of Radiation Oncology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu, China.
| | - Yu-Suo Tong
- Department of Radiation Oncology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu, China.
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Jinnouchi H, Yamashita H, Kiritoshi T, Miki Y, Katano A, Nakagawa K, Abe O. Prognostic value of pre-treatment maximum standardized uptake value and CRP in radiotherapy of esophageal cancer. Mol Clin Oncol 2021; 15:146. [PMID: 34094544 DOI: 10.3892/mco.2021.2308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 04/01/2021] [Indexed: 11/05/2022] Open
Abstract
The aim of the present study was to evaluate the prognostic value of the pre-treatment maximum standardized uptake value (SUVmax) 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 SUVmax >12.85, the rates of 2-year OS and DFS were 49.0 and 35.7%, respectively. In the group of SUVmax ≤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 SUVmax was associated with lower OS, while high CRP was associated with lower OS and DFS.
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Affiliation(s)
- Haruka Jinnouchi
- Department of Radiology, University of Tokyo Hospital, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Hideomi Yamashita
- Department of Radiology, University of Tokyo Hospital, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Tomoki Kiritoshi
- Department of Radiology, University of Tokyo Hospital, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Yosuke Miki
- Department of Radiology, University of Tokyo Hospital, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Atsuto Katano
- Department of Radiology, University of Tokyo Hospital, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Keiichi Nakagawa
- Department of Radiology, University of Tokyo Hospital, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Osamu Abe
- Department of Radiology, University of Tokyo Hospital, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
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3
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Fan XW, Wang HB, Mao JF, Li L, Wu KL. Sequential boost of intensity-modulated radiotherapy with chemotherapy for inoperable esophageal squamous cell carcinoma: A prospective phase II study. Cancer Med 2020; 9:2812-2819. [PMID: 32100452 PMCID: PMC7163105 DOI: 10.1002/cam4.2933] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/17/2019] [Accepted: 02/06/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose This prospective phase II study aimed to determine the efficacy and tolerability of sequential boost of intensity‐modulated radiation therapy (IMRT) with chemotherapy for patients with inoperable esophageal squamous cell carcinoma (ESCC). Methods Patients with histologically or cytologically proven inoperable ESCC were enrolled in this study (ChiCTR‐OIC‐17010485). A larger target volume for subclinical lesion was irradiated with 50 Gy, and then, a smaller target volume only including gross tumor was boosted to 66 Gy. The fraction dose was 2 Gy, and no elective node was irradiated. Concurrent and consolidation chemotherapy of fluorouracil (600 mg/m2, days 1‐3) plus cisplatin (25 mg/m2, days 1‐3) was administered every 4 weeks, for 4 cycles in total. The primary endpoint was 2‐year progression‐free survival (PFS). Results Eighty‐eight patients were enrolled in this study. The median age was 65 years (range: 45‐75 years), and 69 patients (78.4%) were men. With the median follow‐up of 26 (range: 3‐95) months, the 2‐ and 5‐year PFS were 39.3% and 36.9%, respectively, and overall survival (OS) were 57.1% and 39.2%, respectively. Tumor stage and concurrent chemotherapy were independent OS predictors. Major acute adverse events were myelosuppression and esophagitis, most of which were grades 1‐2. Nine percent and 2.3% of patients had grade 3 acute esophagitis and late esophageal strictures, respectively. Conclusions Sequential boost to 66 Gy by IMRT with chemotherapy was safe and effective for inoperable ESCC. A randomized phase III study to compare with standard dose of 50 Gy is warranted.
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Affiliation(s)
- Xing-Wen Fan
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hong-Bing Wang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jing-Fang Mao
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ling Li
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Kai-Liang Wu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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4
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Qiu X, Li J, Zhou H, Zhang M, Jiang C, Shen Z, Zhu X, Li A, Che Y, Wu T, Wang Z. Concurrent chemoradiotherapy with raltitrexed and nedaplatin regimen for esophageal squamous cell carcinoma. Medicine (Baltimore) 2020; 99:e18732. [PMID: 31977864 PMCID: PMC7004679 DOI: 10.1097/md.0000000000018732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
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.
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5
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Zhu H, Pan W, Chen Y, Chen H, Zuo Y, Sun X. What Is the Optimal Radiotherapy Target Size for Non-Operable Esophageal Cancer? A Meta-Analysis. Oncol Res Treat 2019; 42:470-479. [PMID: 31344698 DOI: 10.1159/000501594] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 06/18/2019] [Indexed: 12/28/2022]
Abstract
Definitive radiotherapy has an affirmative role in treating non-operable esophageal cancer; however, the controversy between elective lymph node irradiation (ENI) and involved-field irradiation (IFI) still remains. To ascertain the benefits and disadvantages of the two radiation target volumes, we performed a meta-analysis with 7 related publications. According to our findings, patients treated with ENI and IFI had nearly identical 1, 2, and 3-year survival rates (pooled odds ratio [OR] = 1.004, p = 0.980, and pooled OR = 1.15, p = 0.594, and pooled OR = 0.918, p = 0.679, respectively). Likewise, no significant differences were detected in local recurrence rates (pooled OR = 1.04, p = 0.883), regional recurrence rates (pooled OR = 0.65, p = 0.555), and distant metastasis rates (pooled OR = 1.29, p = 0.309) between the two treatment groups. However, IFI could significantly decrease the incidences of acute radiation esophagitis (pooled OR = 2.30, p = 0.001) and late pneumonia (pooled OR = 2.52, p = 0.04) compared with ENI. This meta-analysis provides evidence that IFI is more feasible for non-operable esophageal cancer than ENI.
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Affiliation(s)
- Huiping Zhu
- Department of Oncology, the Affiliated Zhangjiagang Hospital of Soochow University, Suzhou, China
| | - Wei Pan
- Department of Oncology, The Second Hospital of Nanjing Jiangning, Nanjing, China
| | - Yong Chen
- Department of Medical Oncology, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Hui Chen
- Department of Radiation Oncology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yun Zuo
- Department of Oncology, the Affiliated Zhangjiagang Hospital of Soochow University, Suzhou, China
| | - Xinchen Sun
- Department of Radiation Oncology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China,
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6
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Jimenez-Jimenez E, Mateos P, Ortiz I, Aymar N, Roncero R, Gimenez M, Pardo J, Sabater S. Nodal FDG-PET/CT uptake influences outcome and relapse location among esophageal cancer patients submitted to chemotherapy or radiochemotherapy. Clin Transl Oncol 2019; 21:1159-1167. [PMID: 30661172 DOI: 10.1007/s12094-019-02038-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 01/10/2019] [Indexed: 01/30/2023]
Abstract
PURPOSE Our aim was investigate whether lymph node uptake is associated with survival and regional relapses, and relapse patterns with respect to the radiotherapy fields in esophageal cancer (EC). MATERIALS AND METHODS The FDG-PET/CT image datasets of 56 patients were analyzed. All patients underwent definitive or neoadjuvant radio/chemotherapy (RCT). All patients suffering from persistent or recurrent local/regional-only disease after RCT were considered for salvage resection. Patients with adenocarcinoma without metastatic disease were considered for planned resection (usually within 3 months of treatment). RESULTS Patients with PET-positive lymph nodes before treatment had a worse overall survival and a shorter disease-free survival than those without PET-positive nodes. They also had worse node and metastatic relapse-free survival. N2 patients had statistically significant poorer outcomes than N1-N0 patients and a better survival if the involved nodes were closer to the esophageal tumor. Involved node location by PET/CT also affected global, nodal and metastatic relapses. In addition, an increment of SUVmax value increased relative risk of death and increased relative risk of node and metastatic relapses. The first site of relapse was metastatic recurrence and, second, local recurrence. The most frequent were "in-field" loco/regional recurrence. We observed a relationship between patients classified-N1 and out-field nodal recurrence (p = 0.024), and between patients-N2 and in-field nodal recurrence. The number of PET-positive nodes was an independent significant prognostic predictor for relapse (p < 0.001). CONCLUSION Our study shows that only FDG-PET/CT can provide prognostic information in EC. Nodal PET/CT uptake influences outcome and relapse location among EC patients.
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Affiliation(s)
- E Jimenez-Jimenez
- Radiation Oncology Department, Complejo Hospitalario Universitario de Albacete, Calle Hermanos Falcó, 30, 02008, Albacete, Spain.
| | - P Mateos
- Medical Physics Department, Clinica IMQ Zorrotzaurre, Bilbao, Spain
| | - I Ortiz
- Radiation Oncology Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - N Aymar
- Radiation Oncology Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - R Roncero
- Radiation Oncology Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - M Gimenez
- Nuclear Medicine Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - J Pardo
- Radiation Oncology Department, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - S Sabater
- Radiation Oncology Department, Complejo Hospitalario Universitario de Albacete, Calle Hermanos Falcó, 30, 02008, Albacete, Spain
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7
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Fan XW, Wu JL, Wang HB, Liang F, Jiang GL, Wu KL. Three-dimensional conformal radiation therapy alone for esophageal squamous cell carcinoma: 10-year survival outcomes. Thorac Cancer 2019; 10:519-525. [PMID: 30648821 PMCID: PMC6397900 DOI: 10.1111/1759-7714.12968] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 12/15/2018] [Accepted: 12/16/2018] [Indexed: 12/21/2022] Open
Abstract
Background Concurrent chemoradiation is the standard treatment for locally advanced esophageal squamous cell carcinoma (SCC). We conducted a phase II study to explore the effect of three‐dimensional conformal radiotherapy (3‐DCRT) alone for patients with locally advanced esophageal SCC. This study aimed to analyze the long‐term survival outcomes. Methods Between November 2004 and April 2007, 30 patients with thoracic esophageal SCC underwent late‐course sequential boost 3‐DCRT at Fudan University Shanghai Cancer Center. The planning target volume (PTV1) comprised a 1.2–1.5 cm lateral margin around the gross tumor volume and a 3.0 cm margin, superior and inferior to the gross tumor volume. PTV2 encompassed the gross tumor volume with a margin of 0.5–0.7 cm. The PTV1 dose delivered was 50 Gy, and the PTV2 dose was a boost dose of 16 Gy, resulting in a total dose of 66 Gy. No chemotherapy was administered. Results The median follow‐up time was 30 months for all patients, and 132 months for patients who were alive. The median overall survival was 27 months (95% confidence interval [CI] 18.9–35.0). The 2‐, 5‐, and 10‐year overall survival rates were 56.6%, 33.3%, and 26.6%, respectively. The median progression‐free survival was 14 months (95% CI 7.7–20.2 months), and the 2‐, 5‐, and 10‐year progression‐free survival rates were 33.3%, 30.0%, and 26.6%, respectively. No severe late toxicity was observed in long‐term survivors. Conclusion Late‐course sequential boost 3‐DCRT is safe and feasible with promising long‐term outcomes for esophageal SCC.
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Affiliation(s)
- Xing-Wen Fan
- Department of Radiation Oncology, Fudan University, Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jun-Lan Wu
- Department of Oncology, Shanghai Armed Police Corps Hospital, Shanghai, China
| | - Hong-Bing Wang
- Department of Radiation Oncology, Fudan University, Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Fei Liang
- Clinical Statistics Center, Fudan University, Shanghai Cancer Center, Shanghai, China
| | - Guo-Liang Jiang
- Department of Radiation Oncology, Fudan University, Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Kai-Liang Wu
- Department of Radiation Oncology, Fudan University, Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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8
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Sun Y, Zhang XL, Mao QF, Liu YH, Kong L, Li MH. Elective nodal irradiation or involved-field irradiation in definitive chemoradiotherapy for esophageal squamous cell cancer: a retrospective analysis in clinical N0 patients. ACTA ACUST UNITED AC 2018; 25:e423-e429. [PMID: 30464693 DOI: 10.3747/co.25.3895] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Objective We compared failure patterns and survival after elective nodal irradiation (eni) or involved-field irradiation (ifi) in patients with thoracic esophageal squamous cell carcinoma (escc), clinical stage T2-4N0M0, to determine whether ifi is feasible for such patients. Methods Between 2005 and 2015, 126 patients with clinical stage T2-4N0M0 thoracic escc who received definitive concurrent chemoradiotherapy in Shandong Cancer Hospital and Institute and who had complete data, were analyzed retrospectively. Of those patients, 49 received ifi, and 77 received eni. In the ifi group, the radiation field included the primary tumour, with a 3-cm to 4-cm margin in the craniocaudal direction, and the elective irradiation was delivered to the adjacent regional lymphatics according to the location of the primary tumour. Patterns of failure were classified using the first site of failure, which included primary tumour failure, regional lymph node failure, and distant metastasis. Results Median progression-free survival was 20 months [95% confidence interval (ci): 7.87 months to 39.2 months] in the ifi group and 30 months (95% ci: 17.4 months to 44.6 months) in the eni group (p = 0.580). Median overall survival (os) was 36 months (95% ci: 21.9 months to 50.1 months) in the ifi group and 38 months (95% ci: 26.1 months to 49.9 months) in the eni group (p = 0.761). The estimated 1-year, 3-year, and 5-year os rates were, respectively, 87.8%, 49.4%, and 32.3% for the ifi patients and 92.2%, 52.0%, and 28.9% for the eni patients. Disease persistence and primary lesion recurrence after complete remission (cr) were the most frequent causes of treatment failure in the patients overall (83 of 124, 66.9%). Of the 66 patients achieving a clinical cr, 25 experienced recurrence of the primary lesion, 12 experienced distant relapse, 10 experienced regional nodal failure, and 2 experienced an isolated recurrence. No significant differences in the pattern of failure or in the incidences of grade 3 or greater treatment-related myelosuppression or esophagitis were found between the ifi and eni groups. Conclusions In patients with thoracic escc clinical stage T2-4N0M0 receiving definitive chemoradiotherapy, failure patterns and os were similar with either eni or ifi. Large prospective randomized studies are needed to further investigate and verify those results in this subgroup of patients.
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Affiliation(s)
- Y Sun
- The Second Hospital of Shandong University, Jinan, P.R.C
| | - X L Zhang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong University, Jinan, P.R.C
| | - Q F Mao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong University, Jinan, P.R.C
| | - Y H Liu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong University, Jinan, P.R.C
| | - L Kong
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong University, Jinan, P.R.C
| | - M H Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong University, Jinan, P.R.C
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Definitive chemoradiotherapy with low-dose continuous 5-fluorouracil reduces hematological toxicity without compromising survival in esophageal squamous cell carcinoma patients. Clin Transl Radiat Oncol 2017; 9:12-17. [PMID: 29594245 PMCID: PMC5862669 DOI: 10.1016/j.ctro.2017.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 11/28/2017] [Accepted: 12/20/2017] [Indexed: 12/19/2022] Open
Abstract
Background and purpose To compare chemoradiotherapy (CRT) with low-dose continuous 5-fluorouracil (5FU) to CRT with 5FU+cisplatin (CDDP) for esophageal squamous cell carcinoma (ESCC) in a retrospective cohort study. Methods and materials We reviewed the cases of Stage I–IV ESCC patients who underwent definitive CRT in 2000–2014. Concomitant chemotherapy was one of the three regimens: (1) high-dose intermittent 5FU and CDDP (standard-dose FP: SDFP), (2) low-dose continuous 5FU and CDDP (LDFP), or (3) low-dose continuous 5FU (LD5FU). The general selection criteria for chemotherapy were: SDFP for patients aged <70 yrs; LDFP for those aged 70–74 yrs; LD5FU for those aged ≥75 yrs or with performance status (PS) ≥3. Propensity scores were derived with chemotherapy (LD5FU vs. 5FU+CDDP) as the dependent variable. Results In a multivariate analysis, chemotherapy (LD5FU vs. SDFP, p = .24; LDFP vs. SDFP, p = .52) did not affect the overall survival (OS). LD5FU caused significantly less grade 3–4 leukopenia (9%) compared to SDFP (47%) and LDFP (44%) (p < .001). In a propensity-matched analysis, LD5FU affected neither OS (HR 1.06; 95%CI 0.55–2.05; p = .87) nor progression-free survival (HR 0.95, 95%CI 0.50–1.81; p = .87). Conclusion CRT with low-dose continuous 5FU may be a less toxic option for elderly ESCC patients.
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10
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So B, Marcu LG, Olver I, Gowda R, Bezak E. Cocktail without hangover: in search for the optimal chemotherapy in the combined management of non-operable esophageal carcinomas. Acta Oncol 2017; 56:899-908. [PMID: 28375694 DOI: 10.1080/0284186x.2017.1307518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Bianca So
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Loredana G. Marcu
- Department of Physics, Faculty of Science, University of Oradea, Oradea, Romania
- School of Physical Sciences, University of Adelaide, Adelaide, Australia
| | - Ian Olver
- Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Raghu Gowda
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
| | - Eva Bezak
- School of Health Sciences, University of South Australia, Adelaide, Australia
- Department of Physics, Faculty of Science, University of Oradea, Oradea, Romania
- Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
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11
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Encaoua J, Abgral R, Leleu C, El Kabbaj O, Caradec P, Bourhis D, Pradier O, Schick U. Intérêt de la tomographie par émission de positons au ( 18 F)-fluorodésoxyglucose pour la planification de la radiothérapie des cancers de l’œsophage localement évolués ou inopérables. Cancer Radiother 2017; 21:267-275. [DOI: 10.1016/j.canrad.2016.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 09/10/2016] [Accepted: 12/18/2016] [Indexed: 12/13/2022]
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12
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Yamashita H, Abe O, Nakagawa K. Involved-field irradiation concurrently combined with nedaplatin/5-fluorouracil for inoperable esophageal cancer on basis of 18FDG-PET scans: A long follow-up results of phase II study. Radiother Oncol 2017; 123:488. [PMID: 28427757 DOI: 10.1016/j.radonc.2017.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 04/03/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Hideomi Yamashita
- Department of Radiology, University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan.
| | - Osamu Abe
- Department of Radiology, University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Keiichi Nakagawa
- Department of Radiology, University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
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Yamashita H, Takenaka R, Okuma K, Ootomo K, Nakagawa K. Prognostic factors in patients after definitive chemoradiation using involved-field radiotherapy for esophageal cancer in a phase II study. Thorac Cancer 2016; 7:564-569. [PMID: 27766787 PMCID: PMC5129562 DOI: 10.1111/1759-7714.12369] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 05/01/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND A prospective study was performed on the use of chemoradiotherapy (CRT) for esophageal cancer (EC) with involved-field radiation therapy (IFRT), based on 18-fluorodeoxyglucose positron-emission tomography. Prognostic factors for overall survival (OS) were analyzed. METHODS Eligible patients included 63 adults with newly diagnosed, untreated, inoperable stage I-IV EC with lymph node metastases. Patients received 80 mg/m2 nedaplatin per day on day 1, 800 mg/m2 5-fluorouracil on days 1-4 intravenously repeated every 28 days for two to four cycles, and combined IFRT. Irradiation was applied only to the primary tumor and positive lymph nodes. RESULTS Three-year progression-free survival and OS rates were 44.9% and 47.5%, respectively. The median survival time was 31.5 months. In univariate analyses for OS, Karnofsy Performance Scale <90% (P = 0.027), initial stage (P = 0.0087), T stage (P = 0.066), N stage (P = 0.000086), M stage of M1 (P = 0.0042), dysphagia score (P = 0.00017), tumor marker squamous cell carcinoma antigen >1.5 ng/mL (P = 0.0054), gross tumor volume (GTV) > 60 cc (P = 0.00011), and relative dose intensity (RDI) of chemotherapy ≤50% (P = 0.063) were found to be associated with significantly or marginally worse OS. In multivariate analyses for OS, GTV ≥ 60 cc (P = 0.00040), RDI < 50% (P = 0.00034), and cN2-3 (P = 0.0020) were associated with significantly worse OS. CONCLUSION GTV, RDI and N grading, were associated with OS after definitive CRT using IFRT for EC.
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Affiliation(s)
| | | | - Kae Okuma
- Department of Radiology, University of Tokyo Hospital, Tokyo, Japan
| | - Kuni Ootomo
- Department of Radiology, University of Tokyo Hospital, Tokyo, Japan
| | - Keiichi Nakagawa
- Department of Radiology, University of Tokyo Hospital, Tokyo, Japan
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Hatogai K, Yano T, Kojima T, Onozawa M, Fujii S, Daiko H, Yoda Y, Hombu T, Doi T, Kaneko K, Ohtsu A. Local efficacy and survival outcome of salvage endoscopic therapy for local recurrent lesions after definitive chemoradiotherapy for esophageal cancer. Radiat Oncol 2016; 11:31. [PMID: 26922374 PMCID: PMC4769588 DOI: 10.1186/s13014-016-0604-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 02/18/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Salvage endoscopic therapy (SET), such as endoscopic mucosal resection (EMR) and photodynamic therapy (PDT), is a less-invasive treatment for local failure at the primary site after chemoradiotherapy (CRT) for esophageal squamous cell carcinoma (ESCC). We conducted this retrospective study to clarify the risk factors for local recurrence along with the long term results after SET for recurrent lesions after definitive CRT for ESCC. METHODS We enrolled 77 consecutive patients who underwent EMR or PDT for local recurrence without any metastasis after definitive CRT at our institution. We evaluated the local efficacy, local recurrence-free survival (LRFS), and overall survival (OS), and investigated the risk factors associated with survival outcome using a multivariate analysis. RESULTS The complete resection rate of EMR was 84.6 % (33/39), and the complete response rate for PDT was 65.8 % (25/38). Twenty-two patients (28.6 %) exhibited local recurrence without metastasis. Thirty-four patients (44.2 %) were alive at 5 years after undergoing only initial SET or with repeated SET. The 5-year LRFS rate was 59.6 %, and the presence of lesions occupying an esophageal circumference of 1/4 or larger was the only significant risk factor (HR: 3.10, 95 % CI: 1.35-7.15, P = 0.008). The 5-year OS rate was 48.4 %, and an advanced T factor before CRT was marginally associated with a poor OS (HR: 1.96, 95 % CI: 0.98-3.92, P = 0.055). CONCLUSIONS SET enabled a preferable local control and survival outcome for patients with local recurrence after definitive CRT for ESCC. Careful endoscopic follow-up is needed for patients with a large lesion before SET and those with an advanced T factor before CRT.
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Affiliation(s)
- Ken Hatogai
- Department of Gastroenterology, Endoscopy Division, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
- Department of Gastroenterology, Gastrointestinal Oncology division, National Cancer Center Hospital East, Kashiwa, Chiba, Japan.
- Department of Medical Oncology, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan.
| | - Tomonori Yano
- Department of Gastroenterology, Endoscopy Division, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Takashi Kojima
- Department of Gastroenterology, Gastrointestinal Oncology division, National Cancer Center Hospital East, Kashiwa, Chiba, Japan.
| | - Masakatsu Onozawa
- Department of Radiation Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan.
| | - Satoshi Fujii
- Division of Pathology, Exploratory Oncology Research & Clinical Trial Center, National Cancer Center, Kashiwa, Chiba, Japan.
| | - Hiroyuki Daiko
- Department of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Chiba, Japan.
| | - Yusuke Yoda
- Department of Gastroenterology, Endoscopy Division, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Takuya Hombu
- Department of Gastroenterology, Endoscopy Division, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Toshihiko Doi
- Department of Gastroenterology, Gastrointestinal Oncology division, National Cancer Center Hospital East, Kashiwa, Chiba, Japan.
| | - Kazuhiro Kaneko
- Department of Gastroenterology, Endoscopy Division, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Atsushi Ohtsu
- Department of Gastroenterology, Gastrointestinal Oncology division, National Cancer Center Hospital East, Kashiwa, Chiba, Japan.
- Exploratory Oncology Research & Clinical Trial Center, National Cancer Center, Kashiwa, Chiba, Japan.
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15
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Li M, Zhang X, Zhao F, Luo Y, Kong L, Yu J. Involved-field radiotherapy for esophageal squamous cell carcinoma: theory and practice. Radiat Oncol 2016; 11:18. [PMID: 26846932 PMCID: PMC4743321 DOI: 10.1186/s13014-016-0589-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 01/14/2016] [Indexed: 12/14/2022] Open
Abstract
Esophageal carcinoma (EC) is characterized by a high rate of lymph node metastasis and its spread pattern is not always predictable. Chemoradiotherapy has an important role in the treatment of EC in both the inoperable and the pre-operative settings. However, regarding the target volume for radiation, different clinical practices exist. Theoretically, in addition to the clinical target volume administered to the gross lesion, it might seem logical to deliver a certain dose to the uninvolved regional lymph node area at risk for microscopic disease. However, in practice, it is difficult because of the intolerance of normal tissue to radiotherapy (RT), particularly if all regions containing the cervical, mediastinal, and upper abdominal nodes are covered. To date, the use of elective nodal irradiation (ENI) is still controversial in the field of radiotherapy. Some investigators use involved-field radiotherapy (IFRT) in order to reduce treatment-related toxicities. It is thought that micrometastases can be controlled, to some extent, by chemotherapy and the abscopal effects of radiation. It is the presence of overtly involved lymph nodes rather than the micrometastatic nodes negatively affects survival in patients with EC. In another hand, lymph nodes stationed near primary tumors also receive considerable incidental irradiation doses that may contribute to the elimination of subclinical lesions. These data indicate that an irradiation volume covering only the gross tumor is appropriate. When using ENI or IFRT, very few patients experience solitary regional node failure and out-of-field lymph node failure is not common. Primary tumor recurrence and distant metastases, rather than regional lymph node failure, affect the overall survival in patients with EC. The available evidence indicates that the use of ENI seems to prevent or delay regional nodal relapse rather than improve survival. In a word, these data suggest that IFRT is feasible in EC patients.
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Affiliation(s)
- Minghuan Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, Shandong Province, 250117, China.
| | - Xiaoli Zhang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, Shandong Province, 250117, China. .,Department of Oncology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China.
| | - Fen Zhao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, Shandong Province, 250117, China.
| | - Yijun Luo
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, Shandong Province, 250117, China.
| | - Li Kong
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, Shandong Province, 250117, China.
| | - Jinming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong Academy of Medical Sciences, Jiyan Road 440, Jinan, Shandong Province, 250117, China.
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Yamashita H, Haga A, Takenaka R, Kiritoshi T, Okuma K, Ohtomo K, Nakagawa K. Efficacy and feasibility of ambulatory treatment-based monthly nedaplatin plus S-1 in definitive or salvage concurrent chemoradiotherapy for early, advanced, and relapsed esophageal cancer. Radiat Oncol 2016; 11:4. [PMID: 26781439 PMCID: PMC4717830 DOI: 10.1186/s13014-016-0587-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 01/07/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Standard chemoradiotherapy (CRT) using cisplatin (CDDP) and 5-fluorouracil (5-FU) is an optional treatment for patients with stage II-III esophageal cancer. However, there are some demerits in this regimen because CDDP administration requires a large transfusion volume and 5-FU must be continuously infused over 24 h. Therefore, hospitalization is unavoidable. We collected retrospectively the data of definitive CRT with nedaplatin and S-1 as carried out in our institution. METHODS Patients with early and advanced esophageal cancer and relapsed esophageal cancer after radical surgery were included. Nedaplatin 80 mg/m(2) was given on days 1 and 29, and S-1 80 mg/m(2) on days 1-14 and 29-42. No prophylactic treatment with granulocyte colony stimulating factor was administered. Patients received two courses of concurrent radiotherapy of more than 50 Gy with or without two additional courses as adjuvant therapy every 4 weeks. RESULTS Between August 2011 and June 2015, 89 patients (age range, 44-86 years; K-PS 90-100, 81 %; squamous cell carcinoma histology, 97 %; definitive/salvage CRT, 75/25 %) were collected. Twenty-one (24 %) patients completed four cycles, and 94 % received two or more cycles. Grade 4 leukopenia, thrombocytopenia, and anemia occurred in 12, 7, and 10 % of the patients, respectively. Five patients developed febrile neutropenia. Grade 3 non-hematological toxicity included infection in 12 %, mucositis/esophagitis in 3 %, kidney in 3 %, and fatigue in 3 %. Sixty-four patients (72 %) received the prescribed full dose and full cycles of chemotherapy. A complete response was achieved in 76 patients (85 %). The 3-year overall survival rate was 54.4 % in definitive CRT and 39.8 % in salvage CRT, respectively. Sixty-two subjects (70 %) received treatment as outpatients. CONCLUSIONS Nedaplatin and S-1 in combination with radiotherapy is feasible, and toxicity is tolerable. This treatment method has the potential to shorten hospitalization without impairing the efficacy of CRT.
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Affiliation(s)
- Hideomi Yamashita
- Department of Radiology, University of Tokyo Hospital of Bunkyo-ku, Tokyo, Japan.
| | - Akihiro Haga
- Department of Radiology, University of Tokyo Hospital of Bunkyo-ku, Tokyo, Japan.
| | - Ryousuke Takenaka
- Department of Radiology, University of Tokyo Hospital of Bunkyo-ku, Tokyo, Japan.
| | - Tomoki Kiritoshi
- Department of Radiology, University of Tokyo Hospital of Bunkyo-ku, Tokyo, Japan.
| | - Kae Okuma
- Department of Radiology, University of Tokyo Hospital of Bunkyo-ku, Tokyo, Japan.
| | - Kuni Ohtomo
- Department of Radiology, University of Tokyo Hospital of Bunkyo-ku, Tokyo, Japan.
| | - Keiichi Nakagawa
- Department of Radiology, University of Tokyo Hospital of Bunkyo-ku, Tokyo, Japan.
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Feasibility of Elective Nodal Irradiation (ENI) and Involved Field Irradiation (IFI) in Radiotherapy for the Elderly Patients (Aged ≥ 70 Years) with Esophageal Squamous Cell Cancer: A Retrospective Analysis from a Single Institute. PLoS One 2015; 10:e0143007. [PMID: 26636574 PMCID: PMC4670202 DOI: 10.1371/journal.pone.0143007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 10/29/2015] [Indexed: 11/19/2022] Open
Abstract
PURPOSE We conducted a retrospective analysis to assess the feasibility of involved field irradiation (IFI) in elderly patients with esophageal squamous cell cancer (ESCC). MATERIALS AND METHODS We performed a retrospective review of the records of elderly patients (≥ 70 years) with unresectable ESCC and no distant metastases who received treatment with radiotherapy between January 2009 and March 2013. According to the irradiation volume, patients were allocated into either the elective nodal irradiation (ENI) group or the IFI group. Overall survival (OS), progression-free survival (PFS) and treatment-related toxicities were compared between the two groups. RESULTS A total of 137 patients were enrolled. Fifty-four patients (39.4%) were allocated to the ENI group and 83 patients (60.6%) to the IFI group, the median doses in the two groups were 60 Gy and 59.4 Gy, respectively. For the entire group, the median survival time (MST) and PFS were 16 months and 12 months, respectively. The median PFS and 3-year PFS rate in the ENI group were 13 months and 20.6%, compared to 11 months and 21.0% in the IFI groups (p = 0.61). The MST and 3-year OS rate in the ENI and IFI groups were 17 months and 26.4% and 15.5 months and 21.7%, respectively (p = 0.25). The rate of grade ≥ 3 acute irradiation esophagitis in the ENI group was significantly higher than that in the IFI group (18.5% vs. 6.0%; p = 0.027). Other grade ≥ 3 treatment-related toxicities did not significantly differ between the two groups. CONCLUSIONS IFI resulted in decreased irradiation toxicities without sacrificing OS in elderly patients with ESCC.
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18
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Atlas of the thoracic lymph nodal delineation and recommendations for lymph nodal CTV of esophageal squamous cell cancer in radiation therapy from China. Radiother Oncol 2015; 116:100-6. [PMID: 26142269 DOI: 10.1016/j.radonc.2015.06.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 04/21/2015] [Accepted: 06/21/2015] [Indexed: 01/31/2023]
Abstract
PURPOSE To construct an anatomical atlas of thoracic lymph node regions of esophageal cancer (EC) based on definitions from The Japan Esophageal Society (JES) and generate a consensus to delineate the nodal clinical target volume (CTVn) for elective nodal radiation (ENI) of esophageal squamous cell carcinoma (ESCC). METHODS AND MATERIALS An interdisciplinary group including two dedicated radiation oncologists, an experienced radiologist, a pathologist and two thoracic surgeons were gathered to generate a three-dimensional radiological description for the mediastinal lymph node regions of EC on axial CT scans. Then the radiological boundaries of lymph node regions were validated by a relatively large number of physicians in multiple institutions. RESULTS An atlas of detailed anatomic boundaries of lymph node station No. 105-114 was defined on axial CT, along with illustrations. From the previous work, the study provided a guide of CTVn contouring for ENI of thoracic ESCC from a single center. CONCLUSION It is feasible to use such an atlas of thoracic lymph node stations for radiotherapy planning. A phase III study based on the atlas is ongoing in China to measure quantitatively the ENI received by patients with ESCC.
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