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

Do higher radiation doses improve survival for cervical esophageal squamous cell cancer patients treated with definitive chemoradiotherapy using intensity-modulated radiotherapy? A propensity-score matched analysis

OBJECTIVE

This study was conducted to determine whether higher doses of intensity-modulated radiotherapy (IMRT) could improve the survival rate in patients of cervical esophageal squamous cell carcinoma (CESCC), and lead to more severe treatment-related toxicity.

METHODS

The clinical records of stage I-IVA CESCC patients treated with definitive chemoradiotherapy (CRT) using IMRT between January 2013 and June 2018 were retrospectively analyzed. The patients in the high-dose (HD) group received ≥60 Gy and those in the standard-dose group received <60 Gy. A propensity score matching (PSM) was applied to balance the confounding factors between both groups. The primary endpoint was over-survival (OS). progression-free survival (PFS), loco-regional control (LRC), and treatment-related toxicity were also evaluated.

RESULTS

A total of 136 patients with CESCC were included. Patients with N1-3 nodal and stages III-IVA of the disease (P < 0.05) were included in the HD group. The differences in the OS, PFS, and LRC between the two groups were not statistically significant (P = 0.350, 0.063, and 0.099, respectively). After PSM, significantly longer PFS and LRC were observed in the HD group. The difference in OS between the two groups was not statistically significant. There was no significant difference in the incidence of treatment-related toxicity between the two groups.

CONCLUSIONS

The results of this PSM analysis suggested that higher doses may improve PFS and LRC for CESCC patients receiving CRT using OMRT, but do not demonstrate any statistically significant advantage in improving OS.

Treatment and survival analysis for 40-year SEER data on upper esophageal cancer

Background

Upper esophageal cancer (UEC) is rare in both Eastern and Western countries. The epidemiological characteristics and long-term survival of UEC patients are less known. In addition, the choice of optimal treatment for UEC has been controversial.

Methods

Cases of UEC (C15.3 and C15.0) arising during the period from 1973 to 2013 were identified and selected using the SEER database. Student's t-test and Pearson's chi-square test were used to compare the differences in parameters among different groups. Esophageal cancer-specific survival (ECSS) and overall survival (OS) rates were calculated by using the Kaplan-Meier method. Cox proportional hazard regression was used to analyze predictive factors.

Results

In the past 40 years, the cases of UEC have gradually increased, and the proportion of adenocarcinoma (AD) has gradually increased (from 3.6% to 11.8%, p < 0.001). There has been a significant increase (1973-1982 vs. 2004-2013) in median OS (7 months vs. 10 months, p < 0.001) and median ECSS (7 months vs. 11 months, p < 0.001) among UEC patients from 1973 to 2013. For the impact of different treatments, the results showed that the ECSS and OS of surgery without radiation (SWR) and radiation plus surgery (R+S) were superior to those of radiation without surgery (RWS). Subgroup analysis showed that ECSS and OS were highest among patients treated with SWR compared with R+S and RWS for patients with localized disease. For regional disease, ECSS and OS were highest among patients with R+S compared with SWR or RWS. Among patients with regional-stage squamous cell carcinoma (SCC), OS was higher with neoadjuvant radiotherapy or adjuvant radiotherapy compared with SWR. Multivariate analysis showed that radiotherapy sequence was dependently associated with OS among patients with regional-stage SCC.

Conclusion

Although the long-term survival of UEC remains poor, it has gradually increased since 1973. This should be closely related to the improvement of medical care over the past 40 years. Different treatment methods have a great influence on the long-term survival of UEC. For localized diseases, surgery may be a better choice. For regional disease, surgery plus adjuvant or neoadjuvant radiotherapy may be more beneficial to improve the long-term prognosis of UEC patients.

Treatment and Outcomes of Proximal Esophageal Squamous Cell Carcinoma

INTRODUCTION

This study evaluated the treatment of proximal (cervical or upper thoracic) esophageal squamous cell carcinoma (SCC), for which chemoradiation is the recommended therapy.

METHODS

Treatment and outcomes of patients with cT1-3N0-1M0 proximal esophageal SCC in the National Cancer Database between 2004 and 2016 was evaluated using logistic regression, Kaplan-Meier analysis, and propensity-score matching.

RESULTS

Therapy of 2159 patients was chemoradiation (n = 1500, 69.5%), no treatment (n = 205, 9.5%), surgery (n = 203, 9.4%), radiation alone (n = 190, 8.8%), and chemotherapy alone (n = 61, 2.8%). Factors associated with definitive therapy with either chemoradiation or surgery were younger age, non-Black race, being insured, cervical tumor location, clinical T2 and T3 stage, clinical nodal involvement, and treatment at a research/academic program. Five-year survival was significantly better in patients treated with definitive therapy than patients not treated definitively (34.0% vs. 13.3%, p < 0.001). In multivariable survival analysis, receiving definitive therapy (hazard ratio [HR] 0.39, p = 0.017) was associated with improved survival, while increasing age, male sex, clinical T3 stage, positive clinical nodal involvement, and increasing Charlson Comorbidity Index were associated with worse survival. Esophagectomy was not associated with improved survival in multivariable analysis of the definitive therapy cohort (HR 0.84, p = 0.08) or propensity matched analysis. However, the pathologic complete response was only 33.3% (40/120) for patients who did have an esophagectomy after chemoradiation.

CONCLUSIONS

This national analysis supports definitive chemoradiation for not only cervical but also proximal thoracic esophageal SCC. Routine surgery does not appear to be necessary but may have a role in patients with residual disease after chemoradiation.

Radiation Dose-Effect Relation in Patients with Esophageal Squamous Cell Carcinoma: A National Cancer Center Data and Literature-Based Analysis

Introduction

Despite receiving definitive chemoradiotherapy (dCRT) with radiation dose (RTD) of 50.4 Gy, survival of esophageal carcinoma was dismal. The effect of RTD in cancer control and radiotoxicity, and the extent to which local-regional control (LRC) influenced survival remain vague. This study aimed at evaluating RTD-effect relationship in esophageal squamous cell carcinoma (ESCC).

Methods

1440 dRT/CRT-treated ESCC patients were enrolled. Restricted cubic spline regression model was applied to reveal nonlinear relationship between RTD and survival/radiotoxicity. Linear regression analysis (LRA) was performed to evaluate correlations between LRC and overall survival (OS) or progression-free survival (PFS).

Results

For 1440 dRT/CRT-treated ESCC patients, with RTD escalating, hazard ratios (HRs) of OS, PFS, LRC declined until RTD exceeded 60 Gy, then increased. HR of treatment-related mortality was stable until RTD exceeded 60 Gy, then increased. HR of LRC was lower for majority of patients treated with RTD≥60 Gy, except for those with KPS<80, T1-2 lesion, or without lymph node metastasis. LRA revealed strong correlations between LRC and OS/PFS. 45.5% and 44.9% of OS and PFS improvements were owing to improved LRC.

Conclusions

RTD of 60 Gy was well tolerated, with favorable survival resulted of LRC improvement in local-advanced ESCC. Further stratification analyses based on radiation sensitivity will be helpful to determine potential beneficiaries of RTD escalation.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Comparison of involved-field intensity-modulated radiotherapy combined with S-1 vs radiotherapy alone for elderly patients with esophageal cancer

BACKGROUND

It is estimated that about 30% of esophageal cancer (EC) patients are over 70 years old. Therefore, there is less evidence on the diagnosis and management of elderly EC patients. It is important to explore how elderly EC patients benefit from radical radiochemotherapy regimens, including the target area of radiotherapy (RT), radiation dose and fraction, and choice of chemotherapy drugs.

AIM

To compare the efficacy of involved-field intensity-modulated RT (IF-IMRT) combined with S-1 vs RT alone in the treatment of elderly EC patients in terms of safety, short-term response, and survival.

METHODS

Thirty-four EC patients aged > 70 years were prospectively enrolled between December 2017 and December 2019. Based on the random number table, they were divided into an IF-IMRT + S-1 group and an IF-IMRT alone group, with 17 patients in each group. All patients were treated with IF-IMRT at a dose of 50.4-56 Gy in 28-30 fractions (1.8-2 Gy/fraction, 5 fractions/wk). Oral S-1 was administered concomitantly in the IF-IMRT + S-1 group for 14 consecutive days, and a second cycle was started 7 d after drug withdrawal. After RT, 4 cycles of S-1 treatment were offered as the consolidation chemotherapy. The safety, short-term response, and survival were observed after the treatment.

RESULTS

As of April 2022, these 34 patients had been followed up for 15.2-32.5 mo, with a median follow-up period of 24.5 mo. Complete efficacy indicators were obtained from all the patients. The objective response rate was 88.2% vs 76.5%, respectively, in the IF-IMRT + S-1 group and the RT alone group, where as the disease control rate was 100% vs 82.4%, respectively. The incidence of adverse events including grade 1-2 fatigue, granulocytopenia, thrombocytopenia, anemia, radiation esophagitis, radiation-induced skin injury, and radiation-induced lung injury was not significantly different between these two groups, so was the incidence of the grade 3 radiation esophagitis (0% vs 5.7%). The rate of progressive disease (PD) was 52.9% (n = 9) in the IF-IMRT + S-1 group and 64.7% (n = 11) in the RT alone group. The median progression-free survival (PFS) was 23.4 mo vs 16.3 mo, and the 2-year PFS rate was 42% vs 41.2%. The median overall survival (OS) was 27.0 mo vs 23.0 mo, and the 2-year OS rate was 58.8% vs 47.1%. Multivariate analysis showed that age was a significant prognostic factor (P = 0.0019); patients aged < 75 years had a significant survival advantage over patients aged ≥ 75 years. The locations of EC also affected the prognosis. In the IF-IMRT + S-1 group, the number of chemotherapy cycles was a significant prognostic factor (P = 0.0125), and the risk of PD was significantly lower in EC patients who had received 6 cycles of chemotherapy than those who had received 2-5 cycles of chemotherapy.

CONCLUSION

Compared with IF-IMRT alone, IF-IMRT + S-1 shows the benefits of preventing PD and prolonging survival without increasing adverse reactions. Therefore, this concurrent radiochemotherapy deserves clinical application.

Intensity-modulated radiotherapy with more than 60 Gy improved the survival of inoperable patients with locally advanced esophageal squamous cell carcinoma: A population-based real-world study

Intensity-modulated radiotherapy (IMRT) is widely applied during the treatment of esophageal squamous cell carcinoma (ESCC), but the optimal radiation dose still lacks a consensus. The aim of this study was to explore the optimal radiation dose for inoperable locally advanced ESCC patients treated with IMRT in a real-world clinical setting.A total of 90 inoperable ESCC patients with locally advanced stages of II-IVA treated with IMRT in our institute between February 1, 2014 and June 30, 2019 were included in this retrospective study. Sixty patients had received >60 Gy (high dose group) and 30 patients had received ≤60 Gy (low dose group). The median radiation dose was 66 Gy (range: 61-70 Gy) and 50.2 Gy (range: 40-60 Gy), respectively. Concurrent chemotherapies were platinum-based regimens.The median progression free survival (PFS) and overall survival (OS) of all patients were 7.6 and 14.1 months, respectively. Patients in the high dose group exhibited a significantly better PFS (1-year PFS 34.6% vs 22.8%; 2-year PFS 11.9% vs 0%, P = .008) and OS (1-year OS 57.5% vs 39.5%; 2-year OS 31.4% vs 15.8%, P = .007). The median PFS in the high and low dose groups were 8.1 and 6.1 months, and the median OS were 15.4 and 8.5 months, respectively. Multivariate Cox analysis showed that radiation dose (>60 Gy vs ≤60 Gy) was independently prognostic factor for OS (HR: 0.44; 95% CI: 0.22-0.89; P = .021), but not for PFS (HR: 0.56; 95% CI: 0.31-1.02; P = .058). There was no significant difference in treatment-related toxicities of grade ≥3 between the 2 groups (P = .402).This retrospective study confirmed that higher radiation dose (>60 Gy) resulted in better survival outcomes for inoperable patients with locally advanced ESCC treated with IMRT.

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

Background

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

Methods

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

Results

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

Conclusion

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

Supplementary Information

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

Patterns of recurrence following definitive chemoradiation for patients with proximal esophageal cancer

INTRODUCTION

The aim of this retrospective study was to determine the patterns of recurrence and overall survival (OS) in patients achieving clinical complete response after treatment with definitive chemoradiation (CRT) for proximal esophageal cancer.

MATERIALS AND METHODS

Patients with proximal esophageal cancer treated with CRT between 2004 and 2014 in 11 centers in the Netherlands were included. OS and progression-free survival (PFS) were calculated using the Kaplan-Meier method. Cumulative incidence of first recurrence (locoregional or distant) and locoregional recurrence (LRR) were assessed using competing risk analyses.

RESULTS

In 197 of the 200 identified patients, response was evaluated, 133 (68%) showed a complete response. In complete responders, median OS, three-year OS, and PFS were 45.0 months (95% CI 34.8-61.5 months), 58% (95% CI 48-66), and 49% (95% CI 40-57), respectively. Three- and five-year risk of recurrence were respectively 40% (95% CI 31-48), and 45% (95% CI 36-54). Three- and five-year risk of LRR were 26% (95% CI 19-33), and 30% (95% CI 22-38). Eight of 32 patients with an isolated LRR underwent salvage surgery, with a median OS of 32.0 months (95% CI 6.8-not reached).

CONCLUSION

In patients with a complete response after definitive CRT for proximal esophageal cancer, most recurrences were locoregional and developed within the first three years after CRT. These findings suggest to shorten locoregional follow-up from five to three years.

Larynx-preserving limited resection with total thoracic esophagectomy and gastric pull-up reconstruction: A promising treatment for selected cervical esophageal squamous cell carcinoma

BACKGROUND/AIMS

There is no consensus on treatment for cervical esophageal squamous cell carcinoma (ESCC). Our aim is to evaluate the feasibility and outcome of larynx-preserving limited resection with total thoracic esophagectomy and gastric pull-up reconstruction for the treatment of cervical ESCC without tumor involvement of the larynx and hypopharynx.

MATERIALS AND METHODS

Retrospective analysis of patients with cervical ESCC who underwent R0 surgical resection from 2006 to 2011 in our center was performed. Kaplan-Meier method was used to calculate the survival time for patients.

RESULTS

In total, 74 cervical ESCC patients were enrolled in the study. The mortality rate in 30 days was 8.1%, the total complication rate (at least one) was 47.3%, anastomosis leakage occurrence was 37.8%, mechanical ventilation ratewas12.2%, the rate of normal oral diet within 15 days was 71.6%, and the anastomosis recurrence rate in follow-up was 8.1%. Detailed analysis showed that the anastomosis leakage, pulmonary infection, laryngeal recurrent nerve injury, and chylothorax were the most common complications in surgical patients. Finally, the survival data showed that the median survival time was 31.83 months (95% CI=12.39-51.28 months) and the 3-year and 5-year survival rates were 49.1% and 35.5%, respectively.

CONCLUSION

Larynx-preserving limited resection with total thoracic esophagectomy and gastric pull-up reconstruction might be a feasible and effective surgical alternative for the cervical ESCC patients whose tumor does not involve the larynx and hypopharynx.

Docetaxel and nedaplatin twice a week with concurrent definitive radiotherapy in inoperable esophageal squamous cell carcinoma: A phase I trial (GASTO-1021)

PURPOSE

This phase I trial aimed to determine the maximal tolerated dose (MTD) of incorporating a twice-weekly docetaxel and nedaplatin regimen into definitive concurrent chemoradiotherapy (CCRT) as radiosensitizers in patients with inoperable esophageal squamous cell carcinoma (ESCC).

METHODS

The CCRT regimen included docetaxel (5 mg/m², 10 mg/m², or 15 mg/m²) and nedaplatin (5 mg/m², 10 mg/m², or 15 mg/m²) twice-weekly based on the traditional 3 + 3 dose escalation strategy, and radiotherapy (64 Gy in 32 fractions). The primary goals were to determine the MTD of concurrent chemotherapy and the dose limiting toxicities (DLTs). In-field objective response rate (ORR) was investigated.

RESULTS

Fifteen patients had been recruited and analyzed. DLT involving persistent grade 3 esophagitis over 1 week was observed in all three patients (3/3) at dose level 3 (15 mg/m²), and two patients (2/6) experienced DLTs in the dose level 2 (10 mg/m²) due to esophageal fistula and persistent grade 3 esophagitis over 1 week, while one patient (1/6) treated at dose level 1 (5 mg/m²) exhibited DLT owing to Grade 3 increased liver enzymes, suggesting a MTD of 5 mg/m². The in-filed ORR was both 100% in all patients and those receiving MTD. The 1-year loco-regional recurrence-free survival rate was 83.3%, 83.3% and 66.7% in dose level 1, 2, and 3, respectively.

CONCLUSIONS

The MTD of twice-weekly docetaxel and nedaplatin regimen was 5 mg/m² in inoperable ESCC patients treated with definitive CCRT. Low dose concurrent docetaxel and nedaplatin showed promising radiosensitizing effect on in-filed disease control and good tolerability.

Multidisciplinary Evaluation and Management of Early Stage Esophageal Cancer

Early esophageal cancer involves the mucosal and submucosal layers of the esophagus. Early esophageal cancer is a heterogeneous group, and achieving optimal outcomes requires a multidisciplinary approach to align patients to their optimal treatment. Although organ-sparing endoscopic resection has become the preferred management option for superficial esophageal cancer, it is not adequate in all tumors, such as high-risk lesions with poorly differentiated pathology, lymphovascular invasion, or deep submucosal invasion. In such high-risk lesions, surgery, chemotherapy, and/or radiation may be required. In this article, we present our multidisciplinary approach to early esophageal cancer.

Mapping of Regional Failures After Definitive Radiotherapy in Patients with Locally Advanced Cervical Esophageal Carcinoma

Purpose

This study aimed to retrospectively analyze the failure patterns and clinical outcomes in patients with locally advanced cervical esophageal carcinoma (CEC) after definitive radiotherapy (RT), and illustrate the mapping of regional failures.

Patients and Methods

We reviewed 82 patients with CEC confirmed as squamous cell carcinoma who had completed definitive RT from August 2008 to December 2017. Data on clinical characteristics were collected from the medical records system. Patterns of treatment failures and the survival follow-up were analyzed.

Results

The median age was 58 (38–78) years. In 37 patients, the lesions were limited to the cervical esophagus, while in the remaining 45 patients, the disease got beyond the cervical esophagus (pharynx or thoracic esophagus involved). While 10 patients had stage Ⅱ disease, 72 had stage III disease. The completed median dose for 95% PGTV and 95% PTV was 66 Gy and 58 Gy. While the median follow-up was 27.6 months, the median progression-free survival (PFS) and overall survival (OS) was 16.1 and 28.3 months, respectively. The 3-year PFS and OS was 30.3% and 45.3%, respectively. Treatment failures were reported in 55 patients, of which 22, 8, 7, 9, 2, 3, and 4 patients had developed local, regional, distant, local-regional, regional-distant, local-distant and local-regional-distant failure, respectively. Of the 41 relapsed nodal sites, 28 were located “in-field” whereas 1 was “marginal” and 12 were “out-field”. The most frequent regional relapses were at level VIb, IV and the upper-middle mediastinum.

Conclusion

Regional recurrences focused on lower neck and upper-middle mediastinum, and mainly “in-field”, after definitive RT in patients with CEC.

Neoadjuvant Chemoradiotherapy and Larynx-Preserving Surgery for Cervical Esophageal Cancer

Neoadjuvant concurrent chemoradiotherapy (CCRT) followed by surgery is widely used for treating locally advanced esophageal cancer in the thorax. This study evaluated the feasibility of neoadjuvant CCRT as a larynx preservation strategy for treating cervical esophageal squamous cell carcinoma (SCC) by a multidisciplinary team. Fifteen patients with cervical esophageal SCC who received neoadjuvant CCRT and radical surgery at our institution were reviewed. All patients received CCRT using the intensity-modulated radiation therapy with 48 Gy to gross tumor and 43.2 Gy to regional lymphatic basin in 24 fractions. Side effects, clinical tumor responses, pathological responses, and surgical margin status were analyzed. Pathological T down-staging was noted in seven patients (46.7%); pathological complete response was achieved in three patients (20%). Fourteen patients (93.3%) had larynx preservation; eight patients (53.3%) achieved negative surgical margins. The 2-year overall survival, local relapse-free survival, and regional relapse-free survival were 50.6%, 62.2%, and 47.5%, respectively. Neoadjuvant CCRT and larynx-sparing surgery are feasible and tolerable in patients with cervical esophageal SCC. Prospectively designed studies for large patient groups and long-term follow-up results are needed for validating this multimodality therapy.

Three-Dimensional Conformal Radiotherapy-Based or Intensity-Modulated Radiotherapy-Based Concurrent Chemoradiotherapy in Patients with Thoracic Esophageal Squamous Cell Carcinoma

Background: To date, intensity-modulated radiation therapy (IMRT) with concurrent chemoradiotherapy (CCRT) and CCRT with standard fractionation three-dimensional conformal radiation therapy (3D-CRT) have not been compared. In this study, the outcomes of IMRT-based concurrent CCRT and those of 3D-CRT-based CCRT were compared in patients with thoracic esophageal squamous cell carcinoma (TESCC). Methods: We enrolled 2062 patients with TESCC who had received CCRT and categorized them into two groups on the basis of their treatment modality: Group 1 (3D-CRT-based CCRT) and Group 2 (IMRT-based CCRT). Results: Multivariate Cox regression analysis indicated that the American Joint Committee on Cancer advanced stages (≥IIIA) and 3D-CRT were significant independent predictors of poor outcomes in patients with TESCC who received definitive CCRT. Moreover, receiving IMRT-based CCRT (adjusted hazard ratio [aHR]: 0.88, 95% confidence interval [CI]: 0.78–0.98) was a significant independent prognostic factor for overall survival (p = 0.0223). In Group 2, aHRs (95% CIs) for overall mortality at early (IA–IIB) and advanced clinical stages were 0.91 (0.67–1.25, p = 0.5746) and 0.88 (0.77–0.99, p = 0.0368), respectively. Conclusion: IMRT-based CCRT resulted in higher survival rates in patients with advanced clinical stages of TESCC (i.e., IIIA–IIIC), namely, clinical T3, clinical T4, or lymph node involvement.

Intensity-Modulated Radiotherapy versus Three-Dimensional Conformal Radiotherapy in Definitive Chemoradiotherapy for Cervical Esophageal Squamous Cell Carcinoma: Comparison of Survival Outcomes and Toxicities

PURPOSE

The purpose of this study was to compare the survival and toxicities in cervical esophageal squamous cell carcinoma (CESCC) treated by concurrent chemoradiothrapy with either three-dimensional conformal radiotherapy (3D-CRT) or intensity-modulated radiotherapy (IMRT) techniques.

Materials and Methods

A total of 112 consecutive CESCC patients were retrospectively reviewed. 3D-CRT and IMRT groups had been analyzed by propensity score matching method, with sex, age, Karnofsky performance status, induction chemotherapy, and tumor stage well matched. The Kaplan-Meier method and Cox proportional hazards model were used for overall survival (OS) and progression-free survival (PFS). Toxicities were compared between two groups by Fisher exact test.

RESULTS

With a median follow-up time of 34.9 months, the 3-year OS (p=0.927) and PFS (p=0.859) rate was 49.6% and 45.8% in 3D-CRT group, compared with 54.4% and 42.8% in IMRT group. The rates of grade ≥ 3 esophagitis, grade ≥ 2 pneumonitis, esophageal stricture, and hemorrhage were comparable between two groups, while the rate of tracheostomy dependence was much higher in IMRT group than 3D-CRT group (14.3% vs.1.8%, p=0.032). Radiotherapy technique (hazard ratio [HR], 0.09; 95% confidence interval [CI], 0.01 to 0.79) and pretreatment hoarseness (HR, 0.12; 95% CI 0.02 to 0.70) were independently prognostic of tracheostomy dependence.

CONCLUSION

No survival benefits had been observed while comparing IMRT versus 3D-CRT in CESCC patients. IMRT with fraction dose escalation and pretreatment hoarseness were considered to be associated with a higher risk for tracheostomy dependence. Radiation dose escalation beyond 60 Gy should be taken into account carefully when using IMRT with hypofractionated regimen.

A meta-analysis on salvage surgery as a potentially curative procedure in patients with isolated local recurrent or persistent esophageal cancer after chemoradiotherapy

BACKGROUND

Isolated local recurrent or persistent esophageal cancer (EC) after curative intended definitive (dCRT) or neoadjuvant chemoradiotherapy (nCRT) with initially omitted surgery, is a potential indication for salvage surgery. We aimed to evaluate safety and efficacy of salvage surgery in these patients.

MATERIAL AND METHODS

A systematic literature search following PRISMA guidelines was performed using databases of PubMed/Medline. All included studies were performed in patients with persistent or recurrent EC after initial treatment with dCRT or nCRT, between 2007 and 2017. Survival analysis was performed with an inverse-variance weighting method.

RESULTS

Of the 278 identified studies, 28 were eligible, including a total of 1076 patients. Postoperative complications after salvage esophagectomy were significantly more common among patients with isolated persistent than in those with locoregional recurrent EC, including respiratory (36.6% versus 22.7%; difference in proportion 10.9 with 95% confidence interval (CI) [3.1; 18.7]) and cardiovascular complications (10.4% versus 4.5%; difference in proportion 5.9 with 95% CI [1.5; 10.2]). The pooled estimated 30- and 90-day mortality was 2.6% [1.6; 3.6] and 8.0% [6.3; 9.8], respectively. The pooled estimated 3-year and 5-year overall survival (OS) were 39.0% (95% CI: [35.8; 42.2]) and 19.4% [95% CI:16.5; 22.4], respectively. Patients with isolated persistent or recurrent EC after initial CRT had similar 5-year OS (14.0% versus 19.7%, difference in proportion -5.7, 95% CI [-13.7; 2.3]).

CONCLUSIONS

Salvage surgery is a potentially curative procedure in patients with locally recurrent or persistent esophageal cancer and can be performed safely after definitive or neoadjuvant chemoradiotherapy when surgery was initially omitted.

Cervical Esophageal Cancer Treatment Strategies: A Cohort Study Appraising the Debated Role of Surgery

BACKGROUND

Few studies have examined optimal treatment specifically for cervical esophageal carcinoma. This study evaluated the outcome of three common treatment strategies with a focus on the debated role of surgery.

METHODS

All patients with cervical esophageal cancer treated at a single center were identified and their outcomes analyzed in terms of morbidity, mortality, and recurrence according to the treatment they received, i.e. surgery alone, definitive platinum-based chemoradiation (CRT), or CRT followed by surgery.

RESULTS

The study population included 148 patients with cervical esophageal cancer from a prospective database of 3445 patients. Primary surgery was the treatment of choice for 56 (37.83%) patients, definitive CRT was the treatment of choice for 52 (35.13%) patients, and CRT followed by surgery was the treatment of choice for 40 (27.02%) patients. CRT-treated patients obtained 36.96% complete clinical response, with overall morbidity and mortality rates of 36.95 and 2.17%, respectively. Surgical complete resection was achieved in 71.88% of surgically treated cases, with morbidity and mortality rates of 52.17 and 6.25%, respectively. No significant survival difference existed among the three treatments, but patients who underwent surgery alone had a significantly lower stage of disease (p = 0.031). Compared with patients with complete response after CRT, surgery did not confer any significant survival benefit, and overall 5-year survival was lower than definitive CRT alone. In contrast, surgery improved survival significantly in patients with non-complete response after definitive CRT (p = 0.023).

CONCLUSIONS

Definitive platinum-based CRT should be the treatment of choice for cervical esophageal cancer. Surgery has a role for patients with non-complete response as it adds significant survival benefit, with acceptable morbidity and mortality.

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.

Synchronous Supraglottic and Esophageal Squamous Cell Carcinomas Treated with a Monoisocentric Hybrid Intensity-Modulated Radiation Technique

Risk factors for squamous cell carcinomas (SCCs) of the head and neck (HN) and esophagus are similar. As such, synchronous primary tumors in these areas are not entirely uncommon. Definitive chemoradiation (CRT) is standard care for locally advanced HNSCC and is a preferred option for inoperable esophageal SCC. Simultaneous treatment of both primaries with CRT can present technical challenges. We report a case of synchronous supraglottic and esophageal SCC primary tumors, highlighting treatment with a monoisocentric hybrid radiation technique and normal tissue toxicity considerations.

What is the optimal radiation dose for non-operable esophageal cancer? Dissecting the evidence in a meta-analysis

The standard radiation dose 50.4 Gy with concurrent chemotherapy for localized inoperable esophageal cancer as supported by INT-0123 trail is now being challenged since a radiation dose above 50 Gy has been successfully administered with an observable dose-response relationship and insignificant untoward effects. Therefore, to ascertain the treatment benefits of different radiation doses, we performed a meta-analysis with 18 relative publications. According to our findings, a dose between 50 and 70 Gy appears optimal and patients who received ≥ 60 Gy radiation had a significantly better prognosis (pooled HR = 0.78, P = 0.004) as compared with < 60 Gy, especially in Asian countries (pooled HR = 0.75, P = 0.003). However, contradictory results of treatment benefit for ≥ 60 Gy were observed in two studies from Western countries, and the pooled treatment benefit of ≥ 60 Gy radiation was inconclusive (pooled HR = 0.86, P = 0.64). There was a marginal benefit in locoregional control in those treated with high dose (> 50.4/51 Gy) radiation when compared with those treated with low dose (≤ 50.4/51 Gy) radiation (pooled OR = 0.71, P = 0.06). Patients that received ≥ 60 Gy radiation had better locoregional control (OR = 0.29, P = 0.001), and for distant metastasis control, neither the > 50.4 Gy nor the ≥ 60 Gy treated group had any treatment benefit as compared to the groups that received ≤ 50.4 Gy and < 60 Gy group respectively. Taken together, a dose range of 50 to 70 Gy radiation with CCRT is recommended for non-operable EC patients. A dose of ≥ 60 Gy appears to be better in improving overall survival and locoregional control, especially in Asian countries, while the benefit of ≥ 60 Gy radiation in Western countries still remains controversial.

Interim 18F-FDG-PET/CT during chemo-radiotherapy in the management of oesophageal cancer patients. A systematic review

Oesophageal cancer is an aggressive disease. The possibility to early stratify patients as responsive and non-responsive with a non-invasive method is extremely appealing. The uptake of Fluorodeoxyglucose (¹⁸F-FDG) in tumours, provided by positron emission tomography (PET) images, has been proved to be useful to assess the initial staging of the disease, recurrence, and response to chemotherapy and chemo-radiotherapy (CRT). In the last years, efforts have been focused on the possibility to use ad interim ¹⁸F-FDG-PET/CT (PET_int) to evaluate response during radiation therapy. However, controversial findings have been reported, although some relevant results would support its use for individual therapeutic decision. The present review assembles the comprehensive literature of the last decade to evaluate whether and in which cases PET_int may offer predictive potential in oesophageal cancer. All the analysed studies (13 studies, 697 patients) denoted PET_int as a challenging examination for early assessment of outcomes during CRT. In particular, 8 studies advocated the predictivity of PET_int, whilst 5 did not find any correlation between the interim variation of PET parameters and the pathological complete response and/or the clinical outcome. The reasons that possibly have caused contradictions among the studies demand further research with prospective and uniform protocols and methods of analysis to assess the predictive and prognostic value of PET_int in oesophageal 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.

Improved survival with higher radiation dose for esophageal squamous cell carcinoma patients treated with definitive chemoradiotherapy

Purpose

The optimal radiation dose for patients with esophageal squamous cell carcinoma (ESCC) has long been debated. We undertook the retrospective study to evaluate the survival impact of high dose vs standard dose in patients with stage II–III esophageal cancer treated with definitive chemoradiotherapy (CRT).

Results

A total of 137 patients were included in our study, 63 patients classified as standard-dose group and 74 as high-dose group. For the 63 patients in the standard-dose group, the median PFS and the 1-, 2-, and 3-year PFS rates were 12.6 months, 58.0%, 26.0% and 12.0%, respectively; for the 74 patients in the high-dose group, they were 20.0 months, 80.1%, 31.0% and 20.0%, respectively (P = 0.013). The median OS of the patients in the standard-dose group and high-dose group groups were 19.0 months and 26.6 months, respectively, and the 1-, 2- and 3-year survival rates were 78.0%, 39.0%, and 24.0% , and 89.0%, 61.0%, and 30.0%, respectively (P = 0.037). Besides the rate of grade ≥ 3 acute irradiation esophagitis in the high-dose group (10.5% versus. 2.2%, P < 0.01), there were no significantly differ of treatment-related toxicities between the two groups.

Materials and Methods

According to the radiation dose, patients from 2010 to 2014 were allocated into either the standard-dose group (50–50.4 Gy) or the high-dose group (≥ 59.4 Gy). Overall survival (OS), progression-free survival (PFS) and treatment-related toxicities were assessed and compared between the two groups.

Conclusions

Our findings suggest that higher radiation dose could perform better outcomes for esophageal squamous cell carcinoma patients.

The impact of histology on recurrence patterns in esophageal cancer treated with definitive chemoradiotherapy

BACKGROUND

To assess the impact of histology on recurrence patterns and survival outcomes in patients with esophageal cancer (EC) treated with definitive chemoradiotherapy (CRT).

METHODS

We analyzed 590 consecutive EC patients who received definitive CRT from 1998 to 2014, including 182 patients (30.8%) with squamous cell carcinoma (SCC) and 408 (69.2%) with adenocarcinoma. Recurrence pattern and timing, survival, and potential prognostic factors were compared.

RESULTS

After a median follow-up time of 58.0months, the SCC group demonstrated a comparable locoregional recurrence rate (42.9% vs. 38.0%, P=0.264) but a significantly lower distant failure rate (27.5% vs. 48.0%, P<0.001) than adenocarcinoma group. No significant difference was found in overall survival or locoregional failure-free survival between groups, whereas the SCC group was associated with significantly more favorable recurrence-free survival (P=0.009) and distant metastasis-free survival (P<0.001). The adenocarcinoma group had higher hematogenous metastasis rates of bone, brain, and liver, whereas the SCC group had a marginally higher regional recurrence rate. Among patients who received salvage surgery after locoregional recurrence, no significant difference in survival was found between groups (P=0.12).

CONCLUSIONS

The patterns and sites of recurrence, survival outcomes, and prognostic factors were significantly different between esophageal SCC and adenocarcinoma.

Outcome of proximal esophageal cancer after definitive combined chemo-radiation: a Swiss multicenter retrospective study

Objective

To report oncological outcomes and toxicity rates, of definitive platin-based chemoradiadiationtherapy (CRT) in the management of proximal esophageal cancer.

Methods

We retrospectively reviewed the medical records of patients with cT1-4 cN0-3 cM0 cervical esophageal cancer (CEC) (defined as tumors located below the inferior border of the cricoid cartilage, down to 22 cm from the incisors) treated between 2004 and 2013 with platin–based definitive CRT in four Swiss institutions. Acute and chronic toxicities were retrospectively scored using the National Cancer Institute’s Common Terminology Criteria for Adverse Events, version 4.0 (CTCAE-NCI v.4.0). Primary endpoint was loco-regional control (LRC). We also evaluated overall survival (OS) and disease-free survival (DFS) rates. The influence of patient- and treatment related features have been calculated using the Log-rank test and multivariate Cox proportional hazards model.

Results

We enrolled a total of 55 patients. Median time interval from diagnosis to CRT was 78 days (6–178 days). Median radiation dose was 56Gy (28–72Gy). Induction chemotherapy (ICHT) was delivered in 58% of patients. With a median follow up of 34 months (6–110months), actuarial 3-year LRC, DFS and OS were 52% (95% CI: 37–67%), 35% (95% CI: 22–50%) and 52% (95% CI: 37–67%), respectively. Acute toxicities (dysphagia, pain, skin-toxicity) ranged from grade 0 – 4 without significant dose-dependent differences. On univariable analyses, the only significant prognostic factor for LRC was the time interval > 78 days from diagnosis to CRT. On multivariable analysis, total radiation dose >56Gy (p <0.006) and ICHT (p < 0.004) were statistically significant positive predictive factors influencing DFS and OS.

Conclusion

Definitive CRT is a reliable therapeutic option for proximal esophageal cancer, with acceptable treatment related toxicities. Higher doses and ICHT may improve OS and DFS and. These findings need to be confirmed in further prospective studies.

Clinicopathological features and surgical treatment of cervical oesophageal cancer

Cervical oesophageal cancer (CEC) is a relatively uncommon malignancy. The biological behaviour and treatment have not been well studied. This retrospective study reviewed the clinicopathological features of 28 patients with CEC who underwent surgical resection to investigate the biological behaviour, treatment and prognosis of CEC. The long-term outcomes of these patients were compared with those of the CEC patients who received definitive chemoradiotherapy and those of thoracic or abdominal oesophageal cancer patients who underwent surgery. The study group contained 21 men and 7 women, ranging in age from 41 to 67 years (median: 56.5 years). The median survival time and the 1-, 3-, and 5-year overall survival rates were 25.0 months, 83.8%, 48.8%, and 41.9%, respectively. Only salvage surgery was found to affect the overall survival (P = 0.007). The long-term outcomes for CEC patients who underwent surgery were significantly better than those who received definitive chemoradiotherapy (P = 0.045) but were similar to those of thoracic or abdominal oesophageal cancer patients. In summary, CEC is an uncommon and aggressive malignancy. The malignant potential of CEC is similar to that of thoracic or abdominal oesophageal cancer. Surgical resection is an important therapeutic strategy and may be associated with better survival rates than definitive chemoradiotherapy.

Clinicopathological Features of Cervical Esophageal Cancer: Retrospective Analysis of 63 Consecutive Patients Who Underwent Surgical Resection

OBJECTIVE

The objectives of this retrospective study were to elucidate the clinicopathological features and recent surgical results of cervical esophageal cancer.

SUMMARY BACKGROUND DATA

Cervical esophageal cancer has been reported to have a dismal prognosis. Accurate knowledge of the clinical characteristics of cervical esophageal cancer is warranted to establish appropriate therapeutic strategies.

METHODS

The clinicopathological features and treatment results of 63 consecutive patients with cervical esophageal cancer (Ce group) who underwent surgical resection from 1980 to 2013 were analyzed and compared with 977 patients with thoracic or abdominal esophageal cancer (T/A group) who underwent surgical resection during that time.

RESULTS

Among the patients who received curative resection, the 5-year overall and disease-specific survival rates of the Ce patients were significantly better than those of the T/A patients (overall: 77.3% vs 46.5%, respectively, P = 0.0067; disease-specific: 81.9% vs 55.8%, respectively, P = 0.0135). Although total pharyngo-laryngo-esophagectomy procedures were less frequently performed in the recent period, the rate of curative surgical procedures was markedly higher in the recent period (2000-1013) than that in the early period (1980-1999) (44.4% vs 88.9%, P = 0.0001). The 5-year overall survival rate in the recent period (71.5%) was significantly better than that in the early period (40.7%, P = 0.0342).

CONCLUSIONS

Curative resection for cervical esophageal cancer contributes to favorable outcomes compared with other esophageal cancers. Recent surgical results for cervical esophageal cancer have improved, and include an increased rate of curative resection and decreased rate of extensive surgery.

Dose escalation of definitive radiation is not associated with improved survival for cervical esophageal cancer: a National Cancer Data Base (NCDB) analysis

For cervical esophageal cancer (CEC), National Comprehensive Cancer Network guidelines support RT to 50-50.4 Gy with chemotherapy but acknowledge higher doses may be appropriate. This study uses the National Cancer Database (NCDB) to characterize RT practices and identify if a dose-response relationship exists for overall survival (OS) for definitive treatment of CEC. We queried the NCDB for patients diagnosed with Stage I-III CEC from 2004 to 2013, and selected patients receiving definitive RT with doses between 50 and 74 Gy. Using multivariate logistic regression, the database was analyzed to determine factors associated with use of RT > 50.4 Gy. Patients were then stratified into three dose categories. Predictors of OS were analyzed with univariate and multivariate methods using the Kaplan-Meier curves, the log-rank test, and the Cox proportional hazards analysis. We stratified 789 patients with CEC who were treated with definitive radiation ± chemotherapy: 50-50.4 Gy ('standard'), >50.4 and <66 Gy ('medium'), and 66-74 Gy ('high'). Of these patients, 215 (27%) received standard doses, 375 (48%) received medium doses, and 199 (25%) received high doses. Patients with Medicaid insurance and those with Stage II disease were less likely (P < 0.05) to receive >50.4 Gy. Sex, histology, distance to treatment facility, and academic/community facility type were not significantly associated with receipt of >50.4 Gy. There was no association between dose and OS for the medium or high groups when using univariate analysis or analysis adjusted for demographic, facility, and clinical attributes. Stage III disease and the Charlson-Deyo scores of 1 or 2 were associated with higher mortality (P < 0.05), while female sex and use of chemotherapy were associated with lower mortality (P < 0.01). Nearly three-fourths of CEC patients in the United States are treated with RT > 50.4 Gy. Higher radiation doses were not associated with increased OS in CEC patients in the NCDB.

A phase II study of concurrent chemoradiotherapy combined with a weekly paclitaxel and 5-fluorouracil regimen to treat patients with advanced oesophageal carcinoma

BACKGROUND

A phase II study was performed to investigate the safety and efficacy of weekly doses of combined paclitaxel and 5-fluorouracil (5-FU) with concurrent radiation therapy, followed by 2 cycles of consolidation chemotherapy to treat patients with advanced oesophageal carcinoma.

METHODS

The eligibility criteria included local, advanced, newly diagnosed and postoperative local regional lymph node metastasis; an Eastern Cooperative Oncology Group (ECOG) score of ≤ 2; and adequate organ function. Patients received chemoradiotherapy consisting of radiotherapy (50.4 Gy/28 Fx or 61.2 Gy/34 Fx) and concurrent paclitaxel (50 mg/m²) and 5-FU (300 mg/m²) for 96 h on days 1, 8, 15, 22, and 29. The two-cycle consolidation chemotherapy protocol included paclitaxel (175 mg/m²) plus continuously infused 5-FU (1800 mg/m²) for 72 h administered on days 57 and 85, after concurrent chemoradiotherapy.

RESULTS

Between February 2012 and August 2013, 53 patients with oesophageal carcinoma were enrolled in the study. Among these patients, 33 (62.2%) were newly diagnosed and 20 (37.7%) had postoperative local regional lymph node metastasis. The median overall survival (OS) time was 17.9 months (95% CIs = 11.9-23.9), and the median progression-free survival (PFS) time was 12.4 months (95% CIs = 8.6-16.1). Approximately 84.9% (45/53) and 50.9% (27/53) of the patients completed ≥ 5 cycles and all 7 cycles of chemotherapy, respectively. Approximately 86.7% (46/53) of patients completed radiation therapy. The 1-, 2-, and 3-year OS rates were 66.0%, 37.7%, and 35.8%, respectively. The 1-, 2-, and 3-year local control rates were 76.9%, 66.4%, and 66.4%, respectively. Seventeen patients (32%) experienced grade 3 or higher toxicity. Grade 3 to 5 toxicity during chemoradiotherapy included neutropaenia (7.5%), thrombocytopaenia (1.8%), fatigue (7.5%), anaemia (1.8%), dermatitis radiation (1.8%), pneumonitis (5.6%), oesophagitis (9.4%) and vomiting (3.7%).

CONCLUSIONS

The combination of weekly doses of paclitaxel and 5-FU was well tolerated and produced comparable results among patients with locally advanced oesophageal cancer. A randomised phase III trial (NCT01591135) comparing paclitaxel plus 5-FU with cisplatin plus 5-FU is on-going at our hospital.

Anatomic distribution of supraclavicular lymph node in patients with esophageal cancer

PURPOSE

Definitive chemoradiation therapy remains the standard of care for patients with localized esophageal carcinoma who choose nonsurgical management. However, there is no consensus regarding delineation of the nodal clinical target volume (CTVn), especially for lower cervical lymph nodes. This study aimed to map the location of metastatic supraclavicular lymph nodes in thoracic esophageal carcinoma patients with supraclavicular node involvement and generate an atlas to delineate the CTVn for elective nodal radiation of esophageal squamous cell carcinoma.

PATIENTS AND METHODS

In this study, the supraclavicular regional lymph node was further divided into four subgroups. The locations of the involved supraclavicular nodes for all patients were then transferred onto a template computed tomography (CT) image. A volume probability map was then generated with nodal volumes, and was displayed on the template CT to provide a visual impression of nodal frequencies and anatomic distribution.

RESULTS

We identified 154 supraclavicular nodal metastases based on CT image in 96 patients. Of these, 29.2% were located in group I region, 59.7% in group II region, 10.4% in group III region, and 0.7% in group IV region.

CONCLUSION

On the basis of our study, we suggest that the appropriate radiation field of CTVn should include the group I and II regions and the CTVn exterior margin along the lateral side of the internal jugular vein may be suitable.

Radiation Dose Escalation in Esophageal Cancer Revisited: A Contemporary Analysis of the National Cancer Data Base, 2004 to 2012

PURPOSE

To evaluate the effect of radiation dose escalation on overall survival (OS) for patients with nonmetastatic esophageal cancer treated with concurrent radiation and chemotherapy.

METHODS AND MATERIALS

Patients diagnosed with stage I to III esophageal cancer treated from 2004 to 2012 were identified from the National Cancer Data Base. Patients who received concurrent radiation and chemotherapy with radiation doses of ≥50 Gy and did not undergo surgery were included. OS was compared using Cox proportional hazards regression and propensity score matching.

RESULTS

A total of 6854 patients were included; 3821 (55.7%) received 50 to 50.4 Gy and 3033 (44.3%) received doses >50.4 Gy. Univariate analysis revealed no significant difference in OS between patients receiving 50 to 50.4 Gy and those receiving >50.4 Gy (P=.53). The dose analysis, binned as 50 to 50.4, 51 to 54, 55 to 60, and >60 Gy, revealed no appreciable difference in OS within any group compared with 50 to 50.4 Gy. Subgroup analyses investigating the effect of dose escalation by histologic type and in the setting of intensity modulated radiation therapy also failed to reveal a benefit. Propensity score matching confirmed the absence of a statistically significant difference in OS among the dose levels. The factors associated with improved OS on multivariable analysis included female sex, lower Charlson-Deyo comorbidity score, private insurance, cervical/upper esophagus location, squamous cell histologic type, lower T stage, and node-negative status (P<.01 for all analyses).

CONCLUSIONS

In this large national cohort, dose escalation >50.4 Gy did not result in improved OS among patients with stage I to III esophageal cancer treated with definitive concurrent radiation and chemotherapy. These data suggest that despite advanced contemporary treatment techniques, OS for patients with esophageal cancer remains unaltered by escalation of radiation dose >50.4 Gy, consistent with the results of the INT-0123 trial. Furthermore, these data highlight that many radiation oncologists have not embraced the concept that dose escalation does not improve OS. Although local control, not investigated in the present study, might benefit from dose escalation, novel therapies are needed to improve the OS of patients with esophageal cancer.

Cervical esophageal cancer: a gap in cancer knowledge

BACKGROUND

The aim of this systematic review is to provide an overview of the diagnosis, treatment options and treatment-related complications of cervical esophageal carcinoma (CEC) and to subsequently provide recommendations to improve quality of care.

DESIGN

Studies were identified in PubMed, EMBASE and Web of Science. A total of 107 publications fulfilled the inclusion criteria and were included.

RESULTS

CEC is uncommon, accounting for 2%-10% of all esophageal carcinomas. These tumors are often locally advanced at presentation and have a poor prognosis, with a 5-year overall survival of 30%. Tobacco and alcohol consumption seem to be the major risk factors for developing CEC. Surgery is usually not possible due to the very close relationship to other organs such as the larynx, trachea and thyroid gland. Therefore, the current standard of care is definitive chemoradiation (dCRT) with curative intent. Treatment regimens used to treat CEC are adapted by established regimens in lower esophageal squamous cell carcinoma and head and neck squamous cell carcinoma. However, dCRT may be accompanied by severe side-effects and complications. Several diagnostic and predictive markers have been studied, but currently, there is no other biomarker than clinical stage to determine patient management. Suggestions to improve patient outcomes are to determine the exact radiation dose needed for adequate locoregional control and to combine radiotherapy with optimal systemic therapy backbone.

CONCLUSION

CEC remains unchartered territory for many practising physicians and patients with CEC have a poor prognosis. To improve the outcome for CEC patients, future studies should focus on the identification of new diagnostic biomarkers or targets for radiosensitizers, amelioration of radiation schedules, optimal combination of chemotherapeutic agents and/or new therapeutic targets.

Re-evaluating the optimal radiation dose for definitive chemoradiotherapy for esophageal squamous cell carcinoma

BACKGROUND

The optimal radiation dose for treating esophageal squamous cell carcinoma (ESCC) has long been debated. We evaluated if doses greater than 50.4 Gy delivered with modern techniques are beneficial in terms of tumor control, survival, and toxicity.

METHODS

We included 193 consecutive patients with ESCC treated with definitive concurrent chemoradiotherapy from 1998 to 2012. Patients were treated to a dose of ≤50.4 Gy (low-dose, n = 137) or greater than 50.4 Gy (high-dose, n = 56). Tumor response, local-regional control, survival, and treatment toxicity were compared between groups.

RESULTS

High-dose group had a significantly lower local failure rate (17.9% versus 34.3%, p = 0.024) and a marginal better 5-year local-regional failure-free survival (68.7% versus 55.9%, p = 0.052) than the low-dose group. No significant differences were found between high- and low-dose groups in tumor complete response rate (p = 0.975), regional failure rate (p = 0.336), distant metastasis rate (p = 0.390), or 5-year overall survival (p = 0.617). No difference in the incidence of toxic effects was observed between the two groups except for grade 3 skin reaction (12.5% [high] versus 2.2% [low], p < 0.001) and grade greater than or equal to 3 esophageal stricture (32.1% [high] versus 18.2% [low], p = 0.037).

CONCLUSIONS

Local tumor control might be improved by higher dose of greater than 50.4 Gy, when delivered with modern techniques and concurrent chemotherapy, at the consequence of increased toxicity without impact on overall survival.

Esophageal Carcinoma: Current Concepts in the Role of Imaging in Staging and Management

Over the past few decades, the survival of esophageal cancer patients has improved owing to early detection and advances in multimodality treatment strategies. Imaging plays an important role in every step in the management of esophageal cancer, including diagnosis, staging, assessment of treatment response, and post-treatment surveillance. In this article, we provide a comprehensive review of the role of imaging in these various time points of esophageal cancer management.

Definitive intensity-modulated radiotherapy compared with definitive conventional radiotherapy in cervical oesophageal squamous cell carcinoma

PURPOSE

The authors compared definitive intensity-modulated radiotherapy (IMRT) with definitive conventional radiotherapy (2D-RT) in cervical oesophageal squamous cell carcinoma (CESCC).

MATERIALS AND METHODS

A total of 101 patients with CESCC treated with definitive radiotherapy from January 2001 to April 2012 were analysed. 37 patients were irradiated using 2D-RT, whereas 64 cases were treated using IMRT.

RESULTS

The median follow-up time was 15.5 months for all the patients. For all patients, the overall 2-year local failure-free survival (LFFS), regional failure-free survival (RFFS), and overall survival (OS) rate was 67.4, 85.2 and 46.2%, respectively. The 2-year LFFS rate and the 2-year RFFS rate in the IMRT group were higher than the 2D-RT group, although no statistically significant difference was observed in LFFS and RFFS. No statistically significant difference was observed in overall survival (OS) between the groups. Compared with 2D-RT, the rate of grade 3 dysphagia after radiotherapy was lower (6.3 vs. 8.1%) and none had hypothyroidism requiring lifelong thyroxine replacement in the IMRT group. Matched-cases analysis did not show a statistical difference in terms of LFFS, RFFS and OS between the groups.

CONCLUSIONS

Although no statistically significant difference was observed in OS, LFFS and RFFS between the IMRT group and the 2D-RT group, the incidence of late toxicity declined using IMRT, thereby resulting in an improved therapeutic ratio for patients with CESCC.

Involved-field irradiation concurrently combined with nedaplatin/5-fluorouracil for inoperable esophageal cancer on basis of (18)FDG-PET scans: a phase II study

PURPOSE

A prospective study was performed on chemoradiotherapy (CRT) for esophageal cancer using involved-field radiation therapy (IFRT) based on 18-fluorodeoxyglucose positron-emission tomography. The goal of this phase II study was to evaluate the efficacy of the IFRT procedure in newly diagnosed esophageal cancer.

PATIENTS AND METHODS

Eligible patients were adults with newly diagnosed untreated, inoperable esophageal cancer in stages I-IV with lymph node metastases. Patients received nedaplatin 80mg/m(2) per day on day 1, 5-fluorouracil 800mg/m(2) on days 1-4 intravenously repeated every 28days for 2-4 cycles, and combined IFRT. Elective nodal irradiation was not performed. Irradiation was applied only to the primary tumor and positive lymph nodes.

RESULTS

From September 2009 to July 2012, of the 63 patients enrolled, 58 were evaluable for response. The primary end point of isolated out-of-field loco-regional nodal recurrence was seen in only two patients. The expectant rate was assumed to be less than 5%. The threshold value was set as 10% to calculate the number of registrations. Progression-free and overall survival rates at 36months were 47.7% and 51.1%, respectively. The median progression-free survival was 34.6months, and overall survival was 38.4months. Salvage surgery was tried for 11 patients (17.5%) due to residual or recurrent disease.

CONCLUSION

The primary end point of the trial was demonstrated, indicating the efficacy of IFRT in the treatment of inoperable esophageal cancer mostly of squamous cell carcinoma.

Esophageal cancer: staging system and guidelines for staging and treatment

Survival of esophageal cancer is improving but remains poor. Esophageal cancer stage is based on depth of tumor invasion, involvement of regional lymph nodes, and the presence or absence of metastatic disease. Appropriate work-up is critical to identify accurate pre-treatment staging so that both under-treatment and unnecessary treatment is avoided. Treatment strategy should follow guideline recommendations, and generally should be developed after multidisciplinary evaluation.

Pattern of Failure in Surgically Treated Patients with Cervical Esophageal Squamous Cell Carcinoma

OBJECTIVE

The aim of this study was to analyze the pattern of failure in patients who have undergone surgical resection for cervical esophageal squamous cell carcinoma.

STUDY DESIGN

Case series with chart review.

SETTING

University hospital.

SUBJECTS AND METHODS

Sixty-two patients who had undergone surgical resection of cervical esophageal squamous cell carcinoma from January 2001 through April 2012. Sites of failure were documented.

RESULTS

Twenty-nine patients had developed treatment failure. Of the 29 patients, 14, 13, and 14 had developed local failure, regional failure, and distant metastasis, respectively. Of the 13 regional failures, the images of 2 patients were lost. The other 11 regional failures included left lateral nodal disease at level II (n = 2), level III (n = 4), and level IV (n = 7); right lateral nodal disease at level II (n = 2), level III (n = 3), and level IV (n = 3); and level VI (n = 4). The overall 2-year local failure-free survival rate and regional failure-free survival rates were 79.6% and 58.6% (P = .04) for patients with stage II disease and 79.6% and 59.6% (P = .054) for patients with stage III disease, respectively.

CONCLUSIONS

The pattern of failure of cervical esophageal squamous cell carcinoma is characterized by early locoregional failure, especially in patients with stage III disease.

Definitive radiotherapy for cervical esophageal cancer

BACKGROUND

The role of contemporary radiotherapy (RT) has not yet been elucidated, mainly because of the low incidence of cervical esophageal cancer. The purpose of this study was to analyze the outcome in patients with cervical esophageal cancer treated with definitive RT.

METHODS

A total of 115 patients with cervical esophageal cancer treated with definitive RT during January 2001 through April 2012 in our center were analyzed. Eighty patients received RT alone and 35 patients received concurrent chemoradiotherapy with cisplatin administered either weekly (30 mg/m2) or every 3 weeks (80 mg/m2).

RESULTS

The median follow-up time was 17.1 months. For all patients, the overall 2-year local failure-free survival (LFFS), regional failure-free survival (RFFS), distant failure-free survival (DFFS), and overall survival (OS) rate was 68.3%, 83.3%, 75.7%, and 47.6%, respectively.

CONCLUSION

Definitive RT accomplished a satisfactory local control rate and contributed to organ preservation for patients with cervical esophageal cancer. 2015.

Larynx-preserving limited resection and free jejunal graft for carcinoma of the cervical esophagus

BACKGROUND

There is no generally accepted treatment strategy for cervical cancer. The aim of this study was to evaluate the safety and efficacy of larynx-preserving limited resection with free jejunal graft for cervical esophageal cancer.

METHODS

We retrospectively reviewed data of 58 patients with cervical esophageal cancer who underwent limited resection and free jejunal graft with or without laryngeal preservation. Among them, 45 patients received neoadjuvant treatment.

RESULTS

Larynx-preserving surgery was conducted in 33 of the 58 patients (56.9%). A higher proportion of patients who underwent laryngopharyngectomy with cervical esophagectomy (larynx-nonpreserving group) had cT4 tumors than those who underwent larynx-preserving cervical esophagectomy (larynx-preserving group) (72 vs. 12%). The overall incidence of postoperative complications was similar in the two groups (56 vs. 52%). The 5-year survival rate was 44.9% for the entire group. Laryngeal preservation did not reduce overall survival compared with the larynx-nonpreserving operation (5-year survival rate: 57.8 vs. 25.8%). Multivariate analysis identified the number of metastatic lymph nodes as the only independent prognostic factor.

CONCLUSIONS

The present study demonstrated that larynx-preserving limited resection with free jejunal graft is feasible. Also, this approach did not worsen the prognosis compared with the larynx-nonpreserving operation. Limited resection with free jejunal graft and laryngeal preservation is a promising treatment strategy for cervical esophageal cancer.