1
|
Meng RY, Jin H, Nguyen TV, Chai OH, Park BH, Kim SM. Ursolic Acid Accelerates Paclitaxel-Induced Cell Death in Esophageal Cancer Cells by Suppressing Akt/FOXM1 Signaling Cascade. Int J Mol Sci 2021; 22:11486. [PMID: 34768915 PMCID: PMC8584129 DOI: 10.3390/ijms222111486] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/17/2021] [Accepted: 10/20/2021] [Indexed: 12/29/2022] Open
Abstract
Ursolic acid (UA), a pentacyclic triterpenoid extracted from various plants, inhibits cell growth, metastasis, and tumorigenesis in various cancers. Chemotherapy resistance and the side effects of paclitaxel (PTX), a traditional chemotherapy reagent, have limited the curative effect of PTX in esophageal cancer. In this study, we investigate whether UA promotes the anti-tumor effect of PTX and explore the underlying mechanism of their combined effect in esophageal squamous cell carcinoma (ESCC). Combination treatment with UA and PTX inhibited cell proliferation and cell growth more effectively than either treatment alone by inducing more significant apoptosis, as indicated by increased sub-G1 phase distribution and protein levels of cleaved-PARP and cleaved caspase-9. Similar to the cell growth suppressive effect, the combination of UA and PTX significantly inhibited cell migration by targeting uPA, MMP-9, and E-cadherin in ESCC cells. In addition, combination treatment with UA and PTX significantly activated p-GSK-3β and suppressed the activation of Akt and FOXM1 in ESCC cells. Those effects were enhanced by the Akt inhibitor LY2940002 and inverted by the Akt agonist SC79. In an in vivo evaluation of a murine xenograft model of esophageal cancer, combination treatment with UA and PTX suppressed tumor growth significantly better than UA or PTX treatment alone. Thus, UA effectively potentiates the anti-tumor efficacy of PTX by targeting the Akt/FOXM1 cascade since combination treatment shows significantly more anti-tumor potential than PTX alone both in vitro and in vivo. Combination treatment with UA and PTX could be a new strategy for curing esophageal cancer patients.
Collapse
Affiliation(s)
- Ruo Yu Meng
- Department of Physiology, Institute for Medical Sciences, Jeonbuk National University Medical School, Jeonju 54907, Korea;
| | - Hua Jin
- School of Pharmaceutical Sciences, Tsinghua University, Beijing 100084, China;
| | - Thi Van Nguyen
- Department of Anatomy, Institute for Medical Sciences, Jeonbuk National University Medical School, Jeonju 54907, Korea; (T.V.N.); (O.-H.C.)
| | - Ok-Hee Chai
- Department of Anatomy, Institute for Medical Sciences, Jeonbuk National University Medical School, Jeonju 54907, Korea; (T.V.N.); (O.-H.C.)
| | - Byung-Hyun Park
- Department of Biochemistry, Jeonbuk National University Medical School, Jeonju 54907, Korea;
| | - Soo Mi Kim
- Department of Physiology, Institute for Medical Sciences, Jeonbuk National University Medical School, Jeonju 54907, Korea;
| |
Collapse
|
2
|
Ai D, Chen Y, Liu Q, Zhang J, Deng J, Zhu H, Ren W, Zheng X, Li Y, Wei S, Ye J, Zhou J, Lin Q, Luo H, Cao J, Li J, Huang G, Wu K, Fan M, Yang H, Zhu Z, Zhao W, Li L, Fan J, Badakhshi H, Zhao K. Comparison of paclitaxel in combination with cisplatin (TP), carboplatin (TC) or fluorouracil (TF) concurrent with radiotherapy for patients with local advanced oesophageal squamous cell carcinoma: a three-arm phase III randomized trial (ESO-Shanghai 2). BMJ Open 2018; 8:e020785. [PMID: 30344165 PMCID: PMC6196866 DOI: 10.1136/bmjopen-2017-020785] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Concurrent chemoradiation is the standard therapy for patients with local advanced oesophageal carcinoma unsuitable for surgery. Paclitaxel is an active agent against oesophageal cancer and it has been proved as a potent radiation sensitiser. There have been multiple studies evaluating paclitaxel-based chemoradiation in oesophageal cancer, of which the results are inspiring. However, which regimen, among cisplatin (TP), carboplatin (TC) or fluorouracil (TF) in combination with paclitaxel concurrent with radiotherapy, provides best prognosis with minimum adverse events is still unknown and very few studies focus on this field. The purpose of this study is to confirm the priority of TF to TP or TF to TC concurrent with radiotherapy in terms of overall survival and propose a feasible and effective plan for patients with local advanced oesophageal cancer. METHODS AND ANALYSIS ESO-Shanghai 2 is a three-arm, multicenter, open-labelled, randomised phase III clinical trial. The study was initiated in July 2015 and the duration of inclusion is expected to be 4 years. The study compares two pairs of regimen: TF versus TP and TF versus TC concurrent with definitive radiotherapy for patients with oesophageal squamous cell carcinoma (OSCC). Patients with histologically confirmed OSCC (clinical stage II, III or IVa based on the sixth Union for International Cancer Control-tumour, node, metastasis classification) and without any prior treatment of chemotherapy, radiotherapy or surgery against oesophageal cancer will be eligible. A total of 321 patients will be randomised and allocated in a 1:1:1 ratio to the three treatment groups. Patients are stratified by lymph node status (N0, N1, M1a). The primary endpoint is overall survival and the secondary endpoint is progression-free survival and adverse events. ETHICS AND DISSEMINATION This trial has been approved by the Fudan University Shanghai Cancer Centre Institutional Review Board. Trial results will be disseminated via peer reviewed scientific journals and conference presentations. TRIAL STATUS The trial was initiated in July 2015 and is currently recruiting patients in all of the participating institutions above. TRIAL REGISTRATION NUMBER NCT02459457.
Collapse
Affiliation(s)
- Dashan Ai
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yun Chen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Qi Liu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Junhua Zhang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jiaying Deng
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hanting Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wenjia Ren
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xiangpeng Zheng
- Department of Radiation Oncology, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Yunhai Li
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center Minhang Branch Hospital, Shanghai, China
| | - Shihong Wei
- Department of Radiation Oncology, Gansu Province Cancer Hospital, Lanzhou, China
| | - Jinjun Ye
- Department of Radiation Oncology, Jiangsu Cancer Hospital, Nanjing, China
| | - Jialiang Zhou
- Department of Radiation Oncology, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China
| | - Qin Lin
- Department of Radiation Oncology, First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Hui Luo
- Department of Radiation Oncology, Jiangxi Province Cancer Hospital, Nanchang, China
| | - Jianzhong Cao
- Department of Radiation Oncology, Shanxi Province Cancer Hospital, Taiyuan, China
| | - Jiancheng Li
- Department of Radiation Oncology, Fujian Province Cancer Hospital, Fuzhou, China
| | - Guang Huang
- Department of Radiation Oncology, Hainan Province People’s Hospital, Haikou, China
| | - Kailiang Wu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Min Fan
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Huanjun Yang
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhengfei Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Weixin Zhao
- 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
| | - Jianhong Fan
- Department of Gynecology, Renhe Hospital, Shanghai, China
| | - Harun Badakhshi
- Department of Radiation Oncology, Charité School of Medicine and Centre for Cancer Medicine, Berlin, Germany
| | - Kuaile Zhao
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| |
Collapse
|
3
|
Chen Y, Zhu Z, Zhao W, Li L, Ye J, Wu C, Tang H, Lin Q, Li J, Xia Y, Li Y, Zhou J, Zhao K. A randomized phase 3 trial comparing paclitaxel plus 5-fluorouracil versus cisplatin plus 5-fluorouracil in Chemoradiotherapy for locally advanced esophageal carcinoma-the ESO-shanghai 1 trial protocol. Radiat Oncol 2018; 13:33. [PMID: 29482649 PMCID: PMC5828310 DOI: 10.1186/s13014-018-0979-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 02/16/2018] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND Concurrent chemoradiotherapy is a standard modality for locally advanced esophageal squamous cell carcinoma (ESCC) patients. Cisplatin combined with 5-fluorouracil continuous infusion (PF) remains the standard concurrent chemotherapy regimen. However, radiotherapy concurrent with PF showed a high incidence of severe side effects. Paclitaxel showed a promising radiosensitivity enhancement in the treatment of esophageal carcinoma in both vitro and vivo studies. The ESO-Shanghai 1 trial examines the hypothesis that paclitaxel plus 5-fluorouracil (TF) concurrent with radiotherapy has better overall survival and lower toxicity for patients with local advanced ESCC. METHOD Four hundred thirty-six ESCC patients presenting with stage IIa to IVa will be enrolled in a prospective multicenter randomized phase 3 study. Patients will be randomized to either concurrent chemoradiotherapy with PF (cisplatin 25 mg/m2/d, d1-3, plus 5-fluorouracil 1800 mg/m2, continuous infusion for 72 h) once every 4 weeks for 2 cycles followed by consolidation chemotherapy for 2 cycles or concurrent chemoradiotherapy with weekly TF (5-fluorouracil 300 mg/m2, continuous infusion for 96 h plus paclitaxel 50 mg/m2, d1) for 5 weeks followed by consolidation chemotherapy (5-fluorouracil 1800 mg/m2, continuous infusion for 72 h, plus paclitaxel 175 mg/m2 d1) once every 4 weeks for 2 cycles. The radiotherapy dose is 61.2 Gy delivered in 34 fractions to the primary tumor including lymph nodes. The primary end-point is the 3-yr overall survival analyzed by intention to treat. The secondary endpoints are disease progression-free survival, local progression-free survival, and number and grade of participants with adverse events. DISCUSSION The aim of this phase 3 study is to determine whether the TF regimen could replace the standard PF regimen for inoperable ESCC patients. An overall survival benefit of 12% at 3 years should be expected in the TF group to achieve this goal. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01591135 . Registered 18 April 2012.
Collapse
Affiliation(s)
- Yun Chen
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 DongAn Road, Shanghai, 200032, China
| | - Zhengfei Zhu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 DongAn Road, Shanghai, 200032, China
| | - Weixin Zhao
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 DongAn Road, Shanghai, 200032, China
| | - Ling Li
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 DongAn Road, Shanghai, 200032, China
| | - Jinjun Ye
- Jiangsu Cancer Hospital, Nanjing, China
| | - Chaoyang Wu
- Zhenjiang First People's Hospital, Zhenjiang, China
| | - Huarong Tang
- Zhenjiang First People's Hospital, Zhenjiang, China
| | - Qin Lin
- The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Jiancheng Li
- Fujian Provincial Cancer Hospital, Fuzhou, China
| | - Yi Xia
- Fudan University Shanghai Cancer Center Minhang Branch, Shanghai, China
| | - Yunhai Li
- Fudan University Shanghai Cancer Center Minhang Branch, Shanghai, China
| | - Jialiang Zhou
- Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Kuaile Zhao
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, 270 DongAn Road, Shanghai, 200032, China.
| |
Collapse
|
4
|
A Phase II Study of Concurrent Chemoradiotherapy With Paclitaxel and Cisplatin for Inoperable Esophageal Squamous Cell Carcinoma. Am J Clin Oncol 2017; 39:350-4. [PMID: 24732811 DOI: 10.1097/coc.0000000000000069] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES A phase II study was performed to investigate the efficacy and the safety of a 3-week schedule of paclitaxel (PTX) plus cisplatin (DDP) combined with concurrent radiotherapy for esophageal squamous cell cancer. PATIENTS AND METHODS Patients with newly diagnosed esophageal squamous cell cancer who had histologic proof of local-regional carcinoma of the esophagus, a Karnofsky performance status of 80 or greater, and normal liver, renal, and bone marrow functions were enrolled in the phase II trial. Chemotherapy consisted of DDP (25 mg/m/d) for 3 days plus PTX (175 mg/m) given for 3 hours, every 3 weeks for 4 cycles. The total dose of concurrent radiation with 68.4 Gy/44 Fx (late course-accelerated radiotherapy) or 61.2 Gy/34 Fx (conventional radiotherapy) was given at the first day of chemotherapy. RESULTS Between July 2008 and November 2011, 76 patients were enrolled in this trial. The median age was 58 years (range, 37 to 74 y). The stages were stage II (21 patients), stage III (27 patients), and stage IV (28 patients). A total of 89.5% (68/76) and 63.2% (48/76) patients completed ≥2 cycles and all 4 cycles of chemotherapy, respectively. With the median follow-up of 36 months, the overall median survival time was 28.5 months and the progression-free survival time was 14.7 months. One- and 3-year survival rates were 75% and 41%, respectively. Neutropenia grade 3 and 4 occurred in 30.3% and 31.6% of the patients, respectively. CONCLUSIONS Radiotherapy concurrent with a 3-week schedule of PTX and DDP resulted in an encouraging overall survival rate, but a relatively higher hematological toxicity.
Collapse
|
5
|
EUS-guided paclitaxel injection as an adjunctive therapy to systemic chemotherapy and concurrent external beam radiation before surgery for localized or locoregional esophageal cancer: a multicenter prospective randomized trial. Gastrointest Endosc 2017; 86:140-149. [PMID: 27890801 DOI: 10.1016/j.gie.2016.11.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 11/03/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS OncoGel (Protherics Salt Lake City, Inc, Salt Lake City, UT) is paclitaxel (PTX) formulated in a thermosensitive, biodegradable copolymer for focused cytotoxicity and radiosensitization. A phase 2a study suggested that EUS-guided PTX injection into esophageal tumors subsequently receiving radiotherapy was safe. METHODS In an international multicenter, prospective, randomized phase 2b study, patients with local or locoregional adenocarcinoma or squamous cell carcinoma (SCC) of the esophagus/gastroesophageal junction and eligible for neoadjuvant chemoradiotherapy (CRT) before surgery were randomized to standard of care (SOC) plus EUS-guided PTX injection or SOC alone. PTX was injected in 0.5 to 1.0 mL aliquots throughout the tumor. Planned CRT as SOC was intravenous 5-fluorouracil for the first 4 days (weeks 1 and 5), intravenous cisplatin on the first day of each 5-fluorouracil course, and radiotherapy over 5.5 weeks. Patients were evaluated weekly during CRT and re-evaluated at 12 weeks for surgical eligibility and CT for change in overall tumor volume. RESULTS The analysis included 137 patients (97 males; mean age, 58 ± 9.1 years) randomized to PTX + SOC (n = 72) and SOC (n = 65) by using a modified intention-to-treat approach. Overall response by tumor volume between the PTX (12.5%) and the SOC group (20.0%; P = .24; odds ratio, 0.57; 95% confidence interval, 0.23-1.44) was similar. Pathologic complete response was higher in the SOC group (26.2% vs 12.5%; P = .046); however, 12-month survival (P = .412) and the overall frequency of 1 or more adverse events (P = .17) were similar between the 2 groups. CONCLUSIONS SOC + PTX is safe but does not improve overall survival or overall tumor response at the primary tumor site for patients with local or locoregional cancer of the esophagus/gastroesophageal junction. (Clinical trial registration number: NCT00573131.).
Collapse
|
6
|
Jamorabo DS, Lin SH, Jabbour SK. Successes and Failures of Combined Modalities in Upper Gastrointestinal Malignancies: New Directions. Semin Radiat Oncol 2016; 26:307-19. [PMID: 27619252 PMCID: PMC10794083 DOI: 10.1016/j.semradonc.2016.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Upper gastrointestinal malignancies generally have moderate to poor cure rates, even in the earliest stages, thereby implying that both local and systemic treatments have room for improvement. Therapeutic options are broadening, however, with the development of new immunotherapies and targeted agents, which can have synergistic effects with radiotherapy. Here we discuss the current state of combined modality therapy for upper gastrointestinal malignancies, specifically recent successes and setbacks in trials of radiation therapy with targeted therapies, vaccines, immunotherapies, and chemotherapies.
Collapse
Affiliation(s)
- Daniel S Jamorabo
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ.
| |
Collapse
|
7
|
Shen K, Huang XE, Lu YY, Wu XY, Liu J, Xiang J. Phase II study of docetaxel (Aisu®) combined with three- dimensional conformal external beam radiotherapy in treating patients with inoperable esophageal cancer. Asian Pac J Cancer Prev 2014; 13:6523-6. [PMID: 23464486 DOI: 10.7314/apjcp.2012.13.12.6523] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE This study was designed to investigate treatment efficacy and side effects of concomitant Aisu® (docetaxel) with three-dimensional conformal external beam radiotherapy for the treatment of inoperable patients with esophageal cancer. METHODS Inoperable patients were treated with three-dimensional conformal external beam radiotherapy (5/week, 2 GY/day, and total dose 60GY) plus docetaxel (30-45 mg/m2, iv, d1, 8). RESULTS Twenty eight patients met the study eligibility criteria and the response rate was evaluated according to RICIST guidelines. Among 28 patients, 2 achieved CR, 22 PR, 3 SD and 1 patient was documented PD. Mild gastrointestinal reaction and bone marrow suppression were also documented. All treatment related side effects were tolerable. CONCLUSION Three-dimensional conformal external beam radiotherapy combined with docetaxel is an active and safe regimen for inoperable patients with esophageal cancer.
Collapse
Affiliation(s)
- Kang Shen
- Department of Chemotherapy, Affiliated Jiangsu Cancer Hospital of Nanjing Medical University and Jiangsu Institute of Cancer Research, Nanjing, China
| | | | | | | | | | | |
Collapse
|
8
|
Ku GY, Ilson DH. Multimodality therapy for the curative treatment of cancer of the esophagus and gastroesophageal junction. Expert Rev Anticancer Ther 2014; 8:1953-64. [DOI: 10.1586/14737140.8.12.1953] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
9
|
Tu L, Sun L, Xu Y, Wang Y, Zhou L, Liu Y, Zhu J, Peng F, Wei Y, Gong Y. Paclitaxel and cisplatin combined with intensity-modulated radiotherapy for upper esophageal carcinoma. Radiat Oncol 2013; 8:75. [PMID: 23531325 PMCID: PMC3622578 DOI: 10.1186/1748-717x-8-75] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Accepted: 03/22/2013] [Indexed: 02/05/2023] Open
Abstract
Purpose This study was conducted to evaluate the effectiveness and safety of intensity-modulated radiotherapy (IMRT) and concurrent paclitaxel plus cisplatin (TP regimen) for upper esophageal carcinoma. Methods 36 patients of upper esophageal carcinoma were retrospectively analyzed. Patients were treated with IMRT (median 60 Gy) combined with concurrent TP regimen chemotherapy. The Kaplan-Meier analysis was performed in statistical analysis. Toxicities were recorded according to the NCI CTC version 3.0. Results 36 patients aged 43–73 years (median 57 years). The median follow-up period was 14.0 months. The 1-year and 2-year survival rates were 83.3% and 42.8% respectively. The median progression-free survival (PFS) time and overall survival (OS) time were 12.0 (95% CI: 7.8–16.2 months) and 18.0 months (95% CI: 9.9–26.1 months), respectively. Grade 3 neutropenia, radiation-induced esophagitis and radiodermatitis were observed in 5 (13.9%), 3 (8.3%) and 8 (22.2%) patients respectively. There were two treatment-related deaths due to esophageal perforation and hemorrhea. Conclusions For those patients with upper esophageal carcinoma, IMRT combined with concurrent TP regimen chemotherapy was an effective treatment. However, more attention should be paid to the occurrence of perforation and hemorrhea.
Collapse
Affiliation(s)
- Lingli Tu
- Department of Thoracic Oncology and State Key Laboratory of Biotherapy, Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Zhong Z, Gu X, Zhang Z, Wang D, Qing Y, Li M, Dai N. Recombinant human endostatin combined with definitive chemoradiotherapy as primary treatment for patients with unresectable but without systemic metastatic squamous cell carcinoma of the oesophagus. Br J Radiol 2012; 85:e1104-9. [PMID: 22898155 PMCID: PMC3500809 DOI: 10.1259/bjr/15321801] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Revised: 10/07/2011] [Accepted: 10/31/2011] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE The objective of this study was to review the outcomes of recombinant human endostatin combined with chemoradiotherapy (CRT) as primary treatment for patients with unresectable but without systemic metastatic squamous cell carcinoma (SCC) of the oesophagus. METHODS A total of 38 patients with unresectable but without systemic metastatic SCC of the oesophagus (T(4) or stage IVA) were retrospectively studied. 18 patients were treated with recombinant human endostatin combined with 5-fluorouracil (5-FU)/cisplatin (CDDP)-based CRT and 20 were treated with 5-FU/CDDP-based CRT alone. Short- and long-term effects including initial treatment response, survival and treatment-related complications were assessed with a median follow-up period of 36.1 months. RESULTS CRT combined with endostatin resulted in a marked improvement in complete response rates (44.4% vs 30% in the CRT-alone group), and an increase in the 1-year and 3-year overall survival rates (72% vs 50.0% and 32% vs 22.0%, respectively), while the median time to progression was extended to 11.3 months in the combination group vs 8.1 months in the CRT-alone group. There were no treatment-related toxicities that could be attributed specifically to the endostatin, and the toxicities observed across the two groups are probably due to the CRT itself. CONCLUSIONS The short- and long-term effects of CRT combined with endostatin were an improvement over that of CRT alone in this retrospective cohort study. This combined treatment modality may be a promising treatment modality for the patients with unresectable but without systemic metastatic oesophageal cancer. Further prospective randomised control studies are needed to confirm this finding.
Collapse
Affiliation(s)
- Z Zhong
- Department of Cancer Center, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, China.
| | | | | | | | | | | | | |
Collapse
|
11
|
Herskovic A, Russell W, Liptay M, Fidler MJ, Al-Sarraf M. Esophageal carcinoma advances in treatment results for locally advanced disease: review. Ann Oncol 2012; 23:1095-1103. [PMID: 22003242 DOI: 10.1093/annonc/mdr433] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The treatment results of patients with locally advanced esophageal carcinomas have evolved since the publication of the first trial of concurrent mitomycin C and 5-fluorouracil with radiotherapy (RT) in 1983. Subsequent studies refined and improved on the concurrent chemotherapy (chemo) with administration of cisplatin and 5-fluorouracil infusion (PF). Chemo (PF) before surgery improved overall survival (OS) in those patients in most of the randomized trials and in meta-analyses. Two courses of PF concurrent with irradiation followed by additional two courses of PF were superior to RT alone without surgery for both groups. Concurrent chemoradiotherapy followed by surgery was found to have statistically improved OS as compared with surgery only in randomized trials and meta-analyses. In most of these studies, it was found that those patients with pathologic complete response to the initial treatment(s) did better than those who had no improvement at all. Current treatment outcome for these diseases is disappointing; newer strategies including induction chemo with the optimal combination, proper dosage of each drug, and proper number of courses before concurrent chemoradiotherapy; improvement in RT; and immunotherapy with or without subsequent surgery are exciting and definitely need to be investigated in prospective randomized trial(s).
Collapse
Affiliation(s)
| | | | | | - M J Fidler
- Department of Section of Medical Oncology, Rush University Medical Center, Chicago
| | - M Al-Sarraf
- Department of Medicine, Wm Beaumont Hospital, Royal Oak, USA
| |
Collapse
|
12
|
Ilson DH, Minsky BD, Ku GY, Rusch V, Rizk N, Shah M, Kelsen DP, Capanu M, Tang L, Campbell J, Bains M. Phase 2 trial of induction and concurrent chemoradiotherapy with weekly irinotecan and cisplatin followed by surgery for esophageal cancer. Cancer 2011; 118:2820-7. [PMID: 21990000 DOI: 10.1002/cncr.26591] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 07/08/2011] [Accepted: 08/09/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND Preoperative chemoradiation improves survival in esophageal and gastroesophageal junction (GEJ) cancer. We evaluated irinotecan and cisplatin as induction chemotherapy followed by concurrent chemoradiation in esophageal cancer. METHODS Patients with uT1N1M0 or uT2-4NanyM0 resectable squamous cancer or adenocarcinoma of the esophagus or GEJ received irinotecan 65 mg/m(2) and cisplatin 30 mg/m(2) for 4 treatments in weeks 1 through 5, followed by 4 treatments in weeks 7 through 11 with 50.4 Gy in daily fractions, followed by surgery. The primary endpoint was pathologic complete response (pCR). Positron emission tomography (PET) scan was performed prior to chemotherapy and as restaging prior to radiotherapy. RESULTS Fifty-five patients were evaluable, 75% of whom had adenocarcinoma and 65% of whom had uT3N1 disease. Thirty-eight patients underwent R0 resection (69%). The incidence of pCR was 16% (95% confidence interval, 8%-29%). Median overall survival was 31.7 months. An exploratory analysis of PET response to induction chemotherapy indicated a correlation with pCR (32% vs 4%), R0 resection (84% vs 57%), progression-free survival (24.1 vs 7.7 months), and overall survival (40.2 vs 25.5 months). CONCLUSIONS Weekly treatment with irinotecan, cisplatin, and radiation achieved results no better and potentially inferior to other phase 2 chemoradiotherapy trials with a low rate of pCR. The use of PET scan after induction chemotherapy to direct chemotherapy during subsequent radiotherapy merits further study.
Collapse
Affiliation(s)
- David H Ilson
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
LIN QIANG, GAO XIANSHU, QIAO XUEYING, LIU CHAOXING, ZHOU ZHIGUO, GUO ZHIJUN, ZHAO YANNAN, CHEN KUN, ASAUMI JUNICHI. Comparison between late-course accelerated hyperfractionation radiotherapy and concurrent chemoradiotherapy in patients with esophageal carcinoma. Oncol Lett 2011. [DOI: 10.3892/ol.2011.287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
|
14
|
Orditura M, Galizia G, Napolitano V, Martinelli E, Pacelli R, Lieto E, Aurilio G, Vecchione L, Morgillo F, Catalano G, Ciardiello F, Genio AD, Martino ND, De Vita F. Weekly Chemotherapy with Cisplatin and Paclitaxel and Concurrent Radiation Therapy as Preoperative Treatment in Locally Advanced Esophageal Cancer: A Phase II Study. Cancer Invest 2010; 28:820-7. [DOI: 10.3109/07357901003630926] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
15
|
Power DG, Ilson DH. Integration of targeted agents in the neo-adjuvant treatment of gastro-esophageal cancers. Ther Adv Med Oncol 2009; 1:145-65. [PMID: 21789119 PMCID: PMC3126001 DOI: 10.1177/1758834009347323] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Pre- and peri-operative strategies are becoming standard for the management of localized gastro-esophageal cancer. For localized gastric/gastro-esophageal junction (GEJ) cancer there are conflicting data that a peri-operative approach with cisplatin-based chemotherapy improves survival, with the benefits seen in esophageal cancer likely less than a 5-10% incremental improvement. Further trends toward improvement in local control and survival, when combined chemotherapy and radiation therapy are given pre-operatively, are suggested by recent phase III trials. In fit patients, a significant survival benefit with pre-operative chemoradiation is seen in those patients who achieve a pathologic complete response. In esophageal/GEJ cancer, definitive chemoradiation is now considered in medically inoperable patients. In squamous cell carcinoma of the esophagus, surgery after primary chemoradiation is not clearly associated with an improved overall survival, however, local control may be better. In localized gastric/GEJ cancer, the integration of bevacizumab with pre-operative chemotherapy is being explored in large randomized studies, and with chemoradiotherapy in pilot trials. The addition of anti-epidermal growth factor receptor and anti-human epidermal growth factor receptor-2 antibody treatment to pre-operative chemoradiation continues to be explored. Early results show the integration of targeted therapy is feasible. Metabolic imaging can predict early response to pre-operative chemotherapy and biomarkers may further predict response to pre-operative chemo-targeted therapy. A multimodality approach to localized gastro-esophageal cancer has resulted in better outcomes. For T3 or node-positive disease, surgery alone is no longer considered appropriate and neo-adjuvant therapy is recommended. The future of neo-adjuvant strategies in this disease will involve the individualization of therapy with the integration of molecular signatures, targeted therapy, metabolic imaging and predictive biomarkers.
Collapse
Affiliation(s)
- D G Power
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065
| | | |
Collapse
|
16
|
|
17
|
Abstract
This article examines the role of combined-modality therapy for treating locally advanced esophageal cancer. Although surgery remains a cornerstone of treatment, recent studies have demonstrated that pre- or perioperative chemotherapy is associated with improved survival for patients who have adenocarcinoma histology. Primary chemoradiotherapy is the accepted standard of care for medically inoperable patients. Recent studies also suggest that definitive chemoradiotherapy is acceptable for patients who have squamous histology, while subsequent surgery improves local control without conferring a clear survival benefit. Neoadjuvant chemoradiotherapy continues to be investigated but is associated with several advantages over neoadjuvant chemotherapy alone, including an improvement in the pathologic complete response rate and resectability. Patients who achieve a pathologic complete response also appear to have improved survival. Adjuvant chemoradiotherapy may be considered for patients who undergo primary resection of lower esophageal/gastroesophageal junction adenocarcinoma.
Collapse
Affiliation(s)
- Geoffrey Y Ku
- Ludwig Center for Cancer Immunotherapy, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | | |
Collapse
|
18
|
|
19
|
Abstract
In the United States, esophageal cancer is an uncommon but aggressive malignancy. Prior research has focused on the incorporation of chemotherapy and radiotherapy in both the pre- and postoperative setting. Both squamous cell and adenocarcinoma histologies have been treated in trials, with adenocarcinoma now the predominant histology seen in the United States. Although preoperative chemotherapy improves survival compared with surgery alone, the addition of concurrent radiotherapy to preoperative chemotherapy improves rates of curative resection, reduces local tumor recurrence, and achieves a significant rate of pathologic complete response. Combined preoperative chemoradiotherapy is the preferred preoperative strategy for locally advanced esophageal cancers in the United States. Definitive chemoradiotherapy alone appears to be equivalent in terms of overall survival compared with chemoradiotherapy followed by surgery in squamous cancers, although the addition of surgery after chemoradiotherapy may afford superior local control of disease. Postoperatively, survival is improved with postoperative chemotherapy and radiotherapy in adenocarcinoma of the gastroesophageal junction, if none has been delivered preoperatively. Ongoing research involves evaluating regimens with newer chemotherapeutic drugs, such as paclitaxel or irinotecan, as well as the incorporation of targeted molecular therapies.
Collapse
Affiliation(s)
- Geoffrey Y Ku
- Department of Medicine, Memorial Sloan-Kettering Cancer Center and Weill-Cornell University Medical College, New York, NY 10021, USA
| | | |
Collapse
|
20
|
Moon BS, Park MT, Park JH, Kim SW, Lee KC, An GI, Yang SD, Chi DY, Cheon GJ, Lee SJ. Synthesis of novel phytosphingosine derivatives and their preliminary biological evaluation for enhancing radiation therapy. Bioorg Med Chem Lett 2007; 17:6643-6. [DOI: 10.1016/j.bmcl.2007.09.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2007] [Revised: 08/31/2007] [Accepted: 09/08/2007] [Indexed: 10/22/2022]
|
21
|
Safran H, Suntharalingam M, Dipetrillo T, Ng T, Doyle LA, Krasna M, Plette A, Evans D, Wanebo H, Akerman P, Spector J, Kennedy N, Kennedy T. Cetuximab with concurrent chemoradiation for esophagogastric cancer: assessment of toxicity. Int J Radiat Oncol Biol Phys 2007; 70:391-5. [PMID: 17980508 DOI: 10.1016/j.ijrobp.2007.07.2325] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2007] [Revised: 07/03/2007] [Accepted: 07/04/2007] [Indexed: 12/13/2022]
Abstract
PURPOSE To determine the feasibility and toxicity of the addition of cetuximab with paclitaxel, carboplatin, and radiation for patients with esophagogastric cancer on a Phase II study. METHODS AND MATERIALS Patients with locoregional esophageal and proximal gastric cancer without distant organ metastases were eligible. All patients received cetuximab, paclitaxel, and carboplatin weekly for 6 weeks with 50.4 Gy radiation. RESULTS Sixty patients were enrolled, 57 with esophageal cancer and 3 with gastric cancer. Forty-eight had adenocarcinoma and 12 had squamous cell cancer. Fourteen of 60 patients (23%) had Grade 3 dermatologic toxicity consisting of a painful, pruritic acneiform rash on the face outside of the radiation field. The rates of Grades 3 and 4 esophagitis were 12% and 3%, respectively. Three patients had Grade 3/4 cetuximab hypersensitivity reactions and were not assessable for response. Forty of 57 patients (70%) had a complete clinical response after chemoradiation. CONCLUSION Cetuximab can be safely administered with chemoradiation for esophageal cancer. Dermatologic toxicity and hypersensitivity reactions were associated with the addition of cetuximab. There was no increase in esophagitis or other radiation-enhanced toxicity.
Collapse
Affiliation(s)
- Howard Safran
- Brown University Oncology Group, Providence, RI, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Abstract
Cancer of the esophagus continues to be a threat to public health. The common practice is esophagectomy for surgically resectable tumors and radiochemotherapy for locally advanced, unresectable tumors. However, local regional tumor control and overall survival of esophageal cancer patients after the standard therapies remain poor, approximately 30% of patients treated with surgery only will develop local recurrence, and 50% to 60% patients treated with radiochemotherapy only fail local regionally due to persistent disease or local recurrence. Esophagectomy after radiochemotherapy or preoperative radiochemotherapy has increased the complete surgical resection rate and local regional control without a significant survival benefit. Induction chemotherapy followed by preoperative radiochemotherapy has produced encouraging results. In addition to patient-, tumor-, and treatment-related factors, involvement of celiac axis nodes, number of positive lymph nodes after preoperative radiochemotherapy, incomplete pathologic response, high metabolic activity on positron emission tomography scan after radiochemotherapy, and incomplete surgical resection are factors associated with a poor outcome. Radiochemotherapy followed by surgery is associated with significant adverse effects, including treatment-related pneumonitis, postoperative pulmonary complications, esophagitis and pericarditis. The incidence and severity of the adverse effects are associated with chemotherapy and radiotherapy dosimetric factors. Innovative treatment strategies including physically and biologically molecular targeted therapy is needed to improve the treatment outcome of patients with esophageal cancer.
Collapse
Affiliation(s)
- Zhongxing Liao
- Department of Radiation Oncology, The University of Texas M.D. Anderson Cancer, Houston, Texas 77030, USA.
| | | | | |
Collapse
|
23
|
Ilson DH, Wadleigh RG, Leichman LP, Kelsen DP. Paclitaxel given by a weekly 1-h infusion in advanced esophageal cancer. Ann Oncol 2007; 18:898-902. [PMID: 17351256 DOI: 10.1093/annonc/mdm004] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The purpose of the study was to evaluate the efficacy of weekly paclitaxel (Taxol) in advanced esophageal cancer. PATIENTS AND METHODS One hundred and two patients with advanced esophageal cancer were treated with paclitaxel 80 mg/m2 weekly over a 1-h infusion. One cycle was defined as 4 weeks of therapy. Ninety-five patients were assessable for toxicity and 86 patients who completed at least two cycles of treatment were assessable for response. Sixty-six patients had adenocarcinoma (66%) and 65 patients (68%) had no prior chemotherapy. RESULTS A median of three cycles was delivered (range 1-11). Partial responses (PRs) were seen in 11 patients [13%, 95% confidence interval (CI) 6% to 20%]. In patients without prior chemotherapy, PRs were seen in 10 patients (15%, 95% CI 6% to 24%), with comparable response in adenocarcinoma (8/50, 16%) and squamous carcinoma (2/15, 13%). Limited response was seen in patients with prior chemotherapy (1/21, 5%). The median duration of response was 172 days. The median survival was 274 days. Therapy was well tolerated with minimal hematologic or grade 3 or 4 toxicity. CONCLUSION Weekly paclitaxel has limited activity in esophageal cancer. The median survival, modest activity, and tolerance of therapy indicate that weekly paclitaxel may be an option in patients unable to tolerate combination chemotherapy.
Collapse
Affiliation(s)
- D H Ilson
- Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
| | | | | | | |
Collapse
|
24
|
Lin CC, Hsu CH, Cheng JC, Wang HP, Lee JM, Yeh KH, Yang CH, Lin JT, Cheng AL, Lee YC. Concurrent chemoradiotherapy with twice weekly paclitaxel and cisplatin followed by esophagectomy for locally advanced esophageal cancer. Ann Oncol 2007; 18:93-98. [PMID: 17028244 DOI: 10.1093/annonc/mdl339] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To test the feasibility of incorporating a twice-weekly paclitaxel (Taxol) and cisplatin regimen into concurrent chemoradiotherapy (CCRT), followed by surgery, for patients with locally advanced esophageal cancer. PATIENTS AND METHODS Patients with operable T3N0-1M0 or T1-3N1M0 esophageal cancer were enrolled. The CCRT regimen included paclitaxel (35 mg/m2 1 h on days 1 and 4/week), cisplatin (15 mg/m2 1 h on days 2 and 5/week), and radiotherapy (2 Gy on days 1-5/week). When the accumulated radiation dose reached 40 Gy, the feasibility of esophagectomy was evaluated in all patients. In patients for whom esophagectomy was not feasible, CCRT was continued to a dose of 60 Gy. RESULTS The majority of 97 patients enrolled had squamous cell carcinoma on histology (95%) and T3N1 disease by endoscopic ultrasonographic staging (90%). All patients received CCRT to 40 Gy. Sixty-one patients underwent surgery, and 26 patients continued definitive CCRT to 60 Gy. The intention-to-treat pathological complete response rate was 25% [24/97, 95% confidence interval (CI) 16-33]. At a median follow-up of 25.3 months, the median progression-free and overall survival was 15.6 and 28.8 months, respectively. The most common grade 3/4 toxic effects were leukopenia (30%), thrombocytopenia (10%), and diarrhea (15%). CONCLUSIONS CCRT with a twice-weekly paclitaxel and cisplatin regimen followed by esophagectomy is an active treatment of locally advanced esophageal cancer.
Collapse
Affiliation(s)
- C-C Lin
- Department of Oncology, National Taiwan University Hospital; Cancer Research Center, National Taiwan University College of Medicine
| | - C-H Hsu
- Department of Oncology, National Taiwan University Hospital; Cancer Research Center, National Taiwan University College of Medicine
| | - J C Cheng
- Department of Oncology, National Taiwan University Hospital
| | - H-P Wang
- Department of Emergency Medicine
| | | | - K-H Yeh
- Department of Oncology, National Taiwan University Hospital; Cancer Research Center, National Taiwan University College of Medicine; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - C-H Yang
- Department of Oncology, National Taiwan University Hospital; Cancer Research Center, National Taiwan University College of Medicine
| | - J-T Lin
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - A-L Cheng
- Department of Oncology, National Taiwan University Hospital; Cancer Research Center, National Taiwan University College of Medicine; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | | |
Collapse
|
25
|
Safran H, Dipetrillo T, Akerman P, Ng T, Evans D, Steinhoff M, Benton D, Purviance J, Goldstein L, Tantravahi U, Kennedy T. Phase I/II study of trastuzumab, paclitaxel, cisplatin and radiation for locally advanced, HER2 overexpressing, esophageal adenocarcinoma. Int J Radiat Oncol Biol Phys 2006; 67:405-9. [PMID: 17097832 DOI: 10.1016/j.ijrobp.2006.08.076] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Revised: 08/28/2006] [Accepted: 08/28/2006] [Indexed: 12/13/2022]
Abstract
PURPOSE To determine the overall survival for patients with locally advanced, HER2 overexpressing, esophageal adenocarcinoma receiving trastuzumab, paclitaxel, cisplatin, and radiation on a Phase I-II study. METHODS AND MATERIALS Patients with adenocarcinoma of the esophagus without distant organ metastases and 2+/3+ HER2 overexpression by immunohistochemistry (IHC) were eligible. All patients received cisplatin 25 mg/m2 and paclitaxel 50 mg/m2 weekly for 6 weeks with radiation therapy (RT) 50.4 Gy. Patients received trastuzumab at dose levels of 1, 1.5, or 2 mg/kg weekly for 5 weeks after an initial bolus of 2, 3, or 4 mg/kg. RESULTS Nineteen patients were entered: 7 (37%) had celiac adenopathy, and 7 (37%) had retroperitoneal, portal adenopathy, or scalene adenopathy. Fourteen of 19 patients (74%) had either 3+ HER2 expression by immunohistochemistry, or an increase in HER2 gene copy number by HER2 gene amplification or high polysomy by fluorescence in situ hybridization. The median survival of all patients was 24 months and the 2-year survival was 50%. CONCLUSIONS Assessment of the effect of trastuzumab in the treatment of patients with esophageal adenocarcinoma overexpressing HER2 is limited by the small number of patients in this study. Overall survival, however, was similar to prior studies without an increase in toxicity. Evaluation of HER2 status should be performed in future trials for patients with adenocarcinoma of the esophagus that investigate therapies targeting the HER family.
Collapse
Affiliation(s)
- Howard Safran
- Brown University Oncology Group, Providence, RI, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Abstract
Esophageal cancer, an uncommon, but highly virulent malignancy in the United States, will be responsible for nearly 14,000 deaths in the year 2005. The prognosis for patients who have adenocarcinoma of the distal esophagus and gastroesophageal junction and who are treated with the standard approaches of surgery or combined chemoradiation therapy is poor. Recent clinical trials have evaluated the use of preoperative chemotherapy followed by surgery, combined concurrent preoperative chemoradiotherapy followed by surgery, or definitive chemoradiotherapy alone without surgery. This article focuses on recent advances in the use of combined modality therapy in adenocarcinoma of the esophagus and gastroesophageal junction.
Collapse
Affiliation(s)
- David H Ilson
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center and Weill-Cornell University Medical College, 1275 York Avenue, New York, NY 10021, USA.
| |
Collapse
|
27
|
Abstract
Active chemotherapy agents in metastatic adenocarcinoma of the esophagus include taxanes (docetaxel or paclitaxel), 5-fluorouracil, irinotecan, platinum drugs (including cisplatin, oxaliplatin, and carboplatin), and anthracyclines. Conventional chemotherapy combines infusional 5-fluorouracil with cisplatin. The addition of a third drug to this backbone results in greater toxicity and only marginal improvements in outcome. Alternative and potentially better-tolerated chemotherapy involves two-drug regimens, combining 5-fluorouracil with a taxane or irinotecan, or combining a platinum drug with irinotecan or a taxane. Although preoperative chemotherapy improves survival compared with surgery alone, the addition of radiation therapy to chemotherapy preoperatively improves rates of curative resection, reduces local tumor recurrence, and achieves a significant rate of pathologic complete response. Combined preoperative chemotherapy and concurrent radiotherapy is the preferred preoperative strategy for locally advanced adenocarcinoma of the esophagus. Survival is improved with postoperative chemotherapy and radiotherapy if none has been delivered preoperatively.
Collapse
Affiliation(s)
- David H Ilson
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center and Weill-Cornell University Medical College, 1275 York Avenue, New York, NY 10021, USA.
| |
Collapse
|
28
|
Dipetrillo T, Milas L, Evans D, Akerman P, Ng T, Miner T, Cruff D, Chauhan B, Iannitti D, Harrington D, Safran H. Paclitaxel poliglumex (PPX-Xyotax) and concurrent radiation for esophageal and gastric cancer: a phase I study. Am J Clin Oncol 2006; 29:376-9. [PMID: 16891865 DOI: 10.1097/01.coc.0000224494.07907.4e] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To determine the maximal tolerated dose (MTD) and dose limiting toxicities of poly(l-glutamic acid)-paclitaxel (PPX) and concurrent radiation (PPX/RT) for patients with esophageal and gastric cancer. METHODS Patients with esophageal or gastric cancer receiving chemoradiation for loco-regional, adjuvant, or palliative intent were eligible. The initial dose of PPX was 40 mg/m2/wk, for 6 weeks with 50.4 Gy radiation. Dose levels were increased in increments of 10 mg/m2/wk of PPX. RESULTS Twenty-one patients were enrolled over 5 dose levels. Sixteen patients had esophageal cancer and 5 had gastric cancer. Twelve patients received PPX/RT as definitive loco-regional therapy, 4 patients had undergone resection and received adjuvant PPX/RT, and 5 patients had metastatic disease and received PPX/RT for palliation of dysphagia. Dose limiting toxicities of gastritis, esophagitis, neutropenia, and dehydration developed in 3 of 4 patients treated at the 80 mg/m2 dose level. Four of 12 patients (33%) with loco-regional disease had a complete clinical response. CONCLUSIONS The maximally tolerated dose of PPX with concurrent radiotherapy is 70 mg/m2/wk for patients with esophageal and gastric cancer.
Collapse
|
29
|
Ng T, Dipetrillo T, Purviance J, Safran H. Multimodality treatment of esophageal cancer: A review of the current status and future directions. Curr Oncol Rep 2006; 8:174-82. [PMID: 16618381 DOI: 10.1007/s11912-006-0017-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Surgical resection will cure only 15% to 20% of patients with seemingly localized esophageal cancer. Multimodality therapy has the potential to increase the cure rate by improving locoregional control and preventing systemic relapse. Randomized trials demonstrate that chemoradiation followed by surgery decreases local relapse as compared with surgery alone; however, the effect on overall survival remains uncertain. The additional impact of surgery following chemoradiation also remains unclear, with two randomized trials demonstrating an improvement in locoregional control without a benefit in survival. Morbidity and mortality of trimodality therapy have limited potential gains. Incorporation of docetaxel, irinotecan, and oxaliplatin into chemotherapy regimens prior to chemoradiation or as adjuvant therapy may decrease systemic recurrence. New radiation sensitizers may improve locoregional control. Biologic agents, such as cetuximab, trastuzumab, erlotinib, and bevacizumab, may enhance chemoradiation and target systemic micrometastases. Advances in radiation oncology and surgery may decrease morbidity and mortality from trimodality therapy, improving patient outcome.
Collapse
Affiliation(s)
- Thomas Ng
- Department of Medicine, The Miriam Hospital, 164 Summit Avenue, Providence, RI 02906, USA
| | | | | | | |
Collapse
|
30
|
Mukherjee S, Abraham J, Brewster A, Hardwick R, Havard T, Lewis W, Askill C, Manson J, Williamst GT, Roberts SA, Court J, Crosby T. Pilot Study of Preoperative Combined Modality Treatment for Locally Advanced Operable Oesophageal Carcinoma: Toxicities and Long-term Outcome. Clin Oncol (R Coll Radiol) 2006; 18:338-44. [PMID: 16703753 DOI: 10.1016/j.clon.2005.12.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
AIMS Paclitaxel, a radiosensitiser, has significant activity in oesophageal cancer. We aimed to conduct a feasibility study of preoperative chemoradiation using paclitaxel, cisplatin and 5-fluorouracil (5-FU). MATERIALS AND METHODS Sixteen eligible patients were enrolled. Infusional 5-FU, paclitaxel and cisplatin were given for 6 weeks before and concurrent with radiation. Conformal radiotherapy was delivered in two phases (45 Gy in 25 fractions). RESULTS A total of 62.5% of the patients experienced Grade 3-4 toxicities, 50% required admission; one patient died during the neo-adjuvant phase. Twelve (75%) patients had oesophagectomy, and two (12.5%) died after surgery. Pathological complete remission (PCR) and minimal residual disease were observed in 25% (95% CI 0.5-49.5%) and 18% (95% CI 0-38%) of patients, respectively, who underwent surgery. The median survival was 39.7 months (95% CI 15, not reached); 1-, 2-, 3-, and 4-year survivals were 75% (95% CI 56.5-99.5), 56.3% (36.5-86.7), 50% (30.6-81.6), and 50% (30.6-81.6), respectively. CONCLUSION Paclitaxel, cisplatin and 5-FU (TCF)-chemoradiation is an active regimen; the current dose schedule tested is associated with unacceptable toxicity, and cannot be recommended for routine clinical use.
Collapse
Affiliation(s)
- S Mukherjee
- Velindre Hospital, Whitchurch, Cardiff, Wales, UK
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Bosset JF, Lorchel F, Mantion G, Buffet J, Créhange G, Bosset M, Chaigneau L, Servagi S. Radiation and chemoradiation therapy for esophageal adenocarcinoma. J Surg Oncol 2005; 92:239-45. [PMID: 16299784 DOI: 10.1002/jso.20365] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The aims of preoperative chemoradiation therapy (preop-CRT) for esophageal adenocarcinoma are to reduce incomplete local resection (R1,R2), local and systemic recurrences that are reported in up to 30% of patients who undergo surgery alone. Phase II studies of preop-CRT, with radiation doses in the 40-50 Gy range, and concurrent chemotherapy with 5-fluorouracil (5-FU)-cisplatin +/- paclitaxel, or cisplatin-paclitaxel, have reported subsequent RO resection rates of 80%-100%, with tumor sterilization achieved in 8%-49% of cases, and consequently improved local control. New chemotherapy regimens omitting 5-FU have reduced the incidence of severe esophagitis, unplanned hospitalization, with comparable efficacy. Among three randomised trials that compared preop-CRT to surgery alone, one shown a debatable survival advantage. Reducing local recurrence rates lead to a switch to more distant failures, and increasing the radiation dose beyond 45 Gy appears to be of little value. However, it should be remembered that preop-CRT has associated toxicity, and may increase postoperative mortality. Novel strategies, which include induction with chemotherapy followed by preop-CRT, and for radiation therapy, three dimensional conformation techniques, image fusioning, and improved definition of treatment volumes, are still considered experimental and should be tested in specialized centers.
Collapse
Affiliation(s)
- Jean-François Bosset
- Department of Radiation-Oncology, Besançon University Hospital, Boulevard Fleming, F-25030 Besançon Cedex, France.
| | | | | | | | | | | | | | | |
Collapse
|
32
|
Bedenne L. [Chemoradiation: an alternative to surgery for the curative treatment esophageal cancer?]. ACTA ACUST UNITED AC 2005; 29:551-6. [PMID: 15980749 DOI: 10.1016/s0399-8320(05)82127-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Laurent Bedenne
- Hépato-Gastroentérologie, CHU Dijon, Bd de Lattre de Tassigny
| |
Collapse
|
33
|
Yu E, Dar R, Rodrigues GB, Stitt L, Videtic GMM, Truong P, Tomiak A, Ash R, Brecevic E, Inculet R, Malthaner R, Vincent M, Craig I, Kocha W, Lefcoe M. Is extended volume external beam radiation therapy covering the anastomotic site beneficial in post-esophagectomy high risk patients? Radiother Oncol 2004; 73:141-8. [PMID: 15542160 DOI: 10.1016/j.radonc.2004.08.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2003] [Revised: 05/27/2004] [Accepted: 08/10/2004] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE To assess the impact of extended volume radiation therapy (RT) with anastomotic coverage on local control in high risk post-operative esophageal cancer patients. PATIENTS AND METHODS This is a retrospective study of high risk (T(3), T(4), nodes positive, with or without margin involvement) post-operative esophageal cancer patients treated at London Regional Cancer Centre from 1989 to 1999. After esophagectomy, all patients received adjuvant combined modality therapy consisting of four cycles of fluorouracil-based chemotherapy, and loco-regional RT with or without coverage of the anastomotic site. RT dose ranged from 45 to 60 Gy at 1.8-2.0 Gy/fraction with treatment fields tailored to the pathologic findings and location of the anastomosis. CT planning was used in all patients to design spinal cord sparing beam arrangements. First relapse rate (first incidence of an event), disease specific survival and overall survival were calculated by Chi-Square, Log-Rank, and Kaplan-Meier (K-M) methods. RESULTS During the study period, 72 patients had underwent esophagectomy and were considered for adjuvant chemoradiation therapy. Three patients were excluded due to disease progression prior to therapy. The 69 remaining patients formed the study cohort for the present analysis. The median age of the study group was 60 years (range 35-82 years). Pathologic stage distribution (AJCC 1997 staging) was T(2,3) N(1) in 94% patients, 65% of the cases were adenocarcinoma and had undergone transhiatal esophagectomy (86%) with positive/close margins in 34 (49%) patients. Median follow-up was 30.5 months (range 3.4-116.3 months). Two- and 5-year actuarial overall survivals rates were 50 and 31%, respectively. First relapse rate after adjuvant therapy was 63.7% (n = 44) and median time to relapse was 27.2 months. Anastomosis recurrence rates were 29% with small volume and 0% with extended volume RT (P = 0.041). Local and regional relapse occurred in 74.2% of patients treated with small volume RT compared to 15.4% in patients treated with extended volume RT (P < 0.001). After adjusting for resection margin status, the local control benefit of extended volume RT remained significant (P = 0.003). Treatment interruptions and late gastrointestinal toxicity were not significantly increased with the use of extended volume RT. CONCLUSIONS A significant decrease in local and regional relapse without added late toxicity was achieved with the use of extended volume RT encompassing the anastomotic site post-operatively in high risk esophageal cancer patients.
Collapse
Affiliation(s)
- Edward Yu
- Department of Radiation Oncology, London Regional Cancer Centre, 790 Commissioners Road, E., London, Ont., Canada N6A 4L6
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Aiba K, Ogawa M. Upper gastrointestinal tumors. ACTA ACUST UNITED AC 2004; 21:485-508. [PMID: 15338760 DOI: 10.1016/s0921-4410(03)21023-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Affiliation(s)
- Keisuke Aiba
- Tokyo Jikei University School of Medicine, Japan.
| | | |
Collapse
|
35
|
Fréchette E, Buck DA, Kaplan BJ, Chung TD, Shaw JE, Kachnic LA, Neifeld JP. Esophageal cancer: outcomes of surgery, neoadjuvant chemotherapy, and three-dimension conformal radiotherapy. J Surg Oncol 2004; 87:68-74. [PMID: 15282698 DOI: 10.1002/jso.20094] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Neoadjuvant chemotherapy and radiation are being utilized with increasing frequency in the multimodal treatment of esophageal cancer, although their effects on morbidity, mortality, and survival remain unclear. The objective of this study was to determine the outcome of multimodal treatment in patients with localized esophageal cancer treated at a single institution. Between 1995 and 2002, 118 patients underwent treatment for localized esophageal cancer, utilizing surgery alone, chemoradiation alone, or surgery following neoadjuvant chemoradiation. There was no statistically significant difference in morbidity, mortality, or length of stay between the patients who received multimodal therapy when compared to surgery alone. A surgical resection after down-staging was possible in 9 out of 28 patients (32%) with a clinically non-resectable tumor (T4 or M1a). Forty-seven percent of the patients who received neoadjuvant therapy had a complete pathologic response with a 3-year survival of 59% as compared to only 20 months in those patients who did not achieve a complete response (P = 0.037). Neoadjuvant chemotherapy administered concomitantly with conformal radiotherapy can be performed safely in the treatment of esophageal cancer, without increasing the operative morbidity, mortality, or length of stay. The higher complete response rates to neoadjuvant treatment (as compared to other reports) may be due to the use of three-dimensional conformal radiation therapy or the novel use of weekly carboplatin and paclitaxel.
Collapse
Affiliation(s)
- Eric Fréchette
- Division of Surgical Oncology, Department of Surgery, Virginia Commonwealth University, Richmond 23298-0645, Virginia, USA
| | | | | | | | | | | | | |
Collapse
|
36
|
Anderson SE, Minsky BD, Bains M, Kelsen DP, Ilson DH. Combined modality therapy in esophageal cancer: the Memorial experience. ACTA ACUST UNITED AC 2004; 21:228-32. [PMID: 14648780 DOI: 10.1002/ssu.10041] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Over the past 20 years in the United States, esophageal cancer has shown the most rapid rate of increase of any solid tumor malignancy. Esophageal cancer is an aggressive disease, and poor survival is achieved with surgery or chemoradiation therapy alone. Ongoing trials are investigating the use of preoperative chemoradiation followed by surgical resection. Chemoradiation employing a combination of cisplatin and a continuous infusion of 5-fluorouracil (5-FU) is the most commonly used therapy. The significant gastrointestinal toxicity of traditional cisplatin/5-FU-based regimens has prompted the evaluation of new agents in combined-modality therapy. The Memorial Sloan-Kettering Cancer Center has conducted chemoradiation trials with weekly paclitaxel/cisplatin and irinotecan/cisplatin, and the results suggest that this regimen has the potential to improve the therapeutic index without compromising efficacy. Randomized trials are now being conducted to evaluate the tolerance and efficacy of paclitaxel/cisplatin in comparison with paclitaxel/5-FU combined with radiotherapy in locally advanced esophageal cancer. The incorporation of these non-5-FU-based therapies with novel biologic agents is planned.
Collapse
Affiliation(s)
- Sibyl E Anderson
- Department of Medicine, Gastrointestinal Oncology Service-Division of Solid Tumor Oncology, Memorial Sloan-Kettering Cancer Center and Cornell University Weill Medical College, New York, New York 10021, USA
| | | | | | | | | |
Collapse
|
37
|
Constantinou M, Tsai JY, Safran H. Paclitaxel and concurrent radiation in upper gastrointestinal cancers. Cancer Invest 2004; 21:887-96. [PMID: 14735693 DOI: 10.1081/cnv-120025092] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Effective locoregional treatments are needed for adenocarcinomas of the esophagus, stomach, and pancreas. Paclitaxel has been investigated as a radiation sensitizer for upper gastrointestinal malignancies. In esophageal cancer, the combination of low-dose weekly paclitaxel, platinum, and concurrent radiation therapy (RT) has substantial activity and is well tolerated. Regimens that add fluorouracil (5-FU) to paclitaxel and platinum or incorporate hyperfractionation radiation have a higher incidence of severe esophagitis. In gastric cancer, adjuvant concurrent paclitaxel, 5-FU, and radiation is being investigated in the cooperative group setting. In pancreatic cancer, paclitaxel may be a radiation sensitizer even to tumor cells that are resistant to paclitaxel as a single agent. The Radiation Therapy Oncology Group (RTOG) demonstrated a 43% 1-year survival with paclitaxel/RT for patients with locally advanced pancreatic cancer. This represented a 40% improvement in survival compared to the previous RTOG 92-09 study of 5-FU-based chemoradiation. Ongoing trials in pancreatic cancer are investigating the addition of gemcitabine to paclitaxel and radiation and incorporating molecular targeting agents.
Collapse
|
38
|
Brenner B, Ilson DH, Minsky BD, Bains MS, Tong W, Gonen M, Kelsen DP. Phase I trial of combined-modality therapy for localized esophageal cancer: escalating doses of continuous-infusion paclitaxel with cisplatin and concurrent radiation therapy. J Clin Oncol 2004; 22:45-52. [PMID: 14701767 DOI: 10.1200/jco.2004.05.039] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE To define the maximum-tolerated dose (MTD) of paclitaxel when given as a weekly 96-hour infusion with cisplatin and radiotherapy for patients with esophageal cancer. PATIENTS AND METHODS Thirty-four patients with locally advanced esophageal cancer and three patients with local recurrence or positive resection margins were treated. Weekly paclitaxel doses of 10, 20, 30, 40, 60, and 80 mg/m(2), given as a continuous 96-hour infusion, were administered with weekly cisplatin, 30 mg/m(2) on day 1, weeks 1 to 6, and concurrent radiation (50.4 Gy). Plasma paclitaxel steady-state levels were measured. RESULTS Dose-limiting toxicity, defined as a treatment break longer than 2 weeks for toxicity, occurred in one patient in the 80-mg/m(2)/wk dose level. Major causes for any (including < or = 2 weeks) treatment breaks were mediport complications and neutropenic fever, which occurred mostly at that dose level. At a paclitaxel dose of 60 mg/m(2)/wk, myelosuppression, mostly neutropenia, was relatively mild and transient; stomatitis, esophagitis, diarrhea. and peripheral neuropathy were uncommon and usually of grade 2 or less. Therefore, the MTD was established at 60 mg/m(2)/wk. The mean steady-state concentration of paclitaxel at the MTD was 17.2 nmol/L. Complete (R0) resection was possible in 16 (73%) of 22 patients who underwent subsequent surgery, and the pathologic complete response rate was 24%. CONCLUSION Weekly, 96-hour infusion of paclitaxel 60 mg/m(2)/wk, given with concurrent cisplatin and radiotherapy, is a safe and tolerable regimen for patients with localized esophageal cancer. Preliminary efficacy data are encouraging. This regimen is the basis of ongoing Radiation Therapy Oncology Group phase II randomized trials in esophageal and gastric cancers.
Collapse
Affiliation(s)
- Baruch Brenner
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
| | | | | | | | | | | | | |
Collapse
|
39
|
Harari PM, Ritter MA, Petereit DG, Mehta MP. Chemoradiation for upper aerodigestive tract cancer: balancing evidence from clinical trials with individual patient recommendations. Curr Probl Cancer 2004; 28:7-40. [PMID: 14688789 DOI: 10.1016/j.currproblcancer.2003.10.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Paul M Harari
- Department of Human Oncology, University of Wisconsin Comprehensive Cancer Center, Madison, WI, USA
| | | | | | | |
Collapse
|
40
|
Abstract
Oesophageal cancer is a rare but highly virulent malignancy in the United States and Western countries, and adenocarcinoma of the oesophagus has had the most rapid rate of increase of any solid tumour malignancy. Systemic metastatic disease is present in 50% of patients at diagnosis, and in the remaining 50% of patients presenting initially with loco-regional disease, systemic metastatic disease will develop in the vast majority of these patients. Combined chemotherapy and radiotherapy is the standard of care in the nonsurgical management of oesophageal cancer. Preoperative chemoradiotherapy followed by surgery continues to be actively studied in the surgical management of locally advanced oesophageal cancer. Pathologic complete responses are seen in 20-40% of patients, with five-year survival achieved in 25-35% of patients. The limited efficacy and substantial toxicity of conventional 5-FU-cisplatin-based chemotherapy combined with radiation, or used to treat advanced disease, has prompted the evaluation of newer agents, including the taxanes and irinotecan. These trials have indicated promising antitumour activity and therapy tolerance in both advanced disease and in combined modality therapy trials, depending on the dose and schedule of therapy administered. The advent of newer, targeted therapies, including agents directed against growth factor receptor pathways, tumour angiogenesis, and tumour invasion and metastasis, is leading to a new generation of clinical trials combining these agents with conventional cytotoxic chemotherapy and radiation.
Collapse
Affiliation(s)
- David H Ilson
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10011, USA.
| |
Collapse
|
41
|
Urba SG, Orringer MB, Ianettonni M, Hayman JA, Satoru H. Concurrent cisplatin, paclitaxel, and radiotherapy as preoperative treatment for patients with locoregional esophageal carcinoma. Cancer 2003; 98:2177-83. [PMID: 14601087 DOI: 10.1002/cncr.11759] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND A Phase II trial was conducted at the University of Michigan to determine the efficacy of a preoperative regimen of concurrent cisplatin, paclitaxel, and radiation for patients with locoregional esophageal carcinoma. METHODS Sixty-nine patients with esophageal carcinoma were treated with cisplatin 75 mg/m(2) on Day 1, paclitaxel 60 mg/m(2) on Days 1, 8, 15, and 22, and radiation 1.5 Gray (Gy) twice per day on Days 1-5, 8-12, and 15-19, for a total dose of 45 Gy. Transhiatal esophagectomy was performed on approximately Day 50. RESULTS The treatment regimen was well tolerated. Only 13% of patients developed Grade 3 or 4 neutropenia and 17% of patients required feeding tubes. Ninety percent of all patients had complete tumor resection at the time of surgery. Nineteen percent of patients achieved a complete histologic response in the resected specimen. The median survival period was 24 months. One-, 2-, and 3-year survival probabilities were 75%, 50%, and 34%, respectively. CONCLUSIONS This cisplatin-based preoperative regimen, which contained paclitaxel rather than 5-fluorouracil, was well tolerated. The survival data compared favorably with other previously reported combinations. This regimen is a reasonable preoperative approach for patients with localized esophageal carcinoma.
Collapse
Affiliation(s)
- Susan G Urba
- Division of Hematology/Oncology, University of Michigan Comprehensive Cancer Center, Ann Arbor, Michigan 48109, USA.
| | | | | | | | | |
Collapse
|
42
|
Ilson DH, Bains M, Kelsen DP, O'Reilly E, Karpeh M, Coit D, Rusch V, Gonen M, Wilson K, Minsky BD. Phase I trial of escalating-dose irinotecan given weekly with cisplatin and concurrent radiotherapy in locally advanced esophageal cancer. J Clin Oncol 2003; 21:2926-32. [PMID: 12885811 DOI: 10.1200/jco.2003.02.147] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE To identify the maximum-tolerated dose and dose-limiting toxicity (DLT) of weekly irinotecan combined with cisplatin and radiation in esophageal cancer. PATIENTS AND METHODS Nineteen patients with clinical stage II to III esophageal squamous cell or adenocarcinoma were treated on this phase I trial. Induction chemotherapy with weekly cisplatin 30 mg/m2 and irinotecan 65 mg/m2 was administered for four treatments during weeks 1 to 5. Radiotherapy was delivered weeks 8 to 13 in 1.8-Gy daily fractions to a dose of 50.4 Gy. Cisplatin 30 mg/m2 and escalating-dose irinotecan (40, 50, 65, and 80 mg/m2) were administered on days 1, 8, 22, and 29 of radiotherapy. DLT was defined as a 2-week delay in radiotherapy for grade 3 to 4 toxicity. RESULTS Minimal toxicity was observed during chemoradiotherapy, with no grade 3 or 4 esophagitis, diarrhea, or stomatitis. DLT caused by myelosuppression was seen in two of six patients treated at the 80-mg/m2 dose level, thus irinotecan 65 mg/m2 was defined as the recommended phase II dose. Dysphagia improved or resolved after induction chemotherapy in 13 (81%) of 16 patients who reported dysphagia before therapy. Only one patient (5%) required a feeding tube. Six complete responses (32%) were observed, including four pathologic complete responses in 15 patients selected to undergo surgery (27%). CONCLUSION Cisplatin, irinotecan, and concurrent radiotherapy can be administered on a convenient schedule with relatively minimal toxicity and an acceptable rate of complete response in esophageal cancer. Further phase II evaluation of this regimen is ongoing. A phase III comparison to fluorouracil or taxane-containing chemoradiotherapy should be considered.
Collapse
Affiliation(s)
- David H Ilson
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Suntharalingam M, Moughan J, Coia LR, Krasna MJ, Kachnic L, Haller DG, Willett CG, John MJ, Minsky BD, Owen JB. The national practice for patients receiving radiation therapy for carcinoma of the esophagus: results of the 1996-1999 Patterns of Care Study. Int J Radiat Oncol Biol Phys 2003; 56:981-7. [PMID: 12829133 DOI: 10.1016/s0360-3016(03)00256-6] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE A Patterns of Care Study (PCS) was conducted to evaluate the standards of practice for patients receiving radiation therapy for esophageal cancer from 1996 to 1999. This study examined the evaluation and treatment schemes used during this time and compared these results to the PCS data obtained between 1992 and 1994 to identify any fundamental changes in national practice. METHODS A national survey was conducted using a two-stage cluster sampling technique. Specific information was collected on 414 patients with esophageal cancer who received radiotherapy (RT) as part of definitive or adjuvant management at 59 institutions. Patients were staged according to the 1983 AJCC. Eligibility criteria for case review included RT between 1996 and 1999, no evidence of distant metastasis (including CT evidence of either supraclavicular or celiac nodes >1 cm), squamous cell or adenocarcinoma histology, Karnofsky performance status >60, tumors in the thoracic esophagus with <2 cm extension into the stomach, and no prior malignancies within the last 5 years. Statistical analysis was performed on the database using SUDAAN software to accurately reflect the type of sampling technique used by PCS. For the purpose of this analysis, institutions were stratified as either large or small based on the number of new cases seen each year. For the purposes of comparison, the 1992-1994 PCS esophageal survey results were subjected to the same statistical procedures and tests. RESULTS The median age of patients was 64 years. Seventy-seven percent were male, and 23% were female. Karnofsky performance status was >or=80% in 85% of patients. The racial profile mirrors the previous survey with 75% Caucasian, 21% African-American, 3% Asian, and <1% Hispanic. A review of the histology revealed a nearly 50:50 split between squamous cell and adenocarcinoma. Sixteen percent were clinical Stage I, 39% clinical Stage II, and 33% clinical Stage III according to the 1983 AJCC system. Workup included endoscopy (96%), CT of the chest (87%), CT of the abdomen (75%), and esophagram (64%). Endoscopic ultrasound (EUS) was used in 18% of cases as compared to <2% in the original survey (p < 0.0001). Patients treated at large centers were more likely to undergo EUS than those treated at small centers (23% vs. 12%, p = 0.047). Fifty-six percent of patients received concurrent chemoradiation as definitive treatment. There was a significant increase in the use of concurrent chemoradiation before planned surgical resection as compared to the original survey (27% vs. 10%, p = 0.007). Other schemes included RT alone (10%), postoperative RT (1%), and postoperative chemoradiation (5%). Forty-six percent of patients with adenocarcinoma underwent trimodality therapy as compared to 19% with squamous cell carcinomas (p = 0.0002). Patients undergoing preoperative chemoradiation were more likely to have had an EUS. The median total dose of external RT was 50.4 Gy, and the median dose per fraction was 1.8 Gy. Brachytherapy was used in 6% of cases. The chemotherapy agents most commonly used included 5-fluorouracil (82%), cisplatin (67%), and paclitaxel (22%). Paclitaxel was more commonly employed as part of a preoperative chemoradiation regimen than in the setting of definitive chemoradiation (46% vs. 12%, p = 0.03). Compared to the original survey, paclitaxel use significantly increased between 1996 and 1999 (0.2% vs. 22%, p = 0.001). CONCLUSIONS The Patterns of Care Survey confirms the use of concurrent chemoradiation as part of the national standards of practice for the management of esophageal cancer patients. A comparison with the previous study documents the significant rise in the use of EUS, preoperative chemoradiation followed by surgery, and the increasing use of paclitaxel as part of a combined modality regimen.
Collapse
Affiliation(s)
- Mohan Suntharalingam
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Abstract
PURPOSE OF REVIEW The majority of esophageal cancers are advanced at presentation, rendering cure unlikely, especially by surgery alone. Consequently, much research effort has been directed towards studies of adjuvant chemotherapy and chemoradiation, particularly in defining the best regimens from the standpoint of efficacy and minimal toxicity and in an attempt to predict response. RECENT FINDINGS Overall results of adjuvant therapy have been conflicting, although a survival advantage has been documented in those demonstrating objective response to chemoradiation. In such circumstances, comparable survival has been demonstrated using chemoradiation alone, leading to the hypothesis that surgery may be best reserved for nonresponders. For those with stage IV disease or unfit for radical treatment, a variety of palliative modalities exist including stenting, laser photocoagulation, brachytherapy, and chemotherapy used singly or in combination, the latter providing encouraging improvement in survival over single-modality treatment. SUMMARY Current research is directed towards securing better results using newer chemotherapeutic agents such as taxanes and irinotecan and deploying molecular markers both to predict response to chemotherapy and to target its delivery to tumor sites.
Collapse
Affiliation(s)
- Anthony Watson
- Royal Free and University College Medical School, London, UK.
| |
Collapse
|
45
|
Abstract
Patients diagnosed with adenocarcinoma or squamous cell carcinoma of the esophagus should undergo computed tomography of the chest and abdomen and positron emission tomography to look for evidence of distant metastatic disease. In the absence of systemic metastases, locoregional staging should be performed with endoscopic ultrasonography and fine needle aspiration of accessible periesophageal lymph nodes and any detectable celiac lymph nodes. Patients found to have T3 tumors (transmural extension), T4 tumors (invasion of adjacent structures), or N1-M1a (lymph node-positive) disease do poorly when treated with surgery alone; 5-year survival is less than 20%. These patients should be considered for combined modality therapy. Patients with T4 disease are generally not deemed candidates for surgical resection; they may be considered for definitive chemoradiotherapy. Patients with T3 disease or lymph node-positive disease may be treated with neoadjuvant chemoradiotherapy followed by surgery or definitive chemoradiotherapy alone. Patients considered for trimodality therapy should be fully restaged before surgery to assess their response to neoadjuvant treatment. This should include repeat endoscopic ultrasound and fine needle aspiration of lymph nodes. Patients whose lymph node metastases do not completely respond to neoadjuvant therapy are unlikely to benefit from the addition of surgery. Patients with persistently positive celiac lymph nodes have a very poor prognosis and should not undergo surgery. Patients with persistent nodal disease who have good performance status may be considered for additional chemotherapy. Patients with locally advanced esophageal cancer who have poor performance status are not good candidates for combined modality therapy. These individuals are best managed with palliative intent. Particular attention should be given to alleviating the common problem of dysphagia, which causes significant morbidity.
Collapse
Affiliation(s)
- Carol A Sherman
- Hollings Cancer Center, Medical University of South Carolina, 86 Jonathan Lucas Street, Charleston, SC 29425, USA.
| | | | | | | |
Collapse
|
46
|
van Lanschot JJB, Aleman BMP, Richel DJ. Esophageal carcinoma: surgery, radiotherapy, and chemotherapy. Curr Opin Gastroenterol 2002; 18:490-5. [PMID: 17033326 DOI: 10.1097/00001574-200207000-00015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Several new developments in the potentially curative therapy of esophageal cancer have drawn attention over the past year. There is a potential benefit of centralization of esophagectomies in dedicated centers. Early mucosal lesions are increasingly treated by local ablative therapy. Tumors invading the submucosa are preferably treated by surgical resection. There is ongoing controversy about the optimal surgical approach. Positron emission tomography scanning is a promising tool in the preoperative work-up but needs critical evaluation. The question of whether chemoradiation with voice preservation (followed by salvage surgery in case of tumor recurrence) can replace pharyngolaryngectomy in patients with cervical esophageal cancer is still unanswered. A review of eight randomized trials demonstrated that chemoradiation as primary treatment of esophageal cancer provides an absolute reduction of mortality. The addition of new drugs like paclitaxel and irinotecan into induction regimens for the treatment of advanced disease results in higher response rates but also in increased toxicity. Preoperative radiotherapy as single modality treatment does not improve overall survival, whereas the benefit of preoperative chemotherapy and chemoradiation has not been proven unequivocally. Several retrospective studies with a small number of patients suggest that local response parameters like pathologic complete response and downstaging of regional lymph node (N) status are correlated with longer survival.
Collapse
|
47
|
Abstract
Esophageal cancer is a rare but highly virulent malignancy in the United States and Western Europe, and adenocarcinoma of the esophagus has had the most rapid rate of increase of any solid tumor malignancy. Combined chemoradiotherapy is the standard of care in the nonsurgical management of esophageal cancer. Trials of preoperative chemotherapy followed by surgery have not shown a consistent benefit. Preoperative chemoradiotherapy followed by surgery continues to be actively studied in the surgical management of locally advanced esophageal cancer. Pathologic complete responses are seen in 20% to 40% of patients, with 5-year survival achieved in 30% to 35%. Newer agents, such as the taxanes and irinotecan, have been evaluated in combined chemoradiotherapy trials. These trials have shown promising antitumor activity and therapy tolerance, depending on the dose and schedule of therapy administered. Increasing the dose of radiotherapy, or adding a brachytherapy boost to chemoradiotherapy, has not improved the outcome of treatment in clinical trials. The advent of newer targeted therapies, including agents directed against growth factor receptor pathways, tumor angiogenesis, and tumor invasion and metastasis, is leading to a new generation of clinical trials combining these agents with conventional cytotoxic chemotherapy and radiation.
Collapse
Affiliation(s)
- David H Ilson
- Gastrointestinal Oncology Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10011, USA.
| |
Collapse
|
48
|
Minsky BD, Pajak TF, Ginsberg RJ, Pisansky TM, Martenson J, Komaki R, Okawara G, Rosenthal SA, Kelsen DP. INT 0123 (Radiation Therapy Oncology Group 94-05) phase III trial of combined-modality therapy for esophageal cancer: high-dose versus standard-dose radiation therapy. J Clin Oncol 2002; 20:1167-74. [PMID: 11870157 DOI: 10.1200/jco.2002.20.5.1167] [Citation(s) in RCA: 833] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To compare the local/regional control, survival, and toxicity of combined-modality therapy using high-dose (64.8 Gy) versus standard-dose (50.4 Gy) radiation therapy for the treatment of patients with esophageal cancer. PATIENTS AND METHODS A total of 236 patients with clinical stage T1 to T4, N0/1, M0 squamous cell carcinoma or adenocarcinoma selected for a nonsurgical approach, after stratification by weight loss, primary tumor size, and histology, were randomized to receive combined-modality therapy consisting of four monthly cycles of fluorouracil (5-FU) (1,000 mg/m(2)/24 hours for 4 days) and cisplatin (75 mg/m(2) bolus day 1) with concurrent 64.8 Gy versus the same chemotherapy schedule but with concurrent 50.4 Gy. The trial was stopped after an interim analysis. The median follow-up was 16.4 months for all patients and 29.5 months for patients still alive. RESULTS For the 218 eligible patients, there was no significant difference in median survival (13.0 v 18.1 months), 2-year survival (31% v 40%), or local/regional failure and local/regional persistence of disease (56% v 52%) between the high-dose and standard-dose arms. Although 11 treatment-related deaths occurred in the high-dose arm compared with two in the standard-dose arm, seven of the 11 deaths occurred in patients who had received 50.4 Gy or less. CONCLUSION The higher radiation dose did not increase survival or local/regional control. Although there was a higher treatment-related mortality rate in the patients assigned to the high-dose radiation arm, it did not seem to be related to the higher radiation dose. The standard radiation dose for patients treated with concurrent 5-FU and cisplatin chemotherapy is 50.4 Gy.
Collapse
Affiliation(s)
- Bruce D Minsky
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Anderson MR, Jankowski JA. The treatment, management and prevention of oesophageal cancer. Expert Opin Biol Ther 2001; 1:1017-28. [PMID: 11728233 DOI: 10.1517/14712598.1.6.1017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The combination of a rising incidence and a poor survival rate makes oesophageal cancer a major health issue. Adenocarcinoma of the oesophagus is associated with one of the commonest pre-malignant lesions recognised, Barrett's metaplasia. This provides a focus for early detection and intervention. The subjects of acid suppression, bile reflux, COX-2 inhibition and ablation therapy will be discussed herewith. Established carcinoma is now rarely treated by surgery alone and this review discusses the benefits of multimodality therapy combined with more accurate staging techniques. Finally an emerging understanding of the molecular events that characterise the transition to carcinoma may provide novel targets in cancer therapy such as epidermal growth factor receptor (EGFR) and TNF-alpha. This review will focus on some of the future developments in the treatment of oesophageal cancer.
Collapse
Affiliation(s)
- M R Anderson
- Epithelial Laboratory, Division of Medical Sciences, University of Birmingham, Edgbaston, B15 2TH, UK
| | | |
Collapse
|