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

Oral maintenance therapy using apatinib combined with S-1/capecitabine for esophageal squamous cell carcinoma with residual disease after definitive chemoradiotherapy

Background: A substantial number of patients with esophageal squamous cell carcinoma (ESCC) do not achieve complete remission after definitive concurrent chemoradiotherapy (dCRT). We performed this retrospective study to evaluate the efficacy and safety of apatinib combined with S-1/capecitabine as the oral maintenance therapy for these patients.

Methods: Thirty-nine ESCC patients with residual disease after dCRT were included. Patients were treated with apatinib combined with S-1 /capecitabine after dCRT. Efficacy, toxicity, and survival were analyzed.

Results: Of the 39 patients, 5 (12.8%) achieved a partial response and 29 (74.4%) achieved stable disease, yielding a disease control rate of 87.2%. The median progression-free survival (PFS) and overall survival (OS) were 27.5 (95%CI: 14.9 - 40.1) and 38.1 (95%CI: 31.3 - 44.8) months. Most frequent adverse events were of grade 1 to 2. Multivariate analysis revealed the occurrence of any adverse events (HR = 0.274, 95%[CI] = 0.119 - 0.630) correlated to better PFS and occurrence of proteinuria (HR = 0.108, 95%[CI] = 0.025 - 0.456) predicted better OS.

Conclusion: The oral combination therapy consisting of apatinib and S-1/capecitabine showed a tolerable toxicity profile and achieved satisfactory disease control in ESCC patients with residual disease after dCRT.

Chemoradiotherapy and Increased Prescription Dose in Esophageal Squamous Cell Cancer: A Retrospective Study

To analyze the outcomes and adverse events of patients with esophageal squamous cell carcinoma (ESCC) treated with definitive chemoradiation with modified radiotherapy volume and increased radiation dose. This was a retrospective analysis of patients with ESCC treated with definitive chemoradiotherapy at the Sun Yat-sen University Cancer Center (02/2015 to 02/2017). The dose to the planning gross tumor volume (PGTV) and planning clinical tumor volume (PTV1) was 66-68 Gy (2.0-2.2 Gy/fraction). The dose to the planning regional lymph node drainage area volume (PTV2) was 46 Gy (2.0 Gy/fraction). Treatment response, adverse events, progression-free survival (PFS), overall survival (OS), and locoregional failure-free survival (LRFFS) were analyzed. Twenty-six patients were included. The median follow-up was 31 (range, 4.3-51.3) months. Sixteen (61.5%) patients had a complete response, and four (15.4%) achieved a partial response. The objective response rate was 76.9%, and the disease control rate was 80.8%. The median PFS and OS were not achieved. The 4-year PFS was 63.9%, and the 4-year OS was 71.0%. Grade 1-2 and 3-4 radiation-related esophagitis was observed in 15 (57.7%) and one (4.5%) patients, respectively. Grade 1-2 and 3-4 radiation-related pneumonitis was observed in 12 (46.2%) and one (4.5%) patients, respectively. No patients developed radiation-related heart or skin damage. The modified target volume definition and increased dose of definitive radiotherapy combined with chemotherapy in patients with ESCC had low toxicity and might improve survival, but additional trials are necessary to prove the superiority of this strategy.

Single-Agent Versus Double-Agent Chemotherapy in Concurrent Chemoradiotherapy for Esophageal Squamous Cell Carcinoma: Prospective, Randomized, Multicenter Phase II Clinical Trial

LESSONS LEARNED

The efficacy of single-agent chemotherapy was not significantly different from that of double-agent chemotherapy in concurrent chemoradiotherapy for inoperable esophageal squamous cell carcinoma. Single-agent concurrent chemoradiotherapy had lower gastrointestinal and hematologic toxicity. Overall survival and progression-free survival were not significantly different between single- and double-agent concurrent chemoradiotherapy.

BACKGROUND

This multicenter, randomized, phase II trial aimed to compare the efficacy and safety of single-agent concurrent chemoradiotherapy using the oral fluoropyrimidine S-1 with those of double-agent concurrent chemoradiotherapy using S-1 and cisplatin in patients with inoperable esophageal squamous cell carcinoma.

METHODS

Patients with inoperable esophageal squamous cell carcinoma (clinical stages I to III) were randomly allocated to the single-agent group (S-1) or the double-agent group (S-1/cisplatin). The concurrent intensity-modulated radiation therapy plan was similar for both groups: planning target volume 1.8 Gy/f*30-33f and planning gross target volume of 2 Gy/f*30-33f. The primary outcome measure was the endoscopic complete response rate.

RESULTS

Of the 105 patients randomized, 89 were assessable. The endoscopic complete response rate was 46.9% (23/49) in the single-agent group and 52.5% (21/40) in double-agent group. The median progression-free survival within a median follow-up of 23 months was 20 and 21 months, respectively. The median overall survival was 26 months and not reached, respectively. Grade 3 hematological toxicities occurred in 4.1% and 27.5% of the patients in the single- and the double-agent group, respectively.

CONCLUSION

Single-agent chemotherapy in concurrent chemoradiotherapy for inoperable esophageal squamous cell carcinoma has good efficacy and safety, thus warranting a phase III trial.

Salvage camrelizumab plus apatinib for relapsed esophageal neuroendocrine carcinoma after esophagectomy: a case report and review of the literature

The current evidence regarding immunotherapy plus targeted therapy in esophageal neuroendocrine carcinoma (NEC) is lacking. Camrelizumab is a programmed cell death protein 1 inhibitor. Apatinib is a selective tyrosine kinase inhibitor of vascular endothelial growth factor receptor-2. A 50-year-old female was initially diagnosed as primary esophageal NEC. Neoadjuvant chemotherapy and Ivor Lewis esophagectomy were performed (ypT3N0M0, stage Ⅱ). Twenty months after the surgery, an isolated mediastinal lymph node recurrence of NEC was recorded. The specimen revealed a positive expression of vascular endothelial growth factor and programmed cell death ligand 1. The diseased lymph node was slightly enlarged after two cycles of first-line paclitaxel liposome and S-1. Second-line apatinib and S-1 for 2 months also resulted in progressive disease. Subsequently, third-line camrelizumab plus apatinib was continued for 5 months. The patient demonstrated a progression-free status for more than 10 months following the combination therapy. Meanwhile, relevant studies of camrelizumab in gastric or esophageal cancer were briefly reviewed. Based on the current evidence, camrelizumab is a promising agent for esophageal cancer. More prospective trials are warranted before a definite recommendation could be drawn.

Elective nodal irradiation or involved-field irradiation in definitive chemoradiotherapy for esophageal squamous cell cancer: a retrospective analysis in clinical N0 patients

Objective

We compared failure patterns and survival after elective nodal irradiation (eni) or involved-field irradiation (ifi) in patients with thoracic esophageal squamous cell carcinoma (escc), clinical stage T2-4N0M0, to determine whether ifi is feasible for such patients.

Methods

Between 2005 and 2015, 126 patients with clinical stage T2-4N0M0 thoracic escc who received definitive concurrent chemoradiotherapy in Shandong Cancer Hospital and Institute and who had complete data, were analyzed retrospectively. Of those patients, 49 received ifi, and 77 received eni. In the ifi group, the radiation field included the primary tumour, with a 3-cm to 4-cm margin in the craniocaudal direction, and the elective irradiation was delivered to the adjacent regional lymphatics according to the location of the primary tumour. Patterns of failure were classified using the first site of failure, which included primary tumour failure, regional lymph node failure, and distant metastasis.

Results

Median progression-free survival was 20 months [95% confidence interval (ci): 7.87 months to 39.2 months] in the ifi group and 30 months (95% ci: 17.4 months to 44.6 months) in the eni group (p = 0.580). Median overall survival (os) was 36 months (95% ci: 21.9 months to 50.1 months) in the ifi group and 38 months (95% ci: 26.1 months to 49.9 months) in the eni group (p = 0.761). The estimated 1-year, 3-year, and 5-year os rates were, respectively, 87.8%, 49.4%, and 32.3% for the ifi patients and 92.2%, 52.0%, and 28.9% for the eni patients. Disease persistence and primary lesion recurrence after complete remission (cr) were the most frequent causes of treatment failure in the patients overall (83 of 124, 66.9%). Of the 66 patients achieving a clinical cr, 25 experienced recurrence of the primary lesion, 12 experienced distant relapse, 10 experienced regional nodal failure, and 2 experienced an isolated recurrence. No significant differences in the pattern of failure or in the incidences of grade 3 or greater treatment-related myelosuppression or esophagitis were found between the ifi and eni groups.

Conclusions

In patients with thoracic escc clinical stage T2-4N0M0 receiving definitive chemoradiotherapy, failure patterns and os were similar with either eni or ifi. Large prospective randomized studies are needed to further investigate and verify those results in this subgroup of patients.

Negative lymph node at station 108 is a strong predictor of overall survival in esophageal cancer

A negative lymph node (NLN) may represent a stronger predictor for the overall survival (OS) rate of patients with esophageal squamous cell carcinoma (ESCC), when compared with a positive LN (PLN). The present study aimed to investigate which LN station, containing the NLN, was associated with OS rate. A retrospective review was conducted in 216 patients with ESCC and a forward stepwise Cox regression model analysis was used to assess the relationship between clinical parameters and OS rate. Patients were divided into subgroups according to the status of the LN at station 108. Survival analysis was performed using the Kaplan-Meier method. The ratio of albumin-to-globulin (AGR), and of lymphocytes to neutrophil granulocytes (LNR) in the subgroups were also investigated. Overall, 105p (the PLN number at station 105), 108p, 109p and 7p were confirmed to be risk factors for OS rate (all P<0.05). Conversely, 108n (the NLN number at station 108) was identified as a protective factor for OS rate [hazard ratio (HR) 0.457, P=0.001]. Survival analysis demonstrated that patients with an NLN identified at the station 108 had an improved OS rate compared with those with a PLN identified at station 108 (P=0.006). Patients with only an NLN identified at station 108 had the best OS rate among all the sub-groups examined, and the AGR of this group of patients was higher than those of the other groups. The LN status at station 108 may indicate the prognosis of patients with ESCC, and an NLN may reflect the reaction of the immune system to tumor metastasis in these patients.

Pattern of lymph node metastasis in thoracic esophageal squamous cell carcinoma with poor differentiation

The aim of the present study was to explore the pattern of lymph node metastasis (LNM) in poorly-differentiated esophageal squamous cell carcinoma (pdESCC) and the implication of postoperative irradiation. A total of 690 patients with pdESCC were retrospectively investigated. The rates of intro-thoracic and extra-thoracic LNM in pdESCC were investigated and compared to previous research on ESCC en bloc. The comparison of the rates between pdESCC and ESCC were performed using the Cochran-Mantel-Haenszel test. The clinicopathological factors associated with LNM in pdESCC were analyzed by Chi-squared tests, and Fisher's exact test was used to assess the rate difference of extra-thoracic LNM. Logistic-regression analysis was used to explore risk factors associated with lymph node (LN) station. Results demonstrated that the distribution pattern of LNM in pdESCC was significantly different compared with that of ESCC (P<0.05). Univariate and multivariate analysis indicated that risk factors associated with LNM were depth and length (P<0.001 and P<0.001) and multivariate analysis also indicated that the location of the tumor (P=0.042) was a risk factor associated with LNM in pdESCC. Metastasis in the abdominal cavity was significantly higher than in the neck in the middle and lower thoracic pdESCC (both P<0.01). LN station 102 and 7 for upper thoracic ESCC, 101 and 105 for middle thoracic ESCC, and 100 for lower thoracic ESCC were identified as high-risk stations for metastases in pdESCC compared to ESCC. Several parameters, including location and neck metastasis, were identified as risk factors of metastasis for the above sites, respectively. In conclusion, postoperative therapy should include more LN stations in pdESCC depending on risk factors of tumor metastasis individually.

Long-term outcome of concurrent chemoradiotherapy with elective nodal irradiation for inoperable esophageal cancer

Elective nodal irradiation (ENI) might improve overall survival in patients with inoperable esophageal cancer. We conducted a retrospective analysis to assess the long‐term survival and toxicity of esophageal cancer patients treated with ENI versus conventional‐field irradiation (CFI). All data in the present study were based on our institutional experience from 2000 to 2005 of patients with inoperable esophageal cancer treated with ENI or CFI plus two concurrent cycles of paclitaxel/cisplatin. Based on the inclusion and exclusion criteria, 89 patients were included in the analysis. Of these patients, 51 were treated with ENI, whereas 38 were treated with CFI. For the per‐protocol population, the patients in the ENI group significantly improved in terms of their 10‐year disease‐specific overall survival (43.1% vs 10.5%, P = 0.019), 10‐year disease‐free survival (36.7% vs 10.2%, P = 0.040) and 10‐year local recurrence‐free survival (47.2% vs 17.2%, P = 0.018) compared with the CFI group. Aside from radiation esophagitis, the incidence of grade 3 or greater acute toxicities did not differ between the two groups. Multivariate analysis showed that radiation field, tumor length and clinical stage were independent prognostic factors associated with OS. Concurrent chemoradiotherapy with ENI improves both disease‐specific overall survival and loco‐regional control in patients with inoperable esophageal cancer receiving per‐protocol treatment. The regimen has a manageable tolerability profile.

Can involved-field irradiation replace elective nodal irradiation in chemoradiotherapy for esophageal cancer? A systematic review and meta-analysis

Chemoradiotherapy is the most common treatment for inoperable esophageal cancer. However, there is no consensus on the delineation of the clinical target volume. Elective nodal irradiation (ENI) is recommended for inoperable esophageal cancer. A few studies have reported a decrease in the incidence of radiation-related toxicity of involved-field irradiation (IFI) for esophageal cancer. A systematic review and pooled analysis were performed to determine whether IFI in definitive chemoradiotherapy was more beneficial than ENI for esophageal cancer. The results showed no significant differences in the overall survival and local control rates between the IFI and ENI arms. Meanwhile, the incidences of esophageal and lung toxicities were significantly decreased in the IFI arm. These results suggest that IFI is a feasible treatment option for locally advanced esophageal cancer, especially to minimize irradiation-related toxicity.