Concurrent chemoradiotherapy with S-1 and cisplatin in advanced esophageal cancer

Intensity modulated radiotherapy might be effective for locally advanced esophageal carcinosarcoma: A single center's experience and review of literature

Esophageal carcinosarcoma is a rare type of esophageal cancer; however, few studies have investigated the effects of radiotherapy in locally advanced patients. This study aimed to report experience of the safety and efficacy of intensity-modulated radiotherapy for locally advanced esophageal carcinosarcoma and review the literature. By searching the institutional database between January 2010 and December 2020, along with the literature review, 25 patients were eligible for the study. The clinical and radiologic information of all patients with esophageal carcinosarcoma who underwent radiotherapy were collected. Survival outcomes were calculated using Kaplan-Meier plots. In our series, 5 patients were in the curative/neoadjuvant radiotherapy group and 10 patients were in the adjuvant group. Most tumors were protruding (n = 10, 66.7%). All patients underwent intensity-modulated radiotherapy. In the curative/neoadjuvant radiotherapy group, 2 patients underwent concurrent chemoradiotherapy before surgery, and the other three received radiotherapy alone as the initial treatment. The median follow-up time was 43.1 months. All patients showed a partial response at the efficacy evaluation. The median time of overall survival and progression-free survival were 40.2 months (95% confidence interval [CI], 13.1-67.3 months) and 19.0 months (95% CI, 13.9 months-24.1 months) for the entire cohort, but were not reached for curative/neoadjuvant radiotherapy group. Overall survival (hazard ratio [HR] 0.81, 95% CI, 0.15-4.43; P = .805) and progression-free survival (HR 1.68, 95% CI, 0.35-8.19; P = .514) did not differ significantly between the 2 groups. When considering the literature review data in the final analysis, overall survival (HR 0.84, 95% CI, 0.25-2.81; P = .779) and progression-free survival (HR, 0.68; 95% CI, 0.26-1.76; P = .425) were also not different between the 2 groups. Treatment based on intensity-modulated radiotherapy with neoadjuvant or curative intent may be an option for patients with unresectable esophageal carcinosarcoma. Further research with a larger sample size is needed to validate the reliability.

Long-Term Results of a Phase 2 Study of Definitive Chemoradiation Therapy Using S-1 for Esophageal Squamous Cell Carcinoma Patients Who Were Elderly or With Serious Comorbidities

Background

The optimal evidence-based management for the subsets of locally advanced esophageal squamous cell carcinoma (ESCC) patients who rejected or were intolerant to intravenous chemotherapy due to old age or serious comorbidities is currently lacking. This study aimed to assess the safety and local control rate (LCR) of S-1 (tegafur–gimeracil–oteracil potassium) combined with radiotherapy in these subsets of ESCC patients.

Methods

Locally advanced ESCC patients who rejected or were intolerant to intravenous chemotherapy due to age >75 years or serious comorbidities were enrolled in a prospective, single-arm, phase 2 trial. The patients were treated with definitive concurrent chemoradiotherapy with S-1, which was administered orally twice daily for 28 days. The radiotherapy dose was 61.2 Gy delivered in 34 fractions. The primary end-point was the 3-year LCR.

Results

One hundred five ESCC patients were recruited between March 2013 and October 2015. At the median follow-up of 73.1 months (IQR 65.5–81.4 months), 3-year LCR was 61.1%, and 1, 3, and 5-year overall survival was 77.9, 42.3, and 24.8% respectively. For safety analysis, ≥grade 3 acute adverse events included thrombocytopenia (6.7%), leukopenia (2.9%), anemia (1.0%), anorexia (1.0%), fatigue (10.5%), hiccup (1.0%), pneumonitis (4.8%), and esophagitis (3.8%). Two patients (1.9%) died of late esophageal hemorrhage, and one patient (1.0%) died of late radiation-induced pneumonitis.

Conclusion

S-1 is a promising regimen in concurrent chemoradiotherapy with low toxicity and a favorable LCR in ESCC patients who rejected or were intolerant to intravenous chemotherapy due to old age or serious comorbidities.

Clinical Trial Registration

ClinicalTrials.gov, NCT01831531.

Concurrent Selective Lymph Node Radiotherapy and S-1 Plus Cisplatin for Esophageal Squamous Cell Carcinoma: A Phase II Study

BACKGROUND

The efficacy, toxicity, and patterns of failure of esophageal squamous cell carcinoma (ESCC) treated with selective lymph node (SLN) conventional fraction radiotherapy (CFRT) and S-1 plus cisplatin (CDDP) were evaluated.

PATIENTS AND METHODS

67 Patients with clinical stage II-IVa ESCC were enrolled. The total dose of SLN CFRT was 60 Gy in 30 fractions over 6 weeks. The first course of radiation covered the primary and metastatic regional tumors and high-risk lymph nodal regions, given at 2 Gy/fraction for a dose of 40 Gy. In the second course, CFRT was delivered to the boost volume for an additional 20 Gy in 10 days, using 2 Gy/fraction. Two cycles of chemotherapy were given at the beginning of radiotherapy. CDDP at 25 mg/m²/day was given on days 1-3 and days 22-24, and S-1 at 80 mg/m²/day on days 1-14 and days 22-35. Patients achieving objective response after concurrent chemoradiotherapy underwent two additional cycles of chemotherapy.

RESULTS

The objective response rate (ORR) was 82.5%. Grade 3 or 4 toxicities included leukopenia (23.8%), neutropenia (14.3%), thrombocytopenia (14.3%), hemoglobin (4.8%), gastrointestinal (12.7%), skin (1.6%), and esophagus fistula (1.6%). One patient died of severe pneumonia, and two died of late toxicity because of esophagus fistula. With median follow-up of 32 months, the overall survival (OS) and progression-free survival (PFS) at 1 year and 2 years were 81.0% and 73.0%, and 63.5% and 49.2%, respectively.

CONCLUSIONS

SLN RT concurrent with S-1 plus CDDP may represent a better strategy for treatment of ESCC patients.

Palliative radiotherapy and chemoradiotherapy in stage IVA/B esophageal cancer patients with dysphagia

BACKGROUND

Palliative therapeutic strategies in esophageal squamous cell carcinoma (ESCC) patients with dysphagia remain controversial. Only few studies have assessed therapeutic effect factors related to improvement in dysphagia score and nutrition-support-free survival (NSFS).

OBJECTIVE

The present study assessed the efficacy and therapeutic effect factors related to the use of palliative radiotherapy (RT) and chemoradiotherapy (CRT) in ESCC patients with dysphagia.

METHODS

We retrospectively evaluated 70 patients with stage IVA/B ESCC. Patients received RT of 30 Gy in 10 fractions or concurrent CRT using 5-fluorouracil plus cisplatin of 40 Gy in 20 fractions. The change in the dysphagia score from before to after treatment was assessed, and NSFS was evaluated.

RESULTS

The median follow-up duration was 6 months (range 1-41 months). The overall rate of improvement in the dysphagia score was 60%. The median NSFS was 7.5 months. Craniocaudal tumor length < 6 cm, tumor circumference < 3/4, and CRT of 40 Gy in 20 fractions were associated with a significant improvement in the dysphagia score (p = 0.0036, p = 0.0069, and p = 0.03, respectively). NSFS was significantly longer with CRT than with RT (p = 0.048).

CONCLUSION

Palliative RT and CRT are effective treatment options for ESCC patients with dysphagia. Craniocaudal tumor length < 6 cm, tumor circumference < 3/4, and CRT of 40 Gy in 20 fractions may improve dysphagia. CRT of 40 Gy in 20 fractions may improve NSFS.

The potential of herb medicines in the treatment of esophageal cancer

Esophageal cancer (EC) is one of common malignant neoplasms in the world. Due to dietary habits, environmental factors, stress and so on, larger numbers of person are diagnose with EC every year. Currently, the clinical treatment of EC mainly includes radiotherapy, chemotherapy, surgical resection alone or combined strategy. These treatment options are insufficient and often associated with a number of side effects. Medicinal herbs containing Traditional Chinese Medicine (TCM) have been used as an adjunct treatment for alleviating the side effects of chemotherapy or radiotherapy and for improving the quality of life of cancer patients. The monomer compounds obtained from medicinal herbs also exhibit potential anti-cancer activity against various type cancer cell lines including esophageal cancer, and have the ability to enhance cancer cells sensitizing to chemotherapy or radiotherapy. In this review, we summarize some monomers and composite of medicinal herbs with anti-cancer activity for EC, and elaborate their mechanism of action. Understanding the exact mechanism of their actions may provide valuable information for their possible application in cancer therapy and prevention. This is beneficial for the use and development of medicinal herbs for diseases therapy in the future.

Luteolin inhibits cell proliferation and induces cell apoptosis via down-regulation of mitochondrial membrane potential in esophageal carcinoma cells EC1 and KYSE450

In current study, we investigated the anti-tumor effect of luteolin in human ESCC cell lines in vitro and in vivo and tried to explore the potential mechanisms. Results from flow cytometry showed that luteolin could induce apoptosis and caspase-3 activation and induce cell cycle arrest at G2/M phase in a dose- and time-dependent manner in EC1 and KYSE450 cells. JC-1 test results showed that membrane potential of mitochondria after luteolin treatment was down-regulated and this was an indicator for intrinsic apoptosis. Western Blot results showed the expression of cell cycle regulatory protein p21 and p53 increased and three apoptosis related proteins that participate in mitochondrial apoptotic pathway, namely, Bim, CYT-c and cPARP, also increased in luteolin treated cells compared with control groups. We further confirmed that luteolin could significantly inhibit the growth of ESCC tumors in xenograft mouse models and no evidence of systemic toxicity was observed. Our results suggest that luteolin can induce cell apoptosis and cell cycle arrest in G2/M phase through mitochondrial pathway in EC1 and KYSE450 cell lines and proper utilization of luteolin might be a practical approach in ESCC chemotherapy.

A retrospective clinical study of comparing paclitaxel plus S-1 versus paclitaxel plus cisplatin as the first-line treatment for patients with advanced esophageal squamous cell carcinoma

BACKGROUND

In advanced esophageal squamous cell carcinoma (ESCC), paclitaxel plus cisplatin are considered as active and tolerable. The current clinical study was conducted to retrospectively compare the efficacy and safety of first-line paclitaxel/S-1(PS) and paclitaxel/cisplatin(TP) regimens in advanced ESCC.

RESULTS

The overall response rate of PS was slightly, but not significantly, higher (25 patients, 46%) than that of TP (23 patients, 39%, P = 0.432). Median overall survival (OS) was similar for PS and TP (11.5 months vs. 10.4 months, p = 0.37). However PS had longer median progression-free survival than TP (PFS: 5.5 months vs5.0months, p = 0.04). When compared with PS, more grade 3 or 4 adverse events were recorded for TP, including leukopenia, neutropenia, anemia, anorexia and vomiting (P < 0.05). No treatment-related deaths were recorded in either group.

PATIENTS AND METHODS

Between 2008 and 2014, all patients diagnosed with advanced ESCC and treated with paclitaxel/S-1 or paclitaxel/cisplatin at Cancer Hospital Affiliated to Zhengzhou University were analyzed retrospectively. One hundred and thirteen patients were included in this study. Disease control rates and progression-free survival (PFS) and overall survival (OS) were recorded. Survival analysis was calculated by using Kaplan-Meier method.

CONCLUSIONS

The PS option improves PFS and its OS is similar to TP. Moreover, the PS regimen is an effective and safe first-line treatment for ESCC with less hematological and non-hematological toxicity.

Association Between Polymorphisms in the Promoter Region of microRNA-34b/c and the Chemoradiotherapy Efficacy for Locally Advanced Esophageal Squamous Cell Carcinoma in Chinese Han Population

The study aims to explore the association between polymorphisms in the promoter region of microRNA-34b/c (miR-34b/c) and the chemoradiotherapy efficacy for locally advanced esophageal squamous cell carcinoma (ESCC) in Chinese Han population. A total of 175 locally advanced ESCC cases and 186 healthy individuals were enrolled as the case and control groups. Denaturing high performance liquid chromatography (DHPLC) was applied to determine the genotypes of subjects. Subjects in the case group were classified into complete response (CR), partial response (PR), stable disease (SD) and progressive disease (PD). CR + PR were defined as the sensitive group, and SD + PD were defined as the resistance group. All patients were followed up for 3 ~ 36 months. Receiver operating characteristic (ROC) curve was used to evaluate the predictive value of rs4938723 in the promoter region of miR-34b/c in the chemoradiotherapy efficacy for patients with locally advanced ESCC. The distribution of genotype and allele of rs4938723 in the promoter region of miR-34b/c was significantly different between the case and control group (both P < 0.05), and CC genotype and C allele could decrease the risk of ESCC (CC genotype: OR = 0.57, 95%CI = 0.32 ~ 0.99, P = 0.045; C allele: OR = 0.72, 95%CI = 0.54 ~ 0.97, P = 0.032). MiR-34b/c rs4938723 was associated with ESCC TNM staging, differentiation degree, and lymph node metastasis (LNM) for ES CC patients (all P < 0.05). The chemoradiotherapy efficacy of patients with CC genotype was better than that of patients with (TT + TC) genotypes (P < 0.05). ROC curve results showed that the area under curve (AUC), sensitivity and specificity were 0.777, 85.1% and 71.3%, respectively. The average median progression free survival (PFS) of patients with (TT + TC) genotypes was significantly shorter than those patients with CC genotype (P < 0.05). Our study provides evidence that miR-34b/c rs4938723 is closely related with the chemoradiotherapy efficacy for locally advanced ESCC.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparative study of cisplatin-based definitive concurrent chemoradiotherapy with S-1 versus paclitaxel for unresectable locally advanced esophageal squamous cell carcinoma

This study compared the efficiency and safety of definitive concurrent chemoradiotherapy (CCRT) using Paclitaxel plus Cisplatin (TP) versus S-1 plus Cisplatin (CS) in unresectable locally advanced esophageal squamous cell carcinoma (LAESCC). Between January 2009 and December 2013, 203 LAESCC patients were retrospectively reviewed. We performed a propensity score matching analysis; 41 patients treated with the CS regimen were matched 1:1 to patients who received the TP regimen. Patient- and disease-related characteristics were well-balanced between the two groups. The CS group showed significantly better treatment compliance (90.2% vs. 70.7%, P = 0.026) and less hospital stay (48 days vs 49 days, P = 0.025) over the TP group during the CCRT course. The complete response rate was comparable between the two groups (51.2% vs. 48.8%, P = 0.825). The 1- and 3-year overall survival (OS) rates in the TP group were 63.4% and 32.4% compared to 62.8% and 32.1% in the CS group, respectively (P = 0.796). The 1- and 3-year progression-free survival (PFS) rates in the TP group were 51.2% and 24.9%, compared to 53.6% and 18.9% in the CS group, respectively (P = 0.630). The incidence of severe and total neutropenia in the TP group was significantly higher compared to the CS group (P = 0.011 and 0.046, respectively). Multivariate analysis revealed that T stage and the complete response rate were strong prognostic factors associated with OS and PFS. In conclusion, both treatment regimens yielded satisfactory survival outcomes, but the CS regimen could significantly improve treatment compliance, reduce hematological toxicities and lengths of hospital stay. Future prospective studies in large cohorts are highly warranted to confirm the findings in our report.

Definitive concurrent chemoradiotherapy with S-1 and cisplatin in elderly esophageal squamous cell carcinoma patients

BACKGROUND

To evaluate the feasibility and efficiency of definitive concurrent chemoradiotherapy (dCRT) with S-1 and cisplatin for elderly esophageal squamous cell carcinoma (ESCC) patients.

METHODS

Fifty-six elderly patients were included from January 2012 to December 2014. Patients received S-1 (tegafur/gimeracil/oteracil) and cisplatin at doses of 70 mg/m²/day for two weeks and 75 mg/m² on day 1, respectively, every 3 weeks. Radiotherapy was delivered at a dose of 180-200 cGy per day to a total dose of 54 Gy. After dCRT, additional chemotherapy was administered for two cycles.

RESULTS

The median age was 74 years (range: 70-87 years) and 38 (67.9%) patients were staged with III-IVa. Totally, 38 patients completed dCRT as planned. An objective response rate (ORR) was seen in 47 (84.0%) patients. The median OS and PFS time were 18.2 and 13.9 months and the 3-year OS and PFS rates were 30.1% and 14.2%, respectively. The most frequent hematological toxicities were leucocytopenia and neutropenia with the incidence of 55.4% and 53.6%, respectively. A significantly higher incidence of severe leucocytopenia was observed between patients aged ≥75 and 70≤ age <75 years. The most common non-hematologic toxicity was esophagitis.

CONCLUSIONS

dCRT with S-1 and cisplatin yielded satisfactory survival outcomes but treatment-related toxicities were relatively high, especially for patients aged over 75 years.

Short-term clinical effect of conformal radiotherapy combined with tegafur gimeracil oteracil potassium in treating recurrent esophagus cancer

OBJECTIVE

To observe clinical effects of three-dimensional conformal radiotherapy combined with Tegafur Gimeracil Oteracil Potassium chemotherapy in the treatment of patients with recurrent esophagus cancer.

METHODS

One hundred and twelve senile patients who suffered from esophagus cancer were selected and randomly divided into two groups, namely, observation group (56 cases) and control group (56 cases). The observation group adopted three-dimensional conformal radiotherapy combined with Tegafur Gimeracil Oteracil Potassium chemotherapy and the control group adopted three-dimensional conformal radiotherapy only.

RESULTS

All patients completed the treatment, with good compliance. Effective rate of the observation group was 82.1%, which was significantly higher than the control group (67.9%), and the difference was statistically significant (P<0.05). Main toxic and side effects of patients of two groups were radiation esophagitis, gastrointestinal reaction, hematologic toxicities and radiative skin reaction. Differences of incidence rates of all types of toxic and side effects were not statistically significant (P>0.05). The one-year and two-year survival rates of patients of the observation group were 80.4% and 53.6%, respectively, while the control group was 55.4% and 30.4%; differences between two groups were statistically significant (P<0.05).

CONCLUSION

Three-dimensional conformal radiotherapy combined with Tegafur Gimeracil Oteracil Potassium chemotherapy has definite curative effect in treating patients with recurrent esophagus cancer and can improve survival rate of patients, without increasing adverse reaction.

Long-term results of definitive concurrent chemoradiotherapy using S-1 in the treatment of geriatric patients with esophageal cancer

Objective

The aim of this study was to investigate the efficiency and safety of using S-1 as monotherapy and maintenance therapy combined with definitive concurrent radiotherapy for elderly patients with esophageal cancer.

Patients and methods

From January 2009 to December 2010, 68 elderly patients were included. Radiotherapy was delivered with a daily fraction of 1.8–2.0 Gy to a total radiation dose of 54.0–60.0 Gy. Preplanned concurrent S-1 (80 mg/m²/d) was given on days 1–14, every 3 weeks. After concurrent chemoradiotherapy, maintenance S-1 was repeated up to four cycles.

Results

The median age of the enrolled patients was 76 years (range: 70–88 years), and the clinical stages were stage I (two patients), stage II (24 patients), stage III (28 patients), and stage IV (14 patients). A total of 51 (75.0%) patients finished treatment on schedule, with a median of five cycles of S-1, in which 35 (51.5%) patients achieved complete response. The median follow-up time was 42.7 months, and the median overall survival (OS) and progression-free survival (PFS) times were 25.7 months and 21.5 months, respectively. The 1-year, 3-year, and 5-year OS and PFS rates were 70.6%, 41.8%, and 25.9% and 68.1%, 32.9%, and 15.9%, respectively. Grade ≥3 neutropenia and leukopenia were found in 14 patients and 13 patients, respectively. The most common nonhematologic toxicity was esophagitis including six patients and one patient with grades 3 and 4, respectively. Multivariate analysis revealed that cycles of S-1 and complete response were strong factors for OS and PFS.

Conclusion

For geriatric patients with esophageal cancer, S-1 as monotherapy and maintenance chemotherapy in combination with definitive concurrent radiation therapy yielded satisfactory survival outcomes with tolerable toxicities. More studies are highly warranted to further clarify this issue.

Palliation of Dysphagia in Carcinoma Esophagus

Esophageal carcinoma has a special place in gastrointestinal carcinomas because it contains two main types, namely, squamous cell carcinoma and adenocarcinoma. Carcinoma esophagus patients require some form of palliation because of locally advanced stage or distant metastasis, where it cannot be subjected to curable treatment with surgery and chemoradiation. Many modalities of palliation of dysphagia are available, but the procedure with least morbidity, mortality, and long-term palliation of dysphagia needs to be chosen for the patient. This study aims to discuss the recent trends in palliation of dysphagia with promising results and the most suitable therapy for palliation of dysphagia in a given patient. A total of 64 articles that were published between years 2005 and 2015 on various modes of palliation of dysphagia in carcinoma esophagus were studied, which were mainly randomized and prospective studies. Through this study, we conclude that stents are the first choice of therapy for palliation, which is safe and cost-effective, and they can be combined with either radiotherapy or chemotherapy for long-term palliation of dysphagia with good quality of life. Radiotherapy can be used as a second-line treatment modality.

Phase I study of concurrent selective lymph node late-course accelerated hyperfractionated radiotherapy and S-1 plus cisplatin for locally advanced oesophageal squamous cell carcinoma

OBJECTIVE

This Phase I study aimed to assess the safety and efficacy of concurrent selective lymph node (SLN) late-course accelerated hyperfractionated (LCAF) intensity-modulated radiotherapy (IMRT) and S-1 plus cisplatin (CDDP) for the locally advanced oesophageal squamous-cell carcinoma (ESCC).

METHODS

The total dose of SLN LCAF IMRT was 59.6 Gy/34 fractions in 5.4 weeks. The concurrent chemotherapy (CCRT) was administered as follows: CDDP 25 mg m(-2) on Days 1-3 and Days 22-24; S-1 was applied in a de-escalating dosage with a decrement of 10 mg m(-2) per day, from its full dose level of 80 mg m(-2), orally twice daily on Days 1-14 and Days 22-35. We inferred the maximum-tolerated dose (MTD), dose-limiting toxicities (DLTs) and recommended dose, according to adverse reaction during CCRT.

RESULTS

Totally, 15 patients with ESCC with T2-4N0-1M0-1a were enrolled in Dose Level 1 (80 mg m(-2)). In the initial five patients, two patients developed DLTs. As MTD was not reached, five additional patients were treated with the same dose level, and DLTs occurred in only one patient. Similar results were found in the last five patients. After CCRT, the objective response rates were 100% for primary tumours and 86.2% for metastatic lymph nodes, respectively. Totally, the observed Grade 3 toxicities during CCRT were leukopenia (20%), neutropenia (20%) and dermatitis (13.3%), and no Grade 4 toxicity occurred. The Kaplan-Meier-estimated overall and progression survival rates were 86.7% and 66.7% (1 year), 73.3% and 60% (2 years) and 73.3% and 60% (3 years).

CONCLUSION

The concurrent SLN LCAF IMRT and chemotherapy with S-1 and CDDP was well tolerated and showed promising efficacy. The dose of S-1 in this regimen was recommended with 80 mg m(-2) orally twice daily on Days 1-14 and Days 22-35.

ADVANCES IN KNOWLEDGE

CCRT with S-1 plus CDDP exhibited encouraging results with milder toxicities, high objective response rates and ideal overall survival time.

High-dose versus conventional-dose irradiation in cisplatin-based definitive concurrent chemoradiotherapy for esophageal cancer: a systematic review and pooled analysis

We investigate whether high-dose (HD, ≥60 Gy) radiotherapy in definitive concurrent chemoradiotherapy (CCRT) based on cisplatin could yield benefits compared to conventional-dose (CD) CCRT. PubMed, Embase and Google Scholar were searched and data were pooled and analyzed for response rate, survival, failure patterns and toxicity. Results showed advantages in response rate, 5-year overall survival rate, local regional recurrence and distant failure rate compared to the CD arm with no difference in Grade ≥3 acute and late esophagitis, other toxicities were rare with moderate tolerance, subgroup analysis of squamous cell carcinoma also showed advantages for HD arm. We concluded that ≥60 Gy CCRT improved clinical outcomes compared to the CD arm, especially for esophageal squamous cell carcinoma. Our findings may provide a basis for future trials.

A Meta-Analysis of Concurrent Chemoradiotherapy for Advanced Esophageal Cancer

Background

Concurrent chemoradiotherapy is a standard treatment for local advanced esophageal cancer, but the outcomes are controversial. Our goals were to compare the therapeutic effects of concurrent chemoradiotherapy and radiotherapy alone in local advanced esophageal cancer using meta-analysis.

Methods

MEDLINE, EMBASE and the Cochrane library were searched for studies comparing chemoradiotherapy with radiotherapy alone for advanced esophageal cancer. Only randomized controlled trials were included, and extracted data were analyzed with Review Manager Version 5.2. The pooled relative risks (RR) and their 95% confidence intervals (CI) were calculated for statistical analysis.

Results

Nine studies were included. Of 1,135 cases, 612 received concurrent chemoradiotherapy and 523 were treated with radiotherapy alone. The overall response rate (complete remission and partial remission) was 93.4% for concurrent chemoradiotherapy and 83.7% for radiotherapy alone (P = 0.05). The RR values of 1-year, 3-year, and 5-year survival rates were 1.14 (95% CI: 1.04 - 1.24, P = 0.006), 1.66 (95% CI: 1.34 - 2.06, P < 0.001), and 2.43 (95% CI: 1.63 - 3.63, P < 0.001), respectively. The RR value of the merged occurrence rate of acute toxic effects was 2.34 (95% CI: 1.90 - 2.90, P <0.001). There was no difference in the incidence of late toxic effects, which had an RR value of 1.21 (95% CI: 0.96 - 1.54, P = 0.11). The RR level of persistence and recurrence was 0.71 (95% CI: 0.62 - 0.81, P <0.001), and for the distant metastasis rate, the RR value was 0.79 (95% CI: 0.61 - 1.02, P = 0.07).

Conclusions

Concurrent chemoradiotherapy significantly improved overall survival rate, reduced the risk of persistence and recurrence, but had little effect on the primary tumor response, and increased the occurrence of acute toxic effects.

Palliative radiotherapy in esophageal cancer

The present study was undertaken to evaluate the efficacy of radiotherapy in palliation of dysphagia in patients with squamous cell carcinoma (SCC) of esophagus and to see the quality of life (QoL) following radiotherapy. This was a prospective clinical study done between September 2006 and May 2008. All consecutive patients with SCC of the esophagus, who are not candidates for definitive treatment, were included in the study. Dysphagia and QoL were assessed using modified Takita's grading and modified questionnaire based on EORTC QLQ 30 respectively. External beam radiotherapy (EBRT) was delivered to all patients using linear accelerator 6 Mv photons. Patients who had good response with EBRT were further subjected to intraluminal brachytherapy (ILBT) at 700 cGy using Iridium-192. The cumulative dose each patient received was 65 Gy. Patients were followed up at 6 weeks from completion of treatment to look for any difference in dysphagia grade and QoL following therapy. Thirty-three patients were included in the study. The mean age among males and females was 60.9 and 49.8 years, respectively. Nineteen patients (57.6 %) received EBRT followed by ILBT; the remaining patients received only EBRT. Seven were lost during follow-up, and seven (21.2 %) died during the study period of 6 weeks. Nineteen (57.6 %) were followed up. On follow-up endoscopy, evidence of residual stricture was observed in 57.9 %, and growth in 36.8 %. Of the patients, 27.8 % had biopsy-confirmed residual disease. The median dysphagia score decreased from 4 to 3 after treatment (p = 0.002) in 17 (89.5 %) patients. The mean QoL score improved from 107.5 to 114.1 at 6-week follow-up. Following radiotherapy, 26.3 % had persistent chest pain, increased cough with expectoration in 15.8 %, and hyperpigmentation of skin in 10.5 %. Radiotherapy gives significant relief of dysphagia and improves QoL in 90 % of patients with SCC of esophagus. However, following radiotherapy, a number of patients will have persistent stricture, ulceration, and residual disease.

Palliative Radiotherapy in the Presence of Well-Controlled Metastatic Disease after Initial Chemotherapy May Prolong Survival in Patients with Metastatic Esophageal and Gastric Cancer

Purpose

We report the outcomes of patients treated with palliative radiotherapy (pRT) to the primary tumour in the context of well-controlled metastatic disease after initial chemotherapy.

Materials and Methods

Clinical records of 132 patients with metastatic esophago-gastric (OG) cancer treated with palliative chemotherapy (pCT) between January 2009 and June 2013 were reviewed. Ninetyseven patients had responding or stable disease after 3 months of chemotherapy, of whom 53 patients received pRT to the primary tumour after initial chemotherapy in the presence of well-controlled metastatic disease (group A, pCT-RT). The remaining 44 patients were treated with pCT alone (group B, pCT). Treatment-related outcomes were assessed in above groups including time to local progression (TTLP), progression-free and overall survival.

Results

The median overall survival for patients treated with pRT after initial chemotherapy (group A) was 23.3 months (95% confidence interval [CI], 17.70 to 28.89 months) and significantly higher than the 14 months (95% CI, 10.91 to 17.08 months) in patients treated with pCT alone (group B) (p < 0.001). The use of pCT-RT was an independent predictor of OS in multivariate analysis. Local recurrence was observed in 12/53 of patients (23%) in group A compared to 16/44 (36%) in group B. The median TTLP was significantly higher in patients after pCT-RT at 17.3 months (5.23 months to 44.50 months) compared to 8.3 months (range, 4.10 to 25.23 months) in patients treated with pCT alone (p=0.006).

Conclusion

The possibility of pRT influencing systemic disease in advanced OG cancer has not been reported, and results from the present study present strong arguments for investigation of this therapeutic strategy in a randomized trial.

Randomized phase 2 trial of S1 and oxaliplatin-based chemoradiotherapy with or without induction chemotherapy for esophageal cancer

PURPOSE

To assess, in a randomized, phase 2 trial, the efficacy and safety of chemoradiotherapy with or without induction chemotherapy (ICT) of S1 and oxaliplatin for esophageal cancer.

PATIENTS AND METHODS

Patients with stage II, III, or IVA esophageal cancer were randomly allocated to either 2 cycles of ICT (oxaliplatin 130 mg/m(2) on day 1 and S1 at 40 mg/m(2) twice daily on days 1-14, every 3 weeks) followed by concurrent chemoradiotherapy (CCRT) (46 Gy, 2 Gy/d with oxaliplatin 130 mg/m(2) on days 1 and 21 and S1 30 mg/m(2) twice daily, 5 days per week during radiation therapy) and esophagectomy (arm A), or the same CCRT followed by esophagectomy without ICT (arm B). The primary endpoint was the pathologic complete response (pCR) rate.

RESULTS

A total of 97 patients were randomized (arm A/B, 47/50), 70 of whom underwent esophagectomy (arm A/B, 34/36). The intention-to-treat pCR rate was 23.4% (95% confidence interval [CI] 11.2-35.6%) in arm A and 38% (95% CI 24.5% to 51.5%) in arm B. With a median follow-up duration of 30.3 months, the 2-year progression-free survival rate was 58.4% in arm A and 58.6% in arm B, whereas the 2-year overall survival rate was 60.7% and 63.7%, respectively. Grade 3 or 4 thrombocytopenia during CCRT was more common in arm A than in arm B (35.4% vs 4.1%). The relative dose intensity of S1 (89.5% ± 20.6% vs 98.3% ± 5.2%, P=.005) and oxaliplatin (91.4% ± 16.8% vs 99.0% ± 4.2%, P=.007) during CCRT was lower in arm A compared with arm B. Three patients in arm A, compared with none in arm B, died within 90 days after surgery.

CONCLUSIONS

Combination chemotherapy of S1 and oxaliplatin is an effective chemoradiotherapy regimen to treat esophageal cancer. However, we failed to show that the addition of ICT to the regimen can improve the pCR rate.

A prospective phase II trial of S-1 and cisplatin-based chemoradiotherapy for locoregionally advanced esophageal cancer

PURPOSE

S-1 is a novel oral fluoropyrimidine anticancer agent designed to enhance clinical efficacy, reduce gastrointestinal toxicity, and enhance radiotherapy effectiveness. A phase II trial was conducted to evaluate the efficacy and safety of preoperative chemoradiation with S-1 and cisplatin in locoregionally advanced esophageal cancer.

METHODS

Eligible patients had stage IIA-IVA esophageal cancer. Patients received two cycles of S-1 (days 1-14 and days 22-35) and cisplatin (days 1 and 22) with concurrent radiotherapy (50.4 Gy total; 1.8 Gy/fraction). Esophagectomy was performed between weeks 12 and 18 as determined by the specialist multidisciplinary team.

RESULTS

Sixty patients were enrolled in this study between March 2008 and August 2011, and 59 were eligible. The clinical stage was ≥T3 in 28 patients (47 %) and N1 in 43 patients (72 %), with squamous cell carcinoma histology in 58 patients (97 %). Fifty-four patients (90 %) completed the planned chemoradiation. After chemoradiation, the clinical tumor response rate was 64.4 %. The primary toxicities included neutropenia (24 %) and esophagitis (8.5 %). Three treatment-related deaths were noted. Twenty-five patients (42 %) underwent esophagectomy following chemoradiation, and 15 achieved complete pathologic regression. The estimated overall survival and progression-free survival rates after 2 years were 65 and 48 %, respectively.

CONCLUSIONS

Concurrent chemoradiation with S-1 and cisplatin exhibited encouraging results with complete pathologic regression. The survival data were promising compared with the historical data of 5FU/cisplatin and should be confirmed in a randomized phase III trial. Toxicities were significant but clinically manageable.

S-1 monotherapy as second- or third-line chemotherapy for unresectable and recurrent esophageal squamous cell carcinoma

PURPOSE

S-1 is widely used for various cancers. It may be useful for esophageal squamous cell carcinoma (ESCC); however, there are insufficient data. The purpose is to provide results of an analysis of S-1 monotherapy for unresectable and recurrent ESCC.

PATIENTS AND METHODS

Twenty patients with histologically proven ESCC who were previously treated with other chemo(radio)therapies were treated with S-1 alone as second- or third-line chemotherapy.

RESULTS

A complete response (CR) was observed in 1 case (5%). A partial response (PR), stable disease (SD), and progressive disease (PD) were seen in 4 (20.0%), 7 (35.0%), and 8 (40.0%) cases, respectively. Two cases (10%) of anemia, 1 case (5%) of leukopenia, 3 cases (15%) of fatigue, and 3 cases (15%) of diarrhea were observed as grade 3 toxicity; however, there were no cases of grade 4 toxicity. The 1-year progression-free survival (PFS) rate was 10.0%, and the median PFS was 100 days. The 1-year overall survival (OS) was 30.5%, and the median OS was 330 days. The 1-year PFS rate in CR/PR/SD and PD was 16.7 and 0%, and the median survival time was 120 and 40 days.

CONCLUSION

S-1 is a promising new drug which can be used as a second- or third-line chemotherapy for ESCC.

Endoscopic stenting and concurrent chemoradiotherapy for advanced esophageal cancer: A case-control study

AIM: To evaluate the role of endoscopic stenting with or without concurrent 3-dimensional conformal chemoradiotherapy (3D-CRT) in patients with inoperable esophageal cancer.

METHODS: Advanced esophageal cancer patients indicated for esophagectomy received esophageal stents. A part of patients completed 3D-CRT after stenting. Efficacy was assessed by endoscopy and computed tomographic scan before and 4 wk after completion of the treatment. The median survival, 3D-CRT toxicity and complications were compared between 3D-CRT and control groups.

RESULTS: From 1999 to 2008, 99 consecutive patients with T3/T4 disease and unsuitable for esophagectomy were placed with esophageal stents. Sixty-seven patients received 3D-CRT, while 36 patients treated with endoscopic stents alone were recruited as controls. After 3D-CRT treatment, the median tumor volume of 3D-CRT patients were reduced significantly from 43.7 ± 10.2 cm³ to 28.8 ± 8.5 cm³ (P < 0.05). The complete and partial response rate was 85.1%, and no response was 14.9%. After 3D-CRT, the incidence rate of T2 and T3 disease evident on CT scan increased to 78.4% while T4 decreased from 66.7% to 21.6% (P < 0.05). 3D-CRT Karnofsky Performance Status improved in 3D-CRT patients compared with the control group (P = 0.031). 3D-CRT patients had a longer survival than the control group (251.7 d vs 91.1 d, P < 0.05). And the median half-year survival rate in 3D-CRT group (91%) was higher than in the control group (50%, P < 0.05). The most common toxicity was leukocytopenia in the 3D-CRT group (46.7% vs 18.8%, P = 0.008). The control group had a higher rate of restenosis than the 3D-CRT group (81.3% vs 9.0%, P < 0.05). The rate of nephrotoxicity was increased in 3D-CRT as compared with the control group (31.3% vs 15.6%, P < 0.05).

CONCLUSION: 3D-CRT can improve dysphagia in patients with inoperable esophageal carcinoma. 3D-CRT combined with stenting results in better survival as compared with endoscopic stents used alone.

Efficacy of concurrent chemoradiotherapy as a palliative treatment in stage IVB esophageal cancer patients with dysphagia

OBJECTIVE

To retrospectively assess the efficacy and safety of palliative chemoradiotherapy in Stage IVB esophageal cancer patients with dysphagia due to the primary lesion.

METHODS

Forty patients with dysphagia caused by metastatic esophageal cancer, which had been treated between January 2004 and June 2009, were retrospectively investigated. The treatment consisted of two courses of chemotherapy (5-fluorouracil and cisplatin) and concurrent irradiation of 40 Gy in 20 fractions to the esophageal primary tumor. The grade of dysphagia was evaluated; nutrition-support-free survival was evaluated using the status of nutritional support of patients. Response to treatment, overall survival, progression-free survival and toxicities were also evaluated.

RESULTS

Dysphagia score improved in 75% of the patients. Seventeen of the 20 patients (85%) who had required nutritional support at baseline improved their oral intake to no longer need the support, in a median time of 43 days. The median nutrition-support-free survival was 301 days in the 20 patients who had had adequate oral intake before the treatment. Disease control rate of the primary lesion was 95%, including 12 patients (30%) who achieved a complete response. The overall response rate was 55%. The median survival was 308 days, and the 1-year-survival rate was 45.0%. The median progression-free survival was 139 days. Toxicities were generally well tolerated. Major toxicities (Grade 3 or 4) involved hemoglobin (23%), leukocytes (15%), neutrophils (20%), anorexia (10%), nausea (3%), esophageal perforation (5%) and febrile neutropenia (3%). Two patients (5%) died within 30 days of terminating radiotherapy.

CONCLUSIONS

Palliative chemoradiotherapy using 5-fluorouracil plus cisplatin combined with concurrent 40 Gy irradiation effectively improved the symptom of dysphagia in Stage IVB esophageal cancer with acceptable toxicity and favorable survival.

A complete response in small cell carcinoma of the esophagus treated by s-1/cisplatin combined chemotherapy and radiotherapy

Small cell carcinoma of the esophagus (SmCCE) is a rare disease which is considered to be more malignant than the most common types of esophageal cancer. The optimal treatment strategy for this disease still remains controversial. A 69-year-old male was diagnosed to have SmCCE (stage IIIA, T3N1M0). Due to the patient's poor general condition, chemo-radiotherapy consisting of S-1/cisplatin therapy and a total of 60 Gy of radiotherapy was performed. After the treatment, the main lesion completely disappeared while some ulceration remained. A histological examination revealed no viable cancer cells in biopsy specimens obtained by endoscopy. Computed tomographic examinations showed a decreased wall thickness of the esophagus and an improvement in the swelling of the lymph nodes. S-1 monotherapy was administered following the main chemoradiation therapy, and it was performed for a total of 20 courses. The patient has been doing well without recurrence for over 3 years. We judged the effect to be a complete response. This combination chemo-radiotherapy with S-1 and cisplatin may therefore be one of the effective treatments against SmCCE.

Do all patients with carcinoma of the esophagus benefit from treatment at teaching facilities?

BACKGROUND

We sought to determine whether patients with esophageal carcinoma benefit from regionalization of care.

METHODS

The Florida Cancer Data System (FCDS) and the Agency for Health Care Administration data sets (1998-2002) were merged and queried.

RESULTS

A total of 5,041 patients (87.6% Caucasian vs. 11.1% African American (AA)) demonstrated a median survival time of 9.8 months overall and 23.4 months following surgical resection (P < 0.001). Adenocarcinoma arose predominantly in Caucasian patients (98.1%). Patients with adenocarcinoma (n = 2,248) derived a treatment benefit at a TF (HR = 1.35, P = 0.003), including an improved 90-day mortality following surgery (2.1% vs. 4.0%, P < 0.001). Squamous cell carcinoma (SCC) arose predominantly in AA patients (91.6%). No overall survival benefit at TF was observed (HR = 1.01, P = 0.915), however a trend for reduced 90-day surgical mortality was observed at TF (1.9% vs. 5.2%, P = 0.062). Multivariate analysis for adenocarcinoma demonstrates that poverty, lack of chemotherapy or surgery, and failure to provide treatment at a TF are independent predictors of worse survival. For SCC patients, AA race was a significant predictor of poorer survival while TF and poverty level were not.

CONCLUSIONS

These data suggest no benefit from potential regionalized care for patients with squamous histology, which disproportionately affects AA.

Concurrent chemoradiotherapy with S-1 for T2N0 glottic squamous cell carcinoma

In this study, we evaluated the feasibility, efficacy and toxicity of concurrent chemoradiotherapy with S-1 (tegafur-gimeracil-oteracil potassium) for T2N0 glottic carcinoma. A total of 23 patients with T2N0 glottic carcinoma received chemoradiotherapy with S-1. Radiotherapy consisted of five daily fractions of 2 Gy per week, to a total median dose of 70 Gy. S-1 was administered 65 mg/m(2) per day for 4 weeks, beginning on the day therapy was started, followed by 2 weeks off the drug and twice a day until the end of radiotherapy. Initial local control rate of the primary tumor was achieved in all patients. The median follow-up period for all patients was 38 months. The 3-year local control rate was 95.4%. Regarding adverse reactions, grade 3 mucositis upon clinical examination, mucositis upon functional/symptomatic examination, dysphagia, hepatic toxicity and anemia were observed in 13, 2, 2, 1 and 1 patients, respectively. This chemoradiotherapy did not result in grade 4 acute toxicity or severe late toxicity. Chemoradiotherapy with S-1 was feasible, well tolerated and effective. This therapy is suggested as a possible regimen for improving local control of T2N0 glottic carcinoma.

Phase I/II study of docetaxel/cisplatin/fluorouracil combination chemotherapy against metastatic esophageal squamous cell carcinoma

INTRODUCTION

More effective regimens are urgently needed for squamous cell carcinoma of esophagus (SCCE), therefore, we conducted a phase I/II trial of a combination of docetaxel, platinum, and fluorouracil (TPF) for treating metastatic SCCE.

METHODS

This phase I/II trial (n = 12/39) was conducted in our institute from April 2005 to June 2008. Progression-free survival (PFS) and overall survival were analyzed by the Kaplan-Meier method.

RESULTS

The recommended dose of docetaxel was determined to be 50 mg/m in phase I. In phase II with a mean follow-up period of 13.3 months, the objective response rate was 66.6%, a median survival period of 13 months and PFS of 7 months was achieved, and the 1-year survival and PFS rates were 52.9% and 19.6%, respectively. Grade 3/4 toxicities of leukopenia, neutropenia, and anorexia were observed in 53.8%, 43.6%, and 25.6%, respectively.

CONCLUSIONS

A TPF regimen against metastatic SCCE was well tolerated and achieved a favorable objective response rate and survival benefit compared with other recently reported regimens. Randomized phase III trials of the TPF regimen are warranted and urgently required.

Outcome for esophageal cancer following treatment with chemotherapy and radiotherapy but not esophagectomy: Nonsurgical treatment of esophageal cancer

Background:

More than 50% of patients with esophageal cancer are not suitable for surgery. The aim of this study was to analyze the outcome of patients undergoing standard nonsurgical treatment.

Methods:

Data of all patients undergoing nonsurgical treatment for esophageal cancer were identified from a prospective database.

Results:

Seventy-five patients were treated for localized disease, and 52 for metastatic disease at diagnosis. Except for age, which was higher in patients without metastases, there were no significant differences between the patients with vs. without metastatic disease. Kaplan–Meier analysis showed a median survival of 10.8 months for all patients. There was a significant difference in survival (p < 0.001) between the groups with versus without metastases, with median survival in the patients without metastases 13.6 months versus 6.5 months in patients with metastases. Patients undergoing nonsurgical treatment for localized disease had a five-year survival of 12%. No significant difference between adenocarcinoma and squamous cell carcinoma was identified. Subanalysis of patients who received chemoradiotherapy revealed similar results to the overall group of patients.

Conclusion:

In patients with localized disease at diagnosis, long-term survival can be achieved in some patients, whereas five-year survival is rare in patients who present with metastatic disease.