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Lavergne C, Youssef A, Niglas M, Humphreys DN, Youssef Y. Outcomes from a single institution cohort of 248 patients with stage I-III esophageal cancer treated with radiotherapy: Comparison of younger and older populations. Tech Innov Patient Support Radiat Oncol 2024; 31:100260. [PMID: 39070540 PMCID: PMC11278076 DOI: 10.1016/j.tipsro.2024.100260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 06/07/2024] [Accepted: 06/28/2024] [Indexed: 07/30/2024] Open
Abstract
Outcomes for patients receiving radiotherapy (RT) for non-metastatic esophageal cancer at a single institution were assessed, as well as the impact of factors including age and intensity modulated RT (IMRT) planning on patient outcomes. A retrospective cohort of patients treated with RT for stage I-III esophageal cancer between 2010 and 2018 was identified. Among 248 identified patients, 28 % identified as older (≥75 years of age). Other than histology, there were no other statistically significant differences in patient and tumour characteristics between the younger and older populations. Treatments varied between the two age groups, with significantly less older patients completing trimodality treatments (17 % vs 58 %). Median overall survival (M-OS) and progression-free survival (M-PFS) were 20 months and 12 months for all patients and 40 months and 26 months for trimodality patients, respectively. In the older patients, the M-OS improved from 13 months for all to 34 months for trimodality patients; and M-PFS from 10 months to 16 months. On multivariate analysis, the use of trimodality therapy showed improved OS (HR 0.26, p < 0.001). In the non-surgical older patient group, significantly better survival was seen in patients who had a heart V30Gy under 46 %. There was no significant difference in M-OS in patients planned with IMRT compared with 3D-conformal RT. Clinical outcomes in the treatment of esophageal cancer vary significantly by treatment approach, with the most favourable results in those receiving trimodality therapy. Among older patients deemed fit after assessment by the multidisciplinary team for trimodality treatments, the M-OS is comparable to the younger patient group.
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Affiliation(s)
- Carrie Lavergne
- R.S. McLaughlin Durham Regional Cancer Centre, Lakeridge Health Oshawa, Oshawa, Ontario L1G 2B9, Canada
| | - Andrew Youssef
- Institute of Medical Science, University of Toronto, Toronto, Ontario M5S 1A8, Canada
| | - Mark Niglas
- R.S. McLaughlin Durham Regional Cancer Centre, Lakeridge Health Oshawa, Oshawa, Ontario L1G 2B9, Canada
- Queen’s University, Department of Oncology, Kingston, Ontario, Canada
| | - Deanna Ng Humphreys
- R.S. McLaughlin Durham Regional Cancer Centre, Lakeridge Health Oshawa, Oshawa, Ontario L1G 2B9, Canada
| | - Youssef Youssef
- R.S. McLaughlin Durham Regional Cancer Centre, Lakeridge Health Oshawa, Oshawa, Ontario L1G 2B9, Canada
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van der Poort EKJ, van Holstein Y, Slingerland M, Trompet S, van den Bos F, Portielje JEA, Steyerberg EW, van den Akker-van Marle ME, Bos WJW, Mooijaart SP, van den Hout WB. Allocation and value of curative oncological treatment in frail and fit older patients with esophageal cancer: An observational cohort study. J Geriatr Oncol 2024:102046. [PMID: 39138114 DOI: 10.1016/j.jgo.2024.102046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/14/2024] [Accepted: 08/06/2024] [Indexed: 08/15/2024]
Abstract
INTRODUCTION The Value-Based Health Care (VBHC) model of care provides insights into patient characteristics, outcomes, and costs of care delivery that help clinicians counsel patients. This study compares the allocation and value of curative oncological treatment in frail and fit older patients with esophageal cancer in a dedicated VBHC pathway. MATERIALS AND METHODS Data was collected from patients with primary esophageal cancer without distant metastases, aged 70 years or older, and treated at a Dutch tertiary care hospital between 2015 and 2019. Geriatric assessment (GA) was performed. Outcomes included treatment discontinuation, mortality, quality of life (QoL), and physical functioning over a one-year period. Direct hospital costs were estimated using activity-based costing. RESULTS In this study, 89 patients were included with mean age 75 years. Of 56 patients completing GA, 19 were classified as frail and 37 as fit. For frail patients, the treatment plan was chemoradiotherapy and surgery (CRT&S) in 68% (13/19) and definitive chemoradiotherapy (dCRT) in 32% (6/19); for fit patients, CRT&S in 84% (31/37) and dCRT in 16% (6/37). Frail patients discontinued chemotherapy more often than fit patients (26% (5/19) vs 11% (4/37), p = 0.03) and reported lower QoL after six months (mean 0.58 [standard deviation (SD) 0.35] vs 0.88 [0.25], p < 0.05). After one year, 11% of frail and 30% of fit patients reported no decline in physical functioning and QoL and survived. Frail and fit patients had comparable mean direct hospital costs (€24 K [SD €13 K] vs €23 K [SD €8 K], p = 0.82). DISCUSSION The value of curative oncological treatment was lower for frail than for fit patients because of slightly worse outcomes and comparable costs. The utility of the VBHC model of care depends on the availability of sufficient data. Real-world evidence in VBHC can be used to inform treatment decisions and optimization in future patients by sharing results and monitoring performance over time. TRIAL REGISTRATION The study was retrospectively registered at the Netherlands Trial Register (NTR), trial number NL8107 (date of registration: 22-10-2019).
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Affiliation(s)
- Esmée K J van der Poort
- Department of Biomedical Data Sciences, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands.
| | - Yara van Holstein
- Department of Internal Medicine, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Marije Slingerland
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Stella Trompet
- Department of Internal Medicine, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands; LUMC Center for Medicine for Older People, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Frederiek van den Bos
- Department of Internal Medicine, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands; LUMC Center for Medicine for Older People, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Johanneke E A Portielje
- Department of Medical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | | | - Willem Jan W Bos
- Department of Internal Medicine, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands; Department of Internal Medicine, St. Antonius Hospital, Koekoekslaan 1, 3435CM Nieuwegein, the Netherlands
| | - Simon P Mooijaart
- Department of Internal Medicine, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands; LUMC Center for Medicine for Older People, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands
| | - Wilbert B van den Hout
- Department of Biomedical Data Sciences, Leiden University Medical Center, Albinusdreef 2, 2333ZA Leiden, the Netherlands
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Hirata K, Yoshida K, Katada C, Watanabe A, Tsushima T, Yamaguchi T, Yamamoto S, Ishikawa H, Sato Y, Imamura CK, Tanigawara Y, Ito Y, Kato K, Kitagawa Y, Hamamoto Y. Definitive chemoradiotherapy with paclitaxel for locally advanced esophageal squamous cell carcinoma in older patients (PARADISE-1): a phase I trial. BMC Cancer 2024; 24:873. [PMID: 39030570 PMCID: PMC11264717 DOI: 10.1186/s12885-024-12653-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/17/2024] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND In older patients, esophageal squamous cell carcinoma (ESCC) is difficult to treat using standard therapies, including surgery and cisplatin-based chemoradiotherapy. Paclitaxel (PTX) has radiosensitizing activity. We conducted a phase I trial of PTX combined with radiotherapy to establish a standard therapy for locally advanced ESCC in older patients. METHODS Enrollment was conducted at six centers in Japan from April 2016 to September 2019. The participants were aged ≥ 70 years, had locally advanced ESCC, and were intolerant to surgery or unwilling. A fixed 60-Gy radiation dose was administered in 30 fractions. PTX dosing levels started at 30 mg/m2 weekly for 6 weeks. Depending on the number of DLTs, the dose was set to be increased by 10 mg/m2 or switched to biweekly. A geriatric assessment was performed before treatment using the Geriatric-8 screening tool. The primary endpoint was dose-limiting toxicity (DLT). RESULTS We enrolled 24 patients (6 per group); DLT was observed in one (grade 4 hypokalemia), one (grade 3 aspiration), two (grade 3 radiodermatitis, grade 3 esophageal hemorrhage), and two (grade 3 anorexia, grade 5 pneumonitis) patients in the weekly PTX 30, 40, 50, and 60 mg/m2 groups, respectively. All adverse events, except death in the 60 mg/m2 group, showed reversible improvement, and the safety profile was considered acceptable. The 2-year survival and complete response rates were 40.0% and 54.2%, respectively. There was a significant difference in survival between favorable and unfavorable Geriatric-8 scores. CONCLUSIONS The recommended PTX dose with concomitant radiation was determined to be 50 mg/m2 weekly. Phase II trials at this dose are underway.
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Affiliation(s)
- Kenro Hirata
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
- Keio Cancer Center, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Kayo Yoshida
- Department of Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Chikatoshi Katada
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Akinori Watanabe
- Department of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Takahiro Tsushima
- Division of Gastrointestinal Oncology, Shizuoka Cancer Center, 1007 , Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan
| | - Toshifumi Yamaguchi
- Cancer Chemotherapy Center, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-Cho, Takatsuki, Osaka, 569-8686, Japan
| | - Sachiko Yamamoto
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, 1-3-3Higashinari-Ku, NakamichiOsaka, 537-8511, Japan
| | - Hideki Ishikawa
- Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 3-2-17-2F Imabashi, Chuo-Ku, Osaka, 541-0042, Japan
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Chiyo K Imamura
- Advanced Cancer Translational Research Institute, Showa University, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8555, Japan
| | - Yusuke Tanigawara
- Laboratory of Pharmacometrics and Systems Pharmacology, Keio Frontier Research & Education Collaborative Square at Tonomachi, Keio University, 3-25-10 Tonomachi, Kawasaki-Ku, Kawasaki, Kanagawa, 210-0821, Japan
| | - Yoshinori Ito
- Department of Radiation Oncology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8555, Japan
| | - Ken Kato
- Department of Head and Neck, Esophageal Medical Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Yasuo Hamamoto
- Keio Cancer Center, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan.
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Jang JY, Oh D, Noh JM, Sun J, Kim HK, Shim YM. Prognostic impact of muscle mass loss in elderly patients with oesophageal cancer receiving neoadjuvant chemoradiation therapy. J Cachexia Sarcopenia Muscle 2024; 15:1167-1176. [PMID: 38613258 PMCID: PMC11154764 DOI: 10.1002/jcsm.13462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 12/16/2023] [Accepted: 02/28/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND We aimed to identify the impact of muscle mass on locally advanced oesophageal cancer (LAEC) in elderly patients receiving neoadjuvant chemoradiation therapy (NACRT). METHODS We reviewed the medical records of 345 patients diagnosed with LAEC who underwent NACRT and surgery. Physical variables, including height, weight, skeletal muscle mass, and laboratory values, were obtained before and after NACRT. Body mass index (BMI, kg/m2), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and prognostic nutritional index (PNI) were calculated as height/(weight)2, ANC/ALC, platelet count/ALC, and (10 × albumin + 0.05 × ALC), respectively. The cutoff for low muscle mass was 43.0 cm2/m2 for BMI below 25 kg/m2 and 53.0 cm2/m2 for BMI 25 kg/m2 or higher. The skeletal muscle index (SMI) was defined as skeletal muscle area/(height)2 (cm2/m2). The ΔSMI (%/50 days) was defined as (SMI after NACRT - SMI before NACRT)/interval (days) × 50 (days) to compare changes over the same period. The excessive muscle loss (EML) group was defined as patients with ΔSMI ≤-10% following NACRT. An elderly patient was defined as aged ≥65 years. The primary outcome measure was overall survival (OS). RESULTS During a median follow-up of 32.8 months (range, 2.0-176.2), 192 patients died, with a median OS of 50.2 months. Elderly patients did not show inferior OS (young vs. elderly, 57.7% vs. 54.0% at 3 years, P = 0.247). 71.0% and 87.2% of all patients had low muscle mass before and after NACRT, respectively, which was not associated with OS (P = 0.270 and P = 0.509, respectively). Inflammatory (NLR and PLR) and nutritional index (PNI) values or their changes did not correlate with OS. However, the EML group had worse OS (41.6% vs. 63.2% at 3 years, P < 0.0001). In the multivariate analysis, EML was also a significant prognostic factor for OS. In the subgroup analysis by age, EML was a strong prognostic factor for OS in the elderly group. The 3-year OS was 36.8% in the EML group and 64.9% in the non-EML group (P < 0.0001) in elderly patients, and 47.4% and 62.1% (P = 0.063) in the young patients. In multivariate analysis of each subgroup, EML remained prognostic only in the elderly group (P = 0.008). CONCLUSIONS EML may be strongly associated with a deteriorated OS in elderly patients undergoing NACRT, followed by surgery for LAEC. The strategies for decreasing muscle loss in these patients should be investigated.
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Affiliation(s)
- Jeong Yun Jang
- Department of Radiation Oncology, Konkuk University Medical CenterKonkuk University School of MedicineSeoulKorea
| | - Dongryul Oh
- Department of Radiation Oncology, Samsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Jae Myoung Noh
- Department of Radiation Oncology, Samsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Jong‐Mu Sun
- Department of Medicine, Division of Hematology‐Oncology, Samsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical CenterSungkyunkwan University School of MedicineSeoulKorea
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Ahmed N, Tankel J, Asselah J, Alcindor T, Alfieri J, David M, Najmeh S, Spicer J, Cools-Lartigue J, Mueller C, Ferri L. Survival and perioperative outcomes of octo- and nonagenarians with resectable esophageal carcinoma. Dis Esophagus 2023; 36:doad043. [PMID: 37448141 DOI: 10.1093/dote/doad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Indexed: 07/15/2023]
Abstract
The outcomes of different treatment modalities for patients aged 80 and above with locally advanced and resectable esophageal carcinoma are not well described. The aim of this study was to explore survival and perioperative outcomes among this specific group of patients. A retrospective, cohort analysis was performed on a prospectively maintained esophageal cancer database from the McGill regional upper gastroinestinal cancer network. Between 2010 and 2020, all patients ≥80 years with cT2-4a, Nany, M0 esophageal carcinoma were identified and stratified according to the treatment modality: Neoadjuvant chemotherapy (nCT) or chemoradiotherapy (nCRT); definitive CRT (dCRT); upfront surgery; palliative CT/RT; or best supportive care (BSC). Of the 162 patients identified, 79 were included in this study. The median age was 83 years (80-97), most were cT3 (73%), cN- (56%), and had adenocarcinoma (62%). Treatment included: nCT/nCRT (16/79, 20%); surgery alone (19/79, 24%); dCRT (12/29, 15%); palliative RT/CT (27/79, 34%); and BSC (5/79, 6%). Neoadjuvant treatment was completed in 10/16 (63%). Of the 35/79 who underwent surgery, major complications occurred in 13/35 (37%) and 90-day mortality in 3/35 (9%). Overall survival (OS) for the cohort at 1- and 3-years was 58% and 19%. Among patients treated with nCT/nCRT, this was 94% and 46% respectively. Curative intent treatment (nCT/nCRT/upfront surgery/dCRT) had significantly increased 1- and 3- year OS compared with non-curative treatment (76%/31% vs. 34%/3.3%). Multimodal standard of care treatment is feasible and safe in select octo/nonagenarians, and may be associated with improved OS. Age alone should not bias against treatment with curative intent.
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Affiliation(s)
- Nabeel Ahmed
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - James Tankel
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Jamil Asselah
- Division of Medical Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Thierry Alcindor
- Division of Medical Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Joanne Alfieri
- Department of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marc David
- Department of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sara Najmeh
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Jonathan Spicer
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Jonathan Cools-Lartigue
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Carmen Mueller
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Lorenzo Ferri
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
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Huang Y, Huang X, Wang A, Chen Q, Chen G, Ye J, Wang Y, Qin Z, Xu K. Individualized treatment decision model for inoperable elderly esophageal squamous cell carcinoma based on multi-modal data fusion. BMC Med Inform Decis Mak 2023; 23:237. [PMID: 37872517 PMCID: PMC10594800 DOI: 10.1186/s12911-023-02339-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/15/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND This research aimed to develop a model for individualized treatment decision-making in inoperable elderly patients with esophageal squamous cell carcinoma (ESCC) using machine learning methods and multi-modal data. METHODS A total of 189 inoperable elderly ESCC patients aged 65 or older who underwent concurrent chemoradiotherapy (CCRT) or radiotherapy (RT) were included. Multi-task learning models were created using machine learning techniques to analyze multi-modal data, including pre-treatment CT images, clinical information, and blood test results. Nomograms were constructed to predict the objective response rate (ORR) and progression-free survival (PFS) for different treatment strategies. Optimal treatment plans were recommended based on the nomograms. Patients were stratified into high-risk and low-risk groups using the nomograms, and survival analysis was performed using Kaplan-Meier curves. RESULTS The identified risk factors influencing ORR were histologic grade (HG), T stage and three radiomic features including original shape elongation, first-order skewness and original shape flatness, while risk factors influencing PFS included BMI, HG and three radiomic features including high gray-level run emphasis, first-order minimum and first-order skewness. These risk factors were incorporated into the nomograms as independent predictive factors. PFS was substantially different between the low-risk group (total score ≤ 110) and the high-risk group (total score > 110) according to Kaplan-Meier curves (P < 0.05). CONCLUSIONS The developed predictive models for ORR and PFS in inoperable elderly ESCC patients provide valuable insights for predicting treatment efficacy and prognosis. The nomograms enable personalized treatment decision-making and can guide optimal treatment plans for inoperable elderly ESCC patients.
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Affiliation(s)
- Yong Huang
- Department of Medical Oncology, The Second People's Hospital of Hefei, Hefei, China
| | - Xiaoyu Huang
- Department of Chinese Integrative Medicine Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Anling Wang
- Scholl of Internet, Anhui University, Hefei, China
| | - Qiwei Chen
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Gong Chen
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jingya Ye
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yaru Wang
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhihui Qin
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Kai Xu
- Scholl of Internet, Anhui University, Hefei, China.
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Roeder F, Jensen AD, Lindel K, Mattke M, Wolf F, Gerum S. Geriatric Radiation Oncology: What We Know and What Can We Do Better? Clin Interv Aging 2023; 18:689-711. [PMID: 37168037 PMCID: PMC10166100 DOI: 10.2147/cia.s365495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 04/22/2023] [Indexed: 05/13/2023] Open
Abstract
Elderly patients represent a growing subgroup of cancer patients for whom the role of radiation therapy is poorly defined. Older patients are still clearly underrepresented in clinical trials, resulting in very limited high-level evidence. Moreover, elderly patients are less likely to receive radiation therapy in similar clinical scenarios compared to younger patients. However, there is no clear evidence for a generally reduced radiation tolerance with increasing age. Modern radiation techniques have clearly reduced acute and late side effects, thus extending the boundaries of the possible regarding treatment intensity in elderly or frail patients. Hypofractionated regimens have further decreased the socioeconomic burden of radiation treatments by reducing the overall treatment time. The current review aims at summarizing the existing data for the use of radiation therapy or chemoradiation in elderly patients focusing on the main cancer types. It provides an overview of treatment tolerability and outcomes with current standard radiation therapy regimens, including possible predictive factors in the elderly population. Strategies for patient selection for standard or tailored radiation therapy approaches based on age, performance score or comorbidity, including the use of prediction tests or geriatric assessments, are discussed. Current and future possibilities for improvements of routine care and creation of high-level evidence in elderly patients receiving radiation therapy are highlighted.
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Affiliation(s)
- Falk Roeder
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
- Correspondence: Falk Roeder, Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Müllner Hauptstrasse 48, Salzburg, 5020, Austria, Tel +43 57255 55569, Email
| | - Alexandra D Jensen
- Department of Radiation Oncology, University Hospital Marburg-Giessen, Giessen, Germany
| | - Katja Lindel
- Department of Radiation Oncology, Städtisches Klinikum, Karlsruhe, Germany
| | - Matthias Mattke
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - Frank Wolf
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - Sabine Gerum
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
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Linde P, Mallmann M, Adams A, Wegen S, Rosenbrock J, Trommer M, Marnitz S, Baues C, Celik E. Chemoradiation for elderly patients (≥ 65 years) with esophageal cancer: a retrospective single-center analysis. Radiat Oncol 2022; 17:187. [PMCID: PMC9670495 DOI: 10.1186/s13014-022-02160-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022] Open
Abstract
Background Present studies on the efficacy and safety of curative chemoradiation therapy (CRT) with esophageal cancer reflect heterogenous results especially in elderly patients. The aim of this study was to evaluate the toxicity and efficacy of CRT in patients ≥ 65 years. In a cohort, the focus centered around treatment-related toxicity (CTCAE Grade > 3), overall survival as well as progression free survival, comparing these rates in-between patients older than 70 years to those younger than 70 years.
Methods A total of 67 patients older than 65 years (34 (50.7%) were older than 70 years) met the inclusion criteria for retrospective analysis (period from January 2013 to October 2017). Treatment consisted of radiotherapy and chemotherapy with carboplatin/paclitaxel or fluorouracil (5-FU)/cisplatin with the intention of neoadjuvant or definite chemoradiation. A sum of 67 patients received CRT (44 (65.6%) patients in neoadjuvant, 23 (34.4%) in definite intent). Of these, 22 and 12 patients were older than 70 years (50% and 52.2% in both treatment groups, respectively). Median age was 71 years and patients had a good physical performance status (ECOG 0: 57.6%, ECOG 1: 27.3%). Median follow-up was 24 months. Most patients had advanced tumour stages (T3 stage: n = 51, 79.7%) and nodal metastasis (N1 stage: n = 54, 88.5%). A subgroup comparison was conducted between patients aged ≤ 70 years and > 70 years. Results In severe (CTCAE Grade 3–5) toxicities (acute and late), no significant differences were observed between both patient groups (< 70 years vs. > 70 years). 21% had acute grade 3 events, 4 patients (4%) had grade 4 events, and two patients (3%) had one grade 5 event. Late toxicity after CRT was grade 1 in 13 patients (22%), grade 2 in two (3%), grade 3 in two (3%), grade 4 in four (7%), and grade 5 in one (2%). Median overall survival (OS) of all patients was 30 months and median progression-free survival (PFS) was 16 months. No significant differences were seen for OS (32 months vs. 25 months; p = 0.632) and PFS (16 months vs. 12 months; p = 0.696) between older patients treated with curative intent and younger ones. Trimodal therapy significantly prolonged both OS and PFS (p = 0.005; p = 0.018), regardless of age.
Conclusion CRT in elderly patients (≥ 65 years) with esophageal cancer is feasible and effective. Numbers for acute and late toxicities can be compared to cohorts of younger patients (< 65 years) with EC who received the same therapies. Age at treatment initiation alone should not be the determining factor. Instead, functional status, risk of treatment-related morbidities, life expectancy and patient´s preferences should factor into the choice of therapy.
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Affiliation(s)
- Philipp Linde
- grid.6190.e0000 0000 8580 3777Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener St 62, 50937 Cologne, Germany ,grid.411097.a0000 0000 8852 305XCenter for Integrated Oncology (CIO), University Hospital of Cologne, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
| | - Markus Mallmann
- grid.6190.e0000 0000 8580 3777Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener St 62, 50937 Cologne, Germany ,grid.411097.a0000 0000 8852 305XCenter for Integrated Oncology (CIO), University Hospital of Cologne, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
| | - Anne Adams
- grid.6190.e0000 0000 8580 3777Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
| | - Simone Wegen
- grid.6190.e0000 0000 8580 3777Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener St 62, 50937 Cologne, Germany ,grid.411097.a0000 0000 8852 305XCenter for Integrated Oncology (CIO), University Hospital of Cologne, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
| | - Johannes Rosenbrock
- grid.6190.e0000 0000 8580 3777Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener St 62, 50937 Cologne, Germany ,grid.411097.a0000 0000 8852 305XCenter for Integrated Oncology (CIO), University Hospital of Cologne, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
| | - Maike Trommer
- grid.6190.e0000 0000 8580 3777Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener St 62, 50937 Cologne, Germany ,grid.411097.a0000 0000 8852 305XCenter for Integrated Oncology (CIO), University Hospital of Cologne, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
| | - Simone Marnitz
- grid.6190.e0000 0000 8580 3777Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener St 62, 50937 Cologne, Germany ,grid.411097.a0000 0000 8852 305XCenter for Integrated Oncology (CIO), University Hospital of Cologne, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
| | - Christian Baues
- grid.6190.e0000 0000 8580 3777Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener St 62, 50937 Cologne, Germany ,grid.411097.a0000 0000 8852 305XCenter for Integrated Oncology (CIO), University Hospital of Cologne, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
| | - Eren Celik
- grid.6190.e0000 0000 8580 3777Department of Radiation Oncology, Cyberknife and Radiation Therapy, Faculty of Medicine and University Hospital of Cologne, University of Cologne, Kerpener St 62, 50937 Cologne, Germany ,grid.411097.a0000 0000 8852 305XCenter for Integrated Oncology (CIO), University Hospital of Cologne, Faculty of Medicine and University of Cologne, Kerpener St 62, 50937 Cologne, Germany
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9
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Hamamoto Y, Murakami K, Kato K, Kitagawa Y. Management of elderly patients with esophageal squamous cell cancer. Jpn J Clin Oncol 2022; 52:816-824. [PMID: 35511482 PMCID: PMC9354502 DOI: 10.1093/jjco/hyac067] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 04/07/2022] [Indexed: 12/02/2022] Open
Abstract
This review focuses on the treatment about elderly esophageal cancer to clarify the current situation regarding our clinical question. Although there are several reviews about elderly esophageal cancer treatment, there are fundamental differences between Japan and the rest of the world. Two main differences are raised: histological differences and treatment strategies for resectable patients. We overview each status according to following clinical questions. First, there are no established evaluation criteria for frail. Second, selection criteria for surgery or non-surgery are not established. Third, few specific treatments for elderly patients (EPs) are investigated. In conclusion, there are many reports about treatment of esophageal squamous cell carcinoma for EPs, although treatment strategy is still controversial. We have to consider well-designed prospective trial to confirm specific treatment strategy according to each stage.
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Affiliation(s)
- Yasuo Hamamoto
- Keio Cancer Center, Keio University Hospital, School of Medicine, Tokyo, Japan
| | - Kentaro Murakami
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ken Kato
- Department of Head and Neck, Esophageal Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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10
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van Holstein Y, Trompet S, van Deudekom FJ, van Munster B, de Glas NA, van den Bos F, Uit den Boogaard A, van der Elst MJT, van der Kaaij MAE, Neelis KJ, Langers AMJ, Slingerland M, Portielje JEA, Mooijaart SP. Geriatric assessment and treatment outcomes in a Dutch cohort of older patients with potentially curable esophageal cancer. Acta Oncol 2022; 61:459-467. [PMID: 35193449 DOI: 10.1080/0284186x.2022.2036366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with potentially curable esophageal cancer can be treated with neo-adjuvant chemoradiotherapy followed by surgery or definitive chemoradiotherapy with curative intent. For frail older patients choosing the appropriate oncological treatment can be difficult, and data on geriatric deficits as determinants of treatment outcomes are not yet available. OBJECTIVES To describe the prevalence of geriatric deficits and to study their association with treatment discontinuation and mortality in older patients with potentially curable esophageal cancer. MATERIAL AND METHODS A cohort study was conducted in a Dutch tertiary care hospital including patients aged ≥70 years with primary stage I-IVA esophageal cancer. Geriatric screening and assessment data were collected. Outcomes were treatment discontinuation and one year all-cause mortality. RESULTS In total, 138 patients with curable esophageal cancer were included. Mean age was 76.1 years (standard deviation 4.7), 54% had clinical stage III and 24% stage IVA disease. Most patients received neo-adjuvant chemoradiotherapy and surgery (41%), 32% definitive chemoradiotherapy and 22% palliative radiotherapy. Overall, one year all-cause mortality was 36%. Geriatric screening and assessment was performed in 94 out of 138 patients, of which 60% was malnourished, 20% dependent in Instrumental Activities of Daily Living (IADL) and 52% was frail. Malnutrition was associated with higher mortality risk (Hazard Ratio, 3.2; 95% Confidence Interval, 1.3-7.7)) independent of age, sex and tumor stage. Seventy-six out of 94 patients were treated with chemoradiotherapy, of which 23% discontinued treatment. Patients with IADL dependency and Charlson Comorbidity Index ≥1 discontinued treatment more often. CONCLUSION All-cause mortality within one year was high, irrespective of treatment modality. Treatment discontinuation rate was high, especially in patients treated with definitive chemoradiotherapy. Geriatric assessment associates with outcomes in older patients with esophageal cancer and may inform treatment decisions and optimization in future patients, but more research is needed to establish its predictive value. Trial registration: The study is retrospectively registered at the Netherlands Trial Register (NTR), trial number NL8107. Date of registration: 22-10-2019.
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Affiliation(s)
- Yara van Holstein
- Department of Internal Medicine, section of Gerontology and Geriatrics, Leiden University Medical Center, The Netherlands
| | - Stella Trompet
- Department of Internal Medicine, section of Gerontology and Geriatrics, Leiden University Medical Center, The Netherlands
| | - Floor J. van Deudekom
- Department of Internal Medicine, section of Gerontology and Geriatrics, Leiden University Medical Center, The Netherlands
| | - Barbara van Munster
- Department of Internal Medicine, University Medical Center Groningen, The Netherlands
| | - Nienke A. de Glas
- Department of Medical Oncology, Leiden University Medical Center, The Netherlands
| | - Frederiek van den Bos
- Department of Internal Medicine, section of Gerontology and Geriatrics, Leiden University Medical Center, The Netherlands
| | - Anna Uit den Boogaard
- Department of Internal Medicine, section of Gerontology and Geriatrics, Leiden University Medical Center, The Netherlands
| | - Marjan J. T. van der Elst
- Department of Internal Medicine, section of Gerontology and Geriatrics, Leiden University Medical Center, The Netherlands
| | | | - Karen J. Neelis
- Department of Radiation Oncology, Leiden University Medical Center, The Netherlands
| | - Alexandra M. J. Langers
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
| | - Marije Slingerland
- Department of Medical Oncology, Leiden University Medical Center, The Netherlands
| | | | - Simon P. Mooijaart
- Department of Internal Medicine, section of Gerontology and Geriatrics, Leiden University Medical Center, The Netherlands
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11
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Shi Z, Zhu X, Ke S, Qiu H, Cai G, Zhangcai Y, Chen Y. Survival impact of concurrent chemoradiotherapy for elderly patients with synchronous oligometastatic esophageal squamous cell carcinoma: A propensity score matching and landmark analyses. Radiother Oncol 2021; 164:236-244. [PMID: 34627936 DOI: 10.1016/j.radonc.2021.09.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 09/23/2021] [Accepted: 09/29/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE To evaluate the potential benefits of concurrent chemoradiotherapy (CCRT), and to establish a nomogram for predicting survival outcomes of elderly patients with synchronous oligometastatic esophageal squamous cell carcinoma (SOEC). MATERIALS AND METHODS This study eventually enrolled 314 elderly patients who initially diagnosed with SOEC from two centers. Treatment responses and outcomes of 151 patients receiving CCRT and 163 patients undergoing chemotherapy alone (CT) were compared. Propensity score matching and landmark analyses were performed to control potential confounding factors. A nomogram was established on the basis of the Cox regression model. RESULTS After a median follow-up of 42.3 months, CCRT was superior to CT alone in objective response rate (ORR, 59.6% vs. 39.9%, P < 0.001), median progression-free survival (PFS, 10.0 vs. 7.2 months, P < 0.001), and median overall survival (OS, 18.5 vs. 15.6 months, P < 0.001). The propensity score matching (PSM) and landmark analyses redemonstrated the same trend (P < 0.01). On hierarchical analysis, patients with 1-3 metastatic lesions involving one organ displayed longer median PFS (9.0 vs. 7.8 months, P = 0.008) and OS (17.8 vs. 15.2 months, P < 0.001) than those with 4-5 metastatic lesions involving 2-3 organs. The major toxicities of grade III or higher for CCRT included leukocytopenia (23.2%), radiation esophagitis (7.3%), and radiation pneumonitis (8.6%). Cox multivariate analysis showed that the number of metastatic lesions (P = 0.012) and tumor response (P < 0.001) were independent prognostic factors associated with OS. A nomogram was established by incorporating the number of metastatic lesions and tumor response, with a concordance index of 0.743 after internal cross-validation. Calibration curves and decision curve analysis confirmed that nomogram had a favorable predictive value for individualized survival. CONCLUSIONS Compared with CT alone, CCRT exhibited superior efficacy and acceptable toxicity in the first-line treatment for elderly patients with SOEC. The current study supports the oligometastatic definition of ≤3 metastatic lesions involving one organ for esophageal cancer patients. The constructed nomogram can effectively predict the individualized survival.
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Affiliation(s)
- Zhenguo Shi
- Department of Clinical Oncology, Renmin Hospital of Wuhan University, Wuhan, China; Department of Oncology, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | - Xiaojuan Zhu
- Department of Oncology, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | - Shaobo Ke
- Department of Clinical Oncology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hu Qiu
- Department of Clinical Oncology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Gaoke Cai
- Department of Clinical Oncology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yutian Zhangcai
- Department of Clinical Oncology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yongshun Chen
- Department of Clinical Oncology, Renmin Hospital of Wuhan University, Wuhan, China.
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12
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Rogowski P, Trapp C, von Bestenbostel R, Eze C, Ganswindt U, Li M, Unterrainer M, Zacherl MJ, Ilhan H, Beyer L, Kretschmer A, Bartenstein P, Stief C, Belka C, Schmidt-Hegemann NS. Outcome after PSMA-PET/CT-based salvage radiotherapy for nodal recurrence after radical prostatectomy. Eur J Nucl Med Mol Imaging 2021; 49:1417-1428. [PMID: 34628521 PMCID: PMC8921036 DOI: 10.1007/s00259-021-05557-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/05/2021] [Indexed: 11/27/2022]
Abstract
Purpose Nodal recurrent prostate cancer (PCa) represents a common state of disease, amenable to local therapy. PSMA-PET/CT detects PCa recurrence at low PSA levels. The aim of this study was to evaluate the outcome of PSMA-PET/CT-based salvage radiotherapy (sRT) for lymph node (LN) recurrence. Methods A total of 100 consecutive patients treated with PSMA-PET/CT-based salvage elective nodal radiotherapy (sENRT) for LN recurrence were retrospectively examined. Patients underwent PSMA-PET/CT scan due to biochemical persistence (bcP, 76%) or biochemical recurrence (bcR, 24%) after radical prostatectomy (RP). Biochemical recurrence-free survival (BRFS) defined as PSA < post-RT nadir + 0.2 ng/ml and distant metastasis-free survival (DMFS) were calculated using the Kaplan–Meier method and uni- and multivariate analysis was performed. Results Median follow-up was 37 months. Median PSA at PSMA-PET/CT was 1.7 ng/ml (range 0.1–40.1) in patients with bcP and 1.4 ng/ml (range 0.3–5.1) in patients with bcR. PSMA-PET/CT detected 1, 2, and 3 or more LN metastases in 35%, 23%, and 42%, respectively. Eighty-three percent had only pelvic, 2% had only paraaortic, and 15% had pelvic and paraaortic LN metastases. Cumulatively, a total dose converted to EQD21.5 Gy of 66 Gy (60–70 Gy) was delivered to the prostatic fossa, 70 Gy (66–72 Gy) to the local recurrence, if present, 65.1 Gy (56–66 Gy) to PET-positive lymph nodes, and 47.5 Gy (42.4–50.9 Gy) to the lymphatic pathways. Concomitant androgen deprivation therapy (ADT) was administered in 83% of patients. One-, 2-, and 3-year BRFS was 80.7%, 71.6%, and 65.8%, respectively. One-, 2-, and 3-year DMFS was 91.6%, 79.1%, and 66.4%, respectively. In multivariate analysis, concomitant ADT, longer ADT duration (≥ 12 vs. < 12 months) and LN localization (pelvic vs. paraaortic) were associated with improved BRFS and concomitant ADT and lower PSA value before sRT (< 1 vs. > 1 ng/ml) with improved DMFS, respectively. No such association was seen for the number of affected lymph nodes. Conclusions Overall, the present analysis shows that the so far, unmatched sensitivity and specificity of PSMA-PET/CT translates in comparably high BRFS and DMFS after PSMA-PET/CT-based sENRT for patients with PCa LN recurrence. Concomitant ADT, duration of ADT, PSA value before sRT, and localization of LN metastases were significant factors for improved outcome.
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Affiliation(s)
- Paul Rogowski
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Christian Trapp
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Rieke von Bestenbostel
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Chukwuka Eze
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Ute Ganswindt
- Department of Radiation Oncology, University Hospital, Medical University Innsbruck, Innsbruck, Austria
| | - Minglun Li
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Marcus Unterrainer
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany.,Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Mathias J Zacherl
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Harun Ilhan
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Leonie Beyer
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | | | - Peter Bartenstein
- Department of Nuclear Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Christian Stief
- Department of Urology, University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.,German Cancer Consortium (DKTK), Munich, Germany
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13
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Cooper L, Dezube AR, De León LE, Kucukak S, Mazzola E, Dumontier C, Mamon H, Enzinger P, Jaklitsch MT, Frain LN, Wee JO. Outcomes of trimodality CROSS regimen in older adults with locally advanced esophageal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2021; 47:2667-2674. [PMID: 33895020 PMCID: PMC8448942 DOI: 10.1016/j.ejso.2021.04.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/29/2021] [Accepted: 04/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Chemoradiotherapy for Esophageal cancer followed by Surgery (CROSS regimen) is standard of care for locally-advanced esophageal cancer. We evaluated CROSS completion rates, toxicity, and postoperative outcomes between older and younger adults receiving trimodality therapy. METHODS Retrospective analysis of patients with locally-advanced esophageal cancer who underwent CROSS regimen from May 2016 to January 2020 at a single academic center. Outcomes of those aged ≥70-years-old and <70 years-old were analyzed. RESULTS Of 201 patients, 136 were <70 and 65 were ≥70 years. Older adults were more likely to be male (91% vs. 79%; p = 0.045), have higher ECOG scores (median 1 vs. 0; p = 0.003), Charlson-comorbidity index (median 6 vs. 4; p < 0.001), and undergo open procedures (20% vs. 8% p = 0.008). Most completed CROSS regimen (78% vs. 84% respectively) with similar rates of treatment discontinuation and dose reduction (all p > 0.05). Time to surgery following neoadjuvant therapy was similar between age groups, except in those ≥80-years-old as compared to <70-years-old (p < 0.05). Overall toxicity rates were similar (68% vs. 71% respectively; p = 0.676). Only rates of delirium (19% vs. 5%) and urinary retention (9% vs. 0%) were higher in older adults (both p < 0.05). Length of stay, discharge disposition, mortality, and overall survival were similar. Age was not an independent risk factor for complication, neoadjuvant toxicity or completion, surgery timing, nor worse overall or recurrence-free survival (p > 0.05). CONCLUSION Trimodality CROSS regimen for esophageal cancer in older adults is feasible, with similar completion rates and postoperative outcomes as compared to their younger counterparts.
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Affiliation(s)
- Lisa Cooper
- Division of Aging, Brigham and Women's Hospital, Boston, MA, USA.
| | - Aaron R Dezube
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Luis E De León
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Suden Kucukak
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Emanuele Mazzola
- Department of Data Science, Dana Farber Cancer Institute, Boston, MA, USA
| | - Clark Dumontier
- Division of Aging, Brigham and Women's Hospital, Boston, MA, USA; Marcus Institute of Aging Research, Boston, MA, USA
| | - Harvey Mamon
- Department of Radiation Oncology, Brigham and Women's Hospital, Boston, MA, USA
| | - Peter Enzinger
- Center for Esophageal and Gastric Cancer, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | | | - Laura N Frain
- Division of Aging, Brigham and Women's Hospital, Boston, MA, USA
| | - Jon O Wee
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA
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14
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Ji Y, Du X, Zhu W, Yang Y, Ma J, Zhang L, Li J, Tao H, Xia J, Yang H, Huang J, Bao Y, Du D, Liu D, Wang X, Li C, Yang X, Zeng M, Liu Z, Zheng W, Pu J, Chen J, Hu W, Li P, Wang J, Xu Y, Zheng X, Chen J, Wang W, Tao G, Cai J, Zhao J, Zhu J, Jiang M, Yan Y, Xu G, Bu S, Song B, Xie K, Huang S, Zheng Y, Sheng L, Lai X, Chen Y, Cheng L, Hu X, Ji W, Fang M, Kong Y, Yu X, Li H, Li R, Shi L, Shen W, Zhu C, Lv J, Huang R, He H, Chen M. Efficacy of Concurrent Chemoradiotherapy With S-1 vs Radiotherapy Alone for Older Patients With Esophageal Cancer: A Multicenter Randomized Phase 3 Clinical Trial. JAMA Oncol 2021; 7:1459-1466. [PMID: 34351356 DOI: 10.1001/jamaoncol.2021.2705] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Most older patients with esophageal cancer cannot complete the standard concurrent chemoradiotherapy (CCRT). An effective and tolerable chemoradiotherapy regimen for older patients is needed. Objective To evaluate the efficacy and toxic effects of CCRT with S-1 vs radiotherapy (RT) alone in older patients with esophageal cancer. Design, Setting, and Participants A randomized, open-label, phase 3 clinical trial was conducted at 23 Chinese centers between June 1, 2016, and August 31, 2018. The study enrolled 298 patients aged 70 to 85 years. Eligible participants had histologically confirmed esophageal cancer, stage IB to IVB disease based on the 6th edition of the American Joint Committee on Cancer (stage IVB: only metastasis to the supraclavicular/celiac lymph nodes) and an Eastern Cooperative Oncology Group performance status of 0 to 1. Data analysis was performed from August 1, 2020, to March 10, 2021. Interventions Patients were stratified according to age (<80 vs ≥80 years) and tumor length (<5 vs ≥5 cm) and randomly assigned (1:1) to receive either CCRT with S-1 or RT alone. Main Outcomes and Measures The primary end point was the 2-year overall survival rate using intention-to-treat analysis. Results Of the 298 patients enrolled, 180 (60.4%) were men. The median age was 77 (interquartile range, 74-79) years in the CCRT group and 77 (interquartile range, 74-80) years in the RT alone group. A total of 151 patients (50.7%) had stage III or IV disease. The CCRT group had a significantly higher complete response rate than the RT group (41.6% vs 26.8%; P = .007). Surviving patients had a median follow-up of 33.9 months (interquartile range: 28.5-38.2 months), and the CCRT group had a significantly higher 2-year overall survival rate (53.2% vs 35.8%; hazard ratio, 0.63; 95% CI, 0.47-0.85; P = .002). There were no significant differences in the incidence of grade 3 or higher toxic effects between the CCRT and RT groups except that grade 3 or higher leukopenia occurred in more patients in the CCRT group (9.5% vs 2.7%; P = .01). Treatment-related deaths were observed in 3 patients (2.0%) in the CCRT group and 4 patients (2.7%) in the RT group. Conclusions and Relevance In this phase 3 randomized clinical trial, CCRT with S-1 was tolerable and provided significant benefits over RT alone in older patients with esophageal cancer. Trial Registration ClinicalTrials.gov Identifier: NCT02813967.
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Affiliation(s)
- Yongling Ji
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Xianghui Du
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Weiguo Zhu
- The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Nanjing, China
| | | | - Jun Ma
- Anhui Provincial Hospital, Hefei, China
| | - Li Zhang
- Chongqing Sanxia Central Hospital, Chongqing, China
| | - Jiancheng Li
- Fujian Provincial Cancer Hospital, Fuzhou, China
| | - Hua Tao
- Jiangsu Cancer Hospital, Nanjing, China
| | | | - Haihua Yang
- Taizhou Hospital of Zhejiang Province, Taizhou, China
| | - Jin Huang
- The First People's Hospital of Changzhou, Changzhou, China
| | - Yong Bao
- The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Dexi Du
- Lishui Municipal Central Hospital, Lishui, China
| | - Degan Liu
- Xinghua City People's Hospital, Xinghua, China
| | | | | | - Xinmei Yang
- The First Hospital of Jiaxing, Jiaxing, China
| | - Ming Zeng
- Sichuan Provincial People's Hospital, Chengdu, China
| | - Zhigang Liu
- The Fifth Affiliated Hospital Sun Yat-sen University, Guangzhou, China
| | - Wen Zheng
- Shangrao People's Hospital, Shangrao, China
| | - Juan Pu
- Lianshui County People's Hospital, Lianshui, China
| | - Jun Chen
- Yinzhou People's Hospital, Ningbo, China
| | - Wangyuan Hu
- Jinhua Municipal Central Hospital, Jinhua, China
| | - Peijing Li
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Jin Wang
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Yujin Xu
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Xiao Zheng
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Jianxiang Chen
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Wanwei Wang
- The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Nanjing, China
| | - Guangzhou Tao
- The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Cai
- Nantong Tumor Hospital, Nantong, China
| | | | - Jun Zhu
- Jiangsu Cancer Hospital, Nanjing, China
| | | | - Yan Yan
- Huaian Second People's Hospital, Huaian, China
| | - Guoping Xu
- The First People's Hospital of Changzhou, Changzhou, China
| | | | - Binbin Song
- The First Hospital of Jiaxing, Jiaxing, China
| | - Ke Xie
- Sichuan Provincial People's Hospital, Chengdu, China
| | - Shan Huang
- Sichuan Provincial People's Hospital, Chengdu, China
| | - Yuanda Zheng
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Liming Sheng
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Xiaojing Lai
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Ying Chen
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Lei Cheng
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Xiao Hu
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Wenhao Ji
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Min Fang
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Yue Kong
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Xiaofu Yu
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Huizhang Li
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Runhua Li
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China
| | - Lei Shi
- Shanghai Key Laboratory of Artificial Intelligence for Medical Image and Knowledge Graph, Shanghai, China
| | - Wei Shen
- Shanghai Key Laboratory of Artificial Intelligence for Medical Image and Knowledge Graph, Shanghai, China
| | - Chaonan Zhu
- Shanghai Key Laboratory of Artificial Intelligence for Medical Image and Knowledge Graph, Shanghai, China
| | - Junwei Lv
- Shanghai Key Laboratory of Artificial Intelligence for Medical Image and Knowledge Graph, Shanghai, China
| | - Rong Huang
- The First People's Hospital of Foshan, Foshan, China
| | - Han He
- The First People's Hospital of Foshan, Foshan, China
| | - Ming Chen
- Department of Radiation Oncology, Cancer Hospital of the University of Chinese Academy of Science/Institute of Cancer and Basic Medicine, Chinese Academy of Science, Zhejiang Key Laboratory of Radiation Oncology, Hangzhou, China.,Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
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15
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Jia X, Huang C, Hu Y, Wu Q, Liu F, Nie W, Chen H, Li X, Dong Z, Liu K. Cirsiliol targets tyrosine kinase 2 to inhibit esophageal squamous cell carcinoma growth in vitro and in vivo. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2021; 40:105. [PMID: 33731185 PMCID: PMC7972218 DOI: 10.1186/s13046-021-01903-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/08/2021] [Indexed: 12/19/2022]
Abstract
Background Esophageal squamous cell carcinoma (ESCC) is an aggressive and lethal cancer with a low 5 year survival rate. Identification of new therapeutic targets and its inhibitors remain essential for ESCC prevention and treatment. Methods TYK2 protein levels were checked by immunohistochemistry. The function of TYK2 in cell proliferation was investigated by MTT [(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] and anchorage-independent cell growth. Computer docking, pull-down assay, surface plasmon resonance, and kinase assay were used to confirm the binding and inhibition of TYK2 by cirsiliol. Cell proliferation, western blot and patient-derived xenograft tumor model were used to determine the inhibitory effects and mechanism of cirsiliol in ESCC. Results TYK2 was overexpressed and served as an oncogene in ESCC. Cirsiliol could bind with TYK2 and inhibit its activity, thereby decreasing dimer formation and nucleus localization of signal transducer and activator of transcription 3 (STAT3). Cirsiliol could inhibit ESCC growth in vitro and in vivo. Conclusions TYK2 is a potential target in ESCC, and cirsiliol could inhibit ESCC by suppression of TYK2. Supplementary Information The online version contains supplementary material available at 10.1186/s13046-021-01903-z.
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Affiliation(s)
- Xuechao Jia
- Department of Pathophysiology, The School of Basic Medical Sciences, AMS, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, 450001, Henan, China.,China-US (Henan) Hormel Cancer Institute, Zhengzhou, 450008, Henan, China
| | - Chuntian Huang
- Department of Pathophysiology, The School of Basic Medical Sciences, AMS, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, 450001, Henan, China.,China-US (Henan) Hormel Cancer Institute, Zhengzhou, 450008, Henan, China
| | - Yamei Hu
- Department of Pathophysiology, The School of Basic Medical Sciences, AMS, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, 450001, Henan, China.,China-US (Henan) Hormel Cancer Institute, Zhengzhou, 450008, Henan, China
| | - Qiong Wu
- Department of Pathophysiology, The School of Basic Medical Sciences, AMS, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, 450001, Henan, China.,China-US (Henan) Hormel Cancer Institute, Zhengzhou, 450008, Henan, China
| | - Fangfang Liu
- Department of Pathophysiology, The School of Basic Medical Sciences, AMS, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, 450001, Henan, China.,China-US (Henan) Hormel Cancer Institute, Zhengzhou, 450008, Henan, China
| | - Wenna Nie
- China-US (Henan) Hormel Cancer Institute, Zhengzhou, 450008, Henan, China
| | - Hanyong Chen
- The Hormel Institute, University of Minnesota, Austin, MN, 55912, USA
| | - Xiang Li
- Department of Pathophysiology, The School of Basic Medical Sciences, AMS, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, 450001, Henan, China.,China-US (Henan) Hormel Cancer Institute, Zhengzhou, 450008, Henan, China
| | - Zigang Dong
- Department of Pathophysiology, The School of Basic Medical Sciences, AMS, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, 450001, Henan, China. .,China-US (Henan) Hormel Cancer Institute, Zhengzhou, 450008, Henan, China. .,Cancer Chemoprevention International Collaboration Laboratory, Zhengzhou, Henan, China.
| | - Kangdong Liu
- Department of Pathophysiology, The School of Basic Medical Sciences, AMS, Zhengzhou University, 100 Kexue Avenue, Zhengzhou, 450001, Henan, China. .,China-US (Henan) Hormel Cancer Institute, Zhengzhou, 450008, Henan, China. .,Cancer Chemoprevention International Collaboration Laboratory, Zhengzhou, Henan, China. .,Provincial Cooperative Innovation Center for Cancer Chemoprevention, Zhengzhou University, Zhengzhou, Henan, China. .,State Key Laboratory of Esophageal Cancer Prevention and Treatment, Zhengzhou, Henan, China.
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16
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Dohm A, Diaz R, Nanda RH. The Role of Radiation Therapy in the Older Patient. Curr Oncol Rep 2021; 23:11. [PMID: 33387104 DOI: 10.1007/s11912-020-01000-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW Older patients represent a unique subgroup of the cancer patient population for which the role of radiation therapy (RT) requires special consideration. This review will discuss many of these considerations as well as various radiation treatment techniques in the context of a variety of disease sites. RECENT FINDINGS Several recent studies give insight into the management of older cancer patients considering their age, performance status, comorbid conditions, quality of life, genetics, cost, and individual goals. RT plays an evolving and pivotal role in providing optimal care for this population. Recent advances in RT technique allow for more precise treatment delivery and reduced toxicity. Studies evaluating the use of radiation therapy in breast, brain, lung, prostate, rectal, pancreatic, esophageal, and oligometastatic cancer are summarized and discussed in the context of treating the older patient population. Individual age, performance and functional status, comorbid conditions, and patients' objectives and goals should all be considered when presenting treatment options for older patients and age alone should not disqualify patients from curative intent treatments. When possible, hypofractionated courses should be utilized as outcomes are often equivalent and toxicities are reduced. In many cases, RT may be preferable to other treatment options due to decreased toxicity profile and acceptable disease control.
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Affiliation(s)
- Ammoren Dohm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - Roberto Diaz
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA
| | - Ronica H Nanda
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Dr., Tampa, FL, 33612, USA.
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17
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[F18] FDG-PET/CT for manual or semiautomated GTV delineation of the primary tumor for radiation therapy planning in patients with esophageal cancer: is it useful? Strahlenther Onkol 2020; 197:780-790. [PMID: 33104815 PMCID: PMC8397654 DOI: 10.1007/s00066-020-01701-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/29/2020] [Indexed: 11/15/2022]
Abstract
Background Target volume definition of the primary tumor in esophageal cancer is usually based on computed tomography (CT) supported by endoscopy and/or endoscopic ultrasound and can be difficult given the low soft-tissue contrast of CT resulting in large interobserver variability. We evaluated the value of a dedicated planning [F18] FDG-Positron emission tomography/computer tomography (PET/CT) for harmonization of gross tumor volume (GTV) delineation and the feasibility of semiautomated structures for planning purposes in a large cohort. Methods Patients receiving a dedicated planning [F18] FDG-PET/CT (06/2011–03/2016) were included. GTV was delineated on CT and on PET/CT (GTVCT and GTVPET/CT, respectively) by three independent radiation oncologists. Interobserver variability was evaluated by comparison of mean GTV and mean tumor lengths, and via Sørensen–Dice coefficients (DSC) for spatial overlap. Semiautomated volumes were constructed based on PET/CT using fixed standardized uptake values (SUV) thresholds (SUV30, 35, and 40) or background- and metabolically corrected PERCIST-TLG and Schaefer algorithms, and compared to manually delineated volumes. Results 45 cases were evaluated. Mean GTVCT and GTVPET/CT were 59.2/58.0 ml, 65.4/64.1 ml, and 60.4/59.2 ml for observers A–C. No significant difference between CT- and PET/CT-based delineation was found comparing the mean volumes or lengths. Mean Dice coefficients on CT and PET/CT were 0.79/0.77, 0.81/0.78, and 0.8/0.78 for observer pairs AB, AC, and BC, respectively, with no significant differences. Mean GTV volumes delineated semiautomatically with SUV30/SUV35/SUV40/Schaefer’s and PERCIST-TLG threshold were 69.1/23.9/18.8/18.6 and 70.9 ml. The best concordance of a semiautomatically delineated structure with the manually delineated GTVCT/GTVPET/CT was observed for PERCIST-TLG. Conclusion We were not able to show that the integration of PET/CT for GTV delineation of the primary tumor resulted in reduced interobserver variability. The PERCIST-TLG algorithm seemed most promising compared to other thresholds for further evaluation of semiautomated delineation of esophageal cancer.
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18
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Kawamoto T, Shikama N, Mine S, Tsurumaru M, Sasai K. Clinical impact of baseline renal function on the safety of radiotherapy with concurrent docetaxel for esophageal cancer in elderly patients. Esophagus 2020; 17:425-432. [PMID: 32170545 DOI: 10.1007/s10388-020-00731-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 03/04/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND We aimed to compare the safety of radiotherapy with concurrent docetaxel (DOC-RT) for esophageal cancer (EC) in elderly patients who were divided into a creatinine clearance (Ccr) < 60 mL/min (Ccr-L) group and a Ccr ≥ 60 mL/min (Ccr-H) group. METHODS Eligible patients included those aged ≥ 76 years who were diagnosed with esophageal squamous cell carcinoma. The patients received radiotherapy (60 Gy in 30 fractions) and concurrent docetaxel (10 mg/m2 weekly for six cycles), after which toxicity and treatment completion rates were retrospectively evaluated. RESULTS The 73 elderly EC patients receiving DOC-RT were divided into two groups for evaluation: the Ccr-L group (49 patients) and the Ccr-H group (24 patients). The median survival time for patients in the Ccr-L and Ccr-H groups was 21 and 20 months, respectively (p = 0.2). The incidence of grade 1 acute kidney injury was 8% vs. 8% (p = 1) in the Ccr-L and Ccr-H groups, respectively. No other hematological or nonhematological toxicities differed between patients in the two groups. No grade 4 or 5 toxicities were observed in the two groups. No significant difference was observed in the treatment completion rates (88% vs. 92%, p = 1) between patients in the Ccr-L and Ccr-H groups. CONCLUSIONS Regardless of baseline renal function, DOC-RT is a safe regimen for elderly patients with EC.
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Affiliation(s)
- Terufumi Kawamoto
- Department of Radiation Oncology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Naoto Shikama
- Department of Radiation Oncology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Shinji Mine
- Department of Esophageal and Gastroenterological Surgery, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Masahiko Tsurumaru
- Department of Esophageal and Gastroenterological Surgery, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Keisuke Sasai
- Department of Radiation Oncology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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Mayr P, Martin B, Fries V, Claus R, Anthuber M, Messmann H, Schenkirsch G, Blodow V, Kahl KH, Stüben G. Neoadjuvant and Definitive Radiochemotherapeutic Approaches in Esophageal Cancer: A Retrospective Evaluation of 122 Cases in Daily Clinical Routine. Oncol Res Treat 2020; 43:372-379. [PMID: 32485721 DOI: 10.1159/000507737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 04/04/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Esophageal cancer (EC) is a common malignant tumor entity with increasing occurrence. The incidence of esophageal adenocarcinoma (AC), particularly, is constantly rising in the Western world. The mainstays of therapy with curative intent for EC in advanced stages are neoadjuvant radiochemotherapy (neoRCT) with surgery and definitive radiochemotherapy (defRCT). METHODS We examined our internal files to identify patients suffering from EC. Palliative cases were excluded. Statistical testing was performed by χ2 test, Student's t test, Kaplan-Meier analyses, and the Mann-Whitney U test. RESULTS One hundred and twenty-two cases were included. Histology revealed squamous cell carcinoma in 92 cases and AC in 23 cases. Ninety-five patients underwent defRCT, 27 underwent neoRCT, and 114 (in both therapy regimes) received simultaneous chemotherapy. There was no difference in the overall survival (OS) (p = 0.654; HR 1.145; 95% CI 0.629-2.086) or and progression-free survival (PFS) (p = 0.912) of patients who underwent neoRCT or defRCT. Median OS was 13.5 (2-197) months for defRCT patients and 19.5 (2-134) months for neoRCT patients (p = 0.751). Karnofsky index (KI) with a cut-off of 70% was strongest, but not a significant parameter for OS (p = 0.608) or PFS (p = 0.137). CONCLUSION defRCT is a valid and an equal alternative to neoRCT for patients suffering from EC. Selection of patients for therapy is of crucial relevance. Further studies and improvements in follow-up are needed when neoRCT has been completed before surgery, in order to spare the patient undergoing operative treatment if there is complete remission. The identification of valid markers urgently needed to limit treatment side effects.
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Affiliation(s)
- Patrick Mayr
- Department of Radio-Oncology, University Hospital of Augsburg, Augsburg, Germany, .,Department of Hematology and Oncology, University Hospital of Augsburg, Augsburg, Germany,
| | - Benedikt Martin
- Department of Pathology, University Hospital of Augsburg, Augsburg, Germany
| | - Verena Fries
- Department of Radio-Oncology, University Hospital of Augsburg, Augsburg, Germany
| | - Rainer Claus
- Department of Hematology and Oncology, University Hospital of Augsburg, Augsburg, Germany
| | - Matthias Anthuber
- Department of Surgery, University Hospital of Augsburg, Augsburg, Germany
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany
| | - Gerhard Schenkirsch
- Department of Tumor Data Management, University Hospital of Augsburg, Augsburg, Germany
| | - Vera Blodow
- Department of Nuclear Medicine, University Hospital of Augsburg, Augsburg, Germany
| | - Klaus Henning Kahl
- Department of Radio-Oncology, University Hospital of Augsburg, Augsburg, Germany
| | - Georg Stüben
- Department of Radio-Oncology, University Hospital of Augsburg, Augsburg, Germany
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20
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Rahimy E, Koong A, Toesca D, White MN, Panjwani N, Fisher G, Chang D, Pollom E. Outcomes and Tolerability of Definitive and Preoperative Chemoradiation in Elderly Patients With Esophageal Cancer: A Retrospective Institutional Review. Adv Radiat Oncol 2020; 5:1188-1196. [PMID: 33305080 PMCID: PMC7718494 DOI: 10.1016/j.adro.2020.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/02/2020] [Accepted: 05/05/2020] [Indexed: 12/29/2022] Open
Abstract
Purpose Our purpose was to report outcomes of elderly patients who underwent definitive treatment involving radiation therapy for esophageal cancer at our institution. Methods and Materials We performed a retrospective review of patients aged ≥75 years with esophageal cancer treated with definitive radiation therapy (≥45 Gy) at our institution from 1997 to 2019. Acute and late Radiation Therapy Oncology Group grade 3+ toxicities were recorded. Survival was estimated using the Kaplan-Meier method. Results Of the 89 patients included, median age was 80 and 78% were male. Median adjusted Charlson Comorbidity Index and Karnofsky Performance Status were 5 (3-12) and 80 (50-100), respectively. The majority of cancers were adenocarcinoma (58%), distal (67%), and stage III (62%). Fifty-eight percent underwent definitive chemoradiotherapy, and one-third underwent preoperative intent chemoradiotherapy. Median prescribed dose was 50 Gy (45-66 Gy), and intensity modulated radiation therapy was used in 76%. Eighty-five percent completed the radiation therapy course. Among these, 20% had radiation therapy breaks. For those receiving concurrent chemotherapy, 37% had a dose reduction and 39.5% had a break/cycle reduction. Acute grade 3+ toxicity was 22%, with 2% grade 5 toxicity. Twenty-one of the 29 patients (72%) treated with preoperative intent underwent surgery. There were no deaths 90 days postoperatively. For patients who underwent surgery, 1- and 2-year overall survival were 95% and 84%. For those who did not undergo surgery, 1- and 2-year overall survival were 70% and 52%. Conclusions There is a role for aggressive radiation therapy in well-selected elderly patients with esophageal cancer. However, optimization of supportive care, chemotherapy regimens, radiation therapy dose/fractionation, and surgical indications are needed to reduce toxicity.
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Affiliation(s)
- Elham Rahimy
- Department of Radiation Oncology, Stanford University, Palo Alto, California
| | - Amanda Koong
- Department of Radiation Oncology, Stanford University, Palo Alto, California
| | - Diego Toesca
- Department of Radiation Oncology, Stanford University, Palo Alto, California
| | - Maya N White
- Department of Oncology, Stanford University, Palo Alto, California
| | - Neil Panjwani
- Department of Radiation Oncology, Stanford University, Palo Alto, California
| | - George Fisher
- Department of Oncology, Stanford University, Palo Alto, California
| | - Daniel Chang
- Department of Radiation Oncology, Stanford University, Palo Alto, California
| | - Erqi Pollom
- Department of Radiation Oncology, Stanford University, Palo Alto, California
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21
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Hypofractionated volumetric modulated arc therapy (VMAT) for fragile patients with oesophageal cancer. Clin Transl Oncol 2020; 22:1532-1538. [PMID: 31970685 DOI: 10.1007/s12094-020-02293-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 01/07/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE To evaluate the feasibility, safety, and dosimetric results of volumetric modulated arc therapy (VMAT) to deliver hypofractionated radiotherapy (RT) in oesophageal cancer patients, unfit for a multimodality curative strategy. PATIENTS/METHODS From 2010 to 2017, 22 patients were treated with hypofractionated VMAT for palliative/symptomatic setting. The prescription dose was 40 Gy in 16 fractions (EQD2 41.7 Gy considering an α/β ratio of 10 Gy, and 44 Gy considering an α/β ratio of 3 Gy). RESULTS Eight patients (36%) were symptomatic for grade 3 baseline dysphagia. RT was generally well tolerated, and no patient interrupted the daily treatment. Acute toxicity was generally mild; no G3 acute toxicities were reported. At the end of treatment, 5 patients (22.7%) experienced a stable dysphagia and 14 (63.6%) an improvement of baseline dysphagia, while 3 patients (13.7%) reported a worsening of oesophagitis. At a mean follow-up of 8.7 months, 15 patients (79%) had a complete clinical recovery (G0-1) of the symptomatic moderate/severe dysphagia. At 3 months after the end of RT, seven patients (31.8%) achieved a partial or complete response. Two coplanar arcs were employed for VMAT delivery. Dosimetric results were consistent in terms of both target coverage and normal tissue sparing. Finally, 1-year progression-free and overall survival was 20% and 27.3%, respectively. CONCLUSIONS Hypofractionated VMAT was feasible, safe, and effective to deliver symptomatic radiation in locally advanced oesophageal cancer patients, non-suitable for a standard curative treatment.
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22
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Kawamoto T, Shikama N, Oshima M, Kosugi Y, Tsurumaru M, Sasai K. Safety of radiotherapy with concurrent docetaxel in older patients with esophageal cancer. J Geriatr Oncol 2019; 11:675-679. [PMID: 31471169 DOI: 10.1016/j.jgo.2019.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 07/27/2019] [Accepted: 08/21/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Considering that therapeutic strategies for older adult patients with esophageal cancer (EC) remain controversial, we aimed to assess the safety of radiotherapy with concurrent docetaxel (DOC-RT) among older adult patients with EC. MATERIALS AND METHODS Eligible patients included those aged ≥76 years who were diagnosed with esophageal squamous cell carcinoma. Patients received radiotherapy (60 Gy in 30 fractions) and concurrent docetaxel (10 mg/m2 weekly for six cycles). Survival, toxicity, and treatment completion rates were retrospectively evaluated. RESULTS Among 84 older adult patients receiving radical radiotherapy or chemoradiotherapy, 73 receiving DOC-RT were studied. Median follow-up duration was 14 months (range, 2-101 months). The 1-, 3-, and 5-year overall survival rates were 63%, 33%, and 13%, respectively, with a median survival time of 21 months. Grade 3 acute toxicities included esophagitis (7%), esophageal fistula (3%), pneumonitis (1%), leukopenia (10%), and anemia (8%). Grade 3 late toxicities included esophageal stenosis (4%), pleural effusion (3%), pericardial effusion (1%), and pneumonitis (1%). Grade 4 and 5 toxicities were not observed. DOC-RT was discontinued due to deterioration in the general condition (6%), esophageal fistula (3%), pneumonia (1%), and pain (1%), resulting in a DOC-RT completion rate of 89% (65/73 patients). The non-completion group comprised a higher proportion of older adults (age ≥ 80 years) and undernourished [geriatric nutritional risk index (GNRI <92)] patients than the completion group. CONCLUSION DOC-RT can be a safe regimen for older adult patients with EC. Nonetheless, old age (≥80 years) and undernourishment (GNRI <92) should be considered prior to DOC-RT administration.
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Affiliation(s)
- Terufumi Kawamoto
- Department of Radiation Oncology, Juntendo University, Graduate School of Medicine, Japan.
| | - Naoto Shikama
- Department of Radiation Oncology, Juntendo University, Graduate School of Medicine, Japan
| | - Masaki Oshima
- Department of Radiation Oncology, Juntendo University, Graduate School of Medicine, Japan
| | - Yasuo Kosugi
- Department of Radiation Oncology, Juntendo University, Graduate School of Medicine, Japan
| | - Masahiko Tsurumaru
- Department of Esophageal and Gastroenterological Surgery, Juntendo University, Graduate School of Medicine, Japan
| | - Keisuke Sasai
- Department of Radiation Oncology, Juntendo University, Graduate School of Medicine, Japan
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23
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Lin JB, Hung LC, Cheng CY, Chien YA, Lee CH, Huang CC, Chou TW, Ko MH, Lai YC, Liu MT, Chang TH, Lee J, Chen YJ. Prognostic significance of lung radiation dose in patients with esophageal cancer treated with neoadjuvant chemoradiotherapy. Radiat Oncol 2019; 14:85. [PMID: 31126307 PMCID: PMC6534831 DOI: 10.1186/s13014-019-1283-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 04/25/2019] [Indexed: 12/13/2022] Open
Abstract
Background The prognostic significance of radiation dose to the lung or heart is unknown in esophageal cancer patients receiving neoadjuvant chemoradiotherapy followed by surgery (trimodal therapy). This study aimed to determine the association between lung and heart radiation dose volumes and prognosis of esophageal cancer after trimodal therapy. Methods This study reviewed 123 esophageal cancer patients treated with trimodal therapy in two tertiary institutions between 2010 and 2015. The dose-volume histogram parameter of Vx was defined as the percentage of total organ volume receiving a radiation dose of x (Gy) or more. Predictors of overall survival (OS) were identified using Cox regression models. Receiver-operating characteristic curves were used to select cut-off values for dose-volume. Results Median follow-up was 28.3 months (range: 4.7–92.8 months). Median OS and progression-free survival were 34.0 months (95% confidence interval [CI]: 27.4–40.6 months) and 24.8 months (95% CI, 18.9–30.7 months), respectively. Multivariate analyses showed that lung V20 (hazard ratio, 1.09; 95% CI: 1.04–1.14; p < 0.001) and lung V5 (hazard ratio, 1.02; 95% CI: 1.00–1.05; p = 0.03) were associated with OS when adjusting for surgical margin and pathological treatment response. The 5-year OS for patients with lung V20 ≤ 23% vs. patients with lung V20 > 23% was 54.4% vs. 5% (p < 0.001) whereas that for patients with lung V5 ≤ 56% vs. patients with lung V5 > 56% was 81.5% vs. 23.4% (p < 0.001). Mean heart dose showed no association with survival outcomes. Conclusions Lung radiation dose was independently associated with survival outcomes in esophageal cancer patients treated with neoadjuvant chemoradiotherapy and surgery. Electronic supplementary material The online version of this article (10.1186/s13014-019-1283-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jhen-Bin Lin
- Department of Radiation Oncology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua City, 50006, Taiwan
| | - Li-Chung Hung
- Department of Radiation Oncology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua City, 50006, Taiwan
| | - Ching-Yuan Cheng
- Department of Thoracic Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Yu-An Chien
- Department of Radiation Oncology, Changhua Christian Hospital Yunlin Branch, Yunlin, Taiwan
| | - Chou-Hsien Lee
- Department of Radiation Oncology, E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Chia-Chun Huang
- Department of Radiation Oncology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua City, 50006, Taiwan
| | - Tsai-Wei Chou
- Department of Radiation Oncology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua City, 50006, Taiwan
| | - Ming-Huei Ko
- Division of Medical Physics, Department of Radiation Oncology, Changhua Christian Hospital, Changhua, Taiwan
| | - Yuan-Chun Lai
- Division of Medical Physics, Department of Radiation Oncology, Changhua Christian Hospital, Changhua, Taiwan
| | - Mu-Tai Liu
- Department of Radiation Oncology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua City, 50006, Taiwan.,Department of Medical Imaging and Radiological Technology, Yuanpei University of Science and Technology, Hsinchu, Taiwan
| | - Tung-Hao Chang
- Department of Radiation Oncology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua City, 50006, Taiwan. .,Department of Medical Imaging and Radiological Technology, Yuanpei University of Science and Technology, Hsinchu, Taiwan.
| | - Jie Lee
- Department of Radiation Oncology, MacKay Memorial Hospital, 92, Section 2, Chung Shan North Road, Taipei, 10449, Taiwan. .,Department of Medicine, MacKay Medical College, New Taipei city, Taiwan.
| | - Yu-Jen Chen
- Department of Radiation Oncology, MacKay Memorial Hospital, 92, Section 2, Chung Shan North Road, Taipei, 10449, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei city, Taiwan
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24
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Makino T, Yamasaki M, Tanaka K, Miyazaki Y, Takahashi T, Kurokawa Y, Motoori M, Kimura Y, Nakajima K, Mori M, Doki Y. Treatment and clinical outcome of clinical T4 esophageal cancer: A systematic review. Ann Gastroenterol Surg 2019; 3:169-180. [PMID: 30923786 PMCID: PMC6422802 DOI: 10.1002/ags3.12222] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/29/2018] [Accepted: 11/12/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Survival of patients with cT4 esophageal cancer is dismal. Although the optimal treatment strategy remains to be established, two treatment options are available for cT4 esophageal cancers: definitive chemoradiation (dCRT) and induction treatment followed by conversion surgery (CS). However, little is known concerning the differences in clinical outcome between patients with T4 esophageal tumors treated with dCRT and those eventually treated with CS. METHODS A systematic search of the scientific literature on PubMed/MEDLINE was carried out using the keywords "T4 esophageal cancer," "invading (involving) adjacent organ," "definitive chemoradiation," "induction therapy," "salvage surgery," and "conversion surgery," obtaining 28 reports published up to July 2018. RESULTS/CONCLUSION We found that CS was superior to dCRT with respect to local disease control and short-term survival; however, CS was associated with relatively higher perioperative mortality and morbidity. Alternatively, although dCRT might often cause fistula formation, a clinical complete response to dCRT is likely to lead to a better prognosis. Recent advances in chemotherapeutic agents have led to triple induction chemotherapy, with docetaxel, cisplatin, and 5-fluorouracil (DCF), which has shown promise as an initial induction treatment for cT4 esophageal cancer. Indeed, this regimen could control both local and systemic disease, which enables curative resection without preoperative CRT. Moreover, some appropriate changes in perioperative management and intensive systemic chemotherapy might enhance patient outcome. Randomized controlled trials with a large sample size are needed to establish the standard treatment for cT4 esophageal cancer.
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Affiliation(s)
- Tomoki Makino
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Makoto Yamasaki
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Koji Tanaka
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Yasuhiro Miyazaki
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Tsuyoshi Takahashi
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Yukinori Kurokawa
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | | | - Yutaka Kimura
- Department of SurgeryFaculty of MedicineKindai UniversityOsakaJapan
| | - Kiyokazu Nakajima
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Masaki Mori
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Yuichiro Doki
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
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