Comparative effectiveness of image-guided radiotherapy for non-operated localized esophageal squamous cell carcinoma patients receiving concurrent chemoradiotherapy: A population-based propensity score matched analysis

Chemotherapy alone versus definitive concurrent chemoradiotherapy for cT4b esophageal squamous cell carcinoma: a population-based study

Background

The role of radiotherapy for cT4bNanyM0 esophageal squamous cell carcinoma (ESqCC) is relatively unclear, with both chemotherapy (C/T) alone and definitive concurrent chemoradiotherapy (dCCRT) being treatment options in the current guidelines. We aimed to compare the survival of dCCRT versus C/T for these patients via a population-based approach.

Methods

Eligible cT4b ESqCC patients diagnosed between 2011 and 2017 were identified via the Taiwan Cancer Registry. We used propensity score (PS) weighting to balance the observable potential confounders between groups. The hazard ratio (HR) of death and incidence of esophageal cancer mortality (IECM) were compared between dCCRT and C/T. We also evaluated OS in subgroups of either low or standard radiotherapy doses.

Results

Our primary analysis consisted of 247 patients in whom covariates were well balanced after PS weighing. The HR for death when dCCRT was compared with C/T was 0.36 (95% confidence interval 0.24–0.53, P < 0.001). Similar results were found for IECM. Statistical significance was only observed in the standard RT dose but not in the low dose in subgroup analyses.

Conclusions

In this population-based nonrandomized study of cT4bNanyM0 ESqCC patients from Asia (Taiwan), we found that the use of radiotherapy with chemotherapy was associated with better overall survival than chemotherapy alone. Further studies (especially RCTs) are needed to confirm our findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-01742-4.

Late-course accelerated Hyperfractionation vs. Conventional Fraction Radiotherapy under precise technology plus Concurrent Chemotherapy for Esophageal Squamous Cell Carcinoma: comparison of efficacy and side effects

Background: The accelerated reproliferation of esophageal squamous cell carcinoma (ESCC) after radiation contributes to conventional fraction radiotherapy (CFRT) failure. Late course accelerated hyperfractionated radiotherapy (LCAHFRT) can improve the long-term survival of esophageal cancer patients in China but is associated with a high rate of side effects due to the large exposure field of two-dimensional treatment and drug toxicity. Intensity-modulated radiotherapy (IMRT) can increase the tumor dose while decreasing the normal tissue dose. Therefore, we compared the outcomes and side effects of LCAHFIMRT plus concurrent chemotherapy (CT) and CFIMRT plus CT for ESCC.

Methods and Materials: Between 2013 and 2016, 114 eligible patients with ESCC were recruited and randomly assigned to receive LCAHFIMRT+CT (58 patients) or CFIMRT+CT (56 patients) by a linear accelerator (6-MV X-ray) under image guidance. Two cycles of CT with cisplatin and docetaxel were also administered.

Results: The complete response (CR) rates were 79.3% and 61.8% in the LCAHFIMRT+CT and CFIMRT+CT groups, respectively (P=0.041). The median duration of local control times was 31.0±1.9 months for the LCAHFIMRT+CT group and 24.0±3.3 months for the CFIMRT+CT groups,and the 1-, 2-, and 3-year local control rates were 86.2%, 63.8%, and 41.4% and 85.7%, 51.8%, and 32.1% for the LCAHFIMRT+CT and CFIMRT+CT groups (P=0.240), respectively. The median survival times were 34.0±1.1 months for the LCAHFIMRT+CT group and 28.0.0±3.7 months for the CFIMRT groups,and the 1-, 2-, and 3-year survival rates were 87.9%, 74.1%, and 44.8% and 87.5%, 60.7%, and 39.3% for the LCAHFIMRT+CT and CFIMRT+CT groups, respectively (P=0.405). The incidence of side effects was not significantly different between the two groups. Local recurrence and uncontrolled disease resulted in more deaths in the CFIMRT+CT group than in the LCAHFIMRT+CT group (58.9% vs. 39.7%) (P=0.040).

Conclusion: For ESCC patients, LCAHFRT delivered by image-guided intensity-modulated techniques Plus Concurrent Chemotherapy with cisplatin and docetaxel keeps safety and high CR rate, as well as local control and long-term survival rates.

Effectiveness of image-guided radiotherapy for locally advanced esophageal squamous cell carcinoma patients treated with definitive concurrent chemoradiotherapy

BACKGROUND

Image-guided radiotherapy (IGRT) is an advanced radiotherapy technique to improve the accuracy of treatment delivery. However, a recent randomized controlled trial (RCT) for prostate cancer patients treated with radiotherapy either via IGRT or routine care (no daily IGRT) reported a statistically significant worse overall survival for those treated with IGRT. This raised the concern regarding the effectiveness of IGRT for definitive concurrent chemoradiotherapy (dCCRT) for locally advanced esophageal squamous cell carcinoma (LA-ESqCC).

METHODS

Eligible LA-ESqCC patients diagnosed between 2011 and 2015 were identified via the Taiwan Cancer Registry. We estimated propensity scores to construct a 1:1 propensity-score-matched groups and balance observable potential confounders. The hazard ratio (HR) of death as well as other outcomes was compared between IGRT and non-IGRT matched groups during the entire follow-up period. The impact of additional covariables was considered in the sensitivity analysis.

RESULTS

Our study population included 590 patients in the primary analysis. The HR for death when IGRT was compared with non-IGRT was 0.92 (95% confidence interval 0.77-1.10, P = 0.35). There were also no significant differences for other outcomes or sensitivity analyses.

CONCLUSIONS

In this updated nonrandomized study using real world data, we found that the overall survival of LA-ESqCC patients treated with dCCRT was not statistically different between those treated with IGRT versus those without IGRT, although the hazard ratio was less than unity, ie, in favor of IGRT. The results should be interpreted with caution given the nonrandomized design and RCTs are needed to clarify our findings.

KEY POINTS

Significant findings of the study: The OS of LA-ESqCC patients treated with dCCRT was not statistically different between those treated with IGRT versus those without IGRT, although the hazard ratio was less than unity, ie, in favor of IGRT.

WHAT THIS STUDY ADDS

In this updated nonrandomized study using real world data with additional potential confounders, our study provided a reasonable tentative evidence of lack of RCT as suggested in the literature.

Effectiveness of image-guided radiotherapy for rectal cancer patients treated with neoadjuvant concurrent chemoradiotherapy: A population-based propensity score-matched analysis

AIM

The effects of image-guided radiotherapy (IGRT, an advanced RT technology) have been debated in the literature. We compared the outcomes of locally advanced rectal cancer (LARC) patients treated with neoadjuvant concurrent chemoradiotherapy (NCCRT; with vs without IGRT) in a large population-based propensity score (PS)-matched analysis.

METHODS

We identified LARC patients diagnosed between 2007 and 2015 via the Taiwan cancer registry (TCR) and constructed a PS-matched cohort to balance observable potential confounders. Outcomes (R0 resection, overall survival, incidence of local regional recurrence [ILRR], rectal cancer mortality [IRCM], other cancer mortality [IOCM] and cardiovascular mortality [ICVM]) were obtained from TCR and the national death registry. We compared the hazard ratio (HR) of death and other endpoints between IGRT and non-IGRT groups. We performed supplementary analysis (SA) to evaluate the robustness of these results in a subgroup, taking an additional potential confounder into account.

RESULTS

Our study population comprised of 586 patients that were balanced with regard to observed covariables. There was no significant difference in HR for death (0.99; 95% confidence interval 0.70-1.39; P = 0.94) between IGRT and non-IGRT groups. There were also no significant differences in R0 resection, ILRR, IRCM, IOCM or ICVM. The results of our SA were consistent with these findings.

CONCLUSION

For LARC patients treated with NCCRT, the treatment outcome was not significantly different among patients treated with and without IGRT. Further study is needed to clarify these results with consideration to additional potential confounding factors and toxicity profiles at endpoints.

miRNA‑30a‑3p inhibits metastasis and enhances radiosensitivity in esophageal carcinoma by targeting insulin‑like growth factor 1 receptor

It has been demonstrated that microRNAs (miRNAs) serve important roles in various biological processes, such as tumorigenesis. In the present study, the role of miR‑30a‑3p in the pathogenesis of esophageal carcinoma (EC) was investigated. Reverse transcription‑quantitative polymerase chain reaction was performed to determine the levels of miR‑30a‑3p expression in EC tissues and cell lines. Then, the effects of miR‑30a‑3p on the migration, invasion and radiosensitivity of EC cells were investigated using scratch‑wound, Transwell and radiosensitivity assays, respectively. A dual‑luciferase reporter assay was performed to determine potential interactions between miR‑30a‑3p and the 3'‑untranslated region (3'‑UTR) of insulin‑like growth factor 1 receptor (IGF‑1R). The results demonstrated that the levels of miR‑30a‑3p expression in EC tissues and cell lines were significantly decreased compared with those in paired healthy tissues and a human esophageal epithelial cell line. Upregulation of miR‑30a‑3p expression significantly suppressed migration, invasion and epithelial‑mesenchymal transition (EMT), and enhanced radiosensitivity in EC cells. Analysis of luciferase activity demonstrated that miR‑30a‑3p interacted with the 3'‑UTR of IGF‑1R, and knockdown of IGF‑1R induced similar effects on the migration, invasion, EMT and radiosensitivity of EC cells. The results indicated that miR‑30a‑3p suppressed metastasis and enhanced the radiosensitivity of EC cells via downregulation IGF‑1R, suggesting that miR‑30a‑3p may be a potential therapeutic target in the treatment of EC.

Neoadjuvant vs definitive concurrent chemoradiotherapy in locally advanced esophageal squamous cell carcinoma patients

Background

The optimal treatment for locally advanced esophageal squamous cell carcinoma remains unclear. We compared the clinical outcomes of neoadjuvant concurrent chemoradiotherapy (CCRT) followed by esophagectomy [the surgery group] and CCRT without surgery [the CCRT group] in patients with squamous cell carcinoma from an Asian population.

Methods

Eligible patients diagnosed from 2008 to 2015 were identified through the Taiwan Cancer Registry. To balance observable potential confounders, we constructed a 1:1 propensity score-matched cohort [surgery vs CCRT]. We compared the hazard ratios between the surgery and CCRT groups for death using a robust variance estimator. We also evaluated the outcomes of patients for freedom from local regional recurrence (FFLRR) and esophageal cancer-specific survival (ECSS). Extensive supplementary analyses were performed to examine the robustness of our findings.

Results

Our study population included 298 patients balanced with respect to the observed covariables. The hazard ratio of death was 0.56 [95% confidence interval 0.42~0.75] when surgery was compared to CCRT. The results remained significant in the FFLRR and ECSS outcomes. In the supplementary analyses, our results also remained significant when additional covariables were taken into consideration or when the definition of the index date was changed.

Conclusions

When compared to definitive CCRT, neoadjuvant CCRT followed by esophagectomy was associated with improved overall survival for locally advanced esophageal squamous cell carcinoma. However, given the nonrandomized nature of the study and the sensitivity to potentially unmeasured confounders, our results should be interpreted cautiously.

Comparison of intensity-modulated radiotherapy vs 3-dimensional conformal radiotherapy for patients with non-metastatic esophageal squamous cell carcinoma receiving definitive concurrent chemoradiotherapy: A population-based propensity-score-matched analysis

Whether the survival outcome of patients with non-metastatic esophageal squamous cell carcinoma (NM-ESCC) receiving definitive concurrent chemoradiotherapy (CCRT) is better with intensity-modulated radiotherapy (IMRT) or with 3-dimensional conformal radiotherapy (3DCRT) has been debated in the literature. We designed this population-based propensity-score (PS)-matched analysis to address this question. We identified eligible patients diagnosed between 2008 and 2015 from the Taiwan Cancer Registry and constructed a PS-matched cohort (1:1 for IMRT vs 3DCRT) to balance observable potential confounders. We compared the hazard ratio (HR) of death between IMRT and 3DCRT during the entire follow-up period. We also evaluated freedom from local regional recurrence (FFLRR) and esophageal cancer-specific survival (ECSS). Sensitivity analyses (SA) were performed to examine the robustness of our findings. Our study population constituted 558 patients who were well balanced with regard to the measured covariables. The HR of death with IMRT compared to 3DCRT was 0.43 (95% confidence interval 0.35-0.52, P < .001). The results remained significant for FFLRR and ECSS. In SA, our results remained significant when additional covariables were taken into consideration. The survival outcome of patients with NM-ESCC receiving CCRT might be better with IMRT vs 3DCRT. These study results should be interpreted with caution given some possible covariates lacking in the registry. Further studies are needed to clarify this issue.

Effectiveness of tomotherapy vs linear accelerator image-guided intensity-modulated radiotherapy for localized pharyngeal cancer treated with definitive concurrent chemoradiotherapy: a Taiwanese population-based propensity score-matched analysis

OBJECTIVE

This study used a population-based propensity score (PS)-matched analysis to compare the effectiveness of tomotherapy-based image-guided intensity-modulated radiotherapy (referred to as T-IMRT) with that of linear accelerator based (referred to as L-IMRT) for clinically localized pharyngeal cancer (LPC, divided into nasopharyngeal cancer and non-nasopharyngeal cancer) with definitive concurrent chemoradiotherapy (CCRT).

METHODS

Eligible LPC patients diagnosed between 2007 and 2014 were identified among all citizens in Taiwan from the Health and Welfare Data Science Center database. A PS-matched sample based on the PS estimated from the covariables of interest was constructed to compare the effectiveness of T-IMRT with L-IMRT. In the primary analysis, overall survival (OS) was compared for assessment of effectiveness. We also evaluated freedom from local regional recurrence and pharyngeal cancer-specific survival and performed supplementary analyses.

RESULTS

The study population included 960 patients equally divided into two groups. OS did not differ significantly between the T-IMRT and L-IMRT groups (hazard ratio for death: 0.82, p = 0.15, 5-year OS rate: 79 and 74% for T-IMRT and L-IMRT, respectively), and there were no significant differences in the other endpoints or supplementary analyses.

CONCLUSION

For LPC patients treated with definitive CCRT, we found no significant difference in disease control or survival between the T-IMRT and L-IMRT groups. However, further studies, especially randomized trials or studies focusing on other dimensions, such as quality of life, are needed. Advances in knowledge: We provide the first population-based study, as well as the largest study, on the clinical effectiveness of T-IMRT compared with L-IMRT in conjunction with CCRT in LPC patients.

2-Acetylamino-3-[4-(2-acetylamino-2-carboxyethylsulfanylcarbonylamino) phenyl carbamoylsulfanyl] propionic acid, a glutathione reductase inhibitor, induces G2/M cell cycle arrest through generation of thiol oxidative stress in human esophageal cancer cells

Esophageal squamous cell carcinoma (ESCC) is a highly malignant cancer with poor response to both of chemotherapy and radiotherapy. 2-Acetylamino-3-[4-(2-acetylamino-2-carboxyethylsulfanylcarbonylamino) phenyl carbamoylsulfanyl] propionic acid (2-AAPA), an irreversible inhibitor of glutathione reductase (GR), is able to induce intracellular oxidative stress, and has shown anticancer activity in many cancer cell lines. In this study, we investigated the effects of 2-AAPA on the cell proliferation, cell cycle and apoptosis and aimed to explore its mechanism of action in human esophageal cancer TE-13 cells. It was found that 2-AAPA inhibited growth of ESCC cells in a dose-dependent manner and it did not deplete reduced glutathione (GSH), but significantly increased the oxidized form glutathione (GSSG), resulting in decreased GSH/GSSG ratio. In consequence, significant reactive oxygen species (ROS) production was observed. The flow cytometric analysis revealed that 2-AAPA inhibited growth of esophageal cancer cells through arresting cell cycle in G₂/M phase, but apoptosis-independent mechanism. The G₂/M arrest was partially contributed by down-regulation of protein expression of Cdc-25c and up-regulation of phosphorylated Cdc-2 (Tyr15), Cyclin B1 (Ser147) and p53. Meanwhile, 2-AAPA-induced thiol oxidative stress led to increased protein S-glutathionylation, which resulted in α-tubulin S-glutathionylation-dependent depolymerization of microtubule in the TE-13 cells. In conclusion, we identified that 2-AAPA as an effective thiol oxidative stress inducer and proliferation of TE-13 cells were suppressed by G₂/M phase cell cycle arrest, mainly, through α-tubulin S-glutathionylation-mediated microtubule depolymerization. Our results may introduce new target and approach for esophageal cancer therapy through generation of GR-mediated thiol oxidative stress.