Survival benefit of neoadjuvant versus adjuvant radiotherapy in lymph node positive esophageal cancer: a population based analysis

Treatment and survival analysis for 40-year SEER data on upper esophageal cancer

Background

Upper esophageal cancer (UEC) is rare in both Eastern and Western countries. The epidemiological characteristics and long-term survival of UEC patients are less known. In addition, the choice of optimal treatment for UEC has been controversial.

Methods

Cases of UEC (C15.3 and C15.0) arising during the period from 1973 to 2013 were identified and selected using the SEER database. Student's t-test and Pearson's chi-square test were used to compare the differences in parameters among different groups. Esophageal cancer-specific survival (ECSS) and overall survival (OS) rates were calculated by using the Kaplan-Meier method. Cox proportional hazard regression was used to analyze predictive factors.

Results

In the past 40 years, the cases of UEC have gradually increased, and the proportion of adenocarcinoma (AD) has gradually increased (from 3.6% to 11.8%, p < 0.001). There has been a significant increase (1973-1982 vs. 2004-2013) in median OS (7 months vs. 10 months, p < 0.001) and median ECSS (7 months vs. 11 months, p < 0.001) among UEC patients from 1973 to 2013. For the impact of different treatments, the results showed that the ECSS and OS of surgery without radiation (SWR) and radiation plus surgery (R+S) were superior to those of radiation without surgery (RWS). Subgroup analysis showed that ECSS and OS were highest among patients treated with SWR compared with R+S and RWS for patients with localized disease. For regional disease, ECSS and OS were highest among patients with R+S compared with SWR or RWS. Among patients with regional-stage squamous cell carcinoma (SCC), OS was higher with neoadjuvant radiotherapy or adjuvant radiotherapy compared with SWR. Multivariate analysis showed that radiotherapy sequence was dependently associated with OS among patients with regional-stage SCC.

Conclusion

Although the long-term survival of UEC remains poor, it has gradually increased since 1973. This should be closely related to the improvement of medical care over the past 40 years. Different treatment methods have a great influence on the long-term survival of UEC. For localized diseases, surgery may be a better choice. For regional disease, surgery plus adjuvant or neoadjuvant radiotherapy may be more beneficial to improve the long-term prognosis of UEC patients.

Effects of preoperative radiotherapy on survival of patients with stage II and III esophageal squamous cell carcinoma: A population-based study

The impact of preoperative radiotherapy (PRT) on survival in patients with stage II and III esophageal squamous cell carcinoma (ESCC) remains controversial. The aim of this study was to explore the effect of PRT on survival of these patients.Patients with stage II and III ESCC who underwent chemotherapy ± PRT were identified and retrieved from the SEER database from 2010 to 2015. Cox regression analysis was used to identify independent prognostic factors in patients. Subgroup analysis stratified by T stage and N stage was performed. Kaplan-Meier survival analysis was performed to assess disease specific survival (DSS).A total of 1160 patients were retrieved, of whom 289 (24.9%) underwent PRT plus chemotherapy, and 871 (75.1%) did not receive PRT. In multivariate analysis, PRT plus chemotherapy was a favorable prognostic factor for patients with stage T2 (hazard ratio [HR], 0.364, 95% CI, 0.202-0.658; P < .001), T3 (HR, 0.536, 95% CI, 0.413-0.695; P < .001) and T4 (HR, 0.318, 95% CI, 0.125-0.805; P = .016), but PRT plus chemotherapy was not statistically significant on DSS in patients with T1 disease (HR, 0.556, 95% CI, 0.262-1.179; P = .126). All 3 different N stages (N0, N1, and N2 + N3) were statistically significant (P < .05) in chemotherapy with or without PRT.In conclusion, patients with stage II and III ESCC at the T2-T4 stage gained significant survival benefit from PRT plus chemotherapy.

Adjuvant Radiotherapy of Involved Field versus Elective Lymph Node in Patients with Operable Esophageal Squamous Cell Cancer: A Single Institution Prospective Randomized Controlled Study

Background: To evaluate locoregional failure and its impact on survival by comparing involved field irradiation (IFI) with elective lymph node irradiation (ENI) for patients with esophageal squamous cell cancer who underwent post-operative radiotherapy.

Methods and Materials: The enrolled patients were randomized allocated to IFI or ENI group. CTV of IFI was generated according to pre-operative primary tumor location and post-operative pathological characters and positive LNs regions. CTV of ENI was generated according to pre-operative tumor position to administer selective lymph node irradiation. Radiotherapy planning was delivered using either 3D-CRT or IMRT.

Results: A total of 57 patients were enrolled, 28 patients in ENI group and 29 patients in IFI group. There were not statistical differences between two groups in baseline (p>0.05). The initial locoregional failure rate was 17.9 % in ENI arm and 20.7% in IFI arm respectively (p=0.085). The 1-, 3-, and 5-year Progression-free Survival (PFS) were 63.2, 43.5, and 21.8 % in ENI arm versus 78.2, 60.1, and 55.1% in IFI arm (p =0.038). The 1-, 3-, and 5-year overall survival (OS) were 78.6, 46.9, and 23.5 % in ENI arm versus 72.9, 59.7, and 54.3 % in IFI arm (p=0.06). Acute radiation pneumonitis (p=0.005) and hematological toxicities (p =0.029) also showed statistical differences between groups, ENI arm was more than IFI arm.

Conclusions: The results indicated that IFI tended to improve survival and reduce toxicities for patients with operative ESCC and did not increase locoregional failure compared to ENI. It is thus suggested that IFI for ESCC PORT is worthy of clinical recommendation and further study.