Concurrent chemoradiotherapy using paclitaxel plus cisplatin in the treatment of elderly patients with esophageal cancer

Development and internal validation of a nomogram for predicting survival of nonoperative EGFR-positive locally advanced elderly esophageal cancers

Purpose

This study aims to develop and validate a prediction model for non-operative, epidermal growth factor receptor (EGFR)-positive, locally advanced elderly esophageal cancer (LAEEC).

Methods

A total of 80 EGFR-positive LAEEC patients were included in the study. All patients underwent radiotherapy, while 41 cases received icotinib concurrent systemic therapy. A nomogram was established using univariable and multivariable Cox analyses. The model's efficacy was assessed through area under curve (AUC) values, receiver operating characteristic (ROC) curves at different time points, time-dependent AUC (tAUC), calibration curves, and clinical decision curves. Bootstrap resampling and out-of-bag (OOB) cross-validation methods were employed to verify the model's robustness. Subgroup survival analysis was also conducted.

Results

Univariable and multivariable Cox analyses revealed that icotinib, stage, and ECOG score were independent prognostic factors for LAEEC patients. The AUCs of model-based prediction scoring (PS) for 1-, 2-, and 3-year overall survival (OS) were 0.852, 0.827, and 0.792, respectively. Calibration curves demonstrated that the predicted mortality was consistent with the actual mortality. The time-dependent AUC of the model exceeded 0.75, and the internal cross-validation calibration curves showed good agreement between predicted and actual mortality. Clinical decision curves indicated that the model had a substantial net clinical benefit within a threshold probability range of 0.2 to 0.8. Model-based risk stratification analysis demonstrated the model's excellent ability to distinguish survival risk. Further subgroup analyses showed that icotinib significantly improved survival in patients with stage III and ECOG score of 1 (HR 0.122, P<0.001).

Conclusions

Our nomogram model effectively predicts the overall survival of LAEEC patients, and the benefits of icotinib were found in the clinical stage III population with good ECOG scores.

Chemoradiation for elderly patients (≥ 65 years) with esophageal cancer: a retrospective single-center analysis

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.

A Prospective Phase II Study of Simultaneous Modulated Accelerated Radiotherapy Concurrently With CDDP/S1 for Esophageal Squamous Cell Carcinoma in the Elderly

Background

To explore the efficacy and toxicity of simultaneous modulated accelerated radiotherapy (SMART) concurrently with cisplatin (CDDP) and S1 (tegafur/gimeracil/oteracil) in elderly patients with esophageal squamous cell carcinoma (ESCC).

Methods

This single-arm, phase II study enrolled pathologically confirmed, stage II-IVa ESCC of 70-80 years old and Eastern Cooperative Oncology Group performance status (ECOG PS) 0-2. Patients received SMART (64 Gy to gross tumor volume and 48 Gy to clinical target volume in 30 fractions) with concurrent CDDP (day 1 of each week) and S1 (days 1-14, 22-35). The primary endpoint was objective response rate (ORR). The secondary endpoints included progression-free survival (PFS), overall survival (OS) and toxicities.

Results

Thirty-seven eligible patients were analyzed with median follow-up of 25.7 months for all and 46.1 months for survivors. The ORR was 88.9%. Patients with baseline weight loss <5% (p=0.050) and nutritional risk index (NRI) ≥105.2 (p=0.023) had better tumor response. Median PFS was 13.8 months with 2-year PFS of 37.5%. Median OS was 27.7 months with 2-year OS of 57.5%. OS was significantly associated with ECOG PS (p=0.005), stage (p=0.014), gross tumor volume (p=0.004), baseline NRI (p=0.036), baseline C-reactive protein (CRP) level (p=0.003) and tumor response (p=0.000). CRP level (p=0.016) and tumor response (p=0.021) were independently prognostic of OS. ≥grade 3 anemia, neutropenia and thrombocytopenia occurred in 2.7%, 10.8% and 13.5% of patients; ≥grade 3 esophagitis and pneumonitis occurred in 18.9% and 2.7% of patient, respectively.

Conclusion

SMART concurrently with CDDP/S1 yielded satisfactory response rate, survival outcome and tolerable treatment-related toxicities in elderly patients with ESCC. Further studies are warranted to validate the results.

Protein deubiquitylase USP3 stabilizes Aurora A to promote proliferation and metastasis of esophageal squamous cell carcinoma

Aurora A kinase is a cell cycle regulator that is dysregulated in several different malignancies. Nevertheless, its regulatory mechanisms are still not fully understood. Here, we report that ubiquitin specific peptidase 3 (USP3) promotes proliferation and metastasis of esophageal squamous cell carcinoma (ESCC) cells by mediating deubiquitination of Aurora A. Analysis of human clinical samples indicated that USP3 and Aurora A are highly expressed in ESCC. Cellular experiments confirmed that high expression of USP3 and Aurora A in ESCC cells promoted malignant cell proliferation and invasion. In this mechanism, USP3 leads to suppression of Aurora A ubiquitination, resulting less proteasome degradation. We constructed the deubiquitinated mimetic K143R of Aurora A and found that K143R significantly promoted the proliferation and invasion of ESCC cells and was not regulated by the deubiquitination of USP3. Moreover, Aurora A K143R potentiated the kinase activity of Aurora A in ESCC cells. Thus, our findings demonstrate that the tumorigenic feature of ESCC is in part mediated by USP3-facilitated deubiquitination of Aurora A.

Icotinib With Concurrent Radiotherapy vs Radiotherapy Alone in Older Adults With Unresectable Esophageal Squamous Cell Carcinoma: A Phase II Randomized Clinical Trial

Importance

Palliative radiotherapy (RT) is generally recommended for older patients with esophageal squamous cell carcinoma (ESCC) with poor prognosis. A new combination treatment is therefore needed.

Objective

To assess the efficacy and toxicity of RT plus icotinib vs RT alone in older patients with ESCC.

Design, Setting, and Participants

This randomized, multicenter, open-label, phase II clinical trial was conducted in China, with enrollment between January 1, 2015, and October 31, 2016. Patients aged 70 years or older with clinical stage T2 to T4, N0/1, M0/1a unresectable (because of comorbidities, T4 disease, unresectable lymph node, or refused surgery) ESCC were randomized 1:1 to receive RT plus icotinib or RT alone. Radiation was prescribed at 60 Gy in 30 fractions in both groups, and icotinib was administered at a dosage of 125 mg 3 times a day in the RT plus icotinib group. The last follow-up was completed on June 30, 2019, and data were analyzed from July 1 to September 30, 2019.

Interventions

Patients were randomized to either RT plus icotinib or RT alone.

Main Outcomes and Measures

The primary end point was overall survival (OS). Treatment-related toxic effects were evaluated. Immunohistochemistry was performed to analyze epidermal growth factor receptor (EGFR) expression if available.

Results

A total of 127 patients (median age, 76 years [range, 70-91 years]; 76 men [59.8%]) were enrolled and were eligible for survival analysis. Median OS was 24.0 (95% CI, 22.2-25.8) months in the RT plus icotinib group vs 16.3 (95% CI, 13.8-18.8) months in the RT group (hazard ratio, 0.53; 95% CI, 0.33-0.87; P = .008). No difference was observed in grades 3 or 4 adverse events. Patients with EGFR overexpression had a significantly better median overall survival (not reached vs 16.3 months [range, 2.6-45.1 months]; P = .03) in the RT plus icotinib group.

Conclusions and Relevance

In this randomized clinical trial, icotinib plus RT was well tolerated and improved OS in older patients with ESCC relative to RT alone. Patients with EGFR overexpression benefitted more from icotinib with RT.

Trial Registration

ClinicalTrials.gov Identifier: NCT02375581.

Prognostic Value of the Geriatric Nutritional Risk Index in Patients Exceeding 70 Years Old with Esophageal Squamous Cell Carcinoma

To investigate the prognostic value of the Geriatric Nutritional Risk Index (GNRI) in esophageal squamous cell carcinoma (ESCC) patients treated with radiotherapy (RT) or definitive concurrent chemoradiotherapy (dCRT). Fifty-two ESCC patients were included from July 2014 to December 2018. RT was delivered at a dose of 1.8-2.0 Gy per day to a total dose of 50-60 Gy. Tumor response was assessed using the RECIST 1.1 system. Overall survival (OS) and progression-free survival (PFS) were calculated and compared with the Kaplan-Meier method. Multivariate analysis of predictive factors of response and survival was performed using a logistic regression and a Cox model, respectively. In multivariate analysis, GNRI score (HR 0.278, P = 0.036) was the only independent prognostic factor for tumor response. As for survival outcomes, GNRI score (OS: HR 0.505, P = 0.028; PFS: HR 0.583, P = 0.045) and treatment modality (OS: HR 0.356, P = 0.015; PFS: HR 0.392, P = 0.0014) were both independent prognostic factors for better OS and PFS. Additionally, there was no correlation between GNRI score and treatment modality (Spearman's ρ = 0.200; P = 0.154). In conclusion, routine use of the GNRI criteria may help in the risk stratification of elderly patients undergoing RT/dCRT. The dCRT treatment could provide survival benefits for elderly ESCC patients.

Concurrent liposomal paclitaxel and cisplatin chemotherapy improved outcomes for locally advanced esophageal squamous cell carcinoma treated with intensity-modulated radiotherapy

Background

To ascertain whether concurrent chemotherapy using liposomal paclitaxel and cisplatin could improve the outcomes of patients with locally advanced esophageal squamous cell carcinoma receiving intensity-modulated radiotherapy (IMRT).

Methods

A total of 72 patients with locally advanced esophageal squamous cell carcinoma, which were admitted to our hospital from October 2011 to December 2013, were retrospectively analyzed in this study.

Results

Thirty-six patients (50%) were treated with IMRT alone, while the other 36 patients (50%) were treated by IMRT combined with chemotherapy containing liposomal paclitaxel and cisplatin. Patients treated with chemoradiotherapy showed significantly superior overall survival (OS) and progression-free survival (PFS) compared to patients treated with IMRT alone (median OS: respectively, 29.7 vs. 12.9 months, P=0.0287; median PFS: respectively, 14.0 vs. 6.5 months, P=0.0186). Multivariate Cox analysis confirmed the inclusion of chemotherapy as an independent predictor of favorable OS and PFS. Both chemoradiotherapy and IMRT were well-tolerated in our cohort.

Conclusions

Chemotherapy improved the prognosis of locally advanced esophageal squamous cell carcinoma treated with IMRT. Large prospective studies are needed to confirm the therapeutic value of IMRT combined with chemotherapy in locally advanced esophageal squamous cell carcinoma.

Definitive Radiotherapy for Older Patients Aged ≥75 Years With Localized Esophageal Cancer

BACKGROUND/AIM

To evaluate the predictive factors in older patients with localized esophageal cancer treated with definitive radiotherapy.

PATIENTS AND METHODS

We retrospectively analyzed patients aged ≥75 years who were treated with three-dimensional conformal radiotherapy between 2008 and 2017. The patients were classified into the oldest-old group (≥80 years) and the old group (75-79 years).

RESULTS

Fifty patients were identified, 28 in the oldest-old group and 22 in the old group. Forty-six patients (92%) completed the planned radiotherapy. The median follow-up time was 21 months. Two-year overall survival (OS), disease-free survival, and locoregional control rates were 53%, 42%, and 51%, respectively. Univariate analyses for OS showed that neither the radiotherapy field nor total radiotherapy dose was a significant factor. Clinical T stage, clinical N stage, and age were independent predictors of OS.

CONCLUSION

Age ≥80 years is an independent prognostic factor for OS. Elective nodal irradiation and total radiotherapy dose above 50.4 Gy did not improve survival. Our findings may help in the treatment decisions for localized esophageal cancer in older patients.

Feasibility and efficiency of concurrent chemoradiotherapy with a single agent or double agents vs radiotherapy alone for elderly patients with esophageal squamous cell carcinoma: Experience of two centers

The incidence of elderly patients with esophageal cancer (OC) is increasing as the population ages. Until now, the treatment strategy in these patients has been unclear. The aim of our study was to assess the efficiency and tolerance of treatment with radiotherapy alone (RT alone), single‐agent‐based concurrent chemoradiotherapy (CCRT‐1), or double‐agent‐based concurrent chemoradiotherapy (CCRT‐2) in elderly patients (≥65 years) with OC. A total of 271 patients with OC aged 65 years or older were included in this study. The median overall survival (OS), median progression‐free survival (PFS), overall response rate (ORR), disease control rate (DCR), and treatment‐related toxicities were assessed. The median OS time for all patients was 23.6 ± 2.3 months, with 2‐year survival rates of 48.0 ± 3.0%. The median PFS time was 13.6 ± 1.3 months with the 2‐year PFS rate was 33.0 ± 4.0%. Among patients who received CCRT‐1, better OS, and PFS were found in patients who received docetaxel than in patients received fluorouracil and platinum. In a subgroup analysis, 118 patients who underwent RT alone had a median OS time of 15.6 ± 1.9 months and median PFS time of 10.4 ± 0.9 months. The median OS time of patients who received CCRT‐1 was 28.8 ± 10.1 months compared with 27.8 ± 2.5 months for the patients treated with CCRT‐2 (P = 0.537). The similar results were observed for median PFS, with 16.5 ± 3.2 months in the CCRT‐1 group and 17.0 ± 2.0 months in the CCRT‐2 group (P = 0.321). Grade ≥3 leukocytopenia and grade ≥2 weight loss during treatment occurred in 40.6% and 17.9% of patients, respectively, in the CCRT‐2 group, which was higher than that observed in the CCRT‐1 group. Our results suggested that CCRT could be considered as an acceptable treatment for elderly patients with OC. The CCRT‐1 group presented with a lower incidence of treatment toxicities but comparable survival outcomes, compared to the CCRT‐2 group. Docetaxel was superior to fluorouracil and platinum in terms of OS.

Concurrent chemoradiation therapy tailored to the older adults with esophageal cancer: state of the art and the future

Purpose

The aim of this study was to review the published literature addressing the question of whether geriatric assessment (GA) should be routinely applied in the treatment of older adults with esophageal cancer (EC) who have received definitive concurrent chemoradiotherapy (dCRT).

Materials and methods

A literature search of PubMed, Embase, and Cochrane Library was performed. Studies that contained original data outlining the inclusion and exclusion criteria, treatment compliance rate, and severe toxicity reports were reviewed. Additionally, criteria from ongoing clinical trials in the World Health Organization and National Institutes of Health registries were reviewed to evaluate the utilization of GA-related domains in elderly EC patients who received dCRT.

Results

Twenty-nine studies were identified based on the selection criteria: five were single-arm prospective studies, and the other studies were retrospective studies. All studies used chronological age and performance status as basic descriptors for this subpopulation. The comorbidity index and the malnutrition level were mentioned in several studies. However, factors such as “Demographic data and social support,” “Psychology,” “Polypharmacy,” and “Geriatric syndromes” were not described in any of the included studies. Unfortunately, the results were similar for the registered clinical trials. Finally, treatment compliance and toxicity profile were found to be acceptable in selected elderly EC patients.

Conclusion

The current experience for older adults with EC receiving dCRT is mainly based on the results of a series of retrospective studies. Ongoing clinical trials should routinely consider GA-related domains to select appropriate treatments for patients in the future.

Efficacy and safety of weekly nab-paclitaxel plus cisplatin with concurrent intensity-modulated radiotherapy in patients with inoperable, locally advanced esophageal cancer: a pilot trial

Background

Nab-paclitaxel is produced by the combination of paclitaxel particles with human serum albumin. Encouraging efficacy has been observed with nab-paclitaxel-based chemotherapy in a variety of solid tumors. The aim of the study reported here was to evaluate the efficacy and safety of weekly nab-paclitaxel plus cisplatin with concurrent intensity-modulated radiotherapy in patients with locally advanced esophageal cancer.

Methods

Seventeen patients with esophageal cancer were enrolled between July 2014 and December 2015.The treatment included radical radiotherapy (95% planning target volume 60Gy/30f) and concurrent chemotherapy comprising nab-paclitaxel 60mg/m²/week plus cisplatin 25mg/m²/week, administered on days 1, 8, 15, and 22 of each 28-day cycle. The end point of this study included objective response rate (ORR), local-recurrence free survival (LRFS), distant metastasis-free survival (DMFS), progression-free survival (PFS), and overall survival (OS).

Results

All the patients enrolled in the trial had squamous cell carcinoma. The median follow-up duration was 20.47 months. The ORR was 88.2%. LRFS, DMFS, PFS and OS at 3 years were 61%, 40%, 17% and 35%, respectively. The trial regimen was well tolerated, with grade 3-4 myelosupression, grade 3 radioactive esophagitis, and grade 3 radiation pneumonitis rates of 17.6%, 17.6%, and 11.8%, respectively.

Conclusion

Weekly nab-paclitaxel plus cisplatin with concurrent intensity-modulated radiotherapy is an effective and well-tolerated treatment option for inoperable, locally advanced squamous cancer of esophageal.

A Novel Prognostic Scoring System Using Inflammatory Response Biomarkers for Esophageal Squamous Cell Carcinoma

Background

We describe a novel scoring system, namely the inflammatory response biomarker (IRB) score. The aim of this study is to evaluate the clinical value of IRB score in patients undergoing curative resection for esophageal squamous cell carcinoma (SCC).

Methods

We retrospectively reviewed patients who underwent curative esophagectomy. We evaluated IRB score in both non-elderly (<70 years) and elderly (≥70 years) SCC patients. The IRB score was determined as follows: a high lymphocyte-to-monocyte ratio (LMR) (>4), a high neutrophil-to-lymphocyte ratio (NLR) (>1.6), and a low platelet-to-lymphocyte ratio (PLR) (<147) were each scored as 1, and the remaining values were scored as 0; the individual scores were then summed to produce the IRB score (range 0−3).

Results

Univariate analyses demonstrated that the TNM pStage (p < 0.0001), tumor size (p = 0.002), LMR (p = 0.0057), PLR (p = 0.0328) and IRB score (p = 0.0003) were significant risk factors for a worse prognosis. On multivariate analysis, the TNM pStage (p < 0.0001) and IRB score (p = 0.0227) were independently associated with worse prognosis in overall patients. Among non-elderly patients, multivariate analyses demonstrated that the pStage (p = 0.0015) and IRB score (p = 0.0356) were independent risk factors for a worse prognosis. Among elderly patients, multivariate analysis demonstrated that the pStage (p = 0.0016), and IRB score (p = 0.0102) were independent risk factors for a worse prognosis.

Conclusion

The present study provides evidence that the preoperative IRB score can be considered a promising independent prognostic factor of cancer-specific survival in patients undergoing curative resection for SCC, and that its predictive ability is useful in both non-elderly and elderly patients.

Esophageal Metal Stents with Concurrent Chemoradiation Therapy for Locally Advanced Esophageal Cancer: Safe or Not?

BACKGROUND

The purpose of this study was to review the risks and benefits of concurrent chemoradiation therapy (CCRT) with esophageal self-expandable metal stents (SEMS) for the treatment of locally advanced esophageal cancer.

MATERIALS AND METHODS

Between January 2014 and December 2016, the data from 46 locally advanced esophageal cancer patients who received CCRT at our institution were retrospectively reviewed. Eight patients who received CCRT concomitant with SEMS placement (SEMS plus CCRT group) and thirty-eight patients who received CCRT without SEMS placement (CCRT group) were identified. The risk of developing esophageal fistula and the overall survival of the two groups were analyzed.

RESULTS

The rate of esophageal fistula formation during or after CCRT was 87.5% in the SEMS plus CCRT group and 2.6% in the CCRT group. The median doses of radiotherapy in the SEMS plus CCRT group and the CCRT group were 47.5 Gy and 50 Gy, respectively. SEMS combined with CCRT was associated with a greater risk of esophageal fistula formation than CCRT alone (hazard ratio [HR], 72.30; 95% confidence interval [CI], 8.62-606.12; p < .001). The median overall survival times in the SEMS plus CCRT and CCRT groups were 6 months and 16 months, respectively. Overall survival was significantly worse in the SEMS plus CCRT group than in the CCRT group (HR, 5.72; 95% CI, 2.15-15.21; p < .001).

CONCLUSION

CCRT concomitant with SEMS for locally advanced esophageal cancer results in earlier life-threatening morbidity and a higher mortality rate than treatment with CCRT alone. Further prospective and randomized studies are warranted to confirm these observations.

IMPLICATIONS FOR PRACTICE

Patients treated with SEMS placement followed by CCRT had higher risk of esophageal fistula formation and inferior overall survival rate compared with patients treated with CCRT alone. SEMS placement should be performed cautiously in patients who are scheduled to receive CCRT with curative intent.

Treatment utilization and outcomes in elderly patients with locally advanced esophageal carcinoma: a review of the National Cancer Database

For elderly patients with locally advanced esophageal cancer, therapeutic approaches and outcomes in a modern cohort are not well characterized. Patients ≥70 years old with clinical stage II and III esophageal cancer diagnosed between 1998 and 2012 were identified from the National Cancer Database and stratified based on treatment type. Variables associated with treatment utilization were evaluated using logistic regression and survival evaluated using Cox proportional hazards analysis. Propensity matching (1:1) was performed to help account for selection bias. A total of 21,593 patients were identified. Median and maximum ages were 77 and 90, respectively. Treatment included palliative therapy (24.3%), chemoradiation (37.1%), trimodality therapy (10.0%), esophagectomy alone (5.6%), or no therapy (12.9%). Age ≥80 (OR 0.73), female gender (OR 0.81), Charlson-Deyo comorbidity score ≥2 (OR 0.82), and high-volume centers (OR 0.83) were associated with a decreased likelihood of palliative therapy versus no treatment. Age ≥80 (OR 0.79) and Clinical Stage III (OR 0.33) were associated with a decreased likelihood, while adenocarcinoma histology (OR 1.33) and nonacademic cancer centers (OR 3.9), an increased likelihood of esophagectomy alone compared to definitive chemoradiation. Age ≥80 (OR 0.15), female gender (OR 0.80), and non-Caucasian race (OR 0.63) were associated with a decreased likelihood, while adenocarcinoma histology (OR 2.10) and high-volume centers (OR 2.34), an increased likelihood of trimodality therapy compared to definitive chemoradiation. Each treatment type demonstrated improved survival compared to no therapy: palliative treatment (HR 0.49) to trimodality therapy (HR 0.25) with significance between all groups. Any therapy, including palliative care, was associated with improved survival; however, subsets of elderly patients with locally advanced esophageal cancer are less likely to receive aggressive therapy. Care should be taken to not unnecessarily deprive these individuals of treatment that may improve survival.

What is the optimal radiation dose for non-operable esophageal cancer? Dissecting the evidence in a meta-analysis

The standard radiation dose 50.4 Gy with concurrent chemotherapy for localized inoperable esophageal cancer as supported by INT-0123 trail is now being challenged since a radiation dose above 50 Gy has been successfully administered with an observable dose-response relationship and insignificant untoward effects. Therefore, to ascertain the treatment benefits of different radiation doses, we performed a meta-analysis with 18 relative publications. According to our findings, a dose between 50 and 70 Gy appears optimal and patients who received ≥ 60 Gy radiation had a significantly better prognosis (pooled HR = 0.78, P = 0.004) as compared with < 60 Gy, especially in Asian countries (pooled HR = 0.75, P = 0.003). However, contradictory results of treatment benefit for ≥ 60 Gy were observed in two studies from Western countries, and the pooled treatment benefit of ≥ 60 Gy radiation was inconclusive (pooled HR = 0.86, P = 0.64). There was a marginal benefit in locoregional control in those treated with high dose (> 50.4/51 Gy) radiation when compared with those treated with low dose (≤ 50.4/51 Gy) radiation (pooled OR = 0.71, P = 0.06). Patients that received ≥ 60 Gy radiation had better locoregional control (OR = 0.29, P = 0.001), and for distant metastasis control, neither the > 50.4 Gy nor the ≥ 60 Gy treated group had any treatment benefit as compared to the groups that received ≤ 50.4 Gy and < 60 Gy group respectively. Taken together, a dose range of 50 to 70 Gy radiation with CCRT is recommended for non-operable EC patients. A dose of ≥ 60 Gy appears to be better in improving overall survival and locoregional control, especially in Asian countries, while the benefit of ≥ 60 Gy radiation in Western countries still remains controversial.

Radiotherapy Alone or Concurrent Chemoradiation for Esophageal Squamous Cell Carcinoma in Elderly Patients

Purpose: The reported data of elderly ESCC are rather limited and there is a lack of information to guide treatment decisions for elderly patients with esophageal cancer. This study aims to identify the efficacy and factors for optimal treatment approaches for elderly esophageal squamous cell carcinoma (ESCC) treated with radiotherapy (RT) alone or concurrent chemoradiation (CCRT).

Methods: This study included 184 I-III elderly ESCC patients aged ≥70 years treated by oral single agent CCRT (sCCRT) or double agents CCRT (dCCRT) or RT alone at a single institution in China. RT was delivered with Intensity Modulated Irradiation Therapy (IMRT) or Volumetric-Modulated Arc Therapy (VMAT). Sequential or simultaneous integrated boost (SIB) approach was applied for GTV dose escalation. Toxicities were evaluated by criteria of Radiation Therapy Oncology Group. Statistical analyses were performed on survival and failure patterns.

Results: At a median follow-up time of 15.5 months, the 2- and 3-year estimated overall survival (OS) were 43.5% and 35.2%, respectively. T and N stage, GTV dose (cutoff value 56Gy), simultaneous integrated boost (SIB) technique and CCRT were significant predictors for the outcomes. sCCRT was significantly associated with higher OS, LRFS, and DFS when compared with RT alone and no difference was observed between sCCRT and dCCRT. 44% patients experienced treatment failure, among whom 65.4% developed local failure. 81.3% local failure occurred in GTV and 70.6% regional failures occurred out of radiation field. dCCRT was the only independent prediction factor for grade ≥ 2 neutropenia and gastrointestinal reactions compared with sCCRT and RT alone. No significant difference of toxicities was observed between sCCRT and RT alone.

Conclusions: Our results demonstrated that CCRT in elderly patients had significant survival benefit compared to RT alone, especially using Single oral agent. sCCRT had less toxicities compared to dCCRT, and the toxicity was similar to RT alone. GTV dose ≥ 56 Gy and SIB technique were optimal approaches for radiotherapy.

A phase II study of S-1 with concurrent radiotherapy in elderly patients with esophageal cancer

Background

Concurrent chemoradiotherapy (CCRT) using conventional platinum-based doublets are often associated with significant incidence of toxic effects in elderly patients with esophageal cancer. We previously reported a phase I trial of CCRT using S-1, an oral 5-fluorouracil derivative, which yielded well safe and active outcomes.

Methods

Patients with histologically confirmed esophageal cancer, who were age of 70 years or older with performance status (PS) score of 0-2 or age of 66 to 69 with PS score of 2, were eligible for this Phase II trial. Radiotherapy was delivered in 1.8 Gy per fraction to a total dose of 54 Gy. Concurrently, S-1 was administered at 70 mg/m² on days 1–14 and 29–42. The primary end point was 2-year overall survival rate.

Results

Thirty patients were enrolled, and 28 patients completed the full course of radiotherapy. No grade 4 toxicity or treatment-related death occurred. The grade 3 toxicities included esophagitis (16.7%), leucopoenia (13.3%), neutropenia (10%), anaemia (3.3%), pneumonitis (3.3%) and fatigue (3.3%). The median progression-free survival time and median survival time was 19 and 24 months, respectively. The 2-year overall survival rate was 45.1%, which exceeded the predefined threshold of 2-year OS 35% and met the primary end point of the study.

Conclusions

The results suggest that CCRT using S-1 is effective with mild toxicity in elderly patients with esophageal cancer. A phase III trial is needed to further evaluate this regimen.

Primary radio(chemo)therapy for esophageal cancer in elderly patients: are efficiency and toxicity comparable with younger patients?

Purpose

In elderly patients with esophageal cancer (EC), esophagectomy is associated with an increased mortality, and therefore these patients are often treated with definite (chemo)radiation. The purpose of this study was to assess the toxicity and efficiency of definite radio(chemo)therapy in patients >75 years compared with definite radio(chemo)therapy in patients <75 years.

Methods

32 patients >75 years were treated with definite radio(chemo)therapy for EC. We compared baseline parameters, efficiency and toxicity rates of these patients to 39 patients <75 years.

Results

Patients <75 years were more likely to receive simultaneous chemotherapy, and had a lower age-adjusted Charlson comorbidity index (ACCI). 25% of elderly patients were treated in palliative intent. There was no significant difference in progression-free survival between patient groups. No significant differences were seen for overall survival (15.7 months vs. 19.9 months; p = 0.102) and progression-free survival (10.5 months vs. 9.2 months, p = 0.470) between older patients treated with curative intent and younger patients. In addition, there were no significant differences for dysphagia and hematological side effects between elderly patients and younger patients.

Conclusion

Definite (chemo)radiation is a feasible therapy for elderly patients. OS and PFS in elderly patients with a curative treatment approach are comparable to younger patients and it is not associated with higher toxicity rates.

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

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-term results of paclitaxel plus cisplatin with concurrent radiotherapy for loco-regional esophageal squamous cell carcinoma

AIM

To evaluate the long-term effectiveness and late toxicities of paclitaxel (PTX) plus cisplatin (DDP) with concurrent radiotherapy for locally advanced esophageal squamous cancer.

METHODS

Between 2008 and 2011, 76 patients were enrolled in a phase II study on the treatment of loco-regionally advanced esophageal cancer with radiotherapy (68.4 Gy/44 fractions or 61.2 Gy/34 fractions) combined with 4-cycle chemotherapy consisting of DDP (25 mg/m² per day for 3 d) and PTX (175 mg/m² for 3 h). The primary endpoints were overall survival and progression-free survival, and the secondary endpoints were toxicity and the treatment failure pattern.

RESULTS

A total of 76 patients were enrolled in this study, of whom 63.2% finished the whole regimen. The 5-year survival rates for the per-protocol population and intent-to-treat population were 25.4% and 26.4%, respectively, and the median survival rates were 23.7 mo and 28.5 mo, respectively. Grade 3 or 4 late toxicity was observed in only one patient (heart failure). In log-rank analysis, the pretreatment stage (stage II + III: 36.1 mo vs stage IV: 14.9 mo) and the completed cycle (1-3 cycles: 16.1 mo vs 4 cycles: 35.5 mo) were significant prognostic factors (P = 0.037 < 0.05 and P = 0.013 < 0.05).

CONCLUSION

Radiotherapy combined with chemotherapy consisting of PTX and DDP is a safe and effective definitive treatment for loco-regionally advanced esophageal squamous cancer.

Long-term results of definitive concurrent chemoradiotherapy using paclitaxel plus oxaliplatin in unresectable locally advanced esophageal cancer: a prospective phase II trial

This prospective study aimed at assessing the efficiency and safety of concurrent chemoradiotherapy (CCRT) using paclitaxel (PTX) plus oxaliplatin (OHP) in unresectable locally advanced esophageal cancer patients. Between January 2006 and December 2010, 34 patients with unresectable locally advanced esophageal cancer were enrolled in this study. Radiotherapy was delivered with a daily fraction of 2.0 Gy to a total dose of 60 Gy over 6 weeks. Concurrent PTX (135 mg/m², d₁ ) and OHP (130 mg/m², d₁ ) were administered on Day 1 and Day 29 of radiotherapy. Of these patients, 76.5% completed the treatment course with a response rate of 73.5%, including eight (23.5%) patients with complete response and 17 (50.0%) patients with partial response. The median overall survival (OS) time was 23.7 months (range: 4.0-65.5 months) with 1-, 3- and 5-year OS rates were 64.3%, 36.6% and 25.8%, respectively. The median progression-free survival (PFS) time was 21.2 months with 1-, 3- and 5-year PFS rates were 63.8%, 30.9% and 20.4%, respectively, During the CCRT course, the main grade 3 or greater acute toxicities were leukopenia (38.2%), esophagitis (14.7%), and dysphagia (11.8%), with late toxicity being infrequent. Although this study did not meet its primary endpoint, the application of CCRT with PTX and OHP in unresectable locally advanced esophageal carcinoma yielded satisfactory clinical outcomes and manageable toxicities.

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

Objective

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

Patients and methods

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

Results

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

Conclusion

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