A retrospective study of pattern of recurrence after radical surgery for thoracic esophageal carcinoma with or without postoperative radiotherapy

Patterns of failure and long-term outcome of postoperative radiotherapy on the survival of patients with pathological T3N0M0 esophageal cancer

Purpose

The prognostic effect of postoperative radiotherapy (PORT) on pathological T3N0M0 (pT3N0M0) esophageal squamous cell carcinoma (ESCC) remains inconclusive. This study aimed to retrospectively investigate patterns of failure and whether PORT after R0 resection improves survival in patients with pT3N0M0 ESCC, compared with surgery alone.

Patients and methods

The clinical data of 256 patients with pT3N0M0 ESCC from January 2007 to December 2010 were retrospectively reviewed. The included patients were classified into two groups: the surgery-plus-postoperative radiotherapy group (S + R) and the surgery-alone group (S). Propensity score matching (PSM) was used to create comparable groups that were balanced across several covariates (n = 71 in each group). Statistical analyses were performed using the Kaplan–Meier method and Chi-squared test.

Results

In the study cohort, the 5- and 10-year overall survival (OS) rates in the S + R group were 53.4% and 38.4%, and those in the S group were 50.3%, 40.9% (p = 0.810), respectively. The 5- and 10-year disease-free survival (DFS) rates in the S + R group were 47.9% and 32.9%, and those in the S group were 43.2%, 24.0% (p = 0.056), respectively. The results were coincident in the matched samples (p = 0.883, 0.081) after PSM. Subgroup analysis showed that patients with upper thoracic lesions in the S + R group had significantly higher OS than patients in the S group (p = 0.013), in addition, patients with upper and middle thoracic lesions in the S + R group had significantly higher DFS than patients in the S group (p = 0.018, 0.049). The results were also confirmed in the matched samples after PSM. The locoregional recurrence between the two groups were significantly different before and after PSM (p = 0.009, 0.002). The locoregional control rate (LCR) in the S + R group was significantly higher than that in the S group before and after PSM (p = 0.015, 0.008).

Conclusion

Postoperative radiotherapy may be associated with a survival benefit for patients with pT3N0M0 upper thoracic ESCC. A multicenter, randomized phase III clinical trial is required to confirm the results of this study.

Preliminary evaluation of postoperative radiotherapy with small T-shaped field in thoracic esophageal squamous cell carcinoma

Background

The optimal extent of clinical target volume (CTV) for postoperative radiotherapy in complete resection thoracic esophageal squamous cell carcinoma (ESCC) patients remains controversial. This study aimed to evaluate the primary outcome of postoperative radiotherapy with small T-shaped field encompassing the tumor bed, positive lymph node areas, bilateral supraclavicular areas, and upper and middle mediastinal areas.

Methods

A total of 96 thoracic ESCC patients were enrolled, with 49 and 47 cases in the small T-shaped field group and tumor bed field group, respectively. All of the patients received intensity-modulated radiotherapy (IMRT), and chemotherapy was administrated concurrently or sequentially. The median time of follow-up was 25 (range, 7-47) months.

Results

At the end of the follow-up period, in the small T-shaped field group, 8 (16.3%) patients had locoregional recurrence (LRR) and 12 (24.5%) had distant metastasis (DM), while in the tumor bed field group, 15 (31.9%) patients had LRR and 11 (23.4%) had DM. Although the rates of LRR and DM were not statistically different, LRR incidence in the mediastinal lymph nodes of the small T-shaped field group was strikingly lower than that of the tumor bed field group. The overall survival (OS) of the small T-shaped field group was higher than that of the tumor bed field group, but the difference was not statistically significance. In addition, we observed grade 2 radiation pneumonitis and grade 2 radiation esophagitis in both groups; all of these side effects were tolerable and controllable, and none of the patients experienced ≥ grade 3 pneumonitis, esophagitis, esophageal stricture, or life-threatening hemorrhage.

Conclusions

In conclusion, radiotherapy with small T-shaped field might be a feasible and efficacious postoperative approach for ESCC patients.

Mapping of Cervical and Upper Mediastinal Lymph Node Recurrence for Guiding Clinical Target Delineation of Postoperative Radiotherapy in Thoracic Esophageal Squamous Cell Carcinoma

Background

The lower neck and upper mediastinum are the major regions for postoperative radiotherapy (PORT) in thoracic esophageal squamous cell carcinoma (TESCC). However, there is no uniform standard regarding the delineation of nodal clinical target volume (CTVnd). This study aimed to map the recurrent lymph nodes in the cervical and upper mediastinal regions and explore a reasonable CTVnd for PORT in TESCC.

Methods

We retrospectively reviewed patients in our hospital with first cervical and/or upper mediastinal lymph node recurrence (LNR) after upfront esophagectomy. All of these recurrent lymph nodes were plotted on template computed tomography (CT) images with reference to surrounding structures. The recurrence frequency at different stations was investigated and the anatomic distribution of recurrent lymph nodes was analyzed.

Results

A total of 119 patients with 215 recurrent lymph nodes were identified. There were 47 (39.5%) patients with cervical LNR and 102 (85.7%) patients with upper mediastinal LNR. The high-risk regions were station 101L/R, station 104L/R, station 106recL/R, station 105 and station 106pre for upper TESCC and station 104L/R, station 106recL/R, station 105, station 106pre and station 106tbL for middle and lower TESCCs. LNR in the external group of station 104L/R was not common, and LNR was not found in the narrow spaces where the trachea was in close contact with the innominate artery, aortic arch and mediastinal pleura. LNR below the level of the cephalic margin of the superior vena cava was also not common for upper TESCC.

Conclusions

The CTVnd of PORT in the cervical and upper mediastinal regions should cover station 101L/R, station 104L/R, station 106recL/R, station 105 and station 106pre for upper TESCC and station 104L/R, station 106recL/R, station 105, station 106pre and station 106tbL for middle and lower TESCCs. Based on our results, we proposed a useful atlas for guiding the delineation of CTVnd in TESCC.

Para-aortic lymph node metastasis in lower Thoracic Esophageal Squamous Cell Carcinoma after Radical Esophagectomy: a CT-based atlas and its clinical implications for Adjuvant Radiotherapy

Background: Our previous work showed that para-aortic lymph node (PALN) metastasis was the major failure pattern in lower thoracic esophageal squamous cell carcinoma (LTESCC) patients who presented abdominal LN failure after curative surgery. We thereby aim to generate a computerized tomography (CT)-based documentation of PALNs and to propose a clinical target volume (CTV) for this region. Methods: Sixty-five patients were enrolled. The epicentre of each PALN was drawn onto an axial CT image of a standard patient with reference to the surrounding anatomical landmarks. A CTV for PALN was generated based on the final result of node distribution, and was evaluated for dosimetric performance in three simulated patients. Results: All the studied 248 LNs were below the level of 1.0 cm above the celiac artery (CA), and 94.76% were above the bottom of vertebra L3. Horizontally, 93.33% of the LNs in the celiac level were located within an expansion of 1.5 cm on the CA, and 94.12% of the LNs in the superior mesenteric artery (SMA) level were within 1.5 cm on the left side of the SMA. Below the SMA, all the LNs were behind the left renal vein, left to the right border of the inferior vena cava, and 98.51% of the LNs were medial to the lateral surface of the left psoas major. The proposed CTV could cover 92.74% of the LNs and was dosimetrically feasible. Conclusions: The proposed CTV is the first one to focus on the high-risk area of abdominal failure in LTESCC patients after surgery and can serve as a reference in the adjuvant radiotherapy for LTESCC patients.

Postoperative Radiotherapy for Thoracic Esophageal Carcinoma with Upfront R0 Esophagectomy

Multidisciplinary therapies can improve the survival of patients with locally advanced esophageal carcinoma. However, the determination of the optimal modality is still a controversial subject. Many randomized controlled trials in the late 20th century showed that there was no survival benefit when postoperative radiotherapy was added to surgery for esophageal carcinoma. As a result, the treatment modality shifted thereafter to neoadjuvant therapies. Even so, these trials are criticized for many limitations and an increasing number of studies (mainly nonrandomized controlled trials) has indicated that postoperative radiotherapy/chemoradiotherapy can improve the survival of patients with a poor prognosis after R0 esophagectomy. Additionally, a large number of patients with locally advanced esophageal carcinoma still choose upfront surgery in the clinical practice due to many reasons. Therefore, postoperative radiotherapy seems to be a feasible treatment for these patients with a poor prognosis, particularly in the new era of conformal radiotherapy. Here, we review published studies on postoperative radiotherapy/chemoradiotherapy, and we discuss the clinical issues related to postoperative radiotherapy, such as the indication, target volume, total radiation dosage, time interval and complications of postoperative radiotherapy with or without chemotherapy, to make recommendations of postoperative radiotherapy for both current practice and future research in esophageal carcinoma.

Risk Factors and Patterns of Abdominal Lymph Node Recurrence After Radical Surgery for Locally Advanced Thoracic Esophageal Squamous Cell Cancer

Background

We aimed to identify the suitable indication and delineate the target volume based on the pattern of abdominal lymph node recurrence (ALNR) after radical surgery for guiding postoperative radiotherapy in thoracic esophageal squamous cell cancer (TESCC).

Methods

Clinical data of patients with locally advanced TESCC after radical surgery without perioperative anti-tumor therapies from June 2011 to June 2016 were reviewed. Logistic regression analysis was used to find out the high-risk factors of ALNR. The pattern of ALNR was analysed and a template CT in the Pinnacle treatment plan system was used to reconstruct the distribution of the sites of ALNR.

Results

A total of 63 (19.57%) patients with 276 lymph nodes of ALNR were identified in 322 patients. Univariate logistic regression indicated that pathological tumor location, width of tumor, T stage, N stage, TNM stage, ratio of lymph node metastasis (LNM), vessel carcinoma embolus, cancerous node, LNM in the middle and lower mediastinum, LNM in the abdominal region, ratio of LNM in the abdominal region were risk factors of ALNR. Multivariate logistic regression analysis showed that only LNM in the abdominal region was an independent risk factor. The odds ratio was 7.449 (95% CI=2.552–22.297, P<0.001). Station 16a2, station 9, station 16b1, and station 8 were the major regions of ALNR. The recurrence rates were 10.56%, 9.63%, 7.14% and 5.28% in these stations, respectively.

Conclusion

Positive pathological abdominal lymph nodes should be the major indication for abdominal irradiation in postoperative radiotherapy for locally advanced TESCC. We recommended that the target volume includes station 8, station 9, station 16a2 and station 16b1 and proposed a specific delineation of the clinical target volume based on the distribution of ALNR on template CT images.

The impact of adjuvant therapies on patient survival and the recurrence patterns for resected stage IIa-IVa lower thoracic oesophageal squamous cell carcinoma

Background

This study evaluated the impact of adjuvant therapies on patient survival and disease recurrence patterns to identify an effective adjuvant therapy for resected lower thoracic oesophageal squamous cell carcinoma (LTESCC).

Methods

Clinical data of 127 patients with stage IIa-IVa LTESCC with a minimum 2-year follow-up after oesophagectomy were analysed. The survival and recurrence patterns were compared among patients who received adjuvant radiotherapy, adjuvant chemotherapy, adjuvant chemoradiotherapy, or surgery alone.

Results

Eighty-eight patients (69.3%) were identified as having disease recurrence. The regional lymph node recurrence rate was 57.5%, and the recurrence rates were high in the lower neck, upper mediastinum, and upper abdomen. Compared to surgery alone, adjuvant radiotherapy or chemoradiotherapy significantly decreased the recurrence rate (p < 0.05). Adjuvant chemoradiotherapy significantly improved overall survival, disease-free survival, and locoregional recurrence-free survival compared to surgery alone (p = 0.01, 0.01, and 0.00, respectively). Pathologically positive lymph nodes (PPLNs) in the lower mediastinum represented a potential risk factor for cervical recurrence (HR 2.97, 95%CI 1.19–7.39). Multivariable analysis showed that postoperative radiotherapy (HR 0.30, 95%CI 0.13–0.68) and PPLNs in the upper mediastinum (HR 3.72, 95%CI 1.30–10.67) were independent risk factors for upper mediastinal recurrence, while postoperative radiotherapy (HR 0.37, 95%CI 0.16–0.85) and PPLNs in the abdomen (HR 2.57, 95%CI 1.12–5.92) were independent risk factors for abdominal recurrence.

Conclusion

Adjuvant chemoradiotherapy was the most effective adjuvant therapy for resected stage IIa-IVa LTESCC. The lower neck, upper mediastinum, and upper abdomen were high-risk regions for postoperative radiotherapy. The regions of PPLNs may be important factors for individual targets.