Preliminary experience with a combined-modality approach to the management of oesophageal cancer

A combined modality approach to the management of oesophageal cancer

This study aims to update the experience of multimodality approaches in the management of oesophageal cancer that have been adopted in several Australian and New Zealand hospitals. Between 1984 and 1985, 92 patients received pre-operative radiotherapy (30-36 Gy over 3 weeks) and one of two chemotherapy regimes (one or two courses of i.v. cisplatin 80 mg/m2 plus a 4-5 day continuous i.v. of fluorouracil 5-800 mg/m2/day) concurrently prior to surgery. Eighty-two patients (89%) underwent resection as planned. Operative specimens were microscopically free of residual tumour in 18 patients. Eight patients (9%) had treatment-related deaths: seven from surgery and one due to pre-operative chemoradiation. The Kaplan-Meier 5-year cause-specific survival estimates were 32.9 +/- 7.8% for the 58 patients with squamous cancer and 0% for the 32 with adenocarcinoma. Complete pathological response to the pre-operative regime was more common in females and was associated with a survival advantage. Five-year cause-specific survival expectation in patients who experienced a complete pathological response was 71.5 +/- 12.4%, whereas it was only 15.9 +/- 5.6% in patients who had residual cancer in their surgical specimens. Although less toxic the pre-operative regime utilizing only one cycle of chemotherapy was no less efficacious either in producing a complete pathological response or in terms of survival expectation. This uncontrolled pilot study has produced encouraging long-term results, especially for patients with squamous carcinoma that experienced a complete response to pre-operative synchronous chemoradiotherapy. A randomized controlled study comparing surgery alone with (one cycle) chemoradiation followed by surgery is now underway.

Factors influencing outcome following radio-chemotherapy for oesophageal cancer. The Trans Tasman Radiation Oncology Group (TROG)

BACKGROUND AND PURPOSES

To define new directions, the Trans Tasman Radiation Oncology Group (TROG) has conducted a detailed analysis of its unrandomised experience with radio-chemotherapy in oesophageal cancer.

METHODS AND PATIENTS

Since 1984, 373 patients with oesophageal cancer have been treated on three prospective, but unrandomised, protocols involving radiation with concurrent cisplatin and infusional fluorouracil. Centres in Australia and New Zealand have contributed patients. Reasons for case selection have been examined in detail and prognostic models have been examined in the light of biases exposed.

RESULTS

Cause specific survival in 92 patients treated pre-operatively with 35 Gy, infusional fluorouracil and cisplatin was 25.5 +/- 6.0% at 5 years and similar to the 5 year expectations of 169 patients treated with 60 Gy and two courses of the same chemotherapy (23.8 +/- 4.7%). Analysis of failure in these groups suggests that local relapse precedes the development of metastases and competes as a cause for ultimate failure. Although patients treated surgically were less likely to relapse locally, survival was no better because more developed metastases. Some of the 112 patients treated "palliatively" with 30-35 Gy concurrent with chemotherapy without surgery have become long-term survivors with 5 year survival figure in this group 7.7 +/- 3.4%. Apart from variables related to disease stage and performance status at presentation, tumour site emerged as a strong predictor of outcome. Prognosis worsens the nearer the tumour is to the stomach. In addition, indications of a radiation dose response relationship emerged.

CONCLUSIONS

Concurrent radio-chemotherapy protocols can improve outcome in patients fit enough to tolerate these approaches. New strategies remain necessary, however.

Combined modality therapy for esophageal carcinoma: preliminary results from a large Australasian multicenter study

PURPOSE

This report updates local control and survival experience and focuses on treatment toxicity in 294 patients with esophageal cancer who have been treated at six Australasian centers using three prospective unrandomized protocols that used concurrent radiation, cisplatin, and modest dose infusional fluorouracil.

METHODS AND MATERIALS

Protocol 1--"definitive" chemoradiation. One hundred and thirty-seven patients have been treated with "definitive" radiation to 60 Gy in 6 weeks plus two courses of cisplatin (80 mg/m2) and infusional fluorouracil (800 mg/m2/day over 4 days) during the first and fourth weeks of radiation. Protocol 2--"preoperative" chemoradiation and surgery. Seventy-eight patients received chemoradiation using the same chemotherapy, but 30-35 Gy in 3-4 weeks prior to surgery. Protocol 3--"palliative" chemoradiation. Seventy-nine patients deemed incurable were treated "palliatively" with the same chemoradiation protocol without surgery. Follow-up ranges from 6 months to 7 years (mean 22 months) in live patients.

RESULTS

Durable palliation of dysphagia in all three treatment groups has been reflected by encouraging 3-year survival expectations of 43.2 +/- 5% in definitively treated patients, 40.3 +/- 7.65% in surgically treated patients, and 8.5% +/- 3.9% in the palliatively treated patients. There are early indications that female patients have fared better than males. Toxicity levels were modest in all three groups. Following definitive treatment, severe myelotoxicity (World Health Organization grades 3 and 4) occurred in 19%, severe esophagitis (World Health Organization grade 3) in 11%, and moderate or severe benign stricture in 17%, depending upon age and sex of the patient (being worse in female patients).

CONCLUSIONS

These studies demonstrate that the concurrent addition of modest dose cisplatin and infusional dose fluorouracil to radiation in the definitive, preoperative, and palliative settings contribute to high rates of durable dysphagia-free survival, with overall survival comparable to (and possibly better than) the chemoradiation arm of the recently reported Intergroup Study, but at the cost of less morbidity.

Radiotherapy and concurrent chemotherapy for oesophageal carcinoma

This retrospective non-randomized study reports the outcome of 67 patients who received radical radiotherapy with or without two courses of concomitant chemotherapy using 5-fluorouracil and cis-platin at Westmead Hospital from 1985 to 1992. The overall median survival was 14.0 months, the actuarial 5-year survival was 18%, and median disease-free survival was 11.3 months. Forty-eight per cent of the 67 patients had complete endoscopic response and this resulted in a significantly improved survival for those patients. A pretreatment baseline Karnofsky performance > or = 80, and a baseline swallowing score > or = 80 also predicted for better survival. The development of acute toxicity did not predict the likelihood of developing chronic toxicity. The incidence of stricture formation (benign and malignant) requiring dilatation was 37%. There was no significant improvement in overall or disease-free survival, nor significant worsening of toxicity in the group of patients who received concurrent radiotherapy and chemotherapy compared with patients receiving radiotherapy alone.

Shades of gray: a personal view of palliation by radiotherapy

Palliation is a significant part of the work of a radiation oncologist and yet is discussed infrequently. All too often it is considered simple when in many cases the contrary is the case. The philosophy of palliation is discussed and is defined as non-curative treatment. Further sub-division into symptom control, growth restraint/local control is helpful. The aim of palliation must be clearly defined if it is to be achieved, taking into account not only the lesion causing the problem but also many other factors including the patient's general condition, the clinical evolution of the tumour, previous treatment and social factors. The aim should be communicated to the patient and relatives. Doses for effective palliation vary from low to high and require different fractionation regimens. Examples are given from clinical practice with emphasis on difficult and controversial areas. There are as many diseases as patients and the need to individualise treatment is stressed.

Treatment of adenocarcinoma of the cardia with synchronous chemotherapy and radiotherapy

Twenty-nine evaluable patients with adenocarcinoma of the cardia were treated with synchronously administered chemotherapy (two cycles of 5-fluouracil and cisplatin and 30-36 Gy of radiation to determine whether these tumours are responsive to such treatment. Complete regression of tumour was observed endoscopically in 19 patients, and partial regression in four. Fourteen patients had their tumours resected and in six no microscopic tumour was found in the specimen. Nine patients received additional radiotherapy to a total dose of 54-60 Gy instead of surgery. Tumour response was associated with rapid reversal of dysphagia. Only one patient required subsequent intervention for relief of dysphagia due to fibrous stricture. Enhanced survival was associated with a complete endoscopic response to initial chemotherapy and radiotherapy, and a tumour of less than 5 cm in length. The median survival of responding patients was 15 months. Synchronous chemotherapy and radiotherapy was of major palliative benefit in this series and merits further evaluation.

Endoscopic Nd-YAG laser therapy for palliation of upper gastrointestinal malignancy

Endoscopic laser therapy with the neodymium-yttrium-aluminium-garnet (Nd-YAG) laser has been shown to provide good palliation of upper gastrointestinal obstruction caused by malignancy, and to be associated with a low morbidity and a low mortality rate. Fifty patients with inoperable upper gastrointestinal malignancy have been treated with this method: 22 had oesophageal carcinoma, 16 adenocarcinoma at the cardio-oesophageal junction, two carcinoma of the antrum and 10 recurrent tumours at the site of previous anastomoses. The main symptoms were dysphagia in 40 and vomiting in seven; three others had recurrent bleeding. An Nd-YAG laser was used to photocoagulate the tumours using power levels of 50-100 W and an average energy output per treatment of 10,000 J. Thirty patients (75%) with dysphagia improved with treatment but vomiting was relieved in only three of the seven patients with this symptom. Complications were infrequent--two patients (4%) developed a perforation and one had a respiratory arrest which was reversible. The 30-day mortality rate was 14% with 2% being related to the procedure. Endoscopic Nd-YAG laser therapy is an acceptable alternative to the more established methods of palliation such as surgical or endoscopic intubation.

Neoadjuvant therapy of squamous cell carcinoma of the esophagus: role of resection and benefit in partial responders

Twenty-eight patients were treated between 1981 and 1987 with a combination of radiation therapy and two courses of 5-fluorouracil and cisplatin followed by esophageal resection. Sixteen patients (57%) underwent resection. Operative mortality was 6% (1 of 16), and the 15 operative survivors have been followed for more than 23 months. Complete pathological response was achieved in 8 of the 15 patients, and 10 patients (66%) are alive with no evidence of disease; 4 patients (27%) have survived with no evidence of disease for more than 5 years. Four partial responders are alive, and 3 are alive with no evidence of disease for more than 5 years. An aggressive approach with a low mortality has demonstrated survival benefit to complete responders and, contrary to findings of previous reports, has established a role for surgical resection and survival benefit in patients with partial response, with 3 of 7 (47%) patients surviving more than 5 years.

Correlation between automated karyometric measurements of squamous cell carcinoma of the esophagus and histopathologic and clinical features

The clinical staging of esophageal carcinoma is unreliable currently, making it difficult to select patients for aggressive therapy. To further refine staging criteria, the nuclear characteristics of a series of 31 patients with squamous cell carcinoma of the esophagus were studied using a computerized image analysis system (MicroTICAS). Karyometric measurements, including total nuclear DNA content, nuclear area, and nuclear roundness were compared with various clinical and histologic variables. Nearly all tumors (30 of 31) were aneuploid. Tumors with nuclear areas greater than 70 microns2 were associated with transmural esophageal penetration (P less than 0.05) and to a lesser extent with poor survival (less than 6 months; P = 0.06). Surprisingly, nuclear ploidy did not correlate with either variable. These data support a role for nuclear analysis on preoperative biopsy specimens as an adjunct in clinical staging.

Eversion extraction of the oesophagus

The technique of eversion extraction of the oesophagus has been used in Japan and China, but is little used in the Western world. This is a report of the technique of the procedure as undertaken in 10 cases of oesophageal disease.