Long-term results of infusional 5-FU, mitomycin-C and radiation as primary management of esophageal carcinoma

Resectable esophageal carcinoma: local control with neoadjuvant chemotherapy and radiation therapy

PURPOSE

To evaluate the usefulness of neoadjuvant chemotherapy and radiation therapy before esophagectomy for invasive cancer of the esophagus or gastroesophageal junction (GEJ).

MATERIALS AND METHODS

The authors conducted a retrospective analysis of 154 patients who underwent esophagectomy for invasive cancer between September 1, 1991, and December 31, 1995. The end points evaluated were overall, disease-free, local-regional relapse-free, and systemic relapse-free survival.

RESULTS

Seventy of the 154 patients received neoadjuvant combined-modality therapy (CMT) consisting of concurrent cisplatin and fluorouracil administration and accelerated, hyperfractionated radiation therapy. The remaining 84 patients underwent immediate esophagectomy. With a median follow-up of 34.7 months, the 3-year overall, disease-free, and distant metastatic relapse-free survival rates were 38.0%, 41.9%, and 56.0%, respectively. Although neoadjuvant therapy did not appear to prevent distant metastases, there was a dramatic effect on local control. After CMT, the 5-year local control rate was 90% compared to 64% after surgery (P < .001). Tumors in the GEJ recurred more frequently (P = .01); however, multivariate analysis showed CMT was the only independent predictor of local control. Postoperative mortality was 15.7% after CMT versus 5.9% without CMT (P = .05).

CONCLUSION

Local control of esophageal cancer is excellent following neoadjuvant chemotherapy and radiation therapy. However, the effects of CMT on overall and disease-free survival are less clear due to significant differences between the treatment groups.

Is combined chemotherapy and radiation therapy equally effective as surgical resection in localized esophageal carcinoma?

PURPOSE

This is a retrospective cohort comparison of combined chemotherapy and radiation versus esophagectomy in nonmetastatic esophageal cancers.

METHODS AND MATERIALS

Between 1984 and 1994, 82 patients received concurrent chemotherapy and radiation as their primary treatment. Their treatment consisted of 50-60 Gy of radiation in 20-30 fractions over 4-6 weeks, concurrent with bolus mitomycin C (8 mg/m2) on day 1, 5-fluorouracil (5-FU) infusion (20 mg/kg/day) +/- leucovorin (20 mg/m2/day) on days 1-4 and 22-25. This group was compared to another cohort of 81 patients who had esophagectomy. Both groups were restaged according to the 1983 AJCC clinical staging system and there was more clinical Stage III disease in the chemoradiation group, 30% versus 16%.

RESULTS

The complete response rate was 68% after chemoradiation (by clinical assessment) and 83% for esophagectomy (by pathological assessment). At 5 years, the local relapse rate was 59% for chemoradiation and 51% for esophagectomy. The 5-year disease-free rate and survival were 23% and 25% for chemoradiation, and 21% and 23% for esophagectomy respectively. There was no significant difference in the disease control and survival between the two treatments. The pretreatment AJCC clinical stage was a strong prognosticator of outcome. The 5-year survival was 55% for Stage I, 16% for Stage II, and 8% for Stage III (p = 0.00003).

CONCLUSION

Combined chemotherapy and radiation appeared to be as effective as esophagectomy in localized esophageal cancer.

Definitive chemoradiotherapy for T4 and/or M1 lymph node squamous cell carcinoma of the esophagus

PURPOSE

To investigate the efficacy and feasibility of concurrent chemoradiotherapy for locally advanced carcinoma of the esophagus.

PATIENTS AND METHODS

Fifty-four patients with clinically T4 and/or M1 lymph node (LYM) squamous cell carcinoma of the esophagus were enrolled. Patients received protracted infusion of fluorouracil 400 mg/m(2)/24 hours on days 1 to 5 and 8 to 12, 2-hour infusion of cisplatin 40 mg/m(2) on days 1 and 8, and concurrent radiation therapy at a dose of 30 Gy in 15 fractions over 3 weeks. Filgrastim was prophylactically administered to 35 patients. This schedule was repeated twice every 5 weeks, for a total radiation dose of 60 Gy, followed by two courses of fluorouracil (800 mg/m(2)/24 hours for 5 days) and cisplatin (80 mg/m(2) on day 1).

RESULTS

There were 21 patients with T4M0 disease, one with T2M1 LYM, 17 with T3M1 LYM, and 15 withT4M1 LYM. Forty-nine patients (91%) completed at least the chemoradiotherapy segment. The 18 patients (33%) who achieved a complete response included nine (25%) of the 36 with T4 disease and nine (50%) of the 18 with non-T4 disease. Major toxicities were leukocytopenia and esophagitis; there were four (7%) treatment-related deaths. Prophylactic filgrastim reduced the incidence of grade 3 or worse leukopenia without improving dose-intensity or response. With a median follow-up duration of 43 months, median survival time was 9 months. The 3-year survival rate was 23%.

CONCLUSION

Despite its significant toxicity, this combined modality seemed to have curative potential even in cases of locally advanced carcinoma of the esophagus.

Esophageal cancer: therapeutic approaches and nursing care

OBJECTIVES

To review the various treatment approaches, complications, and nursing management of patients with esophageal cancer.

DATA SOURCES

Review articles, staging manual, textbook chapters, and research studies.

CONCLUSIONS

The diagnosis and treatment of esophageal cancer is a complicated process. Combined multimodal therapy with chemotherapy, radiotherapy, and surgery is showing promising results. However, each treatment approach has complications and side effects that must be managed.

IMPLICATIONS FOR NURSING PRACTICE

Nursing care is complicated and requires coordinating various support services, patient and family education, clinical assessment, nutritional management, management of side effects, and palliative care.

The Role of Radiation Therapy in the Management of Esophageal Cancer

BACKGROUND: Esophageal cancer is a challenging clinical problem with an estimated 12,300 new cases diagnosed in 1998. METHODS: A detailed review of pertinent literature is used to describe the epidemiology and management of this disease. RESULTS: Radiation therapy remains an important cornerstone of therapy. In combination with chemotherapy and/or surgery, radiation therapy may offer an improved therapeutic outcome. CONCLUSIONS: Radiation therapy remains an important therapy in the treatment of esophageal cancer.

Concurrent chemotherapy (5-fluorouracil and cisplatin) and radiation therapy followed by surgery for T4 squamous cell carcinoma of the esophagus

BACKGROUND AND OBJECTIVES

Since the prognosis of patients with T4 squamous cell carcinoma (SCC) of the esophagus is extremely poor, an effective multimodal treatment needs to be established.

METHODS

Forty-five patients with SCC of the esophagus at the T4 classification of the disease but no hematogenous metastasis were treated with concurrent chemoradiation therapy followed by surgical resection. Twenty-eight patients were treated with a regimen (protocol A) of 5-fluorouracil 750 mg/m2 on days 1-5 and 22-26, and cisplatin 70 mg/m2 on days 1 and 22. The remaining 17 patients were treated with a modified regimen (protocol B) of 5-fluorouracil 400 mg/m2 and cisplatin 10 mg/m2 on days 1-5, 8-12, 15-19, and 22-26. Radiation was delivered daily for 5 days/week for 4 weeks at the rate of 2 Gy/day to a total dose of 40 Gy in both protocols.

RESULTS

A major clinical response was observed in 29 [3 complete response (CR) and 26 partial response (PR)] patients (64.4%). Twenty-eight patients (62.2%) underwent esophagectomy with no postoperative death. The median survival time of the resected patients (959 days) was significantly longer than that of the non-resected patients (178 days). Protocol B showed significantly higher pathologic effectiveness than protocol A. The pathologic CR rate for the main tumors was 1 (6.3%) of 16 patients for protocol A and 7 (58.3%) of 12 patients for protocol B. The pathologic CR rate for metastasized lymph nodes was 4/11 (36.4%) for protocol A and 5/5 (100%) for protocol B. Good histological response of the main tumors correlated well with long survival. The treatments were well tolerated except for one treatment-related death.

CONCLUSIONS

Concurrent chemoradiation therapy followed by surgery is an effective and safe multimodal therapy for patients with primary inoperable T4 SCC of the esophagus.

Neoadjuvant Therapy for Cancer of the Esophagus

BACKGROUND: The standard of care for esophageal cancer has historically been surgical resection. However, survival following surgical treatment of esophageal cancer remains poor. In inoperable patients, both radiation therapy and chemotherapy alone and in combination have been used with some success. Consequently, these therapies have been utilized in the neoadjuvant setting to improve palliation and prolong survival. METHODS: The author reviewed the literature regarding clinical trials that employed neoadjuvant chemotherapy and radiation therapy in the treatment of squamous cell carcinoma and adenocarcinoma of the esophagus. RESULTS: In most patients, surgery alone is noncurative therapy, even when performed with curative intent. Most phase III trials of neoadjuvant therapy have not been designed with adequate statistical power to detect clinically relevant improvement. The available data are insufficient to determine a benefit to preoperative radiation therapy alone. Preoperative chemotherapy with 5-FU plus cisplatin followed by surgery probably offers little or no improvement over surgery alone. Trials of combined preoperative chemoradiation therapy have yielded promising but not definitive results. CONCLUSIONS: Outside of a clinical trial, neoadjuvant therapy for esophageal cancer should be reserved for only a select group of patients. Future clinical trials may determine a role for neoadjuvant chemoradiation and identify more active chemotherapeutic agents and populations most likely to benefit.

[Concomitant chemoradiotherapy of cancer of the esophagus]

Radiation therapy with concomitant chemotherapy is the standard treatment for non resectable esophageal carcinoma. For patients with operable tumors, surgery is the traditional treatment. However several data have suggested that preoperative chemo- and radiotherapy could improve therapeutic results. At the present time, no randomized trial has demonstrated, except for adenocarcinoma of the cardia, the benefit of preoperative treatment. Other randomized trials are needed to determine the role and the optimal modalities of these treatments. This is a review of the literature data in concomitant chemotherapy and radiation in the management of esophagus.

High dose chemoradiotherapy followed by esophagectomy for adenocarcinoma of the esophagus and gastroesophageal junction: results of a phase II study of the Eastern Cooperative Oncology Group

BACKGROUND

To assess the toxicity, local response, and survival associated with multimodality therapy in a cooperative group setting, patients with biopsy-proven clinical Stage I or II adenocarcinoma of the esophagus (staged according to 1983 American Joint Committee on Cancer criteria) or gastroesophageal junction were treated with concomitant radiation and chemotherapy followed by esophagectomy.

METHODS

Radiotherapy was administered in daily 2-gray (Gy) fractions 5 days a week until a total of 60 Gy was reached. 5-fluorouracil (5-FU) was infused continuously at a dose of 1000 mg/m2/day for 96 hours on Days 2-5 and 28-31. On Day 2, a 10 mg/m2 bolus of mitomycin was injected intravenously. Esophagectomy was performed 4-8 weeks following completion of the radiotherapy.

RESULTS

During the 18-month study period (August 1991 through January 1993), 46 eligible patients were accrued from 21 institutions. Eight patients were Stage I and 38 Stage II. Eighty-seven percent of patients (40 of 46) received 6000 centigray (cGy), and all received >5000 cGy. Seventy-eight percent of patients (36 of 46) received >90% of the planned 5-FU dose. Follow-up ranged from 11 to 36 months (median, 22 months). There were eight treatment-related deaths; two were preoperative (from adult respiratory distress syndrome) and six were postoperative. Complete or partial response prior to esophagectomy was observed in 63% of cases, stable disease in 15%, and progression in 20%. Thirty-three patients underwent esophagectomy (transhiatal, n=14; Ivor Lewis, n=16; other, n=3). No tumor was found in the specimens resected from 8 of these 33 patients; this represented a pathologic complete response rate of 17% overall and 24% for those who underwent esophagectomy. Overall median survival was 16.6 months, 1-year survival 57%, and 2-year survival 27%. Survival was significantly worse for patients with circumferential cancers (median, 18.1 months vs. 8.3 months; P <0.05).

CONCLUSION

High dose radiation therapy with concurrent 5-FU and mitomycin may be administered to patients with esophageal adenocarcinoma with acceptable morbidity. However, in a cooperative group setting, esophagogastrectomy following intensive chemoradiotherapy is associated with excessive morbidity and mortality. Circumferential tumor growth is a significant adverse prognostic factor.

Induction chemotherapy, surgery, and concomitant chemoradiotherapy for carcinoma of the esophagus: a long-term analysis

PURPOSE

To define the activity and toxicity of preoperative chemotherapy and postoperative concomitant chemoradiotherapy in patients with carcinoma of the esophagus, and to determine the effect on survival in patients treated with this approach.

PATIENTS AND METHODS

Patients were treated with two 21-day cycles of induction chemotherapy with cisplatin 100 mg/m2 on day 1, 5-fluorouracil (5-FU) 800 mg/m2/day continuous infusion on days 1-5, and leucovorin 100 mg/m2 every four hours on days 1-5. Surgical resection was performed if feasible (and could also be performed prior to chemotherapy). Patients then received radiotherapy (50 to 60 Gy) every other week x five to six weeks, concomitantly with 5-FU 800 mg/m2 continuous infusion daily and hydroxyurea 1 g twice daily x five days.

RESULTS

Forty-six patients were treated. With a minimum follow-up of 58 months, the median survival for the entire group was 16 months; the median survivals for patients with squamous carcinoma and adenocarcinoma were 29 months and 12 months, respectively. Toxicities of induction chemotherapy were severe neutropenia and mucositis; there was one toxic death. Toxicities of concomitant chemoradiotherapy were neutropenia, mucositis and esophagitis. There were five cases of radiation pneumonitis, one fatal.

CONCLUSION

Induction chemotherapy and postoperative concomitant chemoradiotherapy can be added to surgical resection for carcinoma of the esophagus. Combined modality therapy, as reported here, produces long-term survival benefit, particularly in patients with squamous carcinoma. However, similar outcome results have been reported with less toxic and shorter treatment regimens as tested in randomized studies.

Current status of new drugs and multidisciplinary approaches in patients with carcinoma of the esophagus

The incidence of distal esophageal adenocarcinoma and primary proximal gastric carcinoma has increased substantially in the past 15 years, particularly in North America and in some European countries. Patients with curatively resected cancer consistently have a 10 to 20% 5-year survival rate. Radiation therapy alone should not be recommended. Based on the Radiation Therapy Oncology Group/Eastern Cooperative Oncology Group (ECOG) trial in patients with predominantly squamous cell carcinoma, chemoradiotherapy (fluorouracil [5-FU]/cisplatin + 50 Gy of radiotherapy) has been shown to be superior in this setting. The most active single agents against squamous cell carcinoma are cisplatin, 5-FU, bleomycin, paclitaxel, mitomycin, mitoguazone, vinorelbine, and methotrexate. The most active agents against adenocarcinoma include paclitaxel and probably mitomycin, mitoguazone, and cisplatin. To my knowledge, there is currently no effective postoperative adjuvant therapy (chemotherapy, radiation therapy, or both). Evidence that preoperative therapy can prolong survival of patients with potentially resectable carcinoma of the esophagus is lacking. Preoperative chemoradiotherapy can result in an approximately 25% complete pathologic response of the primary tumor. Preoperative chemoradiotherapy, however, results in substantial morbidity and even mortality. A recent single-institution, randomized study comparing surgery alone with preoperative 5-FU/cisplatin/vinblastine and concurrent radiotherapy demonstrated no difference in median survival (18 months). Nevertheless, combined-modality therapy holds promise. Multiple combined-modality strategies have been formulated and will be investigated in the next few years.

The role of chemoradiotherapy in maintaining quality of life for advanced esophageal cancer

From May 1996 to July 1996, three male patients with advanced esophageal cancer with complete obstruction were treated with concurrent chemoradiotherapy. The first two courses of chemotherapy using 5-Fluorouracil (500 mg/m2) and Leucovorin (200 mg/m2) on day one through day five were given concurrently with radiotherapy. After completion of radiotherapy, four more courses of chemotherapy using the same regimen were given every four weeks. The total dose of irradiation using six MV linear accelerator given to the primary tumor was 5,000 cGy in 28 fractions. All three patients had relief of their obstruction with complete regression of the tumor after the completion of their treatment. All patients improved clinically and were able to remain symptom-free until the time of their death. The first patient survived for 12 months and died of respiratory failure because of his chronic obstructive pulmonary disease. The second patient also survived 12 months but died of liver metastasis. The third patient lived for 10 months and died of aspiration pneumonia.

The role of radiotherapy in the surgical management of gastrointestinal cancer

Surgery is the main mode of treatment in most gastrointestinal malignancies. Radiotherapy with or without chemotherapy is playing an increasing role as an adjunct to improve local control, survival and palliation. The principles of radiotherapy and the rationale for combination therapy are presented. The current role of radiation therapy in the GI tract is discussed by various sites. New and investigational radiotherapy techniques are outlined.

Neoadjuvant chemotherapy followed by concurrent chemotherapy and radiotherapy for locally advanced esophageal carcinoma with bulky upper abdominal lymphadenopathy. Case report

A 60-year old male patient who had locally advanced esophageal carcinoma with bulky upper abdominal lymphadenopathy underwent neoadjuvant chemotherapy consisting of 5-fluorouracil (5-FU) and cisplatin (CDDP), followed by concurrent radiotherapy and chemotherapy using protracted low-dose continuous infusion of 5-FU and CDDP. The treatment brought about complete remission in the primary lesion and good partial remission in the upper abdominal lymphadenopathy. He subsequently underwent trans-hiatal esophagectomy after one cycle of adjuvant chemotherapy because local recurrence was suspected. Histopathologic study of the resected specimen demonstrated no malignant tissue in the primary lesion and the lymph nodes. The patient is still alive and disease-free at 26+ months. This result suggests that neoadjuvant chemotherapy followed by concomitant chemotherapy and radiotherapy for patients who have locally advanced squamous cell carcinoma of the esophagus with intensive abdominal lymphadenopathy may offer some chance for sterilization of local and regional metastases and longer survival.

Multimodality therapy for esophageal cancer

Over the past decade and a half, several strategies have been developed to improve the survival of patients with esophageal cancer. Two strategies employ either neoadjuvant chemotherapy or chemoradiotherapy followed by surgery to improve local-regional control and decrease the incidence of distant metastases. A third strategy uses nonsurgical therapy as definitive treatment for patients without metastatic disease. Single-institution pilot trials and randomized comparative trials have been conducted evaluating each approach. The rationale for these trials, results, and current recommendations are presented.

Biology of esophageal cancer and the role of combined modality therapy

1. The biology of esophageal cancer involves multifactorial environmental and genetic events. 2. The understanding of the clinical significance of molecular markers is rapidly evolving. 3. Combined-modality approaches should still include surgery in good performance status (ECOG scale < or = 2) patients. 4. Neoadjuvant chemoradiation is probably better than surgical resection alone for patients with potentially curable disease, but only validation of this approach by CALGB-9781 can justify this as a new "proven" standard-of-care in the United States. 5. A pathologic complete response to neoadjuvant therapy is the strongest predictor of long-term survival. 6. 5-FU, by either short course or protracted continuous infusion, comprises the backbone of combination chemotherapy in combined-modality design. 7. Radiation therapy should be given at standard 1.8 to 2 Gy/fraction without a scheduled break. 8. Only by enrolling sufficient numbers of patients in prospective clinical trials will clinicians be able to further define the optimal sequencing and actual necessity of each individual component of combined-modality therapy.

Review: chemotherapy, irradiation and their roles in the management of oesophageal cancer

The role of multimodality therapy in the treatment of oesophageal cancer has been extensively investigated in many longitudinal studies and randomized trials. Despite some promising results, no clear beneficial evidence has consistently been produced. At present it cannot be routinely recommended outside the context of controlled clinical trials.

Accelerated fractionation in esophageal cancers: a multivariate analysis on 88 patients

PURPOSE

Accelerated fractionation was used to shorten overall treatment time to increase locoregional control and cause-specific survival.

METHODS AND MATERIALS

Eighty-eight patients with cancer of the esophagus ineligible for surgery were entered in the study between 1986 and 1993. Neoadjuvant chemotherapy was given to 64% of patients. Accelerated radiotherapy using the concomitant boost technique delivered a median dose of 65 Gy in a median overall treatment time of 32 days.

RESULTS

The 3-year actuarial local control rate in patients with T1, T2, and T3 tumors was 71%, 42%, and 33%, respectively. The 3-year cause-specific survival rates were 40%, 22%, and 6%, respectively. Sixteen percent of patients experienced Grade 3 esophagitis. Late toxicity included esophageal stenosis and pulmonary fibrosis in 8% and 9% of the patients, respectively. Multivariate analysis demonstrated that T stage and overall treatment time were prognostic factors for cause-specific survival. T stage and neoadjuvant chemotherapy were independent prognostic factors for locoregional control.

CONCLUSION

These findings suggest that accelerated fractionation given in an overall treatment time of <35 days might be beneficial for early-stage cancer of the esophagus. Neoadjuvant chemotherapy is not recommended, as it was a significant adverse prognostic factor in the multivariate analysis for local control. Accelerated fractionation can be carried out with moderate acute and late toxicity.

Radiotherapy with high dose rate brachytherapy boost and concomitant chemotherapy for Stages IIB and III esophageal carcinoma: results of a pilot study

PURPOSE

Radiotherapy (RT) and concomitant chemotherapy (CT) is the standard treatment for non resectable esophageal cancer. Usual total radiation dose is 50 Gy. In order to enhance local control rate a Phase II study was initiated to evaluate the feasibility of a combined treatment with an external radiation dose of 60 Gy and three cycles of concomitant CT, using the three main active drugs (CDDP, 5 FU and MMC), followed by a high dose rate (HDR) brachytherapy delivering 10 Gy.

METHODS AND MATERIALS

Fifty-three patients, 48 men and 5 women, were entered in this study. Stages were evaluated with CT scan and with endoscopic sonography. Fifteen were Stage IIB, 38 Stage III. Treatment consisted of conventional fractionated RT to a total dose of 60 Gy delivered with 2 Gy per fraction, one fraction per day and five fractions per week. The CT regimen was a combination of Cisplatinum (CDDP) 20 mg/m2 and 5 Fluorouracil (5FU) 600 mg/m2 continuous infusion, from days 1-4 Mitomycin C (MMC) was given at 6 mg/m2 on day 1. Three cycles were administered on days 1, 22, and 43. Brachytherapy was delivered one week after the end of external radiation therapy.

RESULTS

Full radiation therapy dose was delivered for 94% of the patients. CT compliance, evaluated on the mean relative dose-intensity was 85% for CDDP, 81% for 5FU and 51% for MMC. Overall grade 3 and 4 WHO toxicity rates were 23% and 7%, respectively. Haematologic toxicity was the most limiting factor. One patient died from treatment toxicity. Local control rate at one year was 74%. Three-year actuarial survival rate was 27%. Distant metastasis was the main cause of treatment failure. Swallowing score was good for 75% of the patients. Stage, performance status and weight loss were prognostic factors.

CONCLUSION

This regimen with high dose RT, HDR brachytherapy and concomitant CT is feasible; however, a high level of haematologic toxicity was observed with the CDDP, 5FU and MMC regimen. Despite a poor compliance with CT, treatment results are very encouraging for patients with locally advanced disease.

Induction chemoradiotherapy followed by esophagectomy in patients with carcinoma of the esophagus

BACKGROUND

Induction chemoradiotherapy followed by esophagectomy may provide results superior to those of single-modality treatment in patients with esophageal cancer. The purpose of this study was to review our experience with this approach for esophageal cancer.

METHODS

From 1988 to 1996, 166 consecutive patients with esophageal cancer were evaluated; 66 entered a protocol of chemotherapy (5-fluorouracil, cisplatin) concurrent with radiation (45 Gy) followed by esophagectomy. Fifty-four patients completed the protocol.

RESULTS

Toxicity associated with induction chemoradiotherapy was minimal. The actuarial survival at 12, 24, and 36 months was 59%, 42%, and 32%, respectively. The pathologic complete response (pCR) rate was 41%, with 12-, 24-, and 36-month survivals of 77%, 50%, and 45%, whereas non-pCR patients had survivals of 46%, 35%, and 23%. The difference in survival between pCR and non-pCR patients was not significant (p = 0.13), but the difference in recurrence-free survival was significant (p = 0.007).

CONCLUSIONS

This well-tolerated protocol resulted in a high pCR. Trimodality treatment for esophageal cancer may provide long-term survival in some patients regardless of their pCR status.

Intracavitary brachytherapy for carcinoma of the esophagus

Local control of unresectable esophageal carcinomas remains a significant problem in spite of aggressive treatments. External beam radiation therapy, chemotherapy, and combined modality treatment have all been employed with limited success. Here we review the existing literature and our own experience with external beam radiation followed by low-dose-rate or high-dose-rate intracavitary radiation for carcinoma of esophagus. The addition of intracavitary brachytherapy to external beam irradiation is well tolerated, causes no significant toxicity, and improves local control. Low-dose-rate intracavitary boost compared to high-dose-rate intracavitary boost has the advantage of a greater margin of safety, requires a single application, does not require highly sophisticated computerized technology, and is accompanied with fewer high-grade toxicities. Combined modality therapy consisting of concomitant infusional chemotherapy, external beam irradiation, and low-dose-rate intracavitary boost needs to be investigated.

Safety of esophagoscopy in the irradiated esophagus

Carcinoma of the esophagus is a disease with a poor prognosis. Surgery is considered the treatment of choice. Patients who are surgically unresectable may receive radiotherapy, plus or minus chemotherapy. While this offers reasonable palliation, a significant number of patients develop benign or malignant strictures. Frequent esophagoscopy with dilation is required if they are to swallow. Patients with strictures or malignancy of the esophagus are more prone to complications if they undergo an esophagoscopy. We examined the morbidity of esophagoscopy in a group of patients who had received radiotherapy for carcinoma of the esophagus. Over a 10-year period, 21 patients receiving irradiation for carcinoma of the esophagus were examined. All patients underwent esophagoscopy for staging and diagnosis. The tumor locations were upper (6), middle (6), and lower (9) esophagus. The T-stages were 1 (7), 2 (6), 3 (6), and 4 (2). Five patients had dilation of a malignant stricture at the time of diagnosis. Fever developed and resolved within 24 hours in 2 patients. Following completion of irradiation, a total of 83 esophagoscopies were performed (range 1 to 11 per patient). Six patients with no tumor or stricture underwent 8 esophagoscopies (3 rigid, 5 flexible). There was 1 episode of minimal bleeding and 1 fever that resolved within 24 hours. Ten patients with malignant strictures underwent 62 esophagoscopies (5 rigid, 57 flexible). There were 17 (27%) episodes of fever (all resolved within 24 hours) and 14 (22%) episodes of bleeding. Five patients with benign strictures underwent 13 esophagoscopies (2 rigid, 11 flexible). One patient had a perforation that resolved with conservative treatment, and 1 patient developed an epidural abscess 2 months following dilation. This patient is the only one that required surgical intervention and had prolonged hospitalization. Esophagoscopy of the irradiated esophagus can be performed relatively safely and excellent palliation obtained. Morbidity consisting of minimal bleeding, and fever lasting less than 24 hours, is frequent but self-limited.

Treatment of squamous cell carcinoma of the esophagus with alternating radiotherapy and chemotherapy (cisplatin, methotrexate, and peplomycin)

Between 1985 and 1990, 20 patients with stage 2 and 3 esophageal cancer without esophagopulmonary fistulas were treated with alternating radiotherapy and chemotherapy (cisplatin, methotrexate, and peplomycin). Patients given the combined therapy received courses of chemotherapy during weeks 1 and 6 and radiotherapy during weeks 2-5 and 7-9. Chemotherapy consisted of i.v. cisplatin (80 mg/ m2 of body surface area) on day 1, i.v. methotrexate (40 mg/ m2) on day 2, and s.c. peplomycin (10 mg/day) continuously from day 2 to day 5. Radiotherapy was external irradiation with or without intracavitary irradiation. In seven cases, external irradiation alone was administered at 65-70 Gy, and in 13 cases, external irradiation (50-55 Gy) was combined with intracavitary irradiation (14-20 Gy). At the end of treatment, the rate of complete response was 60% with an overall response rate of 95%. Five-year total survival was 25%; cause-specific survival was 36.8%. The most common acute toxicities were bone marrow suppression, hepatic and renal damage, pneumonitis, and esophagitis. There was no life-threatening toxicity.

Phase II study of cisplatin, 5-fluorouracil, and leucovorin in inoperable squamous cell carcinoma of the esophagus. ONCOPAZ Cooperative Group, Spain

Cisplatin (P) and 5-fluorouracil (5FU) have demonstrated activity for the treatment of squamous cell carcinoma of the esophagus. Previous studies have shown that leucovorin (L) may potentiate the antitumoral activity of 5FU, so we tested the combination P-5FU-L in 31 patients with inoperable squamous cell esophageal carcinoma. Chemotherapy consisted of P 20 mg/m2 in 4 h, followed by L 200 mg/m2 in 2 h and 5FU 600 mg/m2 in 18 h. This schedule was repeated for 5 days every 4 weeks. The treatment plan included three courses of chemotherapy followed by radiotherapy. The overall response rate was 58% (95% CI = 39-76%), with one complete remission (3%), and 61% of patients reported an improvement in dysphagia. Gastrointestinal toxicity was the main side effect: grade 3-4 mucositis appeared in 19% of patients, grade 3-4 nausea/vomiting in 13%, and grade 3-4 diarrhea in 6.5%. There was one toxic death caused by neutropenia and sepsis. Nineteen patients received local radiotherapy after chemotherapy, which increased the overall response rate to 63% (5% complete responses). Dysphagia improved in 75% of them. The median survival for all patients was 11 months. This study shows that sequential therapy with P-5FU-L and radiotherapy achieves a high response rate as well as adequate symptomatic relief in patients with inoperable esophageal cancer. The results justify further evaluation of P-5FU-L in patients with earlier-stage disease.

High dose rate brachytherapy before external beam irradiation in inoperable oesophageal cancer

To induce fast relief of dysphagia in patients with oesophageal cancer high dose rate (HDR) brachytherapy was applied before external radiotherapy in a prospective study. Seventy-four patients with inoperable oesophageal cancer (36 squamous cell, 38 adenocarcinoma) were treated with a combination of 10 Gy HDR brachytherapy, followed by 40 Gy in 4 weeks external beam radiotherapy (EBRT), starting 2 weeks later. Tumour response, as measured by endoscopy and/or barium swallow, revealed complete remission in 21 and partial response in 38 patients (overall response rate 80%). Improvement of dysphagia was induced by brachytherapy within a few days in 39%, and achieved at the end of treatment in 70% of patients. Further weight loss was prevented in 39 of the 59 patients who presented with weight loss. Pain at presentation improved in 12 out of 25 patients. Median survival was 9 months. No differences in either response rate or survival were found in squamous cell or adenocarcinoma. Side-effects were either acute with minimal discomfort in 32 (42%) or late with painful ulceration in five patients (7%), occurring after a median of 4 months. A fistula developed in six patients, all with concurrent tumour. In conclusion, brachytherapy before EBRT was a safe and effective procedure to induce rapid relief of dysphagia, especially when combined with EBRT.

Oesophageal carcinoma--past and present studies

Surgery is a crucial part of therapy of oesophageal cancer. The many trials which are described focus on variations in surgical technique. A trend is found that results are better with more extensive procedures. Local control evidently is improved, but an effect on survival is not yet sufficiently shown. Combinations of neoadjuvant radiotherapy and/or chemotherapy with surgery are effective by downstaging offering seemingly better survival in responding patients. Interpretation of trial data, however, is difficult because of the relatively small numbers in individual studies; the differences of the used treatment modalities make an overview approach less reasonable. Great attention should be given in the future trial work to better standardization (interpretation of definitions). Directives for optimal staging should be described in all study protocols.

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.

Role of Radiation Therapy and Fluoropyrimidines in the Treatment of Gastrointestinal Malignancies

BACKGROUND: The use of combined chemotherapy and radiation for gastrointestinal malignancies has several theoretical advantages, and clinical trials to determine the type and extent of clinical benefits have been performed. METHODS: The basic science and clinical trial data evaluating such combinations are reviewed, with an emphasis on the interactions between fluoropyrimidines and radiation. RESULTS: Improved outcomes from chemoradiotherapy have been demonstrated in patients with selected stages of anal, esophageal, rectal, and pancreatic cancer. CONCLUSIONS: Despite these positive results, further work is needed to demonstrate even more effective and less toxic treatment regimens.

Combined intensive chemoradiotherapy for organ preservation in patients with resectable and non-resectable oesophageal cancer

From January 1990 to April 1993, 60 oesophageal cancer patients were enrolled in a protocol of non-surgical treatment that consisted of induction chemotherapy followed by concurrent chemoradiotherapy. Induction chemotherapy consisted of cisplatin 40 mg/m2 intravenous bolus days 1, 2, 14, 15; 24 h continuous infusion of 5-fluorouracil (5-FU) 1000 mg/m2 days 1 and 14; leucovorin 20 mg/m2 days 1 and 14 given before and with 5-FU; bleomycin 30 UI days 1 and 14; mitomycin C 10 mg/m2 day 14. Concurrent chemoradiotherapy consisted of 60 Gy (6 weeks) from day 21 and cisplatin 70 mg/m2 days 28, 42 and 56; leucovorin 20 mg/m2 followed by 5-FU 425 mg/m2 days 28, 35, 42, 49 and 56. Complete response occurred in 44 of 55 evaluable patients (80%). The median survival is 32 months; the actuarial survival at 40 months is 35% (CI 18-53). These results appear improved over those reported with surgery or radiation alone, and suggest that organ preservation as a secondary treatment goal should be vigorously investigated.

Preoperative concomitant radiochemotherapy in squamous cell carcinoma of the esophagus: results of a study of 56 patients

PURPOSE

Today the prognosis for patients with esophageal carcinoma still remains quite poor. In the last few years interesting results have been obtained by associating radio- and chemotherapy with or without surgery with this type of cancer. In this work we report the results of concomitant radio- and chemotherapy in a split-course schedule preceeding surgery for the treatment of squamous cell carcinomas of the esophagus.

METHODS AND MATERIALS

Fifty-six patients with squamous cell carcinomas of the esophagus were treated between April 1989 and September 1993 in the Centre Hospitalier Universitaire in Brest, France with two courses of preoperative concomitant radiochemotherapy, separated by a 2-week interval, and followed by surgery (each course 18.5 Gy in five fractions, days 1-5 with continuous infusion 5-fluorouracil (5-FU) 800 mg/m2 days 1-5 and cisplatinum 70 mg/m2 day 2). Patients who had responded well to preoperative treatment (response > 50%) received four more courses of chemotherapy alone. The two patients who were not operated and those with palliative surgery received a third course of radiochemotherapy (radiotherapy 12 Gy in five fractions, days 1-5).

RESULTS

Fifty-four patients were operated on. Twenty-one showed histological complete response at surgery (37.5% of the whole group). Actuarial survival for the 56 patients was 55% at 3 years and 30% at 4 years, with a median survival of 37.4 months (40.4 months for complete responders to preoperative treatment). Toxicity of preoperative concomitant radio-chemotherapy was low (5-FU had to be stopped in one patient because of cardiac rythm disturbances and in another patient because of aplasia Grade 4 associated with infection after the first course). Postoperative mortality was 11% (six patients).

CONCLUSION

This combination of preoperative radiochemotherapy followed by surgery seems to improve both response rates and survival in patients with esophageal cancer when compared with previous patients treated with surgery alone in our hospital or with results found in literature and it warrants further studies.

Radiation therapy alone or combined with chemotherapy in the treatment of esophageal cancer

Radiation therapy has been used in the adjuvant setting or as a primary treatment modality for esophageal cancer. Although there are design flaws in all of the trials of adjuvant radiation therapy for esophageal cancer, there is no clear survival advantage when radiation therapy is delivered in the adjuvant setting (preoperatively or postoperatively). Phase II results of preoperative, combined modality therapy are encouraging; however, the approach remains investigational. When radiation therapy is used as a primary modality, the most favorable results are seen when it is combined with adequate doses of systemic chemotherapy. Phase III intergroup trials are in progress which are examining the effectiveness of higher doses of radiation therapy when combined with chemotherapy.

Comparison of different treatments for unresectable esophageal cancer

Many patient with esophageal cancer have advanced disease that in not amenable to curative treatment. For these individuals the relief of dysphagia is of utmost importance to the quality of their remaining survival time. This article reviews and compares the methods of palliation with focus on indications and contraindications, advantages as well as disadvantages of each technique, success rates, and complications. Tumor characteristics, the physician's experience, the institution's capabilities, cost, and patient preference will influence choice of palliation. Methods are often complementary rather than competitive.

Diagnosis and treatment of esophageal neoplasms

During the last 10 years, the diagnosis and treatment of esophageal carcinoma have improved considerably. Endoscopy with Lugol staining and endoscopic ultrasonography have been newly introduced and used for early diagnosis and more accurate tumor staging. As a result, the number of patients with tumors at an early stage has increased remarkably (superficial carcinoma, 23%). In the field of treatment, surgical results have improved not only in the short term (30-day mortality rate, 4%) but also in the long term (5-year survival rate, 30%). The field of operation has been extended (3-field lymph node dissection), with lower morbidity and mortality. On the other hand, some techniques for limited treatment such as endoscopic mucosal resection, intraluminal radiotherapy, and laser irradiation have been introduced for the treatment of esophageal carcinoma at an early stage with curative intent. However, there are still many patients with esophageal carcinoma at an advanced stage for whom these treatments fail or are futile. The role of radiotherapy has been made more significant by the introduction of brachytherapy or in combination with other treatment modalities such as surgery, chemotherapy and hyperthermia. Response rates for existing anticancer drugs used as a single agent are 0-38%. Chemotherapy appears to have created significant improvements when used in combined modalities (response rate, 16-76%). However, chemotherapy for patients with esophageal carcinoma still offers an unsatisfactory survival benefit and remains experimental. Studies to evaluate multimodality treatments using chemotherapy, combined with radiotherapy and/or surgery have started. The contribution of molecular biology to the diagnosis and treatment of this disease is a subject for future investigation.

Combined radiochemotherapy for postoperative recurrence of oesophageal cancer

Postoperative recurrences are common after resection for oesophageal cancer. From January 1986 to September 1993 31 patients (30 males, one female, mean (SD) age: 57.5 (8.8) years) were treated for locoregional recurrence (n = 24), metastases (n = 6) or both (n = 1) occurring 15.0 (12.6) months after initial surgery. Radiotherapy and chemotherapy were combined in all cases. Symptomatic improvement was seen in 23 cases (74%) and lasted (excluding treatment period) for 6.3 (4) months. Objective tumoral response was seen in 20 patients (65%) including eight (26%) complete responses. Survival rates were at respectively six months, one, two, and three years: 70.7%, 47.1%, 17.1%, 4.3%. In conclusion, these results show that combined therapy could have a beneficial symptomatic effect and can be associated with prolonged survival in patients with postoperative recurrences of oesophageal cancer.

Management of adenocarcinoma of the esophagus with chemoradiation alone or chemoradiation followed by esophagectomy: results of sequential nonrandomized phase II studies

PURPOSE

The incidence of adenocarcinoma of the esophagus is increasing, but the optimal treatment for this disease is unknown. We evaluated the efficacy of chemoradiation and chemoradiation followed by esophagectomy as treatment for adenocarcinoma of the esophagus in sequential prospective nonrandomized phase II studies.

METHODS AND MATERIALS

Between May 1981 and June 1992, all previously untreated patients (N = 35) with potentially resectable adenocarcinoma of the esophagus (clinical Stage I or II) were treated with curative intent in sequential prospective Phase II studies. From May 1981 to August 1987, 11 patients (median age 66) were treated with concurrent chemotherapy [mitomycin C, and 5-fluorouracil (5-FU)] and radiotherapy to a median dose of 60 Gy (CRT group). From September 1987 to June 1992, 24 patients (median age 65) were treated with the same regimen of chemoradiation followed by planned esophagectomy (CRT+PE group). Of these, 12 patients (median age 62) actually underwent esophagectomy (CRT+E subgroup).

RESULTS

The median overall survival was 19 months for the CRT group and 15 months for the CRT+PE group. For the CRT+E subgroup, the median overall survival was 33 months. The 3-year actuarial overall survival for the CRT and the CRT+PE groups were 36 and 28% (p = 0.949). The subset of patients treated with chemoradiation followed by esophagectomy had a 3-year actuarial overall survival of 33% (p = 0.274). The 3-year actuarial freedom from local failure rates were similar: 62% in the CRT group vs. 58% in the CRT+PE group. Of the 12 patients who underwent esophagectomy (CRT+E group), 9 (75%) were free of local failure. Four of 12 (33%) patients had no pathologic evidence of malignancy in their surgical specimen. Six of 11 patients (55%) in the CRT group were free of local failure at the time of analysis. Two of five patients in this group who had local recurrence at 2 and 10 months underwent surgical salvage with subsequent survivals of 20 and 100 months, respectively. Treatment-related mortality was 0 out of 11 in the CRT group and 2 out of 24 in the CRT+PE group. Dysphagia relief was similar in the CRT group vs. the CRT+E subgroup; however, a greater percentage of patients treated with chemoradiation alone had normal long-term swallowing function when compared to those patients also undergoing esophagectomy (100% vs. 73%).

CONCLUSION

High-dose chemoradiation alone appears to provide similar survival and relief of dysphagia compared with high-dose chemoradiation followed by esophagectomy for patients with potentially resectable esophageal adenocarcinoma. Local failure may be higher in patients undergoing chemoradiation compared to chemoradiation followed by esophagectomy, but surgical salvage is possible, thus providing similar overall local control. However, because of the small number of patients in each group, these treatment modalities need to be further evaluated in a prospective randomized Phase III study.

Chemotherapy and combined-modality therapy for esophageal cancer

Treatment of esophageal carcinoma with radiation alone or surgery alone has yielded unsatisfactory cure rates and has not had a major impact on survival. The failure to cure or prolong survival of patients with esophageal cancer is because of our inability to eradicate residual disease at the primary site and to early systemic dissemination of disease. Three neoadjuvant approaches involving chemotherapy have been studied in patients with apparently localized esophageal cancer: preoperative chemotherapy followed by surgery, chemotherapy and concurrent radiation therapy followed by surgery, and chemotherapy and radiation therapy without surgery. All of these approaches have shown potential in pilot trials. Large-scale trials comparing surgery alone with chemotherapy prior to operation are underway. For patients with local-regional epidermoid carcinoma who are not able to undergo or who refuse operation, chemotherapy plus concurrent radiation appears, in random assignment trials, to be superior to radiation alone.

Downstaging of esophageal cancer after preoperative radiation and chemotherapy

OBJECTIVE

This retrospective, nonrandomized review evaluates 125 patients with esophageal carcinoma (adenocarcinoma and squamous cell) who underwent either surgery only or preoperative chemotherapy and/or radiation therapy followed by surgery. Major end points were survival and postchemoradiation downstaging.

METHODS

Forty-four patients underwent radiation therapy of 4500 cGy over 5 weeks. Fluorouracil and cisplatin were administered on the first and fifth week of radiotherapy. Ninety-eight patients underwent "potentially curative" resections-transhiatal esophagectomy (70), Lewis esophagogastrectomy (25), and left esophagogastrectomy (3). All patients with preoperative adjuvant therapy underwent endoscopy and biopsy before surgery.

RESULTS

There were no differences in overall mortality (5%) or surgical complications in either group. Fourteen of 44 patients (32%) downstaged to complete pathologic response, with 5-year survival of 57%. Fifteen of 44 patients (34%) downstaged to microscopic residual tumor, with 1- and 3-year survival of 77% and 31%, respectively. Twenty-eight of 29 patients in the two downstaged groups were lymph node negative. Overall, 5-year survival in the adjuvant therapy plus surgery group versus surgery only was 36% and 11% (p = 0.04). Five-year survival in lymph node-negative adjuvant therapy and surgery patients was 49% (p = 0.005). Positive nodes in the surgery only group was 48% versus 23% in the adjuvant therapy and surgery group (p = 0.02).

CONCLUSION

Although retrospective and nonrandomized, these results suggest that preoperative chemoradiation results in significant clinical and pathologic downstaging, increases survival, and may sterilize local and regional lymph nodes, accounting for both downstaging and survival statistics.

Multimodality therapy for adenocarcinoma of the esophagus

Few reports exist detailing results of multimodality treatment for adenocarcinoma of the esophagus. We have treated 28 such patients using a preoperative regimen consisting of two courses of cisplatin and 5-fluorouracil with radiation (either 3,000 or 3,600 cGy). There were 25 men and 3 women (mean age, 62.9 years; range, 35 to 86 years), and 16 patients were known to have Barrett's esophagus. Dysphagia was present for a mean of 2.7 months, and the average weight loss was 6.5 kg. Tumors ranged from 2 to 10 cm in length (mean, 5.2 +/- 1.8 cm) with American Joint Committee on Cancer clinical stage I in 2 patients, stage II in 19 patients, and stage III in 7. Dysphagia improved in 23 patients (82%), and in 8 (29%) no tumor was detected during radiologic and endoscopic staging after neoadjuvant therapy. Four patients refused operation. Esophagectomy via standard Ivor Lewis approach was accomplished in 20 of 24 patients (87%) undergoing operation. There were no operative deaths, and mean hospital stay was 15.5 +/- 11.6 days. Four patients (17%) were complete responders with no tumor in the resected specimen. Actuarial survival in the 28 patients at 1, 2, and 3 years is 71%, 28%, and 20% respectively. Of the 20 esophagectomy patients, 6 are alive with no evidence of disease at 10, 50, 54, 70, 77, and 84 months. Three of these were complete responders. Only 1 of the 8 patients no undergoing resection is alive at 16 months with no evidence of disease after further radiotherapy and chemotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)