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

Late effects of radiation therapy on the gastrointestinal tract

Late gastrointestinal complications of radiation therapy have been recognized but not extensively studied. In this paper, the late effects of radiation on three gastrointestinal sites, the esophagus, the stomach, and the bowel, are described. Esophageal dysmotility and benign stricture following esophageal irradiation are predominantly a result of damage to the esophageal wall, although mucosal ulcerations also may persist following high-dose radiation. The major late morbidity following gastric irradiation is gastric ulceration caused by mucosal destruction. Late radiation injury to the bowel, which may result in bleeding, frequency, fistula formation, and, particularly in small bowel, obstruction, is caused by damage to the entire thickness of the bowel wall, and predisposing factors have been identified. For each site a description of the pathogenesis, clinical findings, and present management is offered. Simple and reproducible endpoint scales for late toxicity measurement were developed and are presented for each of the three gastrointestinal organs. Factors important in analyzing late complications and future considerations in evaluation and management of radiation-related gastrointestinal injury are discussed.

Multimodal treatment for squamous cell esophageal cancer

Preoperative chemotherapy (CTx) and combination radiochemotherapy (RTx/CTx) in patients with squamous cell esophageal carcinoma has recently received increasing attention. Although several prospective randomized trials could not show any benefit of neoadjuvant therapy in patients with potentially resectable tumors, preoperative CTx and combination RTx/CTx appear to increase the resection rate, the rate of complete tumor resection, and survival time in patients with locally advanced tumors. Most available studies show that a survival benefit from multimodal therapy can be expected primarily in patients who have a complete histopathologic response to preoperative treatment (i.e., no viable tumor in the resected specimen). Preoperative RTx/CTx increases the response rate and improves local tumor control compared to preoperative CTx alone, but it is associated with substantial perioperative mortality and morbidity. Distant tumor recurrences are insufficiently controlled with current combined modality protocols. These data indicate that neoadjuvant therapy must be considered investigational in patients with potentially resectable esophageal carcinoma but may soon become standard in patients with locally advanced tumors. Research must focus on modalities that allow pretherapeutic identification of those patients who will respond to neoadjuvant therapy. Furthermore, more effective and less toxic preoperative therapy regimens are required to increase the response rates and combat systemic recurrences. Finally, randomized prospective studies are essential to assess the role, extent, and timing of surgical resection for the combined modality approach to patients with squamous cell esophageal carcinoma.

Malignant esophageal stricture and fistula: palliative treatment with polyurethane-covered Gianturco stent

PURPOSE

To evaluate the effectiveness of a polyurethane-covered Gianturco stent in the palliative treatment of malignant esophageal stricture and fistula.

PATIENTS AND METHODS

Twenty-seven patients with recurrent stricture (n = 24), fistula formation (n = 8), or both (n = 5) underwent palliative treatment for aphagia (n = 15) or dysphagia (n = 12). Eight patients had fistulas to the respiratory tract or mediastinum. A 15-F delivery sheath system was passed through the stricture; the inner dilator was removed, and the stent was compressed into the sheath and advanced with a pusher catheter. Follow-up included chest radiography for 3 days and monthly esophagography or endoscopy.

RESULTS

Covered stents occluded fistulas and opened strictures in 100% of patients. Food intake was upgraded to liquids in 7% of patients, to soft foods in 37% and to regular foods in 56%. New stricture or fistula occurred in 4% and 7% of patients, respectively. Stent migration occurred in 15% of patients. Twenty-one patients died after stent placement, and average life expectancy was 11 weeks.

CONCLUSION

A polyurethane-covered Gianturco stent is effective in the palliation of advanced malignant esophageal strictures and fistulas.

Long-term survival after photodynamic therapy for esophageal cancer

BACKGROUND/AIMS

Photodynamic therapy (PDT) has been adapted to the endoscopic treatment of digestive cancer, but its indications and efficacy remain uncertain. The aim of this study was to assess its feasibility in the curative treatment of small esophageal tumors.

METHODS

From 1983 to 1991, PDT was used to treat 123 patients with esophageal cancer who were recommended for nonsurgical treatment of squamous cell carcinoma (n = 104) and adenocarcinoma (n = 19). Endoscopic ultrasonography (EUS) was performed in 88 patients; 61 were staged uT1 and 27 were staged uT2. A hematoporphyrin derivative was injected 72 hours before laser irradiation with a 630-nm dye laser. PDT was applied alone in 56 patients and as part of a multimodal protocol in the 67 others.

RESULTS

The complete response rate at 6 months was 87%. The 5-year survival rate was 25% +/- 6%, and the 5-year disease-specific survival rate was 74% +/- 5%. The complete response rate and survival rate were not different (1) between the PDT alone and the PDT multimodal treatment groups, (2) between the adenocarcinoma and squamous cell carcinoma groups, and (3) between the uT1 and uT2 EUS groups. PDT-related complications were esophageal stenosis (n = 43) and cutaneous photosensitization (n = 16).

CONCLUSIONS

In patients with small esophageal tumors who pose high surgical risk, photodynamic therapy is an effective treatment.

Sequential chemotherapy and radiotherapy for patients with squamous cell carcinoma of the esophagus

BACKGROUND

Despite surgical improvements the prognosis of patients with squamous cell carcinoma (SCC) of the esophagus remains poor, with a 5-year survival rate of less than 20%. Most patients do not undergo surgery with curative intent. The aim of this study was to assess the toxicity and efficacy of sequential chemoradiotherapy.

METHODS

Between May 1986 and June 1991, 50 patients with nonmetastatic SCC of the esophagus were included in this study. Three patients had recurrence after surgery, 8 patients were classified Stage I disease, 24 Stage II, 5 Stage III, and 10 Stage VI. Treatment consisted of cisplatin (100 mg/m2 on Days 1 and 29), 5-fluorouracil (5-FU) (600 mg/m2 on Days 2-9 and Days 30-33) and 30 Gy of radiotherapy (2 Gy x 15 on Days 8-26 and 30 Gy on Days 36-54).

RESULTS

Thirty-seven patients (74%) received the whole treatment course; treatment was modified for 8 patients because of Grades III and IV hematologic, digestive, or renal toxicity. Five patients did not complete treatment because of disease progression or death. Median survival was 13 months; 1- and 2- year survival rates were 63% (49-75) and 36% (25-50), respectively. No late treatment complications were observed (in the 11 survivors after 2 years.

CONCLUSIONS

Sequential chemoradiotherapy of SCC of the esophagus was well tolerated with acceptable acute morbidity and resulted in local control and survival results at least equivalent to those in trials of neoadjuvant chemoradiotherapy plus surgery.

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

Twenty-four previously untreated patients with primary inoperable squamous cell carcinoma of the esophagus showing no evidence of hematogenous metastasis were treated with concurrent chemotherapy and radiation therapy (CRT) followed by surgical resection if possible. The chemotherapy regimen consisted of 5-fluorouracil 750 mg/m2 on days 1-4 and 21-24, and cisplatin 70 mg/m2 on days 1 and 21. Radiation therapy was administered over days 1-26 (200 cGy/day five times per week with an initial planned dose of 40 Gy). Five patients (8%) showed complete response (CR), 14 patients (58%) had partial response (PR), and 19 had good local control (CR 2, PR 17). Eleven cases (48%) underwent esophageal resection with no operative mortality. Curative resection was accomplished in eight cases (35%). Toxicities observed in CRT were leukopenia (grades 3 and 4) 38%, nausea and vomiting (grades 2 and 3) 67%, esophagitis 42%, and fever 42%. The median survival time (MST) for 11 neoadjuvant cases was 349 days (P < 0.05) compared to 212 days for palliative treatment (six cases) and 126 days for no treatment (six cases) after CRT. The MST of eight patients who received curative resection had not been reached after a 17-month median follow-up time. Concurrent chemotherapy with 5-fluorouracil plus cisplatin and radiation proved to be a safe regimen yielding a satisfactory response and minimal toxicity in this particular group of patients. Extensive surgery was thus determined to be feasible after CRT and to contribute to prolonging survival.

Current options in the management of gastrointestinal cancer

Surgery is the standard approach for localized gastrointestinal malignancy both in the upper GI tract and for cancer of the large bowel. Adjuvant chemotherapy following curatively resected colorectal cancer, results in a definite survival advantage. The use of chemotherapy in an attempt to downstage inoperable gastric cancer to allow for subsequent radical resection has yielded promising results. Likewise improved survival rate in patients treated with adjuvant chemotherapy after resection, justify further exploration of perioperative chemotherapy in operable gastric cancer. In squamous oesophageal cancer, modem chemo-radiation regimens are superior to radiotherapy alone in localized disease. Some series demonstrate impressive survival rates in the absence of surgical intervention raising the question as to the precise role of surgery in a combined modality approach. Ongoing randomized trials will clarify the relative contributions of these treatment modalities in the management of this disease. In metastatic disease of both upper GI and colonic tumours maintenance of good quality of life should be the primary endpoint. Randomised trials of chemotherapy against best supportive care have provided strong justification for the use of chemotherapy in the management of advanced gastric, pancreatic and colorectal cancer.

Feasibility of five courses of pre-operative chemotherapy in patients with resectable adenocarcinoma of the oesophagus or gastrooesophageal junction

The purpose of this study was to examine the feasibility of administering all chemotherapy pre-operatively to patients with resectable adenocarcinoma of the oesophagus or gastrooesophageal junction. 32 patients with potentially resectable adenocarcinoma of the oesophagus or gastrooesophageal junction were studied in a stepwise fashion in which combination chemotherapy with cisplatin, high-dose arabinoside and 5-fluorouracil was administered. In the first part, 15 patients were to receive three chemotherapy courses pre-operatively and two chemotherapy courses postoperatively. In the second part, the next 15 patients were to receive all five chemotherapy courses pre-operatively, provided there was an objective response after three courses. Endoscopic ultrasonography was also performed, when feasible, prior to chemotherapy and surgery, and in some patients sequentially between chemotherapy courses. All of the 14 assessable patients in the first group tolerated all three courses of pre-operative chemotherapy, and 86% of patients in this group completed all protocol chemotherapy. In the second group, 9 of 18 (50%) assessable patients tolerated all five courses of preoperative chemotherapy, and 100% of patients in this group received all protocol chemotherapy. The median number of chemotherapy courses for the entire group (32 patients) was five (range one to five). Forty-one per cent (13/32) of patients had a major response to chemotherapy. Sixty-nine per cent (or 76% of 29 patients taken to surgery) had a curative resection. One patient had a pathological complete response. The median survival time of 32 patients was 17 months (range 2-36+ months). 14 patients (37%) remain alive at a median follow-up time of 26+ months. There was a correlation between endoscopic ultrasonographic tumour and nodal stage and pathological tumour and nodal stages in 16 patients. The tumour stage correlation was higher (75%) than the nodal stage correlation (62%). Our data suggest that it is feasible to administer five courses of cisplatin-based chemotherapy to patients with potentially resectable adenocarcinoma of the oesophagus or gastrooesophageal junction. More effective chemotherapy regimens that might result in higher pathological complete response rates and acceptable toxic effects are needed.

Radiotherapy for superficial esophageal cancer

PURPOSE

The results of definitive radiotherapy for superficial esophageal cancer is presented.

METHODS AND MATERIALS

Twenty-one patients with superficial squamous cell carcinoma of the esophagus were treated by definitive radiotherapy with megavoltage x-rays in Tokyo Women's Medical College from 1975 to December 1990. Eight patients refused surgery and 13 patients were considered to be unsuitable for surgery due to advanced age or morbid conditions such as severe pulmonary dysfunction, myocardial infarction, liver cirrhosis, and other cancer. Radiotherapy was performed using 1.8-2.2 Gy fraction dose, 5 times a week and with a total dose of 50-76 Gy/5-7 weeks (median; 70 Gy). Three patients received intraluminal radiotherapy in addition. Combined chemotherapy was performed in four cases, and three cases received it before radiotherapy and one case after radiotherapy.

RESULTS

Overall survival rate was 40.8%, and the cause-specific 5-year survival rate was 61.7%. The 5-year survival rate of the group with morbid conditions was 17.5%, but that of the group without morbid conditions was 60.6%. Seven patients developed recurrence (primary site: 3, lymph nodes: 3, lung: 1) and one patient revealed multicentric cancer of the hypopharynx with wide submucosal spread of the esophagus at 28 months after radiotherapy. No patient developed severe side effect due to radiotherapy.

CONCLUSION

Definitive radiotherapy with or without chemotherapy can be applied as an alternative therapy to surgery for superficial esophageal cancer, even for the operable patients under good general condition.

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.

Impact of age and sex on survival after curative resection for carcinoma of the esophagus

BACKGROUND

The impact of age and sex-related changes in the endogenous hormonal milieu on survival after curative resection for esophageal epithelial cancer is explored. Adami et al. have suggested that the event of puberty has a favorable impact on survival after treatment of epithelial cancers.

METHODS

The database consisted of 469 patients with esophageal cancer treated surgically with an intent to cure (without any gross residual disease at the end of the primary treatment) at Tata Memorial Hospital between 1980 and 1989.

RESULTS

Life-stable analysis revealed a significantly better 5-year survival for women younger than 49 years (35%, CI 24-48) compared with men of the same age (16%, CI 8-27) (P < 0.008). There was no difference in survival between men (17%, CI 12-23) and women (26%, CI 16-37) older than 49 years (P = 0.08). A Cox proportional hazard model showed sex to be the second most significant determinant of survival (P = 0.002) after lymph node metastasis (P < 0.0001).

CONCLUSION

The finding that the survival benefit is confined to women younger than 49 years is consistent with the hypothesis that the endocrine milieu in premenopausal women may prevent the establishment of micrometastases and thus improve the prognosis for esophageal epithelial cancer.

Esophageal cancer

Esophageal cancer is an important problem in the United States. It results in more deaths (over 10,000 annually) than rectal cancer. Furthermore, the incidence of esophageal adenocarcinoma is increasing at a rate faster than that of nearly any other cancer and the reasons for the increase are not well understood. A variety of tumor-suppressor genes (including p53, APC, DCC and Rb) and proto-oncogenes (including prad1, EGFR, c-erb-2 and TGF alpha) may be involved in the development and progression of esophageal cancer. Clinical prognostic factors include stage, Karnofsky performance status, sex, age, anatomic location of the tumor, and degree of weight loss. A new staging system based on depth of wall penetration and lymph node involvement correlates well with prognosis for patients undergoing esophagectomy. Newer staging procedures including endoscopic ultrasound as well as the use of minimally invasive surgery, such as thoracoscopy and laparoscopy, may allow accurate staging without esophagectomy. Surgical resection provides excellent palliation; however, the chance for cure with esophagectomy alone is only 10% to 20%. Adjuvant treatment with pre- or postesophagectomy radiation may improve local-regional control but does not improve survival. Nor has preoperative chemotherapy been shown to improve survival; however, it remains an active area of investigation. Multimodality therapy, namely, chemotherapy and radiation (chemoradiation), given concurrently prior to surgical resection shows promise, with one study indicating a 5-year survival of 34%. A complete pathologic response to chemoradiation correlates with improved survival. Chemoradiation has been shown to be superior to radiation as primary management of esophageal cancer. There has been no successfully completed randomized trial of surgery versus definitive radiation or chemoradiation. However, chemoradiation represents a reasonable alternative to esophagectomy in the primary management of squamous cell carcinoma of the esophagus and chemoradiation also appears to be effective in the treatment of patients with adenocarcinoma of the esophagus, offering significant palliation and a chance for long-term survival as well. Randomized studies of preoperative chemoradiation versus surgery or versus chemoradiation alone are needed. The treatment of advanced esophageal cancer must be directed toward palliation of symptoms. Newer endoscopic techniques, including the use of expansile metal stents, laser ablation, intraluminal high-dose rate brachytherapy, BICAP tumor probe, or photodynamic therapy, offer selected patients short-term palliation.(ABSTRACT TRUNCATED AT 400 WORDS)

A randomized study of chemotherapy, radiation therapy, and surgery versus surgery for localized squamous cell carcinoma of the esophagus

BACKGROUND

Despite well-established surgical approaches, the prognosis for patients with squamous cell carcinoma of the esophagus remains dismal. To assess the benefit of adjuvant chemotherapy and radiation therapy (CRT), a randomized trial with and without sequential preoperative CRT was undertaken; CRT combined 20 Gy and two courses of 5-FU and cisplatin.

METHODS

Patients were included on the basis of the following criteria: squamous cell carcinoma of the esophagus, younger than 70 years of age, World Health Organization status below 2, estimated survival time greater than 3 months, and no previous treatment for the cancer. Patients were not included if they had experienced a loss in body weight greater than 15% or had tracheoesophageal fistula, metastases, or uncontrollable infection.

RESULTS

Eighty-six patients thus fulfilled the criteria for inclusion (41 CRT, 45 non-CRT). The groups were well-matched for age, sex, tumor location, size, and grade. Operative mortality was 8.5% and 7%, respectively, for each group with a 27-day hospital stay for both groups. Long-term survival was not significantly different, with 47% of both groups alive at 1 year.

CONCLUSIONS

The authors concluded that this neoadjuvant treatment did not change operative mortality or survival time for patients with squamous cell carcinoma of the esophagus.

A randomized study of chemotherapy, radiation therapy, and surgery versus surgery for localized squamous cell carcinoma of the esophagus

BACKGROUND

Despite well-established surgical approaches, the prognosis for patients with squamous cell carcinoma of the esophagus remains dismal. To assess the benefit of adjuvant chemotherapy and radiation therapy (CRT), a randomized trial with and without sequential preoperative CRT was undertaken; CRT combined 20 Gy and two courses of 5-FU and cisplatin.

METHODS

Patients were included on the basis of the following criteria: squamous cell carcinoma of the esophagus, younger than 70 years of age, World Health Organization status below 2, estimated survival time greater than 3 months, and no previous treatment for the cancer. Patients were not included if they had experienced a loss in body weight greater than 15% or had tracheoesophageal fistula, metastases, or uncontrollable infection.

RESULTS

Eighty-six patients thus fulfilled the criteria for inclusion (41 CRT, 45 non-CRT). The groups were well-matched for age, sex, tumor location, size, and grade. Operative mortality was 8.5% and 7%, respectively, for each group with a 27-day hospital stay for both groups. Long-term survival was not significantly different, with 47% of both groups alive at 1 year.

CONCLUSIONS

The authors concluded that this neoadjuvant treatment did not change operative mortality or survival time for patients with squamous cell carcinoma of the esophagus.

High dose external beam radiation therapy with or without concomitant chemotherapy for esophageal carcinoma

Esophageal cancer patients treated with radiotherapy (RTx) are most often those with malignancies too extensive for surgery or those who deemed medically unsuitable for an aggressive surgical approach. Summarizing RTx series, the 2-year survival rate is in the range of 10% and at 5 years about 5%. Although not randomly compared, these results are not significantly worse than those achieved with surgery in more advanced tumors. In stage I/II tumors, more recent trials reported of 5-year survival rates varying between 12% and 20%. These data indicate that irradiation may be administered with curative intention but usually only for patients who are also candidates for primary surgery. On the other hand, modern RTx (doses > 60 Gy) +/- endoluminal after-loading may provide good palliation (relief of dysphagia) for patients with good prognostic factors such as weight loss of less than 10% body weight, good performance status, younger age, and location of the tumor. In the perioperative setting, RTx reduced the frequency of the local recurrences but did not increase the overall resection and R0 resection rates and did not improve survival due to more patients relapsing at distant sites. Combined chemoradiotherapy has shown to be superior to RTx alone with respect to local control, disease free survival and overall survival and in a marked reduction of distant failures. These data support the use of chemoradiotherapy as standard treatment of locally advanced and nonresectable esophageal cancer. They also provide a basis for randomized trials comparing chemoradiotherapy alone versus preoperative treatment modalities.

Neoadjuvant therapy for squamous cell esophageal carcinoma

A number of studies have demonstrated that preoperative chemotherapy (CTx) and combination radiochemotherapy (RTx/CTx) in patients with potentially resectable and locally advanced squamous cell esophageal carcinoma is feasible. In patients with potentially resectable tumors, neoadjuvant therapy followed by surgical resection has, however, so far not shown an increase in the resection rate, rate of complete macroscopic and microscopic tumor resections, i.e. R0-resections according to the UICC, or survival time as compared to patients who had surgical resection alone. In this situation a survival benefit, if at all, can be expected only in those who respond to preoperative therapy. At the present time preoperative CTx or RTx/CTx in patients with potentially resectable esophageal carcinoma must therefore be considered investigational and should not be performed outside the context of clinical trials. In patients with locally advanced esophageal carcinoma, neoadjuvant therapy markedly increases the rate of R0-resections and appears to prolong survival. Combined modality therapy in this context is, however, associated with a substantial perioperative mortality and morbidity. Open questions that have to be addressed by randomized studies include the role, extent and timing of surgical resection in the combined modality approach to patients with locally advanced squamous cell esophageal carcinoma. Research has to focus on preoperative staging modalities and the development of more effective and less toxic preoperative therapy regimen to improve identification of patients that might benefit from combined modality therapy and to more effectively combat systemic recurrences.

Preoperative high-dose radiation and chemotherapy in adenocarcinoma of the esophagus and esophagogastric junction

BACKGROUND

Esophageal adenocarcinoma (EA) incidence is rising. Defining optimal management is essential because median survival after surgery alone is only approximately 12 months. High-dose radiation (> 5000 cGy) and chemotherapy (HDRCT) preoperatively for patients with EA has not been fully investigated. We evaluated tumor response, resectability, and survival following HDRCT in patients with localized EA.

METHODS

Thirty patients with American Joint Committee on Cancer (AJCC) clinical stage I or II EA were prospectively treated with HDRCT. The treatment consisted of 60 Gy radiation at 2 Gy per fraction with concurrent infusional 5-fluorouracil (5-FU) and a bolus of mitomycin C followed by esophagogastrectomy. The range of follow-up was 7 to 69 months, with a median of 31 months.

RESULTS

Twenty of 30 patients (67%) received full-course HDRCT. Severe esophagitis precluded full-dose radiation in 10 patients. Three patients developed neutropenia and fever requiring admission to a hospital. Two patients died preoperatively of treatment-related complications. Nine patients were not explored. Eighteen patients were resected with curative intent; the remaining three had metastatic disease at laparotomy. Seven of 18 resected patients (39%), or 7/30 (23%) of all patients treated, had a pathologic complete response. There was one operative death. Overall local control was seen in 25/30 patients (83%). Median overall survivals for resected and for all patients were 23 and 13 months, respectively.

CONCLUSIONS

Preoperative HDRCT in patients with EA results in encouraging local tumor response and local control. Overall survival, however, may not be improved, and the treatment-related mortality of 10% is higher than reported with surgery alone or with preoperative chemotherapy.

Neoadjuvant chemotherapy and radiotherapy in locally advanced esophagus carcinoma: long-term results

PURPOSE

A prospective study with neoadjuvant chemotherapy and radiotherapy in patients with locally advanced esophagus carcinoma for evaluating: toxicity, response rate, pattern of recurrence, and survival after a long follow-up.

METHODS AND MATERIALS

Between 1983-1988, 40 patients with locally advanced squamous cell carcinoma of the thoracic esophagus were entered into a prospective trial of neoadjuvant chemotherapy and radiotherapy. Eight patients (20%) were Stage II and 32 patients (80%) were Stage III, according to American Joint Committee staging criteria. Neoadjuvant chemotherapy consisted of two cycles with cisplatin (120 mg/m2 day 1), vindesine (3 mg/m2 days 1, 8, 15, and 22) and bleomycin (10 mg/m2 days 3 to 6). Second cycle was initiated on day 29. Radiation therapy was administered 2-4 weeks after completion of chemotherapy, with a total dose on tumor of 60 Gy.

RESULTS

Two patients died from treatment-related toxicity. Complete response was observed in 20 patients (53%) and symptomatic improvement in 31 patients (82%). The median survival was 11 months, with an actuarial survival at 1 year of 45%, 3 year 20%, and 5 years 15%. Significantly (p < 0.05) longer survival was observed in patients with Stage II (median survival 18 months) vs. Stage III (median survival 10 months). The pattern of failure was predominantly local/regional (62%).

CONCLUSION

This treatment scheme is an effective and tolerable regimen but long-term survival was poor.

Mitomycin C as an adjunct to postoperative radiation therapy in squamous cell carcinoma of the head and neck: results from two randomized clinical trials

PURPOSE

This study was undertaken to assess the benefit of mitomycin C as an adjunct to postoperative radiation therapy in patients with operable squamous cell carcinoma of the head and neck.

METHODS AND MATERIALS

Between May 1980 and May 1991, 182 patients have been enrolled in two consecutive randomized clinical trials testing mitomycin C as an adjunct to radiation therapy in squamous cell carcinoma of the head and neck. In both trials, patients were stratified by stage, disease site and intent of therapy. This subset analysis includes 113 patients entered into these two randomized trials treated with surgery and postoperative radiation therapy. In the first trial, patients were randomized to receive standard postoperative radiation therapy alone compared with postoperative radiation therapy with concomitant mitomycin C. In the second trial, patients were randomized to postoperative radiation therapy or postoperative radiation therapy with concomitant mitomycin C plus dicoumarol.

RESULTS

As of November 1991, the 113 patients treated with surgery and postoperative radiation therapy in both trials had a median follow-up of 93 months. There have been a total of 12 local recurrences in the radiation therapy alone arm compared to 0 local recurrences in the radiation therapy/mitomycin C arm. There were eight regional recurrences in the radiation therapy alone arm compared with five regional recurrences in the mitomycin C arm. Patients in the mitomycin C arm experienced a superior 5-year actuarial local regional control rate (87% vs. 67%, p < .015) and a statistically significant disease-free survival benefit (67% vs. 44%, p < .03). Overall survival difference between the two arms (56% vs. 41%) has not reached statistical significance.

CONCLUSIONS

We conclude from these prospectively designed randomized clinical trials that in patients with operable head and neck cancer treated with surgery and postoperative radiation therapy, concomitant administration of mitomycin C with radiation therapy will result in a statistically significant disease-free survival and local regional control benefit. We are currently investigating the value of other bioreductive alkylating agents as adjuncts to radiation therapy in patients with squamous cell carcinoma of the head and neck.

Swallowing function in patients with esophageal cancer treated with concurrent radiation and chemotherapy

BACKGROUND

Major goals of concurrent radiation and chemotherapy in the treatment of esophageal cancer are the early restoration and long-term maintenance of swallowing function. The purpose of this study was to determine the impact of concurrent radiation and chemotherapy on swallowing function.

METHODS

Between September 1980 and September 1990, 120 patients with esophageal cancer were treated at the Fox Chase Cancer Center on the basis of one of three prospective nonrandomized protocols using concurrent chemotherapy and radiation. Swallowing function was retrospectively assessed in these patients by use of a swallowing-function scoring system. In addition, patients who had long-term control of their esophageal cancer underwent a more detailed analysis of swallowing function.

RESULTS

Initial improvement in dysphagia occurred in 88% of the 102 assessable patients, with a median time to improvement of 2 weeks. There was no difference in overall percentage of initial improvement for patients with adenocarcinoma versus squamous cell carcinoma. Patients with distal tumors, however, showed both earlier and higher frequency of initial improvement than did patients with tumors in the upper two-thirds of the thoracic esophagus (95% versus 79%). Local relapse-free survival of definitively treated patients at 3 years was 60% and was significantly better for patients with Stage I (76%) versus Stage II cancers (55%) (P < 0.05). All 25 patients treated with curative intent who survived for more than 1 year without evidence of disease were able to eat soft or solid foods and had a benign stricture rate of only 12%. Even in patients with advanced disease who were treated with palliative intent, 91% had an initial improvement in swallowing function and 67% had improvement in swallowing function that lasted until death.

CONCLUSIONS

High-dose concurrent radiation and chemotherapy provides rapid improvement in dysphagia, and this improvement results in normal or near-normal swallowing function of long duration.

Combined chemotherapy and radiotherapy compared with radiotherapy alone in patients with cancer of the esophagus

BACKGROUND

The efficacy of conventional treatment with surgery and radiation for cancer of the esophagus is limited. The median survival is less than 10 months, and less than 10 percent of patients survive for 5 years. Recent studies have suggested that combined chemotherapy and radiation therapy may result in improved survival.

METHODS

This phase III prospective, randomized, and stratified trial was undertaken to evaluate the efficacy of four courses of combined fluorouracil (1000 mg per square meter of body-surface area daily for four days) and cisplatin (75 mg per square meter on the first day) plus 5000 cGy of radiation therapy, as compared with 6400 cGy of radiation therapy alone, in patients with squamous-cell carcinoma or adenocarcinoma of the thoracic esophagus. The trial was stopped after the accumulated results in 121 patients demonstrated a significant advantage for survival in the patients who received chemotherapy and radiation therapy.

RESULTS

The median survival was 8.9 months in the radiation-treated patients, as compared with 12.5 months in the patients treated with chemotherapy and radiation therapy. In the former group, the survival rates at 12 and 24 months were 33 percent and 10 percent, respectively, whereas they were 50 percent and 38 percent in the patients receiving combined therapy (P less than 0.001). Seven patients in the radiotherapy group and 25 in the combined-therapy group were alive at the time of the analysis. The patients who received combined treatment had fewer local (P less than 0.02) and fewer distant (P less than 0.01) recurrences. Severe and life-threatening side effects occurred in 44 percent and 20 percent, respectively, of the patients who received combined therapy, as compared with 25 percent and 3 percent of those treated with radiation alone.

CONCLUSIONS

Concurrent therapy with cisplatin and fluorouracil and radiation is superior to radiation therapy alone in patients with localized carcinoma of the esophagus, as measured by control of local tumors, distant metastases, and survival, but at the cost of increased side effects.

Patterns of failure following combined modality therapy for esophageal cancer, 1984-1990

From 1984-1990, 143 patients with squamous cell or adenocarcinoma of the esophagus were enrolled in a Phase I/II study of neoadjuvant chemotherapy followed by concurrent chemotherapy plus radiotherapy with or without subsequent esophagectomy. Patients received one cycle of Cisplatin or Carboplatin plus Etoposide for squamous cell carcinoma, or Cisplatin or Carboplatin plus 5FU for adenocarcinoma, followed by two cycles of the same chemotherapy given concurrently with 44-46 Gy over 5 weeks. Operable patients then underwent esophagectomy. Inoperable patients and those with positive surgical margins received additional irradiation (16-18 Gy). Twelve percent of the surgical group received preoperative radiotherapy doses > or = 50 Gy. Seventy-two percent (103) had clinical Stage I-III tumors and 28% (40) were clinical Stage IV (1983 American Joint Committee on Cancer criteria). Only clinical Stage I-III patients were analyzed with respect to patterns of failure. Isolated local failure occurred in 19/103 (18%) of clinical Stage I-III patients. Both local and distant relapse occurred in 15/103 (15%), and distant metastases alone occurred in 25/103 (24%). The 3-year actuarial rates of local and distant failures were 45% and 60%, respectively. Among the clinical Stage I-III patients who underwent surgery (n = 58) versus those who did not (n = 45), the 3-year actuarial local and distant failure rates were 30% versus 60% and 45% versus 45%, respectively. Multivariate analysis was performed to identify significant predictors of local control. For all clinical Stage I-III patients, treatment with surgery (p = 0.001) and with three or more cycles of chemotherapy (p = 0.02) were significant predictors of improved local control. Patients who underwent surgery were significantly younger and had a better performance status than those who did not. The improvement in local control with surgery did not translate into better survival, likely on account of a high operative mortality rate in older patients and those receiving > or = 50 Gy preoperatively. We conclude that local control remains poor with concurrent chemotherapy + radiotherapy for esophageal cancer. The addition of surgery improved local control, but distant metastases remain a problem both in this group of patients as well as those treated without esophagectomy. Efforts to improve local control appear warranted, but it remains to be demonstrated that improved local control translates into improved survival in esophageal cancer because of a high rate of distant metastases in patients whose disease is controlled in the esophagus.