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Schiffner C, Christiansen H, Brandes I, Grannas G, Wichmann J, Merten R. Neoadjuvant versus definitive radiochemotherapy of locoregionally advanced oesophageal cancer-who benefits? Strahlenther Onkol 2022; 198:1062-1071. [PMID: 35416495 DOI: 10.1007/s00066-022-01929-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 03/10/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE For years, there have been discussions on whether neoadjuvant radiochemotherapy followed by surgery (nRCT-S) is superior to definitive radiochemotherapy (dRCT) as the standard of care for locoregionally advanced oesophageal cancer (OC). This retrospective study aimed to evaluate our patient cohort regarding differences in survival and recurrence between nRCT‑S and dRCT. METHODS Data from 68 patients with dRCT and 33 patients with nRCT‑S treated from 2010 to 2018 were analysed. Comorbidities were recorded using the Charlson Comorbidity Index (CCI). Recurrence patterns were recorded as in-field or out-field. Kaplan-Meier analyses were used to compare survival data (overall survival [OS], progression-free survival [PFS], and locoregional control [LRC]). RESULTS Patients with nRCT‑S showed significantly lower CCI values than those with dRCT (p = 0.001). The median follow-up was 47 months. The median OS times were 31 months for nRCT‑S and 12 months for dRCT (p = 0.009), the median PFS times were 11 and 9 months, respectively (p = 0.057), and the median LRC times were not reached and 23 months, respectively (p = 0.037). The only further factor with a significant impact on OS was the CCI (p = 0.016). In subgroup analyses for comorbidities regarding differences in OS, the superiority of the nRCT‑S remained almost significant for CCI values 2-6 (p = 0.061). CONCLUSION Our study showed significantly longer OS and LRC for patients with nRCT‑S than for those with dRCT. Due to different comorbidities in the groups, it can be deduced from the subgroup analysis that patients with few comorbidities seem to especially profit from nRCT‑S.
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Affiliation(s)
- Christoph Schiffner
- Department of Radiation Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Hans Christiansen
- Department of Radiation Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Iris Brandes
- Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Gerrit Grannas
- Department of Visceral and Transplantation Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Jörn Wichmann
- Department of Radiation Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Roland Merten
- Department of Radiation Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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[F18] FDG-PET/CT for manual or semiautomated GTV delineation of the primary tumor for radiation therapy planning in patients with esophageal cancer: is it useful? Strahlenther Onkol 2020; 197:780-790. [PMID: 33104815 PMCID: PMC8397654 DOI: 10.1007/s00066-020-01701-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/29/2020] [Indexed: 11/15/2022]
Abstract
Background Target volume definition of the primary tumor in esophageal cancer is usually based on computed tomography (CT) supported by endoscopy and/or endoscopic ultrasound and can be difficult given the low soft-tissue contrast of CT resulting in large interobserver variability. We evaluated the value of a dedicated planning [F18] FDG-Positron emission tomography/computer tomography (PET/CT) for harmonization of gross tumor volume (GTV) delineation and the feasibility of semiautomated structures for planning purposes in a large cohort. Methods Patients receiving a dedicated planning [F18] FDG-PET/CT (06/2011–03/2016) were included. GTV was delineated on CT and on PET/CT (GTVCT and GTVPET/CT, respectively) by three independent radiation oncologists. Interobserver variability was evaluated by comparison of mean GTV and mean tumor lengths, and via Sørensen–Dice coefficients (DSC) for spatial overlap. Semiautomated volumes were constructed based on PET/CT using fixed standardized uptake values (SUV) thresholds (SUV30, 35, and 40) or background- and metabolically corrected PERCIST-TLG and Schaefer algorithms, and compared to manually delineated volumes. Results 45 cases were evaluated. Mean GTVCT and GTVPET/CT were 59.2/58.0 ml, 65.4/64.1 ml, and 60.4/59.2 ml for observers A–C. No significant difference between CT- and PET/CT-based delineation was found comparing the mean volumes or lengths. Mean Dice coefficients on CT and PET/CT were 0.79/0.77, 0.81/0.78, and 0.8/0.78 for observer pairs AB, AC, and BC, respectively, with no significant differences. Mean GTV volumes delineated semiautomatically with SUV30/SUV35/SUV40/Schaefer’s and PERCIST-TLG threshold were 69.1/23.9/18.8/18.6 and 70.9 ml. The best concordance of a semiautomatically delineated structure with the manually delineated GTVCT/GTVPET/CT was observed for PERCIST-TLG. Conclusion We were not able to show that the integration of PET/CT for GTV delineation of the primary tumor resulted in reduced interobserver variability. The PERCIST-TLG algorithm seemed most promising compared to other thresholds for further evaluation of semiautomated delineation of esophageal cancer.
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Rades D, Bartscht T, Hunold P, Schmidberger H, König L, Debus J, Belka C, Homann N, Spillner P, Petersen C, Kuhnt T, Fietkau R, Ridwelski K, Karcher-Kilian K, Kranich A, Männikkö S, Schild SE, Maderer A, Moehler M. Radiochemotherapy with or without cetuximab for unresectable esophageal cancer: final results of a randomized phase 2 trial (LEOPARD-2). Strahlenther Onkol 2020; 196:795-804. [PMID: 32533228 PMCID: PMC7449950 DOI: 10.1007/s00066-020-01646-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/23/2020] [Indexed: 12/12/2022]
Abstract
Purpose To investigate the efficacy and toxicity of cetuximab when added to radiochemotherapy for unresectable esophageal cancer. Methods This randomized phase 2 trial (clinicaltrials.gov, identifier NCT01787006) compared radiochemotherapy plus cetuximab (arm A) to radiochemotherapy (arm B) for unresectable esophageal cancer. Primary objective was 2‑year overall survival (OS). Arm A was considered insufficiently active if 2‑year OS was ≤40% (null hypothesis = H0), and promising if the lower limit of the 95% confidence interval was >45%. If that lower limit was >40%, H0 was rejected. Secondary objectives included progression-free survival (PFS), locoregional control (LC), metastases-free survival (MFS), response, and toxicity. The study was terminated early after 74 patients; 68 patients were evaluable. Results Two-year OS was 71% in arm A (95% CI: 55–87%) vs. 53% in arm B (95% CI: 36–71%); H0 was rejected. Median OS was 49.1 vs. 24.1 months (p = 0.147). Hazard ratio (HR) for death was 0.60 (95% CI: 0.30–1.21). At 2 years, PFS was 56% vs. 44%, LC 84% vs. 72%, and MFS 74% vs. 54%. HRs were 0.51 (0.25–1.04) for progression, 0.43 (0.13–1.40) for locoregional failure, and 0.43 (0.17–1.05) for distant metastasis. Overall response was 81% vs. 69% (p = 0.262). Twenty-six and 27 patients, respectively, experienced at least one toxicity grade ≥3 (p = 0.573). A significant difference was found for grade ≥3 allergic reactions (12.5% vs. 0%, p = 0.044). Conclusion Given the limitations of this trial, radiochemotherapy plus cetuximab was feasible. There was a trend towards improved PFS and MFS. Larger studies are required to better define the role of cetuximab for unresectable esophageal cancer.
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Affiliation(s)
- Dirk Rades
- Department of Radiation Oncology, University of Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Germany.
| | - Tobias Bartscht
- Department of Hematology and Oncology, University of Lübeck, Lübeck, Germany
| | - Peter Hunold
- Department of Radiology and Nuclear Medicine, University of Lübeck, Lübeck, Germany
| | - Heinz Schmidberger
- Department of Radiation Oncology, Johannes-Gutenberg University Mainz, Mainz, Germany
| | - Laila König
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany
| | - Claus Belka
- Department of Radiation Oncology, Ludwig-Maximillians University, Munich, Germany
| | - Nils Homann
- Medical Department II, Klinikum Wolfsburg, Wolfsburg, Germany
| | - Patrick Spillner
- Department of Radiation Oncology, Eberhard-Karls University, Tübingen, Germany
| | - Cordula Petersen
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Kuhnt
- Department of Radiation Oncology, University Hospital Leipzig, Leipzig, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Karsten Ridwelski
- Department of General and Visceral Surgery, Klinikum Magdeburg, Magdeburg, Germany
| | - Kerstin Karcher-Kilian
- Practice for Gastroenterology, Diabetology, Oncology and Hematology Lübeck, Lübeck, Germany
| | - Anne Kranich
- Gesellschaft für Studienmanagement und Onkologie mbH, Hamburg, Germany
| | | | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic Scottsdale, AZ, USA
| | - Annett Maderer
- 1st Department of Internal Medicine, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Markus Moehler
- 1st Department of Internal Medicine, Johannes Gutenberg-University Mainz, Mainz, Germany
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Mayr P, Martin B, Fries V, Claus R, Anthuber M, Messmann H, Schenkirsch G, Blodow V, Kahl KH, Stüben G. Neoadjuvant and Definitive Radiochemotherapeutic Approaches in Esophageal Cancer: A Retrospective Evaluation of 122 Cases in Daily Clinical Routine. Oncol Res Treat 2020; 43:372-379. [PMID: 32485721 DOI: 10.1159/000507737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 04/04/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Esophageal cancer (EC) is a common malignant tumor entity with increasing occurrence. The incidence of esophageal adenocarcinoma (AC), particularly, is constantly rising in the Western world. The mainstays of therapy with curative intent for EC in advanced stages are neoadjuvant radiochemotherapy (neoRCT) with surgery and definitive radiochemotherapy (defRCT). METHODS We examined our internal files to identify patients suffering from EC. Palliative cases were excluded. Statistical testing was performed by χ2 test, Student's t test, Kaplan-Meier analyses, and the Mann-Whitney U test. RESULTS One hundred and twenty-two cases were included. Histology revealed squamous cell carcinoma in 92 cases and AC in 23 cases. Ninety-five patients underwent defRCT, 27 underwent neoRCT, and 114 (in both therapy regimes) received simultaneous chemotherapy. There was no difference in the overall survival (OS) (p = 0.654; HR 1.145; 95% CI 0.629-2.086) or and progression-free survival (PFS) (p = 0.912) of patients who underwent neoRCT or defRCT. Median OS was 13.5 (2-197) months for defRCT patients and 19.5 (2-134) months for neoRCT patients (p = 0.751). Karnofsky index (KI) with a cut-off of 70% was strongest, but not a significant parameter for OS (p = 0.608) or PFS (p = 0.137). CONCLUSION defRCT is a valid and an equal alternative to neoRCT for patients suffering from EC. Selection of patients for therapy is of crucial relevance. Further studies and improvements in follow-up are needed when neoRCT has been completed before surgery, in order to spare the patient undergoing operative treatment if there is complete remission. The identification of valid markers urgently needed to limit treatment side effects.
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Affiliation(s)
- Patrick Mayr
- Department of Radio-Oncology, University Hospital of Augsburg, Augsburg, Germany, .,Department of Hematology and Oncology, University Hospital of Augsburg, Augsburg, Germany,
| | - Benedikt Martin
- Department of Pathology, University Hospital of Augsburg, Augsburg, Germany
| | - Verena Fries
- Department of Radio-Oncology, University Hospital of Augsburg, Augsburg, Germany
| | - Rainer Claus
- Department of Hematology and Oncology, University Hospital of Augsburg, Augsburg, Germany
| | - Matthias Anthuber
- Department of Surgery, University Hospital of Augsburg, Augsburg, Germany
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital of Augsburg, Augsburg, Germany
| | - Gerhard Schenkirsch
- Department of Tumor Data Management, University Hospital of Augsburg, Augsburg, Germany
| | - Vera Blodow
- Department of Nuclear Medicine, University Hospital of Augsburg, Augsburg, Germany
| | - Klaus Henning Kahl
- Department of Radio-Oncology, University Hospital of Augsburg, Augsburg, Germany
| | - Georg Stüben
- Department of Radio-Oncology, University Hospital of Augsburg, Augsburg, Germany
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