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

Esophagogastric Cancer: The Current Role of Radiation Therapy

Radiation therapy is an effective treatment modality in the management of patients with esophageal cancer regardless of tumor location (proximal, middle, or distal esophagus) or histology (squamous cell vs adenocarcinoma). The addition of neoadjuvant CRT to surgery in patients who are surgical candidates has consistently shown a benefit in terms of locoregional recurrence, pathologic downstaging, and overall survival. For patients who are not surgical candidates, CRT has a role as definitive treatment.

The Evolution of Neo-Adjuvant Therapy in the Treatment of Oesophageal and Gastro-Oesophageal Junction Adenocarcinomas

Historically, oesophageal and gastro-oesophageal junction adenocarcinomas were associated with a poor prognosis. The advent of neoadjuvant therapy has transformed the management of oesophageal and gastro-oesophageal junction adenocarcinomas further and offers the possibility to reverse disease progression, eliminate micrometastasis, and offer potentially better outcomes for these patients. This review provides an overview of landmark clinical trials in this area, with different treatment regimens considered over the years as well as potential therapeutic agents on the horizon that may transform the management of oesophageal and gastro-oesophageal junction adenocarcinomas further.

Salvage Surgery for Recurrent Disease after Definitive Chemoradiotherapy for Esophageal Squamous Cell Carcinoma

BACKGROUND

Outcomes of salvage surgery after failed definitive chemoradiation (CRT) for esophageal cancer have been well defined. However, only a few studies have focused on salvage esophagectomy for recurrent disease after CRT.

METHODS

In 227 patients with esophageal cancer who underwent salvage esophagectomy after definitive CRT, consisting of 116 patients who underwent esophagectomy for persistent disease (the persistent group) and 111 patients who underwent esophagectomy for recurrent disease (the recurrent group), the short- and long-term outcomes were investigated.

RESULTS

The rates of any postoperative complication were similar between the groups (49.1% in the persistent group vs. 49.5% in the recurrent group, p = 0.951), although there was a higher rate of anastomotic leakage in the recurrent group (p = 0.027). Thirty-day mortality was also similar between the groups (1.7% in the persistent group vs. 0.9% in the recurrent group, p = 0.587). The 3-year and 5-year overall survival rates were 33.7% and 28.0% in the persistent group and 48.7% and 41.7% in the recurrent group, respectively (p = 0.0175). In the recurrent group, clinically nodal status before CRT as well as pathologically nodal status and time to relapse were identified as independent prognostic factors. In the persistent group, pT and resection margin were identified as independent factors associated with survival.

CONCLUSIONS

The present study showed that salvage surgery for recurrent disease can provide acceptable short- and long-term outcomes. Considering clinically and pathologically nodal status and time to relapse, adjuvant therapy might be offered for patients who underwent salvage esophagectomy for recurrent disease after definitive CRT.

Survival predictors associated with signet ring cell carcinoma of the esophagus (SRCCE): A population-based retrospective cohort study

Purpose

Signet ring cell carcinoma of the esophagus (SRCCE) is an uncommon tumor associated with significant morbidity and mortality. There is still no consensus regarding cut-off values for tumor size, age and optimal treatment for SRCCE. Thus, we elucidated the current survival outcomes of patients with SRCCE and analyzed factors associated with prognosis.

Methods

A retrospective cohort study based on the SEER (The Surveillance, Epidemiology, and End Results) program database was conducted. We identified 537 patients (461 men and 76 women) newly diagnosed with SRCCE between January 2004 and December 2014. A multivariate Cox proportional hazards model was utilized to measure the mortality-associated risk factors in patients with SRCCE after adjusting for various variables.

Results

The 1-, 2- and 5-year disease-specific mortalities (DSM) were 51.6%, 67.6%, and 78.4%, respectively, and the median survival time was 12.0 months. The factors correlated with mortality hazard were marital status (unmarried versus married, Hazard Ratio (HR) = 1.443), tumor size (≥ 5 cm versus < 5 cm, HR = 1.444), tumor grade (high grade versus low grade, HR = 3.001), condition of primary tumor (T4 versus T1, HR = 2.178), regional lymph node metastasis (N1 versus N0, HR = 1.739), further metastasis (M1 versus M0, HR = 1.951) and chemotherapy (receiving chemotherapy versus no chemotherapy, HR = 0.464).

Conclusions

The contemporary 5-year DSM was 78.4%. Being unmarried, having a tumor size ≥ 5 cm, a high tumor grade, a score of T4 for tumor invasion of adjacent organs, a score of N1 for regional lymph node metastasis, a score of M1 for distant metastasis and no chemotherapy were independent predictors of high DSM.

The Benefit of Chemotherapy in Esophageal Cancer Patients With Residual Disease After Trimodality Therapy

INTRODUCTION

The objective of this retrospective study was to determine the potential benefits of chemotherapy in esophageal cancer patients treated with chemoradiation followed by surgery.

MATERIALS AND METHODS

At our institution, 145 patients completed trimodality therapy from 1993 to 2009. Neoadjuvant treatment predominantly consisted of 5-fluorouracil and cisplatin with a concurrent median radiation dose of 50.4 Gy. Sixty-two patients received chemotherapy postoperatively. The majority (49/62) received 3 cycles of docetaxel.

RESULTS

Within the entire cohort, a 5-year overall survival (OS) benefit was found in those who received postoperative chemotherapy, OS 37.1% versus 18.0% (P=0.024). The response after neoadjuvant chemoradiation was as follows: 33.8% had a pathologic complete response and 62.8% with residual disease. A 5-year OS and cause-specific survival (CSS) advantage were associated with postoperative chemotherapy among those with macroscopic residual disease after neoadjuvant therapy: OS 38.7% versus 13.9% (P=0.016), CSS 42.8% versus 18.8% (P=0.048). This benefit was not seen in those with a pathologic complete response or those with microscopic residual. A stepwise multivariate Cox regression model evaluating the partial response group revealed that postoperative chemotherapy and M stage were independent predictors of overall and CSS.

CONCLUSIONS

This analysis revealed that patients with gross residual disease after trimodality therapy for esophageal cancer who received postoperative chemotherapy had an improved overall and CSS. These data suggest that patients with residual disease after trimodality therapy and a reasonable performance status may benefit from postoperative chemotherapy. Prospective trials are needed to confirm these results to define the role of postoperative treatment after trimodality therapy.

Induction chemoradiation therapy prior to esophagectomy is associated with superior long-term survival for esophageal cancer

The purpose of this study was to examine the role of induction chemoradiation in the treatment of potentially resectable locally advanced (T2-3N0 and T1-3N+) esophageal cancer utilizing a large national database. The National Cancer Data Base (NCDB) was queried for all patients undergoing esophagectomy for clinical T2-3N0 and T1-3N+ esophageal cancer of the mid- or lower esophagus. Patients were stratified by the use of induction chemoradiation therapy versus surgery-first. Trends were assessed with the Cochran-Armitage test. Predictors of receiving induction therapy were evaluated with multivariable logistic regression. A propensity-matched analysis was conducted to compare outcomes between groups, and the Kaplan-Meier method was used to estimate long-term survival. Within the NCDB, 7921 patients were identified, of which 6103 (77.0%) were treated with chemoradiation prior to esophagectomy, while the remaining 1818 (23.0%) were managed with surgery-first. Use of induction therapy increased over time, with an absolute increase of 11.8% from 2003-2011 (P < 0.001). As revealed by the propensity model, induction therapy was associated with higher rates of negative margins and shorter hospital length of stay, but no differences in unplanned readmission and 30-day mortality rates. In unadjusted survival analysis, induction therapy was associated with better long-term survival compared to a strategy of surgery-first, with 5-year survival rates of 37.2% versus 28.6%, P < 0.001. Following propensity score matching analysis, the use of induction therapy maintained a significant survival advantage over surgery-first (5-year survival: 37.9% vs. 28.7%, P < 0.001). Treatment with induction chemoradiation therapy prior to surgical resection is associated with significant improvement in long-term survival, even after adjusting for confounders with a propensity model. Induction therapy should be considered in all medically appropriate patients with resectable cT2-3N0 and cT1-3N+ esophageal cancer, prior to esophagectomy.

What is the optimal management of dysphagia in metastatic esophageal cancer?

BACKGROUND

The palliation of dysphagia in metastatic esophageal cancer remains a challenge, and the optimal approach for this difficult clinical scenario is not clear. We therefore sought to define and determine the efficacy of various treatment options used at our institution for this condition.

METHODS

We reviewed a prospective database for all patients managed in an esophageal cancer referral centre over a 5-year period. All patients receiving palliation of malignant dysphagia were reviewed for demographics, palliative treatment modalities, complications, and dysphagia scores (0 = none to 4 = complete). The Wilcoxon signed rank test was used to determine significance (p < 0.05).

RESULTS

During 2004-2009, 63 patients with inoperable esophageal cancer were treated for palliation of dysphagia. The primary treatment was radiotherapy in 79% (brachytherapy in 18 of 50; external-beam in 10 of 50; both types in 22 of 50), and stenting in 21%. Mean wait time from diagnosis to treatment was 22 days in the stent group and 54 days in the radiotherapy group (p = 0.003). Mean duration of treatment was 1 day in the stent group and 40 days in the radiotherapy group (p = 0.001). In patients treated initially by stenting, dysphagia improved within 2 weeks of treatment in 85% of patients (dysphagia score of 0 or 1). However, 20% of patients presented with recurrence of dysphagia at 10 weeks of treatment. In the radiotherapy group, the onset of palliation was slower, with only 50% of patients palliated at 2 weeks (dysphagia score of 0 or 1). However, long-term palliation was more satisfactory, with 90% of patients remaining palliated after 10 weeks of treatment.

CONCLUSIONS

In inoperable esophageal cancer at our centre, radiation treatment provided durable long-term relief, but came at a high price of a long wait time for initiation of treatment and a long lag time between initiation of treatment and relief of symptoms. On the other hand, endoluminal stenting provided more rapid and effective early relief from symptoms, but was affected by recurrence of dysphagia in the long-term. It is now time for a prospective randomized trial to assess the safety and efficacy of combined-modality treatment with both endoluminal stenting and radiation therapy compared with either treatment alone.

Submucosal tumor appearance is a useful endoscopic predictor of early primary-site recurrence after definitive chemoradiotherapy for esophageal squamous cell carcinoma

Chemoradiotherapy (CRT) for esophageal cancer is disadvantageous because of a high locoregional failure rate. Detecting early small recurrent cancers at the primary site is necessary for potential salvage treatment. However, most endoscopists are inexperienced and therefore, a role for surveillance endoscopy after complete remission (CR) has not been established. We retrospectively evaluated serial surveillance endoscopic images from patients eventually proved to have primary-site recurrence in order to identify useful endoscopic features for early diagnosis. From January 2000 to December 2004, 303 patients with esophageal squamous cell carcinoma underwent definitive CRT, and 133 of them achieved CR. The surveillance endoscopic images stored at intervals of 1-3 months for the 16 patients with recurrence only at the primary tumor site and the 61 patients with no recurrence were collected for reexamination. Among 133 patients who achieved CR, 16 (12%) developed only local recurrence at the primary site. Thirteen of the 16 primary-site recurrent tumors (81%) appeared as submucosal tumors (SMT), with the remaining appearing as erosions or mild strictures. Of biopsy-proven recurrences, 81% were preceded by newly developed lesions such as SMT, erosions, or mild strictures detected by earlier surveillance endoscopies. For all 77 patients achieving CR with no metastasis, 86% of the evolving SMT with negative biopsies were eventually confirmed as cancer at later endoscopies. Thirteen of the 21 evolving lesions were subsequently confirmed as recurrent cancer. Early primary-site recurrence of esophageal cancer after a complete response to CRT is detectable with frequent endoscopic surveillance. SMT appearance is a useful endoscopic sign of early recurrence, as well as a predictor of subsequent diagnosis of recurrence.

Long-term outcome of a phase II study of docetaxel-based multimodality chemoradiotherapy for locally advanced carcinoma of the esophagus or gastroesophageal junction

We performed a phase II trial to evaluate a docetaxel-based regimen in locoregionally advanced esophageal cancer. Untreated stage II-IVa esophageal cancer patients with performance status 0-2 were included. Tumor resectability was determined prior to initiation of study. Induction docetaxel (75 mg/m(2)) and cisplatin (75 mg/m(2)) day 1 with prophylactic filgrastim was delivered every 21 days for 3 cycles. Subsequent concomitant chemoradiotherapy (CRT) utilized weekly docetaxel (20 mg/m(2)) and concurrent radiotherapy (2 Gy/day) in resectable/resected patients (50 Gy) and in unresectable patients (66 Gy). A total of 78 patients (15 squamous cell carcinoma, 60 adenocarcinoma, 3 mixed/undifferentiated; 68 men, 10 women; median age 61 years) were accrued. The regimen was administered to 59 (76%) potentially resectable patients and 13 (17%) unresectable patients; 6 patients (8%) received the regimen post-operatively. Response rate in 66 evaluable patients following induction chemotherapy was 30%. Sixty-nine patients underwent CRT. Ten patients had disease progression during CRT. Forty-five out of 59 potentially resectable patients underwent esophagectomy after CRT, and 42 patients had complete tumor resection with negative margins. Eighteen out of 59 patients who were potentially resectable patients had pathologic complete response (pCR-31%). Grade 3/4 toxicity during induction chemotherapy included leucopenia, neutropenia, vomiting, and neuropathy. Esophagitis was the predominant toxicity during CRT. Median overall survival was 11.4 months for unresectable patients, 14.3 months for resectable patients and 10.4 months for patients who received the regimen post-operatively (log-rank P = 0.2492). Docetaxel-based CRT regimen is active and tolerable in esophageal cancer. The observed pCR in the potentially resectable group indicates good local control.

Salvage esophagectomy after definitive chemoradiotherapy for thoracic esophageal cancer

BACKGROUND AND OBJECTIVES

Although locoregional failure frequently occurs after definitive chemoradiotherapy (CRT), the role of salvage esophagectomy has not been fully evaluated. The aim of this study was to compare the outcome of salvage esophagectomy after high-dose definitive CRT with neoadjuvant CRT.

METHODS

From 1994 to 2007, 33 patients with thoracic esophageal cancer underwent salvage esophagectomy after definitive CRT, and 115 patients underwent neoadjuvant CRT followed by surgery.

RESULTS

The postoperative mortality rate in the salvage group (12%) was higher than in the neoadjuvant group (3.6%, P = 0.059). The rates of postoperative complications were significantly higher in the salvage group than in neoadjuvant group: Anastomotic leakage (39% vs. 22%, respectively, P = 0.049), bleeding (15% vs. 1.7%, respectively, P = 0.002), cardiovascular complications (24% vs. 5.4%, respectively, P = 0.001). Univariate analysis showed that pretherapy T stage, pretherapy lymph node status, pathological T stage, and operative curability were significant prognostic factors affecting survival of patients who underwent salvage esophagectomy. In particular, patients with cT3-T4 tumors or cN1 tumors before definitive CRT showed worse prognosis after salvage esophagectomy.

CONCLUSIONS

Salvage esophagectomy after high-dose definitive CRT was associated with higher postoperative mortality and morbidity rates compared with neoadjuvant CRT. Only selected patients can be rescued by salvage esophagectomy.

Survival effect of neoadjuvant radiotherapy before esophagectomy for patients with esophageal cancer: a surveillance, epidemiology, and end-results study

PURPOSE

The role of neoadjuvant radiotherapy (NeoRT) before definitive surgery for esophageal cancer remains controversial. This study used a large population-based database to assess the effect of NeoRT on survival for patients treated with definitive surgery.

METHODS AND MATERIALS

The overall survival (OS) and cause-specific survival for patients with Stage T2-T4, any N, M0 (cT2-T4M0) esophageal cancer who had undergone definitive surgery between 1998 and 2004 were analyzed by querying the Surveillance, Epidemiology, and End-Results database. Kaplan-Meier survival curves were generated and univariate comparisons were made using the log-rank test. Cox proportional hazards survival regression multivariate analysis was performed with NeoRT, T stage (T2 vs. T3-T4), pathologic nodal status (pN0 vs. pN1), number of nodes dissected (>10 vs. </=10), histologic type (adenocarcinoma vs. squamous cell carcinoma), age (<65 vs. >/=65 years), and gender as covariates.

RESULTS

A total of 1,033 patients were identified. Of these, 441 patients received NeoRT and 592 underwent esophagectomy alone; 77% were men, 67% had adenocarcinoma, and 72% had Stage T3-T4 disease. The median OS and cause-specific survival were both significantly greater for patients who received NeoRT compared with esophagectomy alone (27 vs. 18 months and 35 vs. 21 months, respectively, p <0.0001). The 3-year OS rate was also significantly greater in the NeoRT group (43% vs. 30%). On multivariate analysis, NeoRT, age <65 years, adenocarcinoma histologic type, female gender, pN0 status, >10 nodes dissected, and Stage T2 disease were all independently correlated with increased OS.

CONCLUSION

These results support the use of NeoRT for patients with esophageal cancer. Prospective studies are needed to confirm these results.

Phase III trial of trimodality therapy with cisplatin, fluorouracil, radiotherapy, and surgery compared with surgery alone for esophageal cancer: CALGB 9781

PURPOSE

The primary treatment modality for patients with carcinoma of the esophagus or gastroesophageal junction has been surgery, although primary radiation therapy with concurrent chemotherapy produces similar results. As both have curative potential, there has been great interest in the use of trimodality therapy. To this end, we compared survival, response, and patterns of failure of trimodality therapy to esophagectomy alone in patients with nonmetastatic esophageal cancer.

PATIENTS AND METHODS

Four hundred seventy-five eligible patients were planned for enrollment. Patients were randomly assigned to either esophagectomy with node dissection alone or cisplatin 100 mg/m(2) and fluorouracil 1,000 mg/m(2)/d for 4 days on weeks 1 and 5 concurrent with radiation therapy (50.4 Gy total: 1.8 Gy/fraction over 5.6 weeks) followed by esophagectomy with node dissection.

RESULTS

Fifty-six patients were enrolled between October 1997 and March 2000, when the trial was closed due to poor accrual. Thirty patients were randomly assigned to trimodality therapy and 26 were assigned to surgery alone. Patient and tumor characteristics were similar between groups. Treatment was generally well tolerated. Median follow-up was 6 years. An intent-to-treat analysis showed a median survival of 4.48 v 1.79 years in favor of trimodality therapy (exact stratified log-rank, P = .002). Five-year survival was 39% (95% CI, 21% to 57%) v 16% (95% CI, 5% to 33%) in favor of trimodality therapy.

CONCLUSION

The results from this trial reflect a long-term survival advantage with the use of chemoradiotherapy followed by surgery in the treatment of esophageal cancer, and support trimodality therapy as a standard of care for patients with this disease.

Esophagectomy for locally advanced esophageal cancer, followed by chemoradiotherapy and adjuvant chemotherapy

AIM: To compare the efficacy and toxicity of a three-step combination therapy with post-operative radiation alone for locally advanced esophageal cancer.

METHODS: Patients with T3-4 and N0-1 esophageal carcinoma from a number of institutions were non-randomly, prospectively enrolled in the study. All patients underwent single-stage curative en bloc esophagectomy. The patients were then assigned into one of two treatment groups based on treatment consisting of either post-operative concurrent chemoradiotherapy (CCRT) with weekly cisplatin 30 mg/m² followed by systemic adjuvant chemotherapy (four monthly cycles of cisplatin 20 mg/m² and 5-fluorouracil 1 000 mg/m² for five consecutive days), or, post-operative radiation alone. The radiotherapy dose was 55-60 Gy for all patients. Primary end-point of this study was to assess the per-protocol patients’ improvement of overall survival benefit. Secondary end-point was designed to evaluate both the per-protocol and intent-to-treat patients’ outcome of survival.

RESULTS: A total of 60 patients (n = 30 per group) were enrolled in this study. The two groups were generally comparable for demographic characteristics and hematological and non-hematological toxicities. The CCRT with weekly cisplatin was well tolerated, with significantly better overall survival (30.9 mo vs 20.7 mo; 95% CI, 27.5-36.4 vs 15.2-26.1) and 3-year survival (70.0% vs 33.7%; P = 0.003). Low histological grade of tumor (P < 0.001) was associated with favorable survival in these locally advanced patients.

CONCLUSION: For locally advanced esophageal cancer, the combination of esophagectomy, post-operative CCRT with weekly cisplatin and systemic adjuvant chemotherapy is well tolerated and effective. A large-scale, prospective randomized trial of this regimen is in progress.

Esophagectomy after concurrent chemoradiotherapy improves locoregional control in clinical stage II or III esophageal cancer patients

PURPOSE

To evaluate the effect of surgical resection on the outcome of patients with clinical Stage II or III cancer of the esophagus treated with concurrent chemoradiotherapy.

METHODS AND MATERIALS

A retrospective review of 132 consecutive patients with clinical Stage II or III esophageal cancer treated with concurrent chemoradiotherapy between January 1990 and December 1998 was performed. Of the 132 patients, 60 underwent esophagectomy 6-8 weeks after chemoradiotherapy. The median radiation dose was 50 Gy (range, 30-64.8 Gy) in the definitive chemoradiation group and 45 Gy (range, 30-50.4 Gy) in the chemoradiation plus esophagectomy group.

RESULTS

Statistically significant differences were found between the two groups in median age, histologic subtype, tumor location, and number of patients with T4 disease. Patients who underwent definitive chemoradiotherapy were older (p = 0.0004) and more likely to have squamous cell carcinoma than adenocarcinoma (p <0.000), upper thoracic or cervical esophageal tumors (p <0.000), and T4 tumors (p = 0.024). Patients treated with chemoradiation plus esophagectomy had statistically significant superior 5-year loco-regional control (67.1% vs. 22.1%, p <0.000), disease-free survival (40.7% vs. 9.9%, p < 0.000), and 5-year overall survival (52.6% vs. 6.5%, p < 0.000) rates and median survival time (62 vs. 12 months) compared with patients treated with chemoradiotherapy only. However, no statistically significant difference was found in the rate of distant metastasis-free survival between the two groups (67.5% vs. 65.8%, p = 0.3). Surgical resection of the tumor was an independent predictor of improved locoregional control and overall survival in both univariate and multivariate analyses. To reduce the effect of the selection bias on the outcome, 34 patients in each group with matched pretreatment characteristics were compared. The results showed statistically significant better overall survival, disease-free survival, and locoregional control in favor of the chemoradiotherapy plus esophagectomy group. No statistically significant difference in distant metastasis-free survival was found in this subgroup analysis.

CONCLUSIONS

Locoregional control was better in clinical Stage II or III esophageal cancer patients treated with concurrent chemoradiation plus esophagectomy. An improvement in survival occurred in the chemoradiation plus esophagectomy group, although this observation may have reflected selection bias. The results from this study suggest the need for a randomized trial to compare chemoradiation with or without esophagectomy in the treatment of cancer of the esophagus.

Salvage esophagectomy after definitive chemotherapy and radiotherapy for advanced esophageal cancer

BACKGROUND

Although local recurrence of advanced esophageal cancer is frequent after definitive chemoradiotherapy (CRT), the clinical benefit of salvage esophagectomy has not been elucidated.

METHODS

We reviewed 27 patients with squamous-cell cancer who underwent esophagectomy after definitive CRT (> or = 50 Gy) (salvage group) and 28 patients who underwent planned esophagectomy after neoadjuvant CRT (30 to 45 Gy) (neoadjuvant group).

RESULTS

The preoperative albumin level and vital capacity were significantly lower in the salvage group than in the neoadjuvant group. Two patients (7.4%) from the salvage group who underwent extended esophagectomy with three-field lymphadenectomy died of postoperative complications, but no deaths occurred after less-invasive surgery. There was no difference of overall postoperative survival between the salvage and neoadjuvant groups.

CONCLUSIONS

The outcome of salvage esophagectomy after definitive CRT was similar to that of planned esophagectomy after neoadjuvant CRT. Less-invasive procedures might be better for salvage esophagectomy because of the high operative risk.

Multiple Management Modalities in Esophageal Cancer: Combined Modality Management Approaches

The overall success rate nationally in treating esophageal carcinomas remains poor, with over 90% of patients succumbing to the disease. In part I of this two-part series, we explored epidemiology, presentation and progression, work-up, and surgical approaches. In part II, we explore the promising suggestions of integrating chemotherapy and radiation therapy into the multimodal management of esophageal cancers. Alternative approaches to resection alone have been sought because of the overall poor survival rates of esophageal cancer patients, with failures occurring both local-regionally and distantly. Concomitant chemotherapy and radiation therapy (XRT) have been shown, by randomized trial, to be more effective than XRT alone in treating unresectable esophageal cancers and also have shown promise as a neoadjuvant treatment when combined with surgery in the multimodal treatment of this disease. Various studies have also addressed issues such as preoperative chemotherapy, radiation dose escalation, chemotherapy/XRT as a definitive treatment versus use as a surgical adjuvant, and alternative chemotherapy regimens. There are suggestions of some progress, but this remains a difficult problem area in which management is continuing to evolve.

Optimal therapy for oesophageal cancer

Oesophageal carcinoma is one of the commonest cancers in the world and has an increasing incidence in Western civilisation. As the epidemiology of the disease has changed so too has our treatment strategies. The present standard of care is surgery but this is associated with disappointing survival figures. The role of chemotherapy and radiation is now established in inoperable disease. How best to deliver these modes of therapy has yet to be defined. Extrapolation of data from previous trials is difficult as these trials have many deficiencies and do not account for recent advances in therapeutics or techniques of delivery. The role of chemo-radiotherapy in operable disease is even more controversial. A number of prospective randomised trials of trimodality therapy versus surgery alone suggests a benefit for multimodal therapy. These trials also reveal evidence to support the use of chemo-radiotherapy alone in a subset of patients with resectable disease. The appropriate application of these varied therapeutic interventions remains unanswered. Further progress in diagnostic techniques and predictive markers may allow us to stratify patients into different treatment groups. Continued investigation is required to keep pace with the evolution of oesophageal cancer and its therapy. This will facilitate a better understanding of the disease and optimise the treatment offered to patients.

Planejamento tridimensional para radioterapia de tumores de esôfago: comparação de técnicas de tratamento e análise de probabilidade de complicações

Para comparar diversas técnicas de irradiação para o câncer de esôfago, foi utilizado sistema de planejamento tridimensional. Em um paciente com carcinoma espinocelular de esôfago médio, foram estudadas as seguintes técnicas de tratamento: dois campos ântero-posteriores e dois campos látero-laterais paralelos e opostos, três campos em "Y" e em "T" e quatro campos em "X". Foram obtidos os histogramas dose-volume, considerando como órgãos de risco medula espinhal e pulmões. Os resultados foram analisados de acordo com as recomendações da Normal Tissue Complication Probability (NTCP) e Tumor Control Probability (TCP). Quanto às doses de irradiação em pulmão, a melhor opção foi a técnica em dois campos ântero-posteriores paralelos e opostos. A medula foi mais poupada quando se utilizaram campos látero-laterais. Sugerimos a combinação de pelo menos duas técnicas de tratamento: ântero-posterior e as técnicas com campos em "Y", "T" ou látero-laterais, para o balanceamento das doses em pulmões e medula espinhal. Ou, ainda, a utilização de técnicas de três campos durante todo o tratamento.

Factors predictive of survival for esophageal carcinoma treated with preoperative radiotherapy with or without chemotherapy followed by surgery

PURPOSE

To evaluate parameters that may influence prognosis in patients treated with preoperative radiotherapy (RT) or chemoradiation.

METHODS AND MATERIALS

One hundred seventy-six patients with esophageal carcinoma received preoperative radiotherapy (45 patients) or chemoradiation (131 patients). Forty-three received no surgery (NS), 32 had exploratory surgery (ES), and 101 received definitive surgery (DS).

RESULTS

Five-year cause-specific survival and absolute survival rates were overall, 19% and 16%; NS group, 0% and 0%; ES group, 3% and 3%; DS group, 30% and 26%. On univariate analysis, definitive surgery (P < 0.0001), tumor size less than 5 cm (P < 0.0001), and chemotherapy (P = 0.0015) were significant predictors of improved cause-specific survival. Cause-specific survival was 51% for tumors </=3 cm (n = 33), 32% for 3.1 to 4 cm (n = 28), and 16% for 4.1 to 5 cm (n = 29). No patient with a tumor >/=6 cm (n = 86) survived. Multivariate analysis of the DS group showed complete or partial pathologic response (P = 0.0001), chemotherapy (P = 0.0026), and overall treatment time less than 3 months (P = 0.0405) significantly predicted improved cause-specific survival. Tumor <5 cm was marginally significant (P = 0.0515).

CONCLUSION

Patients who undergo preoperative chemoradiation and definitive surgery have improved survival.

Bi-modality (chemo-radiation) versus tri-modality (chemo-radiation followed by surgery) treatment for carcinoma of the esophagus

The purpose of the study was to investigate the difference in overall survival in patients with localized carcinoma of esophagus treated using chemo-radiation (bi-modality, BM) or chemo-radiation followed by surgery (tri-modality, TM). From 1981 to 1999, 65 patients were identified who had localized carcinoma of the esophagus treated with either concurrent chemo-radiation (BM, n=22) or concurrent chemo-radiation followed by surgery (TM, n=43) at the University of Texas Medical Branch at Galveston. All 65 patients received concurrent chemotherapy and external beam radiation. Radiation was delivered by linear accelerators (greater-than-or-equal 6 MV), except in one patient who had part of his treatment given by a Co-60 machine. Chemotherapy consisted of 5-fluorouracil and cisplatin plus minus vinblastine under different regimens. Median follow-up time was 10 months (range=1-195 months) for all patients. Of the 14 patients still alive, the median follow-up time was 32 months (range=2-192 months). No difference in overall survival was detected between the two treatment groups, BM vs. TM (P=0.394) despite a selection bias favoring the TM group. Five-year survival rates of the BM and TM groups were 17% and 18%, respectively; 10-year survival rates were 17% and 12%, respectively. The presence of significant past medical history (P=0.017) and a complete pathologic response in the TM group (P < 0.001) were significant independent predictors of survival. We did not find any difference in survival between chemo-radiation or chemo-radiation followed by surgery in patients with localized carcinoma of the esophagus. Use of biologic markers and functional imaging should be explored in order to segregate patients with different tumor biology for treatment using different treatment strategies.

The use of chemoradiotherapy in oesophageal cancer

The results of treatment for oesophageal carcinoma remain poor and few patients are curable by surgery alone. The use of chemoradiotherapy (CRT) given as a definitive treatment or in combination with surgery may improve locoregional control and survival, when compared with radiotherapy or surgery alone. Using the keywords "chemoradiotherapy" and "radiochemotherapy", a Medline-based literature review (1980-2001) was performed. Additional literature was obtained from original papers and published meeting abstracts. Two-year survival rates of 28-72% in squamous cell carcinoma and 14-29% in adenocarcinoma from definitive CRT were reported. This is comparable to results achievable by surgery alone. The use of preoperative CRT followed by surgery may further improve survival, but current data are insufficient to justify this approach within routine clinical practice. Acute treatment-related toxicity is increased with CRT. In selected patients with localised unresectable oesophageal cancer, definitive CRT is recommended. There are uncertainties about the role of routine surgery following CRT in patients with resectable disease. For the future, the pretreatment staging of patients needs to be improved and standardised, the optimal CRT regimen needs to be defined and the role of predictive markers for CRT response needs to be developed.

Preoperative hyperfractionated radiotherapy with concurrent chemotherapy in resectable esophageal cancer

PURPOSE

To evaluate the local control rates, survival rates, and patterns of failure for esophageal cancer patients receiving preoperative concurrent chemotherapy and hyperfractionated radiotherapy followed by esophagectomy.

METHODS AND MATERIALS

From May 1993 through January 1997, 94 patients with resectable esophageal cancers received continuous hyperfractionated radiation (4,800 cGy/40 fx/4 weeks), with concurrent FP chemotherapy (5-FU 1 g/m(2)/day, days 2-6, 30-34, CDDP 60 mg/m(2)/day, days 1, 29) followed by esophagectomy 3-4 weeks later. If there was evidence of disease progression on preoperative re-evaluation work-up, or if the patient refused surgery, definitive chemoradiotherapy was delivered. Minimum follow-up time was 2 years. RESULTS; All patients successfully completed preoperative treatment and were then followed until death. Fifty-three patients received surgical resection, and another 30 were treated with definitive chemoradiotherapy. Eleven patients did not receive further treatment. Among 91 patients who received clinical reevaluation, we observed 35 having clinical complete response (CR) (38.5%). Pathologic CR rate was 49% (26 patients). Overall survival rate was 59.8% at 2 years and 40.3% at 5 years. Median survival time was 32 months. In 83 patients who were treated with surgery or definitive chemoradiotherapy, the esophagectomy group showed significantly higher survival, disease-free survival, and local disease-free survival rates than those in the definitive chemoradiation group.

CONCLUSION

Preoperative chemoradiotherapy in this trial showed improved clinical and pathologic tumor response and survival when compared to historical results. Patients who underwent esophagectomy following chemoradiation showed decreased local recurrence and improved survival and disease-free survival rates compared to the definitive chemoradiation group.

Mismatched clinicopathological response after concurrent chemoradiotherapy for thoracic esophageal cancer

We have been treating patients with operable thoracic esophageal cancer according to our own protocol. It includes the initial concurrent chemoradiotherapy (CRT) followed by continuous CRT or surgery. Patients with good response to initial chemoradiotherapy were allowed to continue chemoradiotherapy, whereas the others were treated with surgery. However, there were two cases which showed discrepancies in the clinicopathological response. Both patients received initial chemoradiotherapy, including two courses of cisplatin (100-120 mg), 5-fluorouracil (750-1000 mg for 4 days) and radiation (44-50 Gy). On completion of the initial chemoradiotherapy, all diagnostic imaging modalities including barium swallow, esophagoscopy, endoscopic ultrasonography and thoracic computed tomography strongly implicated residual tumor with a reduction rate of 40-50%. The patients underwent radical esophagectomy 15-20 days after initial chemoradiotherapy. Pathological specimens only revealed thickening of the esophageal wall due to inflammatory change without residual carcinoma. These facts suggest the current limitations of diagnostic images in evaluating the response to chemoradiotherapy.

Preoperative (neoadjuvant) chemoradiotherapy in oesophageal cancer

BACKGROUND

Oesophageal cancer carries a poor prognosis. The 5-year survival rate following resection ranges from 10 to 35 per cent. Recent evidence suggests that the addition of non-surgical treatments to surgery may improve resection rates, reduce the risk of recurrence and improve survival. This review examines the role of preoperative chemoradiotherapy (CRT) in oesophageal cancer.

METHODS

A Medline-based literature review (1980-2000) was performed using the key words 'neoadjuvant or preoperative' and 'chemoradiotherapy or radiochemotherapy'. Additional literature was obtained from original papers and published meeting abstracts.

RESULTS

Forty-six non-randomized and six randomized trials of preoperative CRT were found. Resection rates, pathological complete response (pCR), treatment-related mortality rates and relapse patterns are documented. Improved 5-year survival rates approaching 60 per cent may be achieved following pCR. Three of the six randomized trials show a benefit in either overall survival or disease-free survival compared with surgery alone. Treatment-related toxicity can be significant.

CONCLUSION

Preoperative CRT may improve survival. Emerging evidence suggests that CRT alone can achieve similar survival rates to surgery alone. New imaging modalities may help to select which patients require surgery. Larger randomized trials of preoperative CRT or chemotherapy are needed to define optimal regimens and produce higher pCR rates with acceptable toxicity.

Impact on survival of surgery after concomitant chemoradiotherapy for locally advanced cancers of the esophagus

BACKGROUND

To evaluate the results of chemoradiotherapy with or without surgery in locally-advanced esophageal carcinomas (T3 and/or nodal involvement).

METHODS

One hundred twelve patients with locally-advanced carcinoma of the esophagus without histologically proven invasion of the tracheobronchial tree or distant visceral metastases were treated with concomitant chemoradiotherapy followed by re-evaluation; surgery was performed or chemoradiotherapy continued, based on tumor regression and the patient's general status. Chemoradiotherapy consisted of concomitant 5-fluorouracil (5FU)(1 g/m(2) day 1-3), cisplatinum (50 mg/m(2) day 1 and 2), and external beam irradiation up to a dose of 40 or 43.2 Gy. After a 4-week rest period, radical esophagectomy or a new cycle of chemoradiotherapy (up to a total dose of 65 Gy) was performed.

RESULTS

A complete clinical response was obtained in 25.7% of the patients and a partial response in 45.9%. Fifty patients underwent surgery, but only 38 patients had an esophagectomy. Post-esophagectomy mortality was 5.3%. A complete histologic response rate of 23.7% was obtained. Two- and 5-year survival rates were, respectively, 41.5% and 28.6% for the whole population. According to multivariate analysis, prognostic factors for survival were Karnofsky index, esophagectomy, and response to chemoradiotherapy. Five-year survival for patients who experienced a partial response to radiation and chemotherapy was 49.1% for those who had surgery and 23.5% for those treated without surgery (p = 0.003). There was no obvious benefit for the small number of patients treated surgically after complete response to radiation and chemotherapy. Toxicity, essentially hematologic, was moderate.

CONCLUSION

For locally-advanced esophageal carcinomas, esophagectomy, after concomitant chemoradiotherapy, could improve the survival rate, especially for patients who responded partially to the latter.

Preoperative chemo-radiation for carcinoma of the vulva with N2/N3 nodes: a gynecologic oncology group study

PURPOSE

To determine if patients with carcinoma of the vulva, with N2/N3 lymph nodes, could undergo resection of the lymph nodes and primary tumor following preoperative chemo-radiation. METHODS AND MATERILAS: Fifty-two patients were entered in the study, but six patients did not meet the criteria of the protocol and were excluded. The remaining 46 patients are the subject of this report. Patients underwent a split course of radiation, 4760 cGy to the primary and lymph nodes, with concurrent chemotherapy, cisplatin/5-FU, followed by surgery.

RESULTS

Four patients did not complete the chemo-radiation, because three expired and one refused to complete the treatment. Four patients who completed chemo-radiation did not undergo surgery, because two of them died of non-cancer-related causes, and in the other two patients, the nodes remained unresectable. Following chemo-radiation, the disease in the lymph nodes became resectable in 38/40 patients. Two patients who completed the course of chemo-radiation did not undergo surgery as per protocol because of pulmonary metastasis. One underwent radical vulvectomy and unilateral node dissection and the other radical vulvectomy only. The specimen of the lymph nodes was histologically negative in 15/37 patients. Nineteen patients developed recurrent and/or metastatic disease. The sites of failure were as follows: primary area only, 9; lymph node area only, 1; primary area and distant metastasis, 1; distant metastasis only, 8. Local control of the disease in the lymph nodes was achieved in 36/37 and in the primary area in 29/38 of the patients. Twenty patients are alive and disease-free, and five have expired without evidence of recurrence or metastasis. Two patients died of treatment-related complications.

CONCLUSION

High resectability and local control rates of the lymph nodes were obtained in patients with carcinoma of the vulva with N2/N3 nodes treated preoperatively with chemo-radiation.

Radiation treatment for cervical esophagus: patterns of practice study in Canada, 1996

PURPOSE

To assess the patterns of practice among Canadian radiation oncologists who treat esophageal cancers, using a trans-Canada survey, completed at the end of 1996.

METHODS AND MATERIALS

One of 3 case presentations of different stages of cervical esophageal cancer was randomly assigned and sent to participating radiation oncologists by mail. Respondents were asked to fill in questionnaires regarding treatment techniques and to outline target volumes for the boost phase of radiotherapy. Radiation oncologists from 26 of 27 (96%) of all Canadian centers participated.

RESULTS

High-energy X-rays (>/= 10 MV) were employed by 68% of the respondents in part of the treatment course. The majority (83%) of the radiation oncologists used at least two phases of treatment. Very few, 10 of 59 (17%), responses started with multifield treatment. The most frequently used prescription dose was 60 Gy/30 fractions/6 weeks, given with concurrent chemotherapy. Dose prescriptions were to the isocenter in 39 of 48 (81%) or to a particular isodose line in 9 of 48 (19%) of respondents.

CONCLUSION

There was a variety of radiation treatment techniques in this trans-Canada survey. The majority of the patients had combined cisplatin-based chemoradiation. The isocenter was not used consistently as a dose prescription point.

Induction chemo-radiotherapy for squamous cell carcinoma of the thoracic esophagus: long-term results of a phase II study

BACKGROUND

This study was done to evaluate the results of the combined use of chemo- and radiotherapy before surgery in a group of patients with squamous cell esophageal carcinoma after a median follow-up period of more than 5 years.

METHODS

Between June 1987 and January 1995, 111 patients with squamous cell carcinoma of the thoracic esophagus were submitted to a preoperative course of radiotherapy (3000 cGy) and chemotherapy (cisplatin and 5-FU) before surgery in the First Division of General Surgery at the University of Verona.

RESULTS

The neoadjuvant treatment was completed in 90.9% of the cases (101/111). After an average of 29 days, 87 patients underwent surgery (operability rate: 78.3%) and, of these, 80 underwent esophagectomy (resectability rate: 91.9%). Histopathologic studies showed no residual disease in the specimen (T0) in 17 cases (21.2%), only microscopic clusters of neoplastic cells within the esophageal wall (Minimal Residual Disease, MRD) in 14 cases (17.5%) and in 5 cases the tumor did not extend beyond the submucosal layer (T1). The median overall survival time of the 111 patients who were eligible for the study protocol was 14 months, and the 2- and 5-year survival rates were 32.0% and 17.5%, respectively. Kaplan-Meier determination of survival showed a statistically significant difference between the good responders (T0, T1, and MRD) to the neoadjuvant treatment and the remaining cases. The 2- and 5-year survival rates were 50.3% and 34.9%, respectively, in the good responder group compared with 26.7% and 10.7%, respectively, in the other cases, with a median survival time of 24 months vs. 13 months, respectively.

CONCLUSIONS

The neoadjuvant treatment showed promising results, especially in the group of patients that had a good response. The identification of these patients may be the key to selecting which patients should be submitted to preoperative radio- and chemotherapy.

Analysis of postoperative complications after esophagectomy for esophageal cancer in patients receiving neoadjuvant therapy

Postoperative complications were investigated in 72 patients who received neoadjuvant therapy with esophagectomy. Preoperative chemotherapy consisted of 5-fluorouracil (700 mg/m2/day, on days 1 to 5), cisplatinum (70 mg/m2/day, on day 1) and leucovorin (20 mg/m2/day, on days 1 to 5). Preoperative chemoradiotherapy consisted of cisplatinum combined chemotherapy and radiotherapy (total dosage of 30-70 Gy). The incidence of postoperative pneumonia (16%) and anastomotic leakage (24%) in the preoperative chemotherapy group was slightly higher than that in the control group (n = 506), and mortality (6.0%) after esophagectomy in the preoperative chemotherapy group was higher than that (2.4%) of the control group. Postoperative morbidity and mortality were observed more frequently in patients who received two cycles of the chemotherapy than those receiving only one cycle. Postoperative complications occurred more frequently in patients suffering high grade toxicities due to the preoperative chemotherapy. The highest preoperative serum creatinine value correlated to that of postoperative period (r = 0.6494). The use of the preoperative chemoradiotherapy with a total exposure dosage of 60 Gy or more significantly increased the postoperative pneumonia rate (67%; p < 0.05) compared to the group receiving 40 Gy or less. The mortality rate (33%) also increased. The second cycle of the preoperative chemotherapy should be cancelled if patients suffer high grade toxicities during or after the first cycle, and the total exposure dosage of the preoperative chemoradiotherapy should be limited to 40 Gy or less.

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.

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.

Multimodality therapy for adenocarcinoma of the esophagus

The incidence of adenocarcinoma of the esophagus is rapidly increasing in the Western world. In North America and western Europe, a marked shift in the epidemiologic profile of this disease has occurred. In the past, most patients with esophageal cancer were found to have epidermoid carcinoma. These patients frequently abused tobacco or alcohol, had multiple comorbid medical conditions, and were elderly. Over the last 10 to 15 years, a rapid increase in the number of patients having adenocarcinoma of the esophagus has been noted. In contrast, these patients are predominantly young white men from 35 to 55 years old who much less frequently smoke or drink, and many have few or no comorbid medical conditions, are fit, and are able to tolerate aggressive combined therapy. This article focuses on the adenocarcinoma subgroup of patients, although identical therapeutic approaches are being studied in appropriate patients with epidermoid carcinomas.

Preoperative chemotherapy versus surgical therapy alone for squamous cell carcinoma of the esophagus: a prospective randomized trial

OBJECTIVE

This study investigated the role of preoperative chemotherapy in squamous cell cancer of the esophagus.

METHODS

A prospective randomized trial was undertaken in 147 patients: 74 received preoperative chemotherapy comprising cisplatin and 5-fluorouracil and 73 had surgical therapy alone. End points were cancer and therapy-related deaths.

RESULTS

Sixty-six patients (89%) in the chemotherapy group underwent resection compared with 69 (95%) in the control group (p = not significant). Of the 60 patients who had resection after completing the chemotherapy program, 35 (58%) had a significant response, of whom four (6.7%) had a complete pathologic response. Postoperative mortality rates were 8.3% and 8.7% in the chemotherapy and control groups, respectively (p = not significant). Significant downstaging was evident with chemotherapy; curative resections were possible in 67% of these patients compared with 35% in the control group (p = 0.0003). T3 and T4 tumors were found in 67% and 91% of the chemotherapy and control groups, respectively (p = 0.0002). The respective figures for N1 disease were 70% and 88% (p = 0.009). An intent-to-treat analysis of survival showed no significant difference between the two groups. Median survivals were 16.8 and 13 months, respectively (p = 0.17). Of those who completed the chemotherapy and resection, responders fared better than control patients. Median survivals were 42.2 months and 13.8 months, respectively (p = 0.003). Median survival (8.3 months) was worse for nonresponders than for control patients (p = 0.03). The recurrence pattern suggested a significant reduction in locoregional disease with chemotherapy.

CONCLUSIONS

Preoperative chemotherapy was safe and resulted in significant downstaging and an increased likelihood of curative resection. Survival was not better than that in the surgery-alone group, but responders did fare better than nonresponders.

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.

Short communication: oesophageal tumour volume measurement using spiral CT

A CT technique for measuring oesophageal cancer tumour volume in the monitoring of local disease response following radiotherapy or chemotherapy is described. Patients with newly diagnosed oesophageal carcinoma were referred for pre- and post-chemotherapy CT scans. IV Buscopan was given to abolish peristalsis. Patients were scanned in prone position. Effervescent gas granules and Calogen (a negative contrast of fat density) were given. Spiral scanning was performed. The area of tumour on each 1 cm slice was measured. The sum of these areas gave tumour volume in cubic centimetres. The accuracy of the method was tested on patients who had had surgery. The volume of the segment of oesophagus containing tumour was measured by its weight and water displacement. Lumenal distention proximal and distal to the tumour was achieved in all patients. 10 gross surgical specimens were available for comparison with pre-operative CT. The correlation coefficient was 0.95. In conclusion, accurate tumour volume assessment was achieved with our technique.

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.

Pattern of recurrence after oesophageal resection for cancer: clinical implications

Patterns of disease recurrence were reviewed in 108 patients who had curative resection for squamous cell cancer of the thoracic oesophagus. At a median follow-up of 20 months, 56 patients (52 per cent) had recurrence. Most presented within 2 years. Extrathoracic recurrence was found in 41 per cent of patients and intrathoracic recurrence in 25 per cent. Systemic organ metastases (26 per cent) were as frequent as intrathoracic recurrences. Twelve patients (11 per cent) developed cervical lymph node (CLN) recurrence; their mean time to recurrence was 12.6 months, compared with 13.1 months for recurrence at locations other than the neck (P = 0.8). Median survival was 23 and 13 months respectively (P = 0.27). Preoperative chemotherapy lowered the recurrence rate from 60 per cent to 30 per cent, (P = 0.01) but did not affect survival. The addition of cervical lymphadenectomy would benefit few patients and must be counterbalanced with increased morbidity and cost. The frequency of systemic organ metastases calls for further investigation of the possible benefits of chemotherapy.

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.

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

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

The role of radiation therapy in treating patients with potentially resectable carcinoma of the esophagus

Radiotherapy (RT) in conjunction with surgery may have a number of roles in the treatment of patients with potentially resectable esophageal carcinoma. The use of RT alone either preoperatively or postoperatively can be expected to improve resectability rates only modestly. The risk of locoregional failure, a common problem in esophageal carcinoma, has been substantially reduced with preoperative or postoperative RT in trials with a duration of follow-up of 3 or more years, although this effect has not been seen in trials with shorter follow-up. Because of the high risk of distant failure associated with these tumors and perhaps because of the inadequate doses used, most trials of RT have not shown notable improvements in overall survival rates. The risk of severe complications following preoperative or postoperative RT is small, provided that very high doses or fraction sizes are avoided. Concurrent chemotherapy and RT administration have been shown to be superior to RT alone in patients who have medically or surgically inoperable conditions; randomized trials using this combined modality in patients with resectable disease have only recently begun. In addition to evaluating the efficacy of this approach, investigators hope to establish the optimal sequencing and timing of administration of these modalities with regard to each other and to surgery.

The significance of c-erb B-2 and p53 immunoreactivity in patients with adenocarcinoma of the esophagus

OBJECTIVE

Studies in breast cancer suggest that p53 and c-erb B2 protein overexpression are predictive of outcome. The authors determined whether these molecular markers correlated with treatment response and survival in patients with adenocarcinoma of the esophagus and esophagogastric junction.

METHOD

Immunostaining for p53 and c-erb B2 was performed on paraffin-embedded specimens from 42 patients with esophageal adenocarcinoma. All patients received neoadjuvant chemotherapy (cisplatin and fluorouracil [5-FU] x 3 cycles) and irradiation (4500 rads) followed by resection.

RESULTS

In this cohort of patients, 79% (33/42) were positive for p53, and 43% (18/42) were positive for c-erb B2. p53 positivity correlated with residual disease in the resection specimen but not with disease-free survival. Although c-erb B2 negatively correlated with residual disease after resection and a 5-year survival of 10%, c-erb B2 positivity was associated with a 5-year actuarial survival of 60%.

CONCLUSIONS

Although p53 protein overexpression is commonly observed in adenocarcinoma of the esophagus, its prognostic value appears limited. In contrast, c-erb B2 protein expression predicts a favorable response to therapy and improved survival.

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.

Concurrent radiotherapy and chemotherapy with protracted continuous infusion of 5-fluorouracil in inoperable esophageal squamous cell carcinoma

PURPOSE

The feasibility of a concurrent chemoradiotherapeutic protocol for patients with inoperable esophageal squamous cell carcinoma was tested.

METHODS AND MATERIALS

Concurrent chemoradiotherapy using protracted low-dose continuous infusions of five-fluorouracil (5-FU; 250-300 mg/m2/24 h) and standard external beam irradiation was given to 28 patients with inoperable esophageal squamous cell carcinoma between November 1991 and June 1993.

RESULTS

For 25 patients receiving a total dose of > or = 60 Gy and concurrent 5-FU infusion for more than 5 weeks, the complete response rate was 52%. Local progression-free rate in this chemoradiotherapy group was significantly higher than the historical controls treated by radiotherapy alone (p < 0.05). A multivariate analysis revealed the treatment scheme (concomitant chemoradiotherapy vs. radiotherapy alone) to be a significant factor in local control (p < 0.01). Swallowing pain (39%), anorexia (39%), and nausea (32%) were the most frequent early reactions. Serious late radiation complications have not been observed.

CONCLUSION

The concurrent chemoradiotherapy using protracted low-dose continuous infusion of 5-FU and standard radiotherapy is an effective and safe method to obtain a local control in inoperable esophageal squamous cell carcinoma.