Phase II study of neo-adjuvant chemotherapy with paclitaxel and cisplatin given every 2 weeks for patients with a resectable squamous cell carcinoma of the esophagus

A phase II study of concurrent chemoradiotherapy combined with a weekly paclitaxel and 5-fluorouracil regimen to treat patients with advanced oesophageal carcinoma

BACKGROUND

A phase II study was performed to investigate the safety and efficacy of weekly doses of combined paclitaxel and 5-fluorouracil (5-FU) with concurrent radiation therapy, followed by 2 cycles of consolidation chemotherapy to treat patients with advanced oesophageal carcinoma.

METHODS

The eligibility criteria included local, advanced, newly diagnosed and postoperative local regional lymph node metastasis; an Eastern Cooperative Oncology Group (ECOG) score of ≤ 2; and adequate organ function. Patients received chemoradiotherapy consisting of radiotherapy (50.4 Gy/28 Fx or 61.2 Gy/34 Fx) and concurrent paclitaxel (50 mg/m²) and 5-FU (300 mg/m²) for 96 h on days 1, 8, 15, 22, and 29. The two-cycle consolidation chemotherapy protocol included paclitaxel (175 mg/m²) plus continuously infused 5-FU (1800 mg/m²) for 72 h administered on days 57 and 85, after concurrent chemoradiotherapy.

RESULTS

Between February 2012 and August 2013, 53 patients with oesophageal carcinoma were enrolled in the study. Among these patients, 33 (62.2%) were newly diagnosed and 20 (37.7%) had postoperative local regional lymph node metastasis. The median overall survival (OS) time was 17.9 months (95% CIs = 11.9-23.9), and the median progression-free survival (PFS) time was 12.4 months (95% CIs = 8.6-16.1). Approximately 84.9% (45/53) and 50.9% (27/53) of the patients completed ≥ 5 cycles and all 7 cycles of chemotherapy, respectively. Approximately 86.7% (46/53) of patients completed radiation therapy. The 1-, 2-, and 3-year OS rates were 66.0%, 37.7%, and 35.8%, respectively. The 1-, 2-, and 3-year local control rates were 76.9%, 66.4%, and 66.4%, respectively. Seventeen patients (32%) experienced grade 3 or higher toxicity. Grade 3 to 5 toxicity during chemoradiotherapy included neutropaenia (7.5%), thrombocytopaenia (1.8%), fatigue (7.5%), anaemia (1.8%), dermatitis radiation (1.8%), pneumonitis (5.6%), oesophagitis (9.4%) and vomiting (3.7%).

CONCLUSIONS

The combination of weekly doses of paclitaxel and 5-FU was well tolerated and produced comparable results among patients with locally advanced oesophageal cancer. A randomised phase III trial (NCT01591135) comparing paclitaxel plus 5-FU with cisplatin plus 5-FU is on-going at our hospital.

Clinical Study on Lobaplatin Combined with 5-Fu and Concurrent Radiotherapy in Treating Patients with Inoperable Esophageal Cancer

OBJECTIVE

To investigate short- and long-term treatment effects and side reactions of lobaplatin plus 5-Fu combined and concurrent radiotherapy in treating patients with inoperable middle-advanced stage esophageal cancer.

METHODS

Sixty patients with middle-advanced stage esophageal squamous cell cancer were retrospectively analyzed. All patients were administered lobaplatin (50 mg intravenously) for 2 h on day 1, and 5-Fu (500 mg/m2) injected intravenously from day 1 to 5 for 1 cycle, in an interval of 21 days for totally 4 cycles. At the same time, late-course accelerated hyperfractionated three-dimensional conformal radiotherapy was performed. Patients were firstly treated with conventional fractionated irradiation (1.8 Gy/d, 5 times/week, a total of 23 treatments, and DT41.4 Gy), and then treated with accelerated hyperfractionated irradiation (1.5 Gy, 2 times/d, a total of 27 Gy in 9 days, an entire course of 6-7 weeks, and DT 68.4 Gy).

RESULTS

All patients completed treatment, including 10 complete response (CR), 41 partial response (PR), 7 stable disease (SD), and 2 progressive disease (PD). The total effective rate was 85.0% (51/60). Thirty-nine patients had an increased KPS score. One-, 2-, and 3-year survival rates were 85.3%, 57.5%, and 41.7%, respectively. The median survival time was 27 months. The adverse reactions included myelosuppression, which was mainly degreeI and II. The occurrence rate of radiation esophagitis was 17.5%. No significant hepatic or renal toxicity was observed.

CONCLUSION

Lobaplatin plus 5-Fu combined with concurrent radiotherapy is safe and effective in treating patients with middle-advanced stage esophageal cancer. However, this result warrants further evaluation by randomized clinical studies.

Perioperative versus Preoperative Chemotherapy with Surgery in Patients with Resectable Squamous Cell Carcinoma of Esophagus: A Phase III Randomized Trial

BACKGROUND

Perioperative chemotherapy for resectable squamous cell carcinoma of esophagus remains elusive. Thus, we assessed whether a perioperative regimen of paclitaxel, cisplatin, and 5- fluorouracil (PCF) improved outcomes among patients with curable squamous cell carcinoma of esophagus comparing with preoperative chemotherapy alone.

METHODS

Overall, 346 patients with resectable squamous cell carcinoma of esophagus were randomly assigned to receive surgery plus perioperative chemotherapy (175, arm A) or preoperative chemotherapy (171, arm B). Both arms received two preoperative cycles of PCF: intravenous paclitaxel (100 mg per square meter of body surface area) and cisplatin (60 mg per square meter of body surface area) on day 1, and a continuous intravenous infusion of 5- fluorouracil (700 mg per square meter of body surface area per day) for 5 days. Arm A received two added postoperative cycles of PCF. The primary end point was relapse-free survival, and the secondary end point was overall survival.

RESULTS

Compared with preoperative chemotherapy group, perioperative chemotherapy group had a greater likelihood of 5-year relapse-free survival (hazard ratio for relapse, 0.62; 95% confidence interval, 0.49-0.73; 31% versus 17%, p < 0.001) and of 5-year overall survival (hazard ratio for death, 0.79; 95% confidence interval, 0.59-0.95; 38% versus 22%, p < 0.001). A pathologic complete response rate was achieved in 77 of 320 patients (24.1%) who underwent resection after chemotherapy. The increased PCF-related toxic events were not detected with the addition of two postoperative cycles of PCF.

CONCLUSION

In patients with operable esophageal squamous cell carcinoma, perioperative regimen of PCF can significantly improve 5-year relapse-free and overall survival comparing with preoperative chemotherapy alone. (The trial has been registered at ClinicalTrials.gov, number NCT01225523.).

Progress in surgery-based multimodality therapy for resectable esophageal cancer

The incidence of esophageal cancer is rather high in China. For patients with resectable esophageal cancer, surgery is the standard treatment. However, the overall survival of patients with locally advanced esophageal cancer remains low, which necessitates the development of multimodality therapies for this malignancy. Among currently available multimodality treatments, preoperative chemoradiotherapy followed by surgery is the most promising strategy in terms of improving the prognosis of advanced esophageal cancer. Postoperative chemotherapy or radiotherapy is also feasible for selected patients. The aim of this article is to provide a complete review of the current status of esophageal cancer treatment with the addition of chemotherapy and radiotherapy to the surgical management of resectable disease.

The safety and effectiveness of endoscopic and non-endoscopic approaches to the management of early esophageal cancer: a systematic review

INTRODUCTION

Traditionally, management of early cancer (stages 0-IIA) has comprised esophagectomy, either alone or in combination with chemotherapy and/or radiotherapy. Recent efforts to improve outcomes and minimize side-effects have focussed on minimally invasive, endoscopic treatments that remove lesions while sparing healthy tissue. This review assesses their safety and efficacy/effectiveness relative to traditional, non-endoscopic treatments for early esophageal cancer.

METHODS

A systematic review of peer-reviewed studies was performed using Cochrane guidelines. Bibliographic databases searched to identify relevant English language studies published in the last 3 years included: PubMed (i.e., MEDLINE and additional sources), EMBASE, CINAHL, The Cochrane Library, the UK Centre for Reviews and Dissemination (NHS EED, DARE and HTA) databases, EconLit and Web of Science. Web sites of professional associations, relevant cancer organizations, clinical practice guidelines, and clinical trials were also searched. Two independent reviewers selected, critically appraised, and extracted information from studies.

RESULTS

The review included 75 studies spanning 3124 patients and 10 forms of treatment. Most studies were of short term duration and non-comparative. Adverse events reported across studies of endoscopic techniques were similar and less significant compared to those in the studies of non-endoscopic techniques. Complete response rates were slightly lower for photodynamic therapy (PDT) relative to the other endoscopic techniques, possibly due to differences in patient populations across studies. No studies compared overall or cause-specific survival in patients who received endoscopic treatments vs. those who received non-endoscopic treatments.

DISCUSSION

Based on findings from this review, there is no single "best practice" approach to the treatment of early esophageal cancer.

A phase II trial of paclitaxel and cisplatin in patients with advanced squamous-cell carcinoma of the esophagus

OBJECTIVE

To evaluate the response rate, survival, and toxicities of paclitaxel plus cisplatin combination in patients with advanced or metastatic squamous-cell carcinoma of the esophagus.

METHODS

Thirty-nine patients with definite measurable indices and no prior chemotherapy were enrolled. Patients were treated with paclitaxel 175 mg/m(2) and cisplatin 75 mg/m(2) by 2-hour infusion on day 1. Treatment was repeated every 21 days.

RESULTS

Thirty-nine patients were enrolled of which 35 patients were eligible to be evaluated to have had a response. The overall response rate was 48.6% [95% confidence interval (CI), 0.31-0.65] with complete and partial response rates of 2.8% and 45.7%, respectively. The median time to progression was 7 months, and median survival time of all patients was 13 months. There was a significant difference in the median overall survival between the patients who had showed response versus those who had not (P = 0.006). Median survival was 17 (95% CI, 11.9-22.0) and 10 months (95% CI, 7.6-12.4), respectively. The 1-year survival probability was 39%. Relief of dysphagia and pain were observed in 86.2% of all the patients. The most common toxicities were neutropenia and alopecia. No grade 4 toxicities and treatment-related deaths were recorded in all patients.

CONCLUSION

Paclitaxel and cisplatin is a promising treatment for patients with squamous-cell carcinoma of the esophagus. The toxicity of this regimen is within acceptable range.

Neoadjuvant concurrent chemoradiation with weekly paclitaxel and carboplatin for patients with oesophageal cancer: a phase II study

This study was performed to assess the efficacy and safety of preoperative chemoradiation consisting of carboplatin and paclitaxel and concurrent radiotherapy for patients with resectable (T2-3N0-1M0) oesophageal cancer. Treatment consisted of paclitaxel 50 mg m⁻² and carboplatin AUC=2 on days 1, 8, 15, 22 and 29 and concurrent radiotherapy (41.4 Gy in 23 fractions, 5 days per week), followed by oesophagectomy. All 54 entered patients completed the chemoradiation without delay or dose-reduction. Grade 3–4 toxicities were: neutropaenia 15%, thrombocytopaenia 2%, and oesophagitis 7.5%. After completion of the chemoradiotherapy 63% had a major endoscopical response. Fifty-two patients (96%) underwent a resection. The postoperative mortality rate was 7.7%. All patients had an R0-resection. The pathological complete response rate was 25%, and an additional 36.5% had less than 10% vital residual tumour cells. At a median follow-up of 23.2 months, the median survival time has not yet been reached. The probability of disease-free survival after 30 months was 60%. In conclusion, weekly neoadjuvant paclitaxel and carboplatin with concurrent radiotherapy is a very tolerable regimen and can be given on an outpatient basis. It achieves considerable down staging and a subsequent 100% radical resection rate in this series. A phase III trial with this regimen is now ongoing.

Concurrent cisplatin, 5-FU, paclitaxel, and radiation therapy in patients with locally advanced esophageal cancer

PURPOSE

Phase I-II data regarding neoadjuvant cisplatin, 5-fluorouracil (5-FU), paclitaxel, and radiation (PFT-R) from our institution demonstrated encouraging pathologic complete response (pCR) rates. This article updates our experience with PFT-R, and compares these results to our experience with cisplatin, 5-FU, and radiation therapy (PF-R) in locally advanced esophageal cancer.

PATIENTS AND METHODS

We searched the Massachusetts General Hospital cancer registry for esophageal cancer patients treated with radiation therapy and chemotherapy between 1994-2002. Records of patients treated with curative, neoadjuvant therapy were examined for chemotherapeutic regimen. Outcomes of patients treated with PF-R or PFT-R were assessed for response to therapy, toxicity, and survival.

RESULTS

A total of 177 patients were treated with neoadjuvant therapy with curative intent; 164 (93%) received PF-R (n=81) or PFT-R (n=83). Median overall survival was 24 months. After a median follow-up of 54 months for surviving patients, 3-year overall survival was 40% with no significant difference between PF-R (39%) and PFT-R (42%).

CONCLUSIONS

Our findings failed to demonstrate an improvement in pCR or survival with PFT-R vs. PF-R. These results do not support this regimen of concurrent neoadjuvant PFT-R in esophageal cancer, and suggest that further investigations into alternative regimens and novel agents are warranted.

Pilot Study of Preoperative Combined Modality Treatment for Locally Advanced Operable Oesophageal Carcinoma: Toxicities and Long-term Outcome

AIMS

Paclitaxel, a radiosensitiser, has significant activity in oesophageal cancer. We aimed to conduct a feasibility study of preoperative chemoradiation using paclitaxel, cisplatin and 5-fluorouracil (5-FU).

MATERIALS AND METHODS

Sixteen eligible patients were enrolled. Infusional 5-FU, paclitaxel and cisplatin were given for 6 weeks before and concurrent with radiation. Conformal radiotherapy was delivered in two phases (45 Gy in 25 fractions).

RESULTS

A total of 62.5% of the patients experienced Grade 3-4 toxicities, 50% required admission; one patient died during the neo-adjuvant phase. Twelve (75%) patients had oesophagectomy, and two (12.5%) died after surgery. Pathological complete remission (PCR) and minimal residual disease were observed in 25% (95% CI 0.5-49.5%) and 18% (95% CI 0-38%) of patients, respectively, who underwent surgery. The median survival was 39.7 months (95% CI 15, not reached); 1-, 2-, 3-, and 4-year survivals were 75% (95% CI 56.5-99.5), 56.3% (36.5-86.7), 50% (30.6-81.6), and 50% (30.6-81.6), respectively.

CONCLUSION

Paclitaxel, cisplatin and 5-FU (TCF)-chemoradiation is an active regimen; the current dose schedule tested is associated with unacceptable toxicity, and cannot be recommended for routine clinical use.

Systemic treatment for oesophageal cancer

Oesophageal cancer, in particular adenocarcinomas, has shown a rapid and largely unexplained increase in incidence in the Western world. Despite advances in diagnostic and surgical techniques and improved pre- and postoperative care, the prognosis of most patients is poor. This Review will focus on the use of chemotherapy as part of multimodal treatment and for patients with metastatic disease. Randomised phase III trials have, for the most part, failed to demonstrate a survival advantage with the use of chemotherapy. It must be emphasised that many of these phase III trial were underpowered and do not meet today's standards. Recent phase II trials have suggested some progress when chemotherapy is incorporated into the management of patients with oesophageal cancer. However, confirmatory and adequately powered and designed phase III studies are urgently needed to improve patient outcomes and for better palliation of symptoms.