Chemoradiotherapy for cancer of the esophagus: contribution of the leucovorin, 5-fluorouracil bolus, and infusion-cisplatin-radiotherapy schedule starting with two neoadjuvant chemotherapy cycles: results from a pilot study

Dosimetric superiority of IMRT with jaw tracking technique for whole esophagus and T-shaped field radiotherapy in advanced esophageal cancer

Purpose

For whole esophagus and T-shaped field radiotherapy using intensity modulated radiotherapy (IMRT) technique in advanced esophageal cancer, lower absorbed doses to lung and heart remains a challenge. The aim of this study was to investigate the dosimetric superiority in IMRT plans with jaw tracking technique for whole esophagus radiotherapy.

Methods and materials

Thirty-two patients with esophageal cancer were subjected to IMRT treatment plans using Eclipse treatment planning system. For every patient, four different plans were generated with six gantry angles: six large fields IMRT plans with fixed jaw (6F-IMRT), six large fields IMRT plans with jaw tracking technique (6F-IMRT-T), twelve small fields IMRT plans with fixed jaw (12F-IMRT), and twelve small fields IMRT plans with jaw tracking technique (12F-IMRT-T). Dosimetric evaluation was assessed for all plans.

Results

For every technique, there were no differences in planning target volume (PTV) coverage and conformity. 6F-IMRT-T plans could significantly reduce lung irradiation with 7.9% (P<0.001) reduction in V5_lung and 2.5% (P<0.001) reduction in V20 _lung respectively compared to 6F-IMRT plans. 12F-IMRT-T plans resulted in superior plans compared to 12-IMRT plans with a reduction of 2.9% (P<0.001) in V5_lung and 0.9% (P<0.001) in V20 _lung, respectively. For heart irradiation, 6F-IMRT-T and 12F-IMRT-T plans were slightly superior to 6F-IMRT and 12-IMRT plans respectively with a reduction of 1.1 Gy and 0.5 Gy in the respective mean doses.

Conclusions

By the use of jaw tracking technique, the IMRT plans resulted in further lung and heart sparing compared to fixed jaw plans for radiotherapy in esophageal cancer.

Update on Neoadjuvant Regimens for Patients with Operable Oesophageal/Gastrooesophageal Junction Adenocarcinomas and Squamous Cell Carcinomas

Survival outcomes following multimodal treatment of operable oesophageal and gastrooesophageal cancer remain disappointingly poor. Although an appreciation of the impact of both tumour location and histological subtype is now shaping the design of clinical trials, there has been a lack of consensus of the optimal neoadjuvant treatment strategy. This update article will review recent advances in the use of both neoadjuvant chemotherapy and chemoradiotherapy. The emerging role of PET imaging to direct appropriate neoadjuvant treatment regimens and the additive benefit of biological agents are also discussed.

Increasing toxicity during neoadjuvant radiochemotherapy as positive prognostic factor for patients with esophageal carcinoma

The aim of this study was to correlate acute organ toxicity during preoperative radiochemotherapy with overall survival and tumor regression for patients with primarily operable esophageal carcinoma. From 1995 to 2002, 60 patients with primarily operable esophageal carcinoma were treated in a preoperative setting at our department. Thirty-three percent of the patients had International Union against Cancer (UICC)-stage II tumors, 62% had UICC-stage III tumors, and 5% had UICC-stage IVA tumors. All patients received irradiation (40 Gy at 2 Gy/fraction). Chemotherapy for all patients with adenocarcinoma and, from 2001, also for patients with squamous cell carcinoma consisted of two cycles, 5-fluorouracil and cisplatinum; between 1995 and 2001, patients with squamous cell carcinoma received three courses of chemotherapy (folinic acid, etoposide, 5-fluorouracil, and cisplatinum every 3 weeks) before and further cisplatinum and etoposide during radiotherapy. We found a significant correlation between acute organ toxicity and histopathological tumor regression, as well as overall survival. The probability to achieve tumor regression grade 1 after radiochemotherapy was nearly four times higher for patients with worsening of odynophagia than for those without an increase (odds ratio: 3.97). Patients with worsening of odynophagia had a 5-year overall-survival rate of 66% compared with 39% in patients without (P = 0.048). Our data indicate that normal tissue and tumor tissue may behave similar with respect to treatment response, as acute organ toxicity showed to be an independent prognostic marker in our patient population. The hypothesis should be further analyzed on biomolecular and clinical level in future clinical trials.

Use of high-dose cisplatin with aprepitant in an outpatient setting

Chemotherapy-induced nausea and vomiting (CINV) and nephrotoxicity are adverse events induced by cisplatin administration. These effects can be reduced by treatment regimens with low-dose cisplatin, but high-dose cisplatin is still used. In Japan, high-dose cisplatin is usually administered in an inpatient setting to permit management of CINV. However, with use of new-generation antiemetic agents such as aprepitant, CINV and nephrotoxicity are controllable in an outpatient setting. Here, we discuss issues related to the management of high-dose cisplatin administration in outpatients. Grade 2 or worse CINV induced by high-dose cisplatin occurs in more than 40% of patients without treatment with aprepitant, but is controllable by administration of a 5-HT3 receptor antagonist, steroids and aprepitant. Moreover, prevention of CINV using these drugs is cost-effective, since outpatient settings have advantages with regard to health economics and patient quality of life. These findings suggest that shifting high-dose cisplatin administration to the outpatient setting may be achieved with co-administration of aprepitant. Available facilities and the status of the patient should be considered when selecting whether an outpatient setting is suitable for administration of cisplatin, but the use of aprepitant and adequate oral hydration should allow use of cisplatin in this setting.