Outcome of patients receiving radiation for cancer of the esophagus: results of the 1992-1994 Patterns of Care Study

Development of a nomogram for overall survival in patients with esophageal carcinoma: A prospective cohort study in China

BACKGROUND

Esophageal carcinoma (EC) presents a significant public health issue in China, with its prognosis impacted by myriad factors. The creation of a reliable prognostic model for the overall survival (OS) of EC patients promises to greatly advance the customization of treatment approaches.

AIM

To create a more systematic and practical model that incorporates clinically significant indicators to support decision-making in clinical settings.

METHODS

This study utilized data from a prospective longitudinal cohort of 3127 EC patients treated at Chongqing University Cancer Hospital between January 1, 2018, and December 12, 2020. Utilizing the least absolute shrinkage and selection operator regression alongside multivariate Cox regression analyses helped pinpoint pertinent variables for constructing the model. Its efficacy was assessed by concordance index (C-index), area under the receiver operating characteristic curve (AUC), calibration curves, and decision curve analysis (DCA).

RESULTS

Nine variables were determined to be significant predictors of OS in EC patients: Body mass index (BMI), Karnofsky performance status, TNM stage, surgery, radiotherapy, chemotherapy, immunotherapy, platelet-to-lymphocyte ratio, and albumin-to-globulin ratio (ALB/GLB). The model demonstrated a C-index of 0.715 (95%CI: 0.701-0.729) in the training cohort and 0.711 (95%CI: 0.689-0.732) in the validation cohort. In the training cohort, AUCs for 1-year, 3-year, and 5-year OS predictions were 0.773, 0.787, and 0.750, respectively; in the validation cohort, they were 0.772, 0.768, and 0.723, respectively, illustrating the model's precision. Calibration curves and DCA verified the model's predictive accuracy and net benefit.

CONCLUSION

A novel prognostic model for determining the OS of EC patients was successfully developed and validated to help clinicians in devising individualized treatment schemes for EC patients.

Definitive chemoradiotherapy in elderly patients with esophageal cancer: Safety and outcome

Objective: The efficacy and safety of definitive chemoradiotherapy (dCRT) for elderly patients with unresectable esophageal cancer (EC) are not yet fully understood. We conducted this study to evaluate the outcome and toxicity in elder patients (65 years and over) of unresectable EC treated with dCRT. Methods: From four Georgian cancer centers with a radiation oncology department, we identified 44 elderly patients with EC suitable according to the study criteria. Overall survival (OS) was estimated from the beginning of treatment and toxicity scored using CTCAE 5.0 criteria. Results: The median age of patients was 70.0 years (range 65-83 years), with male predominance (77.3%) and 59% of patients were with Eastern Cooperative Oncology Group (ECOG) performance status 1. Because of significant dysphagia (grade 3-4) nine patients underwent intervention (stenting or gastrostomy) before dCRT. More than two-thirds of patients were squamous cell histological type (77.3%). Localization of tumors was equally distributed between the middle and lower parts of the esophagus (38.6%) and in 26 patients (59.1%) tumor length was more than 5 cm. The majority of patients had stage III disease (61.4%). Median survival was 16.0 months (95% confidence interval [CI] 0-35.9). OS at 12 and 24 months was 53.7% and 43.6%, respectively. Fifteen patients (34%) were alive from 2.1 to 5.4 years after treatment. A statistically significant difference (p = 0.011) in median OS was found between patients who received full (not reached) versus overall survival (OS) was 9.0 months in patients who received nonfull dose of radiotherapy (RT) (95% CI 2.79-15.2). Additional analysis between age subgroups revealed that elder subgroup patients (>75 years) had the highest OS, compared to younger (65-70 years) and intermediate groups (71-75 years) (p = 0.001). The most common adverse events were grade 3-4 leukopenia (43.2%), anemia (29.5%), and esophagitis (27.3%). Conclusion: The results of our study support the feasibility and efficacy of dCRT for unresectable EC in carefully selected elderly patients. Survival was correlated to complete dose of RT and therefore accurate selection of patients is crucial for better long-term survival. Our study showed that chronological age alone does not reflect a patient's ability to tolerate dCRT. Toxicity of dCRT is always a very important issue and patient selection must be very cautious in geriatric patients, although dCRT might benefit highly selected patients.

Clinical analysis of 117 cases with synchronous multiple primary esophageal squamous cell carcinomas

BACKGROUND/AIMS

We aimed to study the clinical characteristics, treatment modality, and the prognosis of synchronous multiple primary esophageal squamous cell carcinomas (SMPESCC).

METHODS

A total of 117 SMPESCC cases were evaluated retrospectively from 2010 to 2015.

RESULTS

The most common locations of SMPESCC were mid- and lower thoracic segments (n = 208, 84.9%). The 1-, 2-, and 3-year overall survival rates were 53.8%, 30.8%, and 15.4%, respectively; the median survival time (MST) was 12.5 months. With definitive radiotherapy and surgery, respectively, the MST of stage I/II patients were 34.2 and 26.7 months, of stage III patients were 8.3 and 13.2 months (p = 0.163), and of stage IV patients were and 8 and 12.6 months (p = 0.379). Clinical stage, family history of cancer, and Karnofsky performance status were independent prognostic factors for the whole cohort by Cox multivariate regression analysis (hazard ratio [HR] = 0.859, p < 0.001; HR = 0.579, p = 0.032; and HR = 0.586, p = 0.013).

CONCLUSION

Although the prognosis of SMPESCC is poor, stage I/II patients can achieve long-term survival with aggressive treatment, especially those with a Karnofsky performance score 90 or higher and who have no family history of cancer. Definitive radiotherapy could achieve a similar survival rate to definitive surgery at different clinical stages.

Clinical practice and outcome of radiotherapy for advanced esophageal squamous cell carcinoma between 2002 and 2018 in China: the multi-center 3JECROG Survey

PURPOSE

To determine the survival and prognostic factors of esophageal squamous cell carcinoma (ESCC) patients undergoing radical (chemo)radiotherapy in the era of three-dimensional conformal radiotherapy (3DCRT) and intensity modulated radiotherapy (IMRT) in China.

MATERIAL AND METHODS

The Jing-Jin-Ji Esophageal and Esophagogastric Cancer Radiotherapy Oncology Group (3JECROG) conducted the first nationwide survey of nine institutions. Detailed information was accumulated on 5185 patients with ESCC who received definitive 3DCRT/IMRT between 2002 and 2018. Relevant prognostic factors were evaluated to assess their influence on overall and progression-free survivals.

RESULTS

After a median follow-up time of 47.0 (0.9-157.4) months, the 1-year, 2-year, 3-year and 5-year overall survival rates of the whole group were 69.8%, 46.6%, 37.9% and 30.1%. The 1-year, 2-year, 3-year, and 5-year progression-free survival rates were 54.1%, 36.6%, 30.5% and 24.9%. Multivariate analysis demonstrated that sex, clinical stage, treatment modality and radiation dose were prognostic factors for OS. The survival of patients who received concurrent chemoradiotherapy (CCRT) was better than that of patients who received radiotherapy alone or sequential chemoradiotherapy. Patients receiving adjuvant chemotherapy after CCRT had a better OS than patients receiving CCRT alone. Patients receiving higher radiation dose had a better OS than those patients receiving low-dose radiotherapy.

CONCLUSIONS

The survival of ESCC patients undergoing radical (chemo)radiotherapy was relatively satisfactory in the era of 3DCRTand IMRT. As the largest-scale multicenter research on esophageal cancer radiotherapy conducted in China, this study establishes national benchmarks and helps to provide references for subsequent related researches.

Comparison of nodal irradiation dose using radiotherapy for patients with thoracic esophageal cancer

The present study aimed to compare incidental nodal irradiation (INI) doses using volume-modulated arc therapy (VMAT), 5-field intensity-modulated radiotherapy (5F-IMRT) and 3D-conformal radiotherapy (3D-CRT) treatment plans for patients with thoracic esophageal cancer (EC). A total of 15 patients with thoracic EC were selected for participation between October 2016 and July 2017 at the Hangzhou Cancer Hospital. Regional lymph nodal stations were contoured according to 3D CT-based images of the Japan Esophageal Society Guidelines. All patients were treated with 60 Gy using VMAT, 5F-IMRT and 3D-CRT plans. Dose-volume histograms of planning target volume (PTV), lung, heart, spinal cord and incidental nodal irradiation were compared between the three plans. 5F-IMRT was superior in PTV_V95% (the volume of the PTV receiving 95% of the prescription dose, P=0.003) and the VMAT plan was best in terms of conformal index (P=0.005). V20 and V30 were reduced by 10.7-22.6% (P=0.002) and 12.8-21% (P=0.026), respectively, in normal lung tissue using the VMAT plan. 5F-IMRT demonstrated the lowest maximum dose (Dmax) for the spinal cord (P=0.037). For the INI, 3D-CRT exhibited the highest equivalent uniform dose (EUD) values for 106pre (P=0.014) and 106tb-L (P=0.03) in upper-thoracic EC. The mean EUD of all lymph nodal regions in middle-thoracic EC were >40 Gy in VMAT and 5F-IMRT plans; the VMAT plan had higher EUD values in lower-thoracic EC compared with 5F-IMRT, 3D-CRT plans for INI. VMAT were comparable to the 5F-IMRT plan with respect to dosimetric characteristics for planning and INI doses to thoracic nodal levels NO 105-112 are considerable for thoracic EC.

Outcome of delayed versus timely esophagectomy after chemoradiation for esophageal adenocarcinoma

BACKGROUND

Salvage and delayed esophagectomy after chemoradiation therapy (CRT) have been associated with increased morbidity and mortality, but recent series have shown similar outcomes compared to timely esophagectomy. We aim to evaluate outcomes for delayed and salvage esophagectomy for esophageal adenocarcinoma utilizing a large national database.

METHODS

The National Cancer Database for 2004 to 2014 was queried for patients with clinical stage II or III esophageal adenocarcinoma who underwent preoperative CRT and esophagectomy. Patients who underwent surgery <90 days after CRT were defined as the timely esophagectomy group (n = 7822), and those who underwent surgery ≥90 days after CRT were defined as the delayed esophagectomy group (n = 667).

RESULTS

A total of 8489 patients met our inclusion criteria. The median post-CRT interval was 49 days (range, 40-61 days) for the timely esophagectomy group and 109 days (range, 97-132 days) for the delayed esophagectomy group. The delayed group was more likely to be of black race (2.3% vs 1.2%; P < .01) and more likely to have Medicare (47.9% vs 39.8%; P < .001). There were no significant between-group differences in chemotherapy regimens (P = .17), radiation dose (P = .18), or surgical approach (P = .48). The delayed esophagectomy group had higher rates of pathological complete response (22.2% vs 18.6%; P = .043) and 90-day postoperative mortality (10.4% vs 7.8%; P < .01). On multivariate analysis, delayed esophagectomy was not independently associated with decreased overall survival.

CONCLUSIONS

In this large retrospective database study, despite increased perioperative mortality, delayed and salvage esophagectomy for adenocarcinoma appear to have similar long-term survival as timely esophagectomy. Delayed and salvage esophagectomy may be offered to patients who do not receive timely esophagectomy after CRT.

Feasibility and efficiency of concurrent chemoradiotherapy with a single agent or double agents vs radiotherapy alone for elderly patients with esophageal squamous cell carcinoma: Experience of two centers

The incidence of elderly patients with esophageal cancer (OC) is increasing as the population ages. Until now, the treatment strategy in these patients has been unclear. The aim of our study was to assess the efficiency and tolerance of treatment with radiotherapy alone (RT alone), single‐agent‐based concurrent chemoradiotherapy (CCRT‐1), or double‐agent‐based concurrent chemoradiotherapy (CCRT‐2) in elderly patients (≥65 years) with OC. A total of 271 patients with OC aged 65 years or older were included in this study. The median overall survival (OS), median progression‐free survival (PFS), overall response rate (ORR), disease control rate (DCR), and treatment‐related toxicities were assessed. The median OS time for all patients was 23.6 ± 2.3 months, with 2‐year survival rates of 48.0 ± 3.0%. The median PFS time was 13.6 ± 1.3 months with the 2‐year PFS rate was 33.0 ± 4.0%. Among patients who received CCRT‐1, better OS, and PFS were found in patients who received docetaxel than in patients received fluorouracil and platinum. In a subgroup analysis, 118 patients who underwent RT alone had a median OS time of 15.6 ± 1.9 months and median PFS time of 10.4 ± 0.9 months. The median OS time of patients who received CCRT‐1 was 28.8 ± 10.1 months compared with 27.8 ± 2.5 months for the patients treated with CCRT‐2 (P = 0.537). The similar results were observed for median PFS, with 16.5 ± 3.2 months in the CCRT‐1 group and 17.0 ± 2.0 months in the CCRT‐2 group (P = 0.321). Grade ≥3 leukocytopenia and grade ≥2 weight loss during treatment occurred in 40.6% and 17.9% of patients, respectively, in the CCRT‐2 group, which was higher than that observed in the CCRT‐1 group. Our results suggested that CCRT could be considered as an acceptable treatment for elderly patients with OC. The CCRT‐1 group presented with a lower incidence of treatment toxicities but comparable survival outcomes, compared to the CCRT‐2 group. Docetaxel was superior to fluorouracil and platinum in terms of OS.

Concomitant Chemotherapy and External Radiotherapy plus Brachytherapy for Locally Advanced Esophageal Cancer Results of a Retrospective Multicenter Study

Aims and Background

In October 1995, the Piedmont AIRO (Italian Society of Radiation Oncology) Group started a multi-institutional study of radiochemotherapy on locally advanced esophageal cancer, characterized by external radiotherapy followed by an intraluminal high dose-rate brachytherapy boost. Most patients were re-evaluated for surgery at the end of the program. The primary aim of the study was to assess efficacy of curative radiochemotherapy regarding overall survival and local control rates. The secondary aim was to evaluate the ability of radiochemotherapy to make resectable lesions previously considered inoperable.

Methods and Study Design

Between January 1996 and March 2000, 75 patients with locally advanced esophageal cancer were enrolled. All were treated with definitive radiotherapy; due to age or high expected toxicity, chemotherapy was employed only in 53 of them. Treatment schedule consisted of 60 Gy external radiotherapy (180 cGy/d, 5 days/week for 7 weeks) concomitant with two 5-day cycles of chemotherapy with cisplatin and fluorouracil (weeks 1 and 5). One or two sessions of 5-7 Gy intraluminal high dose-rate brachytherapy were carried out on patients whose restaging showed a major tumor response. Surgery was performed in 14 patients.

Results

At the end of radiotherapy, dysphagia disappeared in 46/75 cases (61%), and in 20/75 (27%) a significant symptom reduction was recorded. Complete objective response at restaging after radiotherapy was obtained in 33% of patients and a partial response in 53%. At the end of the multimodal treatment program, including esophagectomy, complete responses were 34 (45%); 4 of 14 (28.5%) cases proved to be disease free (pTO) at pathological examination. No G3-G4 toxicity was recorded. Two- and 5-year overall survival rates of all patients were, respectively, 38% and 28%; 2- and 5-year local control rates were, respectively, 35% and 33%. In a subgroup of 20 nonsurgical patients in complete response after radiochemotherapy, the overall survival rate at 3 and 5 years was 65% and the local control rate at 3 and 5 years was 75%. According to multivariate analysis, prognostic factors for survival were Karnofsky index and esophagectomy.

Conclusions

For patients with locally advanced disease, radiochemotherapy showed improved clinical and pathologic tumor response and survival compared to surgery or radiotherapy alone. Intraluminal brachytherapy with a small fraction size allows an increased dose to the tumor without higher toxicity. Esophagectomy following radiochemotherapy could improve survival rates compared to definitive radiochemotherapy, but it is necessary to optimize selection criteria for surgery at the re-evaluation phase.

MiR-193a-5p/ERBB2 act as concurrent chemoradiation therapy response indicator of esophageal squamous cell carcinoma

Concurrent chemoradiation therapy (CCRT) is the predominant treatment in esophageal cancer, however resistance to therapy and tumor recurrence are exceedingly common. Elevated ERBB2/Her2 may be at least partially responsible for both the high rates of recurrence and resistance to CCRT. This receptor tyrosine kinase is upregulated in 10–20% of esophageal squamous cell carcinoma (ESCC) tissues, and amplification of ERBB2 has been correlated with poor prognosis in esophageal cancer. Tissues from 131 ESCC patients, along with cell and animal models of the disease were used to probe the underlying mechanisms by which ERBB2 upregulation occurs and causes negative outcomes in ESCC. We found that overexpression of ERBB2 inhibited radiosensitivity in vitro. Furthermore, miR-193a-5p reduced ERBB2 expression by directly targeting the 3′UTR. Increased miR-193a-5p enhanced radiosensitivity and inhibited tumorigenesis in vitro and in vivo. Additionally, low miR-193a-5p expression correlated with poor prognosis in ESCC patients, and ESCC patients with good CCRT response exhibited higher miR-193a-5p expression. Our data suggest that patients with high miR-193a-5p will likely benefit from CCRT treatment alone, however a combination of CCRT with Herceptin may be beneficial for patients with low miR-193a-5p expression.

Handgrip Strength Is Associated With Treatment Modifications During Neoadjuvant Chemoradiation in Patients With Esophageal Cancer

RATIONALE

It has been shown that early nutrition intervention improves nutrition status (NS) and treatment tolerance in patients with esophageal cancer. However, it remains unknown whether pretreatment parameters of NS are associated with treatment modifications (TMs) during neoadjuvant chemoradiation (CR) in patients who are intensively nutritionally supervised during treatment.

METHODS

All outpatients with esophageal cancer who were scheduled for CR in the VU medical center from 2006-2015 were included. NS was assessed by body mass index (BMI), weight loss in the past 6 months (WL), fat mass index (FMI) and fat-free mass index (FFMI), handgrip strength (HGS), and energy/protein intake. Logistic regression analyses, adjusted for age, sex, previous tumor, tumor stage, and physical status, were applied. TMs were defined as delay, dose reduction or discontinuation of chemotherapy and/or radiotherapy, hospitalization, or mortality (yes/no).

RESULTS

In total, 162 patients were included (73% male; mean age 65 ± 9 years). Mean BMI was 25.1 ± 4.5 kg/m2, and WL was 4.8 ± 5.1 kg. HGS and FFMI were below the 10th percentile of reference values in 21 and 37 patients, respectively. Thirty-five (22%) patients experienced at least 1 TM during CR; unplanned hospitalization (n = 18, 11%) was the most prevalent. After adjustments for confounders, only HGS was statistically significantly associated with TMs (odds ratio, 0.93; 95% confidence interval, 0.88-1.00).

CONCLUSION

In this group of intensively supervised patients with esophageal cancer, pretreatment parameters of NS had little influence on TMs during CR. Only a lower HGS was associated with TMs.

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.

Effectiveness of esophagectomy in patients with thoracic esophageal squamous cell carcinoma receiving definitive radiotherapy or concurrent chemoradiotherapy through intensity-modulated radiation therapy techniques

BACKGROUND

Few large, prospective, randomized studies have investigated the effectiveness of esophagectomy in patients with thoracic esophageal squamous cell carcinoma (TESCC) who receive definitive radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) through modern, intensity modulated-RT (IMRT) techniques. The therapeutic effects of esophagectomy in patients with TESCC were evaluated using modern clinical staging and RT techniques and suitable RT doses.

METHODS

The authors analyzed data from patients with TESCC from the Taiwan Cancer Registry database. Patients were categorized into the following groups on the basis of treatment modality to compare their outcomes: group 1 received definitive CCRT, group 2 received neoadjuvant RT followed by esophagectomy (total IMRT dose, ≥50 grays [Gy]), and group 3 receiving neoadjuvant CCRT followed by esophagectomy (total IMRT dose, ≥ 50 Gy). The median total RT dose and fraction size were 50.4 Gy and 1.8 Gy per fraction, respectively. Group 1 was used as the control arm for investigating the risk of mortality after treatment.

RESULTS

In total, 3123 patients who had TESCC without distant metastasis were enrolled. Patient ages 65 years and older, Charlson comorbidity index scores ≥3, advanced clinical stages (IIA-IIIC), alcohol consumption, and cigarette smoking were identified as significant, independent poor prognostic risk factors for overall survival in multivariate Cox regression analyses. In group 3, after adjustment for confounders, the adjusted hazard ratios (95% confidence intervals [CIs]) for overall mortality were 0.62 (95% CI, 0.41-0.93) for patients with clinical stage IIA disease, 0.61 (95% CI, 0.41-0.91) for those with clinical stage IIB disease, 0.47 (95% CI, 0.38-0.55) for those with clinical stage IIIA disease, 0.47 (95% CI, 0.39-0.56) for those with clinical stage IIIB disease, and 0.46 (95% CI, 0.37-0.57) for those with clinical stage IIIC disease.

CONCLUSIONS

Esophagectomy can be beneficial in patients with TESCC after definitive CCRT, especially in those who have advanced-stage disease. Cancer 2017;123:2043-2053. © 2017 American Cancer Society.

Atlas of the thoracic lymph nodal delineation and recommendations for lymph nodal CTV of esophageal squamous cell cancer in radiation therapy from China

PURPOSE

To construct an anatomical atlas of thoracic lymph node regions of esophageal cancer (EC) based on definitions from The Japan Esophageal Society (JES) and generate a consensus to delineate the nodal clinical target volume (CTVn) for elective nodal radiation (ENI) of esophageal squamous cell carcinoma (ESCC).

METHODS AND MATERIALS

An interdisciplinary group including two dedicated radiation oncologists, an experienced radiologist, a pathologist and two thoracic surgeons were gathered to generate a three-dimensional radiological description for the mediastinal lymph node regions of EC on axial CT scans. Then the radiological boundaries of lymph node regions were validated by a relatively large number of physicians in multiple institutions.

RESULTS

An atlas of detailed anatomic boundaries of lymph node station No. 105-114 was defined on axial CT, along with illustrations. From the previous work, the study provided a guide of CTVn contouring for ENI of thoracic ESCC from a single center.

CONCLUSION

It is feasible to use such an atlas of thoracic lymph node stations for radiotherapy planning. A phase III study based on the atlas is ongoing in China to measure quantitatively the ENI received by patients with ESCC.

Curative treatment of esophageal cancer; an evidenced based review

BACKGROUND

In 2013, roughly 18,000 cases of esophageal cancer will be diagnosed in the United States with more than 15,000 people dying from the disease. Worldwide, an estimated 482,300 new esophageal cancer cases were diagnosed with 406,800 deaths in 2008. Squamous cell carcinoma (SCC) and adenocarcinoma (AC) account for >90% of all esophageal cancer cases.

METHODS

The authors will examine the role of radiation therapy, chemotherapy, and surgery in the curative management of esophageal cancer by examining randomized control data, single arm phase II trials, several recently published meta-analyses, as well as retrospective data where there is no clinical trial data available. The role of positron emission tomography (PET) will be reviewed as well.

RESULTS

Current data support the role of neoadjuvant chemoradiotherapy followed by surgical resection for locally advanced esophageal cancer with 3-year overall survival ranging from 30% to 60%. The benefit of adjuvant chemoradiation therapy is limited to margin positive and/or node positive patients. There is emerging data questioning the survival benefit of surgical resection after chemoradiotherapy. External beam radiation therapy alone results in very few long-term survivors and is considered palliative at best. Radiation dose-escalation has failed to improve local control or survival. PET scanning is vital in staging and has become a strong predictor of response and survival.

CONCLUSIONS

Preoperative or definitive concurrent chemoradiotherapy is the established standard of care for locally advanced cancers of the esophagus. While preoperative chemotherapy is supported by level 1 evidence, the true benefit of induction chemotherapy before chemoradiotherapy has not been established in a prospective randomized control trial. The role of surgery in the management of SCC is still a hotly debated subject, however, it is still recommended for AC. There is no data to support adjuvant chemotherapy after preoperative chemoradiotherapy. The benefit of neoadjuvant chemotherapy seems to be limited AC. Radiation without chemotherapy is palliative and never curative. PET continues to be integrated into treatment decisions and predicts for response and survival after therapy.

Single-institution retrospective comparison of preoperative versus definitive chemoradiotherapy for adenocarcinoma of the esophagus

PURPOSE

We sought to determine the impact of esophagectomy on survival in patients with adenocarcinoma of the esophagus cancer after chemoradiotherapy (CRT).

METHODS

A database of esophageal cancer was queried for nonmetastatic patients with adenocarcinoma treated between 2000 and 2011 with CRT. Overall survival (OS) and recurrence-free survival (RFS) curves were calculated according to the Kaplan-Meier method and log-rank analysis. Multivariate analysis was performed by the Cox proportional hazard model.

RESULTS

We identified 154 patients (60 without surgery; 94 with surgery) who were included in the analysis. The only differences between the 2 groups were more advanced disease stage, improved performance status, and younger age in the surgery group. Patients undergoing surgery had significantly higher survival. Median and 5-year OS for surgical patients were 4.1 years and 43.6 %, versus 1.9 years and 35.6 % for nonsurgical patients (p = 0.007). Multivariate analysis for OS and RFS revealed that factors associated with increased survival were surgical resection, tumor length < 5 cm, male gender, and lower stage. Age, tumor location, radiation dose/technique, and induction chemotherapy were not prognostic. There was a trend toward improved survival on univariate analysis (p = 0.10) and multivariate analysis (p = 0.063) for surgical patients compared to nonsurgical patients who were healthy enough for surgery before CRT (n = 38), and no difference in OS in nonsurgical patients healthy enough for surgery after CRT (n = 22).

CONCLUSION

Esophagectomy after CRT is associated with improved survival in patients with adenocarcinoma after CRT. Trimodal therapy should continue to remain the standard of care for esophageal adenocarcinoma.

Radio(chemo)therapy in Elderly Patients with Esophageal Cancer: A Feasible Treatment with an Outcome Consistent with Younger Patients

Background: Although the prevalence of esophageal cancer increases in elderly patients, its clinical history and outcome after treatment remain poorly described.

Methods: Between January 2001 and December 2011, 58 patients (pts) older than 75 years received 3D-conformal radiotherapy (mean dose 51 Gy) in two French cancer centers. 47/58 (82%) patients received concomitant chemotherapy (with CDDP and/or FU regimens) and 8 patients underwent surgery after primary radiochemotherapy (RCT).

Results: Median age was 77.9 years and the performance status (PS) was 0 or 1 in 89%. Tumors were mainly adenocarcinoma of lower esophagus or gastroesophageal junction (n = 51, 89%), T3T4 (n = 54, 95%), and N1 (n = 44, 77%). The mean follow-up was 21.9 months. In the overall population, the median progression-free survival was 9.6 months and median overall survival (OS) was 14.5 months. Using univariate analysis, OS was significantly associated with age (p = 0.048), PS (p < 0.001), and surgery (p = 0.035). 35 (60.3%) and 18 patients (31%) experienced grade 1–2 or 3–4 toxicity, respectively (CTCAE v4.0).

Conclusion: Radiochemotherapy in elderly patients is a feasible treatment and its outcome is close to younger patient’s outcome published in the literature. Surgical resection, after comprehensive geriatric assessment, should be recommended as the standard treatment for adenocarcinoma of lower esophagus or gastroesophageal junction in elderly patients with good PS and low co-morbidity profile, as it is in younger patients.

Management of localized esophageal cancer in the older patient

Most patients with gastroesophageal cancers are older than 65 years of age. The management of older patients poses challenges because they have multiple comorbidities and physiological changes associated with aging. Furthermore, data are limited on tolerance of cancer therapy and the use of combined-modality treatments in this patient population to guide their treatment. In this article, we focus on the management of older patients with localized esophageal cancer, highlighting the role of comprehensive geriatric assessment to identify and better tailor treatment approaches in this patient population. We review the literature and discuss the role of surgical resection and potential complications specific to an older patient. We review the rationale of combined-modality treatment and the potential benefits of a chemoradiotherapy-based approach in this patient population.

Impact of nutritional parameter variations during definitive chemoradiotherapy in locally advanced oesophageal cancer

BACKGROUND

Undernutrition is frequently observed in patients with a locally advanced oesophageal carcinoma. However, variations of nutritional parameters during chemoradiotherapy have not been thoroughly investigated.

AIM

To evaluate the characteristics and the impact of nutritional variations during treatment.

METHODS

Weight loss, body mass index (BMI), serum albumin level and daily food intake at baseline and during treatment (T1=week 1; T2=week 5 or 8; T3=week 11) were retrospectively analyzed in 101 patients with oesophageal carcinoma.

RESULTS

Significant variations occurred during chemoradiotherapy with a decrease in serum albumin level (p<0.001), body mass index (p<0.001) and weight (p<0.001). Response rate to treatment was significantly lower in patients with undernutrition at T1 (p=0.05), from T1 to T2 (p=0.01) and from T1 to T3 (p=0.04). Median overall survival was 25 months in patients with persistent undernutrition from T1 to T2 vs 42 months in wellnourished patients from T1 to T2 and those malnourished only at T1 or T2 (p=0.05). In responders, patients presenting with a lower weight or a lower food intake from T1 to T3 had worse survival (33 vs 59 months, p<0.001 and 29 vs 61 months, p=0.001, respectively).

CONCLUSION

Significant variations of nutritional parameters occurred during chemoradiotherapy with a worse impact on response and survival.

Propensity score analysis of oesophageal cancer treatment with surgery or definitive chemoradiotherapy

BACKGROUND

The role of treatments involving surgery versus definitive chemoradiotherapy (dCRT) for oesophageal cancer remains controversial.

METHODS

Consecutive patients with oesophageal cancer were studied. Those whose treatment involved surgery alone or who received neoadjuvant chemotherapy or chemoradiotherapy were compared with those receiving dCRT. Multiple regression models, including propensity scores, were developed to assess confounding factors associated with undergoing surgery or dCRT, and the risk-adjusted association between treatment and survival.

RESULTS

From a total of 727 patients, regression adjustment to control for bias created a cohort of 521 patients available for comparison (277 in the surgery group and 244 in the dCRT group). Local and distant recurrence rates were 10·1 and 22·0 per cent respectively after surgery, compared with 26·2 and 11·9 per cent following dCRT (P < 0·001). Median survival, and 2- and 5-year survival rates after surgery were 27 months, 53·8 and 31·0 per cent respectively, compared with 28 months, 54·2 and 31·9 per cent after dCRT (P = 0·918). On multivariable analysis, disease-free survival was related to endosonographic tumour category (hazard ratio (HR) 0·76, 95 per cent confidence interval 0·10 to 6·04 for T1; HR 1·57, 0·21 to 11·58 for T2; HR 2·12, 0·29 to 15·49 for T3; HR 3·07, 0·41 to 23·16 for T4; P = 0·003, in relation to T0 as reference), lymph node metastasis count (HR 1·10, 1·04 to 1·15; P < 0·001) and total disease length (HR 0·96, 0·93 to 1·00; P = 0·041).

CONCLUSION

There was no difference in survival after oesophageal cancer treatment involving surgery or dCRT.

Safety and efficacy of radiation and chemoradiation in patients over 70 years old with inoperable esophageal squamous cell carcinoma

The aim of the present study was to perform a retrospective analysis to investigate the outcome and toxicity of radiation (RT) and chemoradiation (CRT) in elderly, inoperable patients >70 years old. Between 2003 and 2012, 1,024 patients with squamous cell carcinoma (SCC) of the esophagus were treated at the Department of Thoracic Cancer, West China Hospital (Chengdu, China). Of these patients, 37 were >70 years old and had not undergone surgery, and were selected for analysis. Of these 37 patients, CRT had been administered to 20 (54%). Actuarial survival rates were determined by the Kaplan-Meier method. The one-year survival rate in the CRT group (n=20) was 85%, while 35% of patients in the RT group (n=17) survived for more than one year. The overall and progression-free survival in the CRT group versus the RT group were 17 months [95% confidence interval (CI), 11.861-22.139] versus eight months (95% CI, 6.674-9.326) (P=0.013) and 14 months (95% CI, 9.617-18.383) versus five months (95% CI, 2.311-7.689) (P=0.01), respectively. Patients irradiated with a dose of >50 Gy exhibited an improved survival rate compared with patients who received a dose of ≤50 Gy (18 vs. 14 months; P=0.049). Furthermore, patients with an Eastern Cooperative Oncology Group (ECOG) score of ≤1 had an improved prognosis compared with those with an ECOG score of 2 (14 vs. seven months; P=0.006). The two regimens were well-tolerated and there were no therapy-associated mortalities. The current retrospective study indicated that patients of >70 years old with inoperable esophageal SCC and a good ECOG score exhibit comparably better safety levels with CRT and improved survival rates compared with RT alone.

Radiation Therapy and Esophageal Cancer

Background

Squamous cell carcinoma and adenocarcinoma account for more than 90% of all esophageal cancer cases. Although the incidence of squamous cell carcinoma has declined, the incidence of adenocarcinoma has risen due to increases in obesity and gastroesophageal reflux disease.

Methods

The authors examine the role of radiation therapy alone (external beam and brachytherapy) for the management of esophageal cancer or combined with other modalities. The impact on staging and appropriate stratification of patients referred for curative vs palliative intent with modalities is reviewed. The authors also explore the role of emerging radiation technologies.

Results

Current data show that neoadjuvant chemoradiotherapy followed by surgical resection is the accepted standard of care, with 3-year overall survival rates ranging from 30% to 60%. The benefit of adjuvant radiation therapy is limited to patients with node-positive cancer. The survival benefit of surgical resection after chemoradiotherapy remains controversial. External beam radiation therapy alone results in few long-term survivors and is considered palliative at best. Radiation dose-escalation has failed to improve local control or survival. Brachytherapy can provide better long-term palliation of dysphagia than metal stent placement. Although three-dimensional conformal treatment planning is the accepted standard, the roles of IMRT and proton therapy are evolving and potentially reduce adverse events due to better sparing of normal tissue.

Conclusions

Future directions will evaluate the benefit of induction chemotherapy followed by chemoradiotherapy, the role of surgery in locally advanced disease, and the identification of responders prior to treatment based on microarray analysis.

The oncoprotein and stem cell renewal factor BMI1 associates with poor clinical outcome in oesophageal cancer patients undergoing preoperative chemoradiotherapy

Background

The polycomb group (PcG) family BMI1, acting downstream of the hedgehog (Hh) pathway, plays an essential role in the self-renewal of haematopoietic, neural, and intestinal stem cells, and is dysregulated in many types of cancer. Our recent report has demonstrated that Hh signalling activation can predict very earlier relapse of oesophageal cancers. As data were not available on the clinical role of BMI1 expression in oesophageal cancers after chemoradiotherapy (CRT), we analysed whether it could be also used to predict disease progression and prognosis in oesophageal cancer patients undergoing trimodality therapy of preoperative CRT and oesophagectomy.

Methods

Expressions of BMI1 and p16^INK4A, a downstream target of PcG, were analysed in 78 patients with histologically confirmed oesophageal squamous cell carcinoma (ESCC) after preoperative CRT by immunohistochemical staining. The association of BMI1 and p16^INK4A expression with clinicopathologic characteristics was analysed by χ²-test. Survival analysis was carried out by the log-rank test using Kaplan-Meier method.

Results

Among 78 ESCC patients, 24 patients (30.8%) showed BMI1 positivity, mainly localised in the nuclei of tumour cells. Patients harbouring BMI1-positive tumour cells showed significantly poorer prognoses than those without such cells or residual tumours (mean disease-free survival (DFS) time 16.8 vs 71.2 months; 3-yr DFS 13.3% vs 49.9%, P=0.002; mean OS time 21.8 vs 76.6 months; 3-yr OS 16.2% vs 54.9%, P=0.0005). There was no significant correlation between p16^INK4A expression and BMI1 expression.

Conclusions

Our study shows that BMI1 expression is a predictor of early relapse and poor prognosis in ESCC after CRT. These findings suggest that BMI1 signal activation might be involved in promoting cancer regrowth and progression after CRT, and might be indicative of emergence of ‘more aggressive’ cancer progenitor cells.

Prognostic factors in definitive radiochemotherapy of advanced inoperable esophageal cancer

The aim of this study was to assess the efficacy and prognostic factors of definitive radiochemotherapy (RCT) for inoperable esophageal cancer. Between 1995 and 2005 all patients with inoperable esophageal cancer that underwent concurrent RCT were included in this retrospective study. Conventional computed tomography-based treatment planning as well as 3D-conformal radiotherapy (RT) was used. Maximum radiotherapy dose was 63 Gy. Chemotherapy consisted of cisplatin (20 mg/m(2) d1-5 and 29-33) and 5-FU (650-1000 mg/m(2) d1-5 and 29-33). Patients not suitable for RCT received radiotherapy alone. Toxicity was measured according to common toxicity criteria (CTC). Two hundred three consecutive patients with inoperable esophageal cancer that received definitive therapy were identified in this time period (160 with squamous cell carcinoma and 43 with adenocarcinoma). The 2-year overall survival probability was 21.2% whereas the progression-free survival at 2 years was 13.8% for all patients. In the univariate analysis, type of histology, T-stage, N-stage, application of chemotherapy, and the radiation dose were significantly correlated with overall/progression-free survival. Moreover, multivariate analysis revealed an independent prognostic impact for N-stage, radiation dose, and concurrent chemotherapy. Definitive RCT is an important palliative treatment option for patients with inoperable esophageal cancer. N-stage, radiation dose, and concurrent chemotherapy are important prognostic factors for survival.

Definitive chemoradiotherapy in patients with esophageal adenocarcinoma: an alternative to surgery?

BACKGROUND AND OBJECTIVES

Definitive chemoradiotherapy (CRT) is considered curative intent treatment for locally advanced esophageal squamous cell carcinoma. Data concerning the usefulness of definitive CRT in patients with esophageal adenocarcinoma (ADC) are lacking. The aim of the study was to compare the results of definitive CRT versus surgery in patients with an ADC.

METHODS

All consecutive patients with a non-metastatic ADC treated between 1994 and 2008 were retrospectively assessed. Patients were divided into two groups: surgery group (±pre-operative treatment) versus definitive CRT group.

RESULTS

In surgery and definitive CRT groups, 67 and 79 patients were evaluated, respectively. A complete resection was achieved in 92.5% of patients in surgery group and a clinical complete response was observed in 49.4% of patients in definitive CRT group. Overall survival was 36.2 ± 2.0 months in surgery group versus 16.5 ± 0.8 months in definitive CRT group (P = 0.02). The predictive factors of survival were age (P < 0.01), stage (P = 0.04), WHO performance status (P < 0.01), initial weight loss (P < 0.01), and the treatment group (P < 0.01).

CONCLUSIONS

The results of the study do not support definitive CRT as an alternative to surgery in esophageal ADC treatment. Definitive CRT should be reserved for patients with a major operative risk.

Stage for stage comparison of recurrence patterns after definitive chemoradiotherapy or surgery for oesophageal carcinoma

AIMS

Definitive chemoradiotherapy (dCRT) has been advocated as an alternative treatment for oesophageal carcinoma, but received criticism for perceived poorer locoregional disease control when compared with surgery. The aim of this study was to determine the relative incidence and pattern of oesophageal carcinoma recurrence after dCRT and surgery in patients receiving stage-directed therapy with curative intent.

MATERIALS AND METHODS

In total, 623 consecutive patients with oesophageal carcinoma (207 squamous cell carcinoma, 416 adenocarcinoma) were studied. The primary outcome measure was disease-free survival, adjusted for baseline differences in gender, age and histological cell type.

RESULTS

Three hundred and eleven patients deemed unsuitable for surgery on the grounds of performance status (n = 137), bulky local disease (n = 121) or personal choice (n = 53) received dCRT and 312 surgery (200 received neoadjuvant chemotherapy). Oesophageal carcinoma recurrence was diagnosed in 44.1% of patients after dCRT compared with 40.7% after surgery (P = 0.222). Locoregional recurrence was more common after dCRT than after surgery (24.1% versus 9.3%, P < 0.0001). In contrast, distant metastases were more common after surgery than after dCRT (22.8% versus 12.9%, P = 0.001). The median time to recurrence in patients receiving dCRT and surgery were 15 and 17 months, respectively (P = 0.052). Stage-related disease-free 2 year survival for dCRT versus surgery was: stage I (68.6 versus 85.6%, P = 0.069), stage II (36.9 versus 47.4%, P = 0.011), stage III (31.0 versus 28.6, P = 0.878), stage IVa (21.4 versus 26.3%, P = 0.710).

CONCLUSIONS

These findings provide further support for a randomised trial of dCRT versus surgery in both oesophageal squamous cell carcinoma and adenocarcinoma.

Radiotherapy in elderly patients with inoperable esophageal cancer. Is there a benefit?

BACKGROUND

Radiation oncologists increasingly face elderly cancer patients impaired by comorbidities and reduced performance status. As less data are available for this particular group of patients, the aim of the study was to assess the prognosis of inoperable esophageal cancer patients ≥ 70 years undergoing definitive radiotherapy or radiochemotherapy. PATIENTS AND TREATMENT PROTOCOL: Patients aged ≥ 70 with inoperable carcinoma of the esophagus undergoing definitive radio(chemo)therapy between 1995 and 2006 at the University of Cologne were included retrospectively. Maximal total dose of radiotherapy administered was 63 Gy (5 × 1.8 Gy/week). Chemotherapy consisted of cisplatin (20 mg/m(2) on days 1-5 and days 29-33) and 5-fluorouracil (650-1,000 mg/m(2) on days 1-5 and days 29-33). Efficacy was compared with a cohort of 152 patients < 70 years treated with the same protocol during the same time period.

RESULTS

A total of 51 patients aged  ≥ 70 with inoperable cancer of the esophagus undergoing definitive therapy were identified (stage I/II 23.5%, stage III 56.9%, stage IV 9.8%; squamous cell carcinoma 74.5%, adenocarcinoma 25.5%). While 15 patients (29.4%) received combined radiochemotherapy (RCT), 40 patients (70.6%) were treated with radiotherapy alone (RT). Median progression-free survival (PFS) was 9.5 months; median overall survival (OS) was 13.9 months. Patients treated with RCT had a 2-year OS rate of 53.3% compared with 16.7% for RT patients (p = 0.039). The 2-year OS for clinically lymph node negative patients was 38.5% compared with 21.2% for lymph node positive patients (p = 0.072). Median OS was not significantly different between patients ≥ 70 years versus the patient cohort (n = 152) aged < 70 years (13.9 vs. 7.2 months, p = 0.072) but PFS showed a significant difference (4.9 vs. 9.5 months, p = 0.026) in favor of the > 70 years group.

CONCLUSION

Prognosis in elderly patients with inoperable esophageal cancer undergoing definitive radiotherapy/radiochemotherapy is limited, although it is not inferior to patients < 70 years.

Differences in sensitivity to tumor-specific CTLs between primary and metastatic esophageal cancer cell lines derived from the same patient

PURPOSE

MHC antigens and adhesion molecules, such as the intracellular adhesion molecule (ICAM-I), play an important role in cellular immune response. We examined the expression patterns of these molecules in both primary and metastatic esophageal carcinoma cells from the same patient and evaluated the cellular immune responses against these cells.

MATERIALS AND METHODS

In the esophageal cancer patient (H122), tumor cell lines were established from primary and subcutaneous metastatic lesions. We compared the expression of cell surface molecules on the metastatic tumor cell line (H122SC) with that on the primary tumor cell line (H122ESO) using flow cytometry. Moreover, we analyzed the differences in cellular immune responses against these cell lines, which expressed similar levels of the Tara antigen, using the Tara antigen-specific CTL clone.

RESULTS

H122SC ICAM-1 expression was significantly lower in H122ESO, and the Tara antigen-specific CTL clone produced lower levels of TNF in response to H122SC than H122ESO. ICAM-1 transfection into the H122SC rendered these cells as sensitive to the CTL clone as the H122ESO.

CONCLUSION

The metastatic tumor cells displayed lower regulated ICAM-1 expression levels and were less sensitive to specific CTLs. ICAM-1 downregulation may be one mechanism by which tumor cells escape immunologic surveillance.

Radiation-sensitizing effect of low-concentration docetaxel on human esophageal squamous cell carcinoma cell lines

Esophageal squamous cell carcinoma (ESCC) is more sensitive to radiation and chemotherapy than other cancers of the digestive system, and combined modality therapy may represent a promising treatment method. The radiation-sensitizing effect of docetaxel on ESCC cell lines was investigated. A colony formation assay was performed in which ESCC cell lines (TE2, TE3) and A431 were exposed to docetaxel (from 1.0×10(-11) to 10(-7) M) for 3 h to determine the concentration of docetaxel that was not able to kill individual cells (i.e., the non-cytocidal concentration). Individual cell lines were then exposed to the non-cytocidal concentration of docetaxel prior to, during, and after irradiation to determine whether the timing of docetaxel administration affected cell survival. In addition, flow-cytometry was performed, and the cell cycle was examined prior to and after docetaxel exposure to assess the mechanism of docetaxel as a radiation sensitizer. Docetaxel exhibited a concentration-dependent cytocidal effect, with a different IC(50) for each cell type. Almost no cytocidal effect was observed at the following docetaxel concentrations: A431, ≤1.0×10(-10) M; TE-2 and TE-3, ≤1.0×10(-9) M. Concurrent treatment with docetaxel and radiation tended to decrease cell survival in all the cell lines compared with docetaxel or radiation alone. Cell survival was lowest when the cells were treated using X-ray irradiation after docetaxel exposure (p<0.05). Flow cytometry revealed that in all three cell lines, docetaxel exposure increased the G2/M cell fraction with a higher increase in the cell line that exhibited the highest radiosensitivity. This study demonstrated that the administration of docetaxel at a non-cytocidal concentration prior to radiotherapy produced a synergistic cell-killing effect in SCC cell lines.

Management of esophageal adenocarcinoma

The incidence of esophageal adenocarcinoma is increasing in Western countries with a tendency to exceed that of squamous-cell carcinoma. Prognosis is unfavorable with 5-year survival less than 15%, irrespective of treatment and the stage. At the time of diagnosis, more than two thirds of patients have a non-operable cancer because of extension or associated co-morbidities. Most studies have included different tumoral locations (esophagus and stomach) and different histological types (adenocarcinoma and squamous-cell carcinoma), making it difficult to interpret results. Surgery is currently the standard treatment for small tumors. Surgery should be preceded by neo-adjuvant treatment for patients with locally advanced resectable tumors, either preoperative chemotherapy or preoperative chemoradiation therapy. The therapeutic choice should be decided during multidisciplinary meetings according to patient and tumor characteristics and the expertise of the center. For patients with contraindications to surgery, exclusive chemoradiation therapy is recommended. Herein we reviewed and synthesized the different therapeutic strategies for esophageal adenocarcinoma.

Definitive chemoradiation for oesophageal cancer--a standard of care in patients with non-metastatic oesophageal cancer

AIMS

A retrospective analysis was carried out of 291 cases of oesophageal cancer treated with definitive chemoradiotherapy (dCRT) at a single UK cancer centre between 1995 and 2009. Our protocol consisted of two cycles of neoadjuvant platinum-based chemotherapy followed by two further cycles given concurrently with 50Gy of external beam radiotherapy delivered in 25 fractions over 5 weeks.

MATERIALS AND METHODS

Demographic, patient and outcome data were recorded prospectively through an electronic health record and retrospectively analysed, using appropriate statistical tools.

RESULTS

Data on 266 patients were available for analysis. The median age was 66.6 years, 53% were adenocarcinomas. dCRT was used instead of surgery because of age/co-morbidity in 44% and disease extent in 39%. Ninety-three per cent of patients completed treatment according to protocol. Grade 3 and 4 toxicities were seen in 42 and 7%, respectively. Median survival was 20.6 months; 2, 3 and 5 year survival rates were 43.6, 32.9 and 19.5%, respectively. Advanced disease was associated with a worse outcome. Shorter disease length was associated with a better median survival, but some patients with disease >10cm had long-term disease control. The effect of other patient- and disease-related factors was also analysed.

CONCLUSION

We present data showing that dCRT is well tolerated and should be considered as an alternative to surgery for all patients with locally advanced oesophageal cancer, not only those with co-morbidity. Furthermore, the benefits of dCRT are not confined to carcinomas with squamous histology.

Phase II randomised trial of chemoradiotherapy with FOLFOX4 or cisplatin plus fluorouracil in oesophageal cancer

Background:

Concurrent chemoradiotherapy is a valuable treatment option for localised oesophageal cancer (EC), but improvement is still needed. A randomised phase II trial was initiated to assess the feasibility and efficacy in terms of the endoscopic complete response rate (ECRR) of radiotherapy with oxaliplatin, leucovorin and fluorouracil (FOLFOX4) or cisplatin/fluorouracil.

Methods:

Patients with unresectable EC (any T, any N, M0 or M1a), or medically unfit for surgery, were randomly assigned to receive either six cycles (three concomitant and three post-radiotherapy) of FOLFOX4 (arm A) or four cycles (two concomitant and two post-radiotherapy) of cisplatin/fluorouracil (arm B) along with radiotherapy 50 Gy in both arms. Responses were reviewed by independent experts.

Results:

A total of 97 patients were randomised (arm A/B, 53/44) and 95 were assessable. The majority had squamous cell carcinoma (82% arm A/B, 42/38). Chemoradiotherapy was completed in 74 and 66%. The ECRR was 45 and 29% in arms A and B, respectively. Median times to progression were 15.2 and 9.2 months and the median overall survival was 22.7 and 15.1 months in arms A and B, respectively.

Conclusion:

Chemoradiotherapy with FOLFOX4, a well-tolerated and convenient combination with promising efficacy, is now being tested in a phase III trial.

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.

Histological regression of squamous esophageal carcinoma assessed by percentage of residual viable cells after neoadjuvant chemoradiation is an important prognostic factor

BACKGROUND

Whether the TNM staging system is applicable after neoadjuvant chemoradiation in esophageal cancer is controversial. The aim of this study was to evaluate the prognostic value of histopathological regression of the primary tumor in postchemoradiated patients.

MATERIALS AND METHODS

The pretherapeutic and pathological ypTNM stages of patients who have had neoadjuvant chemoradiation followed by esophagectomy were analyzed. The percentage of residual viable cells of the primary tumor (ypV) and other clinicopathological factors were tested for their prognostic value.

RESULTS

Of 175 recruited patients, 55 (31.4%) achieved pathological complete response. The median survival of these 55 patients was significantly longer than those with other disease stages (124.8 vs 21.1 months) (P < .001). Gender, ypT, ypN, ypTNM, and ypV stage were significant prognostic factors in univariate analysis. In patients without nodal metastases, the median survival in patients with residual viable cells in the primary tumor (ypV+) was 24.6 months, compared with that of 124.8 months in those with no viable cells (ypV0) (P = .043). In those who had nodal metastases, the median survival of patients with ypV0 and ypV+ were 21.2 months and 17.4 months respectively (P = .37). Cox regression analysis showed that male gender, high percentage of residual viable cells (ypV), and positive nodal status (ypN1) were independent predictors of poor prognosis.

CONCLUSIONS

In patients who underwent neoadjuvant chemoradiation therapy, histopathological regression of the primary tumor indicated by percentage of residual viable cells is an important prognostic factor in addition to nodal status and gender.

Prospective comparison of surgery alone and chemoradiotherapy with selective surgery in resectable squamous cell carcinoma of the esophagus

PURPOSE

Esophagectomy remains the mainstay treatment for esophageal cancer, although retrospective studies have suggested that chemoradiotherapy (CRT) is as effective as surgery. To determine whether CRT can substitute for surgery as the primary treatment modality, we performed a prospective direct comparison of outcomes after treatment in patients with resectable esophageal cancer who had received CRT and those who had undergone surgery.

METHODS AND MATERIALS

Eligible patients had resectable T1-3N0-1M0 thoracic esophageal cancer. After the surgeon explained the treatments in detail, the patients selected either CRT (CRT group) or surgery (OP group). The CRT course consisted of two cycles of cisplatin and fluorouracil with split-course concurrent radiotherapy of 60Gy in 30 fractions. Patients with progressive disease during CRT and/or with persistent or recurrent disease after CRT underwent salvage resection.

RESULTS

Of 99 eligible patients with squamous cell carcinoma registered between January 2001 and December 2005, 51 selected CRT and 48 selected surgery. Of the patients in the CRT group, 13 (25.5%) underwent esophagectomy as salvage therapy. The 3- and 5-year survival rates were 78.3% and 75.7%, respectively, in the CRT group compared with 56.9% and 50.9%, respectively, in the OP group (p = 0.0169). Patients in the OP group had significantly more metastatic recurrence than those in the CRT group.

CONCLUSIONS

Treatment outcomes among patients with resectable thoracic esophageal squamous cell carcinoma were comparable or superior after CRT (with salvage therapy if needed) to outcomes after surgery alone.

Aspectos atuais da terapêutica neo-adjuvante no carcinoma epidermóide do esôfago: revisão da literatura

INTRODUÇÃO: O câncer de esôfago é o oitavo tipo de câncer mais incidente na população, com alta letalidade a despeito da melhora do tratamento cirúrgico nas últimas décadas. O carcinoma epidermóide tem maior prevalência em vários países em também no Brasil. Sendo assim, estratégias de tratamento neo-adjuvante tornaram-se objeto de estudo em vários centros mundiais de referência. OBJETIVO: Identificar aspectos atuais da terapêutica neo-adjuvante no tratamento do carcinoma epidermóide do esôfago. MÉTODOS: Revisão bibliográfica de artigos científicos disponíveis no Medline e na base de dados Cochrane cruzando-se os descritores neoplasia esofágicas, cirurgia, quimioterapia, radioterapia. CONCLUSÃO: A estratégia da terapêutica neo-adjuvante é cada vez mais utilizada como forma de oferecer melhores resultados tardios na sobrevida e na qualidade de vida dos pacientes portadores de carcinoma do esôfago.

Safety and outcome of definitive chemoradiotherapy in elderly patients with oesophageal cancer

Little is known about chemoradiotherapy (CRT) in elderly patients with a locally advanced oesophageal cancer (OC). The aim of our study was to evaluate the tolerance and the outcome of elderly patients older than 70 years treated with CRT for a non-metastatic OC. Chemoradiotherapy was based on radiotherapy combined with a cisplatin-based chemotherapy. Clinical complete response (CCR) to CRT was evaluated on upper digestive endoscopy and computed tomography scan 6-8 weeks after CRT completion. One hundred and nine consecutive patients were included. A CCR was observed in 63 patients (57.8%) and 2-year survival was 35.5%. Adverse events > or =grade 3 were observed in 26 (23.8%) patients. Chemotherapy dose reduction, chemotherapy delays more than 1 week, and treatment discontinuation were observed in 33 (30.3%), 45 (41.3%), and 17 patients (15.6%), respectively. Comorbidity index according to Charlson score was significantly associated with treatment tolerance. In multivariate analysis, a CCR to CRT (P<0.01), a dose of radiotherapy > or =80% (P=0.02), and a Charlson score < or =2 (P=0.046) were identified as independent prognostic factors of overall survival. These results suggest that CRT could be considered as an effective treatment without major toxicity in elderly patients with OC.

A phase II trial of chemoradiation therapy with weekly oxaliplatin and protracted infusion of 5-fluorouracil for esophageal cancer

BACKGROUND

Chemoradiation therapy using regimens containing cisplatin and 5-fluorouracil are most commonly used for inoperable cancer of the esophagus. Cisplatin is relatively toxic and is not suitable for many patients. Little data exists using platinum analogues together with protracted infusion 5-fluorouracil and radiation therapy in the curative setting.

METHODS

Fourteen patients with localised oesophageal cancer suitable for curative chemoradiation therapy registered on the study. Chemotherapy consisted of 5-fluorouracil 225 mg/m(2) daily throughout radiation therapy, with oxaliplatin 60 mg/m(2) weekly. The radiation dose was 56 to 60 Gy in 28 to 30 fractions.

RESULTS

The median age of the patients was 70.5 years. Therapy was associated with excessive grade 3 and 4 non-hematologic toxicity. There was one treatment related death. The median progression-free survival was 31.5 months and median overall survival 32.6 months. Six patients achieved a prolonged complete endoscopic and radiological response.

CONCLUSIONS

Although weekly oxaliplatin in combination with infusional 5 fluorouracil produces durable remissions in esophageal cancer, the regimen used in this trial was not acceptable for routine use. Future protocols should incorporate lower chemotherapy doses.

Response to definitive chemoradiotherapy and survival in patients with an oesophageal adenocarcinoma versus squamous cell carcinoma: a matched-pair analysis

OBJECTIVES

The impact of the histological tumour type in patients treated with definitive chemoradiotherapy (CRT) for an oesophageal cancer is not well established. The aim of this retrospective matched-pair analysis was to evaluate the clinical complete response (CCR) to definitive CRT and the outcome between 2 groups of patients.

METHODS

Fifty-seven patients with an oesophageal adenocarcinoma (ADC) were matched according to the tumour stage and the WHO performance as well as the CRT regimen status including 57 patients with an oesophageal squamous cell carcinoma (SCC). CRT was based on radiotherapy combined with a cisplatin-based chemotherapy.

RESULTS

A CCR was observed in 40 patients (70.2%) with an SCC as compared with 26 patients (45.6%) with an ADC (p = 0.013). SCC patients received significantly more of planned cisplatin and radiotherapy doses than ADC patients (82.0 vs. 67.7%, p = 0.042, and 92.5 vs. 84.5%, p = 0.023, respectively). In responders to CRT, local recurrence was significantly more frequent in SCC patients (52.5 vs. 26.9%, p = 0.046). Median survival in all patients as well as in responders to CRT was not different between the 2 groups.

CONCLUSION

Our study showed that treatment completion and CCR to definitive CRT were more frequent in SCC with, however, more local recurrences in these patients. Further studies are required to confirm this difference in response rate to definitive CRT according to histological type of the tumour in oesophageal cancer.

Hedgehog signal activation in oesophageal cancer patients undergoing neoadjuvant chemoradiotherapy

The zinc finger protein glioma-associated oncogene homologue 1 (Gli-1) is a critical component of the Hedgehog (Hh) signalling pathway, which is essential for morphogenesis and stem-cell renewal, and is dysregulated in many cancer types. As data were not available on the role of Gli-1 expression in oesophageal cancer progression, we analysed whether it could be used to predict disease progression and prognosis in oesophageal cancer patients undergoing neoadjuvant chemoradiotherapy (CRT). Among 69 patients with histologically confirmed oesophageal squamous cell carcinomas (ESCCs), 25 showed a pathological complete response after preoperative CRT. Overall survival (OS) was significantly associated with lymph-node metastasis, distant metastasis, and CRT, and was further correlated with the absence of both Gli-1 nuclear expression and residual tumour. All patients with Gli-1 nuclear expression (10.1%) had distant or lymph-node metastasis, and six out of seven died within 13 months. Furthermore, patients with Gli-1 nuclear-positive cancers showed significantly poorer prognoses than those without (disease-free survival: mean DFS time 250 vs 1738 months, 2-year DFS 0 vs 54.9%, P=0.009; OS: mean OS time 386 vs 1742 months, 2-year OS 16.7 vs 54.9%, P=0.001). Our study provides the first evidence that Gli-1 nuclear expression is a strong and independent predictor of early relapse and poor prognosis in ESCC after CRT. These findings suggest that Hh signal activation might promote cancer regrowth and progression after CRT.

Targeting hedgehog in cancer stem cells: how a paradigm shift can improve treatment response

The integration of developmental biology and cancer therapeutics has revolutionized the understanding of tumor proliferation. Cell-signaling pathways first recognized for their importance in embryogenesis have begun to inspire the scientific community to investigate new avenues in cancer initiation and growth. Other ground-breaking discoveries provided evidence for a revisit to the theory of cancer stem cells, which has long-term implications for the efficient and lasting elimination of cancer. This paradigm shift involves a change from viewing the malignant tumor as a perpetually mutating mass of clonogenic cells to seeing it as an organ mistakenly created by mutations that disrupt cell-signaling pathways in stem cells. As researchers find more evidence of the essential involvement of these signaling pathways in cancer formation and maintenance, the link between tumorigenesis and aberrant stem cell activation can be more clearly drawn. One such pathway is the hedgehog (Hh)-signaling pathway, which is important in growth and differentiation during embryogenesis and for proper functioning in many adult tissues. Investigation of this pathway and its involvement in cancer has already led to drug development that could eradicate basal cell carcinoma, the most common type of cancer in humans. Future research focused on Hh and related signaling pathways involved in cancer might improve treatment response in malignancies resistant to traditional therapy.

Concurrent chemoradiotherapy or endoscopic stenting for advanced squamous cell carcinoma of esophagus: a case-control study

BACKGROUND

We evaluated the role of chemoradiotherapy (CRT) for patients with inoperable squamous esophageal cancer.

METHODS

Patients with locally advanced or metastatic squamous esophageal carcinoma who received CRT were recruited. The CRT consists of continuous infusion of 5-fluorouracil at 200 mg/m(2)/day, and cisplatin at 60 mg/m(2) on days 1 and 22, with concurrent radiotherapy for a total of 50 to 60 Gy in 25 to 30 fractions over 6 weeks. Efficacy was assessed by endoscopy and computed tomographic scan before and 8 weeks after completion of the treatment program. Median survival and the need for palliative esophageal stenting were compared with another group of patients who received endoscopic stenting.

RESULTS

From 1996 to 2003, a total of 36 consecutive patients (33 male, mean +/- SD age 63.2 +/- 9.5 years) with T4 disease (81%) with or without cervical nodal metastasis (50%) received CRT, while 36 patients treated with endoscopic stenting alone were recruited as controls. Both groups were comparable in demographics, pretreatment dysphagia score, comorbidities, and tumor characteristics. CRT was completed in 32 patients (89%). There was no treatment-related mortality. Tumor volume was greatly reduced after CRT in 19 patients. Four patients (11%) received salvage esophagectomy 9 to 42 months after CRT. Compared with the stenting group, CRT statistically significantly improved 5-year survival (15% vs. 0%, P = .01), median survival (10.8 months vs. 4.0 months, P < .005), and need for stenting (22% vs. 100%, P = .005).

CONCLUSIONS

Palliative CRT can effectively improve the symptoms of dysphagia in patients with inoperable squamous esophageal carcinoma. It results in better survival compared with endoscopic stenting in these patients.

Baseline nutritional status is predictive of response to treatment and survival in patients treated by definitive chemoradiotherapy for a locally advanced esophageal cancer

OBJECTIVES

To assess the impact of baseline nutritional status on treatment response and survival in nonmetastatic patients with a locally advanced esophageal cancer (LAEC) treated with definitive chemoradiotherapy (CRT).

METHODS

One hundred five patients with LAEC treated by definitive CRT were retrospectively included. The CRT regimen was based on an external radiotherapy (RT) delivered concomitantly to a cisplatin-based chemotherapy (CT). Patients were considered to have a complete response (CR) to CRT when no residual tumor was detected on CT scan and esophagoscopy performed 2 months after the end of CRT. Multivariate analysis of predictive factors of response to CRT and survival were performed using a logistic regression and a Cox model, respectively.

RESULTS

Mean value of baseline nutritional parameters was significantly different between nonresponder (N = 42) and responder (N = 63) patients to CRT (weight loss 10%vs 5.8%, P= 0.0047; serum albumin level 35 g/L vs 38.7 g/L, P= 0.0004; BMI 22.8 kg/m2vs 25.2 kg/m2, P= 0.01). In multivariate analysis, serum albumin level > 35 g/L was the only independent predictive factor of CR to CRT (P= 0.009). Independent prognostic factors of survival were BMI > 18 kg/m2 (P= 0.003), dysphagia Atkinson score <2 (P= 0.008), dose of RT > 50 Grays (Gy) (P < 0.0001) and CR to CRT (P < 0.0001).

CONCLUSIONS

Survival was influenced by baseline nutritional status as well as dysphagia, dose of RT, and CR to CRT. Despite the retrospective design of the study, our results may provide the concept basis for performing a prospective nutritional intervention study in patients treated by definitive CRT for an esophageal cancer.