Geriatric assessment and treatment outcomes in a Dutch cohort of older patients with potentially curable esophageal cancer

BACKGROUND

Patients with potentially curable esophageal cancer can be treated with neo-adjuvant chemoradiotherapy followed by surgery or definitive chemoradiotherapy with curative intent. For frail older patients choosing the appropriate oncological treatment can be difficult, and data on geriatric deficits as determinants of treatment outcomes are not yet available.

OBJECTIVES

To describe the prevalence of geriatric deficits and to study their association with treatment discontinuation and mortality in older patients with potentially curable esophageal cancer.

MATERIAL AND METHODS

A cohort study was conducted in a Dutch tertiary care hospital including patients aged ≥70 years with primary stage I-IVA esophageal cancer. Geriatric screening and assessment data were collected. Outcomes were treatment discontinuation and one year all-cause mortality.

RESULTS

In total, 138 patients with curable esophageal cancer were included. Mean age was 76.1 years (standard deviation 4.7), 54% had clinical stage III and 24% stage IVA disease. Most patients received neo-adjuvant chemoradiotherapy and surgery (41%), 32% definitive chemoradiotherapy and 22% palliative radiotherapy. Overall, one year all-cause mortality was 36%. Geriatric screening and assessment was performed in 94 out of 138 patients, of which 60% was malnourished, 20% dependent in Instrumental Activities of Daily Living (IADL) and 52% was frail. Malnutrition was associated with higher mortality risk (Hazard Ratio, 3.2; 95% Confidence Interval, 1.3-7.7)) independent of age, sex and tumor stage. Seventy-six out of 94 patients were treated with chemoradiotherapy, of which 23% discontinued treatment. Patients with IADL dependency and Charlson Comorbidity Index ≥1 discontinued treatment more often.

CONCLUSION

All-cause mortality within one year was high, irrespective of treatment modality. Treatment discontinuation rate was high, especially in patients treated with definitive chemoradiotherapy. Geriatric assessment associates with outcomes in older patients with esophageal cancer and may inform treatment decisions and optimization in future patients, but more research is needed to establish its predictive value. Trial registration: The study is retrospectively registered at the Netherlands Trial Register (NTR), trial number NL8107. Date of registration: 22-10-2019.

Benefit of chemotherapy based on platinum with definitive radiotherapy in older patients with locally advanced esophageal squamous cell carcinoma

Objective

There is still no definitely therapeutic evidence of a beneficial effect of chemotherapy with radiotherapy for older patients with esophageal squamous cell carcinoma (ESCC). We aim to determine the influence of chemoradiotherapy (CRT) and radiotherapy (RT) alone in patients aged 65 years or older with locally advanced ESCC.

Methods

We retrospectively analyzed 581 ESCC patients who underwent CRT and RT alone. Univariate and multivariate Cox regression analysis was used to analyze the impact of clinical factors on long‐term overall survival (OS) and progression-free survival (PFS). Finally, we compared the toxicity rates of these patients.

Results

The median OS and PFS of the overall population were 23.2 months (2.0–162.6 months) and 18.6 months (1.1–159.6 months). Multivariate Cox regression analysis showed that chemotherapy (p < 0.05), tumor thickness (p < 0.01), and N stage (p < 0.05) were independent prognostic factors associated with both OS and PFS. In the chemotherapy subgroup, patients who received 2–8 cycles of chemotherapy had better OS than those who received 1 cycle (p = 0.015). The results also revealed that the CRT group has better OS and PFS than RT alone group for patients aged 65–74 years (both p < 0.01). However, for patients aged 75 years or older, there was no statistically significant difference between CRT and RT alone (both p > 0.05). Besides, higher staged ESCC has the inferior OS and PFS than lower staged ESCC for patients received RT alone and aged 65–74 years (both p < 0.05). Finally, there were significantly more severe hematologic toxicities in the CRT group than in those treated with RT alone in this study (p < 0.001).

Conclusions

The present study suggested that CRT for locally advanced ESCC in patients aged 65 years or older had a significant benefit over RT alone in terms of OS and PFS. However, for patients aged 75 years or older, there was no statistically significant difference between CRT and RT alone. CRT should be performed with special attention in patients aged 75 years or older.

Correlation between microvessel density (MVD) and multi-spiral CT (MSCT) perfusion parameters of esophageal cancer lesions and the diagnostic value of combined CtBP2 and P16INK4A

Background

This article aims to analyze the correlation between microvessel density (MVD) and multi-spiral CT(MSCT) perfusion parameters of esophageal cancer lesions, and the diagnostic value of combining C-terminal binding protein 2 (CtBP2) and P16 inhibitor of cyclin-dependent kinase 4a (P16^INK4A).

Methods

A total of 42 cases of normal esophageal mucosa tissues >5 cm from the cancer tissue were selected as the control group. The expression levels of CtBP2 and P16^INK4A and the values of MSCT perfusion parameters and MVD were compared in the control group and esophageal cancer group. SP immunohistochemical staining was used to detect protein expression levels of CtBP2 and P16^INK4A. The Pearson method was used to analyze the differences and pertinence of MSCT perfusion parameters and MVD in the control group and esophageal cancer group. The receiver operating characteristic (ROC) curve was used to calculate the diagnostic value of CtBP2 and P16^INK4A combined with MVD and MSCT perfusion parameters in esophageal cancer.

Results

The positive expression rate of P16^INK4A in the esophageal cancer group was significantly lower than that in the control group. The positive expression rates of CtBP2, blood volume (BV), mean transit time (MTT), surface permeability (permeability surface, PS), and MVD values were significantly higher than those of the control group (P<0.05). There was no significant difference in blood flow (BF) value between the 2 groups (P>0.05). The BF value of the tumor invading the fibrous membrane was significantly higher than that of the non-invading fibrous membrane (P<0.05), and the PS and MVD values of the patients with lymph node metastasis were higher than those without lymph node metastasis (P<0.05). The MSCT perfusion parameters BF and BV were significantly positively correlated with MVD (P<0.05), while MTT, PS, and MVD were not significantly correlated (P>0.05). ROC results showed that the areas under curve (AUC) of CtBP2, P16^INK4A, and MSCT were 0.625, 0.747, and 0.812, respectively. However, the area under the combined detection curve was larger, at 0.869.

Conclusions

MSCT perfusion imaging of esophageal cancer lesions can indirectly reflect the angiogenesis of esophageal cancer, and the combination of CtBP2 and P16^INK4A can effectively improve the diagnostic efficiency of the disease.

Evaluation of Definitive Chemoradiotherapy Versus Radical Esophagectomy in Clinical T1bN0M0 Esophageal Squamous Cell Carcinoma

BACKGROUND

The standard treatment for patients with clinical T1bN0M0 esophageal squamous cell carcinoma is radical esophagectomy. Definitive chemoradiotherapy is regarded as a treatment option, and recently, good clinical outcomes of this treatment have been reported. This study compared prognosis after definitive chemoradiotherapy with radical esophagectomy.

METHODS

From January 2011 to December 2019, 68 consecutive patients who were diagnosed clinical T1bN0M0 squamous cell carcinoma were enrolled and investigated retrospectively. Patients were classified into two groups whether treated by surgery or definitive chemoradiotherapy. Survival outcomes were compared, and subsequent therapies after recurrence were also investigated.

RESULTS

Among 68 patients, 39 patients underwent surgery and 29 patients received definitive chemoradiotherapy. No significant difference was noted in overall survival between the two groups. However, the rate of 5-year recurrence-free survival was significantly lower in definitive chemoradiotherapy group than that of surgery group (91.1 vs. 62.7%, hazard ratio 3.976, 95% confidence interval 1.076-14.696, p = 0.039). Patients who had local recurrence after definitive chemoradiotherapy received endoscopic submucosal dissection or photodynamic therapy as salvage therapies, which resulted in no disease progression and a good prognosis.

CONCLUSIONS

Definitive chemoradiotherapy may become a promising alternative therapy comparable with radical esophagectomy in patients with clinical T1bN0M0 esophageal squamous cell carcinoma. Early detection of recurrence by frequent follow-up after definitive chemoradiotherapy is important to control disease within local recurrence, and salvage therapy for local lesions could contribute to long-term survival.

Survival Comparision of Three-dimensional Radiotherapy Alone vs. Chemoradiotherapy for Esophageal Squamous Cell Carcinoma

BACKGROUND AND OBJECTIVE

To compare the survival of esophageal squamous cell carcinoma (ESCC) patients who received chemoradiotherapy (CRT) or radiotherapy (RT) alone.

METHODS

A total of 753 well-matched patients were enrolled. A total of 299 patients were treated with CRT, and 454 patients were treated with RT alone. Propensity score matching (PSM) was performed with the R project. The Kaplan-Meier method was used to calculate survival rates, and the log-rank test was used to assess differences in survival.

RESULTS

The response rate was 99.0% with CRT and 98.3% with RT alone (p = 0.651). The 1-, 3-, 5- and 10 year overall survival (OS) rates were as follows: 72.2, 40.1, 30.7 and 13.9% with CRT, 68.1, 35.2%, 23.3 and 12.5% with RT alone (p = 0.033); 73.4, 40.1, 31.0 and 16.1% with concurrent chemoradiotherapy (CCRT); and 68.1, 35.2, 23.3 and 12.5% with RT alone (p = 0.028). There was no significant difference in OS between the CCRT group and the sequential chemoradiotherapy (SCRT) group (p = 0.527). Consolidation chemotherapy (CCT) after CCRT led to a significant increase in the OS rate compared with no CCT after CCRT (p = 0.003). Compared with the OS of patients who received 1∼2 cycles of CCT, the OS of patients who received 3∼4 cycles of CCT was significantly improved (p = 0.011). Acute toxic effects were more severe in the CRT, but no significant differences in late reactions. CRT exhibited more appetite loss and fatigue symptoms than RT alone, and dysphagia of CRT relief more obviously. The CRT group had a significantly lower rate of local control failure than the RT alone group (p = 0.019).

CONCLUSIONS

For patients with ESCC, CRT led to a significantly improved OS compared to RT alone, and this trend was more obvious with CCRT. CCT after CCRT prolonged OS, especially in patients who received at least 2 cycles of CCT. CRT can reduce the deaths due to local control failure compared to RT alone.

Survival comparision of three-dimensional radiotherapy alone with concurrent chemoradiotherapy for non-surgical esophageal carcinoma

PURPOSE

Radiotherapy is the main treatment method for patients with locally advanced, unresectable esophageal cancer. The aim of this study is to compare overall survival (OS) using 3D radiotherapy (3DRT) alone with concurrent chemoradiotherapy (CCRT) in 296 non-surgical esophageal carcinoma patients.

PATENTS AND METHODS

Over 10 years, of the 480 patients with esophageal carcinoma treated with 3DRT with or without chemotherapy, 148 patients each comprised 3DRT and CCRT groups after propensity score matching.

RESULTS

The 5- and 10-year OS (P=0.337) and PFS (P=0.715) rates for 3DRT alone were 22.0%, 14.4% and 26.1%, 23.2%, respectively, compared with 28.8%, 18.6% and 34.7%, 29.1% for CCRT, respectively. CCRT did not improve 5-year and 10-year OS or PFS in 60-70Gy group (OS: 27.5% and 25.2%; 17.9% and 17.0%, P=0.938; PFS: 38.3% and 31.8%; 31.9% and 27.8%, P=0.890) nor reduce 10-year hematogenous metastasis (31.7% and 28.3%, P=0.698). CCRT improved 5-year OS and PFS of 50.0-59.9Gy group (OS: 33.3% and 12.0%, P=0.029; PFS: 33.1% and 10.6%, P=0.081). For 3DRT, the 5-year OS and PFS rates were significantly better in the 60-70Gy group (P=0.017) compared with 50.0-59.9Gy group (P=0.002). For CCRT group, 5-year OS and PFS favored the 50.0-59.9Gy group, but the difference was insignificant. Major toxicities were greater with CCRT compared with 3DRT.

CONCLUSION

For non-surgical esophageal carcinoma patients, 3DRT combined with CCRT was effective in prolonging both OS and PFS.

Definitive Chemoradiotherapy Versus Trimodality Therapy for Resectable Oesophageal Carcinoma: Meta-analyses and Systematic Review of Literature

BACKGROUND

Standard therapy for loco-regionally advanced, resectable oesophageal carcinoma is trimodality therapy (TMT) consisting of neoadjuvant chemoradiotherapy and oesophagectomy. Evidence of survival advantage of TMT over organ-preserving definitive chemoradiotherapy (dCRT) is inconclusive. The aim of this study is to compare survival between TMT and dCRT.

METHODS

A systematic review and meta-analyses were conducted. Randomised controlled trials and observational studies on resectable, curatively treated, oesophageal carcinoma patients above 18 years were included. Three online databases were searched for studies comparing TMT with dCRT. Primary outcomes were 1-, 2-, 3- and 5-year overall survival rates. Risk of bias was assessed using the Cochrane risk of bias tools for RCTs and cohort studies. Quality of evidence was evaluated according to Grading of Recommendation Assessment, Development and Evaluation.

RESULTS

Thirty-two studies described in 35 articles were included in this systematic review, and 33 were included in the meta-analyses. Two-, three- and five-year overall survival was significantly lower in dCRT compared to TMT, with relative risks (RRs) of 0.69 (95% CI 0.57-0.83), 0.76 (95% CI 0.63-0.92) and 0.57 (95% CI 0.47-0.71), respectively. When only analysing studies with equal patient groups at baseline, no significant differences for 2-, 3- and 5-year overall survival were found with RRs of 0.83 (95% CI 0.62-1.10), 0.81 (95% CI 0.57-1.14) and 0.63 (95% CI 0.36-1.12).

CONCLUSION

These meta-analyses do not show clear survival advantage for TMT over dCRT. Only a non-significant trend towards better survival was seen, assuming comparable patient groups at baseline. Non-operative management of oesophageal carcinoma patients might be part of a personalised and tailored treatment approach in future. However, to date hard evidence proving its non-inferiority compared to operative management is lacking.

The role of definitive chemoradiation in patients with non-metastatic oesophageal cancer

Definitive chemoradiation (dCRT) is a curative treatment option for patients with oesophageal cancer. It is effective in both adenocarcinoma and squamous cell carcinoma. However, locoregional control is less after dCRT compared to preoperative CRT (pCRT) followed by surgery. Also, overall survival is lower compared to pCRT followed by surgery, which can only partly be explained by a negative selection of patients. The optimal dose of radiotherapy remains to be determined, but dose escalation above 50.4Gy might be beneficial. Cisplatinum/5-FU is the most applied concurrent chemotherapy, but carboplatin/paclitaxel seems equally effective with less toxicity. The addition of 5-FU to a taxane and platinum seems promising. Accelerated fractionation and addition of cetuximab did not improve results. dCRT is a successful treatment for regional lymph node recurrences, but less so for recurrences at the anastomotic site. Re-irradiation after prior curative radiotherapy yields poor results. dCRT can be safely used in carefully selected elderly.

Definitive chemoradiation or surgery in elderly patients with potentially curable esophageal cancer in the Netherlands: a nationwide population-based study on patterns of care and survival

BACKGROUND

The aim of our study was to describe treatment patterns and the impact on overall survival among elderly patients (75 years and older) with potentially curable esophageal cancer.

MATERIAL AND METHODS

Between 2003 and 2013, 13,244 patients from the nationwide population-based Netherlands Cancer Registry (NCR) were diagnosed with potentially curable esophageal cancer (cT2-3, X, any cN, cM0, X) of which 34% were elderly patients (n = 4501).

RESULTS

Surgical treatment with or without neoadjuvant treatment remained stable among elderly patients (around the 16% between 2003 and 2013). However, among younger patients, surgical treatment increased from 60.2 to 67.0%. The use of definitive chemoradiation (dCRT) increased in elderly patients from 1.9 to 19.5% and in younger patients from 5.2 to 17.2%. Due to the increase in dCRT, treatment with curative intent doubled in the elderly from 17 to 37.1%. Multivariable Cox regression revealed that elderly patients with an adenocarcinoma receiving surgery alone or dCRT had a significantly worse overall survival compared to those receiving surgery with neoadjuvant chemo (radio) therapy (nCRT/CT) (HR: 1.7 95% CI 1.4-2.0 and HR: 1.9 95% CI 1.5-2.3). However, among elderly with squamous cell carcinoma overall survival was comparable between dCRT, surgery alone and surgery with nCRT/CT.

CONCLUSIONS

Survival was comparable among elderly patients with squamous cell carcinoma who underwent surgery with nCRT/CT, surgery alone or received dCRT, while elderly patients with an adenocarcinoma who underwent surgery with nCRT/CT had a better overall survival when compared with surgery alone or dCRT. Therefore, dCRT can be considered as a reasonable alternative for surgery among potentially curable elderly patients with esophageal squamous cell carcinoma. However, in elderly patients with esophageal adenocarcinoma surgery with nCRT/CT is still preferable regarding overall survival.

Clinical Effect of Radiotherapy Combined with Chemotherapy for Non-Surgical Treatment of the Esophageal Squamous Cell Carcinoma

Background

Chemoradiotherapy (CRT) is widely accepted and is considered a standard treatment, particularly for unresectable and inoperable esophageal squamous cell carcinoma (ESCC). However, the optimal use of the combined modalities of chemotherapy (CT) and radiotherapy (RT) remains controversial. In addition, no consensus has been reached regarding the exact efficacy of consolidation chemotherapy (CCT) and the most appropriate radiotherapy dose.

Material/Methods

Clinical data from 262 ESCC patients treated with CRT (n=165) or RT alone (n=97) were collected and reviewed. The long-term outcomes were analyzed, and treatment related acute toxicity reactions were compared.

Result

The 1-year, 3-year, and 5-year overall survival (OS) rates were 75.3%, 35.6%, and 25.3%, respectively, for the CRT group and 61.5%, 26.7%, and 17.6% for the RT-alone group (P=0.015). The concurrent chemoradiotherapy (CCRT) and sequential chemoradiotherapy (SCRT) groups exhibited similar survival outcomes (for OS, P=0.568; for progression-free survival (PFS,) P=0.145). CCT after CCRT did not influence OS (P=0.236) but was associated with a more favorable PFS (P=0.020). In addition, high-dose of 60–65 Gy tended to prolong OS compared with low-dose (<60 Gy) or excessive-dose (>65 Gy). The incidence of adverse reactions, such as esophagitis and leukopenia, in the CRT group were significantly higher than in the RT-alone group (P=0.019, P=0.001, respectively), and no significant difference was observed between patients treated with CCRT and CCT after CCRT.

Conclusions

Treating non-surgical ESCC patients with CCRT conferred a significant survival benefit compared with RT alone. CCT after CCRT prolongs PFS but does not increase acute toxicity. High-dose (60–65 Gy) CCRT could generate more favorable survival outcomes.

Clinical outcome of elderly patients (≥ 70 years) with esophageal cancer undergoing definitive or neoadjuvant radio(chemo)therapy: a retrospective single center analysis

BACKGROUND

To analyse the outcome of elderly patients (≥70 years) with esophageal cancer treated with curative intent radio(chemo)therapy.

METHODS

Fifty five patients (median 75 years) receiving curative intent radio(chemo)therapy for esophageal cancer from 1999 to 2015 were retrospectively analyzed. Most patients showed locally advanced disease (T3/4:78%, N+:58%) with squamous cell histology (74%). Charlson comorbidity score was > 1 in 27%. 48 patients (87%) received definitive treatment while 7 patients were treated neoadjuvantly. RT was carried out as 3D-conformal treatment or IMRT. Concurrent chemotherapy was applied in 85%, mainly cisplatin/5-FU or mitomycin/5-FU. ¹⁸FDG-PET/CT staging was used in 65%.

RESULTS

Median follow-up was 11 months (1-68) and 21 months in survivors. 1- and 2-year rates of LRC, DC, FFTF and OS were 60%/45, 81%/72, 55%/41 and 46%/26% for the entire cohort. In univariate analysis, addition of surgery was associated with improved LRC and FFTF, nodal involvement with improved DC and lower T stage, lower Charlson score and use of PET-CT with improved OS. In multivariate analysis, lower T stage and lower Charlson score remained significant for OS. Patients treated after 2008 showed a significantly improved FFTF (1-year FFTF 64% vs 35%) and OS (1-year OS 66% vs 24%). Maximum (chemo)radiation related grade3+ toxicity was observed in 80% including 7 deaths (13%). Grade5 toxicity was significantly associated with Charlson score (CS > 1:33% vs CS ≤ 1:5%) and treatment period (24% before vs 3% after 2008). The patients treated after 2008 included significantly more SCCs, less T4 stages, had a higher percentage of PET-CT staging and were treated with smaller field lengths. Trends were also observed for lower Charlson scores and increased use of IMRT.

CONCLUSION

Curative intent (chemo)radiation of elderly patients with esophageal cancer may result in considerable toxicity and unfavorable outcome. However, a clear improvement over time was observed in our cohort, probably based on improved patient selection. In patients with less advanced stages and lower comorbidity similar results as in younger cohorts seem achievable with modern staging and treatment approaches. Age per se should not be a decisive factor, but careful attention should be paid regarding patient selection including a structured and tight follow-up strategy.

Definitive chemoradiotherapy

Definitive chemoradiotherapy (dCRT) is reflecting a treatment standard in oesophageal cancer. For irresectable localised tumours and for inoperable patients, dCRT can change the treatment intent from palliative to curative. In patients with squamous cell carcinoma (SCC), in particular in those of cervical location, dCRT is a proper alternative for treatment that may include radical surgery. Patients with localised locoregional recurrence after primary surgery can survive for long-term after salvage CRT.

Definitive Chemoradiation Therapy for Esophageal Cancer in the Elderly: Clinical Outcomes for Patients Exceeding 80 Years Old

PURPOSE

The optimal treatment approach for patients ≥80 years ("elderly") with esophageal cancer is not well established. We assessed the clinical outcomes in elderly patients treated with definitive chemoradiation therapy (CCRT) at our institution.

METHODS AND MATERIALS

56 consecutive patients ≥80 years with esophageal cancer treated with conventional CCRT between 2001 and 2016 were propensity score matched 1:2 to generate 2 younger patient cohorts treated with CCRT without surgery: "intermediate" (65-79 years, n=112) and "younger" (<65 years, n=112). Treatment related toxicity was assessed using the Common Terminology Criteria for Adverse Events version 4.0. The rates of overall survival (OS) and recurrence-free survival (RFS) were calculated with the Kaplan-Meier method.

RESULTS

The median ages of the 3 cohorts were 81 years (elderly, 80-92 years), 71 years (intermediate, 65-79 years), and 58 years (younger, 20-64 years). The elderly cohort was more likely to have cardiac comorbidities. Although the clinical complete response (cCR) rate deviated significantly among the 3 cohorts, (78%, 72%, and 56%; P=.004), the data failed to identify statistically significant differences among RFS, 2-year, and 5-year OS, or in median survival, which was 15.5 months, 23.6 months, and 20.2 months (P=.468), respectively. The overall severe toxicity rates were 38%, 32%, and 30%, respectively (P=.644), including comparable rate of radiation pneumonitis (P>.05). The elderly cohort, however, did show statistically significant evidence of an increased rate of severe radiation pneumonitis (grade ≥3) which was observed to be 11% versus 4% and 0%, respectively (P=.003).

CONCLUSIONS

The studied elderly population showed evidence of similar long-term clinical efficacy after definitive CCRT when compared with cohorts of younger patients with similar prognostic status. An increased rate of pulmonary toxicity was identified, without evidence of differences for nonpulmonary severe adverse events. Understanding the prognostic risk factors of pulmonary toxicity after CCRT may effectuate improved long-term outcomes for elderly population.

Comparison of cisplatinum/paclitaxel with cisplatinum/5-fluorouracil as first-line therapy for nonsurgical locally advanced esophageal squamous cell carcinoma patients

Background

To retrospectively evaluate the efficacy and toxicity of definitive concurrent chemoradiotherapy (dCRT) with cisplatinum/paclitaxel versus cisplatinum/5-fluorouracil in patients with locally advanced esophageal squamous cell carcinoma (ESCC) who received nonsurgical treatment.

Methods

This study retrospectively evaluated 202 patients with locally advanced ESCC treated at Shandong Cancer Hospital between January 2009 and December 2013. All the patients initially received dCRT, including platinum and paclitaxel or 5-fluorouracil, with concurrent 1.8 or 2 Gy/fraction radiation (total dose, 54–60 Gy). The patient population was divided into two treatment groups: 105 patients who received the cisplatinum/paclitaxel regimen were allocated to group A, and 97 patients who received the cisplatinum/5-fluorouracil regimen were allocated to group B. We compared the progression-free survival (PFS) and overall survival (OS) by various clinical variables, including prior treatment characteristics, major toxicities (mainly in grade 3 and 4 hematological), and response to dCRT. We used the receiver operating curve analysis to determine the optimal cutoff value of clinical stage and radiation dose. The Kaplan–Meier method was used for survival comparison and Cox regression for multivariate analysis.

Results

Median PFS and OS in group A were significantly better compared with group B (median PFS, 15.9 versus 13.0 months, P=0.016 and median OS, 33.9 versus 23.1 months, P=0.014, respectively). The 1- and 2-year survival rates of the two groups were 82.9% versus 76.3%, and 61.9% versus 47.6%, respectively. The complete response and response rate were 17.1% versus 7.2% (P=0.032) and 52.4% versus 30.9% (P=0.042) in group A and B, respectively. Meanwhile, group B was associated with a significantly lower rate of grade 3/4 overall toxicity than group A (P=0.039).

Conclusion

Our data showed that patients with locally advanced ESCC in group A had longer PFS and OS compared with group B. Cisplatinum/paclitaxel can be considered a good candidate chemotherapy regimen for patients with locally advanced ESCC who are being treated with nonsurgical therapy.

Intensity modulated radiotherapy (IMRT) with concurrent chemotherapy as definitive treatment of locally advanced esophageal cancer

Background

To report our experience with increased dose intensity-modulated radiation and concurrent systemic chemotherapy as definitive treatment of locally advanced esophageal cancer.

Patients and methods

We analyzed 27 consecutive patients with histologically proven esophageal cancer, who were treated with increased-dose IMRT as part of their definitive therapy. The majority of patients had T3/4 and/or N1 disease (93%). Squamous cell carcinoma was the dominating histology (81%). IMRT was delivered in step-and-shoot technique in all patients using an integrated boost concept. The boost volume was covered with total doses of 56-60 Gy (single dose 2-2.14 Gy), while regional nodal regions received 50.4 Gy (single dose 1.8 Gy) in 28 fractions. Concurrent systemic therapy was scheduled in all patients and administered in 26 (96%). 17 patients received additional adjuvant systemic therapy. Loco-regional control, progression-free and overall survival as well as acute and late toxicities were retrospectively analyzed. In addition, quality of life was prospectively assessed according to the EORTC QLQs (QLQ-OG25, QLQ-H&N35 and QLQ-C30).

Results

Radiotherapy was completed as planned in all but one patient (96%), and 21 patients received more than 80% of the planned concurrent systemic therapy. We observed ten locoregional failures, transferring into actuarial 1-, 2- and 3-year-locoregional control rates of 77%, 65% and 48%. Seven patients developed distant metastases, mainly to the lung (71%). The actuarial 1-, 2- and 3-year-disease free survival rates were 58%, 48% and 36%, and overall survival rates were 82%, 61% and 56%. The concept was well tolerated, both in the clinical objective examination and also according to the subjective answers to the QLQ questionnaire. 14 patients (52%) suffered from at least one acute CTC grade 3/4 toxicity, mostly hematological side effects or dysphagia. Severe late toxicities were reported in 6 patients (22%), mostly esophageal strictures and ulcerations. Severe side effects to skin, lung and heart were rare.

Conclusion

IMRT with concurrent systemic therapy in the definitive treatment of esophageal cancer using an integrated boost concept with doses up to 60 Gy is feasible and yields good results with acceptable acute and late overall toxicity and low side effects to skin, lung and heart.

A comparison of carboplatin and paclitaxel with cisplatinum and 5-fluorouracil in definitive chemoradiation in esophageal cancer patients

BACKGROUND

In esophageal cancer (EC) patients who are not eligible for surgery, definitive chemoradiation (dCRT) with curative intent using cisplatinum with 5-fluorouracil (5-FU) is the standard chemotherapy regimen. Nowadays carboplatin/paclitaxel is also often used. In this study, we compared survival and toxicity rates between both regimens.

PATIENTS AND METHODS

This multicenter study included 102 patients treated in five centers in the Northeast Netherlands from 1996 till 2008. Forty-seven patients received cisplatinum/5-FU (75 mg/m(2) and 1 g/m(2)) and 55 patients carboplatin/paclitaxel (AUC2 and 50 mg/m(2)).

RESULTS

Overall survival (OS) was not different between the cisplatinum/5-FU and carboplatin/paclitaxel group {[P = 0.879, hazard ratio (HR) 0.97 [confidence interval (CI) 0.62-1.51]}, with a median survival of 16.1 (CI 11.8-20.5) and 13.8 months (CI 10.8-16.9). Median disease-free survival (DFS) was comparable [P = 0.760, HR 0.93 (CI 0.60-1.45)] between the cisplatinum/5-FU group [11.1 months (CI 6.9-15.3)] and the carboplatin/paclitaxel group [9.7 months (CI 5.1-14.4)]. Groups were comparable except clinical T stage was higher in the carboplatin/paclitaxel group (P = 0.008). High clinical T stage (cT4) was not related to OS and DFS in a univariate analysis (P = 0.250 and P = 0.201). A higher percentage of patients completed the carboplatin/paclitaxel regimen (82% versus 57%, P = 0.010). Hematological and nonhematological toxicity (≥grade 3) in the carboplatin/paclitaxel group (4% and 18%) was significantly lower than in the cisplatinum/5-FU (19% and 38%, P = 0.001).

CONCLUSIONS

In this study, we showed comparable outcome, in terms of DFS and OS for carboplatin/paclitaxel compared with cisplatinum/5-FU as dCRT treatment in EC patients. Toxicity rates were lower in the carboplatin/paclitaxel group together with higher treatment compliance. Carboplatin/paclitaxel as an alternative treatment of cisplatinum/5-FU is a good candidate regimen for further evaluation.