Abstract
BackgroundThis study evaluated patterns of treatment failure (especially locoregional failure; LRF) after radical esophagectomy and proposes a clinical target volume (CTV) for postoperative radiotherapy (PORT) among patients with thoracic esophageal squamous cell carcinoma (SCC).MethodsAll patients who were followed up in our center after radical esophagectomy between 2007 and 2011 were retrospectively enrolled. The patterns of first discovered failure were assessed, and LRFs (including anastomotic and regional lymph node recurrences) were evaluated to determine whether our proposed PORT CTV encompassed these areas. The clinicopathologic factors predictive of lymphatic recurrence type were analyzed.ResultsOf the 414 patients who underwent surgery and were followed up over the study, 207 experienced recurrent or metastatic diseases. The median time to progression was 11.0 months. Of the 173 patients with locoregional recurrence, nodal failure recurred in 160; supraclavicular and superior mediastinal lymph nodes had the highest metastasis rates. All 233 recurrent sites across the 160 patients were located in a standard CTV area, including the bilateral supraclavicular areas, the entire mediastinum, and the left gastric lymphatic drainage region. A total of 203 sites (87.2%) were located in either the bilateral supraclavicular areas or the entire mediastinum, and 185 sites (79.4%) were located in either the bilateral supraclavicular areas or the upper mediastinum. A multivariate analysis revealed the lymph node metastatic ratio (LNMR) and tumor differentiation were risk factors for nodal failure.ConclusionsLocoregional recurrence (especially lymph node recurrence) was the most common and potentially preventable type of initial treatment failure after curative surgery among patients with thoracic esophageal SCC. The proposed PORT CTV covered most LRF sites. The lymphatic drainage regions for PORT are selective, and the supraclavicular and superior mediastinal areas should be considered. However, the value of PORT and the extent of CTV should be investigated in further prospective studies.
Highlights
Surgery is the most important initial treatment for patients with thoracic esophageal squamous cell carcinoma (SCC)
The recurrence rate of SCC is as high as 40%–50% after radical surgery [1], and locoregional recurrence is the major cause of treatment failure [2,3], even among patients with a pathologically complete response to neoadjuvant chemoradiotherapy [4]. van Hagen et al [5] indicated that overall survival (OS) and local tumor control could be improved using neoadjuvant chemoradiotherapy, which is already used at many institutions
postoperative radiotherapy (PORT) should be strongly considered for certain patients with esophageal SCC; selecting patients for adjuvant radiotherapy (RT) can be problematic
Summary
Surgery is the most important initial treatment for patients with thoracic esophageal squamous cell carcinoma (SCC). Van Hagen et al [5] indicated that overall survival (OS) and local tumor control could be improved using neoadjuvant chemoradiotherapy, which is already used at many institutions This standard suggests that postoperative radiotherapy (PORT) should not play an important role in SCC treatment. SCC comprises more than 90% of the esophageal cancer cases in East Asia, and tumors located in the upper and middle thoracic esophagus are most commonly observed In these cases, neoadjuvant radiotherapy often increases the difficulties associated with surgery due to tissue edema and hemorrhage. This study evaluated patterns of treatment failure (especially locoregional failure; LRF) after radical esophagectomy and proposes a clinical target volume (CTV) for postoperative radiotherapy (PORT) among patients with thoracic esophageal squamous cell carcinoma (SCC)
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