Salvage Treatment in Locoregional Recurrent Esophageal Carcinoma (EC) Using Intensity Modulated Radiation Therapy - Helical Tomotherapy (IMRT-HT)

Abstract

Purpose/Objectives: Patients with locally advanced esophageal carcinoma are recommended to undergo treatment with radiation and chemotherapy, which may be followed by surgery in appropriate operative candidates. Radiation has traditionally been delivered with 3D conformal radiation therapy (3D CRT). This study is evaluating early outcomes and acute and late toxicity in patients treated with Intensity Modulated Radiation Therapy (IMRT) with concurrent chemotherapy. Materials/Methods: This is a retrospective review of 17 patients with esophageal carcinoma treated with IMRT and chemotherapy from 2008 2010. Pathology includes squamous cell and adenocarcinomas. Tumor sites include middle thoracic, lower thoracic and GE junction. Initial clinical stages are TX-T3, N0-3, and M0-1. All patients received at least one cycle of concurrent 5-fluorouracil with either cisplatin or oxaliplatin. IMRT dose was 50.4 Gy in 28 fractions prescribed to a target volume which included the tumor and regional lymphatics. All IMRT plans utilized coplanar beams in a 7-9 beam arrangement. Results: Median follow-up is 9 months (range, 4-20). Median patient age is 72 (range, 55-87). Sixteen patients received 50.4 Gy via an IMRT plan, and one received 25.2 Gy. Trimodality treatment was completed in 11 patients (65%). Surgery was either esophagogastrectomy or minimally invasive esophagectomy. Of the 11 patients who proceeded to surgery, 3 (27%) had a pathologic complete response, 7 (64%) had a partial response (PR) and 1 patient (9%) had stable disease. Of the 6 patients who received chemotherapy and IMRT alone, 2 patients had a clinical PR, 1 had disease progression, and 3 did not have follow-up data available. In the initial 17 patients, there were no local or regional recurrences, though 2 patients developed distant metastases. Twelve patients are alive at last follow-up. Of the 5 deaths, 2 were due to esophageal cancer, 1 from radiation complications, 1 from chemotherapy complications, and 1 from surgical complications. Acute CTCAE V4.0 grade 3 toxicities from concurrent chemotherapy and IMRT developed in the following patients: 2 esophagitis, 1 fatigue, 1 nausea/vomiting, 4 dehydration, 1 anemia, 1 thrombocytopenia and 5 neutropenia. Patients with grade 4 toxicities included 1 thrombocytopenia and 1 neutropenia. Four patients developed late grade 3 esophageal strictures. There was one grade 4 cardiac complication, and one grade 5 pleuro-esophageal fistula. There were no cases of radiation pneumonitis or ulcers. Conclusions: IMRT is a feasible treatment modality, which may be equally efficacious to 3D CRT for the treatment of esophageal carcinoma, and may offer fewer treatment complications, including a lower incidence of pneumonitis. Author Disclosure: K.V. Kowalchik: None. G. Kim: None. E. Johnson: None. N. Paryani: None. S. Ko: None.