Bilateral Supraclavicular Regions Research Articles

Clinical Implementation and Evaluation of Automated Contouring for Breast Malignancies.

As breast radiotherapy becomes more conformal, precise target delineation is increasingly important. Multiple atlases are available to provide uniformity, but contouring remains resource intensive and prone to variation. Automated contouring has been investigated to reduce planning time and standardize contouring practices. Herein, we investigate a model trained to autocontour RADCOMP breast regional nodal targets using a small, highly curated set of manual contours. The contours for 15 patients previously treated on the RADCOMP study were edited per the RADCOMP atlas guidelines including bilateral supraclavicular region (SCR), posterior triangle, axilla, breast, and internal mammary nodes (IMN). A 3D U-Net architecture was trained on these volumes to autocontour each structure. For validation, 20 new cases were autocontoured with this model. The autocontours were independently scored for accuracy by three physicians on a 5-point modified Likert scale. A score of 3 indicated that there were edits that the reviewer judged as clinically important, but it was more efficient to edit the automatically generated contours than start without an autocontour. A score of 4 indicated differences were stylistic and not clinically significant. A score of 5 indicated that contours were clinically acceptable without stylistic changes. To evaluate time saved, a breast specialist radiation oncologist first edited the autocontours, then manually contoured bilateral target regions of interest on 5 cases. Finally, these edited contours were objectively compared with unedited autocontours for similarity using Dice Similarity Coefficient (DSC) and Mean Surface Distance (MSD). Twenty retrospectively autocontoured cases were evaluated by 3 physicians for clinical appropriateness. Mean Likert scores for each OAR were as follows: L Breast: 3.6, R Breast: 3.4, L Axilla: 4.0, R Axilla: 3.9, L IMN: 3.6, R IMN: 3.6, L Posterior Triangle: 4.0, R Posterior Triangle: 3.9, L SCR: 3.8, and R SCR: 3.8. For the timed portion of the study, the mean time spent editing autocontours for clinical appropriateness was 5 minutes and 43 seconds ± 64.4 seconds, while the mean contouring time when manually contouring was 11 minutes and 36 seconds ± 50.1 seconds (p<0.001; paired t-test). Average DSC and MSD values measuring differences between pre and post clinical edits were 0.99 and 0.3mm, 0.99 and 0.2mm, 0.93 and 0.3mm, 0.97 and 0.2mm and 0.92 and 0.3mm for Breast, Axilla, IMN, SCR, and posterior triangle, respectively. This study demonstrates that a small and carefully curated dataset can train an autocontouring model that is subjectively useful, time efficient, and objectively accurate. Future studies using the RADCOMP Atlas may benefit from autocontouring to standardize treatment or streamline central verification of treatment planning.

PNEUMORACHIS FROM ASTHMA EXACERBATION: A RARE COMPLICATION

PNEUMORACHIS FROM ASTHMA EXACERBATION: A RARE COMPLICATION

Postoperative Concurrent Chemoradiotherapy for Locally Advanced Thoracic Esophageal Squamous Cell Carcinoma: A Phase II Clinical Trial.

BackgroundThis study aims to investigate the efficacy and safety of postoperative intensity-modulated radiotherapy (IMRT) covering partial regional lymph node areas combined with chemotherapy for locally advanced thoracic esophageal squamous cell carcinoma patients.MethodsThis was a single-center, single-arm phase II clinical trial that began in 2014. Patients who underwent radical transthoracic resection within 3 months and were histologically confirmed esophageal squamous cell carcinoma (pT3-4 or N+, M0 determined according to AJCC Guidelines, Edition 7) were recruited. Postoperative radiotherapy was performed with a total dose of 50.4Gy in 28 fractions using IMRT. Clinical target volumes (CTVs) included tumor bed, anastomosis, bilateral supraclavicular region, and superior mediastinal lymph nodes. Synchronous chemotherapy for 2 cycles (paclitaxel 150mg/m2, day1; Cisplatin 25mg/m2, day1-3; every 4 weeks), followed by 2 cycles of consolidation chemotherapy with the same regimen. The primary endpoint was the 2-year local control rate, and the secondary endpoints were overall survival (OS) and adverse events (AEs).ResultsA total of 75 eligible patients were included from 2014 to 2017. The 2-year LRFS rate, as the primary endpoint, was 73.3%. The 1-year and 3-year OS rates were 88.0% and 68.0%, respectively. Local recurrence occurred in 13/75 (17.4%) patients, of which 2.7% (2/75) were extra-target lymph nodes. Grade 4 adverse events reported in this study included 10 cases (13.3%) of neutropenia, 1 case (1.3%) of anemia, and 2 cases (2.7%) of thrombocytopenia, without toxic-related deaths. Almost all (96%) patients completed the entire postoperative radiotherapy course, and 62 (82.7%) patients completed at least 2 cycles of chemotherapy.ConclusionPostoperative IMRT (clinical target volume including tumor bed, anastomosis, bilateral supraclavicular region, and superior mediastinal lymph nodes) combined with synchronous chemotherapy in patients with locally advanced thoracic esophageal squamous cell carcinoma was well tolerated, with a high local control rate and a low probability of recurrence outside the irradiation field.Clinical Trial Registration https://clinicaltrials.gov/ChiCTR1900022689.

The Prognosis and Feasibility of Extensive Clinical Target Volume in Postoperative Radiotherapy for Esophageal Squamous Cell Carcinoma: A Phase II Clinical Trial

BackgroundThis trial aims to explore the feasibility and safety of postoperative radiotherapy covering all regional lymph node areas for locally advanced thoracic esophageal squamous cell carcinoma patients treated with intensity-modulated radiation therapy (IMRT).MethodsThis was a single-center single-arm, phase II clinical trial initiated in 2014. Patients who were treated with radical transthoracic resection and had negative margins within 3 months and histologically confirmed esophageal squamous cell carcinoma (pT3-4 or N+, M0 determined by the 7th edition of the AJCC guidelines) were recruited in this trial. Postoperative radiotherapy was performed with a total dose of 40 Gy in 20 fractions using IMRT. Clinical target volumes (CTVs) included the tumor bed, anastomosis, bilateral supraclavicular region, mediastinal lymph nodes, left gastric lymph nodes and celiac trunk lymph nodes. The primary endpoint was the 2-year local control rate, and the secondary endpoints were overall survival (OS) and adverse events (AEs).ResultsA total of 70 eligible patients were recruited from 2014 to 2016. The 2-year local control rate, as the primary endpoint, was 67.3%. In addition, the median OS was 57.0 months, with 1-year and 3-year OS rates of 92.8% and 60.9%, respectively. Among the patients, 28/40 (40%) developed locoregional recurrence, with 25.7% involving hematogenous recurrences. All reported AEs occurred during the course of IMRT or within 6 months thereafter. None of them suffered grade 4 hematological or nonhematological AEs. Nearly all patients completed the entire course of postoperative radiotherapy, with a completion rate of 97.1%.ConclusionFor an extensive target volume, 40 Gy is feasible and shows acceptable toxicity in patients with locally advanced thoracic esophageal squamous cell carcinoma, although the local recurrence rate is relatively high. Our findings provide a basis for further exploration of high-dose radiation with extensive CTV combined with chemotherapy.Clinical Trial Registration[http://www.clinicaltrials.gov/ct2/results?cond=&term=NCT02384811&cntry=&state=&city=&dist=], identifier [NCT02384811].

Efficacy and Safety of Large-field Postoperative Radiotherapy Using Three-dimensional Radiation Technique for Local Advanced Thoracic Esophageal Squamous Cell Carcinoma: A Phase II Clinical Trial

This trial aimed to explore the feasibility and safety of large-field postoperative radiotherapy for locally advanced (T3-4 or N+, M0) esophageal cancer using three-dimensional radiation technique. This trial is a single-center single-arm, phase II clinical trial initiated in 2014. Patients who underwent a radical transthoracic resection with negative margins within 3 months and histologically confirmed as esophageal squamous cell carcinoma (pT3-4 or N+, M0 according to AJCC 7th) were eligible for this study. Radiotherapy was delivered with total dose of 40Gy in 20 fractions using three-dimensional conformal radiation technique including conformal and intensity modulated radiotherapy. TV included tumor bed, anastomosis site, bilateral supraclavicular region, all mediastinal lymph node site, left gastric and celiac trunk lymph node site. The primary endpoint was 2-year local control rate. The secondary endpoint was overall survival (OS) and adverse events. 70 patients were enrolled in this phase II study from 2014 to 2016. The majority of patients were Ilia (40%), IIIA (27.1%) and IIIB (27.1%). 17 patients died. The 2 year-local control rate is 67.29%. Median OS was 57months. The 1, 2, 3 and 4-year OS rate were 92.75%, 69.57%, 60.87%, 53.47%. Locoregional recurrence was found in 28 patients (40%), most of which in mediastinal lymph node region (16 patients) and supraclavicular lymph node region (10 patients), followed by anastomosis (5 patients), celiac lymph node region (3 patients). 18 patients (25.7%) was found hematogenous recurrence. Nearly all patients complete the whole course postoperative radiotherapy with the completion rate of 97.1%, except for two patients. Although the tumor volume is relatively high with the median PTV volume of 1273.22cm3, despite the average dose of the heart is slightly higher, the dose volume histogram parameters of the other normal tissue and organ dose-volume are relatively ideal. Incidences of acute grade 3 hematological toxicity including 4(5.7%) leukopenia and 1(1.4%) neutropenia. In term of acute grade 3 nonhematological toxicity, nausea and vomiting (7.1%) were the most frequent AE followed by fatigue (2.8%) and radiation induced pneumonitis (1.4%). Nobody suffered grade 4 hematological or nonhematological AE. A No late AE occurred. This study is the first phase II study of postoperative radiotherapy in three-dimensional era, which proves that the dose distribution of large-field radiation is feasible and the toxicity is acceptable. It provides a basis for further exploration of higher dose large-field radiation and combined chemotherapy.

Effect and Toxicity of Bilateral Supraclavicular Lymph Node Irradiation on Stage III Lower Thoracic Esophageal Cancer After Radical Surgery

Surgery is the most important treatment for patients with lower thoracic esophageal squamous cell carcinoma (LTEC). Treatment failures, especially loco-regional recurrence involving mediastinal, abdominal, and supraclavicular lymph nodes area, are common after radical esophagectomy. Post-operative radiotherapy (PORT) has been demonstrated to benefit patients with stage III disease. However, whether bilateral supraclavicular lymph node radiotherapy should be included in the clinical target volume (CTV) remains unclear for those patients with lower thoracic esophageal cancer. So, we aim to explore whether PORT including the bilateral supraclavicular region can reduce the recurrence of supraclavicular lymph node, prolong overall survival and control distant metastasis in patients with stage III LTEC. We retrospectively analyzed 79 patients with stage III LTEC who had undergone radical surgery and PORT between 2010 and 2014. Among these patients, 51 patients received PORT which CTV excluding the bilateral supraclavicular lymph node region (Group A), and the remaining 28 patients received PORT which CTV including the supraclavicular region (Group B). Clinical outcomes (including local control, survival time, side-effects and prognostic factors) were analyzed with SPSS 25.0. Follow-up to August 2016, the 1-, 2-, and 3-year supraclavicular lymph nodes metastasis rates were 15.7%, 41.2%, 45.1% in Group A, 10.7%, 10.7%, 10.7% in Group B. The median overall survival (OS) of Group A and Group B were 25 and 24.5 months respectively. Univariate and multivariate analysis indicated that radiotherapy to the supraclavicular region decreased supraclavicular lymph node recurrence (p = 0.007/0.016, respectively) but did not prolong OS (p = 0.273/0.324) or control distant metastasis (p = 0.760/0.804). Our data also indicated that PORT including the supraclavicular region was not associated with the increase of radiotherapy-related complications (all p > 0.05). PORT including the bilateral supraclavicular region can reduce the recurrence of supraclavicular lymph node in patients with stage III LTEC without increase of treatment-related toxicities. However, PORT including bilateral supraclavicular region failed to prolong OS or control distant metastasis. Further prospective studies are warranted.

Diffuse epithelioid angiosarcoma of the oral cavity: clinical, radiological and immunohistochemical presentation of a case

Event Abstract Back to Event Diffuse epithelioid angiosarcoma of the oral cavity: clinical, radiological and immunohistochemical presentation of a case Fedora Della Vella1*, Paolo Callea1, Claudia Laudadio1, Eliano Cascardi1, Loren Duda1 and Massimo Petruzzi1 1 University of Bari Aldo Moro, Interdisciplinary Department of Medicine, Italy Aim. Angiosarcomas are extremely rare tumors arising in vascular endothelium. They comprise only 1-2% of soft tissues sarcomas and usually occur in the skin and subcutis, or in visceral sites such as breast, liver and great vessels. Metastatic spread via bloodstream at the time of diagnosis is common.Epithelioid angiosarcoma (EA) is a poorly differentiated morphological variant of this sarcoma, with a histological carcinoma-like aspect. Thirty-three percent out of all angiosarcomas are EA. The literature reports about 1% of angiosarcomas arising in the mouth and in rare cases are a metastatic manifestation. To date about 30 cases of primary oral angiosarcomas are reported. Metastatic involvement of the lung (90%) is more common than primary pulmonary involvement. In the literature at least 3 cases of primary maxillary angiosarcomas with pulmonary metastasis were recorded. Nevertheless, there are no radiological and immunohistochemical differences between PPA and metastatic angiosarcoma of the lung. Materials and Methods. A 46 years-old female patient referred to the Department of Oral Medicine of the Policlinico in Bari, in February 2018, for investigation and management of multifocal gingival and mucosal lumps. The patient had first noticed swellings during November 2017, which quickly enlarged and increased in number. Her recent past medical history revealed the presence of respiratory distress linked to a suspect pulmonary tumor. In December 2017 she got a thoracoabdominal CT scan, that showed multiple masses scattered all over the right pulmonary ileum-mediastinum and in the lower lobe of the lung. Abnormal regional lymph nodes were also displayed by the CT. A bronchoscopy with transbronchial biopsy was performed. This exam revealed a histological diagnosis of "undifferentiated carcinoma of the lung/possible adenocarcinoma". At the time of our first visit, the patient was pale, asthenic, hyper-pyretic and in weight loss. Intra-oral examination revealed soft, red-bluish exophytic masses localized on the premolars regions gingiva and on the hard and soft palate. The neoplasms with bleeding tendency caused dysphagia and hindered oral hygiene practices. Full laboratory investigations including complete blood count (CBC), assessment of liver and renal functions, EKG, HIV-test, OPG X-Ray, and head and neck CT scan were requested. Kaposi Sarcoma, haematological malignancies, oral melanoma, sarcomas and metastatic localization of other neoplasms were considered in differential diagnosis. HIV- test was negative, OPG X-Ray did not show pathological signs, while the CT scan evidenced multiple nodular lesions bordering the right maxillary sinus floor, and multiple lymphadenopathies in submandibular, deep-superficial lateral cervical and bilateral supraclavicular regions. CBC revealed normocytic anaemia (Hgb=8.7 g/dl) and neutrophilic leucocytosis (WBC=21,11 x103/uL). The haematological check excluded a diagnosis of leukaemia and other blood neoplasms. Blood transfusion was given in order to perform the biopsy of the oral lesions. Results. Two different oral lesions were biopsied in order to obtain a definitive diagnosis. The histological exam revealed a malignant tumor with epithelioid cells characterized by strong pleomorphism and abnormal vasoformative growth pattern. Immunohistochemical investigations showed immunoreactivity for CD31, CD10, VIII Factor, R-Ag, FLI-1, while S-100, CD45, TTF-1, Melan-A, HMB45, EMA, CD56, CD34, CD30, AE1/AE3 CKs, 7CK, synaptophysin and chromogranin were negative. A diagnosis of Epithelioid Angiosarcoma was provided and the revised histological pulmonary exam agreed with our diagnosis. The patient underwent to weekly chemotherapy treatment at the Oncology Department in Bari, according to the current protocols. To date, the patient is still receiving the polychemotherapy. Discussion. The present study reports a rare case of oral EA and its complex diagnostic pathway. The angiosarcomas’ clinical, radiological and histological resemblance to other neoplasms, makes the immunohistochemical exam mandatory, in order to provide a correct diagnosis. The prognosis of this tumor is poor: life expectance ranges from 6 months to 3 years. Debate exists about the elective treatment for this neoplasm. Polychemotherapy and radiotherapy are usually provided in association with the surgical treatment, when it is viable.

Characteristics of the local recurrence pattern after curative resection and values in target region delineation in postoperative radiotherapy for lower thoracic esophageal squamous cell cancer.

BackgroundThe aim of this study was to investigate the patterns and influencing factors of local‐regional recurrence of lower thoracic esophageal squamous cell carcinoma (TESCC) after curative resection and to delineate the clinical target volume (CTV) of postoperative radiotherapy (PORT).MethodsFrom January 2009 to December 2013, the clinical data of patients who experienced local‐regional recurrence after curative esophagectomy were collected and analyzed to determine local‐regional recurrence patterns and to evaluate whether a proposed T‐shaped PORT CTV could cover regions of local‐regional failure.ResultsA total of 108 patients were eligible for this study. All patients experienced postoperative recurrence of lower TESCC. The time to local‐regional failure varied from one to 52 months (average 13.4 ± 11.0). Among the 108 patients, 127 recurrence sites were detected as the first recurrence event: 37 cases in the bilateral supraclavicular region, 56 in the upper mediastinum, 14 in the middle mediastinum, 15 in the upper abdominal lymph nodes, and five cases of anastomotic recurrence. The proposed PORT CTV could successfully cover 89 (82.4%) out of the 108 recurrences and 84.2% of the sites (107/127) of recurrence in our sample.ConclusionLocal‐regional recurrence of lower TESCC is mainly distributed in the supraclavicular, upper‐middle mediastinum, anastomotic stoma, and upper abdominal lymph node regions. The proposed T‐shaped PORT CTV field could cover over 80% of local‐regional failure in our sample; therefore, we suggest that PORT should focus on this area.

Effect of bilateral supraclavicular lymph nodes irradiation in stage III lower thoracic esophageal squamous cell carcinoma after radical surgery.

e15555 Background: Surgery is the most important treatment for patients with lower thoracic esophageal squamous cell carcinoma (LT-ESCC) at stage III, but the locoregional failure is common, especially mediastinal and supraclavicular lymph nodes metastases. Postopearative radiotherapy (PORT) is benefit for those patients. However, the clinic target volume (CTV) remains controversial, especially whether or not including bilateral supraclavicular lymph nodes radiotherapy. Methods:79 patients of lower LT-ESCC at stage III who had undergone radical surgery and PORT were enrolled. 51 patients received the PORT CTV without bilateral suparclavicular lymph nodes region (group A), while 28 patients received the CTV with suparclavicular region (group B). Results: Totally, 26 patients had the tumor recurrences of supraclavicular lymph nodes. Among them, 23(45.1%) patients had the metastasis in group A, 3(10.7%) patients had the metastasis in group B. Univariate analysis showed the bilateral supraclavicular region RT can decrease of supraclavicular lymph nodes recurrence (p = 0.007). However, it could not prolong the overall survival (p = 0.273) or control the distant metastasis (p = 0.760).The Cox analysis revealed it was independent factor to control supraclavicular lymph node recurrence (HR = 0.027; 95 % CI 0.068-0.757; p = 0.016). PORT includingsupraclavicular region didn’t increase the radiotherapy complications, such as radiation pneumonia (p = 0.354), radiation esophagitis (p = 0.456), gastrointestinal reaction (p = 0.809), neutropenia (p = 0.470), thrombocytopenia (p = 0.137) and anemia (p = 0.642). Conclusions:PORT including bilateral supraclavicular region can reduce the metastasis of supraclavicular lymph nodes in LT-ESCC at stage III, and it does not increase radiotherapy complications. However, it can’t prolong OS or control the distant metastasis. Chemotherapy is essential to control distant metastasis and prolong OS.

Prognostic analysis of thoracic esophageal carcinoma treated with postoperative prophylactic radiotherapy

Objective To investigate the effect of the extent of postoperative prophylactic radiotherapy after radical surgery on the long-term survival in patients with thoracic esophageal carcinoma. Methods A retrospective analysis was performed on the clinical data of 201 patients with thoracic esophageal cancer who received postoperative prophylactic radiotherapy after radical surgery from 2000 to 2007. The effect of the extent of radiotherapy on survival was evaluated, and the possible prognostic factors were subjected to multivariate Cox regression analysis. The Kaplan-Meier method was used to calculate overall survival (OS) rates, and the log-rank test was used for survival difference analysis. Results The 5-year follow-up rate was 97.0%. The OS rates for patients who received radiotherapy to the whole mediastinum, whole mediastinum+lymph nodes along the left gastric artery, whole mediastinum+bilateral supraclavicular regions, upper and middle mediastinum+bilateral supraclavicular regions, and whole mediastinum+bilateral supraclavicular regions+lymph nodes along the left gastric artery were 21.7%, 37.1%, 38.7%, 34.8%, and 19.8%, respectively (P=0.406). Multivariate analysis showed that postoperative N stage was the independent prognostic factor (P=0.009). After prophylactic irradiation, metastases to the supraclavicular lymph nodes, lymph nodes in the upper and middle mediastinum, and abdominal lymph nodes were observed in 11, 34, and 10 patients, respectively. Conclusions The extent of postoperative prophylactic radiotherapy after radical surgery for thoracic esophageal carcinoma only includes upper and middle mediastinum and bilateral supraclavicular regions. Key words: Esophageal neoplasms; Postoperative prophylactic radiotherapy; Lymph nodes metastases; Prognostic analysis

Multiple symmetrical lipomatosis (Madelung’s disease) : Lipomatose simétrica múltipla (doença de Madelung)

A male patient, 47 years old, white, without comorbidi-ties, alcoholic for 20 years, presented to this unit with a complaint of bulging in the bilateral supraclavicular region, painless, which had been progressively growing for the past five years.At physical examination, he showed good overall status, with bilateral supraclavicular mass of soft consistency, pain -less, measuring 10 × 6 cm to the left and 12 × 8 cm to the right (Fig. 1A). The computed tomography (CT) confirmed the presence of a symmetrical supraclavicular mass, whose density was compatible with fat (Fig. 1C). The mass was sur-gically removed, and the anatomopathological analysis of the specimen evidenced the presence of lipomatosis (Figs. 1D, 1E, 1F). To date, the patient has progressed well with-out recurrence, and outpatient follow-up has been main-tained (Fig. 1B).

290P - Brown Fat Seen on FDG PET/CT is Increased in Breast Cancer Patients Compared to their Age- and Weight-Matched Controls With Other Cancers

ABSTRACT Purpose We previously found increased brown fat deposits in mammary tissue of Rrca1 mutant breast cancer mouse models suggesting a potential role of brown fat environment in the early breast tumorigenesis. The goal of the current human study is to test the hypothesis that the prevalence of brown fat activity seen on FDG PET/CT is increased in breast cancer (BC) patients. Methods We conducted a retrospective study to assess the distribution and intensity of brown fat activity on FDG PET/CT in female BC patients compared to age- and weight-matched control subjects with other cancers mostly colon cancer. We analyzed 124 FDG PET/CT scans of BC patients done at the University of Maryland and 124 age- and weight-matched control subjects who had FDG PET/CT scan on the same day for staging of other cancers (the majority were colon cancer). Results The prevalence of brown fat was higher in BC (12.9% or 16/124) than in their age- and weight-matched control subjects (5.6% or 7/124) (p 50 years of age, there was no difference in brown fat prevalence between BC patients and controls (5.4% or 5/93 vs 4.4% or 4/91; p = NS), respectively. Brown fat was more commonly identified in the bilateral supraclavicular regions in BC patients than controls (22 vs 6, p = 0.049). There was no difference in the intensity of brown fat between the 2 groups (mean SUV max = 3.5 ± 1.5 in BC vs 3.4 ± 0.7 in controls, p = NS). Conclusion The prevalence of brown fat seen on FDG PET/CT is increased in BC patients compared to their age- and weight-matched controls with other cancers, particularly in patients aged Disclosure All authors have declared no conflicts of interest.

Severe Tracheal Compression Due to Cervical Aortic Arch Aneurysm

We report a left-sided cervical aortic arch (CAA) aneurysm that severely compressed the trachea resulting in respiratory insufficiency. A 59-year-old man was referred to our hospital because of a few years history of inspiratory obstruction without dysphagia. Enhanced computed tomography revealed severe tracheal stenosis caused by a large CAA aneurysm. As the location of the aneurysm was located between the left carotid artery and the left subclavian artery, we planned to approach the aneurysm resection via a median sternotomy extending to the bilateral supraclavicular region. Total arch replacement was performed and the tracheal compression was relieved. The postoperative course was uneventful and the tracheal stenosis was gradually decreased by 12 months after surgery.

Target Determination of Postoperative Radiotherapy for Thoracic Esophageal Carcinoma Based on the Data of a Prospective Randomized Trial

To explore the pattern of lymph node metastases and failure sites of radical resected thoracic esophageal carcinoma (TEC), and to determine the proper target for postoperative radiotherapy. Between Sep. 1986 and Dec. 1997, 549 patients with TEC who had undergone radical resection were randomized into surgery alone (S) group and surgery plus radiotherapy group. Radiotherapy was begun 3-4 weeks after surgery. The irradiation regimen was 50-60 Gy in 25-30 fractions over 5-6 weeks given to the bilateral supraclavicular region and whole mediastinum. The 1-, 3- and 5-year overall survival (OS) rates were 75.1%, 41.2% and 31.5% of patients with either intrathoracic or intraabdominal lymph node metastases, which were higher than 66.3%, 22.5% and 16.3% of those with the both regions involvement. The median survival time was 27 months and 19 months, respectively (p = 0.0132). If only patients with ≥2 positive nodes in S group were selected to eliminate the influence of radiotherapy and positive nodes number, the 5-year OS was 24.8% and 4.9% of patients with node metastases in the one and two regions, respectively (p = 0.0458). For patients with tumors of the upper, mid- and lower thoracic esophagus, the median number of resected nodes was 13, 17 and 20 (p < 0.05), and the rate of para-esophageal node metastases was 61.5%, 65.6% and 64.9% (p > 0.05) in patients with positive nodes. In S group, the failure rate at the mediastinum and supraclavicular region was 26.7% and 16.7% for upper TEC, 29.8% and 14.3% for mid-TEC. The recurrence rate at the anastomosis was 16.7% for upper TEC, which was significant higher than that for mid- and lower TEC (3.1% and 7.7%). For TEC patients who undergo radical resection, the OS is worse for those with more lymph node regions involvement. The rate of para-esophageal node metastases in patients with positive nodes is high regardless of the site of primary tumor. The mediastinum and supraclavicular region for tumors of the upper and mid-thoracic esophagus, as well as the anastomosis for tumors of the upper thoracic esophagus, have high recurrence rate and should be included in radiotherapy.

Comparison of Efficacy of Regional and Extensive Clinical Target Volumes in Postoperative Radiotherapy for Esophageal Squamous Cell Carcinoma

To compare and analyze the effect of different clinical target volumes (CTVs) on survival rate after postoperative radiotherapy (RT) for esophageal squamous cell carcinoma (SCC). We studied 102 patients who underwent postoperative RT after radical resection for esophageal SCC (T3/4 or N1). The radiation dose was > or =50 Gy. In the extensive portal group (E group, 43 patients), the CTV encompassed the bilateral supraclavicular region, all mediastinal lymph nodes, the anastomosis site, and the left gastric and pericardial lymphatic. In the regional portal group (R group, 59 patients), the CTV was confined to tumor bed and the lymph nodes in the immediate region of the primary lesion. The 1-, 3-, and 5-year survival rates were compared between the groups, and multivariate/univariate analysis for factors predicting survival was studied. For the entire group, the 1-, 3- and 5-year survival rates were 76.3%, 50.5%, and 42.9%, respectively (median survival, 30 months). The 1-, 3-, and 5-year survival rates were 76.5%, 52.1%, and 41.3%, respectively, in the E group and 76.2%, 49.2%, and 44.6%, respectively, in the R group (not significant). According to the multivariate analysis, N stage, number of lymph nodes with metastatic disease, and tumor length were the independent prognostic factors for survival. Using a regional portal in postoperative RT for esophageal SCC is not associated with compromised survival compared with extensive portal RT and therefore should be considered. N stage, number of affected lymph nodes, and tumor length predict poor survival.

A STUDY ON PULMONARY CHANGES INDUCED BY COMBINED RADIATION AND ANTITUMOR AGENTS

Combined radiotherapy and chemotherapy have been recently carried out effectively to have a good prognosis in malignant lymphoma and small cell carcinoma of the lung. This treatment has been often said to be complicated by bilateral diffuse interstitial pneumonitis, which is sometimes fatal.In this study, bilateral diffuse interstitial pneumonitis was recognized in 10 cases with malignant lymphoma (7 cases) and primary lung cancer (3 cases), treated by combined radiotherapy and chemotherapy. No bilateral diffuse interstitial pneumonitis could be discovered in cases without combined chemotherapy. Mediastinum was irradiated in 8 cases and bilateral supraclavicular region in 6 cases. Radiation doses were ranged from 25 to 60 Gy.Cyclophosphamide (CPM) was given to 9 cases ranging from 1050 mg to 9900 mg. Vincristine (VCR) was given to 9 cases from 1 mg to 9 mg. ACNU was given to one case 100 mg. Antitumor agents were given before or after radiotherapy, or concurrently.This pneumonitis was observed in the period 30 to 130 days after onset of radiotherapy and 25 to 100 days after onset of chemotherapy.These patients had a low grade fever (<38°C), dyspnea and shortness of breath frequently, and rarely had rales or leucocytosis.Chest radiographs were characterized by bilateral diffuse interstitial changes or hazy, homogeneous shadows. Ga-67 scannings were positive in 5 cases performed at the time of development of pneumonitis. Six patients were dead from this pneumonitis without improvement after injection of antibiotics and steroid.Mouse lung induced by combined radiation and antitumor agents was histologically investigated. Mice were irradiated 2000 R or 4000 R to the left hemithorax. CPM, Adriamycin (ADM) and Rinderon (RD) were given to them intraperitoneally.Both CPM and ADM could enhance the lung damage. Histopathologic pictures induced by combined radiation and antitumor agents were characterized not only by alveolar thickening with cellular accumulation, but also by exudate into alveolar lumen. RD was effective in controlling exudate into alveolar lumen at the time of 4 weeks after radiation.In view of the low incidence of pulmonary toxicity and the benefit of improving tumor response, combined radiotherapy and chemotherapy should be carried out. However, it should be kept in mind that fatal pneumonitis could be occurred as a complication of combination therapy.