Cell Carcinoma Of Thoracic Esophagus Research Articles

Impact of Interval Between Neoadjuvant Chemoradiation and Surgery Upon Morbidity and Survival of Patients with Squamous Cell Carcinoma of Thoracic Esophagus.

The present study aimed to determine the effects of intervals between neoadjuvant chemoradiotherapy (nCRT) and esophagectomy on therapeutic outcomes in patients with locally advanced esophageal squamous cell carcinoma (ESCC). We analyzed data from 134 consecutive patients who were diagnosed with locally advanced ESCC of the thoracic esophagus and were treated by nCRT followed by esophagectomy between September 2003 and September 2015. We assigned the patients to groups A and B according to whether they underwent esophagectomy ≤8 or >8 weeks after nCRT. The two groups were comparable in terms of age, gender, performance status, comorbidities, tumor location, clinical stage, R0 resection rates and pathological responses to nCRT. The incidences of pneumonia and respiratory failure were significantly higher in group B (p=0.03, p=0.009, respectively). Recurrence-free (RFS) and overall (OS) survival rates did not significantly differ between the two groups. However, RFS was significantly poorer among patients with R0 resection (p=0.04) and those of cStages III and IV (p=0.009) in group B. Esophagectomy should proceed within eight weeks after nCRT from the viewpoints of respiratory morbidity and impact of RFS on patients with R0 resection.

Comparison of different treatment modalities in node-positive patients after radical resection for squamous cell carcinoma of the thoracic esophagus

Objective To compare the efficacy between different modalities in the treatment of positive lymph nodes after radical resection for squamous cell carcinoma of thoracic esophagus (TESCC), and to explore the best treatment mode. The Kaplan-Meier method was used to calculate survival rates. The log-rank test and Cox model were used for univariate and multivariate prognostic analyses, respectively. Methods A retrospective analysis was performed among 548 patients with TESCC who were admitted to our hospital and had positive lymph nodes after radical resection. The efficacy of different treatment methods was evaluated. Propensity scores (PSM) were used to make 1-to-1 patient matching between different treatment groups to further analyze and figure out the best treatment model for patients. The Kaplan-Meier method was used to calculate the overall survival (OS) and disease-free survival (DFS) rates. The log-rank test was used for survival analysis and univariate prognostic analysis. The Cox regression model was used for multivariate prognostic analysis. Results In all patients, the 1-, 3-, and 5-year OS rates were 79.9%, 38.1% and 28.5%, respectively, while the 1-, 3-, and 5-year DFS rates were 68.5%, 39.8% and 32.5%, respectively. After 1-to-1 matching based on PSM, there were no differences in general clinical pathological data between the four groups. After PSM, there were significant differences in 1-, 3-, and 5-year OS and DFS rates between the surgery alone group, the postoperative radiotherapy group, the postoperative chemotherapy group, and the postoperative chemoradiotherapy (POCRT) group (P=0.000, 0.000). There were significant differences in OS and DFS rates between patients with stage N1, N2, and N3 disease (P=0.000, 0.000). The result of the Cox multivariate analysis showed that treatment method and N staging were two independent prognostic factors for OS and DFS (P=0.001, 0.000, 0.025, 0.016). Conclusions Patients with positive lymph nodes after radical resection for TESCC have a poor prognosis. Moreover, the prognosis becomes worse with the increase in metastatic lymph nodes. POCRT may improve the survival in those patients. Prospective studies are needed to further confirm those conclusions. Key words: Esophageal neoplasms/surgery; Esophageal neoplasms/postoperative adjuvant therapy; Prognosis; Propensity score matching

A phase II trial of neoadjuvant chemotherapy with docetaxel/cisplatin/capecitabine in thoracic esophageal squamous cell carcinoma.

TPS216 Background: The Optimal care for resectable squamous cell carcinoma of thoracic esophagus is uncertain. Effecacy of cisplatin-based two agent chemotherapy as neoadjuvant treatment remains limited. The combination of docetaxel, cisplatin, and capecitabine (DCX) for squamous cell carcinoma of thoracic esophagus in neoadjuvant set has not been investigated. Here, we conducted a phase II study to assess the efficacy and safety of neoadjuvant chemotherapy with modified DCX followed by surgery in patients with resctable thoracic Esophageal Squamous Cell Carcinoma. Methods: This is a single-arm prospective phase II study in Chinese patients. The main inclusion criteria are as follows: 1) Histologically proven squamous cell carcinoma of thoracic esophagus, T2-3, N0-2, T4aN0, M0 (UICC 7th edition); 2) age: 18-75 years, ECOG PS 0-1; 3) Enteral or parenteral feeding planned before the start of treatment if oral calorie intake < 1200 kcal; 4) written informed consent. Neoadjuvant modified DCX regimen consists of docetaxol 60mg/m2 iv d1 and cisplatin 30mg/m2 iv d1-2 and capecitabine 850mg/m2 bid po d1-14 repeated every 21 days for 4-6 cycles, followed by Ivor Lewis Esophagectomy. Primary endpoint is 2-year overall survival rate. Key secondary endpoints include pathological response, R0/1 resection rate, disease free survival , safety and QOL by EORTC QLQ-C30. This study is recruiting in The Sixth Affiliated Hospital of Sun Yat-sen University and registered as NCT02915965. Clinical trial information: NCT02915965.

Impact on Radiological and Pathological Response with Neoadjuvant Chemoradiation and Its Effect on Survival in Squamous Cell Carcinoma of Thoracic Esophagus.

Neoadjuvant chemoradiation (NCRT) has been shown to improve survival in patients with locally advanced esophageal squamous cell carcinoma (SCC). The aim of the present study was to evaluate the role of 18-FDG PET-CT in predicting pathological response to NCRT. We assessed 70 patients of esophageal SCC who underwent NCRT and were evaluated with baseline and post chemoradiation 18F-FDG PET-CT scan. Receiver operating characteristic (ROC) curve was generated by analyzing the sensitivity and specificity of different cut-off points for defining a positive test and their ability to predict pathological complete response. Univariate and multivariate analysis were performed using log-rank and Cox proportional hazards models, and survival curves were estimated using the Kaplan-Meier method. Radiological and pathological complete response was achieved in 44.3% (n=31) and 34.3% (n=24) patients, respectively. Using ROC curves, post-treatment standardized uptake value (SUV) max [3.25, area under curve (AUC) 0.752] and % change in SUVmax cut-off value (72.32%, AUC 0.705) was used to predict pathological response. Significant associations between pathological response in primary tumor and post chemotherapy/radiotherapy SUVmax values (p=0.016), % change in SUVmax (p=0.006), radiological response in primary (p=0.006), and grade of dysphagia at presentation (p=0.041) were observed. Mean overall survival and relapse free survival was 83 and 58%, respectively at 34months. 18F-FDG PET-CT can be used to predict pathological response to NCRT in locally advanced SCC.

Antegrade dissection and systemic lymph node dissection for squamous cell carcinoma of thoracic esophagus

Antegrade dissection and systemic lymph node dissection for squamous cell carcinoma of thoracic esophagus

Multimodality management of squamous cell carcinoma of thoracic esophagus

Most patients with esophageal cancer have advanced disease at presentation. The efficacy of surgical resection alone is often unsatisfactory in patients with stage III or more advanced cancer according to the seventh edition of UICC staging system for esophageal cancer. The systematic multidisciplinary treatment is important. Mounting evidence indicates that preoperative concurrent chemoradiotherapy is the most effective induction therapy to down-stage tumor and increase radical resection rate. For the esophageal squamous cell carcinoma patients with multi-stations and multi-fields lymph node metastasis, preoperative induction chemotherapy would be a viable option. For locally advanced cancers which have been surgically resected, postoperative adjuvant radiotherapy maybe helpful to improve local control for the insufficient surgical dissection. The role of adjuvant chemotherapy also needs further studies. Thoracic esophageal squamous cell carcinoma and lower esophageal adenocarcinoma which is common in western countries are different. We need more prospective clinical studies to establish our treatment modalities for esophageal cancer.

Radically resected node-negative squamous cell carcinoma of thoracic esophagus: recurrence pattern and indication for adjuvant therapy

Results Recurrence happened in 45 patients (40.2%) after operation. Median time to recurrence was 17.4 months. Locoregional relapse was the major recurrence type, detected in 38 patients (33.9%). Distant metastasis alone occurred in only 3 patients (2.7%). All locoregional relapse were in lymph nodes except for 1 (2.6%) at the anastomosis. Altogether, lymph node metastasis accounted for 82.2% of all recurrence. In the 37 cases of lymph node metastasis, the most common sites were neck (56.8%) and superior mediastinum (24.3%). Locoregional relapse was significantly related to tumor location (upper-mid thoracic 41.1% vs. lower thoracic 11.1%), cell differentiation (poor 40% vs. mid-well 25.5%), and depth of invasion (T3-4a 47.1% vs. T1-2 13.6%) (p < 0.05). Upon multivariate analysis, tumor location (p = 0.049, RR 1.092) and depth of invasion (p = 0.017, RR 3.296) were revealed as independent risk factors, with cell differentiation of borderline significance (p = 0.068, RR 1.613). Conclusions Although completely resected together with extended lymph node clearance, 40% of the patients free of lymph node involvement at the time of surgery would still develop recurrence. And the most common recurrence pattern was still locoregional, mainly involving lymph nodes in the cervico-thoracic junction. Greater risk of local relapse is associated with higher location of tumor and deeper depth of invasion. Thus, adjuvant therapy should be studied in high risk patients, including those with poor differentiation tumors.

Dose-escalated image-guided radiation and weekly cisplatin for inoperable squamous cell carcinoma of thoracic esophagus.

e15120 Background: This study evaluates feasibility, toxicity and early outcomes of image guided volumetric modulated arc therapy (IG-RA) and weekly cisplatin for locally advanced inoperable squamous cell carcinoma (LAI-SCC) of thoracic esophagus. Methods: 41 patients diagnosed with LAI-SCC were included. Patients with performance status (ECOG) more than 1, involvement of cervical esophagus or gastroesophageal junction, distant metastasis were excluded from study. Radiotherapy was planned in two phases to a dose of 5940cGy. Phase I CTV was generated by expanding the GTV-primary craniocaudally(CC) by 4cm and laterally to include electively, the corresponding level mediastinal nodes. In the Phase II, GTV was expanded by 2cm CC and 1cm radially. ITV was generated by expanding the CTV by 0.5cm which was then expanded by 0.5cm to yield PTV. Chemotherapy consisted of 4-6 cycles of weekly cisplatin 40mg/m2. Results: The median age of patients was 53 yrs (43-72). The median length of involvement was 6cm with 80% of lesions in upper and middle third. 37/41(90%) patients completed planned chemotherapy with atleast 4 cycles of cisplatin and 40/41 patients completed full dose of radiotherapy. 10% of patients required tube feeding and 5% required hospital admission for supportive care. Endoscopy at 8 weeks post treatment was performed in 38/41 patients of whom 53% had CR, 42% had PR and 5% had stable disease locally. With a median follow up of 19 (6-32) months, 41% of total patients (17/41) are alive at last follow-up of which 32% (13/41) are disease free with no dysphagia, the 1 and 2 year overall survival are 70% and 40% respectively and median survival of 14 months. 16% alive patients have post radiotherapy stricture. The analysis of CBCT and KV image data sets showed a significant intra-fraction and inter-fraction motion of the target. The ITV and PTV margins of 0.5cm each were found to be adequate with current imaging protocol. Conclusions: IG-RA to a dose of 60Gy with concurrent weekly cisplatin is a feasible treatment option for LAI-SCC of thoracic esophagus with low acute and late toxicity and with promising early clinical outcomes. The ITV and PTV margins of 0.5cm were found to be adequate only with image guidance.

Adjuvant chemotherapy versus surgery alone for esophageal squamous cell carcinoma: a meta-analysis of randomized controlled trials and nonrandomized studies

The effect of adjuvant chemotherapy on survival of patients with thoracic esophageal squamous cell carcinomas is still controversial, and the subgroup of patients who will most likely benefit from the adjuvant chemotherapy on long-term survival has not yet been identified clearly. Studies published from 1995 to May 2012 were searched in Medline, Embase, PubMed, Cancerlit, the Cochrane Library, CNKI and major scientific meetings. Randomized controlled trials and nonrandomized studies comparing surgery plus adjuvant chemotherapy with surgery alone in patients with resectable thoracic esophageal squamous cell carcinomas were included. Eleven studies with a total of 2047 patients were identified, consisting of the adjuvant chemotherapy arm (n = 887) and surgery-alone arm (n = 1160). There was not statistically significant benefit on 3-year overall survival for adjuvant chemotherapy (risk ratio [RR] = 0.89, 95% confidence interval [CI], 0.72 to 1.09; P = 0.25). Adjuvant chemotherapy could significantly prolong the 1-year disease-free survival (DFS) (RR = 0.68, 95%CI, 0.51 to 0.89; P = 0.006), but not 3-year DFS (RR = 0.97, 95%CI, 0.73 to 1.29; P = 0.84). Further analysis showed that patients with stage III-IV diseases could benefit from adjuvant chemotherapy on 3-year overall survival (RR = 0.43, 95%CI, 0.31 to 0.61; P = 0.00001), but not in the case of patients with stageI-IIdiseases (RR = 1.12, 95%CI, 0.65 to 1.93; P = 0.68). Additionally, patients with positive lymph node could benefit on 5-year DFS from adjuvant chemotherapy (RR = 0.79, 95%CI, 0.64 to 0.99; P = 0.04). The modality treatment with adjuvant chemotherapy for patients with squamous cell carcinoma of thoracic esophagus might be determined according to pathological stage or the status of lymph node metastasis.

A Prospectively Randomized Study of Clinical Target Volume Margins for 3-dimensional Conformal Radiation Therapy in Patients With Squamous Cell Carcinoma of Thoracic Esophagus

A Prospectively Randomized Study of Clinical Target Volume Margins for 3-dimensional Conformal Radiation Therapy in Patients With Squamous Cell Carcinoma of Thoracic Esophagus

Neoadjuvant Concurrent Chemoradiation Therapy Followed by Definitive High-dose Radiation Therapy or Surgery for Operable T3 Squamous Cell Carcinoma of Thoracic Esophagus

Neoadjuvant Concurrent Chemoradiation Therapy Followed by Definitive High-dose Radiation Therapy or Surgery for Operable T3 Squamous Cell Carcinoma of Thoracic Esophagus

A multi-centered randomized controlled study of neo-adjuvant chemoradiotherapy followed by surgery versus surgery alone for locally advanced squamous cell carcinoma of esophagus: an interim analysis

To evaluate the safety and validity of neo-adjuvant chemoradiotherapy followed by surgery for locally advanced esophageal carcinoma. Patients with IIB, III staged squamous cell carcinoma of thoracic esophagus were randomly allocated to either preoperative chemoradiotherapy followed by surgery (arm A) or surgery alone (arm B). In arm A, chemotherapy and radiotherapy were performed concurrently. Patients received two cycles of vinorelbine and cisplatin. Vinorelbine at 25 mg/m(2) per day was administered as a bolus infusion at d1, d8, d22 and d29. Cisplatin at 75 mg/m(2) was administered by an intravenous infusion at d1 and d22 (or 25 mg/m(2) days 1 - 4 and 22 - 25). A total radiotherapeutic dose of 40 Gy was delivered in 20 daily fractions of 2.0 Gy each (5 d/wk for 4 weeks). Three-incisioned esophagectomy was performed at Weeks 4 - 6 after chemoradiotherapy. Primary outcome was overall survival time. An interim analysis was performed in June 2011. From July 2007 to June 2011, 123 eligible patients were randomly assigned at 7 cooperative cancer centers (54 cases in arm A vs 69 cases in arm B). In arm A, the clinical response rate of chemoradiotherapy was 90.7%. All patients finished the preoperative chemoradiotherapy. Forty-nine cases continued to receive esophagectomy. The pathological complete response rate was 29.6%. The rate of R0 resection in arm A was significant higher than that in arm B(96.0% vs 85.5%, P = 0.015). The most common grade 3/4 toxicity of chemoradiotherapy was leukopenia occurring in 33 cases (61.1%). Vomiting and esophagitis were usually of Grade 1/2. No patient died or abandoned surgery because of chemoradiation toxicity. Between arms A and B, operative duration, blood loss, duration of chest tube drainage and length of postsurgical hospital stay were similar. The incidences of postoperative heart failure (2.0% vs 1.4%, P = 1.000), anastomotic leakage (8.2% vs 11.6%, P = 0.759) and hoarseness (6.1% vs 4.3%, P = 0.691) were not significantly different. The incidence of pulmonary infection in arm A was slightly higher than that in arm B (8.2% vs 1.4%, P = 0.094). No perioperative deaths occurred in either group. There were no significant differences in overall survivals at 1, 2 years between arms A and B (85.6%/75.5% vs 79.1%/66.1%, P = 0.207). The disease-free survivals at 1, 2 years in arm A were slightly higher than in arm B (86.6%/83.2% vs 70.9%/61.8%, P = 0.075). Neo-adjuvant chemoradiation followed by surgery may achieve a high clinical response rate and pathologic complete tumor regression rate. It significantly increases the R0 resection rate and down stage the esophageal cancer patients. But its ultimate efficacy awaits further follow-up studies.

A Prospective Evaluation of Staging and Target Volume Definition of Lymph Nodes by 18FDG PET/CT in Patients With Squamous Cell Carcinoma of Thoracic Esophagus

To determine an optimal standardized uptake value (SUV) threshold for detecting lymph node (LN) metastases in esophageal cancer using (18)F-Fluorodeoxyglucose positron emission tomography/computer tomography (18FDG PET/CT) and to define the resulting nodal target volume, using histopathology as a "gold standard." Sixteen patients with esophageal squamous cell carcinoma who underwent radical esophagectomy and three-field LN dissection after 18FDG PET/CT and CT scans were enrolled into this study. Locations of LN groups were recorded according to a uniform LN map. Diagnostic performance of different SUV thresholds was assessed by receiver operating characteristic analysis. The optimal cutoff SUV was determined by plotting the false-negative rate (FNR) and false-positive rate (FPR), the sum of both error rates (FNR+FPR), and accuracy against a hypothetical SUV threshold. For each patient, nodal gross tumor volumes (GTVNs) were generated with CT alone (GTVNCT), PET/CT (GTVNPET), and pathologic data (GTVNpath). GTVNCT or GTVNPET was compared with GTVNpath by means of a conformity index (CI), which is the intersection of the two GTVNs divided by the sum of them minus the intersection, e.g., CICT&path=GTVNCT&path/(GTVNCT+GTVNpath-GTVNCT&path). LN metastases occurred in 21 LN groups among the 144 specimens taken from the 16 patients. The area under the receiver operating characteristic curve was 0.9017±0.0410. The plot of error rates showed a minimum of FNR+FPR for an SUV of 2.36, at which the sensitivity, specificity, and accuracy were 76.19%, 95.93%, and 93.06%, respectively, whereas those of CT were 33.33%, 94.31%, and 85.42% (p values: 0.0117, 0.7539, and 0.0266). Mean GTVNCT, GTVNPET, and GTVNpath were 1.52±2.38, 2.82±4.51, and 2.68±4.16 cm3, respectively. Mean CICT&path and CIPET&path were 0.31 and 0.65 (p value=0.0352). Diagnostic superiority of PET/CT at an SUV threshold of 2.36 over CT has potential value in nodal target volume definition, but whether this can contribute to better treatment outcomes needs prospective analyses of recurrences in a larger cohort of patients.

Evaluation of the seventh TNM classification system in patients with esophageal cancer receiving chemoradiotherapy.

83 Background: The new 7th edition of the TNM classification system is based on pathologic data of esophageal cancer underwent surgery alone. No report is available on the prognostic evaluation of the new staging system in patients treated with chemoradiotherapy (CRT). The objective of this study was to evaluate the prognostic impact of the 7th edition of the TNM staging system in esophageal cancer patients treated with CRT. Methods: A retrospective review was performed of 301 consecutive patients who met the following inclusion criteria: (1) squamous cell carcinoma of thoracic esophagus; (2) total radiation dose ≥ 50 Gy; (3) concomitant chemotherapy consisting of 5-fluolouracil and platinum; (4) no previous thoracic radiotherapy or surgery. We compared the prognostic impact of the 6th and 7th editions of the TNM staging systems. Also, we compared the prognostic impact of stage group and prognostic group, which was newly defined in the 7th edition. Survival analysis was performed by using log-rank and Cox regression testing. Results: Patients with stage I/II/III/IV were 52/42/54/153 and 57/46/128/70 according to 6th and 7th edition, respectively. Eighty-four patients were shifted to a lower stage in 7th edition compared with 6th edition, and most of these were from stage IV to III (n = 74). There were significant differences among stages I to III (p &lt; 0.01, respectively) according to each edition. However, 7th edition poorly distinguishes between stages III and IV (p = 0.43). The survival curve of stage IV (lymph) almost completely overlapped with stage III (p = 0.69), although there were significant differences between stages IV (lymph) and IV (organ) (p = 0.04). Among the factors included in prognostic group in 7th edition, the histological grade and cancer site had no significant influence on patient survival, and T factor was only independent prognostic factors in multivariate analysis (p &lt; 0.01). Conclusions: Our study suggested several pitfalls in 7th TNM classification as prognostic factor in patients who received CRT. No significant financial relationships to disclose.

Comparison of 18F-Fluorothymidine and 18F-Fluorodeoxyglucose PET/CT in Delineating Gross Tumor Volume by Optimal Threshold in Patients With Squamous Cell Carcinoma of Thoracic Esophagus

To determine the optimal method of using (18)F-fluorothymidine (FLT) positron emission tomography (PET)/computed tomography (CT) simulation to delineate the gross tumor volume (GTV) in esophageal squamous cell carcinoma verified by pathologic examination and compare the results with those using (18)F-fluorodeoxyglucose (FDG) PET/CT. A total of 22 patients were enrolled and underwent both FLT and FDG PET/CT. The GTVs with biologic information were delineated using seven different methods in FLT PET/CT and three different methods in FDG PET/CT. The results were compared with the pathologic gross tumor length, and the optimal threshold was obtained. Next, we compared the simulation plans using the optimal threshold of FLT and FDG PET/CT. The radiation dose was prescribed as 60 Gy in 30 fractions with a precise radiotherapy technique. The mean +/- standard deviation pathologic gross tumor length was 4.94 +/- 2.21 cm. On FLT PET/CT, the length of the standardized uptake value 1.4 was 4.91 +/- 2.43 cm. On FDG PET/CT, the length of the standardized uptake value 2.5 was 5.10 +/- 2.18 cm, both of which seemed more approximate to the pathologic gross tumor length. The differences in the bilateral lung volume receiving > or =20 Gy, heart volume receiving > or =40 Gy, and the maximal dose received by spinal cord between FLT and FDG were not significant. However, the values for mean lung dose, bilateral lung volume receiving > or =5, > or =10, > or =30, > or =40, and > or =50 Gy, mean heart dose, and heart volume receiving > or =30 Gy using FLT PET/CT-based planning were significant lower than those using FDG PET/CT. A standardized uptake value cutoff of 1.4 on FLT PET/CT and one of 2.5 on FDG PET/CT provided the closest estimation of GTV length. Finally, FLT PET/CT-based treatment planning provided potential benefits to the lungs and heart.

Surgical treatment and prognosis in patients with squamous cell carcinoma of thoracic esophagus

To analyze the prognostic factors of thoracic esophageal squamous cell carcinoma (ESCC) after esophagectomy. The clinicopathologic data of 716 patients with thoracic ESCC from January 1990 to December 1998 were analyzed retrospectively. There were 538 male and 178 female patients aged from 24 to 78 years old with a median of 57 years old. Cumulative survival rate was analyzed by the Kaplan-Meier method and compared by the Log-rank test. COX regression model was used for multivariate prognostic analysis. The overall 1-, 3-, 5- and 10-year survival rates were 82.9%, 44.3%, 34.2% and 25.7% respectively. The 5-year survival rates was 80.0%, 51.2%, 19.7% and 13.3% for stage I, stage IIA, stage IIB and stage III respectively. Of the 716 patients, 151 (21.1%) patients recurred, including 48 (84.2%) of stage IIA recurrence, 22 (91.7%) of stage IIB recurrence and 63 (90.0%) of stage III recurrence occurred within 3 years postoperatively. Univariate analysis revealed that the factors impacting the prognosis were gender, depth of invasion, lymph node metastasis, pathologic stage, number of lymph node metastatic field, differentiation, surgical margin and tumor relapse. Multivariate analysis showed that depth of invasion, lymph node metastasis, pathologic stage and tumor relapse were independently associated to poor prognosis. Depth of invasion, lymph node metastasis, pathologic stage and tumor relapse are the independent factors of ESCC. Surgery is still the primary treatment for stage I-IIA esophageal cancer; but it is suggested to adopt surgical treatment as primary modality combined with other therapies for stage IIB-III esophageal cancer.

Concurrent chemoradiotherapy for squamous cell carcinoma of thoracic esophagus: feasibility and outcome of large regional field and high-dose external beam boost irradiation.

To assess the feasibility and outcome of concurrent chemoradiotherapy (CT-RT) with large regional field and high-dose external beam boost irradiation in thoracic esophageal cancer. Patients with clinical stage T1 (submucosal)-4N0-1M0 (UICC 1997) squamous cell carcinoma of the thoracic esophagus were eligible. Radiotherapy consisted of regional irradiation (extending from supraclavicular fossa to the paracardial area) with 39.6 Gy followed by high-dose external beam boost up to 66.6 Gy (1.8 Gy/day, five times per week). Two-hour infusion of cisplatin (80 mg/m(2) on day 1) and continuous infusion of 5-fluorouracil (800 mg/m(2)/day on days 2-6) were administered concurrently with radiotherapy, every 3-4 weeks, for two cycles. Thirty patients (stage I, 3; stage II, 11; stage III, 16) were entered into the study. Twenty-one patients (70%) completed the planned treatment. In elderly (> or = 70 years) patients, four of six withdrew. Grade 3 and 4 toxicities (NCI-CTC) were observed in 20 (67%) and three (10%) patients, respectively. Major toxicities were blood, gastrointestinal (i.e. nausea and esophagitis) and pulmonary. There was no grade 5 (fatal) toxicity. The median follow-up period for surviving patients was 27 months (range: 9-49 months). The median survival time was 21 months. The 1- and 2-year survival rates were 65 and 49% for all 30 patients. The incidence of esophageal stricture (grade 1-2: RTOG) was 21%. No patient suffered fistula formation. Despite poor compliance for elderly patients and frequent severe toxicities, our concurrent CT-RT resulted in a favorable outcome in thoracic esophageal cancer.

Bronchoscopic Staging of Squamous Cell Carcinoma of the Upper Thoracic Esophagus

To identify bronchoscopic findings that predict resectability of squamous cell carcinoma of the upper thoracic esophagus. Tracheobronchoscopy was performed in patients with squamous cell carcinoma of the thoracic esophagus to assess the infiltration of the tracheobronchial tree by the tumor and predict the resectability. Bronchoscopic records were matched with clinical outcome and intraoperative findings. University hospital, tertiary care referral center. A total of 113 patients with supracarinal esophageal carcinoma underwent bronchoscopy as part of the preoperative staging. In 47 patients the bronchoscopy was repeated after a regimen of neoadjuvant chemotherapy. A total of 160 bronchoscopies performed by the same operator. Bronchoscopic records matched with clinical outcome and intraoperative findings. Including patients before and after neoadjuvant chemotherapy, 27 of the 46 with no bronchoscopic abnormalities were operated on: in 24 (89%) of them radical surgical resection was possible. Among the 22 patients with a slight compression on the tracheobronchial tree admitted to surgery, a radical surgical resection was possible in 20 cases (91%). In none of the 5 patients with compression/deviation associated with fixation of the tracheobronchial tree but no mucosal infiltration who underwent surgery was a radical surgical resection possible because of tracheobronchial infiltration. Compression of the tracheobronchial tree does not necessarily mean infiltration by esophageal carcinoma. If the compression is slight and the mobility of the tracheobronchial tree is normal, a radical esophagectomy is possible in 91% of patients.

TREATMENTS AND THEIR OUTCOMES FOR RECURRENCE OF THORACIC ESOPHAGEAL CARCINOMA AFTER CURATIVE RESECTION

In this study, clinical outcomes of treatments for recurrence of throacic esophageal carcinoma after curative resection were analyzed. Fifty six out of 120 patients, who received curative resection for squamous cell carcinoma of thoracic esophagus between March 1983 and December 1995, experienced a recurrence. These 56 cases were subjected to the study. The sites of recurrence were cervical lymph noden (8 cases), upper mediastinal region (25 cases), a distant organ (16 cases) and others. One-and 2-year recurrence rates were 54% and 86% respectively. The median disease-free survilal period was 11 monhs and median survival period after recurrence was 6 months. The incidence of cervical lymph node recurrence of patients with postoperative irradiation of the T-fields was significantly lower than those without radiation therapy (p<0.05). Patients with cervical lymph node dissection for cervical recurrence and patients with irradiation for upper mediastinal recurrence had relatively good prognosis. Although patients with distant organ metastasis had poor prognosis, active therapies such as transcatheter arterial chemotherapy for liver metastasis or resection of brain metastasis brought some better prognosis. To improve the prognosis of patients with recurred esophageal cancer after curative surgery, not only early diagnosis of recurrence but also vigorous treatment appropriate for the recurred site it would be mandatory.