Involved-field Irradiation Group Research Articles

A comparative study of elective nodal irradiation and involved field irradiation in elderly patients with advanced esophageal cancer.

This comparative study aimed to explore the feasibility of involved field irradiation (IFI) in the radiotherapy of elderly patients with advanced esophageal cancer, compared with elective nodal irradiation (ENI). A total of 245 elderly patients (age ≥70 years) with advanced esophageal cancer, who received radiotherapy in our department from January 2014 to December 2020, were divided into the ENI group (n=111) and the IFI group (n=134). Clinical efficacy, toxicities, survival rates, treatment failures, and multifactorial survival analyses were conducted for both groups. The ENI group and the IFI group showed no significant differences in terms of short-term efficacy (91.9% vs 91.0%, P=0.814), 1-year overall survival (OS) (81.1% vs 74.6%, P=0.228), 2-year OS (22.5% vs 25.4%, P= 0.603), 1-year progression-free survival (PFS) (56.8% vs 51.5%, P= 0.198), 2-year PFS (8.1% vs 9.0%, P=0.814), regional failures (38.7% vs 31.3%, P=0.226), and distant metastasis (21.6% vs 14.9%, P=0.174). The median overall survival (OS) was 19 months in the ENI group and 18 months in the IFI group (Log-rankχ 2=0.012, P=0.913). The median progression-free survival (PFS) was 13 months in the ENI group and 11 months in the IFI group (Log-rankχ 2=1.834, P=0.176). There were no significant statistical differences in both OS and PFS (P>0.05). The incidence of grade ≥3 radiation pneumonia and grade ≥3 radiation esophagitis in the IFI group was 8.2% and 11.2%, respectively, which were significantly lower than those in the ENI group (17.1%, P=0.034; 21.6%, P=0.026). Univariate analysis revealed that age, gender, T stage, N stage, and synchronous chemotherapy were factors affecting prognosis. Multivariate analysis showed that age, gender, T stage, and synchronous chemotherapy were independent prognostic factors, with hazard ratios of 1.227, 1.466, 2.441, and 2.714, and P values of <0.001, 0.006, <0.001, and<0.001, respectively. IFI is a suitable choice for elderly patients with advanced esophageal cancer, as it yields similar efficacy to ENI while reducing toxicities. Age, gender, T stage, and synchronous chemotherapy are independent prognostic factors for elderly patients with esophageal cancer.

Involved-field irradiation or elective-nodal irradiation in neoadjuvant chemo-radiotherapy for locally-advanced esophageal cancer: comprehensive analysis for dosimetry, treatment-related complications, impact on lymphocyte, patterns of failure and survival.

To compare the differences between involved-field irradiation (IFI) and elective nodal irradiation (ENI) in selecting the optimal target area for neoadjuvant chemoradiotherapy (nCRT) in patients with locally advanced esophageal squamous cell carcinoma (LA-ESCC). We retrospectively analyzed 267 patients with LA-ESCC, of whom 165 underwent ENI and 102 underwent IFI. Dosimetry, treatment-related complications, pathological responses, recurrence/metastasis patterns, and survival were compared between the two groups. The median follow-up duration was 27.9 months. The R0 resection rates in the IFI and ENI groups were 95.1% and 92.7%, respectively (p=0.441), while the pathological complete response (pCR) rates were 42.2% and 34.5%, respectively (p=0.12). The ENI group received higher radiation doses to the heart (HV30:23.9% vs. 18%, p=0.033) and lungs (LV30:7.7% vs. 4.9%, p<0.001) than the IFI group. Consequently, the ENI group showed a higher incidence of grade 2 or higher radiation pneumonitis (30.3% vs. 17.6%, p=0.004) and pericardial effusion (26.7% vs. 11.8%, p=0.021) than the IFI group. Post-operation fistulas were observed in 3 (2.9%) and 17 cases (10.3%) in the IFI and ENI groups, respectively (p=0.026). In the multivariate analysis, smoking, positive lymph node involvement (pN+), and anastomotic fistula were independent predictors of overall survival (OS). The pN+ patients exhibited a greater propensity for recurrence compared to pN- patients, especially in the first year of follow-up (6.67% vs. 0.56%, p=0.003). The ENI group had a higher incidence of radiation-induced adverse events compared to the IFI group, likely due to the higher radiation doses to normal tissues. Considering the similar disease-free survival (DFS) and OS rates in the two groups, IFI may be suitable for nCRT in patients with LA-ESCC, although further prospective studies are warranted.

Definitive radiotherapy in patients with clinical T1N0M0 esophageal squamous cell carcinoma: A multicenter retrospective study (KROG 21–10)

PurposeTo assess the failure pattern and analyze the treatment scheme of definitive radiation therapy (RT) for T1N0M0 esophageal squamous cell carcinoma (ESCC). MethodsWe performed a multi-institutional retrospective analysis in T1N0M0 ESCC patients who underwent definitive RT from 2010 to 2019. Patterns of failure were demonstrated as in-, and out-field locoregional, and distant metastasis. In the analysis, freedom-from locoregional recurrence (FFLRR) and their association with clinicopathologic factors were evaluated. Propensity score matching in cT1b patients was done. Results168 patients were included with a median follow-up of 34.0 months, and 26 cT1a, 116 cT1b disease. The rates of 3-year all and locoregional recurrence for cT1a were 30.5% and 24.1% and those for cT1b were 27.1% and 25.9%, respectively. Among 116 cT1b patients, 69 patients received elective nodal irradiation (ENI) and 47 received involved field irradiation (IFI). After propensity score matching, the 3-year FFLRR rate was 84.5%. There was no difference between ENI and IFI in FFLRR (P = 0.831) and OS (P = 0.525). The 3-year FFLRR was 83.8% (95% Confidence interval (CI), 61.8–93.8%) in IFI group and 85.3% (95% CI, 65.1–94.3%) in ENI group. In multivariate analysis, concurrent chemotherapy use was marginally associated with FFLRR (Hazard ratio, 0.16; P = 0.064). ConclusioncT1a patients who cannot receive endoscopic resection showed similar failure rates as cT1b patients, questioning the staging accuracy and raised the need for thorough treatment like chemoradiotherapy. In cT1b patients, IFI with 50 to 60 Gy and concurrent chemotherapy could be reasonable.

Elective Nodal Irradiation vs. Involved-Field Irradiation for Stage Ⅱ-Ⅳ Cervical Esophageal Squamous Cell Carcinoma Patients Undergoing Definitive Concurrent Chemoradiotherapy: A Retrospective Propensity Study with Eight-Year Survival Outcomes

Definitive concurrent chemoradiotherapy (dCCRT) is suggested as the standard treatment for cervical esophageal squamous cell carcinoma (CESCC). This retrospective propensity study compared the eight-year survival outcomes and acute treatment toxicities of these patients treated with elective nodal irradiation (ENI) versus involved-field irradiation (IFI). Patients with stage Ⅱ-Ⅳ CESCC treated with dCCRT in our institution between January 1, 2007 and December 31, 2020 were enrolled in the study. All the patients were restaged according to the American Joint Commission (AJCC) 8th edition criteria. The propensity score matching (PSM) was used to minimize the effects of treatment selection bias and potential confounding factors including sex, age, ECOG score, clinical T stage (cT), clinical N stage (cN), clinical TNM stage (cTNM) and radiation dose between the ENI group and IFI group. Survival and the prognostic factors were evaluated. The 131 eligible patients underwent ENI (60 patients, 45.8%) or IFI (71 patients, 54.2%). The median follow-up time was 95.3 months (range, 28.0-186.2 months) for all the patients. The median OS, 1-, 3-, 5-, and 8-year OS rates were 44.4 months, 87.8%, 55.5%, 39.0%, and 28.3%, respectively. After PSM, there were 49 patients in each group. The median OS, 1-, 3-, 5-, and 8-year OS rates for ENI and IFI group were 32.0 months, 83.7%, 48.9%, 38.8% and 32.4% versus 45.2 months, 89.8%, 52.7%, 38.2%, 26.6%, respectively (P = 0.984; HR 0.99, 95% CI 0.61-1.62). Similar locoregional control was obtained in both groups. The tendency of leukocytopenia and neutropenia was higher in ENI than in IFI (59.2% versus 38.8%; P = 0.068 and 30.6% versus 14.3%; P = 0.089) at the end of dCCRT. Cervical esophageal squamous cell carcinoma patients undergoing definitive concurrent chemoradiotherapy has a satisfactory prognosis with organ conservation. The involved-field irradiation might be a better alternative owing to similar overall survival outcomes and local control with less toxicity of myelosuppression.

Elective nodal irradiation versus involved-field irradiation for stage II–IV cervical esophageal squamous cell carcinoma patients undergoing definitive concurrent chemoradiotherapy: a retrospective propensity study with 8-year survival outcomes

BackgroundDefinitive concurrent chemoradiotherapy (dCCRT) is suggested as the standard treatment for cervical esophageal squamous cell carcinoma (CESCC). This retrospective propensity study compared the 8-year survival outcomes and acute treatment toxicities of these patients treated with elective nodal irradiation (ENI) versus involved-field irradiation (IFI).Materials and methodsPatients with stage II–IV CESCC treated with dCCRT at the Fourth Hospital of Hebei Medical University between January 1, 2007 and December 31, 2020 were enrolled in the study. All the patients were restaged according to the American Joint Commission 8th edition criteria. The propensity score matching (PSM) was used to minimize the effects of treatment selection bias and potential confounding factors including sex, age, ECOG score, clinical T stage, clinical N stage, clinical TNM stage and radiation dose between the ENI group and IFI group. Survival and the prognostic factors were evaluated.ResultsThe 131 eligible patients underwent ENI (60 patients, 45.8%) or IFI (71 patients, 54.2%). The median follow-up time was 91.1 months (range, 23.8–182.0 months) for all the patients. The median OS, 1-, 3-, 5-, and 8-year OS rates were 44.4 months, 87.8%, 55.1%, 38.3%, and 27.2%, respectively. After PSM, there were 49 patients in each group. The median OS, 1-, 3-, 5-, and 8-year OS rates for ENI and IFI group were 32.0 months, 83.7%, 48.5%, 38.5% and 31.1% versus 45.2 months, 89.8%, 52.5%, 37.5%, 26.1%, respectively (P = 0.966; HR 0.99, 95% CI 0.61–1.61). Similar locoregional control was obtained in both groups. The tendency of leukocytopenia and neutropenia was higher in ENI than in IFI (59.2% vs. 38.8%; P = 0.068 and 30.6% vs. 14.3%; P = 0.089) at the end of dCCRT.ConclusionCervical esophageal squamous cell carcinoma patients undergoing definitive concurrent chemoradiotherapy has a satisfactory prognosis with organ conservation. The involved-field irradiation might be a better alternative owing to similar overall survival outcomes and local control with less toxicity of myelosuppression.

Concurrent Chemoradiation of Different Doses (50.4 Gy vs. 59.4 Gy) and Different Target Field (ENI vs. IFI) for Locally Advanced Esophageal Squamous Cell Carcinoma: Results from a Randomized, Multicenter Phase Ⅲ Clinical Trial

<h3>Purpose/Objective(s)</h3> Concurrent chemoradiation is standard treatment for locally advanced esophageal squamous cell carcinoma (ESCC), while the optimal regimen of radiotherapy, especially in terms of total dose and planned range of target field, remained unclear. This phase Ⅲ clinical trial was aimed to compare the survival benefits between different total dose and different target field. <h3>Materials/Methods</h3> The clinical trial compared two radiation treatment aspects of total dose and field under two-by-two factorial design. The high radiation dose group (HD) totally received 59.4Gy radiation and standard dose group (SD) received 50.4 Gy. The involved field irradiation (IFI) group and elective nodal irradiation (ENI) group adopted different radiation plans of clinical target volume (CTV), among which the CTV in IFI group was defined as GTV plus extend margin to the primary tumor and in ENI group CTV was defined as GTV plus the extend margins and the high-risk region of elective nodes. Two cycles of Tegafur/gimeracil/oteracil (S-1) and cisplatin were given with concurrent radiotherapy. The participants were assigned to one of the four groups (HD+ENI, HD+IFI, SD+ENI and SD+IFI) by simple randomization (1:1:1:1 ratio). The planned sample size was 147 in each arm (588 totally). The primary endpoint was overall survival (OS) and the second endpoints included progression-free survival (PFS) and objective response rate (ORR). All statistical analysis was performed according to intention-to-treat principle. <h3>Results</h3> The median follow-up period was 47.3 months until December 2021. The median OS were 33.6, 33.9, 41.0 and 28.3 months in HD+ENI, SD+ENI, HD+IFI and SD+IFI groups, respectively. No significant synergistic effect was detected between dose and radiation field in interaction analysis. Compared with SD arms, the HD treatment did not present significantly prolonged OS (HR=0.93, log rank test p value=0.54) but suggested improved PFS (29.1 months to 20.0 months, HR=0.77, log rank test p value=0.023). In subgroup analysis of IFI, the HD treatment was associated with more benefits (HD+IFI arm to SD+IFI arm, HR of PFS is 0.64[0.47-0.84]). In comparison of target field, patients in IFI or ENI group presented similar OS (HR=1.05, log rank test p=0.7) and PFS (HR=1.08, log rank test p=0.5). In the stratified analysis of lymph node status, the ENI treatment suggested benefits compared to IFI in N0 patients (n=108, HR of OS is 0.46[0.24-0.89]). No significant difference in occurrences of severe adverse event was detected in comparisons of dose or field groups. <h3>Conclusion</h3> The HD and SD radiation treatment did not significantly differ in OS, but HD radiation associated with better PFS. The IFI treatment brought similar outcomes to ENI in overall patients, which indicated a reasonable choice for locally advanced ESCC.

Adjuvant Radiotherapy of Involved Field versus Elective Lymph Node in Patients with Operable Esophageal Squamous Cell Cancer: A Single Institution Prospective Randomized Controlled Study.

Background: To evaluate locoregional failure and its impact on survival by comparing involved field irradiation (IFI) with elective lymph node irradiation (ENI) for patients with esophageal squamous cell cancer who underwent post-operative radiotherapy.Methods and Materials: The enrolled patients were randomized allocated to IFI or ENI group. CTV of IFI was generated according to pre-operative primary tumor location and post-operative pathological characters and positive LNs regions. CTV of ENI was generated according to pre-operative tumor position to administer selective lymph node irradiation. Radiotherapy planning was delivered using either 3D-CRT or IMRT.Results: A total of 57 patients were enrolled, 28 patients in ENI group and 29 patients in IFI group. There were not statistical differences between two groups in baseline (p>0.05). The initial locoregional failure rate was 17.9 % in ENI arm and 20.7% in IFI arm respectively (p=0.085). The 1-, 3-, and 5-year Progression-free Survival (PFS) were 63.2, 43.5, and 21.8 % in ENI arm versus 78.2, 60.1, and 55.1% in IFI arm (p =0.038). The 1-, 3-, and 5-year overall survival (OS) were 78.6, 46.9, and 23.5 % in ENI arm versus 72.9, 59.7, and 54.3 % in IFI arm (p=0.06). Acute radiation pneumonitis (p=0.005) and hematological toxicities (p =0.029) also showed statistical differences between groups, ENI arm was more than IFI arm.Conclusions: The results indicated that IFI tended to improve survival and reduce toxicities for patients with operative ESCC and did not increase locoregional failure compared to ENI. It is thus suggested that IFI for ESCC PORT is worthy of clinical recommendation and further study.

Clinical outcomes of different irradiation ranges in definitive intensity-modulated radiotherapy for esophageal cancer

Objective: To explore the therapeutic efficacy and safety of elective nodal irradiation (ENI) and involved field irradiation (IFI) in intensity-modulated radiotherapy for esophageal cancer, screen the patients suitable to undergo ENI radiotherapy and provide evidences for individual treatment of esophageal cancer. Methods: A retrospective analysis was performed on the clinical data of 924 patients with esophageal cancer who received definitive intensity-modulated radiotherapy in our hospital from January 2006 to December 2015. Among them, 272 patients received ENI and the other 652 patients received IFI. The clinicopathologic characteristics of 272 cases in ENI group and 652 cases in IFI group, who were recruited according to the balance of propensity score matching method, were compared. The Kaplan-Meier method was used to calculate 1-year, 3-years and 5-years local-regional failure-free survival (LRFFS), progression-free survival (PFS) and overall survival (OS) rates. The univariate and multivariate analysis of prognostic factors were also determined by Cox proportional hazard model and Long-rank test. Results: The clinicopathologic characteristics of these two group were not significantly different (P>0.05). The median follow-up time was 85.9 months and the follow-up rate was 95.9%. The 1-year, 3-years, 5-years PFS rates of the ENI groups were 65.3%, 31.7%, 18.4%, respectively, higher than 54.0%, 20.9%, 12.7% of the IFI group (P=0.001). The 1-year, 3-years, 5-years OS rates of the ENI groups were 79.0%, 43.7%, 24.9%, respectively, higher than 75.0%, 31.8%, 17.2% of the IFI group (P=0.003). In multivariate analysis, the sex, tumor volume, N stage and radiation field were independent factors for PFS and OS (P<0.05). Subgroup analysis showed that patients with male, age≤66 year, cervical and upper-thoracic location, tumor length≤6 cm, T1-2 stage, N0-1 stage, Ⅰ-Ⅱ stage, tumor volume≤50 cm(3), dosage>60 Gy and≤2 cycles of chemotherapy in the ENI group had a better survival rate than those in the IFI group (P<0.05). The total failure rate, local-regional failure rate in ENI group were significantly lower than those of IFI group (P=0.001, P=0.004). The incidence of bone marrow depression≥ grade 2 and 3 in ENI group was higher than that of the IFI group (P<0.05). However, the incidences of radioactive esophagitis≥ grade 3, radioactive pneumonia and late adverse reactions were not significantly different between these two groups (P>0.05). Conclusion: Compared with IFI, ENI can significantly improve the long-term survival for young, early TN stage and cervical/upper-thoracic esophageal cancer patients underwent chemotherapy.

Comparison between the effects of elective nodal irradiation and involved-field irradiation on long-term survival in thoracic esophageal squamous cell carcinoma patients: A prospective, multicenter, randomized, controlled study in China.

BackgroundThis study's initial results revealed significant decreases in treatment‐related esophagitis and pneumonitis cases in patients with thoracic esophageal squamous cell carcinoma (ESCC) treated with involved‐field irradiation (IFI), compared to elective nodal irradiation (ENI). This report outlines the long‐term trial results, specifically; overall survival (OS), progression‐free survival (PFS), metastasis‐free survival (MFS), and locoregional progression‐free survival (LRFS).Materials and MethodsStage II–III thoracic ESCC patients were assigned randomly, in a 1:1 ratio, into either the ENI or IFI arm. Radiation therapy was delivered once a day in 1.8‐2.0 Gy fractions to a total dose of 60.0‐66.0 Gy to the gross tumor volume and 50.0‐54.0 Gy to the clinical target volume. The primary endpoints were acute treatment‐related esophagitis and pneumonitis. The results for the primary endpoints were previously published in 2018. In this article, we analyzed the secondary endpoints including PFS, LRFS, MFS, and OS.ResultsBetween April 2012 and October 2016, 228 patients from nine participating centers in China were enrolled into this study and randomly assigned to two treatment groups. For ENI and IFI groups, respectively, the results showed similarity and were as follows: median PFS (20.3 months vs 21.4 months), OS (32.5 months vs 34.9 months), MFS (28.2 months vs 26.0 months), and LRFS (25.0 months vs 26.6 months). In particular, respective OS rates in the ENI and IFI groups were 84.6% and 82.5% after 1 year, 45.1% and 48.7% after 3 years, and 29.8% and 30.7% at 5 years. PFS rates after 1, 3, and 5 years were 58.9%, 34.2%, and 26.9%, respectively, in the ENI arm compared to 64.4%, 30.8%, and 27.7%, respectively, in the IFI arm. Multivariate analysis identified clinical stage and tumor responses as independent predictors of OS. Meanwhile, tumor location, cStage, and tumor response were identified as independent factors influencing PFS.ConclusionIFI was associated with similar survival as ENI in patients with thoracic ESCC, suggesting that IFI is an acceptable treatment method for thoracic ESCC.

Efficacy comparison of lymph node involved-field irradiation and elective nodal irradiation for treatment of esophageal cancer among Asian populations: a Meta analysis

Objective To explore the clinical efficacy of lymph node involved-field irradiation (IFI) and elective nodal irradiation (ENI) for treatment of esophageal cancer among Asian populations. Methods The randomized controlled trials and retrospective analyses of Asian esophageal cancer patients treated by IFI and ENI were retrieved by computer in Cochrane Library, PubMed, Embase, CNKI, and Wanfang database. The last retrieval time was May 2018. According to the inclusion and exclusion criteria, the clinical efficacy, adverse reactions and failure modes were selected in each study. A Meta-analysis was performed by using Review Manager 5.3 software to compare the advantages and disadvantages of IFI group and ENI group in treatment of Asian esophageal cancer patients. Results Eventually, a total of 18 domestic and foreign literature that meet the standards (6 randomized controlled trials, 12 retrospective analyses) were included, with a total of 2 220 patients. There were no significant differences in the overall survival rate, the local control rate, the local/regional failure rate, the distant metastasis rate, the intra-field recurrence rate, and the field recurrence rate between the IFI group and the ENI group (all P > 0.05). The overall failure rate of ENI group was slightly lower than that of IFI group (P = 0.05). The incidence of radiation pneumonitis in ENI group was higher than that in IFI group (P = 0.004), and the incidence of radiation esophagitis was higher than that in IFI group (P < 0.01). Conclusion For Asian patients with esophageal cancer, ENI has no obvious advantage compared with IFI, including the increase of adverse reactions. Key words: Esophageal neoplasms; Lymph nodes; Involved-field irradiation; Elective nodal irradiation; Asian populations

Involved-field irradiation for elderly bladder cancer patients

Considering that adjuvant radiation therapy is one of the most common treatment methods and the influence of the clinical target volume to treatment-related toxicity, this study aimed to observe the differences in treatment failures about involved-field irradiation (IFI) without lymph node areas versus elective nodal irradiation (ENI) with lymph node areas in elderly patients with bladder cancer. Ninety-two elderly bladder cancer patients were analyzed from January 2010 to December 2014 in one institution. The primary inclusion criteria were previous after transurethral resection of bladder tumor or partial cystectomy with adjuvant radiotherapy, and the radiation techniques included IFI or ENI. The study required that elderly patients did not received radiotherapy before treatment. We observed treatment-related toxicity and tumor failures, evaluated local progression-free survival, estimated the 3-year overall survival, and analyzed prognostic factors, after IFI and ENI in elderly bladder cancer patients. The outcomes were determined by chi square tests, Kaplan-Meier method and Cox multiple factors analysis. In the experimental group, 42 patients (45.65%) received IFI, and a matched group of 50 patients (54.35%) received ENI. With a median follow-up of 31.47 months (range 4.00-86.00 months), the Kaplan-Meier analysis with a log-rank test demonstrated a statistical difference between the IFI group and the ENI group in acute toxicity (45.23% vs 72.00%, P = 0.008). However, there were no statistical differences in the 3-year overall survival rate (45.20% vs 48.00%, P = 0.860) or the duration of local progression-free survival (24.98 vs 34.30, P =0.729). IFI is feasible in elderly bladder cancer patients, as shown by a decrease in acute toxicity and no increase in local failure. We need a large number of clinical trials and data to further confirm these results.

Target volume delineation for radical radiotherapy of early oesophageal carcinoma in elderly patients

PurposeTo compare the prognosis of elderly patients with early oesophageal carcinoma between radical elective nodal prophylactic irradiation and involved-field irradiation and to estimate the failure modes and adverse effects, then to provide the patients the safe and individual therapeutic regimens. Material and methodsThe charts of 96 patients aged 65 and over with early stage oesophageal carcinoma receiving radical radiotherapy in our department were retrospectively analysed. Of all the patients, 49 received elective nodal prophylactic irradiation and the other 47 received involved-field irradiation. After completion of the whole treatment, we analysed short-term effects, tumour local control, overall survival of the patients, failure modes and adverse effects. ResultsThe 1-, 3-, and 5-year local control rate in elective nodal irradiation and involved-field irradiation groups were 80.6%, 57.4%, 54.0% and 65.4%, 46.5%, 30.5% respectively, and the difference was statistically significant (χ2=4.478, P=0.03). The differences of overall survival and progression-free survival were not significant (P>0.05). The difference of 1-, 3-, and 5-years local regional failure rate was statistically significant between elective nodal prophylactic irradiation and involved-field irradiation groups, except for the overall failure and distant metastasis rates. The overall incidence of radiation-induced oesophagitis after elective nodal irradiation or involved-field irradiation was 79.6% and 59.6%, and the difference was statistically significant (χ2=4.559, P=0.03). The difference of radiation pneumonitis between elective nodal prophylactic irradiation and involved-field irradiation was not significant (12.2% vs 14.9%; χ2=0.144, P=0.7). ConclusionFor elderly patients with early stage oesophageal carcinoma receiving radical radiotherapy, although elective nodal prophylactic irradiation could increase the incidence of radiation-induced oesophagitis, patients could tolerate the treatment and benefit from local control.

Therapeutic effects of extended-field and involved-field irradiation in three-dimensional radiotherapy in patients with esophageal cancer: a meta-analysis

Objective To investigate the therapeutic effects, adverse effects, and patterns of failure of elective irradiation of lymphatic drainage area (extended-field) and involved-field irradiation in three-dimensional radiotherapy (3DRT) in patients with esophageal cancer via a Meta-analysis. Methods The databases Wanfang Data, CNKI, VIP, CBM, PubMed, Embase, and Cochrane Library were searched to collect the controlled clinical trials on extended-field irradiation and involved-field irradiation in 3DRT in patients with esophageal cancer. Stata 11.0 was used for data analysis. The odds ratio (OR) with 95% confidence interval was used to describe the differences between two groups. Results According to the inclusion and exclusion criteria, a total of 12 controlled clinical trials involving 1 095 patients with esophageal cancer were included in this meta-analysis. The results of the meta-analysis showed that compared with the involved-field irradiation group, the extended-field irradiation group had a significantly reduced rate of out-field failure in patients with esophageal cancer who received 3DRT (OR=3.727, P=0.007), but showed significantly higher rates of grade ≥3 acute radiation pneumonitis and radiation esophagitis (acute radiation pneumonitis: OR=0.348, P=0.001; radiation esophagitis: OR=0.385, P=0.000). The two groups had similar 1-, 2-, and 3-year local control rate and overall survival rate (local control rate: OR=0.966/0.946/0.732, P=0.837/0.781/0.098; overall survival rate: OR=0.952/1.149/0.768, P=0.756/0.422/0.120), as well as a similar distant metastasis rate (OR=0.986, P=0.937). Conclusions Compared with involved-field irradiation, extended-field irradiation can reduce the rate of out-field failure in patients with esophageal cancer who receive 3DRT. However, it does not have significant advantages in local control rate and overall survival rate and has an increased incidence rate of adverse effects. Key words: Esophageal neoplasms/three-dimensional radiotherapy; Three-dimensional radiotherapy, elective nodal; Three-dimensional radiotherapy, involved-field; Meta-analysis

SU-F-P-52: A Meta-Analysis of Controlled Clinical Trials Comparing Elective Nodal Irradiation with Involved-Field Irradiation for Conformal Or Intensity-Modulated Radiotherapy in Patients with Esophageal Cancer

Purpose: To compare elective nodal irradiation with involved-field irradiation for three-dimensional conformal radiotherapy or intensity-modulated radiotherapy in patients with esophageal cancer by a metaanalysis. Methods: Wanfang, CNKI, VIP, CBM databases, PubMed, Embase and Cochrane Library were searched to identify the controlled clinical trials of elective nodal irradiation with involved-field irradiation for three-dimensional conformal radiotherapy or intensity-modulated radiotherapy in patients with esophageal cancer. The obtained data were analyzed using Stata 11.0. The difference between two groups was estimated by calculating the odds ratio (OR) with 95% confidence interval (95% CI). Results: A total of 12 controlled clinical trials involving 1095 esophageal cancer patients, which were selected according to inclusion and exclusion criteria, were included in this meta-analysis. The meta-analysis showed that the elective nodal irradiation group reduced the rates of out-field failure comparing with involved-field irradiation group (OR=3.727, P=0.007). However, the rates of ≥grades 3 acute radiation pneumonitis and esophagitis were significantly higher in the elective nodal irradiation group than in the involved-field irradiation group (OR=0.348, P=0.001, OR=0.385, P=0.000). 1-, 2-, 3-year local control rates (OR=0.966, P=0.837, OR=0.946, P=0.781; OR=0.732P=0.098) and 1-, 3-, 5-year survival rates were similar in the two groups (OR=0.966, P=0.837; OR=0.946, P=0.781; OR=0.732, P=0.098; OR=0.952, P=0.756; OR=1.149, P=0.422; OR=0.768, P=0.120). It is the same with the rates of distant metastasis (OR=0.986, P=0.937). Conclusion: Compared with involved-field irradiation, the elective nodal irradiation can reduce the rates of out-field failure for three-dimensional conformal radiotherapy or intensity-modulated radiotherapy in patients with esophageal cancer. However, its advantage of local control and survival rates is not obvious and it increases the incidence of toxicities.

A comparative study of different irradiation ranges in radical radiotherapy for early-stage esophageal cancer

Objective To compare the efficacy of elective nodal prophylactic irradiation (ENI) and involved-field irradiation (IFI) in radical radiotherapy for early-stage esophageal cancer and to determine the appropriate irradiation range for early-stage esophageal cancer. Methods The clinical data of 121 patients with early-stage esophageal cancer receiving radical radiotherapy in our hospital from January 2006 to December 2011 were collected and respectively analyzed. Sixty-one patients received ENI, and the other 60 patients received IFI. The Kaplan-Meier method was used to calculate local control (LC) and overall survival (OS) rates; the log-rank test was used for survival difference analysis and univariate prognostic analysis; the Cox regression model was used for multivariate prognostic analysis. Results The 1-, 3-, and 5-year LC rates in ENI group and IFI group were 81.1%, 60.1%, and 57.5% vs. 64.5%, 43.9%, and 27.2%, respectively (P=0.003). The 1-, 3-, and 5-year OS rates in ENI group and IFI group were 86.9%, 56.8%, and 34.8% vs. 86.7%, 34.3%, and 19.1%, respectively (P=0.019). The 1-, 3-, and 5-year overall failure rates in ENI group and IFI group were 22.3%, 53.8%, and 63.2% vs. 43.3%, 65.8%, and 78.8%, respectively (P=0.023). Multivariate analysis showed that irradiation range was the influencing factor for LC and OS. Conclusions As for the radical radiotherapy for early-stage esophageal cancer, ENI can significantly increase LC and reduce locoregional failure, and therefore improve long-term OS. Key words: Esophageal neoplasms/radiotherapy; Elective nodal prophylactic irradiation; Involved-field irradiation; Prognosis

A comparative study of failure patterns of definitive treatment of esophageal cancer with elective nodal irradiation and involved-field irradiation

Objective To compare the failure pattern between esophageal cancer patients receiving definitive elective nodal irradiation (ENI) and involved-field irradiation (IFI) and to investigate the reasons and influential factors for locoregional recurrence and metastasis.Methods A retrospective analysis was performed on the clinical data of 245 patients with esophageal cancer who received definitive radiotherapy in our hospital from January 2006 to December 2012.One hundred and twenty-six patients received ENI,and the other 119 patients received IFI.Failure patterns were analyzed after treatment.Locoregional failures included local esophageal lesion uncontrol or recurrence and regional lymph node recurrence or metastasis.Distant metastases included distant organ metastasis and distant lymph node metastasis.Comparison of failure pattern between the two therapies was made by chi-square test.Results One hundred and sixty-three patients had failure after treatment.Locoregional failure was observed in 92 patients,distant metastasis in 36 patients,and locoregional failure plus distant metastasis in 35 patients.The 1-,3-,and 5-year overall failure rate for the ENI group were 35.4％,62.5％,and 69.0％,respectively,versus 46.5％,71.5％,and 81.5％ for the IFI group (P =0.036).The 1-,3-,and 5-year locoregional failure rates for the ENI group were 29.9％,48.4％,and 50.0％,respectively,versus 39.6％,62.1％,and 71.4％ for the IFI group (P =0.003).Conclusions For esophageal cancer patients receiving definitive radiotherapy,ENI can significantly reduce locoregional failures and increase locoregional control,thus improving the long-term survival. Key words: Esophageal neoplasms/radiotherapy; Elective nodal prophylactic irradiation; Involved-field irradiation; Failure mode

Evaluation of the value of ENI in radiotherapy for cervical and upper thoracic esophageal cancer: a retrospective analysis.

BackgroundA retrospective study to compare the failure patterns and effects of elective nodal irradiation (ENI) or involved field irradiation (IFI) for cervical and upper thoracic esophageal squamous cell carcinoma (SCC) patients.MethodsOne hundred and sixty nine patients with the cervical and upper thoracic esophageal SCC were analyzed retrospectively; 99 patients (59%) underwent IFI and 70 patients (41%) received ENI. We defined “Out-PTVifi in-PTVeni metastasis” as lymph node metastasis occurring in the cervical prophylactic field of PTVeni thus out of PTVifi.ResultsOut-PTVifi in-PTVeni cervical node metastasis occurred in 8% of patients in the IFI group, all within 2 years after treatment. However, it occurred in 10% of patients in the ENI group, and these failures happened gradually since one year after treatments. No difference was found in OS and the incidences of Grade ≥ 3 treatment-related esophageal and lung toxicities between the two groups.ConclusionsENI for cervical and upper thoracic esophageal SCC patients did not bring longer OS and better long-term control of cervical lymph nodes. Although ENI might delay cervical nodes progression in elective field; it could not decrease the incidence of these failures.

A preliminary study of three-dimensional conformal radiotherapy with different clinical target volumes for esophageal cancer

Objective To investigate the value of prophylactic irradiation to the lymphatic drainage area in radical three-dimensional conformal radiotherapy (3DCRT) and to evaluate the efficacy and adverse effects of 3DCRT with different clinical target volumes.Methods A retrospective analysis was performed on the records of 219 esophageal cancer patients without distant metastasis who received 3DCRT from January 2005 to December 2010.One hundred and five patients received involved-field irradiation (IFI) with a total dose of 54-66 Gy;114 patients received elective nodal irradiation (ENI) with a total dose of 46-52 Gy; the prescribed dose to the primary lesion was 56-70 Gy.The Kaplan-Meier method was used to calculate local control (LC) and overall survival (OS) rates,and the log-rank test was used for univariate prognostic analysis.Results The 1-,3-,and 5-year sample sizes were 219,172 and 67,respectively.The 1-,3-,and 5-year LC rates for IFI group were 63.0％,39.1％,and 27.2％,respectively,versus 70.5％,53.3％,and 51.7％ for ENI group (x2 =6.22,P =0.013) ;the 1-,3-,and 5-year OS rates for IFI group were 67.6％,24.9％,and 15.0％,respectively,versus 73.7％,45.1％,and 26.0％ for ENI group (x2=5.04,P =0.025).The univariate stratified analysis showed that the LC and OS rates were significantly higher in the ENI group than in the IFI group for patients with middle-or lower-thoracic primary lesion or N0 disease (P=0.007,0.015;P=0.054,0.013).Conclusions For esophageal cancer patients with middle-or lower-thoracic primary lesion or without lymph node metastasis,prophylactic irradiation to the lymphatic drainage area can increase LC and OS rates. Key words: Esophageal neoplasms/three-demensional radiotherapy; Involved-field irradiation; Elective nodal irradiation; Prognosis

Involved field irradiation compared with prophylactic nodal irradiation to unresectable esophageal carcinoma: A retrospective study.

e15180 Background: We retrospectively observed the failure patterns in patients of local advanced esophageal squamous cell carcinoma (ESCC) with involved field irradiation (IFI) or with intentional prophylactic nodal irradiation (PNI). Methods: The ESCC patients with unresectable lesion (length &gt;6 cm or T4 or obvious node metastasis) were retrospectively analyzed between 2003 and 2009. All the reviewed patients received 3D-CRT with cisplatin based chemotherapy. For the IFI cases, the GTV was defined as any visible esophageal lesion(GTVe) and clinical involved node(GTVn). The CTVe was defined as the GTVe plus a 3-4cm margin superior and inferior to the primary tumor and a 1.0 cm radial margin. CTVn was defined as the GTVn plus a 0.5cm radial margin. The PTV was defined as CTV plus a 1.0cm margin. For the PNI cases, the same margins outside the primary tumor as that in IFI, and the adjacent regional lymphatics was included in the CTV according to the different location of primary tumor. The prescribed dose to PTV in IFI group was 60-64 Gy in 6-7 weeks and to PNI group was 40-50GY in 4-5weeks followed by 10-20Gy to PTVe+n. Results: Thirty-six cases received IFI and 49 cases underwent PNI. There were no difference between IFI and PNI group in tumor length and nodal status. The clinical response rates were 94.4% and 97.9% in IFI and PNI group, respectively, and no statistical difference was found ( P=0.785).The patterns of first failure in IFI and PNI group were listed as follows:(1) involved field failure, 17/36 vs 34/49 , P=0.046; (2) prophylactic nodal failure, 10/36 vs 4/49 P=0.02; (3) out field of regional nodal failure, 8/36 vs 15/49 , P=0.464; (4) distant metastasis, 17/36 vs 26/49, P=0.663. The medium PFS were 8.5m vs 12.0m( P=0.602), and the median OS were 14.0m vs 16.0m ( P=0.924)in IFI and in PNI group, respectively, and no statistical difference was found. Conclusions: Chemo-radiotherapy with PNI for unresectable ESCC showed better prophylactic field control, but had no advantage over the IFI in LC, PFS and OS.The involved field failure and distant metastasis were the main causes of failure in both groups, which suggests that the prophylactic irradiation may be not necessary for this sub-group patients.

Comparison of Treatment Outcomes Between Involved-field and Elective Nodal Irradiation in Limited-stage Small Cell Lung Cancer

The present study was performed to assess the usefulness of involved-field irradiation and the impact of (18)F-fluorodeoxyglucose-positron emission tomography-based staging on treatment outcomes in limited-stage small cell lung cancer. Eighty patients who received definitive chemoradiotherapy for limited-stage small cell lung cancer were retrospectively analyzed. Fifty patients were treated with involved-field irradiation, which means that the radiotherapy portal includes only clinically identifiable tumors. The other 30 patients were irradiated with a comprehensive portal, including uninvolved mediastinal and/or supraclavicular lymph nodes, so-called elective nodal irradiation. No significant difference was seen in clinical factors between the two groups. At a median follow-up of 27 months (range, 5-75 months), no significant differences were observed in 3 year overall survival (44.6 vs. 54.1%, P= 0.220) and 3 year progression-free survival (24.4 vs. 42.8%, P= 0.133) between the involved-field irradiation group and the elective nodal irradiation group, respectively. For patients who did not undergo positron emission tomography scans, 3 year overall survival (29.3 vs. 56.3%, P= 0.022) and 3 year progression-free survival (11.0 vs. 50.0%, P= 0.040) were significantly longer in the elective nodal irradiation group. Crude incidences of isolated nodal failure were 6.0% in the involved-field irradiation group and 0% in the elective nodal irradiation group, respectively. All isolated nodal failures were developed in patients who had not undergone positron emission tomography scans in their initial work-ups. If patients did not undergo positron emission tomography-based staging, the omission of elective nodal irradiation resulted in impaired survival outcomes and raised the risk of isolated nodal failure. Therefore, involved-field irradiation for limited-stage small cell lung cancer might be reasonable only with positron emission tomography scan implementation.