Unresectable Esophageal Cancer Research Articles

PS02.162: THREE-YEAR OVERALL SURVIVAL UPDATE FROM PHASE II STUDY OF CHEMOSELECTION WITH DCF AND SUBSEQUENT CONVERSION SURGERY FOR LOCALLY ADVANCED UNRESECTABLE ESOPHAGEAL CANCER

Abstract Background A multicenter phase II trial revealed that docetaxel plus 5-fluorouracil and cisplatin (DCF) induction chemotherapy (IC) and subsequent conversion surgery (CS) was tolerable and effective in patients with locally advanced unresectable esophageal cancer (LAUEC) (Br J Cancer 2016;115:1328–1334). Here, we report updated 3-year analyses to further characterize the impact of DCF-IC followed by CS. Methods Esophageal cancer patients with clinical T4 disease and/or unresectable supraclavicular lymph node metastasis were eligible. The treatment starts with 3 cycles of DCF-IC, followed by CS if resectable, or by concurrent radiation plus chemotherapy with 5-fluorouracil and cisplatin (CF-RT) if not resectable. This updated analysis represents 3-year overall survival (OS), 3-year progression free survival (PFS), location of relapse, and subsequent therapy. Results As of October 11, 2017, 25 patients were dead. The median follow-up period in patients surviving without death was 39.3 months (95%CI: 38.7 - 41.7months). The estimated 1-year OS was 66.7% and lower limit of 95% confidence interval was 54.6%. The estimated 3-year OS was 46.6% (95% CI; 34.2 - 63.5%). The OS for patients who underwent R0 resection (n = 19) was significantly longer than those who did not undergo R0 resection (3-year OS: 71.4% vs. 30.1%). The estimated 1-year PFS was 50.6% (95%CI: 38.1 - 67.3%) and the estimated 3-year PFS was 39.6% (95%CI: 27.7 - 56.6%). The PFS for patients who underwent R0 resection (n = 19) was significantly longer than those who did not undergo R0 resection (3-year PFS: 61.3% vs. 25%). The recurrence or progression in primary site was observed in 31% of non R0 group. There was no significant difference in the rates of distant metastasis between the two groups (non R0 group vs. R0 group; 21% vs. 16%). The subsequent therapy after protocol therapy included chemotherapy (n = 18), radiotherapy (n = 11), and surgery (n = 5). Conclusion This longer follow up of DCF-IC followed by CS strategy for patients with LAUEC revealed promising OS and PFS. Based on this phase 2 trial, JCOG1510, a prospective randomized controlled trial to compare chemoselection with DCF-IC followed by CS versus CF-RT as a standard treatment is in preparation for LAUEC. Disclosure All authors have declared no conflicts of interest.

PS01.169: RADICAL ESOPHAGECTOMY COMBINED WITH RESECTION OF INVADED DESCENDING AORTA FOR T4 BARRETT’S ESOPHAGEAL CANCER

Abstract Background Esophageal cancer invading the descending aorta is a frequent subset of locally advanced unresectable esophageal cancer. Radical resection combined with removal of the descending aorta may be the only possible surgical approach for such tumors. Methods [Case report] A 58-year-old man who complained of dysphagia was referred to our hospital. Esophagogastroscopy showed the presence of long-segment Barrett's esophagus 19 cm from the incisors and a type 2 tumor 29–38cm from the incisors. Computed tomography revealed that the metastatic lymph node had markedly invaded the descending aorta and showed left adrenal gland metastasis. This patient was diagnosed with Stage IV lower thoracic Barrett's esophageal adenocarcinoma. The patient was treated with two courses of cisplatin plus 5-fluorouracil. After the chemotherapy, the main tumor, left adrenal gland metastasis and lymph node metastasis had not responded. We judged that R0 surgery was available for excision of the aorta because the distant metastasis was only left adrenal metastasis and there was no emergence of a new lesion. Results [Surgery] First we operated the neck and abdomen simultaneously in the supine position. Superior mediastinal dissection and esophageal transection were performed by mediastinoscope-assisted transhiatal esophagectomy technique. Removal of the left adrenal gland and abdominal esophageal transection were performed. The position of the patient was converted to the left lateral position. With left thoracotomy, the descending aorta was taped above and below the lesion. With ACT 200 or more by heparin administration, PCPC was provided. Transfer descending aorta was replaced with artificial blood vessel. After neutralization by protamine sulfate, the thoracic esophagus was safely removed. The artificial blood vessel was covered with omentum and indwelling thoracic drain was performed. Finally, an esophagocutaneous fistula was built in the anterior chest. The operation time was 14h38min, and the blood loss was 1730g with 2970ml blood transfusion. The patient stayed in the ICU for seven days and discharge was 22 days post-operative. Histopathological diagnosis is adenocarcinoma of Barrett's esophagus, 80 × 30mm, por>tub2, pT4b (aorta). Conclusion Bilateral thoracotomy is necessary in radical surgery for aortic infiltrating thoracic esophageal cancer, but surgical stress is excessive. A mediastinoscope-assisted transhiatal esophagectomy approach is a minimally invasive option to avoid bilateral thoracotomy. Disclosure All authors have declared no conflicts of interest.

Stenting in Palliation of Unresectable Esophageal Cancer

BackgroundThe aim of this study was to analyze the safety and effectiveness of stenting using partially covered self-expandable stents in palliation of dysphagia in patients with unresectable esophageal cancer.MethodsRetrospective analysis of hospital records of all patients who underwent esophageal stenting in the period 2008–2015 was performed. The study included patients with unresectable esophageal and esophagogastric cancer.ResultsThere were 442 patients included. Mean age was 56 years (range 28–89), and 379 were males. In 40 (9.0%) patients, stenting was performed in the cervical, in 150 (39.3%)—in the middle thoracic, in 141 (31.9%)—in lower thoracic esophagus and in 111 (25.1%)—in the esophagogastric junction. Stenting resulted in significant alleviation of dysphagia grade (3.0 vs. 1.0, p = 0.00001). During the follow-up, 55 (12.4%) patients experienced recurrent dysphagia due to tumor or granulation tissue overgrowth, and in 18 (4.1%) patients, migration of the stent occurred, for which an independent risk factor was adjuvant chemo- and/or radiation therapy (p = 0.001). Minor complications included chest pain (54.5%), delayed complete stent expansion (12.0%), feeling of a foreign body (25.3%), hiccup (1.6%), gastroesophageal reflux (45.6%) and post-discharge pneumonia (2.5%). A feeling of a foreign body in the esophagus was significantly more common after stenting of the cervical esophagus (p = 0.0001), and hiccup was more common after stenting of the esophagogastric junction (p = 0.02). Major complications included bleeding (1.3%), respiratory insufficiency (0.7%), esophageal perforation (0.9%) and irregular heartburn (2.3%). Overall procedure-related mortality was 0.4%. The median survival time was 117.8 days (range 2–732).ConclusionsStenting is an effective procedure in relieving dysphagia in patients with unresectable malignant esophageal stenosis and is associated with low rate of postoperative and long-term complications.

Nutrition therapy in esophageal cancer-Consensus statement of the Gastroenterological Society of Taiwan.

A number of clinical guidelines on nutrition therapy in cancer patients have been published by national and international societies; however, most of the reviewed data focused on gastrointestinal cancer or non-cancerous abdominal surgery. To collate the corresponding data for esophageal cancer (EC), a consensus panel was convened to aid specialists from different disciplines, who are involved in the clinical nutrition care of EC patients. The literature was searched using MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the ISI Web of Knowledge. We searched for the best evidence pertaining to nutrition therapy in the case of EC. The panel summarized the findings in 3 sections of this consensus statement, based on which, after the diagnosis of EC, an initial distinction is made between the patients, as follows: (1) Assessment; (2) Therapy in patients with resectable disease; patients receiving chemotherapy or chemoradiotherapy prior to resection, and patients with unresectable disease, requiring chemoradiotherapy or palliative therapy; and (3) Formula. The resulting consensus statement reflects the opinions of a multidisciplinary group of experts, and a review of the current literature, and outlines the essential aspects of nutrition therapy in the case of EC. The statements are: Patients with EC are among one of the highest risk to have malnutrition. Patient generated suggestive global assessment is correlated with performance status and prognosis. Nutrition assessment for patients with EC at the diagnosis, prior to definitive therapy and change of treatment strategy are suggested and the timing interval can be two weeks during the treatment period, and one month while the patient is stable. Patients identified as high risk of malnutrition should be considered for preoperative nutritional support (tube feeding) for at least 7-10 days. Various routes for tube feedings are available after esophagectomy with similar nutrition support benefits. Limited intrathoracic anastomotic leakage postesophagectomy can be managed with intravenous antibiotics and self-expanding metal stent (SEMS) or jejunal tube. Enteral nutrition in patients receiving preoperative chemotherapy or chemoradiation provides benefits of maintaining weight, decreasing toxicity, and preventing treatment interruption. Tube feeding or SEMS can offer nutrition support in patients with unresectable esophageal cancer, but SEMS is not recommended for those with neoadjuvant chemoradiation before surgery. Enteral immunonutrition may preserve lean body mass and attenuates stress response after esophagectomy. Administration of glutamine may decrease the severity of chemotherapy induced mucositis. Enteral immunonutrition achieves greater nutrition status or maintains immune functions during concurrent chemoradiation.

3:45 PM Abstract No. 66 Prognostic factors for clinical outcomes in patients with unresectable esophageal cancer after 125I-seed-loaded stent placement: a multicenter retrospective analysis

3:45 PM Abstract No. 66 Prognostic factors for clinical outcomes in patients with unresectable esophageal cancer after 125I-seed-loaded stent placement: a multicenter retrospective analysis

Effects of S-1 combined with radiotherapy in the treatment of advanced esophageal cancer: A systematic review and meta-analysis protocol.

Background:Esophageal cancer is one of the worst malignant digestive neoplasms with poor treatment outcomes. Definitive concurrent chemoradiotherapy (CRT) has become the standard nonsurgical treatment option for locally advanced esophageal cancer. The chemotherapeutic drugs 5-fluorouracil and cisplatin have been most commonly used in CRT of esophageal cancer. However, radiotherapy combined with 5-FU/cisplatin often delivers severe toxicity to patients. S-1 as an oral chemotherapeutic drug exhibits higher anti-tumor activity, less adverse effects, and better biological availability. S-1 also has excellent effects as a CRT regimen for esophageal cancer.Methods:A systematic literature search will be performed through January 2018 using MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and Google Scholar for relevant articles published in any language. Randomized controlled trials, prospective comparative studies will be included. All meta-analyses will be performed using Review Manager software. The quality of the studies will be evaluated using the guidelines listed in the Cochrane Handbook. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements will be followed until the findings of the systematic review and meta-analysis are reported.Results:The results of this systematic review and meta-analysis will be published in a peer-reviewed journal.Conclusion:Our study will draw an objective conclusion of the effects of S-1 combined with radiotherapy in the treatment of unresectable esophageal cancer and provide level I evidence for clinical decision makings.

Esophageal stenosis and the Glasgow Prognostic Score as independent factors of poor prognosis for patients with locally advanced unresectable esophageal cancer treated with chemoradiotherapy (exploratory analysis of JCOG0303)

BackgroundThe aim of this study was to investigate the possible prognostic factors and predictive accuracy of the Glasgow Prognostic Score (GPS) for patients with unresectable locally advanced esophageal squamous cell carcinoma (LAESCC) treated with chemoradiotherapy.MethodsOne hundred forty-two patients were enrolled in JCOG0303 and assigned to the standard cisplatin and 5-fluorouracil (PF)-radiotherapy (RT) group or the low-dose PF-RT group. One hundred thirty-one patients with sufficient data were included in this analysis. A Cox regression model was used to analyze the prognostic factors of patients with unresectable LAESCC treated with PF-RT. The GPS was classified based on the baseline C-reactive protein (CRP) and serum albumin levels. Patients with CRP ≤1.0 mg/dL and albumin ≥3.5 g/dL were classified as GPS0. If only CRP was increased or only albumin was decreased, the patients were classified as GPS1, and the patients with CRP >1.0 mg/dL and albumin <3.5 g/dL were classified as GPS2.ResultsThe patients’ backgrounds were as follows: median age (range), 62 (37–75); male/female, 119/12; ECOG PS 0/1/2, 64/65/2; and clinical stage (UICC 5th) IIB/III/IVA/IVB, 3/75/22/31. Multivariable analyses indicated only esophageal stenosis as a common factor for poor prognosis. In addition, overall survival tended to decrease according to the GPS subgroups (median survival time (months): GPS0/GPS1/GPS2 16.1/14.9/8.7).ConclusionsEsophageal stenosis was identified as a candidate stratification factor for randomized trials of unresectable LAESCC patients. Furthermore, GPS represents a prognostic factor for LAESCC patients treated with chemoradiotherapy.Clinical Trial InformationUMIN000000861.

Chemoradiation in elderly esophageal cancer patients: rationale and design of a phase I/II multicenter study (OSAGE)

BackgroundThe management of elderly patients with cancer is a therapeutic challenge and a public health problem. Definitive chemoradiotherapy (CRT) is an accepted standard treatment for patients with locally advanced esophageal cancer who cannot undergo surgery. However, there are few reports regarding tolerance to CRT in elderly patients. We previously reported results for CRT in patients aged ≥75 years. Following this first phase II trial, we propose to conduct a phase I/II study to evaluate the combination of carboplatin and paclitaxel, with concurrent RT in unresectable esophageal cancer patients aged 75 years or older.Methods/designThis prospective multicenter phase I/II study will include esophageal cancer in patients aged 75 years or older. Study procedures will consist to determinate the tolerated dose of chemotherapy (Carboplatin, paclitaxel) and of radiotherapy (41.4–45 and 50.4 Gy) in the phase I. Efficacy will be assessed using a co-primary endpoint encompassing health related quality of life and the progression-free survival in the phase II with the dose recommended of CRT in the phase I. This geriatric evaluation was defined by the French geriatric oncology group (GERICO).DiscussionThis trial has been designed to assess the tolerated dose of CRT in selected patient aged 75 years or older.Trial registrationClinicaltrials.gov ID: NCT02735057. Registered on 18 March 2016.

Docetaxel, cisplatin and S-1 as first and second-line regimen in patients with unresectable esophageal cancer

Introduction: The combination of fluorouracil and cisplatin is considered as the standard first-line regimen for unresectable esophageal cancer. However, the prognosis is still dismal. Moreover, there is no established regimen after failure of the first-line therapy. Recently, some study showed the efficacy of induction chemotherapy with docetaxel, cisplatin and fluorouracil (DCF). Considering the results of this regimen, we have been treated the patients with advanced esophageal cancer with docetaxel, cisplatin and S-1(DCS) chemotherapy since 2010. Here, we retrospectively assess the safety and efficacy of DCS for unresectable esophageal cancer as first and second-line therapy. Methods: We enrolled the patients who received DCS as first-line or second-line (or later) for unresectable esophageal cancer. Patients received docetaxel (35mg/m2) plus cisplatin (35mg/m2) intravenously on day1 and 15, and S-1 (80mg/m2) on days 1-14, of a 28 day cycle. If the adverse event was tolerable, patients continued receiving cycles until the progression of the disease was observed or the tumor turned to be resectable. Results: Between May2011 to March 2017, 44 patients were treated with the systemic regimen. Thirty two patients received DCS as first-line therapy (1st-line group), and twelve as second-line or later (2nd-line group). Median age was 62 years (range 47-85) in all. The reason for unresectable were locally advanced (75.0%) and distant metastasis (25.0%). The median number of therapy cycles applied for 1st-line group and 2nd-line group were 3.5 and 3, respectively. In the 1st-line group, complete response (CR), partial response (PR) and stable disease rates ware 12.5%, 62.5% and 18.8%, respectively. Those in the 2nd-line group were 8.3%, 41.7% and 33.3%. In nine patients(20.5%) of all, tumors were turned to be resectable after DCS, they were converted to surgery. The progression free survival (PFS) in all was 6.7±0.2 months [95% confidence interval (CI), 6.3-7.4], and the median overall survival(OS) was 22.7±0.2 months(95%CI, 22.3-23.4). Grade3-4 toxicity were observed in 77.3% with 1st-line and 91.7% with 2nd-line, there was no statistical significance between two groups(p = 0.16). Neutropenia was found as the most common grade3-4 toxicity (65.9%). All the adverse events occurred were manageable. Conclusion: DCS for unresectable esophageal cancer was effective as first-line therapy, and still effective even after failure of the other treatment. Grade3-4 toxity was experienced at a high rate but manageable.

Phase I Study of Definitive Radio-chemotherapy with Cisplatin, 5-Fluorouracil and Cetuximab for Unresectable Locally Advanced Esophageal Cancer

Prognoses of patients receiving radio-chemotherapy with 5-fluorouracil (5-FU) and cisplatin for unresectable esophageal cancer may be improved with the addition of cetuximab. This phase I study aimed to define the maximum tolerated dose of 5-FU when combined with cisplatin, cetuximab and radiotherapy. Treatment included 59.4 Gy of radiotherapy concurrently with two courses of cisplatin (20 mg/m2, d1-4) and 5-FU (dose level 0: 500 mg/m2, dose level 1: 750 mg/m2, d1-4; dose level 2: 1,000 mg/m2, d1-4), followed by two courses of chemotherapy. Cetuximab was given for 14 weeks (400 mg/m2 loading dose followed by 250 mg/m2 weekly). At dose level 1 (n=3) and 2 (n=3), no patient experienced a dose-limiting toxicity. Minor treatment modifications were due to organization or request by physicians/patients. At dose level 2, only five grade 3 adverse events occurred. Dose level 2 appears safe and is used in a subsequent randomized phase II study.

Radioactive self-expanding stents for palliative management of unresectable esophageal cancer: a systematic review and meta-analysis.

Stent insertion is a feasible and safe palliative management for advanced unresectable esophageal cancer. The aim of this study is to assess the efficacy of radioactive stent for unresectable esophageal cancer compared with conventional stent. Systematic searches of the PubMed and Web of science are dated from their beginning to January 25, 2016. Studies that compared radioactive stent with conventional stent for unresectable esophageal cancer were included. The outcomes were postimplantation survival, relief of dysphagia, and complications related to stent implant. Six studies with 539 patients were included. All of them used stent equipped with radioactive iodine beads as a radioactive stent. The pooled weighted mean difference for median survival was 2.734 months (95% CI 1.710-3.775; Z = 5.21, P = 0.000) between two groups. The 1,3,6 month survival rates were higher in radioactive stents than conventional stent, with the pooled ORs 3.216 (95% CI 1.293-7.999; Z = 2.51, P = 0.012), 3.095 (95% CI 1.908-5.020; Z = 4.58, P = 0.000), and 7.503 (95% CI 2.206- 25.516; Z = 3.23, P = 0.001, respectively). The pooled hazard ratio was 0.464 (95% CI 0.328-0.655; Z = 4.35, P = 0.000) between two groups. For relief of dysphagia, two stents all have good relief of the dysphagia effect, but radioactive stent showed a better effect at 3, 6 months follow-up after implantation. For complications related to stent implant, no significant differences were found between two stents in terms of severe chest pain (30.0% vs. 35.7%, OR 0.765, 95% CI 0.490-1.196), gastroesophageal reflux (18.6% vs. 16.1%, OR 1.188, 95% CI 0.453-3.115), fever (12.1% vs. 12.1%, OR 1.014, 95% CI 0.332-3.097), bleeding (16.7% vs. 14.2%, OR 1.201, 95% CI 0.645-2.236), perforation or fistula (6.1% vs. 9.0%, OR 0.658, 95% CI 0.291-1.486), pneumonia (10.7% vs. 14.1%, OR 0.724, 95% CI 0.343-1.526), stent migration (7.0% vs. 10.2%, OR 0.651, 95% CI 0.220-1.924), and restenosis (24.2% vs. 20.6%, OR 1.228, 95% CI 0.674-2.239). Radioactive stent insertion had potential benefits for palliative management for patients with unresectable esophageal cancer. This method prolonged survival and dysphagia relief period without more complications. However, this conclusion should be confirmed by more trials.

The mechanisms of radioresistance in esophageal squamous cell carcinoma and current strategies in radiosensitivity.

Esophageal cancer is the eighth most common cancer and the sixth leading cause of cancer-related death worldwide. Surgery is the primary form of treatment, but the survival is poor, especially for patients with locally advanced esophageal cancer. Radiotherapy has been a critical treatment option that may be combined with chemotherapy in patients with unresectable esophageal cancer. However, resistance to chemoradiotherapy might result in treatment failures and cancer relapse. This review will mainly focus on the possible cellular mechanisms and tumor-associated microenvironmental (TAM) factors that result in radioresistance in patients with esophageal cancer. In addition, current strategies to increase radiosensitivity, including targeted therapy and the use of radiosensitive biomarkers in clinical treatment, are discussed in this review.

Comparison of Efficacy of Self-Expandable Metallic Stent Placement in the Unresectable Esophageal Cancer Patients.

This is a retrospective study to evaluate the prevention of complications of metallic stent placement in patients with unresectable advanced esophageal cancer. A total of 87 patients were treated with 4 types of metal stents in the esophagus over a period of 18 years. Stent placement was technically successful. The most common prior treatment was chemoradiotherapy. There were no significant differences in the rate of patients with no complications among the prior treatments. Approximately, 30% of patients had the most common chest pain in complications. Stent placement within one month after the completion of chemoradiotherapy should be avoided for the prevention of the chest pain. There was no significant difference in the rate of patients with no complications by lesion location. The rate of no complications was higher for the Niti-S stent than the Gianturco Z-stent or Ultraflex stent. Of note, no complications were noted for the Niti-S ultrathin stent at all. Among cases of stent-related death, the most common type of complication was respiratory disorder caused by the stent that seems to be thick and hard. Therefore, the stent with thin and flexible characteristics like the Niti-S ultrathin stent will solve the various problems of esophageal stent placement.

Elevated serum granulocyte-macrophage colony-stimulating factor levels during radiotherapy predict favorable outcomes in lung and esophageal cancer.

The combination of exogenous granulocyte-macrophage colony-stimulating factor (GM-CSF) with radiotherapy (RT) has been demonstrated to strengthen the antitumor immune response. We hypothesized that the variation of GM-CSF during RT was correlated with cancer prognosis. We measured serum levels of GM-CSF and interferon-γ (IFN-γ) before and during RT in 126 unresectable lung and esophageal cancer patients and performed survival analyses. Upregulated GM-CSF levels during RT correlated with longer overall survival (OS) and progression-free survival (PFS). On the other hand, no difference in OS or PFS was seen at different IFN-γ levels. However, the “integrated factor”, computed as the combination of high pre-RT IFN-γ levels and upregulated GM-CSF, correlated with prolonged OS and PFS. Multivariate analyses revealed that GM-CSF levels and the integrated factor were both stronger independent prognostic factors than disease stage. These data demonstrate that GM-CSF levels during RT can be used as a prognostic biomarker for lung and esophageal cancer.

Local Control and Toxicity of a Simultaneous Integrated Boost for Dose Escalation in Locally Advanced Esophageal Cancer: Interim Results from a Prospective Phase I/II Trial

IntroductionApproximately 50% of recurrences after standard-dose chemoradiation for locally advanced esophageal cancer occur within the gross tumor volume (GTV). In this prospective phase I/II clinical trial, we explored the use of a simultaneous integrated boost (SIB) dose to the GTV. MethodsForty-four patients with unresectable esophageal cancer received chemoradiation with an SIB of 58.8 to 63 Gy to the GTV and 50.4 Gy to the planning target volume, all in 28 fractions, with 5 weeks of concurrent docetaxel and fluorouracil or capecitabine. The end points were maximum tolerated dose, time to local failure, and clinical response. ResultsExcluding those with less than 6 months of follow-up, 38 patients were evaluated at the time of analysis. The median age was 65 years (range 37–84). Most patients (71%) were men; 84% had T3 disease, 37% had N1 disease, 26% had N2 disease, 13% had M1 disease, and 50% had adenocarcinoma. The maximum tolerated SIB dose was 63 Gy. None experienced Common Terminology Criteria for Adverse Events grade 4 or 5 toxicity. At a median follow-up time of 13.3 months (range 1.2–36.2), 11 (29%) had local failure (median time to local failure 2.5 months [range 1.5–23.9]). A comparison with 97 similar patients who received 50.4 Gy without an SIB showed that the SIB reduced the local failure rate for patients with node-positive disease (13% versus 56%, p = 0.04), adenocarcinoma (26% versus 59%, p = 0.02), or stage III–IV disease (29% versus 55%, p = 0.04). ConclusionsSIB intensity-modulated radiation therapy to gross primary disease may improve local control for patients with unresectable locally advanced esophageal cancer, especially those with adenocarcinoma.

Assessment of Tumor Size Before and After Palliative Endoscopic Spray Cryotherapy for Treatment of Dysphagia in Advanced Esophageal Cancer: A Pilot Study

Introduction: Endoscopic cryotherapy is increasingly used for the palliation of dysphagia (DP) from bulky esophageal tumors. Our prior research has shown endoscopic cryotherapy to be safe and effective for DP palliation in unresectable esophageal cancer. Although clinical improvements in DP have been documented, there is no evidence to demonstrate objective reduction in tumor size with this treatment modality. The goal of this pilot study was to objectively evaluate the change in the size of the primary esophageal tumor before and after treatment with cryotherapy. Methods: A retrospective consecutive case series of 7 patients with stage IV esophageal adenocarcinoma who received endoscopic cryotherapy for palliation of DP and had contrast enhanced Computerized Tomography (CT) before and after cryotherapy from May 2014 to October 2015. Each mucosal site was treated for 20-30 seconds for 2-3 cycles with at least 45 seconds between freezes to allow complete tissue thawing. Tumor size was assessed using the CT scans. The maximum length and thickness of the tumor was recorded in centimeters (cm). DP was measured using a 4-point Likert scale: 0, no DP; 1, DP to solids; 2, DP to semi-solids; 3, DP to liquids; 4, DP to own saliva. Wilcoxon signed rank test was used to evaluate change in tumor size and DP scores between pre- and post-cryotherapy. Results: Of 7 patients, 6 were males and 1 female. Mean age was 53.3 years. Among 7 patients, a total of 19 cryotherapy treatments were delivered (mean treatments per patient=2.7; range 2-4). All 7 patients also received systemic chemotherapy while undergoing cryotherapy. Six out of 7 patients demonstrated progression of the metastatic disease during this time period. The mean tumor length decreased from 4.4 cm pre-cryo to 3.2 cm post-cryo while the mean tumor thickness decreased from 1.4 cm pre-cryo to 1.2 cm post-cryo. Similarly, the mean DP score improved from 3.5 pre-cryo to 2.5 post-cryo. None of these findings was statistically significant owing to a very small sample size. None of the patients had any adverse effects. Conclusion: Our pilot study provides preliminary evidence of reduction in tumor size following endoscopic cryotherapy for palliation of DP in patients with advanced esophageal cancer. The reduction in tumor size was evident despite progression of distant metastatic disease in the majority of patients. Prospective studies with large sample sizes are needed to confirm this finding.

P-168 Retrospective comparison of efficacy and safety of docetaxel and weekly-paclitaxel as 2nd-line chemotherapy for patients with unresectable or recurrent esophageal cancer

P-168 Retrospective comparison of efficacy and safety of docetaxel and weekly-paclitaxel as 2nd-line chemotherapy for patients with unresectable or recurrent esophageal cancer

P-074 Distant outcome of patients with locally advanced unresectable and metastatic esophageal cancer after multimodality treatment

P-074 Distant outcome of patients with locally advanced unresectable and metastatic esophageal cancer after multimodality treatment

Distribution of lymph node metastases on FDG-PET/CT in inoperable or unresectable oesophageal cancer patients and the impact on target volume definition in radiation therapy.

Definitive chemoradiotherapy (dCRT) is standard care for localised inoperable/unresectable oesophageal tumours. Many surgical series have reported on distribution of lymph node metastases (LNM) in resected patients. However, no data is available on the distribution of at-risk LN regions in this more unfavourable patient group. This study aimed to determine the spread of LNM using FDG-PET/CT, to compare it with the distribution in surgical series and to define its impact on the definition of elective LN irradiation (ENI). FDG-PET/CT images of patients with oesophageal cancer treated with dCRT (from 2003 to 2013) were reviewed to identify the anatomic distribution of FDG-avid LNs. Tumours were divided according to proximal, mid-thoracic or distal localisation. About 105 consecutive patients entered analysis. The highest numbers of FDG-avid LNs in proximal tumours were at LN station 101R (45%) and 106recL (35%). For mid-thoracic tumours at 104R (30%) and 105 (30%). For tumours located in the distal oesophagus, the most common sites were along the lesser curvature of the stomach (21%) and the left gastric artery (21%). Except for the supraclavicular and pretracheal nodes, there were no positive locoregional LNM found outside the standard surgical resection area. Our results show a good correlation between the distribution of nodal volumes at risk in surgical series and on FDG-PET/CT. The results can be used to determine target definition in dCRT for oesophageal cancer. For mid-thoracic tumours, the current target delineation guidelines may be extended based on the risk of node involvement, but more clinical studies are needed to determine if the potential harm of expanding the CTV outweighs the potential benefit.

Phase II study of chemoselection with docetaxel plus 5-fluorouracil and cisplatin induction chemotherapy and subsequent conversion surgery for locally advanced unresectable esophageal cancer.

4021Background: This multicenter phase II trial assessed the safety and efficacy of docetaxel plus 5-fluorouracil and cisplatin (DCF) induction chemotherapy (IC) and subsequent conversion surgery (...