Clinical outcomes and prognostic factors for patients with early esophageal squamous cell carcinoma treated with definitive radiation therapy alone

GOALS AND BACKGROUND: There are great differences between treatment methods for early-stage esophageal cancer in institutions. Radiation therapy has been considered to be an effective modality as organ-preserving treatment of the disease. The aim of this study is to assess the effect and limitation of radiation therapy on patients with early esophageal cancer. STUDY: The subjects were 38 patients with stage I (T1N0M0) squamous cell carcinoma of the esophagus who had received definitive radiation therapy alone. Eleven tumors were assessed within the mucosal layer, whereas 27 tumors showed submucosal invasion by examination using endoscopic ultrasound. All patients were treated with more than 60 Gy using a conventional daily fractionation dose at 2 Gy. An additional boost with brachytherapy was performed for 20 patients, and the prescribed doses were 10 Gy (5 Gy x 2 times) with low dose rate (8 patients) and 9 Gy (3 Gy x 3 times) with high dose rate (12 patients). Outcomes and prognostic factors, including the efficacy of intraluminal brachytherapy, were investigated. RESULTS: The cause-specific survival rate and the local control rate at 5 years were 82.6% and 86.3%, respectively. Recurrences were noted in 8 patients with submucosal cancer, but no recurrence was observed in patients with mucosal cancer. In the present study, tumor length was a statistically significant prognostic factor for cause-specific survival (P = 0.018) and tumor depth tended toward statistical significance (P = 0.073). In 27 patients with submucosal cancer, the tumor length was also statistically significant for the survival (P = 0.032). The 5-year cause-specific survival rates for the short tumor group and the long tumor group were 85.7% and 55.6%, respectively. On the other hand, the use of intraluminal brachytherapy had no significant effect on patient survival. CONCLUSION: Radiation therapy is very effective for early esophageal squamous cell carcinoma with tumor length less than 5 cm, but other treatment modalities, including chemoradiotherapy especially for inoperable patients, should be considered for submucosal cancer with a tumor length of 5 cm or more.     

Long-term results of concurrent chemoradiotherapy followed by high dose rate brachytherapy for T2-3 N0-1 M0 esophageal carcinoma

Background To assess the long-term efficacy and the pattern of failure of concurrent chemoradiotherapy followed by high dose rate (HDR) brachytherapy for stage T2-3 N0-1 M0 esophageal carcinoma. Methods Forty-six patients with clinical stage T2-3 N0-1 M0 esophageal cancer received concurrent chemoradiotherapy followed by HDR brachytherapy. The chemotherapy regimen was a combination of cisplatin 60 mg/m² on day 1 and fluorouracil 600 mg/m² continuous infusion from days 1 to 4 during the first and last week of external-beam irradiation. Radiotherapy consisted of external beam to a total dose of 40–60 Gy (median, 50 Gy) and high dose rate brachytherapy to 8–24 Gy (median, 16 Gy) in 2–4 fractions. External beam was delivered to a field of the primary lesion and the involved nodal lesions. All patients were followed up for at least 5 years. Results The 5-year overall survival rate was 28%. The median survival duration was 22 months. The 5-year cause-specific survival rate was 34% and the median was 22 months. Persistent disease was found in 7 of 46 patients (15%). Of the 39 patients with initial complete tumor disappearance, locoregional failure occurred ultimately in 13 patients. The ultimate local control rate was 57% (26/46). Three patients were salvaged successfully with surgery. Four patients (9%) had regional recurrence out of the irradiated fields as first failure site. Four patients (9%) had recurrence 3 years or longer after treatment. Twelve patients had transient ulcers, which healed spontaneously within a few months. Massive esophageal bleeding, thought to be treatment related, occurred in 2 patients, leading to death. Severe late toxicity with esophageal ulceration was found in patients receiving a dose of 16–24 Gy via brachytherapy. Conclusions Concurrent chemoradiotherapy followed by HDR brachytherapy achieved long-term effective and curative results for stage T2-3 N0-1 M0 esophageal carcinoma. However, severe late toxicity was observed with 16–24 Gy via brachytherapy. We recommend a dose via HDR brachytherapy should be 12 Gy or less following concurrent chemoradiotherapy.     

Effect of Histologic Type on Recurrence Pattern in Radiation Therapy for Medically Inoperable Patients with Stage I Non-Small-Cell Lung Cancer

Japanese randomized trials showed that there was a significant impact on survival from stage I adenocarcinoma (AD) of the lung by adjuvant chemotherapy with uracil-tegaful after complete resection but there was no effect for patients with squamous cell carcinoma (SQ). The purpose of this study was to examine the correlation of tumor histology and clinical outcome of radiation therapy (RT) for stage I non-small-cell lung cancer (NSCLC) and to consider the necessity of adjuvant chemotherapy after RT for these patients. The subjects were 83 patients, 54 with SQ and 29 with AD; they had received definitive RT with the total dose ranging from 60 to 80 Gy with conventional fractionation at a daily dose of 2 Gy. The differences between SQ and AD with respect to survival and recurrence pattern were investigated. The 5-year overall survival and cause-specific survival rates were 26.5% and 49.1%, respectively. No difference in survival was observed between SQ and AD patients, and the recurrence rates were almost identical (44% for SQ and 45% for AD). However, the 5-year primary control rate of SQ was significantly poorer than that of AD (SQ: 61.5%; AD: 87.6%; p = 0.03). Conversely, the 5-year metastasis-free survival rate of SQ was significantly better than that of AD (SQ: 88.2%; AD: 53.0%; p = 0.005). The different failure pattern, according to tumor histology, indicates that taking into consideration the difference in their clinical behaviors would also be important for planning RT and surgery for early lung cancer. Presented in part at the 10th World Conference on Lung Cancer, Vancouver, British Columbia, Canada, August 10–14, 2003.     

Salvage radiation therapy and chemoradiation therapy for postoperative locoregional recurrence of esophageal cancer

The purpose of this retrospective study was to assess the efficacy of salvage radiation therapy (RT) or chemoradiation therapy (CRT) for locoregional recurrence (LR) of esophageal cancer after curative surgery. Forty‐two patients who received salvage RT or CRT for LR of esophageal cancer after curative surgery between November 2000 and May 2012 were reviewed. The intended RT regimen was 60 Gy in 30 fractions combined with concurrent platinum‐based chemotherapy. Median follow‐up periods were 17.9 months for all evaluable patients and 28.2 months for patients still alive (19 patients) at analysis time. The 1‐, 2‐, and 3‐year survival rates were 81.2 ± 6.4%, 51.3 ± 8.6%, and 41.1 ± 8.7%, respectively, with a median survival time of 24.3 ± 4.1 months. Out of 41 evaluable patients, 16 patients (39%) were alive beyond 2 years from salvage therapy. However, univariate analyses for overall survival showed no significant prognostic factor. Grade 3 or higher leukocytopenia was observed in 46% of the patients. Salvage RT or CRT for LR after surgery for esophageal cancer was safe and effective. These therapies may offer long‐term survival to some patients. RT or CRT should be considered for LR.     

Results of chemoradiotherapy for stage I esophageal cancer in medically inoperable patients compared with results in operable patients

The purpose of the present study was to evaluate long‐term results of chemoradiotherapy for clinical T1b‐2N0M0 esophageal cancer and to compare outcomes for operable and inoperable patients. Patients with stage I esophageal cancer (Union for International Cancer Control [UICC] 2009), excluding patients with cT1a esophageal cancer, were studied. All patients had histologically proven squamous cell carcinoma. Operable patients received cisplatin and 5‐fluorouracil with concurrent radiotherapy of 60 Gy including a 2‐week break. Inoperable patients received nedaplatin and 5‐fluorouracil with concurrent radiotherapy of 60–70 Gy without a pause. End‐points were overall survival rate (OS), cause‐specific survival rate (CSS), progression‐free survival rate (PFS), and locoregional control rate (LC). Thirty‐seven operable patients and 30 medically inoperable patients were enrolled. There was a significant difference in only age between the operable group and inoperable group (P = 0.04). The median observation period was 67.9 months. In all patients, 5‐year OS, CSS, PFS, and LC were 77.9%, 91.5%, 66.9%, and 80.8%, respectively. Comparison of the operable group and inoperable group showed that there was a significant difference in OS (5‐year, 85.5% vs. 68.7%, P = 0.04), but there was no difference in CSS, PFS, or LC. Grade 3 or more late toxicity according to Common Terminology Criteria for Adverse Events v 3.0 was found in seven patients. Even in medically inoperable patients with stage I esophageal cancer, LC of more than 80% can be achieved with chemoradiotherapy. However, OS in medically inoperable patients is significantly worse than that in operable patients.     

Positive impact of radiation dose on disease free survival and locoregional control in postoperative radiotherapy for squamous cell carcinoma of esophagus

SUMMARY.  The effect of total radiation dose (TRD) on the outcome of patients with postoperative radiotherapy (RT) for squamous cell carcinoma of esophagus was assessed. Sixty-seven patients with esophagectomy, followed by postoperative RT for squamous cell carcinoma of esophagus from June 1984 through February 2001, were retrospectively reviewed. Of these, 13 patients were excluded. No patient had chemotherapy. Patients were classified into two groups based on TRD delivered: TRD of less than 50 Gy (Group A, n  = 16) and at least 50 Gy (Group B, n  = 38). Follow-up duration of all patients ranged from 4 to 140 months (median, 14). Median TRD of Group A and B were 45 Gy (range, 45–48.6) and 54 Gy (range, 50–59.6), respectively. Median overall survival (OS) and disease-free survival (DFS) of all patients were 15 and 10 months, respectively. Although the TRD of 50 Gy or higher was marginally significant for improved OS (hazard ration [HR] 0.559, P  = 0.066), it was statistically significant for improved DFS (HR 0.398, P  = 0.011), and locoregional recurrence-free survival (HR 0.165, P  = 0.001) with multivariate analysis. Three patients in group A and two in group B experienced a complication of grade 3 or higher. Our study suggests a positive impact of TRD of 50 Gy or higher on DFS and locoregional control, with acceptable morbidity in postoperative RT for patients with squamous cell carcinoma of esophagus. According to the present analysis, TRD should be at least 50 Gy in postoperative RT alone setting.     

EMR as salvage treatment for patients with locoregional failure of definitive chemoradiotherapy for esophageal cancer

BACKGROUND: Definitive chemoradiotherapy is recognized as a standard treatment for esophageal cancer. Although most failures of this combined modality are locoregional, without distant metastasis, there are few curative treatment options available in such cases except salvage esophagectomy. METHODS: Experience with 16 patients with squamous cell carcinoma of the esophagus who underwent EMR as a salvage treatment after locoregional failure of definitive chemoradiotherapy was reviewed retrospectively. EMR was performed by using the mucosal strip technique. Eight patients had local recurrence at the primary site after a complete response to chemoradiotherapy, 5 had metachronous multiple cancers, and 3 had residual tumor after completing chemoradiotherapy. RESULTS: In all patients, the EMR-treated tumors were histopathologic stage T1 and were clinical stage N0M0 as defined by EUS and CT. No serious complication was observed in any patient. At a median follow-up of 33 months (range 11-73 months) from the initiation of chemoradiotherapy, 3 patients (38%) with local recurrence at the primary site, 3 (40%) with metachronous multiple cancers, and two (67%) with residual cancer were still alive and disease-free after salvage EMR, for periods of 30 to 63 months. The 3-year survival rate from the initiation of salvage EMR for all patients was 56%. CONCLUSIONS: Long-term survival can be achieved with salvage EMR for locoregional failure after definitive chemoradiotherapy for esophageal cancer without serious complications. EMR may be a salvage treatment option when a recurrent or residual tumor is superficial or local.     

Salvage esophagectomy after exclusive chemoradiotherapy: results at the Brazilian National Cancer Institute (INCA)

Surgical resection is considered the gold standard treatment for esophageal cancer, with global cure rates ranging from 15 to 40%. Exclusive chemoradiotherapy has been used for patients with locally advanced esophageal carcinoma or without clinical conditions for esophagectomy, reaching a 5‐year survival rate of up to 30%. However, locoregional control is poor, with local recurrence of 40–60%, being reported in the literature. Maybe, these patients can benefit from salvage surgery. In this study, 15 patients with esophageal cancer submitted to salvage esophagectomy after exclusive chemoradiotherapy treatment were retrospectively analyzed. Salvage esophagectomy was demonstrated to be technically feasible. However, it presents with high surgical morbidity. Currently, salvage esophagectomy is considered the best available treatment to attempt cure in cases of tumor recurrence or persistence after exclusive chemoradiotherapy. All the other types of treatments are regarded as palliative with discouraging survival results.     

原发性肝细胞癌伴门静脉癌栓患者接受立体定向放射治疗的疗效观察

目的评价原发性肝细胞癌伴门静脉癌栓患者接受立体定向放射治疗(射波刀)的疗效。方法收集我院2011年1月—2015年5月原发性肝细胞癌伴门静脉癌栓患者59例,均接受射波刀治疗。门静脉癌栓的大体肿瘤体积为24.6~1265.0 cm3,中位数399.0 cm3,单次分割剂量5~13 Gy/次(中位数10 Gy),照射次数4~8次(中位数6次),肿瘤剂量35~56 Gy(中位数49 Gy),每d或隔1~2 d照射1次。采用寿命表法进行生存分析,Cox回归模型分析生存相关的影响因素。结果 59例肝癌伴门静脉癌栓患者接受射波刀治疗,中位无疾病进展生存期为5.19个月,中位总生存期为11.84个月,疾病控制率为62.71%(37/59),治疗后1年、2年、3年的累积生存率分别为49.15%(29/59)、20.34%(12/59)、11.86%(7/59)。Cox回归分析显示:术前AFP水平、性别、年龄、病灶大小、肿瘤数目、肝功能Child-Pugh分级、腹水、癌栓类型及总剂量大小对患者生存期无明显影响。结论射波刀是肝癌伴门静脉癌栓患者较理想的治疗方法,可显著延长患者生存期。     

Combined-modality therapy for locoregional esophageal cancer]

Treatment for patients with esophageal cancer remains unsatisfactory. Although surgery alone or chemoradiotherapy have been generally accepted as reasonable options for patients with locoregional esophageal cancer, 5-year survival rate of either management is about 20%. The limited success of single modality treatment using radiotherapy or surgery has led to the investigation of multimodality therapies, combining chemotherapy, radiotherapy, and surgery. However, the appropriateness of such therapies remains unanswered. A number of prospective randomized trials of trimodality therapy versus surgery alone suggest benefits of combined-modality therapy. Concurrent chemoradiotherapy is an alternative treatment in selected resectable cases to show potential benefits in survival and local control. Patients with complete response following neoadjuvant therapy have consistent, substantial benefits in survival. Pretreatment staging is necessary for standardization of patients undergoing treatment protocols and for outcome evaluation. Biologic markers can be used to predict response to therapy and might allow designation of treatment based on the individual tumor. In the future, clinical trials testing optimal integration of preoperative regimen including new drugs may impact on the prognosis of esophageal cancer.     

Curative treatment of non-metastatic esophageal cancer: concomitant chemoradiotherapy and high-dose-rate endoluminal curietherapy boost

OBJECTIVES: The aim of this study was to evaluate the feasibility, toxicity, and efficacy of a curative combination of chemo-radiotherapy with high-dose-rate brachytherapy (HDRB) in patients with non metastatic esophageal cancer. PATIENTS AND METHODS: Fifty-two patients with esophageal carcinoma were treated with > 50 Gy external irradiation, concomitant chemotherapy (5FU-CDDP) followed by HDRB delivering 12.5 Gy (6-20) as a boost. Twelve patients were stage I, 20 stage IIa, 5 stage IIb, and 13 stage III, 1 Tis, 1 stage N unknown. Surgery was not indicated for medical reasons. RESULTS: The response rate was 96%, with complete response rate 85%. The 1-, 3-, 5-year overall survival rates were 78%, 33%, and 22% respectively. A local failure occurred in 32%, and distant metastasis in 16%. Severe (grade 3, 4) acute toxicity occurred in 6 cases, severe late toxicity in 2 cases and there was 1 toxic death. Tumoral length > or = 5 cm and stage IIa, IIb and III versus stage 1 indicated poor prognosis. CONCLUSION: This regimen is feasible and well tolerated. The 5-year overall survival is 22%, but the local failure rate is still very high. These results are encouraging and will be prospectively evaluated with currently ongoing randomized trial.     

Examined lymph node count is not associated with prognosis in elderly patients with pN0 thoracic esophageal cancer

The purpose of this study was to determine whether the number of lymph nodes dissected predicts prognosis in surgically treated elderly patients with pN0 thoracic esophageal cancer. We searched the Surveillance, Epidemiology, and End Results database and identified the records of younger (<75 years) and older (≥75 years) patients with pN0 thoracic esophageal cancer between 1998 and 2015. The patient characteristics, tumor data, and postoperative variables were analyzed in this study. The Kaplan-Meier method and a Cox proportional hazard model were used to compare overall and cause-specific survival. Data from 1,792 esophageal cancer patients (older: n = 295; younger: n = 1497) were included. The survival analysis showed that the overall and cause-specific survival in the patients with ≥15 examined lymph nodes (eLNs) was significantly superior to that in the patients with 1 to 14 eLNs (P < .001); however, the difference disappeared in the older patients. After stratification by the tumor location, histology, pT classification, and differentiation between the younger and older cohorts to analyze the association between eLNs and survival, we found that the differences remained significant in most subgroups in the younger cohort. There were no differences in any subgroups of older patients. This study replicated the previously identified finding that long-term survival in patients with extensive lymphadenectomy was significantly superior to that in patients with less extensive lymphadenectomy. However, less extensive lymphadenectomy may be an acceptable treatment modality for elderly patients with pN0 thoracic esophageal cancer.     

食管黏膜下肿物的特性以及超声内镜的诊断和治疗意义

背景：食管病变内镜下或手术治疗的风险均较高,术前准确判断病变的层次和性质,对决定手术的方式十分重要。目的：探讨食管黏膜下肿物的特性以及超声内镜对食管黏膜下肿物的诊断、治疗意义。方法：由内镜检查发现的116例食管黏膜下肿物患者行超声内镜检查,并给予相应的切除治疗,总结超声内镜下食管黏膜下肿物的特性。结果：超声内镜下88例（75．9％）食管黏膜下肿物的直径〈1cm,104例（89．7％）病变起源于黏膜肌层,多数（85．3％）表现为低回声或混合偏低回声的声像图。80例接受切除治疗,其中67例（83．8％）行EMR治疗,肿物直径〈1cm者占89．6％,局限于黏膜肌层占97．0％。组织病理学分析表明食管黏膜下肿物以平滑肌瘤最为常见（86．3％）。超声内镜诊断与病理诊断的符合率约为82％。结论：大多数食管黏膜肌层起源的肿物行EMR治疗简便、安全,对于较大的病灶,或起源于固有肌层者ESD仍是一种安全有效的方法。超声内镜可判断食管黏膜下肿物起源并进行定性诊断,从而指导临床合理选择黏膜下肿物的治疗方法。     

Selective dose escalation of chemoradiotherapy for locally advanced esophageal cancer

SUMMARY. This phase II study assessed the use of concurrent continuous infusion of 5‐fluorouracil and weekly carboplatin plus paclitaxel with selective radiation dose escalation for patients with localized esophageal cancer. Patients with esophageal carcinoma were staged by thoracic and abdominal computed tomography, endoscopic ultrasound, and positron emission tomography scans. Patients received a continuous infusion of 5‐fluorouracil 225 mg/m² on days 1 to 38 and intravenous paclitaxel 45 mg/m² and carboplatin AUC 2 on days 1, 8, 15, 22, 29, and 36. Radiotherapy was delivered in 1.8‐Gy fractions, 5 d/wk for 5.5 weeks. Six to 8 weeks after initial therapy, patients without metastatic progression but with a positive biopsy, or less than partial response received a 9‐Gy boost with the same concurrent chemotherapy. Twenty‐four patients were enrolled: 18 patients were enrolled initially; 6 additional patients were enrolled following a protocol amendment designed to reduce the esophagitis by adding the radioprotectant amifostine. Median follow‐up was 30 months. Twenty (83%) patients had adenocarcinomas of the lower esophagus/gastroesophageal junction. Seventeen patients (81%) attained at least a partial response. Six patients received boost treatment. At 4 years, overall survival was 28%, cause‐specific survival was 38%, locoregional control was 61%, and distant metastasis‐free survival was 52%. Radiation delays ranged from 0 to 62 days (median, 8 d), primarily owing to esophagitis. In total, 28% of patients developed esophageal strictures requiring dilatations. There were no differences in esophageal strictures, local control, or survival with the addition of amifostine.     

Long-term outcomes of combined endoscopic resection and chemoradiotherapy for esophageal squamous cell carcinoma with submucosal invasion

BackgroundFor esophageal squamous cell carcinoma (ESCC) with submucosal (SM) invasion, surgery is the standard treatment. Definitive chemoradiotherapy (D-CRT) is a less invasive alternative option, but sometimes results in locoregional failure.AimTo examine whether endoscopic resection for primary lesion removal combined with chemoradiotherapy (ER-CRT) reduces locoregional failure rates in cases of ESCC with SM invasion.MethodsWe retrospectively compared clinical outcomes between ER-CRT and D-CRT in patients diagnosed with ESCC with SM invasion between 2003 and 2014. Twenty-one patients underwent ER-CRT based on a pathological diagnosis, and 43 patients underwent D-CRT based on a clinical diagnosis.ResultsLocoregional failure developed in 26% of patients in the D-CRT group, and in no patients in the ER-CRT group (p < 0.01). Thus, the 5-year relapse-free survival in the ER-CRT group was significantly more favorable than that in the D-CRT group (85.1% vs 59.2%; p < 0.05), although there was no difference in overall survival (85.1% vs 79.1%) nor in cause-specific survival (90.5% vs 87.2%) between the groups. There were no instances of perforation or hemorrhage associated with ER.ConclusionER-CRT is a safe and effective treatment strategy and can be considered as a new minimally invasive treatment option for patients with ESCC with SM invasion.     

Optimal treatment for localized esophageal cancer still uncertain

These articles both report the results of multi-institutional, randomized, phase 3 trials for the treatment of patients with localized (T1-3 N0-1 M0) esophageal squamous cell carcinoma (SCC) or esophageal adenocarcinoma. Both studies were initiated and coordinated by the Radiation Therapy Oncology Group (RTOG) but included patients enrolled by other study groups as well. Cooper et al. report late follow-up results for the RTOG 85-01 trial that was conducted between 1986 and 1990. This trial randomized patients to either radiation therapy (RT) alone (RT, 64 Gy in 32 fractions over 6.4 wk, n = 62) or combined RT and chemotherapy (50 Gy in 25 fractions over 5 wk, plus cisplatin 75 mg/m2 i.v. on first day of wk 1, 5, 8, and 11, and continuous infusion fluorouracil (5FU) 1 g/m2 per day on the first 4 days of the same weeks, n = 61). Most (82%) of the patients had SCC. Eight percent of the cohort randomly assigned to combined modality therapy experienced acute life-threatening toxic effects, and an additional 2% died as a direct consequence of treatment. The randomized trial was halted in 1990 when an interim analysis found a highly significant difference in survival favoring the combined therapy group, after which 73 consecutive patients were enrolled into a nonrandomized study offering only the combined therapy regimen. At 5-yr of follow-up, the overall survival rate for the combined therapy group in the randomized study was 26% (95% CI, 15-37%) compared with 0% for RT alone. In the nonrandomized study, the 5-yr overall survival rate was 14% (95% CI, 6-23%). The histopathological type of tumor did not significantly influence survival. Cooper et al. now report that 22% of the randomized combined modality group survived at least 8 yr after treatment, and that there were no deaths caused by esophageal cancer after 5 yr post-treatment. The study reported by Kelsen et al. included 440 patients with esophageal adenocarcinoma (n = 236) or SCC (n = 204) randomized to either preoperative chemotherapy plus esophagectomy or to esophagectomy alone. The chemotherapy regimen consisted of three cycles of preoperative cisplatin and 5FU and two cycles after operation for responding patients. Doses were higher than those used in the RTOG 85-01 trial. Although radiation therapy was not part of the treatment plan, it could be given in some circumstances. There was no significant difference in median survival (14.9 months for chemotherapy plus surgery compared with 16.1 months for surgery alone), and there were also no significant differences in 1-yr, 2-yr, 3-yr, or disease-free survival rates. There were no significant differences in survival between patients with adenocarcinoma and those with SCC. A clinical response to chemotherapy, as assessed by barium contrast radiography, was found in 19% of patients who received chemotherapy. A complete pathological response was found in 2.5% of patients. There was no significant increase in operative complications in the chemotherapy treated group.     

Trimodality therapy and definitive chemoradiotherapy for esophageal cancer: a single‐center experience and review of the literature

In the UK, the standard of care for esophageal cancer has generally combined surgery with neoadjuvant chemotherapy, with definitive chemoradiotherapy (dCRT) being reserved for certain subgroups. Chemoradiotherapy followed by surgery (trimodality therapy) has not been widely adopted. The outcomes of patients undergoing dCRT or trimodality therapy at our cancer center between 2004 and 2012 were restrospectively analyzed. Trimodality therapy was offered to selected patients of good performance status (World Health Organisation performance status 0/1), with squamous cell carcinoma or bulky adenocarcinoma. dCRT was offered to patients of good PS but with comorbidities, upper third tumors or at patient's request. Patients received four cycles of chemotherapy with a platinum agent (mostly cisplatin) and a fluoropyrimidine (mostly 5‐fluorouracil) over a total of 11 weeks. Cycles 3 and 4 were given concurrently with radiotherapy: 50 Gy in 25 fractions for dCRT and 45 Gy in 25 fractions in the trimodality group. Surgery occurred 8–10 weeks following the completion of chemoradiotherapy. The cut‐off length for maximum gross tumor volume length was 10 cm. One hundred two patients were included (47 received dCRT, and 55 received trimodality treatment). The majority of tumors were stage III (80.4%), and two‐thirds were located in the distal esophagus (64.7%). Median follow‐up was 44 months. The 2‐year overall survival (OS) was 57.3% (median OS 39.7 months) for the dCRT group and 77.8% (median not reached) for the trimodality group. The 5‐year OS rates were 38% and 58%, respectively. Postoperative mortality rate was low at 1.8%, and the pathological complete response rate was 23.6%. In conclusion, trimodality treatment for patients with esophageal and junctional gastroesophageal tumors offers high rates of 2‐year survival, and the potential for long‐term cure. dCRT is an established alternative for patients that are not fit or suitable for surgery.     

Anal carcinoma of the elderly treated with radiotherapy alone or with concomitant radio-chemotherapy

PURPOSE: To analyse the results achieved with radio-chemotherapy (RTCT) or radiotherapy alone (RT) in elderly patients (pts) affected with squamous cell anal cancer. METHODS AND MATERIALS: From 1990 to 2002, 62 pts aged > or =70 years were treated with RT (14) or RTCT (48). There were 9 stage I, 29 stage II, 11 stage IIIa and 13 stage IIIb. MMC+5FU was given concomitantly with RT in an early period, later replaced by Cddp+5FU. In the RTCT group, 36Gy were delivered to pelvic+inguinal lymph nodes, with a tumor boost (18Gy). RESULTS: Stage II fared significantly better than stage III in terms of locoregional control (LRC) but not overall survival (OS). Pts treated with RTCT had improved LRC, but not OS. LRC was 81% at 3 and 5 years for the RTCT group; the RT group had a LRC of 61% at 3 years. There were more locoregional relapses in the MMC group (29%) versus the Cddp group (19%) and in pts treated with a split (32%) versus no split (19%). No G3 acute toxicity was observed in the RT group; in the RTCT group 15 pts (31%) developed a G3+ acute toxicity. G3+ late damage occurred in 2 pts in the RT only group and in 3 pts in the RTCT group. CONCLUSIONS: Elderly people considered fit for RTCT should undergo the same schedules used for younger people. MMC or Cddp+5FU are feasible in the elderly, even without a planned split.     

Palliative radiation therapy practice for advanced esophageal carcinoma in Africa

While numerous surveys of pattern of practices of palliative radiotherapy (RT) in advanced esophageal cancers have been published in developed countries, there is no such survey in African countries. During and after a regional training course by the International Atomic Energy Agency (IAEA) in palliative cancer care, a questionnaire was distributed to African RT centers to gather information about infrastructure and human resources available, and the pattern of practice of palliative RT for esophageal cancers. Twenty‐four of the 35 centers (60%) completed the questionnaire. Twenty out of 23 (87%) centers treat patients with esophageal cancer presenting with dysphagia using external beam RT (16 centers external beam RT alone and 4 centers also use brachytherapy as a boost). Twelve (60%) centers prescribe RT doses of 30 Gy in 10 fractions and 2 centers 20 Gy in 5 fractions. Eighteen centers (78%) have low dose rate (LDR) brachytherapy, and 9 (39%) centers have high dose rate (HDR) brachytherapy. One center only used HDR brachytherapy alone to a dose of 16 Gy in 2 fractions over 8 days. RT remains a major component of treatment of patients with esophageal cancers in African countries. Still, there is a great variety among centers in both indications for RT and its characteristics for a treatment indication.     

Preoperative chemoradiotherapy in cancer of the thoracic esophagus

Surgery with or without adjuvant radiotherapy (RT) is the standard treatment of esophageal cancer. Preoperative radio- and chemotherapy (CT) have been introduced to improve prognosis. We report a phase II prospective non-randomized trial of preoperative RT (42 Gy/25) plus CT (cisplatin 20 mg/mq/day plus 5-fluorouracil 600 mg/mq/day, 1-5 weeks) for the treatment of thoracic esophageal cancer. From 1993, 50 patients were enrolled (40 men and 10 women, mean age 57 years, range 30-75 years). Squamous cell carcinoma accounted for 90% of cases; 10% were adenocarcinoma. Downstaging of the disease was obtained in 77.3% of cases; there were 13 (29.5%) complete responses (CR) and 21 (47.7%) partial responses (PR). Median survival was 28 and 25 months, respectively, for CR and partial response (PR) plus stable disease (SD) and progressive disease (PD) (P = 0.05). Progressive-free median survival was 22 and 17 months, respectively, for CR and PR + SD + PD (P = 0.08). Multimodal treatment of esophageal cancer showed promising results, although not significant, in terms of survival and disease progression for patients achieving a complete pathologic response.