Involved-Field Irradiation in Definitive Chemoradiotherapy for T4 Squamous Cell Carcinoma of the Esophagus

Abstract

Objectives Definitive concurrent chemoradiotherapy (ccrt) is currently a therapeutic option for locally advanced esophageal cancer. However, clinical practice differs with respect to the target volume for irradiation. The purpose of the present study was to analyze failure patterns and survival, and to determine the feasibility of using involved-field irradiation (ifi) with concurrent chemotherapy for T4 squamous cell carcinoma (scc) of the esophagus.Methods Between January 2003 and January 2013, 56 patients with clinical T4M0 scc of the esophagus received ccrt using ifi. The radiation field included the primary tumour and clinically involved lymph nodes. Target volumes and sites of failure were analyzed, as were treatment-related toxicity and survival time.Results In this 56-patient cohort, 13 patients (23.2%) achieved a complete response, and 21 (37.5%) achieved a partial response, for a total response rate of 60.7%. The major toxicities experienced were leucocytopenia and esophagitis, with 14 patients (25.0%) experiencing grade 3 toxicities. At a median follow-up of 34 months, 48 patients (85.7%) had experienced failure: 39 (69.6%) in-field, 7 (12.5%) elective nodal, and 19 (33.9%) distant. Only 1 patient (1.8%) experienced isolated elective nodal failure. The 1-, 2-, and 3-year survival rates were 39.3%, 21.4%, and 12.5% respectively. ConclusionsFor patients with T4M0 scc of the esophagus, definitive ccrt using ifi resulted in an acceptable rate of isolated elective nodal failure and an overall survival comparable to that achieved with elective nodal irradiation. A limited radiation therapy target volume, including only clinically involved lesions, would therefore be a feasible choice for this patient subgroup.

Treatment and clinical outcome of clinical T4 esophageal cancer: A systematic review

“…We found that patients with T4 tumors experienced a clinical complete response (cCR) of 0%‐39% and an overall response rate (both complete and partial responses) of 57%‐88% (Table ) . In contrast, the 1‐, 3‐, and 5‐year overall survival (OS) rates of patients with T4 esophageal cancer that received dCRT were 26%‐79%, 0%‐44%, and 0%‐14%, respectively . Seto et al examined prognosis according to the response to CRT; they reported that the 1‐, 3‐, and 5‐year survival rates of patients that experienced cCR and non‐cCR were 83%, 33%, 33%, and 23%, 0%, 0%, respectively.…”

“…As summarized in Tables and , a total of 16 studies examined the outcome of patients with T4 esophageal cancer after dCRT. Two major clinical studies on dCRT for esophageal cancer conducted in Japan, termed JCOG9516 and JCOG0303, were carried out primarily by the Japanese Clinical Oncology Group.…”

“…Two major clinical studies on dCRT for esophageal cancer conducted in Japan, termed JCOG9516 and JCOG0303, were carried out primarily by the Japanese Clinical Oncology Group. Of the 16 studies, 13 used CF, and three recent studies reported the concurrent use of triplet chemotherapy (DCF). Font et al used a weekly docetaxel regimen (20 mg/m 2 ).…”

“…In contrast, esophagitis, anorexia, oral mucositis, and esophageal dysphagia were common non‐hematological toxicities (Table ). Fistula formation, including esophagotracheal (bronchial or pulmonary) and esophago‐aortic fistulas, was observed in 9%‐22% of patients with cT4 esophageal cancer during or after dCRT. In the JCOG0303 trial, which included patients with cT4 and/or unresectable regional lymph node metastasis, grades 3‐4 fistula formation occurred in 32 of 140 patients (23%) during or after dCRT.…”

“…Seto et al followed nine patients that survived more than 1 year from the start of dCRT; they reported no late toxicity‐related deaths, but they observed grade 2 pericardial effusion and radiation pneumonitis in four and two patients, respectively. An analysis of data from 14 studies with relevant data indicated that the dCRT‐related mortality rate ranged from 0% to 10%. The main causes of dCRT‐related deaths were esophageal fistula with massive bleeding and pneumonitis …”