<p>Postoperative Radiotherapy for Thoracic Esophageal Carcinoma with Upfront R0 Esophagectomy</p>

Abstract

Multidisciplinary therapies can improve the survival of patients with locally advanced esophageal carcinoma. However, the determination of the optimal modality is still a controversial subject. Many randomized controlled trials in the late 20th century showed that there was no survival benefit when postoperative radiotherapy was added to surgery for esophageal carcinoma. As a result, the treatment modality shifted thereafter to neoadjuvant therapies. Even so, these trials are criticized for many limitations and an increasing number of studies (mainly nonrandomized controlled trials) has indicated that postoperative radiotherapy/chemoradiotherapy can improve the survival of patients with a poor prognosis after R0 esophagectomy. Additionally, a large number of patients with locally advanced esophageal carcinoma still choose upfront surgery in the clinical practice due to many reasons. Therefore, postoperative radiotherapy seems to be a feasible treatment for these patients with a poor prognosis, particularly in the new era of conformal radiotherapy. Here, we review published studies on postoperative radiotherapy/chemoradiotherapy, and we discuss the clinical issues related to postoperative radiotherapy, such as the indication, target volume, total radiation dosage, time interval and complications of postoperative radiotherapy with or without chemotherapy, to make recommendations of postoperative radiotherapy for both current practice and future research in esophageal carcinoma.

Mapping of Cervical and Upper Mediastinal Lymph Node Recurrence for Guiding Clinical Target Delineation of Postoperative Radiotherapy in Thoracic Esophageal Squamous Cell Carcinoma

“…After the success of the ChemoRadiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) trial, neoadjuvant chemoradiotherapy has become the standard treatment for locally advanced resectable EC in many countries (3,4). Although postoperative radiotherapy (PORT) has failed to improve survival in EC according to most previous randomized controlled trials, these trials have been criticized for many limitations, and an increasing number of studies have proved that postoperative radiotherapy/chemoradiotherapy can improve the survival of patients with poor prognosis after upfront esophagectomy (5). Therefore, PORT with or without chemotherapy is still a choice for EC in clinical practice, especially for patients with pathologically upstaged clinical early stage EC or patients with locally advanced EC who receive upfront surgery.…”

“…Many clinical target volumes have been used for PORT in EC in past decades, ranging small volumes consisting of the primary tumor bed only to large volumes consisting of the lower neck, total mediastinum and the upper celiac area (5). An appropriate irradiation field may not only improve disease control but also decrease radiotherapy-related complications.…”

“…Due to the characteristics of lymphatic drainage, surgical procedure and recurrence patterns after esophagectomy (6)(7)(8), it has been found that the lower neck, upper mediastinum and paraaortic area are high-risk regions for lymph node recurrence (LNR) in thoracic EC (TEC). Therefore, it is recommended that the lower cervical and upper mediastinal regions should be included in the nodal clinical target volume (CTVnd) for PORT in all TECs, while the celiac region should also be included in the CTVnd in TECs with a high-risk factor for celiac recurrence (5,6,9).…”