Postoperative Extended-Volume External-Beam Radiation Therapy in High-Risk Esophageal Cancer Patients: A Prospective Experience

Abstract

Background and PurposeExtended-volume external-beam radiation therapy (rt) following esophagectomy is controversial. The present prospective study evaluates the feasibility of extended-volume rt treatment in high-risk esophagectomy patients with a cervical anastomosis receiving postoperative combined chemoradiation therapy.Patients and MethodsFrom 2001 to 2006, 15 patients with resected esophageal cancer were prospectively accrued to this pilot study to evaluate the adverse effects of extended-volume rt. Postoperative management was carried out at London Regional Cancer Program. Eligibility criteria were pathology-proven esophageal malignancy (T3–4, N0–1), disease amenable to surgical resection, and esophagectomy with or without resection margin involvement. Patients with distant metastases (M1) and patients treated with previous rt were excluded. All 15 study patients received 4 cycles of 5-fluorouracil–based chemotherapy. External-beam rt was conducted using conformal computed tomography planning, with multi-field arrangement tailored to the pathology findings, with coverage of a clinical target volume encompassing the primary tumour bed and the anastomotic site in the neck. The radiation therapy dose was 50.40 Gy at 1.8 Gy per fraction. The rt was delivered concurrently with the third cycle of chemotherapy. The study outcomes—disease-free survival (dfs) and overall survival (os)—were calculated by the Kaplan–Meier method. Treatment-related toxicities were assessed using the U.S. National Cancer Institute’s Common Toxicity Criteria.ResultsThe study accrued 10 men and 5 women of median age 64 years (range: 48–80 years) and TNM stages T3N0 (n = 1), T2N1 (n = 2), T3N1 (n = 11), and T4N1 (n = 1). Histopathology included 5 adenocarcinomas and 10 squamous-cell carcinomas. Resection margins were clear in 10 patients. The median follow-up time was 19 months (range: 3.5–53.4 months). Before radiation therapy commenced, delay in chemotherapy occurred in 20% of patients, and dose reduction was required in 13.3%. During the concurrent chemoradiation therapy phase, 20% of the patients experienced chemotherapy delay, and 6.6% experienced dose reduction. No patient experienced treatment-related acute and chronic esophagitis above grade 2. Disease recurred in 40% of the patients (6/15), and median time to relapse was 24 months. No tumour recurred at the anastomotic site. The median dfs was 23 months, and the median os was 21 months.ConclusionsExtended-volume external-beam rt encompassing the tumour bed and the anastomotic site is feasible and safe for high-risk T3–4, N0–1 esophageal cancer patients after esophagectomy.

Adjuvant concurrent chemoradiation using intensity-modulated radiotherapy and simultaneous integrated boost for resected high-risk adenocarcinoma of the distal esophagus and gastro-esophageal junction

“…However, it is not possible to ascertain the significance of this observation from our small, retrospective cohort. We note that grade 5 toxicity was not observed in our previously reported series using 3DCRT [15]. Given the similarity of surgical techniques between our current cohort and our previously reported series, and given the radiobiological similarity between our current and previous dose-fractionation regimes, at the very least we expect IMRT-SIB to be comparable in terms of acute and late toxicity to our previous technique, with comparable survival.…”

“…Our original retrospective study suggested an OS benefit to adjuvant chemoRT over surgery alone, with median overall survival (OS) being extended to 47.5 months with adjuvant chemoRT versus 14.1 months without (p = 0.001) [9]. Irradiation of the anastomosis was associated with a significant improvement in local and regional relapse [10] and reduced recurrence at the anastomotic site [15], implying the importance of local control as a determinant of outcome [16]. Similar benefits of adjuvant chemoRT have been recognized by other authors [17-19].…”

“…We compared the observed clinical outcomes of our IMRT-SIB cohort to a previous cohort that we treated using our 3DCRT technique [15]. The relevant results of this comparison are presented in Table 4.…”

A retrospective study of pattern of recurrence after radical surgery for thoracic esophageal carcinoma with or without postoperative radiotherapy

“…Therefore, the postoperative target volume is different from that of non-operative radiotherapy. Many target plans have been used in past decades (16,(17)(18)(19)(20)(21), without a standard criterion.…”

Postoperative radiation in esophageal squamous cell carcinoma and target volume delineation

“… 23 , 43 – 45 Such extensive fields can effectively lower the chance of local recurrence within the range of radiation portals. 23 Although several studies have demonstrated the safety and feasibility of extended-volume RT, 46 such an extensive irradiation field frequently causes severe gastrointestinal and systemic reactions, and many patients who have poor tolerance are required to suspend the treatment or reduce the radiation dose. Some patients even experience severe radiation-induced fibrosis of the lung, noncancerous pericardial and pleural effusions, and alimentary tract hemorrhages.…”