The Impact of the Radiation Dose Delivered to the Fundus and the Stomach on the Incidence of Anastomotic Complications for Patients with Gastro-Esophageal Junction Cancer Treated with Neoadjuvant Chemoradiotherapy and Surgery

Abstract

stage. The rate of grade 3-4 acute toxicity was significantly lower in patients treated with IMRT compared to those treated with 3DCRT (53% vs. 73%, pZ0.004). The composite rate of toxicity-related events (hospitalization, feeding tube, IV rehydration or RT breaks) was also significantly lower in patients treated with IMRT compared to 3DCRT (56% vs. 85%, p<0.001). 73% of patients who received 3DCRT and 68% of patients who received IMRT underwent subsequent surgical resection (pZ0.245). Among patients who underwent surgical resection, there was no significant difference in the rate of positive margins between those who received 3DCRT and those who received IMRT (7% vs 15%, pZ0.13). Among patients who underwent surgical resection, the 3-year OS and PFS rates were not significantly different in patients receiving 3DCRT compared to IMRT (OS 73% vs. 73%, pZ0.93, PFS 65% vs. 64%, pZ0.68). Among patients who did not undergo surgical resection, the 3-year OS and PFS rates were also not significantly different in patients receiving 3DCRT compared to IMRT (OS 27% vs. 28%, pZ0.93; PFS 19% vs. 14%, pZ0.69). Conclusion: Our study indicates a reduction in the rates of grade 3-4 acute toxicity and toxicity-associated events in patients treated with IMRT compared to 3DCRT, with no significant difference in oncologic outcomes. These findings suggest that IMRT should be considered as the preferred radiation modality in patients treated with preoperative chemoradiation for gastric cancer.

Does Radiation Dose to Gastric Fundus during Neoadjuvant Chemoradiotherapy for Esophageal Carcinoma Have an Impact on Postoperative Anastomotic Leak?

“…However, other studies have shown conflicting reports. Koeter et al [17] and Ermenc et al [14] observed that the radiation dose to the GF did not influence the risk of AL. Koeter et al [17] studied 41.4 Gy in 23 fractions and paclitaxel/carboplatin-based NACRT followed by transhiatal esophagectomy with cervical anastomosis using a gastric tube.…”

“…AL is defined as a disruption of the esophagogastric anastomosis which is diagnosed by radiographic examination using contrast, endoscopy, or clinical signs and symptoms. AL is a common complication following esophagectomy with the incidence ranging between 10 and 25% for cervical and 3-25% for intrathoracic anastomoses [1,5,[10][11][12][13][14]. ALs are associated with severe morbidity and mortality.…”

“…Factors which influence the development of AL include the anastomotic technique (hand sewn vs. stapled vs. hybrid) [7], site of the anastomosis (cervical vs. thoracic) [8][9][10], the type of conduit used for anastomosis (stomach vs. colon vs. small bowel) [11], and NACRT [1,2,[12][13][14]. All our patients underwent NACRT and underwent cervical anastomosis using the stomach as the conduit.…”

“…In their multivariate analysis, they found no significant correlation between V20-40, mean dose to the GF, and AL rates. Ermenc et al [14] retrospectively analyzed records of 37 patients with Siewert I and II gastroesophageal junction cancer. A lower leak rate of 13.5% was reported, and no statistically significant relation with D mean /D max /median dose received by the fundus was available for analysis.…”

“…The mortality associated with leak ranged between 11 and 14% [6]. Risk factors that influenced the development of AL include the anastomotic technique (hand sewn vs. stapled vs. hybrid) [7], location of the anastomosis (neck vs. chest) [8][9][10], type of conduit (stomach vs. colon vs. small bowel) [11], neoadjuvant therapy [1,2,[12][13][14], and comorbid conditions [11,15]. In a single-center retrospective review of 393 esophagectomy patients, neoadjuvant therapy was associated with an odds ratio of 2.2 (OR 2.2, 95% CI 1.1-4.5) for developing AL [11].…”