The role of surgery and postoperative chemoradiation therapy in patients with lymph node positive esophageal carcinoma

Bédard, Éric; Inculet, Richard; Malthaner, Richard; Brecevic, Edward; Vincent, Mark; Dar, R.

doi:10.1002/1097-0142(20010615)91:12<2423::aid-cncr1277>3.0.co;2-1

Cited by 119 publications

(76 citation statements)

References 18 publications

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“…The rt dose level sufficient to reduce relapse when delivered to the tumour bed concurrently with chemotherapy, while still balancing acceptable toxicity, is not yet clear. Total rt doses of 45–50 Gy to the tumour bed have been reported 7,8,26 to be acceptable and are associated with tolerable treatment side effects.…”

Section: Discussionmentioning

confidence: 99%

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

Tai²,

Younus

et al. 2009

Current Oncology

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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.

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Section: Discussionmentioning

confidence: 99%

“…Post-operative radiation therapy ( rt ) 2,3 and postoperative chemoradiation 4–6 have been used for esophageal cancer patients deemed to be at high risk for recurrence after esophagectomy. As compared with surgery alone, postoperative chemotherapy and rt 7,8 have been reported to be beneficial with regard to survival.…”

Section: Introductionmentioning

confidence: 99%

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

Tai²,

Younus

et al. 2009

Current Oncology

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“…[7] An institutional study in the UK found that of upfront esophagectomy patients (T1-T4) that were determined to be pathologic N1, approximately 60% of patients were able to proceed with adjuvant chemoradiation therapy with a significant improvement in overall survival (47.5 months versus 14.1 months, p=0.001). [11] These findings from both retrospective institutional studies and national databases likely reflect selection biases that may hinder upstaged/node positive patients from receiving appropriate adjuvant therapy. In our study, patients of non-Caucasian race, non-private insurance, increasing age, and increased length of inpatient stay after esophagectomy were all found to receive adjuvant therapy less frequently, suggesting that both access to care and post-esophagectomy complication/frailty factors may be influencing uptake of adjuvant therapy when clinically indicated.…”

Section: Commentmentioning

confidence: 99%

Clinical T2N0 Esophageal Cancer: Identifying Pretreatment Characteristics Associated With Pathologic Upstaging and the Potential Role for Induction Therapy

Samson

Puri

Robinson

et al. 2016

The Annals of Thoracic Surgery

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Background While studies have suggested standard therapy for clinical T2N0 esophageal cancer should be primary surgery, we hypothesize there is a subgroup for whom induction therapy may result in improved overall survival (OS). Methods cT2N0 esophageal cancer patients receiving induction therapy or upfront esophagectomy (UE) were identified in the National Cancer Data Base (NCDB). UE patients were dichotomized as 1) pathologically upstaged or 2) same-or down-staged. Logistic regression models identified variables associated with upstaging and Kaplan-Meier analysis compared median OS. Results From 2006–2012, 932 (52.2%) cT2N0 patients received UE, while 853 (47.8%) received induction therapy first. 326/713 (45.7%) UE patients were upstaged. 87/326 (26.7%) patients had T upstaging, 98/326 (30.1%) had N upstaging, and 141/326 (43.3%) had both. Patients upstaged after UE had a higher tumor grade (35.1% versus 57.1% Grade 3), and a higher rate of lymphovascular invasion (LVI, 57.1% versus 17.7%), both p<0.001. Variables associated with upstaging included LVI (OR 6.0, 95% CI 2.9 – 12.5, p<0.001) and tumor grade 3 (OR 9.4, 1.8 – 48.4, p=0.007). Of upstaged UE patients, only 144 (44.2%) received adjuvant therapy. The median OS for cT2N0 patients upstaged after UE was 27.5 ± 2.5 months versus 43.9 ± 2.9 months for induction therapy patients (any resultant pathologic stage, p<0.001). Conclusions Half of all cT2N0 patients were pathologically upstaged after UE with worse survival compared to patients receiving induction therapy. Refining an upstaging model would help select patients for induction therapy and increase the rate of chemotherapy in patients at risk for systemic disease.

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“…At the London Regional Cancer Centre, a retrospective review of patients with lymph-node-positive disease who, after surgical resection, were given postoperative chemoradiation showed that the postoperative treatment, as compared with no treatment, was associated with significantly longer survival 36. A definitive clinical trial comparing preoperative with postoperative chemoradiation would be useful in determining the precise benefit in terms of survival and quality of life.…”

Section: The Great Debatesmentioning

confidence: 99%

The 4th Annual Ontario Thoracic Cancer Conference at Niagara-on-the-Lake

Ung

Malthaner

et al. 2009

Current Oncology

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The role of surgery and postoperative chemoradiation therapy in patients with lymph node positive esophageal carcinoma

Cited by 119 publications

References 18 publications

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

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

Clinical T2N0 Esophageal Cancer: Identifying Pretreatment Characteristics Associated With Pathologic Upstaging and the Potential Role for Induction Therapy

The 4th Annual Ontario Thoracic Cancer Conference at Niagara-on-the-Lake

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