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Multimodality Therapy for Esophageal Cancer: The Benefit of Chemoradiation
Proceedings of the 53rd Annual ASTRO Meeting
2201
Multimodality Therapy for Esophageal Cancer: The Benefit of Chemoradiation
S. R. Vossler1, B. Bavan2, P. Kunz3, J. M. Ford3, G. A. Fisher3, R. Whyte4, A. C. Koong2, D. T. Chang2 1 Stanford University School of Medicine, Stanford, CA, 2Stanford University School of Medicine Department of Radiation Oncology, Stanford, CA, 3Stanford University Department of Medicine - Division of Oncology, Stanford, CA, 4Stanford University Department of Cardiothoracic Surgery, Stanford, CA
Purpose/Objective(s): The purpose of this study is to evaluate and compare the survival of patients with esophageal cancer according to treatment modality. Materials/Methods: In this Institutional Review Board-approved study, the records of 392 patients with esophageal carcinoma treated at Stanford University from 1994-2010 were reviewed. Patients with T1N0 disease, concurrent malignancies, prior radiation to the thorax, or radiation treatment at an outside institution were excluded. Clinical and treatment characteristics were collected from medical records and direct patient follow-up. Four separate treatment modalities were analyzed: surgery alone (S), chemoradiation alone (CRT), preoperative chemoradiation followed by surgery (CRT-S), and surgery followed by postoperative chemoradiation (S-CRT). There were 34 (24%) patients in the S group, 59 (41%) in the CRT group, 28 (20%) in the CRT-S group, and 21 (15%) in the S-CRT group. Thirty-three (22%) patients were diagnosed with squamous cell carcinoma, 109 (76%) adenocarcinoma, and 3 (2%) an unknown histology. Results: The median follow-up among the entire group was 21.3 months (range: 1.4-168.1), and among living patients was 29.8 months (range: 2.7-168.1). The median age at diagnosis was 66 years (range: 36-87). Two-year overall survival (OS) was 50% (median = 24.4 months) for the S group, 50% (median = 24.3) for the CRT group, 60.5% (median = 34.6) for the CRT-S group, and 83% (median = 56.7) for the S-CRT group. Patients in the combined CRT-S and S-CRT group had significantly improved OS compared with S (p = 0.03) or CRT (p = 0.02) alone. There was no significant difference between CRT-S and SCRT (p = 0.21). The Cox proportional hazard model showed that compared to S (hazard = 1.0), the hazard ratios for OS for the other groups were: 1) CRT- 0.56 (p = 0.06), 2) CRT-S- 0.43 (p = 0.03), and 3) S-CRT- 0.17 (p\0.01). For patients with adenocarcinoma, CRT-S or S-CRT showed a significantly better overall survival compared with S (p = 0.01) or CRT (p = 0.02). There was no significant difference in OS between CRT-S and S-CRT (p = 0.21). The Cox proportional hazard model showed that compared to S (hazard = 1.0), the hazard ratios for OS for the other groups were: 1) CRT- 0.38 (p = 0.01), CRT-S- 0.34 (p = 0.01), and S-CRT- 0.12 (p\0.01). Three patients had grade 5 toxicity, all in the S group. Grade 3 or higher toxicities included mucositis (n = 1), anemia (n = 1), dysphagia (n = 1), and pneumonia (n = 1) across all groups involving radiation therapy. Conclusions: For locally advanced esophageal carcinoma, combined modality therapy with surgery and chemoradiation improved survival over surgery or chemoradiation alone. No significant difference was seen between preoperative versus postoperative chemoradiation. Author Disclosure: S.R. Vossler: None. B. Bavan: None. P. Kunz: None. J.M. Ford: None. G.A. Fisher: None. R. Whyte: None. A.C. Koong: None. D.T. Chang: None.
2202
Treatment Results of Chemoradiotherapy with a Dose of . = 60 Gy and an Elective Nodal Irradiation for Stage I Esophageal Squamous Cell Carcinoma
Y. Murakami, I. Nishibuchi, T. Kimura, M. Kenjo, Y. Kaneyasu, Y. Nagata Hiroshima University Graduate School of Medicine, Hiroshima, Japan Purpose/Objective(s): Although the efficacy of chemoradiotherapy (CRT) for stage I esophageal cancer has been reported, the optimal irradiation dose and field is still controversial. In this study we assessed the treatment results of CRT with a dose of . = 60 Gy and the elective nodal irradiation for stage I esophageal squamous cell carcinoma. Materials/Methods: Between 2001 and 2009, twenty seven patients with stage I esophageal cancer were treated by definitive CRT. Twenty-five patients were male and 2 were female. Median age was 67 years old. Depth of tumor infiltration was lamina propria mucosae in 1, muscularis mucosae in 4 and submucosa in 22 patients. Main tumor sites were cervical esophagus in 5 patients, upper thoracic in 2, middle thoracic in 16, lower thoracic in 4. Total irradiation dose of our protocol was 60 Gy for tumors infiltrated within inner one-thirds of submucosa and 66 Gy for tumors infiltrated outer two-thirds of submucosa. Elective nodal irradiation fields included the middle to lower neck, supraclavicular and superior mediastinal lymph nodes (LNs) for carcinoma of the cervical esophagus, the supraclavicular and superior mediastinal LNs for carcinoma of the upper thoracic esophagus, the mediastinal and perigastric LNs for carcinoma of the middle or lower thoracic esophagus, and the lower mediastinal, perigastric and celiac axis LNs for carcinoma of the abdominal esophagus. All patients received fluorouracil based chemotherapy concurrently with radiotherapy. Results: The median follow-up was 53 months (range 22-90 months). Overall survival rates at 3 and 5 years were 92% and 80%, respectively. Disease free survival rates were 77% and 58%, and cause specific survival rates were 100% and 100%, respectively. Loco-regional control rates were 100% and 94%, respectively. There was no esophageal primary tumor recurrence. LN recurrence was observed in one patient (4%) and this LN recurrence was outside of the elective nodal irradiation field. There was no LN failure in the elective nodal irradiation field. Esophageal metachronous cancer was detected in 6 patients. Four of them were detected outside of the initial irradiation field and 5 of them were salvaged by endoscopic resection or CRT. Late adverse effects (. = G3) were observed in 3 patients; pleural effusion in 2 and pericardial effusion in 1. No treatment related death was observed. Conclusions: We reported the outcomes of CRT with a dose of . = 60 Gy and an elective nodal irradiation for stage I esophageal squamous cell carcinoma. Toxicities were acceptable and survival was promising. High irradiation dose and the elective nodal irradiation possibly contributed high loco-regional control rate. Author Disclosure: Y. Murakami: None. I. Nishibuchi: None. T. Kimura: None. M. Kenjo: None. Y. Kaneyasu: None. Y. Nagata: None.
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2201
Multimodality Therapy for Esophageal Cancer: The Benefit of Chemoradiation
S. R. Vossler1, B. Bavan2, P. Kunz3, J. M. Ford3, G. A. Fisher3, R. Whyte4, A. C. Koong2, D. T. Chang2 1 Stanford University School of Medicine, Stanford, CA, 2Stanford University School of Medicine Department of Radiation Oncology, Stanford, CA, 3Stanford University Department of Medicine - Division of Oncology, Stanford, CA, 4Stanford University Department of Cardiothoracic Surgery, Stanford, CA
Purpose/Objective(s): The purpose of this study is to evaluate and compare the survival of patients with esophageal cancer according to treatment modality. Materials/Methods: In this Institutional Review Board-approved study, the records of 392 patients with esophageal carcinoma treated at Stanford University from 1994-2010 were reviewed. Patients with T1N0 disease, concurrent malignancies, prior radiation to the thorax, or radiation treatment at an outside institution were excluded. Clinical and treatment characteristics were collected from medical records and direct patient follow-up. Four separate treatment modalities were analyzed: surgery alone (S), chemoradiation alone (CRT), preoperative chemoradiation followed by surgery (CRT-S), and surgery followed by postoperative chemoradiation (S-CRT). There were 34 (24%) patients in the S group, 59 (41%) in the CRT group, 28 (20%) in the CRT-S group, and 21 (15%) in the S-CRT group. Thirty-three (22%) patients were diagnosed with squamous cell carcinoma, 109 (76%) adenocarcinoma, and 3 (2%) an unknown histology. Results: The median follow-up among the entire group was 21.3 months (range: 1.4-168.1), and among living patients was 29.8 months (range: 2.7-168.1). The median age at diagnosis was 66 years (range: 36-87). Two-year overall survival (OS) was 50% (median = 24.4 months) for the S group, 50% (median = 24.3) for the CRT group, 60.5% (median = 34.6) for the CRT-S group, and 83% (median = 56.7) for the S-CRT group. Patients in the combined CRT-S and S-CRT group had significantly improved OS compared with S (p = 0.03) or CRT (p = 0.02) alone. There was no significant difference between CRT-S and SCRT (p = 0.21). The Cox proportional hazard model showed that compared to S (hazard = 1.0), the hazard ratios for OS for the other groups were: 1) CRT- 0.56 (p = 0.06), 2) CRT-S- 0.43 (p = 0.03), and 3) S-CRT- 0.17 (p\0.01). For patients with adenocarcinoma, CRT-S or S-CRT showed a significantly better overall survival compared with S (p = 0.01) or CRT (p = 0.02). There was no significant difference in OS between CRT-S and S-CRT (p = 0.21). The Cox proportional hazard model showed that compared to S (hazard = 1.0), the hazard ratios for OS for the other groups were: 1) CRT- 0.38 (p = 0.01), CRT-S- 0.34 (p = 0.01), and S-CRT- 0.12 (p\0.01). Three patients had grade 5 toxicity, all in the S group. Grade 3 or higher toxicities included mucositis (n = 1), anemia (n = 1), dysphagia (n = 1), and pneumonia (n = 1) across all groups involving radiation therapy. Conclusions: For locally advanced esophageal carcinoma, combined modality therapy with surgery and chemoradiation improved survival over surgery or chemoradiation alone. No significant difference was seen between preoperative versus postoperative chemoradiation. Author Disclosure: S.R. Vossler: None. B. Bavan: None. P. Kunz: None. J.M. Ford: None. G.A. Fisher: None. R. Whyte: None. A.C. Koong: None. D.T. Chang: None.
2202
Treatment Results of Chemoradiotherapy with a Dose of . = 60 Gy and an Elective Nodal Irradiation for Stage I Esophageal Squamous Cell Carcinoma
Y. Murakami, I. Nishibuchi, T. Kimura, M. Kenjo, Y. Kaneyasu, Y. Nagata Hiroshima University Graduate School of Medicine, Hiroshima, Japan Purpose/Objective(s): Although the efficacy of chemoradiotherapy (CRT) for stage I esophageal cancer has been reported, the optimal irradiation dose and field is still controversial. In this study we assessed the treatment results of CRT with a dose of . = 60 Gy and the elective nodal irradiation for stage I esophageal squamous cell carcinoma. Materials/Methods: Between 2001 and 2009, twenty seven patients with stage I esophageal cancer were treated by definitive CRT. Twenty-five patients were male and 2 were female. Median age was 67 years old. Depth of tumor infiltration was lamina propria mucosae in 1, muscularis mucosae in 4 and submucosa in 22 patients. Main tumor sites were cervical esophagus in 5 patients, upper thoracic in 2, middle thoracic in 16, lower thoracic in 4. Total irradiation dose of our protocol was 60 Gy for tumors infiltrated within inner one-thirds of submucosa and 66 Gy for tumors infiltrated outer two-thirds of submucosa. Elective nodal irradiation fields included the middle to lower neck, supraclavicular and superior mediastinal lymph nodes (LNs) for carcinoma of the cervical esophagus, the supraclavicular and superior mediastinal LNs for carcinoma of the upper thoracic esophagus, the mediastinal and perigastric LNs for carcinoma of the middle or lower thoracic esophagus, and the lower mediastinal, perigastric and celiac axis LNs for carcinoma of the abdominal esophagus. All patients received fluorouracil based chemotherapy concurrently with radiotherapy. Results: The median follow-up was 53 months (range 22-90 months). Overall survival rates at 3 and 5 years were 92% and 80%, respectively. Disease free survival rates were 77% and 58%, and cause specific survival rates were 100% and 100%, respectively. Loco-regional control rates were 100% and 94%, respectively. There was no esophageal primary tumor recurrence. LN recurrence was observed in one patient (4%) and this LN recurrence was outside of the elective nodal irradiation field. There was no LN failure in the elective nodal irradiation field. Esophageal metachronous cancer was detected in 6 patients. Four of them were detected outside of the initial irradiation field and 5 of them were salvaged by endoscopic resection or CRT. Late adverse effects (. = G3) were observed in 3 patients; pleural effusion in 2 and pericardial effusion in 1. No treatment related death was observed. Conclusions: We reported the outcomes of CRT with a dose of . = 60 Gy and an elective nodal irradiation for stage I esophageal squamous cell carcinoma. Toxicities were acceptable and survival was promising. High irradiation dose and the elective nodal irradiation possibly contributed high loco-regional control rate. Author Disclosure: Y. Murakami: None. I. Nishibuchi: None. T. Kimura: None. M. Kenjo: None. Y. Kaneyasu: None. Y. Nagata: None.
S309