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Definitive chemo-radiotherapy for esophageal cancer; failure pattern and salvage treatments

Definitive chemo-radiotherapy for esophageal cancer; failure pattern and salvage treatments. Ryuta Koike, Y. Nishimura, K. Nakamatsu, S. Kanamori, M. Okubo, K. Hiroi, T. Shibata T. Nishikawa, H. Shiozaki* Department of Radiation Oncology and Surgery*,

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Definitive chemo-radiotherapy for esophageal cancer; failure pattern and salvage treatments

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  1. Definitive chemo-radiotherapyfor esophageal cancer;failure pattern and salvage treatments Ryuta Koike, Y. Nishimura, K. Nakamatsu, S. Kanamori, M. Okubo, K. Hiroi, T. Shibata T. Nishikawa,H. Shiozaki* Department of Radiation Oncology and Surgery*, Kinki University School of Medicine

  2. Purpose ・ Failure pattern in definitivechemoradiotherapy (CRT) for esophageal cancer were analyzed to evaluate the appropriateness of our RT field.

  3. Patients Characteristics From 1999 to 2006, 136 consecutive patients with esophageal cancer with localized esophageal cancer were treated with definitive CRT at our hospital. Age； 38 ~ 82 years old （median; 64 years） Gender; men：females =116： 20 PS 0/ 1/ 2 /3= 58/ 66/ 11/ 1 Histology; 135 pts squamous cell carcinomas 1 pt adenocarcinoma Stage; I：II：III: IV= 8：25：76: 27 (2002 UICC) T Factor T1:T2:T3：T4 =15:20:27：74, N Factor N0：N1 = 27：109 Location of primary tumor: Ce: Ut: Mt: Lt = 19: 27: 71: 19 Tumor length： 1 ~ 19cm （median 6.5cm）

  4. Initial RT Fields according to the primary site ・Cervical esophagus (Ce) Bilateral neck and subcarinal LNs (Short T-shaped Field) ・ Upper (Ut) and middle (Mt) esophagus Bilateral neck and whole mediastinal LNs (T-shaped Field) ・Lower esophagus (Lt) Whole mediastinal LNs and perigastric LNs (I-shaped Field)

  5. Initial RT Fields Ce Ut, Mt Lt

  6. Radiation and Chemotherapy ・Radiationtherapy 60 Gy/30 fr/7 w (one-week split) for the both groups. Either a 6 MV or 10 MV X-ray was used. Boost was given following 40 Gy. ・Two courses of concurrent CT were combined with RT Ⅰ、low-dose protracted pattern102 pts（75%） CDDP 7mg/m2×10 days 5-FU 250-300mg/m2×14 days Ⅱ、 high-dose pattern 34 pts（25%） CDDP 70mg/m2×1 day 5-FU 700mg/m2×5 days After CRT, 1-2 courses of adjuvant CT of cisplatin/5-FU were given for 75 pts (55%).

  7. Results ・　A total dose of 60 Gy could be delivered for 133 pts (98%). ・　2 courses of planned CT could be combined concurrently with RT for 118 pts (87%). ・　Complete response（CR） in the RT field was achieved in 84 pts（62%）. T115/15（100%） T218/20　（90%） T320/27　（74%） T431/72　（42%） ・Failure Pattern of the 84 pts with CR was evaluated.

  8. Overall survivalT1N0M0 n=8 2-year survival100％ 5-year survival80％ month

  9. Overall survivalstages II-III (excluding T4) n=39 2-year survival59% 5-year survival41% month

  10. Overall survival, stages III-IVT4 or M1-ｌｙｍｐｈ n=84 2-year survival26% 5-year survival19% month

  11. Overall survival rate ; 1999-2006 2-year survival 66% 5-yearsurvival52% CR (n=84) Non-CR (n=52) month

  12. Failure pattern (n=84) Isolated marginal rec. 9 pts (11%) Out-field rec. 33 pts (40%) Distant meta ±regional LN Rec. 24 pts (29%) No rec. 39 pts (46%) In-field rec. 12 pts (14%)

  13. Treatment results for 9 pts with isolated marginal recurrences Lower esophageal （out of RT Field） rec. ２pts （Origin: Ce、Ut） Salvage surgery was performed for 2 pts. ⇒ Local control could be achieved Lymph node rec. (out of RT Field) ７pts Perigastric LN recurrence 4 pts Lymph node dissection 2 ｐｔｓ 2nd-CRT(50-60Gy) 2 ｐｔｓ ⇒ Local control could be achieved Hilar LN rec. 2 pts Neck + retrocrural LNs 　 １ pt 2nd-CRT(50-60Gy) 3 ｐｔｓ Local control could not be achieved. Local control could be achieved Local control could be achieved ⇒ Local control could not be achieved. In all 6 pts with lower esophageal or perigastric LNs recurrence,salvage treatments were successful.

  14. Late toxicities (n=84) RTOG/EORTC *: CTCAE version 3.0 • Grade G1 G2 G3 G4 =>G2 • Esophagus 3 4 5 0 9 (11%) • Heart 17 0 1 1 2 (2%) • Lung 17 3 2 0 5 (6%) • Spinal cord 1 0 0 0 0 (0%) • Pleural* 18 0 1 0 1 (1%) • Hypothyroid* 1 3 1 0 4 (5%) • Renal failure* 0 0 0 1 1 (1%) • Pt. Max. # 28 9 8 2 19 (23%)

  15. Conclusions The 5-year overall survival rates of definitive CRT of 60Gy for both resectable and unresectable esophageal cancer were excellent. Although recurrences after initial CR were noted frequently, salvage treatments were successful for isolated marginal recurrences in the lower esophagus or perigastric LNs. For Ce, Ut and Mt tumors, lower esophageal and perigastric LN region can be excluded from the initial RT field.

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