International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationLate Toxicity After Definitive Concurrent Chemoradiotherapy for Thoracic Esophageal Carcinoma
Introduction
Concurrent chemoradiotherapy (CCRT) has become a standard treatment for patients with unresectable or medically inoperable esophageal carcinoma. A prospective randomized trial (Radiation Therapy Oncology Group [RTOG] 85-01) has demonstrated a significant survival advantage compared with radiotherapy alone 1, 2, 3. Although chemoradiotherapy is more effective than radiotherapy alone, treatment-related late toxicities are reported to be severe 4, 5. Furthermore, the survival rates are not satisfactory: the median survival duration is 12.5 to 21 months, and the 5-year survival rate is 14% to 29% 1, 2, 3, 4, 5. One reason why the late toxicities of CCRT are severe is that the radiation fields for esophageal cancer are extensive for prophylactic lymph node irradiation. Lymph node metastases are found at autopsy in approximately 70% of patients with esophageal cancer (6). Moreover, Sannohe et al. have reported that the incidence of supraclavicular node metastases is higher than 15% in patients with thoracic esophageal carcinoma (7). Therefore, initial radiation fields tend to be extensive to involve the prophylactic lymph node area. An unresolved issue is which patients are the best candidates for such intensive chemoradiotherapy.
In Japan, the incidence of esophageal cancer has increased significantly during the past decades 8, 9, 10, and squamous cell carcinoma is predominant, unlike in Western countries. Since 1999, we have performed CCRT with a total dose of 60 Gy for patients with esophageal carcinoma. The initial radiation fields extended from the supraclavicular fossa to the area of the celiac lymph nodes. Here we report the results of definitive CCRT for esophageal carcinomas.
Section snippets
Patient eligibility and pretreatment evaluation
All patients had histologically confirmed squamous cell carcinoma of the thoracic esophagus and were treated with definitive CCRT at our hospital between February 2002 and April 2005. Patients eligible for this study included those with an Eastern Cooperative Oncology Group performance status of 0 to 2, adequate organ functions, and clinical Stage I to IVA. Patients with Stage IVB disease were eligible if only supraclavicular lymph nodes were involved but were not eligible if they had other
Patient characteristics and radiation techniques
Between February 2002 and April 2005, a total of 74 patients with carcinoma of the esophagus received definitive chemoradiotherapy. Five patients were excluded from this analysis for cervical esophageal carcinoma (3 patients) or small-cell carcinoma (2 patients). The characteristics of the other 69 patients are shown in Table 1. The median age was 67 years (range, 45–83 years), and 14 patients were 75 years or older (20%). Of the patients, 63 (91%) completed the planned radiation therapy. The
Discussion
Chemoradiotherapy has become a standard therapy for patients with inoperable esophageal carcinoma, but severe toxicities are a matter of great concern for CCRT. One manifestation of severe early toxicity is esophageal fistula. Tracheo-esophageal fistulas developed in 4 of our patients. Because all 4 patients had bulky primary lesions infiltrated neighboring organs through the esophageal wall, the esophageal fistulas were related to the destructive tumor characteristics rather than the
Conclusion
In conclusion, the CCRT used in this study with extensive radiation fields is acceptable for younger patients but is not tolerated by patients older than 75 years.
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Cited by (100)
Late Toxicity and Health-Related Quality of Life Following Definitive Chemoradiotherapy for Esophageal Cancer: A Systematic Review and Meta-analysis
2023, International Journal of Radiation Oncology Biology PhysicsPast, Present, and Future of Radiation-Induced Cardiotoxicity: Refinements in Targeting, Surveillance, and Risk Stratification
2021, JACC: CardioOncologyCitation Excerpt :Over the decades, data regarding the incidence of RICD after RT for intrathoracic malignancies have steadily increased following improvements in overall survival with novel therapeutics and treatment approaches. For esophageal cancer, some of the earliest RICD data came from Japan (68,69), where the incidence of esophageal cancer is among the highest worldwide. In more than 70 patients with esophageal squamous cell carcinoma treated with definitive chemoradiation therapy from 2002 to 2005, age ≥75 years was significantly associated with a higher 2-year cumulative incidence of grade ≥3 cardiopulmonary toxicities (∼30% for age ≥75 years vs 3% for age <75 years) (68).
Long-term outcomes of an esophagus-preserving chemoradiotherapy strategy for patients with endoscopically unresectable stage I thoracic esophageal squamous cell carcinoma
2021, Clinical and Translational Radiation OncologyCitation Excerpt :We expect FDG-PET to be validated for response assessment in addition to anatomic approaches such as endoscopic US and CT scans. Although definitive CCRT is superior to surgery in terms of esophageal preservation, late toxicities should be considered [26–28]. According to the clinical trials investigating the effect of radiation dose escalation, such as the Radiation Therapy Oncology Group (RTOG) trial 94-05 and the ARTDECO Study, a higher irradiation dose of 61.6–64.8 Gy was not advantageous for survival outcomes, probably because of the low tolerability against the toxicities [4,29].
Conflict of interest: none.