Patients who undergo surgery after chemoradiotherapy demonstrate improved survival; however, this may be related to underlying comorbidities that preclude surgery. IMRT appears to be a reasonable treatment option that may reduce complications from radiotherapy. Careful attention should be given to heart dose during treatment planning.
Nitesh N. Paryani, MD, Stephen J. Ko, MD, Corey Hobbs, MD, Kristin Kowalchik, MD, Elizabeth Johnson, MD, Laura Vallow, MD, Jennifer Peterson, MD, Katherine Tzou, MD, Steven J. Buskirk, MD; Mayo Clinic
PURPOSE: The current standard of care for locally advanced esophageal cancer includes chemoradiotherapy with or without surgery. Radiation is usually delivered via a three-dimensional (3D) technique. Intensity-modulated radiation therapy (IMRT) has been utilized in the treatment of multiple tumors and has demonstrated similar efficacy while offering the possibility of decreased toxicity.
MATERIALS AND METHODS: A total of 36 patients were treated with IMRT and chemotherapy; 21 patients underwent surgical resection-11 underwent open surgery, and the remainder underwent minimally invasive surgery. Chemotherapy consisted primarily of 5-fluorouracil (5-FU) with oxaliplatin or cisplatin. All but two patients received 50.4 Gy; one patient received 41.4 Gy without surgery, and one patient discontinued treatment after 25.2 Gy. Eleven patients required a treatment break during radiotherapy. The median age was 69 years (range: 46–87 yr). Approximately two-thirds of tumors were adenocarcinomas located in the lower thorax. Two-thirds of patients were stage T3 and had positive lymph nodes. The median tumor size was 5 cm (range: 2–13 cm).
RESULTS: With a median follow-up of 21.3 months for all patients (range: 2.4–44.8 mo) and 33.9 months for survivors (range: 3.7-44.8 mo), overall survival (OS) at 24 months was 55%. The 24-month OS was 75% vs 24% for surgical and nonsurgical patients, respectively. Seven patients had a complete pathologic response. A total of 24 patients experienced grade ≥ 3 acute toxicity, and there was one grade 5 toxicity. Acute toxicity was similar between surgery and nonsurgery patients. Also, 14 patients experienced grade ≥ 3 late toxicity (9 surgery and 5 nonsurgery patients). The most frequent late toxicity was grade 3 stricture (21%). On multivariate analysis, advanced age (relative risk [RR] for 10-year increase in age = 2.01; P = .032) and heart maximum dose > 55 Gy (RR = 3.73; P = .011) were associated with decreased survival.
CONCLUSION: Patients who undergo surgery after chemoradiotherapy demonstrate improved survival; however, this may be related to underlying comorbidities that preclude surgery. IMRT appears to be a reasonable treatment option that may reduce complications from radiotherapy. Careful attention should be given to heart dose during treatment planning.
Proceedings of the 97th Annual Meeting of the American Radium Society - americanradiumsociety.org