The objective of this study is to determine the feasibility and report the outcome of patients with locally advanced esophageal cancer treated with preoperative or definitive chemoradiotherapy (CRT) using intensity-modulated radiation therapy (IMRT). Between 2003 and 2007, 30 patients with non-cervical esophageal cancer received concurrent chemotherapy and IMRT at Stanford University. Eighteen patients were planned for definitive CRT and 12 were planned for preoperative CRT. All patients had computed tomography-based treatment planning and received IMRT. The median dose delivered was 50.4 Gy. Patients planned for preoperative CRT underwent surgery 4-13 weeks (median 8.3 weeks) following completion of CRT. Median follow-up of surviving patients from start of RT was 24.2 months (range 8.2-38.3 months). The majority of tumors were adenocarcinomas (67%) and poorly differentiated (57%). Tumor location was 7% upper, 20% mid, 47% lower, and 27% gastroesophageal junction. Actuarial 2-year local-regional control (LRC) was 64%. High tumor grade was an adverse prognostic factor for LRC and overall survival (OS) (P= 0.015 and 0.012, respectively). The 2-year LRC was 83% vs. 51% for patients treated preoperatively vs. definitively (P= 0.32). The 2-year disease-free and OS were 38% and 56%, respectively. Twelve patients (40%) required feeding tube placement, and the average weight loss from baseline was 4.8%. Twelve (40%) patients experienced grade 3+ acute complications and one patient died of complications following feeding tube placement. Three patients (10%) required a treatment break. Eight patients (27%) experienced grade 3 late complications. No grade 4 complications were seen. IMRT was effective and well tolerated. Disease recurrence remains a challenge and further investigation with dose escalation to improve LRC and OS is warranted.
"Intensity-modulated radiotherapy can significantly spare the lungs from irradiation. La et al.  reported no grade 3-4 pneumonitis in 30 patients with locally advanced esophageal cancer who underwent pre-operative concurrent chemoradiation. Tomotherapy-based IGRT by virtue of its steep dose gradient and daily CT imaging allowing for reduced PTV margins may significantly decrease radiation dose to normal tissues and improve tolerance to chemoradiation in elderly cancer patients [25,26]. "
[Show abstract][Hide abstract] ABSTRACT: In this study the feasibility of intensity-modulated radiotherapy (IMRT) and tomotherapy-based image-guided radiotherapy (IGRT) for locally advanced esophageal cancer was assessed.
A retrospective study of ten patients with locally advanced esophageal cancer who underwent concurrent chemotherapy with IMRT (1) and IGRT (9) was conducted. The gross tumor volume was treated to a median dose of 70 Gy (62.4-75 Gy).
At a median follow-up of 14 months (1-39 months), three patients developed local failures, six patients developed distant metastases, and complications occurred in two patients (1 tracheoesophageal fistula, 1 esophageal stricture requiring repeated dilatations). No patients developed grade 3-4 pneumonitis or cardiac complications.
IMRT and IGRT may be effective for the treatment of locally advanced esophageal cancer with acceptable complications.
BMC Cancer 04/2014; 14(1):265. DOI:10.1186/1471-2407-14-265 · 3.36 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives
Intensity-modulated radiation therapy (IMRT) is evolving for the treatment of gastrointestinal cancers. The purpose of this study is to analyze our outcomes utilizing IMRT chemoradiation for esophageal cancer.
IMRT was incorporated into esophageal cancer treatment at our center in 2006. Patients treated between 2006 and 2011 with either preoperative or definitive IMRT chemoradiation to 50–60 Gy prescribed to the gross tumor volume and 45–50.4 Gy to the clinical target volume concurrently with chemotherapy were evaluated. IMRT techniques included multifield segmented step and shoot, compensator-based, and volumetric arc therapy. Overall survival (OS) and disease-free survival (DFS) were analyzed by Kaplan–Meier and log-rank analysis. Multivariate analysis (MVA) for OS and DFS were performed with a Cox proportional hazard ratio model.
We identified 108 patients with a median follow-up of 19 months. Median OS and DFS were 32 and 21.6 months, respectively. Fifty-eight (53.7 %) patients underwent surgical resection. There was no difference in OS or DFS in patients who underwent surgery compared to patients treated definitively without surgery. Median weight loss was 5.5 %. Rates of hospital admissions, feeding tube placement, stent placement, dilation, and radiation pneumonitis were 15.7, 7.4 4.6, 12, and 1.9 %, respectively. Long-term radiation pneumonitis was observed in six (5.6 %) patients. MVA revealed that age, stage, and surgery were prognostic for DFS, while gender and histology were not. Gender, histology, and stage were prognostic of OS on MVA, while surgery and age were not.
IMRT chemoradiation for esophageal cancer is safe and effective when compared to published series of 2D or 3D conformal radiation therapy. This is the largest single institutional series with long-term follow-up, confirming that IMRT is a viable treatment option for the curative treatment of esophageal cancer.
[Show abstract][Hide abstract] ABSTRACT: Radiotherapy with concurrent chemotherapy and surgery represent the main treatment modalities in esophageal cancer. The goal of modern radiotherapy approaches, based on recent technological advances, is to minimize post-treatment complications by improving the gross tumor volume definition (positron emission tomography-based planning), reducing interfraction motion (image-guided radiotherapy) and intrafraction motion (respiratory-gated radiotherapy), and by better dose delivery to the precisely defined planning target volume (intensity-modulated radiotherapy and proton therapy). Reduction of radiotherapy-related toxicity is fundamental to the improvement of clinical results in esophageal cancer, although the dose escalation concept is controversial.
World Journal of Gastroenterology 11/2010; 16(44):5555-64. · 2.37 Impact Factor
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