Published online Feb 21, 2018. doi: 10.3748/wjg.v24.i7.862
Peer-review started: December 11, 2017
First decision: December 20, 2017
Revised: December 25, 2017
Accepted: January 16, 2018
Article in press: January 16, 2018
Published online: February 21, 2018
The surgical procedure for cervical esophageal cancer (CEC) is extensive, and concurrent chemoradiotherapy (CRT) is the preferred treatment modality. Although a higher-than-standard dose of 50 Gy is suggested for CEC, the increased dose may lead to a higher incidence of severe toxicities, such as ulcer, perforation and stenosis.
Clinical data on radiotherapy with increased dose for CEC are scarce, and a toxicity evaluation is required before the administration of dose-escalated protocols.
To evaluate toxicity and treatment outcome of high dose radiotherapy for CEC, and to determine the factors associated with post-treatment esophageal stenosis.
In this study, the authors reviewed 62 consecutive patients who received definitive RT for stage I to III cervical esophageal cancer between 2001 and 2015. Patients (received < 45 Gy) treated for lesions below sternal notch, treated with palliative aim and subsequent surgical resection, or diagnosed with synchronous hypopharyngeal cancer were excluded. Treatment failures were divided into local, outfield-esophageal, and regional failures. The factors predictive of esophageal stenosis requiring endoscopic dilation were analyzed.
With a median follow-up of 24.3 (range, 3.4-152) mo, the 2-year local control, outfield esophageal control, progression-free survival, and overall survival (OS) rates were 78.9%, 90.2%, 49.6%, and 57.3%, respectively. Grade 1, 2, and 3 esophagitis occurred in 19 (30.6%), 39 (62.9%), and 4 patients (6.5%), respectively, without grade ≥ 4 toxicities. Sixteen patients developed post-RT stenosis, of which 7 cases were malignant. Four patients developed tracheoesophageal fistula (TEF), of which 3 cases were malignant. Factors significantly correlated with OS were complete circumference involvement, stenosis at diagnosis, and occurrence of post-RT stenosis or TEF in univariate analysis, while stenosis at diagnosis and occurrence of post-RT stenosis or TEF were significant in multivariate analysis. Factors significantly correlated with post-RT stenosis were stage T3/4, complete circumference involvement, stenosis at diagnosis, and endoscopic complete response in univariate analysis, while complete circumference involvement was significant in multivariate analysis. A higher dose (≥ 60 Gy) was not associated with the occurrence of post-RT stenosis or TEF.
This study showed that, although pre- and post-RT stenosis was a prognostic factor for patients’ survival, complete circumference involvement rather than a higher radiation dose was the key contributing factor, and suggesting that CEC can be treated with higher than the current standard dose of 50 Gy. CRT for CEC was well tolerated, and patients with complete circumferential involvement require close follow-up.
The data suggests that patients with CEC may undergo radiotherapy of up to 63 Gy without increasing the risk of radiation-induced toxicities. Since prospective data is lacking, our study warrants a prospective trial to investigate toxicity and efficacy of high-dose radiotherapy for CEC.