Retrospective Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. May 15, 2016; 8(5): 474-480
Published online May 15, 2016. doi: 10.4251/wjgo.v8.i5.474
Intensity modulated radiation therapy with simultaneous integrated boost based dose escalation on neoadjuvant chemoradiation therapy for locally advanced distal esophageal adenocarcinoma
Ming Zeng, Fernando N Aguila, Taral Patel, Mark Knapp, Xue-Qiang Zhu, Xi-Lin Chen, Phillip D Price
Ming Zeng, Fernando N Aguila, Taral Patel, Mark Knapp, Xue-Qiang Zhu, Xi-Lin Chen, Phillip D Price, Department of Radiation Oncology, Mount Carmel Health System, Columbus, OH 43219, United States
Ming Zeng, Xue-Qiang Zhu, Cancer Center, Sichuan Academy of Medical Sciences, Sichuan Provincial Hospital, Chengdu 610072, Sichuan Province, China
Fernando N Aguila, Central Ohio Surgical Associates, Inc., Columbus, OH 43219, United States
Taral Patel, Mark Knapp, Department of Hematology and Oncology, Zangmeister Cancer Center, Mount Carmel Health System, Columbus, OH 43219, United States
Xi-Lin Chen, Department of Oncology, 307 Hospital, Beijing 100071, China
Author contributions: Zeng M, Aguila FN, Patel T and Knapp M involved the study protocol design; Zhu XQ and Chen XL collected and analyzed the data; Zeng M, Patel T and Chen X draft the manuscript.
Institutional review board statement: This study was reviewed and approved by Mt Carmel Hospital IRB.
Informed consent statement: All subjects in this study provide radiation therapy consent.
Conflict-of-interest statement: Authors have no conflict of interest.
Data sharing statement: No data available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Ming Zeng, MD, PhD, Department of Radiation Oncology, Mount Carmel Health System, 3100 Plaza Properties Blvd, Columbus, OH 43219, United States.
Telephone: +1-614-2168721
Received: October 18, 2015
Peer-review started: October 21, 2015
First decision: November 27, 2015
Revised: February 1, 2016
Accepted: March 7, 2016
Article in press: March 9, 2016
Published online: May 15, 2016
Processing time: 203 Days and 16.7 Hours

AIM: To evaluate impact of radiation therapy dose escalation through intensity modulated radiation therapy with simultaneous integrated boost (IMRT-SIB).

METHODS: We retrospectively reviewed the patients who underwent four-dimensional-based IMRT-SIB-based neoadjuvant chemoradiation protocol. During the concurrent chemoradiation therapy, radiation therapy was through IMRT-SIB delivered in 28 consecutive daily fractions with total radiation doses of 56 Gy to tumor and 5040 Gy dose-painted to clinical tumor volume, with a regimen at the discretion of the treating medical oncologist. This was followed by surgical tumor resection. We analyzed pathological completion response (pCR) rates its relationship with overall survival and event-free survival.

RESULTS: Seventeen patients underwent dose escalation with the IMRT-SIB protocol between 2007 and 2014 and their records were available for analysis. Among the IMRT-SIB-treated patients, the toxicity appeared mild, the most common side effects were grade 1-3 esophagitis (46%) and pneumonitis (11.7%). There were no cardiac events. The Ro resection rate was 94% (n = 16), the pCR rate was 47% (n = 8), and the postoperative morbidity was zero. There was one mediastinal failure found, one patient had local failure at the anastomosis site, and the majority of failures were distant in the lung or bone. The 3-year disease-free survival and overall survival rates were 41% (n = 7) and 53% (n = 9), respectively.

CONCLUSION: The dose escalation through IMRT-SIB in the chemoradiation regimen seems responsible for down-staging the distal esophageal with well-tolerated complications.

Keywords: Intensity modulated radiation therapy, Esophageal adenocarcinoma, Simultaneous integrated boost, Neoadjuvant chemoradiation, Dose escalation, Resection rate

Core tip: There are more data supporting neoadjuvant chemoradiation for locally advanced esophageal cancer. The best regimen of neoadjuvant chemoradiation remains to be defined, current available data using three-dimensional vs intensity modulated radiation therapy deliver modest dose to downstage the tumor. In this report, we reviewed our experience using dose escalation technique to Gross Tumor Volume with compromising dose to organ at risk, the high R0 resection rate results suggest the feasibility of using this approach for future prospective study.