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Objective:To analyze the fail mode of neoadjuvant therapy combined with surgery for locally advanced esophageal squamous cell carcinoma (ESCC) after long-term follow-up.Methods:Clinical data of consecutive 238 patients with locally advanced resectable ESCC who underwent neoadjuvant therapy combined with surgery in Zhejiang Cancer Hospital from September 2012 to October 2019 were retrospectively analyzed. The failure mode in the whole cohort was analyzed after long-term follow-up. The overall survival (OS) and disease free survival (DFS) rates were analyzed by Kaplan-Meier method. Survival differences were determined by log-rank test.Results:The pathological complete response (pCR) rate was 42.0% in 238 patients. After a median follow-up of 46.1 months, tumor progression occurred in 96 patients (40.3%), including 25 patients (10.5%) with local recurrence, 61 patients (25.6%) with distant metastases, and 10 patients (4.2%) with simultaneous local recurrence and distant metastases. The median OS and DFS were 64.7 months and 49.9 months. And the 3-, 5-, and 7-year OS and DFS rates were 70.0%, 52.8%, 36.4% and 63.5%, 42.5%, and 30.0%, respectively. The 3-, 5-, and 7-year locoregional recurrence-free survival rates and distant metastasis-free survival rates were 86.0%, 71.4%, 61.2% and 70.6%, 55.9%, 43.0%. Compared with non-pCR patients, the overall progression rate and distant metastasis rate of pCR patients were lower (26.0% vs. 50.7%, 16.0% vs. 32.6%, both P<0.05). And the 3-, 5-, and 7-year OS (83.0% vs. 60.2%, 69.7% vs. 41.7%, 50.4% vs. 27.7%, all P<0.001) and DFS rates (80.4% vs. 51.4%, 63.9% vs. 31.2%, 45.9% vs. 20.3%, all P<0.001) were significantly better in pCR patients. Conclusions:Distant metastasis is the main failure mode of patients with locally advanced ESCC after neoadjuvant therapy. Patients with postoperative pCR can achieve better long-term survival.
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Objective:Small cell lung cancer (SCLC) is a highly malignant tumor with a high risk of brain metastasis (BMs). The purpose of this study was to evaluate the clinical factors affecting the occurrence of BMs in patients with stage IIB-IIIB SCLC who achieved complete remission (CR) after thoracic radio-chemotherapy.Methods:Clinical data of 191 patients with stage IIB-IIIB SCLC who achieved CR after thoracic radio-chemotherapy in Zhejiang Cancer Hospital from January 2009 to April 2016 were retrospectively analyzed. Common clinical factors related to the risk of BMs, including gender, age, thoracic radiotherapy dose, combined mode of radiotherapy and chemotherapy, pretreatment serum NSE and LDH, whether PCI was performed, TMN stage and PS score, were analyzed using log-rank method for univariate analysis, COX regression method for multivariate analysis and Kaplan-Meier method to plot the survival curve.Results:Univariate analysis showed that pretreatment LDH level≥240IU, pretreatment NSE ≥17 ng/ml and no PCI were positively correlated with the risk of BMs (all P＜0.05). Multivariate analysis showed that the risk of BMs was only positively correlated with pretreatment LDH≥240IU [HR: 1.90, 95%CI(1.07-3.37), P=0.029], and no PCI [HR:2.08, 95%CI(1.17-3.72), P=0.013]. Conclusion:Pretreatment serum LDH levels provide important value for predicting the risk of BMs in patients with stage IIB-IIIB SCLC who achieve CR after thoracic radio-chemotherapy.
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Objective:To evaluate the risk and prognostic factors of brain metastasis (BM) after prophylactic cranial irradiation (PCI) in limited stage small cell lung cancer (LS-SCLC) patients with complete and partial remission (CR/PR) after radiochemotherapy.Methods:Baseline data of 550 patients with LS-SCLC who obtained CR/PR after chemoradiotherapy and received PCI in Zhejiang Cancer Hospital between 2002 and 2017 were collected. The risk of BM and clinical prognosis were retrospectively analyzed. The survival analysis was performed by Kaplan-Meier method. Multivariate prognostic analysis was conducted byCox models.Results:The overall BM rate after PCI was 15.6%(86/550), with 9%(4/43), 13%(7/52), and 16.5%(75/455) for stage Ⅰ, Ⅱ and Ⅲ patients, respectively. The median overall survival (OS) for the entire cohort was 27.9 months, and the 5-year OS rate was 31.0%. The OS was 24.9 and 30.2 months for patients with or without BM, and the 5-year OS rates were 8.9% and 36.1%( P<0.001). BM was an independent factor of OS ( P<0.001). Clinical staging remained the influencing factor of OS and BM-free survival ( P<0.001, P=0.027). Having tumors of ≥5 cm in diameter significantly increased the risk of BM ( P=0.034) rather than the OS ( P=0.182). The median OS of patients aged<60 years was significantly longer than those aged ≥60 years (34.9 months vs. 24.6 months, P=0.001). The median OS of patients irradiated with 2 times/d was 29.8 months, significantly longer than 24.5 months of those irradiated with 1 time/d ( P=0.013). Age, sex, radiotherapy fraction and efficacy of radiochemotherapy (CR/PR) were not associated with the incidence rate of BM (all P>0.05). Conclusions:SCLC patients with tumors of ≥5 cm in diameter may have a higher risk of developing BM after PCI. Patients aged<60 years achieve better OS compared with their counterparts aged ≥60 years.
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Objective:To establish a radiomics-based biomarker for predicting pathological response after preoperative neoadjuvant chemoradiotherapy (nCRT) in locally advanced esophageal cancer.Methods:From 2008 to 2018, 112 patients with locally advanced esophageal cancer who received nCRT were enrolled. All patients were treated with preoperative nCRT combined with surgery. Enhanced CT images and clinical information before nCRT were collected. A lesion volume of interest was manually delineated. In total, 670 radiomics features (including tumor intensity, shape and size, texture and wavelet characteristics) were extracted using the pyradiomics package in PYTHON. The stepwise regression combined with the best subset were employed to select the features, and finally the Logistic regression model was adopted to establish the prediction model. The performance of the classifier was evaluated by the area under the ROC curve (AUC). Results:The pathological complete remission (pCR) rate was 58.0%(65/112). 10 radiomics features were included in the final model, The most relevant radiomics feature was the gray feature (the texture information of the image), followed by the shape and voxel intensity-related features. In the training set, the AUC was 0.750 with a sensitivity of 0.711 and a specificity of 0.778, the corresponding values in the testing set were 0.870, 0.757 and 0.900, respectively.Conclusions:Models based on radiomics features from CT images can be utilized to predict the pathological response to nCRT in esophageal cancer. As it is efficient, non-invasive and economic model, it could serve as a promising tool for individualized treatment when validated by further prospective trials in the future.
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Objective To investigate and analyze the reasons for the omission of adjuvant radiotherapy after breast-conserving surgery (BCS) in patients with breast cancer.Methods The clinicopathologial characteristics and socioeconomic data of 55 breast cancer patients undergoing BCS without postoperative adjuvant radiotherapy in our hospital from 2012 to 2016 were retrospectively analyzed.Results Among the 55 patients who did not receive radiotherapy,25 patients were due to low local recurrence risk,12 patients were due to economic or family reasons,12 patients were due to fear of adverse reactions of radiotherapy,and 5 patients were not recommended by primary physicians for radiotherapy.In addition,3 cases with multiple distant metastases and 3 cases with concomitant thyroid cancer didn't received radiotherapy.Conclnsions Low risk local recurrence is the main reason for the omission of adjuvant radiotherapy,followed by the fear of radiation-induced toxicity and poor financial support.Patient education and medical insurance may improve the adjuvant radiotherapy compliance.
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Objective To evaluate the high?risk factors for brain metastases after prophylactic cranial irradiation ( PCI), and to provide a basis for personalized treatment. Methods A retrospective analysis was performed in 188 patients with limited?stage small?cell lung cancer who received PCI in our hospital from 2005 to 2010. The Kaplan?Meier method was used to calculate the cumulative rate of brain metastases. The log?rank test and the Cox model were used for the univariate and multivariate analyses of the potential factors for the cumulative incidence of brain metastases, respectively. Results In the 188 patients, 31 ( 16?5%) had brain metastases. The 1?, 2?, and 3?year cumulative incidence rates of brain metastases were 4%, 15%, and 20%, respectively. The univariate analysis showed that staged Ⅲ disease before treatment, elevated levels of tumor markers, incomplete remission after chemoradiotherapy, and local?regional relapse were risk factors for high incidence of brain metastases ( P= 0?044, 0?037, 0?005, 0?007) . The multivariate analysis revealed that incomplete remission after chemoradiotherapy and local?regional relapse after chemoradiotherapy were risk factors for high incidence of brain metastases after PCI ( P= 0?003, 0?040 ) . Conclusions Patients with incomplete remission or local?regional relapse after chemoradiotherapy have high incidence of brain metastases after PCI. For those patients, a frequent follow?up of the central nervous system plus salvage cranial irradiation might provide an alternative to PCI.
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Objective To investigate the differences of measurement of gross target volume (GTV)between endoscopic ultrasonography ( EUS )-based ( GTVEUS ) and computed tomography ( CT ) -based (GTVCT) method for thoracic esophageal squamous cell carcinoma. Methods EUS was performed on 36consecutive patients with thoracic squamous cell carcinoma, and the superior and inferior boarders of the tumor defined by EUS were marked with hemoclips. The CT planning scan was then performed with the patient in supine position, and the GTVCT and GTVEUS were contoured respectively. The lengths ( LCT and LEUS) and spatial locations of longitudinal GTVCT and GTVEUS were compared. Results The mean LCT and LEUS were (7. 79 ± 3. 15 ) cm and (7. 42 ± 2. 72) cm, respectively ( t = 0. 82, P ＞ 0. 05 ), with a correlation coefficient of 0. 61 (P ＜0. 001 ). Locations of longitudinal GTVCT and GTVEUS were compared in 34cases, with 2 excluded for invisualization on CT. The mean conformal index (CI) was (0. 79 ± 0. 18 ), and spatial variations were found in 71% patients, with 8 patients at proximal end and 21 others at distal end.There was no clip placement associated complication. Conclusion Endoscopic hemoclips placement is safe and reliable. EUS can provide additional information to CT in defining longitudinal GTV in thoracic esophageal squamous cell carcinoma, especially in superficial and submucosal carcinomas.
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Objective To explore the changes and the tendency of breast cancer radiotherapy in China within the past decade.Methods A survey on breast cancer radiotherapy in 1 999 and 2006 was conducted in 4 hospitals located within the southeast coastal region of China,including patients'clinical characteristics,the purpose of radiotherapy and its techniques.Results The percentage of breast conservative treatment(BCT)increased from 3%in 1999 to 13%in 2006.For radiotherapy techniques in 2006 compared with 1999,the growth trend was found in use of breast immobilization devices(80% vs.46%),treatment planning system(70% vs.23%),and CT simulation(14%vs.0).The frequency was increased in the chest wall irradiation after masteetomy(90%vs.67%),but decreased in internal mammary region(30%vs.76%)and axilla(37%vs.69%)treatment.There were no differences in total dose and fractionation prescription.Conclusions BCT was performed more frequently,but postmastectomy radiotherapy was still essential option in China at present.Although some advanced techniques were applied frequently in clinical practice.Simulation,treatment planning,and irradiation target design were urgent for improvement and standardization.
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Objective To evaluate the outcome of radiotherapy for recurrent esophageal cancer after surgery and to determine the prognostic factors. Methods From Jan 2004 to Dec 2009, 93 patients of esophageal carcinoma with loco-regional recurrence as the first site of failure after surgery were retrospectively reviewed. Kaplan-Meier method was used to analyze the survival. Logrank test was used to evaluate the difference between the groups. Multivariate survival analysis was conducted using a Cox proportional hazard regression model with a backward stepwise procedure. Results The overall survival rates at 1, 2 and 3 years were 40. 9% , 10. 1% and 6. 7% ,respectively,but with a median survival time of 11.0 months(95% CI 9. 4-12. 6) . In univariate analysis, age,PS, radiation dose and retreatment methods were independent prognostic factors. In multivariate analysis, only radiation dose and retreatment methods were independent prognostic factors for overall survival. Conclusions The prognosis of patients with postoperative loco-regional recurrence of esophageal cancer is poor. However, a long-term survival maybe expected by definitive chemoradiotherapy.
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Objective To investigate the optimal treatment planning of intensity modulated radiotherapy (IMRT) for non-small cell lung cancer (NSCLC) .Methods Two types of treatment plans were designed for 11 patients with inoperable NSCLC disease.In the first plan(PTV60 plan) ,60 Gy was prescribed to the planning target volume(PTV) which was created using CTV(GTV +6-8 mm) plus the margin for organ motion and setup uncertainties.In the second plan(PTV70 plan) ,70 Gy was prescribed to the PTV which was created using GTV plus the margin for organ motion and setup uncertainties.The dose-volume histogram,the planning target volume coverage,and other dosimetric parameters of normal structures were compared between the two plans.Results These two plans were not significantly different in the dose heterogeneity,but commpared with the PTV60 plan,the PTV70 plan significantly improved 60 Gy volume with regard to PTV coverage.The values of V_(20) and V_5 of lung were reduced in average by (1.69 ±0.42) % ,and (1.29 ±1.09) % (t ＝ 0.047,0.264,P ＝ 0.002) ,respectively.Conclusions The planning of 70 Gy to the PTV using GTV plus the margin for organ motion and setup uncertainties might be better than that of 60 Gy to the PTV using CTV(GTV +6-8 mm) plus the margin for organ motion and setup uncertainties.
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Objective To evaluate the prognostic factors of brain metastasis from non-small cell lung cancer and suggest a individualized treatment method proposal with prognostic estimation. Methods From Dec. 2003 to Jan.2007, 183 patients received whole brain radiation therapy (WBRT) were retrospectively analyzed. Kaplan-Meier method was used to analyze the survival. Logrank test was used to evaluate the difference between the groups. Multivariate survival analysis was conducted using a Cox proportional hazard regression model with a backward stepwise procedure. Results The overall l-, 2- and 3-year survival rate was 40.6%, 16.6% and 11.3%, respectively, but with a median survival time of 10.0 months (95% CI 8.6-11.4 months). In multivariate analysis, RAP grouping, weight loss, LDH in blood serum and treatment method were independent prognostic factors. The median survival time of WBRT alone, WBRT with chemotherapy, surgery with chemoradiotherapy and WBRT with Gefitinib was 9.0, 9.0, 22.0 and 13.0 months, respectively, but their difference were statistical significant (X2 = 10.37, P = 0.016). Conclusions The main prognostic factors of brain metastasis from non-small cell lung cancer are RAP grouping, weight loss, LDH in blood serum and treatment method. The survival time is prolonged by proper multidiseiplinary management than WBRT alone. The effect of combined treatment of surgery with chemoradiotherapy is favorable for the patients operated with single region of metastasis.