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Objective:To investigate the prognostic value of Onodera's prognostic nutrition index (PNI) before treatment in patients with cervical and upper thoracic esophageal squamous cell carcinoma (CUTESCC) undergoing definitive chemoradiotherapy (dCRT) and its predictive value in the occurrence of ≥ grade 2 radiation esophagitis (RE).Methods:The data of 163 CUTESCC patients eligible for inclusion criteria admitted to the Fourth Hospital of Hebei Medical University from January 2012 to December 2017 were retrospectively analyzed. The receiver operating characteristic (ROC) curve was used to calculate the best cut-off value of PNI for predicting the prognosis of patients. The prognosis of patients was analyzed by univariate and Cox multivariate analyses. Logistics binary regression model was adopted to analyze the risk factors of ≥ grade 2 RE in univariate and multivariate analyses. The significant factors in logistic multivariate analysis were used to construct nomogram for predicting ≥ grade 2 RE.Results:The optimal cut-off value of PNI was 48.57 [area under the curve (AUC): 0.653, P<0.001]. The median overall survival (OS) and progression-free survival (PFS) were 26.1 and 19.4 months, respectively. The OS ( χ2=6.900, P=0.009) and PFS ( χ2=9.902, P=0.003) of patients in the PNI ≥ 48.57 group ( n=47) were significantly better than those in the PNI < 48.57 group ( n=116). Cox multivariate analysis showed that cTNM stage and PNI were the independent predictors of OS ( HR=1.513, 95% CI: 1.193-1.920, P=0.001; HR=1.807, 95% CI: 1.164-2.807, P=0.008) and PFS ( HR=1.595, 95% CI: 1.247-2.039, P<0.001; HR=2.260, 95% CI: 1.439-3.550, P<0.001). Short-term efficacy was another independent index affecting PFS ( HR=2.072, 95% CI: 1.072-4.003, P=0.030). Logistic multivariate analysis showed that the maximum transverse diameter of the lesion ( OR=3.026, 95% CI: 1.266-7.229, P=0.013), gross tumor volume (GTV) ( OR=3.456, 95% CI: 1.373-8.699, P=0.008), prescription dose ( OR=3.124, 95% CI: 1.346-7.246, P=0.009) and PNI ( OR=2.072, 95% CI: 1.072-4.003, P=0.030) were the independent factors affecting the occurrence of ≥ grade 2 RE. These four indicators were included in the nomogram model, and ROC curve analysis showed that the model could properly predict the occurrence of ≥ grade 2 RE (AUC=0.686, 95% CI: 0.585-0.787). The calibration curve indicated that the actually observed values were in good agreement with the predicted RE. Decision curve analysis (DCA) demonstrated satisfactory nomogram positive net returns in most threshold probabilities. Conclusions:PNI before treatment is an independent prognostic factor for patients with CUTESCC who received definitive chemoradiotherapy. The maximum transverse diameter of the lesion, GTV, prescription dose and PNI are the risk factors for ≥ grade 2 RE in this cohort. Establishing a prediction model including these factors has greater predictive value.
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Objective:To analyze whether involved-field irradiation (IFI) was associated with improved survival and reduced treatment-related adverse events compared with elective nodal irradiation (ENI) in Chinese patients with esophageal squamous cell carcinoma receiving radiotherapy.Methods:Literature review was conducted from CNKI, Wanfang Data, PubMed, Embase, Web of Science and Cochrane Central databases (until July 31, 2022). Relevant data were collected according to the inclusion and exclusion criteria. Primary outcomes included overall survival (OS) rate and treatment-related adverse events. Secondary outcomes included progression-free survival (PFS) rate and local control rate (LCR). Risk of bias was assessed using the Cochrane Risk of Bias tool. The quality of the results was assessed by using the meta analysis of Evidence Evaluation and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methods.Results:A total of 7 articles with 918 patients were included of which 465 received IFI and 453 received ENI. The 1-, 2-, 3-and 5-year OS rates in the IFI group were not significantly different from those in the ENI group (1-year OS rate: RR=1.00, 95% CI=0.94-1.07, P=0.97, high certainty; 2-year OS rate: RR=1.01, 95% CI=0.90-1.13, P=0.90, high certainty; 3-year OS rate: RR=0.86, 95% CI=0.71-1.05, P=0.14, high certainty; 5-year OS rate: RR=0.76, 95% CI=0.42-1.37, P=0.36, low certainty). In the IFI group, patients with ≥grade 2 acute radiation esophagitis ( RR=0.71, 95% CI=0.58-0.87, P=0.001, high certainty), ≥grade 3 acute radiation esophagitis ( RR=0.39, 95% CI=0.24-0.64, P<0.001, high certainty) and ≥grade 2 acute radiation pneumonitis ( RR=0.72, 95% CI=0.52-0.99, P=0.04, high certainty) were significantly lower compared with those in the ENI group. However, no significant differences were observed in the incidence of ≥grade 3 late radiation esophagitis, ≥grade 3 acute radiation pneumonitis and ≥grade 3 late radiation pneumonitis between two groups. No significant differences were noted in the 1-, 2-, 3-PFS rates and LCR between two groups. Conclusions:For Chinese patients with esophageal squamous cell carcinoma, IFI and ENI yield similar efficacy in terms of OS, PFS and LCR. However, IFI has a lower incidence of ≥grade 2 acute radiation esophagitis, ≥grade 3 acute radiation esophagitis and ≥grade 2 acute radiation pneumonitis than ENI.
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Objective:To analyze the local recurrence patterns after concurrent chemoradiotherapy (CCRT) for thoracic esophageal squamous cell carcinoma (ESCC) through image fusion, and to explore the risk factors of local recurrence and its relationships with dosimetric indices.Methods:A retrospective analysis was conducted for 209 thoracic ESCC patients who received radical CCRT in Fourth Hospital of Hebei Medical University during 2016-2019. For the patients diagnosed as the local recurrence of esophageal lesions, their CT images were fused with the original planning CT images using image registration software to identify the recurrence sites. Through 1∶1 propensity score matching (PSM) of the clinal data of patients with local recurrence (the recurrence group, nbefore = 81, nafter = 62) and those without local recurrence (the recurrence-free group, nbefore = 128, nafter=62), the dose and volume parameters of the treatment plans for the two groups were compared. Univariate and multivariate analyses were conducted using the Kaplan-Meier method and the Cox regression model to analyze the factors affecting the overall survival (OS), progression-free survival (PFS), and recurrence-free survival (RFS). Results:All patients had 1-, 3-, and 5-year OS rates of 80.9%, 42.6%, and 33.0%, respectively, 1-, 3-, and 5-year PFS rates of 67.9%, 34.0%, and 27.9%, respectively, and 1-, 3-, and 5-year RFS rates of 71.3%, 39.2%, and 30.5%, respectively. T stage, N stage, and radiation dose were independent prognostic factors for the OS, PFS, and RFS ( HR = 1.42-1.87, P < 0.05) of the patients, respectively. Among 68 patients with local recurrence, 62 cases (91.2%) suffered recurrence within the gross tumor volume (GTV). The dose and volume parameters of patients with local recurrence, such as GTV- D95%, clinical target volume (CTV)- D95%, GTV- D50%, CTV- D50%, and planning target volume (PTV)- D50%, GTV- V60, CTV- V60, and PTV- V60, were significantly lower than those of patients free from the local recurrence ( t=1.90-2.15, P < 0.05). Conclusions:Local recurrence of patients with thoracic ESCC after radical CCRT occurs mainly within the GTV. Increasing radiation doses may contribute to their survival benefits. The D50% for each target volume in the radiotherapy plan may be related to local recurrence, and it is necessary to conduct further research.
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Objective:To investigate the relationship between Onodera′s prognostic nutritional index (PNI) and prognosis of patients with esophageal squamous cell carcinoma (ESCC) after definitive chemoradiotherapy or radiotherapy, aiming to provide a convenient, effective and accurate predictive indicator for evaluating the long-term survival of patients after treatment.Methods:Clinical data of 231 ESCC patients treated with definitive chemoradiotherapy or radiotherapy at the Fourth Hospital of Hebei Medical University from 2013 to 2015 were retrospectively analyzed. The PNI values of each patient at different radiotherapy periods were calculated and the ROC curve was used to determine the optimal cutoff value of PNI before radiotherapy, 231 patients were divided into the better-nourishment group ( n=86) and worse-nourishment group ( n=145). Kaplan- Meier method was used for survival analysis. Cox proportional hazards model was utilized to analyze the relationship between different nutritional status and prognosis. The short-term clinical efficacy and incidence of acute toxicities were statistically compared between two groups. Results:The mean values of PNI before, at week 3, week 6 and 1 month after radiotherapy were48.68±5.08, 39.68±4.87, 43.74±4.89 and48.31±4.92, respectively. The optimal cutoff value of pretreatment PNI was 49.25, the area under the curve (AUC) was 0.655, the sensitivity and specificity were 68.6% and 60.9%, respectively. The 5-year overall survival (OS) and progression-free survival (PFS) rates in the better-nourishment group (PNI≥49.25) were 36.0% and 31.3%, significantly better than 19.3% and 18.6% in the worse-nourishment group (PNI<49.25)( P=0.001, P=0.039). Multivariate analysis showed PNI before the therapy was an independent prognostic factor for OS ( P=0.021). Stratified analysis demonstrated that Stage Ⅰ/Ⅱ and concurrent chemotherapy patients in the better-nourishment group all obtained significantly better OS than their counterparts in the worse-nourishment group ( P=0.007, P=0.004). In addition, the objective response rate in the better-nourishment group was significantly higher than that in the worse-nourishment group ( P=0.047), whereas the incidence of ≥3 grade radiation esophagitis was lower than that in the worse-nourishment group ( P=0.060). Conclusions:Pretreatment PNI is a convenient and reliable indicator for predicting the long-term survival of ESCC patients after definitive chemoradiotherapy or radiotherapy. Patients with higher PNI have relatively better prognosis and radiotherapy tolerance, especially in those with early stage or concurrent chemotherapy.
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Objective:To evaluate the effects of different irradiation ranges in definitive intensity-modulated radiotherapy (IMRT) combined with chemotherapy on the survival of esophageal cancer patients.Methods:Clinical data of 360 esophageal cancer patients who received definitive chemoradiotherapy in the Fourth Hospital of Hebei Medical University from 2006 to 2015 were retrospectively analyzed. Among them, 131 patients received elective nodal irradiation (ENI) and 229 patients underwent involved-field irradiation (IFI). Platinum-based chemotherapy was adopted. The overall survival (OS) rate was analyzed by Kaplan- Meier method and Logrank test. Results:Until the final follow-up at the end of December 2018, the follow-up rate was 96%. The median follow-up time was 64 months (95% CI: 53-76). The median survival time was 24 months (95% CI: 20-28). The 1-, 3-, 5-year OS rates were 76.1%, 38.7% and 21.0%, respectively. After propensity score matching, the 1-, 3-, 5-year OS rates were 83.9%, 48.6%, 26.8% vs. 74.0%, 33.8%, 17.5% between the ENI ( n=131) and IFI groups ( n=131)( P=0.011), respectively. Subgroup analysis showed that patients with male, aged≤66 years, cervical and upper-thoracic location, tumor length≤7 cm, tumor volume≤50 cm 3, T 1-3 stage, dosage>60 Gy and concurrent chemoradiotherapy obtained better OS rates in the ENI group than their counterparts in the IFI group (all P<0.05). In the ENI group, the total failure rate, locoregional failure rate and distant metastasis rate were significantly lower, whereas the incidence of ≥Grade Ⅲ myelosuppression was remarkably higher than those in the IFI group (all P<0.05). Conclusion:Compared with IFI, ENI can significantly improve the survival for patients with early-stage and cervical and upper-thoracic esophageal cancer receiving definitive IMRT combined with chemotherapy.
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Objective:To evaluate the efficacy of target area of radical radiotherapy for inoperable esophageal carcinoma patients treated with intensity-modulated radiotherapy (IMRT).Methods:A retrospective analysis was performed on the clinical data of 564 Ⅰ-Ⅳ non-surgical esophageal cancer who received definitive intensity-modulated radiotherapy alone in our hospital from 2006 to 2015. Propensity score matching (PSM) was used to identify well-balanced patients for comparison. The Kaplan-Meier method was used to calculate local-regional failure-free survival (LRFFS), progression-free survival (PFS), overall survival (OS) rates and univariate analysis. The multivariate analysis of prognostic factors were tested by COX proportional hazard model.Results:The last follow-up time was December 2018, the median follow-up time was 99.7 (95% CI: 77.5-122.1) months. Follow-up rate was 95.9%. For the 564 patients, the 1-, 3-, 5- year LRFFS were 61.5%, 26.5%, 14.3%, PFS were 56.7%, 25.0%, 13.4%, OS were 73.0%, 31.1%, 16.8%. After PSM, for the elective-nodal irradiation (ENI) ( n=141) and involved-nodal irradiation (IFI) ( n=141) groups, the 1-, 3-, 5- year LRFFS were 68.8%, 34.2%, 19.1% vs. 65.2%, 32.1%, 17.9% ( P>0.05), PFS were 63.1%, 31.0%, 16.6% vs. 60.3%, 29.3%, 16.6% ( P>0.05), OS were 80.9%, 41.5%, 23.3% vs. 80.1%, 35.0%, 20.2% ( P>0.05). In multivariate analysis, tumor volume≤37 cm 3 and Ⅰ+ Ⅱ stage were independent factors for LRFFS, PFS and OS. Subgroup analysis showed that there were no significant differences in the survival rates between the ENI group and IFI group ( P>0.05). Comparing to the IFI group, ENI reduced the local-regional failure rate ( P=0.048). Conclusions:Using intensity-modulated radiation therapy alone for inoperable esophageal carcinoma, ENI can significantly reduce the local-regional failure rate, but not improve survival rates compared to the IFI.
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Objective To investigate the prognostic effects and failure patterns of different clinical target volumes of IMRT in definitive chemoradiotherapy for cervical and upper-thoracic esophageal cancer,in order to provide a reference for radiotherapy target area delineation.Methods A retrospective analysis was performed on the clinical data of 132 patients with cervical and upper-thoracic esophageal cancer who received definitive IMRT and concurrent chemotherapy in our hospital from 2010 to 2014.Seventy-one patients received elective nodal irradiation (ENI) and the other 61 patients received involvedfield irradiation (IFI).The Kaplan-Meier method was used to calculate local control (LC),progressionfree survival (PFS) and overall survival (OS) rates.The significant difference was evaluated by the logrank test.The prognostic factors were determined by Cox univariate and multivariate analyses.Results The last follow-up time was December 2017,the median follow-up time was 59.5 (14.2-95.8) months.Follow-up rate was 99.2％.For the ENI and IFI groups,the 1-,3-,5-year LC were 77.5％,58.8％,48.8％ vs.64.3％,29.1％,26.2％ (x2=9.68,P=0.002),PFS were 68.6％,37.7％,25.9％ vs.47.5％,17.2％,3.6％ (x2=11.39,P=0.001),OS were 81.7％,53.9％,31.3％ vs.70.5％,31.9％,16.3％ (x2=7.70,P =0.006),respectively.In multivariate analysis,T stage,N stage,and RT field were independent factors for LC,PFS and OS(P＜0.05).The total failure rates,local-regional recurrent rate in ENI group were lower than those in IFI group (x2 =13.23,5.24,P＜0.05).No significant differences were found in acute radiation esophagitis,pneumonitis and myelosuppression (Grades ≥ 3) between the two groups(P＞0.05).Conclusions Compared with IFI,ENI can significantly reduce local-regional recurrence and distant metastasis and improve the long-term survival for cervical and upper-thoracic esophageal cancer patients who received definitive chemoradiotherapy.
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Objective To compare the clinical efficacy between simultaneous integrated boost (SIB) and sequential boost (SB) using intensity-modulated radiotherapy (IMRT),and investigate the long-term clinical efficacy and adverse events of SIB-IMRT in combination with chemotherapy in the treatment of esophageal cancer.Methods Clinical data of 330 patients diagnosed with esophageal cancer undergoing radical chemoradiotherapy in Fourth Hospital of Hebei University from January 2006 to December 2015 were respectively analyzed.All patients were assigned into the SIB-IMRT (n=135) and SB-IMRT groups (n=195).All patients received definitive radiotherapy with elective nodal irradiation (ENI).After the propensity score matching (PSM),105 patients were enrolled in each group.Kaplan-Meier method was used to survival analysis.Cox model was used to multivariate prognostic analysis.Results Prior to PSM,the 1-,3-and 5-year local control rates were 80.1％,58.3％,46.7％ and 72.1％,44.9％,40.5％ in the SIB-IMRT and SB-IMRT groups (P=0.050),and the 1-,3-and 5-year OS rates were 81.4％,51.9％,43.5％ and 80.5％,37.9％,22.3％(P=0.014),respectively.After the PSM,the 1-,3-and 5-year LC rates were 80.2％,54.2％,43.9％ and 75.5％,47.2％,41.2％ (P=0.264),and the 1-,3-and 5-year OS rates were 78.9％,49.0％,40.8％ and 83.3％,41.7％,24.8％ (P=0.265),respectively.Multivariate analysis demonstrated that TNM staging was an independent prognostic factor in the SIB-IMRT group,whereas TNM staging and chemotherapy served as the independent prognostic factors in the SB-IMRT group.Stratified analysis revealed that the LC rate in the SIB-IMRT was significantly higher than that in the SB-IMRT group when radiotherapy alone was performed (P =0.018).The OS rate in the SIB-IMRT group was equally higher compared with that in the SBIMRT group.Conclusions The LC and OS rates are almost identical after SB-IMRT and SIB-IMRT in the treatment of esophageal cancer,whereas the prognostic survival in the SIB-IMRT group is significantly longer compared with that in the SB-IMRT group during radiotherapy alone.The findings remain to be validated by multi-center investigations with a large sample size.