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Objective:To explore the value of BLADE sequence in determining the target range of esophageal cancer radiotherapy through the correlation and consistency between measured esophageal cancer length on the MRI-BLADE sequence and the surgical pathological specimens.Methods:Clinical data of 36 patients who were pathologically diagnosed with esophageal carcinoma and received preoperative esophageal MRI in the Affiliated Cancer Hospital of Zhengzhou University between January 2016 to June 2019 were collected. The CT, DWI and BLADE sequence images of all participants were collected and imported into the Monaco system, by which the correlation and consistency between the tumor length measured based on these three imaging methods were statistically compared. Furthermore, the differences in gross tumor volume (GTV) delineated by different physicians in different images were compared.Results:The correlation coefficients of the tumor length measured by CT, DWI and BLADE and pathological specimen length were 0.467, 0.723 and 0.896, respectively. The consistency analysis indicated that all the differences between the BLADE sequence and pathological specimen length were within the 95% consistency limit. The consistency and correlation between the BLADE sequence and actual tumor length were significantly better than those between the DWI sequence and CT images (both P<0.05). The volume of DWI and BLADE images obtained by four physicians was significantly smaller than that of CT images (both P<0.05). The differences in GTV delineated by different physicians by these three imaging methods were insignificant (all P>0.05), but the GTV delineated by the four physicians on the BLADE sequence were more similar (all P>0.05). Conclusions:BLADE sequence can help physicians to determine the upper and lower boundaries of esophageal tumors more accurately and reduce the differences in GTV delineation among different physicians. And it can effectively improve the unity of individual′s understanding of the scope of target area delineation, and improve the objectivity of clinicians′ judgment of GTV. BLADE sequence can be used as an important imaging tool for accurate target delineation in radiotherapy.
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Objective To evaluate the early injury and dynamic changes of the left ventricular diastolic function of patients with esophageal carcinoma after radiotherapy by using two-dimensional speckle tracking imaging (2D-STI).Methods From 2017 to 2018,echocardiography examinations were performed in 39 patients with esophageal carcinoma before,during and after the first thoracic radiotherapy to measure the left ventricular end diastolic volume (LVEDV),left ventricular end systolic volume (LVESV),left ventricular ejection fraction (LVEF),early diastolic mitral flow velocity/early diastolic mitral annular peak velocity (E/e'),left atrial volume (LAV),2D-STI parameters including the left ventricular global longitudinal strain (GLS),global systolic stain rate (GSRs),global early diastolic strain rate (GSRe),global late diastolic strain rate (GSRa) and E/GSRe ratio.According to the GLS of patients with esophageal carcinoma after radiotherapy (cumulative dose≥50 Gy),the patients were divided into good prognosis (n=23) and poor prognosis groups (n=16).The E/GSRe ratio was statistically compared between two groups.Results The E/e'and LAVI were increased significantly only after radiotherapy (both P＜0.05),and LVEF was decreased significantly only after radiotherapy (P＜0.05).The e' tended to decline before,during and after radiotherapy (all P＜0.05).GLS and GSRs were significantly decreased only after radiotherapy (both P＜0.05),whereas GSRa was considerably decreased during radiotherapy (P＜0.05).E/GSRe tended to increase (P＜0.05).Compared with the good prognosis group,E/GSRe was significantly increased after radiotherapy in the poor prognosis group (P＜0.05).Conclusions Diastolic dysfunction can occur in the early stage of radiation-induced heart injury.The global diastolic strain rate and E/GSRe obtained by 2D-STI can be used to assess the early left ventricular dysfunction.E/GSRe can be more sensitive to evaluate the clinical prognosis compared with the global diastolic strain rate.
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In China, radical esophagectomy remains the main strategy for resectable esophageal cancer. However, the high locoregional recurrence rate and hematogenous metastasis rate are the main causes of surgical failure. Therefore, whether postoperative adjuvant therapy can become one of the important means for esophageal cancer remains controversial. In this article, the research progress on the postoperative recurrent pattern and adjuvant therapy for esophageal carcinoma was reviewed to provide references for clinicians.
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Objective@#To evaluate the role of prognostic nutritional index (PNI) in the radiotherapy for elderly patients with esophageal squamous cell carcinoma.@*Methods@#Clinical data of 108 elderly patients (aged>65 years) with esophageal squamous cell carcinoma who underwent radical radiotherapy were retrospectively analyzed. The PNI value of each patient was calculated, and the optimal cutoff value of PNI before treatment was determined by establishing the receiver operating characteristic curve (ROC curve). All patients were divided into the low and high PNI value groups. The overall survival rate was calculated by Kaplan-Meier method. Log-rank test, univariate and Cox’s multivariate prognosis analyses were performed.@*Results@#The ROC curve demonstrated that the optimal cutoff value of PNI was 50.1(n=52 in high PNI group and n=56 in low PNI group). Age, gender and treatment did not significantly differ between two groups, whereas the TNM staging significantly differed (P=0.022). The effective rate of radiotherapy in the high PNI group was 96%, significantly higher than 73% in the low PNI group (P=0.001). In the high PNI group, the 1-, 2-, and 3-year overall survival rates were 94%, 69%, and 62%, significantly higher compared with 70%, 32% and 27% in the low PNI group (all P<0.001). Univariate analysis showed that PNI, T staging, N staging and TNM staging were significantly correlated the overall survival of patients (all P<0.01). Cox’s multivariate analysis revealed that N staging (RR=1.94, 95%CI=1.29-2.94, P=0.002) and PNI (RR=0.83, 95%CI=0.77-0.90, P<0.001) were independent risk factors affecting overall survival.@*Conclusions@#PNI before treatment has a good correlation with the prognosis and radiotherapy efficacy of patients, which can be used as a pivotal index to predict the clinical benefit of radiotherapy for elderly patients with esophageal squamous cell carcinoma.
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Objective@#To investigate the feasibility of assessing the treatment response using diagnostic-quality CT imaging features during radiotherapy for esophageal cancer.@*Methods@#Thirty-three patients with stage Ⅰ to IV esophageal cancer undergoing intensity-modulated radiotherapy were recruited in this study. CT images were acquired using a CT-on-rail imaging system. Imaging data of CT images including gross tumor volume (GTV), the volume of spinal cord and non-irradiated tissue (NIT), CT mean (MCTN), standard deviation , and skewness were collected and analyzed by using MIM image processing system. Patients were divided into the effective group (complete remission and partial remission, n=24) and ineffective group (no change and progression, n=9) based on the outcomes of 3-month follow-up. The imaging data were statistically compared between two groups using the self-designed Matlab software.@*Results@#The tumor volume and MCTN of 33 patients were gradually decreased with the increase of radiotherapy dose. The tumor volume and MCTN were decreased by 42.46% and 5.76 HU in the effective group, more significant compared with 21.76% and 3.66 HU in the ineffective group (both P<0.005). The skewness in the ineffective group was decreased by 0.503 with the increasing radiation dose, whereas that in the effective group was increased by -0.450(P=0.034). Spinal cord and NIT did not significantly change with the increasing radiation dose.@*Conclusion@#Analysis of the characteristic data of CT images of patients with esophageal cancer during radiotherapy may early predict the clinical efficacy of radiotherapy.
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Objective To investigate the feasibility of assessing the treatment response using diagnostic-quality CT imaging features during radiotherapy for esophageal cancer.Methods Thirty-three patients with stage Ⅰ to Ⅳ esophageal cancer undergoing intensity-modulated radiotherapy were recruited in this study.CT images were acquired using a CT-on-rail imaging system.Imaging data of CT images including gross tumor volume (GTV),the volume of spinal cord and non-irradiated tissue (NIT),CT mean (MCTN),standard deviation,and skewness were collected and analyzed by using MIM image processing system.Patients were divided into the effective group (complete remission and partial remission,n=24) and ineffective group (no change and progression,n=9) based on the outcomes of 3-month follow-up.The imaging data were statistically compared between two groups using the self-designed Matlab software.Results The tumor volume and MCTN of 33 patients were gradually decreased with the increase of radiotherapy dose.The tumor volume and MCTN were decreased by 42.46％ and 5.76 HU in the effective group,more significant compared with 21.76％ and 3.66 HU in the ineffective group (both P＜0.005).The skewness in the ineffective group was decreased by 0.503 with the increasing radiation dose,whereas that in the effective group was increased by-0.450(P=0.034).Spinal cord and NIT did not significantly change with the increasing radiation dose.Conclusion Analysis of the characteristic data of CT images of patients with esophageal cancer during radiotherapy may early predict the clinical efficacy of radiotherapy.
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Objective To evaluate the role of prognostic nutritional index (PNI) in the radiotherapy for elderly patients with esophageal squamous cell carcinoma.Methods Clinical data of 108 elderly patients (aged ＞ 65 years) with esophageal squamous cell carcinoma who underwent radical radiotherapy were retrospectively analyzed.The PNI value of each patient was calculated,and the optimal cutoff value of PNI before treatment was determined by establishing the receiver operating characteristic curve (ROC curve).All patients were divided into the low and high PNI value groups.The overall survival rate was calculated by Kaplan-Meier method.Log-rank test,univariate and Cox's multivariate prognosis analyses were performed.Results The ROC curve demonstrated that the optimal cutoff value of PNI was 50.1 (n =52 in high PNI group and n=56 in low PNI group).Age,gender and treatment did not significantly differ between two groups,whereas the TNM staging significantly differed (P=0.022).The effective rate of radiotherapy in the high PNI group was 96％,significantly higher than 73％ in the low PNI group (P=0.001).In the high PNI group,the 1-,2-,and 3-year overall survival rates were 94％,69％,and 62％,significantly higher compared with 70％,32％ and 27％ in the low PNI group (all P＜0.001).Univariate analysis showed that PNI,T staging,N staging and TNM staging were significantly correlated the overall survival of patients (all P＜ 0.01).Cox's multivariate analysis revealed that N staging (RR =1.94,95％CI=1.29-2.94,P=0.002) and PNI (RR=0.83,95％CI=0.77-0.90,P＜0.001) were independent risk factors affecting overall survival.Conclusions PNI before treatment has a good correlation with the prognosis and radiotherapy efficacy of patients,which can be used as a pivotal index to predict the clinical benefit of radiotherapy for elderly patients with esophageal squamous cell carcinoma.
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Objective To evaluate the application of the placement of titanium clips in the upper and lower tumor margins in precision radiotherapy for early esophageal cancer. Methods:Seventeen patients with early esophageal cancer underwent endoscopy-guided implantation of titanium clips to mark the upper and lower tumor margins. CT-based simulation was performed to delineate the gross tumor volume ( GTV) . The application value of this technology in precision radiotherapy was evaluated. Results:For all patients (including 13 cases with initial treatment and 4 patients requiring radiotherapy after endoscopic resection), the esophageal tumors were not explicitly displayed on CT and barium meal images and the GTV range could not be accurately determined. The esophageal tumors were marked by successful placement of at least one titanium clip in the upper and lower tumor margins. Subsequently, the esophageal tumors were successfully displayed on CT simulation and the target area was accurately delineated. No grade 3-4 adverse events, such as bleeding and perforation occurred. Conclusion Endoscopy-guided titanium clip placement is convenient and feasible for early esophageal cancer, which is of clinical significance for determining the target area of radiotherapy.
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Objective To investigate the survival benefits of simultaneous integrated boost intensity-modulated radiotherapy ( SIB-IMRT ) in the treatment of esophageal squamous cell carcinoma ( ESCC ) . Methods From July 2003 to March 2014,1748 patients with ESCC received 3DCRT or IMRT in a single institution were enrolled in this retrospective study. Among them, 809 patients received conventional fractionated radiotherapy with the standard prescription dose and 110 patients received SIB-IMRT ( SIB-IMRT group).Survival analysis was performed and propensity score matching (PSM 1vs1) was conducted to evaluate and compare the survival benefits between SIB-IMRT and conventional fractionated radiotherapy. Results The baseline characteristics significantly differed between two groups. In the SIB group,the age was significantly younger ( 64 years vs. 66 years, P=0. 001 ) , the percentage of patients with cervical/upper thoracic tumors was considerably higher (53. 6％ vs. 31. 0％,P=0. 000) and the proportion of N2 patients was significantly higher ( 21. 8％ vs. 13. 7％,P=0. 027) compared with those in the other group. Accordingto the PSM of 1:1, 218 patients were successfully matched. After matching, the clinical data did not significantly differ between two groups. Prior to matching,the median survival time in the standard dose and SIB-IMRT groups were 23 and 21 months (P=0. 638).After matching,the median survival time in the SIB-IMRT group was 22 months,significantly longer than 18 months in the standard dose group (P=0. 000). Subgroup analysis demonstrated that patients with large tumors ( GTV volume>40 cm3 ) and middle/lower thoracic tumors obtained more survival benefits from SIB-IMRT. The median survival time of patients in the standard dose group was 14 months, significantly shorter than 21 months in the SIB-IMRT group ( P=0. 001).The median survival time of patients with middle/lower thoracic tumors in the SIB-IMRT group was 17 months,significantly longer than 9 months in the standard dose group (P=0. 000).Multivariate analysis using Cox regression model indicated that age, tumor site and radiotherapy modality were the independent prognostic factors. The HR of SIB-IMRT was 0. 551(P=0. 000),which was a factor for survival benefits. Conclusions SIB-IMRT possesses potential survival benefits for ESCC compared with conventional fractionated radiotherapy. Patients with large tumors and middle/lower thoracic tumors are more prone to obtaining benefits from SIB-IMRT than their counterparts.
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Objective To evaluate the survival and prognostic factors of esophageal cancer treated with definitive ( chemo ) radiotherapy by applying novel radiation techniques including three-dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT). Methods Clinical data of 2762 patients with non-operated esophageal squamous cell carcinoma who underwent definitive ( chemo ) radiotherapy from 2002 to 2016 in 10 hospitals were retrospectively analyzed.The prognostic factors were also identified and analyzed. Results The median follow-up time was 60. 8 months. The 1-, 2-, 3-and 5-year overall survival (OS) of all patients was 71. 4％,48. 9％,39. 3％,and 30. 9％,respectively.The 1-,2-,3-and 5-year progression-free survival (PFS) was 59.5％,41.5％,35.2％,and 30％,respectively.The median survival was 23 months.The median time to progression was 17. 2 months.Multivariate analysis demonstrated that age, primary tumor location, clinical stage, tumor target volume, EQD2 and treatment mode were the independent prognostic factors for OS.Primary tumor location,clinical stage,tumor target volume and EQD2 were the independent prognostic factors for PFS. Conclusions In this first large-scale multi-center retrospective analysis of definitive ( chemo) radiotherapy for esophageal squamous cell carcinoma in China, the 5-year OS of patients with esophageal squamous cell carcinoma is significantly improved by 3DCRT, IMRT combined with chemotherapy drugs. However, the findings remain to be validated by prospective clinical trials with high-level medical evidence.
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Along with the intensification of the aging trend,the proportion of elderly patients suffering from esophageal cancer has been ever increased.Radiotherapy plays a pivotal role in the treatment of esophageal cancer in the elderly patients considering their relatively poor tolerance of surgery and high risk of postoperative complications.In this review,the development in the comprehensive treatment of esophageal cancer in the elderly was summarized.
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As the fourth leading cause of cancer death for years,esophageal carcinoma yields a high morbidity in China. In an aging society,the quantity of elderly patients with esophageal carcinoma is ever increasing. However,elderly patients have been excluded in most studies due to more comorbidities,lower performance status grade,worse therapeutic tolerance and other clinical features. Although clinical prognosis of esophageal carcinoma patients has been improved in the past decades, the clinical efficacy in the treatment of esophageal carcinoma in elderly patients is still unsatisfactory. Current options should be combined with novel therapeutic srategies to enhance the clinical efficacy. In this article, the clinical efficacy and adverse events of radiotherapy, radiochemotherapy, targeted therapy or immunotherapy in treating elderly patients with unresectable esophageal carcinoma were retrospectively analyzed.
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Objective To investigate the variations of the spatial position and overlap ratio for gross tumor volume (respiratory phase 50％) (GTV50) and internal gross tumor volume (IGTV) of primary thoracic esophageal cancer during conventional fractionated radiotherapy based on repeated four-dimensional computed tomography (4DCT) scans.Methods Thirty-three patients with thoracic esophageal cancer underwent contrast-enhanced 4DCT scans before radiotherapy and at the 10th and 20th fractions of radiotherapy.Scans were registered to the baseline 4DCT scan using bony landmarks.The GTV50 was delineated by the same radiotherapist on each 4DCT imaging data set,and the IGTV was constructed accordingly.The target volume,degree of inclusion (DI),and matching index (MI) were compared in different phases.Results The volumes of GTV50 and IGTV decreased along with treatment course.No significant changes in the centroid position were observed for the GTV50 and IGTV.The median DIs of the target volumes at the 10th and 20th fractions in the original target volume were 0.75 and 0.63(P =0.000) for GTV50 and were 0.79 and 0.66(P=0.000) for IGTV,while the median MIs were 0.61 and 0.56(P=0.002) for GTV50 and were 0.68 and 0.58 (P =0.005) for IGTV.A positive correlation between the variation of volume ratio and the variation of DI was found for GTV50 and IGTV (r =0.632,r =0.783),and the variation of volume ratio was also positively correlated with the variation of MI (r =0.387,r =0.483) ;the 3D vector was negatively correlated with the MI (r =-0.455,r =-0.438).Conclusions During conventional fractionated radiotherapy,the variation of spatial position is less than 0.8 cm for GTV50 and IGTV of primary thoracic esophageal cancer,and the decline of the target leads to varying degrees of decreases in DI and the MI.
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Objective To study the setup errors in three-dimensional conformal radiotherapy (3DCRT) for thoracic esophageal carcinoma using electronic portal imaging device(EPID) and calculate the margins from CTV to PTV. Methods Forty-one patients with thoracic esophageal carcinoma who received 3DCRT were continuously enrolled into this study. The anterior and lateral electronic portal images (EPI) were aquired by EPID once a week. The setup errors were obtained through comparing the difference between EPI and digitally reconstructed radiographs(DRR). Then the setup margins from CTV to PTV were calculat-ed. By using self paired design,22 patients received definitive radiotherapy with different margins. Group A: the margins were 10 mm in all the three axes;Group B: the margins were aquired in this study. The differ-ence were compared by Paired t-test or Wilcoxon signed-rank test. Results The margins from CTV to PTV in x,y and z axes were 8.72 mm, 10.50 mm and 5.62 mm, respectively. Between the group A and group B, the difference of the maximum dose of the spinal cord was significant(4638.7 cGy±1449.6 cGy vs. 4310.2 cGy±1528.7 cGy; t=5.48, P=0.000), and the difference of NTCP for the spinal cord was also significant (4.82%±5.99% vs. 3.64%±4.70%;Z=-2.70,P=0.007). Conclusions For patients with tho-racic esophageal carcinoma who receive 3DCRT in author's department,the margins from CTV to PTV in x, y and z axes were 8.72 mm, 10.50 mm and 5.62 mm, respectively. The spinal cord could be better protected by using these setup margins than using 10 mm in each axis.