T4 cervical esophageal cancer cured with modern chemoradiotherapy: A case report.

BACKGROUND: T4 esophageal cancer portends a poor prognosis, particularly when it is complicated by a tracheoesophageal fistula (TEF) either resulting from disease or occurring as a complication of treatment. Patients with TEF that occurs during treatment are commonly treated with palliative intent because fistula-associated treatment complications such as aspiration pneumonia and mediastinitis are associated with high morbidity and mortality. To date, there is no clear evidence on the optimal treatment of T4 esophageal cancer, particularly when a TEF formation occurs. CASE SUMMARY: A 67-year-old gentleman who presented with dysphagia and weight loss. Endoscopy and imaging revealed a T4N1M0 cervical esophageal squamous cell carcinoma. He received image-guided intensity-modulated radiation therapy, with concurrent weekly carboplatin (area under curve 2 mg/mL per minute) and paclitaxel (50 mg/m2 of body surface area). One week after treatment initiation (16.2 Gy thus far), he developed cough on swallowing. A TEF was detected on image-guided radiation therapy using cone-beam computed tomography during the treatment course, for which a tracheal stent was inserted. After discussing the risks and morbidity of continuing treatment, he resumed chemoradiotherapy with an additional radiation dose of 45 Gy in 25 fractions. Three months after completion of chemoradiotherapy, he developed an esophageal stricture that required esophageal stenting and dilatation. The patient remains cancer-free at two year on follow-up. Complete response of esophageal cancer was evident on post-treatment endoscopy and computed tomography imaging, with successful closure of TEF. CONCLUSION: This case highlights that successful curative treatment for esophageal cancer complicated by a TEF is possible using novel chemotherapeutic regimens and modern radiation technologies.

Clinical outcomes of external beam radiotherapy in patients with localized prostate cancer: Does dose escalation matter?

BACKGROUND: To report outcomes of localized prostate cancer treated with radical external beam radiation therapy (EBRT) in our institution over a 14-year period, and to determine the impact of dose escalation of prostate cancer outcomes. METHODS: Patients with T1-T4 N0 M0 prostate cancer who received radical EBRT between January 2002 and December 2015 were reviewed retrospectively. Clinical data were obtained via the institutional electronic medical records. The primary endpoint was 5-year overall survival (OS). The secondary endpoints were 5-year freedom from biochemical failure (FFBF) and treatment toxicities. RESULTS: A total of 200 eligible patients were identified. Median follow-up duration was 48 months. 13%, 36% and 51% of patients had low-, intermediate- and high-risk disease. Median dose was 79.2 Gy. The 5-year OS were 90%, 87% and 78% and FFBF were 94%, 100% and 81% for low-, intermediate- and high-risk patients, respectively. Multivariable analysis showed that Eastern Cooperate Oncology Group performance status 2 and Gleason grade group 5 were independent predictors of worse OS. The incidence of grade ≥2 proctitis was 24.5%. Dose escalation was significantly associated with increased incidence of grade ≥2 proctitis (odd ratio, 4.42; 95% confidence interval, 1.95-10.08; P < 0.01). CONCLUSION: Men with localized prostate cancer treated with EBRT in our population had excellent 5-year OS and biochemical outcomes. Dose escalation did not significantly improve these outcomes but was associated with significantly increased risk of grade ≥2 proctitis in our population. Future studies should be performed to identify patients who will benefit the most from dose-escalated EBRT.

Chemoradiotherapy versus chemoradiotherapy plus surgery for esophageal cancer.

BACKGROUND: Please see Appendix 4 for a glossary of terms.The outcome of patients with esophageal cancer is generally poor. Although multimodal therapy is standard, there is conflicting evidence regarding the addition of esophagectomy to chemoradiotherapy. OBJECTIVES: To compare the effectiveness and safety of chemoradiotherapy plus surgery with that of chemoradiotherapy alone in people with nonmetastatic esophageal carcinoma. SEARCH METHODS: We performed a computerized search for relevant studies, up to Feburary 2017, on the CENTRAL, MEDLINE, and Embase databases using MeSH headings and keywords. We searched five online databases of clinical trials, handsearched conference proceedings, and screened reference lists of retrieved papers. SELECTION CRITERIA: We included randomized controlled trials (RCTs) comparing chemoradiotherapy plus esophagectomy with chemoradiotherapy alone for localized esophageal carcinoma. We excluded RCTs comparing chemotherapy or radiotherapy alone with esophagectomy. DATA COLLECTION AND ANALYSIS: Two authors independently selected studies, extracted data, and assessed risk of bias and the quality of the evidence, using standardized Cochrane methodological procedures. The primary outcome was overall survival (OS), estimated with Hazard Ratio (HR). Secondary outcomes, estimated with risk ratio (RR), were local and distant progression-free survival (PFS), quality of life (QoL), treatment-related mortality and morbidity, and use of salvage procedures for dysphagia. Data were analyzed using a random effects model in Review Manager 5.3 software. MAIN RESULTS: From 2667 references, we identified two randomized studies, in six reports, that included 431 participants. All participants were clinically staged to have at least T3 and/or node positive thoracic esophageal carcinoma, 93% of which was squamous cell histology. The risk of methodological bias of the included studies was low to moderate.High-quality evidence found the addition of esophagectomy had little or no difference on overall survival (HR 0.99, 95% CI 0.79 to 1.24; P = 0.92; I² = 0%; two trials). Neither study reported PFS, therefore, freedom from loco-regional relapse was used as a proxy. Moderate-quality evidence suggested that the addition of esophagectomy probably improved freedom from locoregional relapse (HR 0.55, 95% CI 0.39 to 0.76; P = 0.0004; I² = 0%; two trials), but low-quality evidence suggested it may increase the risk of treatment-related mortality (RR 5.11, 95% CI 1.74 to 15.02; P = 0.003; I² = 2%; two trials).The other pre-specified outcomes (quality of life, treatment-related toxicity, and use of salvage procedures for dysphagia) were reported by only one study, which found very low-quality evidence that use of esophagectomy was associated with reduced short-term QoL (MD 0.93, 95% CI 0.24 to 1.62), and low-quality evidence that it reduced use of salvage procedures for dysphagia (HR 0.52, 95% CI 0.36 to 0.75). Neither study compared treatment-related morbidity between treatment groups. AUTHORS' CONCLUSIONS: Based on the available evidence, the addition of esophagectomy to chemoradiotherapy in locally advanced esophageal squamous cell carcinoma, provides little or no difference on overall survival, and may be associated with higher treatment-related mortality. The addition of esophagectomy probably delays locoregional relapse, however, this end point was not well defined in the included studies. It is undetermined whether these results can be applied to the treatment of adenocarcinomas, tumors involving the distal esophagus and gastro-esophageal junction, and to people with poor response to chemoradiation.