Retrospective Study
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Feb 21, 2018; 24(7): 862-869
Published online Feb 21, 2018. doi: 10.3748/wjg.v24.i7.862
Predictors of post-treatment stenosis in cervical esophageal cancer undergoing high-dose radiotherapy
Jun Won Kim, Tae Hyung Kim, Jie-Hyun Kim, Ik Jae Lee
Jun Won Kim, Tae Hyung Kim, Ik Jae Lee, Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, South Korea
Jie-Hyun Kim, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, South Korea
Author contributions: All authors helped to perform the research; Kim JW contributed to manuscript writing, data analysis and drafting design; Kim TH contributed to data analysis; Kim JH contributed to performing procedures; and Lee IJ contributed to drafting concept and design and performing procedures.
Supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education, No. 2017R1D1A1B03035047; and the National Research Foundation of Korea Grant funded by the Korean Government, No. NRF-2017M2A2A4A03083634.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of Gangnam Severance Hospital.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: All authors declare no conflicts-of-interest related to this article.
Data sharing statement: No additional data are 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: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Ik Jae Lee, MD, PhD, Associate Professor, Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, South Korea. ikjae412@yuhs.ac
Telephone: +82-2-20193158 Fax: +82-2-20194855
Received: December 11, 2017
Peer-review started: December 11, 2017
First decision: December 20, 2017
Revised: December 25, 2017
Accepted: January 16, 2018
Article in press: January 16, 2018
Published online: February 21, 2018
Processing time: 60 Days and 4.7 Hours
ARTICLE HIGHLIGHTS
Research background

The surgical procedure for cervical esophageal cancer (CEC) is extensive, and concurrent chemoradiotherapy (CRT) is the preferred treatment modality. Although a higher-than-standard dose of 50 Gy is suggested for CEC, the increased dose may lead to a higher incidence of severe toxicities, such as ulcer, perforation and stenosis.

Research motivation

Clinical data on radiotherapy with increased dose for CEC are scarce, and a toxicity evaluation is required before the administration of dose-escalated protocols.

Research objectives

To evaluate toxicity and treatment outcome of high dose radiotherapy for CEC, and to determine the factors associated with post-treatment esophageal stenosis.

Research methods

In this study, the authors reviewed 62 consecutive patients who received definitive RT for stage I to III cervical esophageal cancer between 2001 and 2015. Patients (received < 45 Gy) treated for lesions below sternal notch, treated with palliative aim and subsequent surgical resection, or diagnosed with synchronous hypopharyngeal cancer were excluded. Treatment failures were divided into local, outfield-esophageal, and regional failures. The factors predictive of esophageal stenosis requiring endoscopic dilation were analyzed.

Research results

With a median follow-up of 24.3 (range, 3.4-152) mo, the 2-year local control, outfield esophageal control, progression-free survival, and overall survival (OS) rates were 78.9%, 90.2%, 49.6%, and 57.3%, respectively. Grade 1, 2, and 3 esophagitis occurred in 19 (30.6%), 39 (62.9%), and 4 patients (6.5%), respectively, without grade ≥ 4 toxicities. Sixteen patients developed post-RT stenosis, of which 7 cases were malignant. Four patients developed tracheoesophageal fistula (TEF), of which 3 cases were malignant. Factors significantly correlated with OS were complete circumference involvement, stenosis at diagnosis, and occurrence of post-RT stenosis or TEF in univariate analysis, while stenosis at diagnosis and occurrence of post-RT stenosis or TEF were significant in multivariate analysis. Factors significantly correlated with post-RT stenosis were stage T3/4, complete circumference involvement, stenosis at diagnosis, and endoscopic complete response in univariate analysis, while complete circumference involvement was significant in multivariate analysis. A higher dose (≥ 60 Gy) was not associated with the occurrence of post-RT stenosis or TEF.

Research conclusions

This study showed that, although pre- and post-RT stenosis was a prognostic factor for patients’ survival, complete circumference involvement rather than a higher radiation dose was the key contributing factor, and suggesting that CEC can be treated with higher than the current standard dose of 50 Gy. CRT for CEC was well tolerated, and patients with complete circumferential involvement require close follow-up.

Research perspectives

The data suggests that patients with CEC may undergo radiotherapy of up to 63 Gy without increasing the risk of radiation-induced toxicities. Since prospective data is lacking, our study warrants a prospective trial to investigate toxicity and efficacy of high-dose radiotherapy for CEC.