Zhang SM, Sun J, Pan XO, Zhu WC, Zhou YK. Toxicity of dose-escalated, hypofractionated helical tomotherapy for inoperable thoracic esophageal squamous cell carcinoma. World J Clin Oncol 2025; 16(5): 101378 [DOI: 10.5306/wjco.v16.i5.101378]
Corresponding Author of This Article
Shu-Min Zhang, MD, Associate Professor, Department of Radiation Oncology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China. zhang.shumin@zs-hospital.sh.cn
Research Domain of This Article
Oncology
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
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/
Shu-Min Zhang, Jing Sun, Xiang-Ou Pan, Wen-Chao Zhu, Yong-Kang Zhou, Department of Radiation Oncology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
Author contributions: Zhang SM and Sun J were responsible for the design of the study, drafted the manuscript, and critically revised the manuscript; Zhang SM, Sun J, and Pan XO analyzed and interpreted the patient data regarding the chemotherapy regimens; Zhou YK analyzed and interpreted the patient data regarding the radiation physics and dosages; Zhu WC was responsible for data auditing and collection and patient follow-up; and all authors read and approved the final version of the manuscript.
Institutional review board statement: This study was approved by the Ethics Committee of the Zhongshan Hospital, in accordance with the Declaration of Helsinki (No. 2011-235).
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement:sharing statement: For legitimate requests, the author can provide the relevant data.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (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: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Shu-Min Zhang, MD, Associate Professor, Department of Radiation Oncology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Shanghai 200032, China. zhang.shumin@zs-hospital.sh.cn
Received: September 12, 2024 Revised: February 19, 2025 Accepted: March 31, 2025 Published online: May 24, 2025 Processing time: 248 Days and 17.1 Hours
Abstract
BACKGROUND
Radiation therapy is an important treatment for esophageal tumors. However, there is still controversy regarding the total dose and fraction dose. The optimal dose and fractionation schedule have not yet been clearly established. Hypofractionated radiotherapy is becoming more popular, but it is unknown whether this is the optimal choice for esophageal tumors. In addition, the appropriate dose per fraction is uncertain. We performed a retrospective study to address these issues.
AIM
To report the cumulative survival and toxicity associated with the delivered dose escalation and hypofractionation schedule of radiation therapy for esophageal squamous cell carcinoma.
METHODS
Forty-seven patients treated for inoperable locally advanced thoracic esophageal squamous cell carcinoma with helical tomotherapy using different total doses and doses per fraction were enrolled. Toxicity and adverse events were evaluated in all patients to determine the acute and long-term effects according to the Toxicity Criteria of The Radiation Therapy Oncology Group. Overall survival was calculated using the Kaplan-Meier method. Logistic analysis was used to identify the correlation between dose delivered to the primary tumor and the degree of toxicity. In multivariate analysis, all variables were entered in a single step using the method of backward stepwise regression.
RESULTS
Six patients died of bleeding related to aorto-esophageal fistulization. Four patients died of tracheo-esophageal fistulas, and 7 patients died of local recurrence. The remaining 20 patients died of metastases and multi-organ failure due to organ metastases. The dose of radiation and the dose level were positively correlated with esophageal toxicity, which was much greater with dose escalation and dose level per fraction increase.
CONCLUSION
Esophageal toxicity can be tolerated below a prescribed radiation dose of 60 Gy and less than 2.3 Gy per fraction.
Core Tip: Hypofractionated radiotherapy is becoming more popular. However, it is unknown whether it is an optimal choice for esophageal tumors. In addition, the appropriate dose per fraction is unclear. At present, there is no systematic report on these issues. In this study, 47 patients with thoracic esophageal carcinoma treated with radiotherapy at different prescribed doses and doses per fraction were enrolled retrospectively. Toxicity and adverse events were evaluated to determine the acute and long-term treatment effects. It was shown that esophageal toxicity can be tolerated below a prescribed dose of 60 Gy of radiation and less than 2.3 Gy per fraction.
