Relapse Patterns after Chemo-radiation for Carcinoma of the Oesophagus

Aim: The detailed review of patterns of failure in this report was undertaken to identify the continuing obstacles to the successful management of oesophageal cancer, and to establish whether there is a case to compare definitive chemo-radiation(Def-CR) and surgery for patients with squamous cancer...

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Published in:Clinical oncology (Royal College of Radiologists (Great Britain)) 2003-05, Vol.15 (3), p.98-108
Main Authors: Denham, J.W, Steigler, A, Kilmurray, J, Wratten, C, Burmeister, B, Lamb, D.S, Joseph, D, Delaney, G, Christie, D, Jamieson, G, Smithers, B.M, Ackland, S, Walpole, E
Format: Article
Language:English
Subjects:
Adenocarcinoma - drug therapy
Adenocarcinoma - pathology
Adenocarcinoma - radiotherapy
Adult
Aged
Aged, 80 and over
Antineoplastic Combined Chemotherapy Protocols - therapeutic use
Carcinoma, Squamous Cell - drug therapy
Carcinoma, Squamous Cell - pathology
Carcinoma, Squamous Cell - radiotherapy
Cisplatin - administration & dosage
Combined Modality Therapy
Esophageal Neoplasms - drug therapy
Esophageal Neoplasms - pathology
Esophageal Neoplasms - radiotherapy
Female
Fluorouracil - administration & dosage
Humans
Infusions, Intravenous
Male
Middle Aged
Neoplasm Recurrence, Local
Oesophageal cancer, chemo-radiation, patterns of failure, metastases, competing risks
Prognosis
Randomized Controlled Trials as Topic
Retrospective Studies
Survival Analysis
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Summary:Aim: The detailed review of patterns of failure in this report was undertaken to identify the continuing obstacles to the successful management of oesophageal cancer, and to establish whether there is a case to compare definitive chemo-radiation(Def-CR) and surgery for patients with squamous cancer in a randomized controlled trial. Materials and Methods: First and subsequent sites of failure were reviewed in 274 patients treated with Def-CR using two cycles of cisplatin, infusional fluorouracil and 60Gy; and 92 patients with limited chemo-radiation (CR), using one cycle and 35Gy, followed by surgery (CR-Surg). All were treated on prospective non-randomized trials run by the Trans-Tasman Radiation Oncology Group between 1985 and 1999. Failure patterns were analysed using competing risks methodology, and pre-treatment variables predicting survival were identified by proportional hazards modelling. Results: Site, stage, performance status and gender were independently predictive of survival following Def-CR. Local failure was evident in 42.3% of patients, but distant failure in isolation occurred in an additional 18.1%. Lowest rates of local and distant failure at 5 years (29.9% and 26%) occurred in patients with squamous cancer (SCC) located in the upper-third, whose 5-year survival was also the most favourable (49.2%). Survival was least favourable in patients with adenocarcinoma (AC) in the lower two-thirds (18.1%) due to higher rates of local (51.5%) and distant (36.1%) failure. Local failure occurred in 31.5% of patients undergoing CR-Surg but distant failure in isolation was observed in a further 34.7%. Outcomes were least favourable in patients with AC of the lower-third in whom 57.7% failed distantly and 5-year survival was 3.8%. Response to pre-operative chemo-radiation was also strongly predictive of outcome. Patients with no residual cancer in the resection specimen had the lowest rates of local (0%) and distant (16.7%) failure and the best survival (64.9%). Survival in patients with residual cancer in nodes, however, was extremely poor (3.5%) with distant failure occurring in 66.7%. Conclusion: The concurrent administration of chemotherapy with radiotherapy seems to have improved loco-regional control and has exposed distant failure as an obstacle to further improvements in outcome. Site, histological subtype, gender and response to chemo-radiation may predict biological differences in oesophageal cancer (OC) that influence outcome. A good case fo
ISSN:0936-6555
1433-2981
DOI:10.1053/clon.2003.0212