Aim & Objective: Radical chemoradiation is one of the options for curative treatment of carcinoma of the esophagus. This study reports the institutional experience with radical chemoradiation in patients with squamous cell carcinoma of the esophagus

Patients & Methods: Patients with non-metastatic squamous cell carcinoma of the esophagus registered between 2013 and 2015 at the hospital were evaluated for retrospective study. The patients were treated with radiation doses of 50-60 Gy by conformal techniques and concurrent platinum, 5-fluorouracil based chemotherapy.

Results: Sixty nine patients were found eligible for the study. The mean age was 60 years and had 76.8% males. Thirty six (52.2%) patients had cT4 disease, and 26 (37.7%) had cN+ disease. All patients received radical radiotherapy, while 90% received chemotherapy. Twenty eight (40.6%) patients developed recurrence, with primary site being the most common site of failure. The median time to recurrence was 17months (range: 0-40months). The median overall survival was 43 months and disease free survival was 40 months. The 2 and 3 year overall survival was 72.6% and 54.4% and disease free survival was 62% and 53.8% respectively.

Conclusion: Radical chemoradiation for squamous cell carcinoma of esophagus is feasible in the real-life setting and provides a good 3 year overall survival of 54%. More accurate staging of disease with endoscopic ultrasound and PET-CT, more sophisticated radiation with potential to reduce organ toxicity and dose-escalation, and reliable assessment of response to treatment with PET-CT and endoscopic ultrasound with early salvage treatment has the potential to improve these survival figures.

Keywords: Esophageal neoplasms, Chemoradiotherapy, Squamous cell carcinoma.

1. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer. 2013 [cited 2018 Jan 17]. Available from: http://globocan.iarc.fr/
2. Barbetta A, Hsu M, Tan KS, Stefanova D, Herman K, Adusumilli PS, et al. Definitive chemoradiotherapy versus neoadjuvant chemoradiotherapy followed by surgery for stage II to III esophageal squamous cell carcinoma. J Thorac Cardiovasc Surg [Internet]. 2018 Feb 15 [cited 2018 Mar 26]; Available from: http://linkinghub.elsevier.com/retrieve/pii/S0022522318303702
3. Naik KB, Liu Y, Goodman M, Gillespie TW, Pickens A, Force SD, et al. Concurrent chemoradiotherapy with or without surgery for patients with resectable esophageal cancer: An analysis of the National Cancer Data Base. Cancer [Internet]. 2017 Sep 15 [cited 2018 Mar 26];123(18):3476–85. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28464264
4. Yen Y-C, Chang J-H, Lin W-C, Chiou J-F, Chang Y-C, Chang C-L, et al. Effectiveness of esophagectomy in patients with thoracic esophageal squamous cell carcinoma receiving definitive radiot-herapy or concurrent chemoradiotherapy through intensity-modulated radiation therapy techniques. Cancer [Internet]. 2017 Jun 1 [cited 2018 Mar 26];123 (11):2043–53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28152166
5. Vellayappan BA, Soon YY, Ku GY, Leong CN, Lu JJ, Tey JCS. Chemora-diotherapy versus chemoradiotherapy plus surgery for esophageal cancer. Cochrane Database Syst Rev. 2013;2013(5).
6. Stahl M, Stuschke M, Lehmann N, Meyer H-J, Walz MK, Seeber S, et al. Chemoradiation With and Without Surgery in Patients With Locally Advanced Squamous Cell Carcinoma of the Esophagus. J Clin Oncol [Internet]. 2005;23(10):2310–7. Available from: http://ascopubs.org/doi/10.1200/JCO.2005.00.034
7. Bedenne L, Michel P, Bouch?? O, Milan C, Mariette C, Conroy T, et al. Chemoradiation followed by surgery compared with chemoradiation alone in squamous cancer of the esophagus: FFCD 9102. J Clin Oncol. 2007;25(10):1160–8.
8. Cooper JS, Guo MD, Herskovic A, Macdonald JS, Martenson James A. J, Al-Sarraf M, et al. Chemoradiotherapy of Locally Advanced Esophageal Cancer. JAMA [Internet]. 1999 May 5;281(17):1623–7. Available from: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.281.17.1623
9. Minsky BD, Neuberg D, Kelsen DP, Pisansky TM, Ginsberg R, Benson A. Neoadjuvant chemotherapy plus concurrent chemotherapy and high-dose radiation for squamous cell carcinoma of the esophagus: A preliminary analysis of the phase II intergroup trial 0122. J Clin Oncol [Internet]. 1996 Jan [cited 2018 Apr 2];14(1):149–55. Available from: http://ascopubs.org/doi/10.1200/JCO.1996.14.1.149
10. Minsky BD, Pajak TF, Ginsberg RJ, Pisansky TM, Martenson J, Komaki R, et al. INT 0123 (Radiation Therapy Oncology Group 94-05) Phase III Trial of Combined-Modality Therapy for Esophageal Cancer: High-Dose Versus Standard-Dose Radiation Therapy. J Clin Oncol [Internet]. 2002 Mar [cited 2018 Mar 14];20(5):1167–74. Available from: http://ascopubs.org/doi/10.1200/JCO.2002.20.5.1167
11. van Hagen P, Hulshof MCCM, van Lanschot JJB, Steyerberg EW, Henegouwen MI van B, Wijnhoven BPL, et al. Preoperative Chemoradiotherapy for Esophageal or Junctional Cancer. N Engl J Med [Internet]. 2012;366(22):2074–84. Available from: http://www.nejm.org/doi/10.1056/NEJMoa1112088
12. Shapiro J, Lanschot JJB Van, Hulshof MCCM, Hagen P Van, Henegouwen MIVB, Wijnhoven BPL. Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for oesophageal or junctional cancer ( CROSS ): long-term results of a randomised controlled trial. Lancet Oncol [Internet]. 2015;16(9):1090–8. Available from: http://dx.doi.org/10.1016/S1470-2045(15)00040-6
13. Wong I, Law S. The CROSS road in neoadjuvant therapy for esophageal cancer: long-term results of CROSS trial. Transl Cancer Res [Internet]. 2016 [cited 2018 Apr 2];3(5):S415–9. Available from: http://tcr.amegroups.com/article/view/9247/html
14. Castoro C, Scarpa M, Cagol M, Alfieri R, Ruol A, Cavallin F, et al. Complete clinical response after neoadjuvant chemoradiotherapy for squamous cell cancer of the thoracic oesophagus: is surgery always necessary? J Gastrointest Surg [Internet]. 2013 Aug 25 [cited 2018 Apr 2];17(8):1375–81. Available from: http://link.springer.com/10.1007/s11605-013-2269-3
15. Herskovic A, Martz K, Al-Sarraf M, Leichman L, Brindle J, Vaitkevicius V, et al. Combined Chemotherapy and Radiotherapy Compared with Radiotherapy Alone in Patients with Cancer of the Esophagus. N Engl J Med [Internet]. 1992 Jun 11;326(24):1593–8. Available from: http://www.nejm.org/doi/abs/10.1056/NEJM199206113262403
16. Cooper JS, Guo MD, Herskovic A, Macdonald JS, Martenson JA, Byhardt R, et al. Chemoradiotherapy of Locally Advanced. 1999;281(17):1623–7.
17. Noronha V, Prabhash K, Joshi A, Patil VM, Talole S, Nakti D, et al. Clinical Outcome in Definitive Concurrent Chemoradiation With Weekly Paclitaxel and Carboplatin for Locally Advanced Esophageal and Junctional Cancer. Oncol Res Featur Preclin Clin Cancer Ther [Internet]. 2016;23(4):183–95. Available from: http://www.ingentaconnect.com/content/10.3727/096504016X14537290676865
18. Versteijne E, van Laarhoven HWM, van Hooft JE, van Os RM, Geijsen ED, van Berge Henegouwen MI, et al. Definitive chemoradiation for patients with inoperable and/or unresectable esophageal cancer: locoregional recurrence pattern. Dis Esophagus. 2015;28(5):453–9.
19. Cohen AT, Goto S, Schreiber K, Torp-Pedersen C. Why do we need observational studies of everyday patients in the real-life setting? Eur Hear Journal, Suppl. 2015;17(April):D2–8.
20. Lowe VJ, Booya F, Fletcher JG, Nathan M, Jensen E, Mullan B, et al. Comparison of Positron Emission Tomography, Computed Tomography, and Endoscopic Ultrasound in the Initial Staging of Patients with Esophageal Cancer. Mol Imaging Biol [Internet]. 2005 Nov 4 [cited 2018 Apr 9];7(6):422–30. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16270235
21. Schreurs LMA, Janssens ACJW, Groen H, Fockens P, van Dullemen HM, van Berge Henegouwen MI, et al. Value of EUS in Determining Curative Resectability in Reference to CT and FDG-PET: The Optimal Sequence in Preoperative Staging of Esophageal Cancer? Ann Surg Oncol [Internet]. 2016 Dec 6 [cited 2018 Apr 9];23(S5):1021–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21547703
22. Freilich J, Hoffe SE, Almhanna K, Dinwoodie W, Yue B, Fulp W, et al. Comparative outcomes for three-dimensional conformal versus intensity-modulated radiation therapy for esophageal cancer. Dis Esophagus [Internet]. 2015 May 1 [cited 2018 Apr 13];28(4):352–7. Available from: https://academic.oup.com/dote/article-lookup/doi/10.1111/dote.12203
23. Xu D, Li G, Li H, Jia F. Comparison of IMRT versus 3D-CRT in the treatment of esophagus cancer. Med (United States). 2017;96(31):1–7.
24. Haefner MF, Lang K, Verma V, Koerber SA, Uhlmann L, Debus J, et al. Intensity-modulated versus 3-dimensional conformal radiotherapy in the definitive treatment of esophageal cancer: Comparison of outcomes and acute toxicity. Radiat Oncol. 2017;12(1):1–7.

Dr Arun Sankar Sudha MD

Division of Radiation oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India,

Email: This email address is being protected from spambots. You need JavaScript enabled to view it.,This email address is being protected from spambots. You need JavaScript enabled to view it., Phone: +91-9249554405