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Post-operative Radiotherapy for Esophageal Cancer

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Post-operative Radiotherapy for Esophageal Cancer

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    1. Post-operative Radiotherapy for Esophageal Cancer Parag Sanghvi, M.D., M.S.P.H. Department of Radiation Medicine Esophageal Care Conference 3/26/2007

    2. Background 5 year OS for locally advanced esophageal cancers (T3 or above, N+) is dismal

    3. Preoperative ChemoRT vs. Post-operative ChemoRT This has not been studied in a randomized trial head to head Prefer pre-operative chemoRT Allows for tumor downstaging ? R0 resection Complete pathologic response improves survival Feasibility and Patient compliance ? Earlier control of micro-metastatic disease Only 1 of 6 randomized trials have shown OS benefit to neoadjuvant chemoRT (Walsh)

    4. Preoperative ChemoRT trials

    5. Post-operative RT+/- Chemotherapy Data is primarily from Asia and Europe Most randomized trials have looked at Surgery + RT vs. Surgery alone No randomized trial has compared post-operative concurrent chemoRT to either chemotherapy or RT alone

    6. Indications for Post-operative RT Standard Indications Positive Margins Gross Residual Disease Less Clear + LN + ECE on adenopathy

    7. Current NCCN Guidelines for Post-operative Therapy

    8. Randomized Trials Teniere et al Surg Gynecol Obstet. Aug 1991; 173(2): 123-30 (France) S+ RT vs. S Fok et al Surgery. Feb 1993; 113(2) 138-47 (Hong Kong) S + RT vs. S Xiao et al The Annals of Thoracic Surgery Feb 2003; 75(2): 331-336 (China) LN + ? S+ RT vs. S Macdonald et al NEJM. Sept 2001; 345:725-730 (USA) GE junction ? S + CRT vs. S

    9. French trial � Post-operative Radiation for Esophageal SCCA 221 patients treated with �curative� resection Squamous cell histology; mid/distal location Post-op RT 45-55 Gy vs. Observation Post-op RT did not improve OS 5 y OS 19% (38% if node -; 7% if node + Locoregional failure decreased after RT: 30 % ? 15% Benefit significant in node negative patients: 35% LR failure vs. 10%

    10. Hong Kong Trial � Postoperative RT for Esophageal cancer Single institution randomized trial, 130 patients Curative Resection 60 patients ? 30 S+ RT vs. 30 S Palliative Resection 70 patients ? 35 S + RT vs. 35 S RT dose/technique unknown

    11. Hong Kong Trial - Results Overall Median Survival, All patients S + RT 8.7 months vs. S 15.2 months (p=0.02) Local Recurrence, Palliative Surgery patients S+ RT 20% vs. S 46 % (p=0.04) Local Recurrence, Curative Surgery S+RT 10% vs. S 13% Complications S+RT 37% vs. S 6% (p<0.0001) Intra-thoracic recurrence, All patients S+RT 4 patients vs. S 13 patients (p=0.01)

    12. Chinese trial � Post-operative radiation for Esophageal SCCA Randomized to post-operative RT vs. observation; 495 patients ? 275 S, 220 S+ RT Most of mid thoracic esophagus (67%), T3 (69%) and 48% had + LN Margin status unknown

    13. Chinese Trial � RT parameters RT Extended Field RT Included bilateral SCV, mediastinal and peri-gastric LN 60 Gy

    14. Chinese Trial - Results 5 y OS S+ RT 41.3 % vs. S 37.1 % (p=0.45) LN � S+RT 52.8 % vs. S 51% (p=0.95) LN+ S+RT 29.2 % vs. S 14.7% (p=0.07) Stage II S+ RT 50.3 % vs. S 51.3 % (p=0.63) Stage III OS S+ RT 35.1% vs. S 13.1 % (p=0.003)

    15. Chinese trial - Results

    16. Chinese trial - Results

    17. Chinese Trial - Sites of Failure

    18. Conclusions Post-operative RT improves OS in Stage III and potentially LN + patients Post-operative RT decreases risk of intra-thoracic LN recurrence and anastomotic recurrence

    19. Macdonald trial � Post-operative chemoRT for GE junction/stomach adenoCA Randomized to post-operative chemoradiation vs. observation 556 patients; 20% GE junction tumors Stage IB � IV M0, negative margins Adenocarcinoma histology D2 dissection recommended 10% D2; 36% D1; 54% D0

    20. Macdonald Trial - Treatment Schema Chemotherapy ? d 28 ChemoRT ? 2 cycles additional chemotherapy Chemotherapy 5FU + Leucovorin RT � 45 Gy/25 fx Tumor bed + Regional LN + 2 cm margin 64% completed chemoRT as planned

    21. Macdonald Trial � Tumor Characteristics

    22. Macdonald Trial Results 5 year Median Survival S+ CRT 36 months vs. S 27 months 3 y OS S+ CRT 50% vs. S 41% (p= 0.005) 3 y RFS S + CRT 48% vs. S 31% (p <0.001)

    23. Macdonald Trial � Overall Survival

    24. Macdonald Trial � Relapse Free Survival

    25. Macdonald Trial � Sites of Relapse

    26. Macdonald Trial - Conclusions Add chemoRT for GE junction adenoCA T3 or higher + LN + margins, + residual disease ? Selected T2 cases

    27. Non Randomized Trials Liu HC et al. World J. Gastroenterology. 2005; 11(34): 5367-5372 S+ CRT vs. S + RT Bedard EL et al. Cancer Jun 2001; 91(12): 2423-2430 N1 patients ? S + CRT vs. S

    28. Taiwan Study � Postoperative ChemoRT vs. RT for esophageal SCCA 60 patients; 30 patients in each arm T3/T4 N0/N1 M0 thoracic esophageal SCCA Surgery included En-bloc esophagectomy � sub-total resection of esophagus with bilateral 10 cm adjacent soft-tissue margin followed by proximal gastrectomy/porta hepatis LN dissection Cervical LN sampling Prospectively enrolled into post-operative chemoRT vs. RT alone

    29. Taiwan study � RT parameters Treatment started within 3 weeks of surgery RT 40 Gy AP/PA followed by 15-20 Gy 3 D boost standard 1.8 Gy/fx Margins Sup / Inf 5 cm Elsewhere 3 cm Mean dose 58.32 Gy (50.4 � 59.4 Gy)

    30. Taiwan study - Chemotherapy Chemotherapy 6 weekly cycles CDDP 30 mg/m2 during RT 4 weeks after chemoRT, additional adjuvant chemotherapy 4 cycles of CDDP 20mg/m2 + 5 FU 1000mg/m2 X 5 days bolus infusion

    31. Taiwan study - Patient Characteristics

    32. Taiwan study - Patient Characteristics

    33. Taiwan Study - Results ChemoRT 30/30 received planned dose RT 15/30 received planned dose concurrent chemo; 10 received 4/6 weekly cycles; 5 received <4 cycles 15/30 received adjuvant chemotherapy RT 24/30 received planned dose RT Median follow-up 18 months

    34. Taiwan Study - Results ChemoRT Mean survival 31.9 months 3 y/o OS 70% 3 y/o LRF 40% 3 y/o DF 27% RT Mean survival 20.7 months 3 y/o OS 33.7% 3 y/o LRF 60% 3 y/o DF 57% Treatment modality and tumor grade were significant on multi-variate analysis

    35. Taiwan Study - Results

    36. Taiwan Study - Results

    37. Taiwan Study - ChemoRT complications Complications Anastomotic Stricture 36% Chronic Aspiration 33% Pneumonia 20%

    38. Taiwan Study - Conclusions ChemoRT showed improved OS compared to RT alone in T3 or higher patients Improved overall survival compared to historical data for surgery alone

    39. Canadian Study � Postoperative chemoRT in patients with N+ esophageal cancer Retrospective review of N1 patients � chemo RT vs. surgery alone; 70 patients 39 pts to chemoRT arm vs. 31 patients to surgery alone; in final analysis 38 pts. ChemoRT & 28 pts. Surgery alone Thoracic & GE junction tumors AdenoCA & Squamous histology T1-T4, all N1 Transhiatal esophagectomy

    40. Canadian Study - Treatment Schema 2 cycles of chemotherapy ? RT with 3rd & 4th cycle of chemotherapy Chemotherapy CDDP 60 mg/m2 Continuous infusion 5-FU Epirubicin 50 mg/m2 in last 6 patients RT 50 Gy (36 Gy AP/PA followed by 14 Gy 3D planning)

    41. Canadian Study - Patient Characteristics Patient characteristics and tumor characteristics well balanced between two groups No data on # LN + or ECE status provided

    42. Canadian Study �Tumor Characteristics

    43. Canadian Study - Results Median follow-up 19 months Surgery + ChemoRT Median DFS � 10.2 months Local Recurrence 13% Median Time to LR 22.2 months Median OS 47.5 months 5 y OS 48% Surgery Median DFS � 10.6 months Local Recurrence 35% Median Time to LR 9.5 months Median OS 14.1 months 5 y OS 0%

    44. Canadian Study � Overall Survival

    45. Canadian Trial - Conclusion Benefit of ChemoRT in node + patients

    46. Additional abstracts Kurtzman SM et al. (ASTRO 1995) 192 patients Esophageal adenoCA Post-op RT with 5FU/Leucovorin & ?-Interferon 39% 3 y OS

    47. Additional abstracts Kang HJ et al (ASCO 1992) Phase 2 trial ChemoRT 40-50 Gy CDDP + 5 FU 47% 20 month survival rate 93% LCR

    48. What about post-op chemotherapy alone? 2 randomized Japanese trials Ando N et al. J of Thoracic and Cardiovascular Surgery. 1997; 114;204-205 Randomized study; 205 patients S + C vs. S alone Chemo � 2 cycles of Cisplatin (70 mg./m2) + Vindesine 5 y OS S + C 48.1 % vs. S 44.9% (p = NS) Ando N et al. JCO. Dec 2003; 21(24): 4592-4596 Randomized study; 242 patients Thoracic SCCA S+C vs. S alone Chemo � 2 cycles of Cisplatin (80 mg/m2) + 5 FU (800mg/m2/5 day infusion) 5 y OS 61 vs. 52 % (p=0.13);5 y DFS 55% vs. 45% (p=0.04); 5 y DFS in N + patients 52% vs. 38% (p=0.04) Significant nodal failure in S + C patients; role of RT??

    49. Overall Conclusions Treatment decisions need to be individualized Pre-operative chemoRT preferable when needed Recognize the morbidity of neoadjuvant chemoRT; consider surgery first in resectable patients with marginal performance status Post-operative chemoRT for + margins, residual gross disease + LN locally advanced disease (T3 or higher) with � margins, - LN?

    50. Acknowledgements Dr. John Holland Dr. Charles Thomas Dr. Tasha Mcdonald

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