Intensity modulated radiation therapy with simultaneous integrated boost based dose escalation on neoadjuvant chemoradiation therapy for locally advanced distal esophageal adenocarcinoma

Abstract

AIM:To evaluate impact of radiation therapy dose escalation through intensity modulated radiation therapy with simultaneous integrated boost (IMRT-SIB). METHODS:We retrospectively reviewed the patients who underwent four-dimensional-based IMRT-SIBbased neoadjuvant chemoradiation protocol. During the concurrent chemoradiation therapy, radiation therapy was through IMRT-SIB delivered in 28 consecutive daily fractions with total radiation doses of 56 Gy to tumor and 5040 Gy dose-painted to clinical tumor volume, with a regimen at the discretion of the treating medical oncologist. This was followed by surgical tumor resection. We analyzed pathological completion response (pCR) rates its relationship with overall survival and event-free RESULTS:Seventeen patients underwent dose escalation with the IMRT-SIB protocol between 2007 and 2014 and their records were available for analysis. Among the IMRT-SIB-treated patients, the toxicity appeared mild, the most common side effects were grade 1-3 esophagitis (46%) and pneumonitis (11.7%). There were no cardiac events. The Ro resection rate was 94% (n = 16), the pCR rate was 47% (n = 8), and the postoperative morbidity was zero. There was one mediastinal failure found, one patient had local failure at the anastomosis site, and the majority of failures were distant in the lung or bone. The 3-year diseasefree survival and overall survival rates were 41% (n = 7) and 53% (n = 9), respectively. CONCLUSION:The dose escalation through IMRT-SIB in the chemoradiation regimen seems responsible for down-staging the distal esophageal with well-tolerated complications. Core tip: There are more data supporting neoadjuvant chemoradiation for locally advanced esophageal cancer. The best regimen of neoadjuvant chemoradiation remains to be defined, current available data using threedimensional vs intensity modulated radiation therapy deliver modest dose to downstage the tumor. In this report, we reviewed our experience using dose escalation technique to Gross Tumor Volume with compromising dose to organ at risk, the high R0 resection rate results suggest the feasibility of using this approach for future prospective study.

Local Control and Toxicity of a Simultaneous Integrated Boost for Dose Escalation in Locally Advanced Esophageal Cancer: Interim Results from a Prospective Phase I/II Trial

“…They reported a local recurrence rate of 11% at 22 months compared with the 29% at 3 years in this study. 11 However, the patients selected in Zeng et al study all had M0 disease, whereas most (71%) presented with N0 disease in contrast to the patients presented in this trial (13% with M1 disease and 63% with N1/N2 disease), making comparison difficult. Further follow-up will determine the importance of SIB-IMRT in local control.…”

Radiation Pneumonitis after Intensity-Modulated Radiotherapy for Esophageal Cancer: Institutional Data and a Systematic Review

“…Grade I generally implies imaging findings without symptoms or only mild symptoms that do not require medical intervention 11 – 13 . No study reported grade IV or grade V RP, however three studies grouped different grades of RP as “≥ grade II” or reported only an overall rate of RP 14 – 16 . Grade I or II RP was the highest reported grade of RP in 13 of 19 studies.…”

Advances in Radiotherapy Management of Esophageal Cancer

“…Table 3 summarizes retrospective, largely single-institutional data of IMRT-based treatment for locally advanced EC [28,29,30,31]. The largest study to date from MD Anderson Cancer Center has examined 676 patients, 413 of which were treated with 3DCRT and 263 IMRT [26].…”