Patterns of Failure after Radical Surgery among Patients with Thoracic Esophageal Squamous Cell Carcinoma: Implications for the Clinical Target Volume Design of Postoperative Radiotherapy

Abstract

BackgroundThis study evaluated patterns of treatment failure (especially locoregional failure; LRF) after radical esophagectomy and proposes a clinical target volume (CTV) for postoperative radiotherapy (PORT) among patients with thoracic esophageal squamous cell carcinoma (SCC).MethodsAll patients who were followed up in our center after radical esophagectomy between 2007 and 2011 were retrospectively enrolled. The patterns of first discovered failure were assessed, and LRFs (including anastomotic and regional lymph node recurrences) were evaluated to determine whether our proposed PORT CTV encompassed these areas. The clinicopathologic factors predictive of lymphatic recurrence type were analyzed.ResultsOf the 414 patients who underwent surgery and were followed up over the study, 207 experienced recurrent or metastatic diseases. The median time to progression was 11.0 months. Of the 173 patients with locoregional recurrence, nodal failure recurred in 160; supraclavicular and superior mediastinal lymph nodes had the highest metastasis rates. All 233 recurrent sites across the 160 patients were located in a standard CTV area, including the bilateral supraclavicular areas, the entire mediastinum, and the left gastric lymphatic drainage region. A total of 203 sites (87.2%) were located in either the bilateral supraclavicular areas or the entire mediastinum, and 185 sites (79.4%) were located in either the bilateral supraclavicular areas or the upper mediastinum. A multivariate analysis revealed the lymph node metastatic ratio (LNMR) and tumor differentiation were risk factors for nodal failure.ConclusionsLocoregional recurrence (especially lymph node recurrence) was the most common and potentially preventable type of initial treatment failure after curative surgery among patients with thoracic esophageal SCC. The proposed PORT CTV covered most LRF sites. The lymphatic drainage regions for PORT are selective, and the supraclavicular and superior mediastinal areas should be considered. However, the value of PORT and the extent of CTV should be investigated in further prospective studies.

A retrospective study of pattern of recurrence after radical surgery for thoracic esophageal carcinoma with or without postoperative radiotherapy

“…Lymphatic recurrence was the most common pattern for patients without PRT, 87.9% in the present study. Other researches also have the same results (3,22,23). Taken in this sense, PRT should be a useful way to reduce recurrence, as sub-clinic lesions or lymphatic micrometastasis can be further controlled.…”

“…Esophagectomy is the standard strategy for resectable EC. Unfortunately locoregional recurrence [especially lymphatic metastasis (LNM)] was the main failure for these patients (3,4).…”

Mapping Patterns of Nodal Metastases in Esophageal Carcinoma: Rethinking the Clinical Target Volume for Supraclavicular Nodal Irradiation

“…The results showed that SCV areas were the most common site of recurrence, followed by mediastinal and abdominal areas. As such, several studies also indicated that the incidence of SCV LN recurrence was a common site of recurrence after radical surgery (range, 33.3% to 75.0%) (7)(8)(9). The available data indicates that postoperative radiotherapy could reduce locoregional recurrence and improve overall survival of ESCC patients.…”

“…Surgery alone has shown rather disappointed survival rates, which the 5-year survival rate is only 20-40%. Furthermore, approximately half of the patients may experience locoregional recurrence, which may result in a decreased survival (8,9). Various studies have suggested that the recurrences of esophageal carcinomas after radical surgery tend to occur in the bilateral supraclavicular (SCV) areas.…”

Chinese expert consensus on mediastinal lymph node dissection in esophagectomy for esophageal cancer (2017 edition)

“…Frequency and distribution of nodal metastases vary greatly depending on the location, size, and depth of invasion of the primary tumor (23)(24)(25)(26)(27). The esophagus has a complex and widespread lymphatic drainage system; in addition to transmural lymphatic vessels that flow to …”