Marc David

What is the optimal management of dysphagia in metastatic esophageal cancer

BACKGROUNDnThe palliation of dysphagia in metastatic esophageal cancer remains a challenge, and the optimal approach for this difficult clinical scenario is not clear. We therefore sought to define and determine the efficacy of various treatment options used at our institution for this condition.nnnMETHODSnWe reviewed a prospective database for all patients managed in an esophageal cancer referral centre over a 5-year period. All patients receiving palliation of malignant dysphagia were reviewed for demographics, palliative treatment modalities, complications, and dysphagia scores (0 = none to 4 = complete). The Wilcoxon signed rank test was used to determine significance (p < 0.05).nnnRESULTSnDuring 2004-2009, 63 patients with inoperable esophageal cancer were treated for palliation of dysphagia. The primary treatment was radiotherapy in 79% (brachytherapy in 18 of 50; external-beam in 10 of 50; both types in 22 of 50), and stenting in 21%. Mean wait time from diagnosis to treatment was 22 days in the stent group and 54 days in the radiotherapy group (p = 0.003). Mean duration of treatment was 1 day in the stent group and 40 days in the radiotherapy group (p = 0.001). In patients treated initially by stenting, dysphagia improved within 2 weeks of treatment in 85% of patients (dysphagia score of 0 or 1). However, 20% of patients presented with recurrence of dysphagia at 10 weeks of treatment. In the radiotherapy group, the onset of palliation was slower, with only 50% of patients palliated at 2 weeks (dysphagia score of 0 or 1). However, long-term palliation was more satisfactory, with 90% of patients remaining palliated after 10 weeks of treatment.nnnCONCLUSIONSnIn inoperable esophageal cancer at our centre, radiation treatment provided durable long-term relief, but came at a high price of a long wait time for initiation of treatment and a long lag time between initiation of treatment and relief of symptoms. On the other hand, endoluminal stenting provided more rapid and effective early relief from symptoms, but was affected by recurrence of dysphagia in the long-term. It is now time for a prospective randomized trial to assess the safety and efficacy of combined-modality treatment with both endoluminal stenting and radiation therapy compared with either treatment alone.

Silver Clear Nylon Dressing is Effective in Preventing Radiation-Induced Dermatitis in Patients With Lower Gastrointestinal Cancer: Results From a Phase III Study

PURPOSEnFor patients with anal canal and advanced rectal cancer, chemoradiation therapy is a curative modality or an important adjunct to surgery. Nearly all patients treated with chemoradiation experience some degree of radiation-induced dermatitis (RID). Prevention and effective treatment of RID, therefore, is of considerable clinical relevance. The present phase III randomized trial compared the efficacy of silver clear nylon dressing (SCND) with that of standard skin care for these patients.nnnMETHODS AND MATERIALSnA total of 42 rectal or anal canal cancer patients were randomized to either a SCND or standard skin care group. SCND was applied from Day 1 of radiation therapy (RT) until 2 weeks after treatment completion. In the control arm, sulfadiazine cream was applied at the time of skin dermatitis. Printed digital photographs taken 2 weeks prior to, on the last day, and two weeks after the treatment completion were scored by 10 blinded readers, who used the common toxicity scoring system for skin dermatitis.nnnRESULTSnThe radiation dose ranged from 50.4 to 59.4 Gy, and there were no differences between the 2 groups. On the last day of RT, when the most severe RID occurs, the mean dermatitis score was 2.53 (standard deviation [SD], 1.17) for the standard and 1.67 (SD, 1.2; P=.01) for the SCND arm. At 2 weeks after RT, the difference was 0.39 points in favor of SCND (P=.39). There was considerable intraclass correlation among the 10 observers.nnnCONCLUSIONSnSilver clear nylon dressing is effective in reducing RID in patients with lower gastrointestinal cancer treated with combined chemotherapy and radiation treatment.

Is there a detrimental effect of waiting for radiotherapy for patients with localized prostate cancer

Objective:To evaluate a possible deleterious effect of waiting time to radiotherapy on the biochemical relapse (BR) of patients with localized prostate cancer. Patients and Methods:Patients included in this retrospective study had localized prostate adenocarcinoma treated with external-beam irradiation alone. Waiting time was defined as the interval between the first consultation and the first radiation treatment. BR was defined as 3 consecutive rises of prostatic specific antigen (PSA). Patients were split into 3 groups of waiting time: group A were treated within 40 days; group B waited 41 to 80 days; group C waited >80 days to receive radiotherapy. The effect of waiting on BR was estimated by the Kaplan-Meier method. Multivariate Cox proportional hazards modeling was adjusted for known prognostic factors. Results:There were 289 patients who participated in the analysis. Median follow-up time was 6.1 year. Overall BR rate was 44% at 5 years. The median waiting time increased over the study period from 26 days in 1992 to 123 days in 2000. In adjusted multivariate analysis there was a nonsignificant higher risk of BR with waiting for 41 to 80 days (hazard ratio [HR] = 0.8; 95% confidence interval [CI] = 0.3–1.6) and for >80 days (HR = 0.6; 95% CI = 0.2–1.5) when compared with patients treated within 40 days after consultation. Conclusion:Delaying the start of radiotherapy showed little effect on the rate of BR in the group of 288 prostate cancer patients analyzed in this study.

Clinical Significance of Incidental Pulmonary Nodules in Esophageal Cancer Patients

IntroductionIncidental pulmonary nodules are frequently identified during staging investigations for esophageal cancer patients. Their clinical significance is unclear and may bias treatment decisions towards palliative options.MethodsFrom 2005 to 2011, 423 esophageal cancer patients were treated at a tertiary hospital. Those with incidental pulmonary nodules were identified. Demographics, imaging, pathology and perioperative outcomes were analyzed.ResultsNinety-two patients (22xa0%) had lung nodules. Twenty-nine (32xa0%) were palliative due to poor performance status or extra-pulmonary distant metastasis on imaging. Sixty-three had no evidence of extra-pulmonary metastasis and underwent curative-intent treatment comprising of neoadjuvant therapy [35 (55xa0%)] followed by esophagectomy [with lung resection, 33 (52xa0%) or without lung resection, 30 (48xa0%)]. Of those 33 lung resections, there were 27 benign lesions, 4 stage I lung cancers, and 1 esophageal cancer metastasis. Of 30 patients with lung nodules that underwent curative esophagectomy without lung resection, none showed interval size increase on follow-up imaging [median 9xa0months (3–40)]. There was no difference in perioperative complications or mortality between patients with combined esophagectomy and lung resection and those with esophagectomy alone.ConclusionIncidental pulmonary nodules in the absence of extra-pulmonary metastases in esophageal cancer patients are rarely metastases and should not bias caregivers towards palliative therapy.

Tu1597 Outcomes of Salvage Curative Intent Therapy for Recurrences of Esophago-Gastric Adenocarcinoma

difference was seen in total lymph nodes harvested. Conclusion: The findings of this study suggest an important association between esophageal cancer tumor length and regional lymph node metastasis as well as overall survival. Future clinical staging of esophageal cancer may benefit from adding tumor length to current methods relying on depth of invasion (T status) and an estimation of positive lymph nodes from CT or EUS (N status).

Hypofractionated radiotherapy (66Gy at 3Gy per fraction) for favorable-risk prostate cancer: Long-term outcomes.

141 Background: Hypofractionated radiotherapy (HypoRT) is increasingly being used to treat prostate cancer to take advantage of its likely low α/β ratio. There is limited experience in delivering a high biologically equivalent dose with HypoRT. We report long-term outcomes from patients treated with high-dose HypoRT.nnnMETHODSnPatients with low and intermediate risk prostate cancer were treated using 3-dimensional conformal radiotherapy at a dose of 66Gy in 22 daily fractions of 3Gy without hormonal therapy. A uniform 7mm margin was created around the prostate for the planning target volume (PTV) and treatment was prescribed to the isocentre. Treatment was delivered using daily ultrasound image guided radiotherapy (IGRT). The CTCv3.0 was used to prospectively score toxicity. Biochemical failure was defined using the Phoenix criteria of nadir+2ng/ml.nnnRESULTSnA total of 129 patients were treated between November 2002 and December 2005. With a median follow-up of 90 months, the 5- and 8-year actuarial biochemical control rate was 97% and 92% respectively. The 5- and 8-year actuarial overall survival was 92% and 88% respectively. Only one patient died from prostate cancer at 92 months after treatment resulting in an 8-year actuarial cancer specific survival of 98%. Radiotherapy was well tolerated with 57% of patients experiencing no acute gastrointestinal (GI) or genitourinary (GU) toxicity. For late toxicity, the worst grade ≥2 rate for GI and GU toxicity was 27% and 33% respectively, but at the last follow-up the rate of grade ≥2 was only 1.5% for both GI and GU toxicity (Table).nnnCONCLUSIONSnHigh dose HypoRT delivering 66 Gy in 22 fractions at 3Gy per fraction is a safe, effective and convenient modality of delivering radiotherapy to patients with favorable risk prostate cancer with excellent biochemical control rates and acceptable rates of acute and late GI and GU toxicity. [Table: see text].