Samual Francis

Self-expanding stent effects on radiation dosimetry in esophageal cancer

It is the purpose of this study to evaluate how self‐expanding stents (SESs) affect esophageal cancer radiation planning target volumes (PTVs) and dose delivered to surrounding organs at risk (OARs). Ten patients were evaluated, for whom a SES was placed before radiation. A computed tomography (CT) scan obtained before stent placement was fused to the post‐stent CT simulation scan. Three methods were used to represent pre‐stent PTVs: 1) image fusion (IF), 2) volume approximation (VA), and 3) diameter approximation (DA). PTVs and OARs were contoured per RTOG 1010 protocol using Eclipse Treatment Planning software. Post‐stent dosimetry for each patient was compared to approximated pre‐stent dosimetry. For each of the three pre‐stent approximations (IF, VA, and DA), the mean lung and liver doses and the estimated percentages of lung volumes receiving 5 Gy, 10 Gy, 20 Gy, and 30 Gy, and heart volumes receiving 40 Gy were significantly lower (p‐values <0.02) than those estimated in the post‐stent treatment plans. The lung V5, lung V10, and heart V40 constraints were achieved more often using our pre‐stent approximations. Esophageal SES placement increases the dose delivered to the lungs, heart, and liver. This may have clinical importance, especially when the dose‐volume constraints are near the recommended thresholds, as was the case for lung V5, lung V10, and heart V40. While stents have established benefits for treating patients with significant dysphagia, physicians considering stent placement and radiation therapy must realize the effects stents can have on the dosimetry. PACS number: 87.55.dk

Adjuvant therapy for resected pN2 non-small cell lung cancer: sequence is not all that matters

We appreciate the comments from Zhao and Ng (1) regarding our recent National Cancer Database (NCDB) study comparing survival outcomes after postoperative adjuvant concurrent chemoradiotherapy (CRT) versus sequential chemotherapy followed by postoperative radiotherapy (C→PORT) for locally advanced or incompletely resected non-small cell lung cancer (NSCLC).

Benefit of adjuvant chemotherapy based on lymph node involvement for oesophageal cancer following trimodality therapy

Background Oesophageal cancer (OC) survival rates have improved since the widespread adoption of neoadjuvant chemoradiation therapy (NACRT) followed by oesophagectomy (trimodality therapy). Unfortunately, the overall prognosis for patients with locally advanced disease remains poor. In this study, we sought to assess the effect of adjuvant chemotherapy (AC) in patients treated with trimodality therapy. Methods Using the National Cancer Database we retrospectively identified 6785 patients with locally advanced (cT1b-T4a, N0-N+, M0) OC who were treated with trimodality therapy from 2006 to 2014. Patients were separated based on receipt of AC (n=463), as well as clinical and pathological lymph node involvement. Overall survival (OS) between groups was compared using the Kaplan-Meier method and Cox proportional hazard modelling. Results Based on multivariate analysis, AC was associated with a statistically significantly reduced risk of death (HR 0.77, p<0.001). Subgroup analysis revealed that AC was associated with reduced risk of death compared with NACRT alone in the cN+/pN0 (median OS 64 vs 43 months; p=0.019) and the cN+/pN+ (median OS 27 vs 22 months; p=0.010) groups, but not in the cN0/pN0 (median OS 48 vs 49 months; p=0.253) or cN0/pN+ (median OS 31 vs 24 months; p=0.077) groups. Conclusion AC following trimodality therapy may improve survival in patients with locally advanced OC. Patients who undergo lymph node downstaging may be the most likely to benefit from AC. Prospective studies are needed to confirm this finding.

Sequencing of Postoperative Radiotherapy and Chemotherapy for Locally Advanced or Incompletely Resected Non–Small-Cell Lung Cancer

Purpose Although several feasibility studies have demonstrated the safety of adjuvant concurrent chemoradiotherapy (CRT) for locally advanced or incompletely resected non-small-cell lung cancer (NSCLC), it remains uncertain whether this approach is superior to sequential chemotherapy followed by postoperative radiotherapy (C→PORT). We sought to determine the most effective treatment sequence. Patients and Methods Using the National Cancer Database, we selected two cohorts of patients with nonmetastatic NSCLC who had received at least a lobectomy followed by multiagent chemotherapy and radiotherapy; cohort one included patients with R0 resection and pN2 disease, whereas cohort two included patients with R1-2 resection regardless of nodal status. Overall survival (OS) was examined using a propensity score-matched analysis with a shared frailty Cox regression. Results A total of 747 patients in cohort one and 277 patients in cohort two were included, with a median follow-up of 32.8 and 27.9 months, respectively. The median OS was 58.8 months for patients who received C→PORT versus 40.4 months for patients who received CRT in cohort one (log-rank P < .001). For cohort two, the median OS was 42.6 months for patients who received C→PORT versus 38.5 months for patients who received CRT (log-rank P = .42). After propensity score matching, C→PORT remained associated with improved OS compared with CRT in cohort one (hazard ratio, 1.35; P = .019), and there was no statistical difference in OS between the sequencing groups for cohort two (hazard ratio, 1.35; P = .19). Conclusion Patients with NSCLC who undergo R0 resection and are found to have pN2 disease have improved outcomes when adjuvant chemotherapy is administered before, rather than concurrently with, radiotherapy. For patients with positive margins after surgery, there is not a clear association between treatment sequencing and survival.