Cancer Res Treat.  2015 Oct;47(4):706-717. 10.4143/crt.2014.174.

Palliative Radiotherapy in the Presence of Well-Controlled Metastatic Disease after Initial Chemotherapy May Prolong Survival in Patients with Metastatic Esophageal and Gastric Cancer

• Hingorani
• Dixit S
• Johnson M
• Plested V
• Alty K
• Colley P
• Beavis AW
• Roy R
• Maraveyas

• KMID: 2403389
• DOI: http://doi.org/10.4143/crt.2014.174

Abstract

PURPOSE
We report the outcomes of patients treated with palliative radiotherapy (pRT) to the primary tumour in the context of well-controlled metastatic disease after initial chemotherapy.
MATERIALS AND METHODS
Clinical records of 132 patients with metastatic esophago-gastric (OG) cancer treated with palliative chemotherapy (pCT) between January 2009 and June 2013 were reviewed. Ninetyseven patients had responding or stable disease after 3 months of chemotherapy, of whom 53 patients received pRT to the primary tumour after initial chemotherapy in the presence of well-controlled metastatic disease (group A, pCT-RT). The remaining 44 patients were treated with pCT alone (group B, pCT). Treatment-related outcomes were assessed in above groups including time to local progression (TTLP), progression-free and overall survival.
RESULTS
The median overall survival for patients treated with pRT after initial chemotherapy (group A) was 23.3 months (95% confidence interval [CI], 17.70 to 28.89 months) and significantly higher than the 14 months (95% CI, 10.91 to 17.08 months) in patients treated with pCT alone (group B) (p < 0.001). The use of pCT-RT was an independent predictor of OS in multivariate analysis. Local recurrence was observed in 12/53 of patients (23%) in group A compared to 16/44 (36%) in group B. The median TTLP was significantly higher in patients after pCT-RT at 17.3 months (5.23 months to 44.50 months) compared to 8.3 months (range, 4.10 to 25.23 months) in patients treated with pCT alone (p=0.006).
CONCLUSION
The possibility of pRT influencing systemic disease in advanced OG cancer has not been reported, and results from the present study present strong arguments for investigation of this therapeutic strategy in a randomized trial.

Keyword

Esophageal neoplasms; Stomach neoplasms; Palliative treatment; Radiotherapy; Chemotherapy

MeSH Terms

Drug Therapy*
Esophageal Neoplasms
Humans
Multivariate Analysis
Palliative Care
Radiotherapy*
Recurrence
Stomach Neoplasms*

Figure

• 

  Fig. 1. (A) Schematic illustration of study design. (B) Palliative radiotherapy after initial palliative chemotherapy (pCT-RT) prolongs progression-free survival (PFS) and overall survival (OS) compared to palliative chemotherapy (pCT) alone. The median PFS of patients treated with pCT-RT was significantly increased at 14 months compared to 9.5 months in patients treated with pCT (p < 0.015). The median OS of patients after pCT-RT was 23.3 months compared to 14 months in patients treated with pCT alone (p < 0.001). OG, esophago-gastric.

• 

  Fig. 2. Effect of different variables on survival outcomes. (A) The use of pCT-RT was an independent predictor of overall survival on multivariate analysis that was not influenced by the site of tumour or nature of metastatic disease. (B) The survival benefit of pCT-RT was observed in all sub-groups independent of site and number of metastasis and subsequent lines of systemic chemotherapy. (C) There was favorable trend with increased survival benefit (non-significant) in patients treated with higher biological equivalent dose of radiation (p=0.08). HR, hazard ratio; CI, confidence interval; GOJ, gastro-esophageal junction; pCT-RT, palliative chemotherapy-radiotherapy.

• 

  Fig. 3. Case examples of diagnosis and multi-modality management of cancers of esophagus. (A) A 50-year-old female; cancer of lower esophagus and GOJ (arrow) (AC); liver and brain metastasis (arrow); 8 cycles of EOX chemotherapy; palliative radiotherapy to whole brain and primary tumor (20 Gy in 5 fractions); OS of 11 months (dead). (B) A 48-year-old male; cancer of esophagus and GOJ (AC); enlarged FDG-avid coeliac (yellow arrow) and para-aortic lymphadenopathy (red arrow) with lung metastasis; 6 cycles of EOX chemotherapy; palliative radiotherapy to primary tumor (30 Gy in 10 fractions); OS of 35 months (alive). GOJ, gastro-esophageal junction; AC, adenocarcinoma; EOX, epirubicin, oxaliplatin, capecitabine; OS, overall survival.

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  Fig. 4. Case examples of diagnosis and multi-modality management of cancers of stomach. (A) A 61-year-old male; cancer of stomach (AC); locally advanced disease at pylorus with contiguous involvement of left lobe of liver (arrow); liver and lung metastasis; 6 cycles of EOX chemotherapy; palliative radiotherapy to primary tumor (20 Gy in 5 fractions); OS of 20 months (dead). (B) A 75-year-old male; cancer of stomach (AC); locally advanced disease at linitis plastica (arrow); omental disease; 6 cycles of EOX chemotherapy; palliative radiotherapy to primary tumor (30 Gy in 10 fractions); OS of 12.4 months (dead). AC, adenocarcinoma; EOX, epirubicin, oxaliplatin, capecitabine; OS, overall survival.

Reference

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