1. Definitive chemo-radiotherapy for esophageal cancer; failure pattern and salvage treatments Ryuta Koike, Y. Nishimura, K. Nakamatsu, S. Kanamori, M. Okubo, K. Hiroi, T. Shibata T. Nishikawa, H. Shiozaki* Department of Radiation Oncology and Surgery*, Kinki University School of Medicine

2. ・ Failure pattern in definitive chemoradiotherapy (CRT) for esophageal cancer were analyzed to evaluate the appropriateness of our RT field. Purpose

3. Patients Characteristics From 1999 to 2006, 136 consecutive patients with esophageal cancer with localized esophageal cancer were treated with definitive CRT at our hospital. Age ； 38 ~ 82 years old （ median; 64 years ） Gender; men ： females =116 ： 20 PS 0/ 1/ 2 /3= 58/ 66/ 11/ 1 Histology; 135 pts squamous cell carcinomas 1 pt adenocarcinoma Stage; I ： II ： III: IV= 8 ： 25 ： 76: 27 (2002 UICC) T Factor T1:T2:T3 ： T4 =15:20:27 ： 74, N Factor N0 ： N1 = 27 ： 109 Location of primary tumor: Ce: Ut: Mt: Lt = 19: 27: 71: 19 Tumor length ： 1 ~ 19cm （ median 6.5cm ）

4. Initial RT Fields according to the primary site ・ Cervical esophagus (Ce) Bilateral neck and subcarinal LNs (Short T-shaped Field) ・ Upper (Ut) and middle (Mt) esophagus Bilateral neck and whole mediastinal LNs (T-shaped Field) ・ Lower esophagus (Lt) Whole mediastinal LNs and perigastric LNs (I-shaped Field)

5. Initial RT Fields CeUt, Mt Lt

6. Radiation and Chemotherapy ・ Radiation therapy 60 Gy/30 fr/7 w (one-week split) for the both groups. Either a 6 MV or 10 MV X-ray was used. Boost was given following 40 Gy. ・ Two courses of concurrent CT were combined with RT Ⅰ、 low-dose protracted pattern 102 pts （ 75% ） CDDP 7mg/m 2 × 10 days 5-FU 250-300mg/m 2 × 14 days Ⅱ、 high-dose pattern 34 pts （ 25% ） CDDP 70mg/m 2 × 1 day 5-FU 700mg/m 2 × 5 days After CRT, 1-2 courses of adjuvant CT of cisplatin/5-FU were given for 75 pts (55%).

7. Results ・ A total dose of 60 Gy could be delivered for 133 pts (98%). ・ 2 courses of planned CT could be combined concurrently with RT for 118 pts (87%). ・ Complete response （ CR ） in the RT field was achieved in 84 pts （ 62% ）. T1 15/15 （ 100% ） T2 18/20 （ 90% ） T3 20/27 （ 74% ） T4 31/72 （ 42% ） ・ Failure Pattern of the 84 pts with CR was evaluated.

8. Overall survival T1N0M0 n=8 2-year survival 100 ％ 5-year survival 80 ％ month

9. Overall survival stages II-III (excluding T4) n=39 2-year survival 59% 5-year survival 41% month

10. Overall survival, stages III-IV T4 or M1- ｌｙｍｐｈ n=84 2-year survival 26% 5-year survival 19% month

11. CR (n=84) Overall survival rate ; 1999- 2006 2-year survival 66% 5-year survival 52% Non-CR (n=52) month

12. Failure pattern (n=84) No rec. 39 pts (46%) In-field rec. 12 pts (14%) Out-field rec. 33 pts (40%) Isolated marginal rec. 9 pts (11%) Distant meta ±regional LN Rec. 24 pts (29%)

13. Treatment results for 9 pts with isolated marginal recurrences Lower esophageal （ out of RT Field ） rec. ２ pts （ Origin: Ce 、 Ut ） Salvage surgery was performed for 2 pts. ⇒ Local control could be achieved Lymph node rec. (out of RT Field) ７ pts Perigastric LN recurrence 4 pts Lymph node dissection 2 ｐｔｓ 2nd-CRT(50-60Gy) 2 ｐｔｓ ⇒ Local control could be achieved Hilar LN rec. 2 pts Neck + retrocrural LNs １ pt 2nd-CRT(50-60Gy) 3 ｐｔｓ Local control could not be achieved. In all 6 pts with lower esophageal or perigastric LNs recurrence,salvage treatments were successful. In all 6 pts with lower esophageal or perigastric LNs recurrence, salvage treatments were successful. Local control could be achieved Local control could not be achieved. ⇒

19. Late toxicities (n=84) RTOG/EORTC *: CTCAE version 3.0 Grade G1G2G3G4 =>G2 Esophagus 34 509 (11%) Heart 170112 (2%) Lung 173205 (6%) Spinal cord10000 (0%) Pleural*180101 (1%) Hypothyroid*13104 (5%) Renal failure* 00011 (1%) Pt. Max. #2898219 (23%)

20. Conclusions The 5-year overall survival rates of definitive CRT of 60Gy for both resectable and unresectable esophageal cancer were excellent. Although recurrences after initial CR were noted frequently, salvage treatments were successful for isolated marginal recurrences in the lower esophagus or perigastric LNs. For Ce, Ut and Mt tumors, lower esophageal and perigastric LN region can be excluded from the initial RT field.