ObjectiveTo analyze intrathoracic or extrathoracic recurrence pattern after surgical resection of thoracic esophageal squamous cell carcinoma (TESCC) and its help for further modify and improvement on the target of postoperative radiation therapy. Methods One hundred and ninety-five patients who had undergone resection of TESCC at the Cancer Hospital,Chinese Academy of Medical Sciences enrolled from April 1999 to July 2007.Sites of failure on different primary location of esophageal cancer were documented.Results Patients with upper or middle thoracic esophageal cancer had higher proportion of intrathoracic recurrence.Patients with lower thoracic esophageal cancer had more intrathoracic reccurence and abdominal lymph node metastatic recurrence.Histological lymph node status has nothing to do with intrathoracic recurrence,supraclavicular lymph node ( SLN ) metastasis or distant metastasis ( χ2 =1.58,0.06,0.04,P =0.134,0.467,0.489,respectively),whereas the chance of abdominal lymph node metastases in N positive patients was significantly higher than that in N0 patients (28.7％: 10.6％,χ2 =9.94,P =0.001 ),and so did in middle thoracic esophageal cancer ( 20.0％: 5.6％,χ2 =5.67,P =0.015). Anatomic recurrence rate of patients with proximal resection margin no more than 3 cm was significantly higher compared to those more than 3 cm (25.0％: 11.3％,χ2=5.65,P=0.019).ConclusionsMediastinum is the most common recurrence site.According to recurrence site,the following radiation targets are recommended:when tumor was located at the upper or middle thoracic esophagus with negative N status,the mediastinum,the tumor bed and the supraclavicular region should be included as postoperative RT target;when tumor was located at the middle thoracic esophagus with positive N or located at the lower thoracic esophagus,the abdominal lymph node should be added.If the proximal resection margin was no more than 3 cm,the anastomotic-stoma should be included.

Objective To study if tumor retraction assessed by endiscopic uhrasonography (EUS) during radiotherapy has prognostic value in esophageal carcinoma, which may further predict the radiosensi-tivity. Methods The maximal tumor thickness was measured by EUS before radiotherapy and at 40 Gy in patients with esophaged carcinoma. Response was defined as at least 50% reduction in tumor thickness. Re-suits A total of 51 patients were included. The median follow-up time was 28.5 months. The median sur-vival time was 24.3 months. The treatment was radiotherapy alone, concurrent chemoradiotherapy and pre-operative treatment in 35, 10 and 6 patients, respectively. Tumor response was assessed by EUS in 18 pa-tients (34%). The 2-year overall survival (OS) and progression-free survival (PFS) were 69% and 59% for responders, comparing with 37% and 29% for non-responders (χ~2= 5.78, P = 0.016 and χ~2= 3.97, P =0.046, respectively). In radiotherapy alone group, the 2-year OS and PFS were significantly higher in responders (n = 11) comparing with non-responders (n =24)(60% vs 44% ,χ~2 =5.84,P =0.016 and 20% vs 10% ,χ~2 =4.20, P =0. 040). In preoperative radio (chemo) therapy group (n =6), pathological-ly complete response, partial response and minimal response were observed in 4, 1 and 1 patients, respec-tively. EUS detected tumor response in 4 of 5 (80%) patients with tumor regression, and non-response in 1 of 1 patient without tumor regression. Conclusions The prognosis is better in patients with esophageal car-cinoma responding to neoadjuvant treatment identified by EUS than that of non-responders.

Objective To study the dynamic changes of anatomy and the dosimeter distribution those changes influenced. Methods Initially simplified intensity modulated radiation therapy (sIMRT)were performed to twenty-nine patients with phase Ⅲ - Ⅳa esophageal carcinoma from January 2007 to March 2009. The target volumes and involving organs were contoured on the primary spiral CT pictures.After sIMRT planning being finished, secondary CT scan was acquired to rectify the treatment center. For eleven patients at every other week and eighteen patients at the fourth week, spiral CT images were acquired according to the same treatment center, and thereafter fused with the first CT images. Firstly, the law of change and the best time of replanning were searched:the changed gross tumor volume (GTV), gross node volume (GTVnd), plan target volume (PTV) and normal organs (lung, spinal cord, heart and outline) on the fusion interface were modified by a single physician, the changes for each structure throughout treatment were measured by system software. Secondly, dose distributions were computed and evaluated for replanning CT using the same beams arrangement as the initial plan. Cumulative dose was estimated using weighted average and compared with the original plan. Results For eleven patients, The law of change:the volume of outlines and GTV gradually decreased, and the change come to peak in the fourth week. The conformal index for PTV gradually decreased, whereas the heterogeneous index gradually increased. For twenty-nine patients on the fourth week, the dose of GTV were more than 60 Gy. The dose of PTV-D95 and CTV-D99 decreased ( t = 1.49, P = 0. 147 and t = 2. 07, P = 0. 048 respectively). The dose of CTV-D99 in two patients deceased to 54 Gy or less. The cord-Dmax and lung V30 increased significantly ( t = - 2. 42, P = 0. 022 and t = -2. 26,P =0. 032). Conclusions During the course of sIMRT for esophageal cancer, the volume of GTV decreased and the change come to peak in the fourth week. It is the best time for evaluating the change of dose of target volume using CT-CT fusion. For some patients, revise of the treatment plan is needed to ensure adequate target volume dosage and safety of normal tissues.

Objective To investigate independent prognostic factors for overall survival (OS) in extensive disease small cell lung cancer (EDSCLC). Methods Between January 2003 and December 2006, 154 patients diagnosed with extensive stage small cell lung cancer were enrolled in this study.Prognostic factors such as gender, age, performance status, smoking history, weight loss, distant metastasis, the number of matastasis, brain metastasis, the cycle of chemotherapy and thoracic radiation therapy (TRT) for EDSCLC patients were evaluated by univariate and multivariate analysis. Results The median following-up time was 40. 5 months. The rate of follow-up was 92. 2%. The MST and overall survival rates at 3-year in smoking group and no-smoking group were 13 months, 11.8% and 17 months,22. 8%,respectively (χ2=3.40,P =0. 064);in ChT/TRT group and ChT group, they were 17. 2 months, 17.9%and 9.3 months,13.9%, respectively(χ2=10.47,P=0.001);and in the cycle of chemotherapy ≥4 group and ＜ 4 group, they were 16 months, 20. 1% and 9.3 months, 2. 9%, respectively (χ2=17.79,P=0. 000). By multivariate analysis, smoking history was a statistically significant unfavorable factor for OS in EDSCLC patients (versus no-smoking, hazard ratio (HR)=1.462, χ2=4.40, P=0.036). In addition, ≥4 cycles of chemotherapy and TRT were favorable prognostic factors ( ≥4 cycles vs ＜4 cycles, HR =0. 420,χ2 = 17. 17, P = 0. 000; ChT/TRT vs ChT, HR = 0. 634, χ2 = 6. 20, P = 0. 013). Conclusions Smoking is a independent unfavorable prognostic factor and ≥ 4 cycles of chemotherapy And TRT are independent favorable prognostic factors for OS in EDSCLC.

Objective To evaluate the relation between lung dosimetric parameters and the risk of symptomatic radiation pneumonitis (RP) in patients with non-small cell lung cancer (NSCLC) who had re-ceived postoperative radiotherapy. Methods From November 2002 to March 2006, 90 patients with NSCLC who had received postoperative 3-dimentinal conformal radiotherapy (3DCRT) were retrospectively analyzed, including 53 with stage ⅢA disease, 25 with stafe ⅢB disease and 12 with stage Ⅰ-Ⅱ disease but positive margins. Seventy (78%) patients underwent lobectomy, 20 ( 22% ) underwent pneumonectomy, and 38 ( 46% ) received adjuvant chemotherapy. The median radiation dose was 60 Gy given in 30 fractions of 2 Gy using 6 MV X-ray. The percentage of the whole lung volume ( Vx ) and the ipsilateral absolute lung volume ( Vipsi-dosewhich received more than a certain dose were calculated. The endpoint was grade 2 and above RP based on CTC AE 3.0. The relation between the dosimetric factors and RP was also analyzed with receiver operating characteristic (ROC) curves. Results Nine patients ( 10% ) developed symptomatic RP ( grade 2 in 7 and grade 3 in 2), and all of them were in the lobectomy group. No RP was observed in patients who received pneumonectomy. Both V30 and V35 were higher in patients with RP than those without ( 19% vs 14% ,U= -2.16,P=0.030, and 15% vs 11%,U= -2.65,P =0.007, respectively). The area under curve in receiver operating characteristic curves based on the relation between incidence of RP and the value of Vipsi-dose was 0. 757. Using Vipsi-30 of 340 cm3 as a cut-off to predict RP, the sensitivity and specificity were 88% and 70%, respectively. The incidence of RP was 3% in patients with Vipsi-30< 340 cm3 compared with 29% in those with Vipsi-30>340cm3 ( X2 = 9.75 , P = 0.003 ) . Conclusions More than340 cm3 of the ipsilateral lung receiving 30 Gy is significantly related to the risk of RP in patients undergoing lobectomy. It is safe for patients who undergo pneumonectomy to receive postoperative 3DCRT if lung V20 is less than 10%.

Objective To analyze the rule of lymph node metastasis in thoracic esophageal carcinoma,and to study the proper radiation target. Methods From September 1986 to December 1997,549 patients with esophageal carcinoma who had undergone radical reseetion were divided into surgery alone group (S,275 patients) or surgery plus radiotherapy group( S + R,274 patients). Radiotherapy was begun 3 to 4 weeks after operation. The radiation target included beth supra-clavicular areas and the entire mediastinum. The total dose was 50 Gy in 25 fractions over 5 weeks for the supra-clavicular areas and 60 Gy in 30 fractions over 6 weeks for the entire mediastinum. Results The 5-year overall survival of patients with lymph node metastasis in one anatomic site and two anatomic sites was 31.5% and 13.9% (P=0.013), respectively. For patients with > 2 positive nodes metastasis receiving surgery alone, the corresponding 5-year survival was 24.8% and 4.9% (P=0.046) ,respectively. The median number of dissected lymph nodes of the upper-,middle-and lower-segment esophageal carcinoma was 13,17 and 20, respectively. The rate of metastatic lymph node in the para-esophagus region was the highest(61.5%-64.9%) ,which was not different among the different primary sites(P=0.922). The anastomotic stoma recurrence rate of the upper-segment esophageal carcinoma was higher than that of the middle- or lower-segment carcinomas(16.7% ,3.1% ,and 7.7%, χ2=9.02,P<0.05). Conclusions For the thoracic esophageal carcinoma,the number of anatomic sites of lymph node metastasis is an important factor affecting the survival. The lower rate of lymph node metastasis of the upper segment esophageal carcinoma may be corrected with the less lymph node dissected. The rate of lymph node metastasis in para-esophageal region is not related with the lesion segment. The anastemotie stoma is an important radiotherapy target for upper segment esophageal carcinoma.

Objective To evaluate the efficacy of rescue treatment for recurrent esophageal cancer after radical esophagectomy, and to provide insights into the development of comprehensive treatment for esophageal cancer.Methods The clinical data of 218 patients who were confirmed with recurrent metastatic esophageal cancer after R0 resection and received rescue treatment in our hospital from 2004 to 2014 were retrospectively reviewed.The survival rate was determined by the Kaplan-Meier method.Univariate and multivariate prognostic analyses were performed using the log-rank test and Cox proportional hazards model, respectively.Results The median post-recurrence follow-up time was 53 months.The 1-and 3-year overall survival (OS) rates after recurrence were 57.2% and 24.4%, respectively.Among the 163 patients with local recurrence, the 1-and 3-year OS rates were 70% and 42% for patients treated with chemoradiotherapy (n=40), 55% and 24% for those with radiotherapy alone (n=106), and 23% and 8% for those with supportive therapy (n=13)(chemoradiotherapy vs.radiotherapy alone P=0.045, radiotherapy alone vs.supportive therapy P=0.004;none of the patients who were treated with chemotherapy alone survived for one year or more).Univariate analysis showed that N staging, TNM staging, and post-recurrence rescue treatment regimen were independent prognostic factors for esophageal cancer (all P=0.001).On the other hand, multivariate analysis indicated that only rescue treatment regimen was the independent prognostic factor for esophageal cancer (P=0.013).Conclusions Rescue chemoradiotherapy or radiotherapy alone can bring significant survival benefits for patients with recurrent and metastatic, especially locally recurrent, esophageal cancer following radical esophagectomy.

At present,although magnetic resonance imaging(MRI)is not a routine examination of esophageal cancer,the preliminary results of some studies have indicated that MRI may become an important alternative for esophageal cancer staging, radiotherapy target delineation, and efficacy assessment. This article mainly discusses the value of MRI in the staging and radiotherapy for esophageal cancer.

Objective To retrospectively analyze treatment results of radiotherapy for medically inoperable stage Ⅰ/Ⅱ non-small cell lung cancer. Methods Between Jan.2000 and Dec.2005,fifty-eight such patients were enrolled into the database analysis,including 37 with clinical stage Ⅰ and 21 with stage Ⅱ disease.Fifty patients received radiotherapy alone and eight with radiotherapy and chemotherapy.Fortythree patients were treated with 3-D conformal radiotherapy(3D-CRT)and 15 with conventional radiotherapy.Results The 1-,2-and 3- year overall survival rates were 85%,54%and 30%,and the median survival time was 26.2 months for the whole group.The corresponding figures were 88%,60%,36%and 30.8 months for cancer-specific survival:84%,64%,31%and 30.8 months for Stage Ⅰ disease;81%,47%,28%and 18.8 months for Stage Ⅱ disease;95%,57%,33%and 30.8 months for 3D-CRT group and 53%,44%,24%and 15.3 months for conventional radiotherapy group.By logrank test,tumor volume,pneumonitis of Grade Ⅱ or higher and weight loSS more than 5%showed statistically significant impact on overall survival.Tumor volume was the only independent prognostic factor in Cox muhivariable regression.Pneumonitis and esophagitis of Grade Ⅱ or higher were 16%and 2%,respectively.Age and lung function before treatment had a significant relationship with pneumonitis.Failure included the local recurrence(33%)and distant metastasis(21%).There was no difference between the treatment modalities and failure sites. Conclusions For medically inoperable early stage non-small cell lung cancer patients,tumor volume is the most important prognostic factor for overall survival.The conformal radiotherapy marginally improves the survival.The age and pulmonary function are related to the incidence of treatment induced pneumonitis.

Objective To evaluate the treatment effects of chemotherapy comparing with chemotherapy and radiotherapy in the limited-stage small cell lung cancer (SCLC). Methods 234 patients were cyto-pathologically diagnosed and staged as limited small cell lung cancer. The patients were treated with combined chemotherapy and radiotherapy,in which 22 cases were treated by alone chemotherapy (C),39 patients by chemotherapy plus radiotherapy(C+R),and 173 cases by combined chemotherapy and radiotherapy + chemotherapy (C+R+C). The chemotherapy regimen included CE (or PE),CAP or CAV for 4~6 cycles. Irradiation treatment covering the primary tumor,the ipsilateral hilar nodes and mediastinum was delivered once daily with 6 megavoltage X-ray beam to a median irradiation does of 56 Gy being given in 5~6 weeks. Results The 1-,2-,3-,and 5-year overall survival rates were 76.5%,38.2%,25.3%,15.6% respectively,and the median survival time (MST) was 19 months. There was a significantly difference on the survival rate between C+R+C group and C+R group or C group (P