| PartⅠTitle:Comparison of Two Major Staging Systems in Predicting Survival and Recommendation of Postoperative Radiotherapy Based on the 11th Japanese Classification for Esophageal Carcinoma After Curative Resection:A Propensity Score-Matched AnalysisPurpose:The aim of this study was to compare the prognostic predictive power of the 11th Japan Esophageal Society(JES)staging system with the 8th edition of the American Joint Committee on Cancer(AJCC)staging system in patients with thoracic esophageal squamous cell carcinoma(TESCC),and to estimate the survival benefits of postoperative radiotherapy(PORT)based on a substage of the JES staging system.Materials and methods:Area under the curve(AUC)values of the receiver operating characteristic curve were calculated to evaluate prognostic efficacy.Propensity score matching(PSM)analysis was conducted to balance the two groups(surgery only[S group]or surgery plus PORT[S+RT group])across substages of the 11 th JES staging system according to independent prognostic factors for overall survival(OS)identified using Cox proportional hazards regression.Results:A total of 2960 patients were eligible.The 5-year OS AUC for the 8th AJCC staging system was significantly higher than that for the 11th JES staging system(0.701 vs.0.675,p<0.001).Before PSM,PORT significantly improved 5-year OS rates for patients in stage Ⅲ and ⅣA(the 11th JES staging)by 9.1%(p<0.001)and 21.1%(p<0.001),respectively.And multivariate regression analysis identified PORT as independent prognostic factors for stage Ⅲ(hazard ratio[HR]=0.771,95%confidence interval[CI]0.666-0.892;p=0.003)and stage IVA(HR=0.439,95%CI 0.275-0.702;p=0.001)except for stage Ⅱ(HR=0.768,95%CI 0.579-1.019;p=0.062).After PSM,there were 175,444,and 34 pairs of cases in stage Ⅱ,Ⅲ,and ⅣA of the 11th JES staging,respectively.The 5-year OS rates in stage Ⅱ,Ⅲ,and ⅣA of the S+RT group were significantly higher than those in the S group(70.9%,39.7%,and 35.1%vs.57.8%,27.2%,and 10.3%,respectively;p<0.001).Conclusion:The 11th JES staging system was less capable of predicting prognosis than the 8th AJCC staging system.Patients in stage Ⅲ of the JES staging system were highly recommended to undergo PORT and the value of PORT in stage ⅣA was needed the more large-sample size studies to confirm.Part ⅡTitle:Recurrence risk stratification based on a competing-risks nomogram to identify patients with esophageal cancer who may benefit from postoperative radiotherapyPurpose:A reliable model is needed to estimate the risk of postoperative recurrence and the benefits of postoperative radiotherapy(PORT)in patients with thoracic esophageal squamous cell cancer(TESCC).Materials and methods:The study retrospectively reviewed 3652 TESCC patients in stage ⅠB-ⅣA after radical esophagectomy,with or without PORT.In one institution as the training cohort(n=1620),independent risk factors associated with locoregional recurrence(LRR),identified by the competing-risks regression,were used to establish a predicting nomogram,which was validated in an external cohort(n=1048).Area under curve(AUC)values of receiver operating characteristic curves were calculated to evaluate discrimination.Risk stratification was conducted using a decision tree analysis based on the cumulative point score of the LRR nomogram.After balancing the baseline of characteristics between treatment groups by inverse probability of treatment weighting(IPTW),the effect of PORT was evaluated in each risk group.Results:Sex,age,tumor location,tumor grade,and N category were identified as independent risk factors for LRR and added into the nomogram.The AUC values were 0.638 and 0.706 in the training and validation cohorts,respectively.Three risk groups were established.The 3-year LRR rates for low-,intermediate-and high-risk groups were 19.2%,28.9%and 39.8%,respectively(p<0.001),and the 3-year DM rates were 8.0%,15.2%and 23.7%,respectively(p<0.001),with the 5-year OS rates of 67.6%,47.4%and 19.1%,respectively(p<0.001).Before IPTW,the 5-year OS rates in low-,intermediate-and high-risk groups were 67.6%,47.4%and 19.1%in the S group as compared with 67.7%(p=1.0),49.8%(p=0.11)and 30.5%(p<0.001)in the PORT group.And multivariate analysis identified PORT as independent prognostic factors for the intermediate-(HR=0.73,95%CI:0.63-0.84,p<0.001)and high-risk groups(HR=0.66,95%CI:0.55-0.80,p<0.001).After IPTW,the 5-year OS rates in low-,intermediate-and high-risk groups were 66.8%,45.2%and 19.6%in the S group as compared with 71.9%(p=0.461),55.4%(p<0.001)and 29.0%(p<0.001)in the PORT group.Conclusion:The nomogram can effectively estimate the individual risk of LRR,and patients in the intermediate-and high-risk groups are highly recommended to undergo PORT.The combination with system therapy was consider in the high-risk group as the high incidence of DM rates.Our study provided an important foundation on the postoperative therapy based on the risk stratification.Part ⅢTitle:Postoperative radiotherapy with appropriate target volume definition is an efficient complement for esophagectomy in patient with thoracic esophageal squamous cell carcinomaPurpose:Our study aimed to compare the recurrence patterns between the surgery alone(S alone)and surgery plus RT(S+RT)treatment groups,so that it could help delineate the optimal target volumes in the intensity-modulated RT technique era and guide the decision-making of combined modality therapy for patients with thoracic esophageal squamous cell cancer(TESCC)after surgery.Materials and methods:The study retrospectively reviewed TESCC patients after radical esophagectomy from 2004 to 2012.The RT fields were determined by the location of primary lesions and the pathological nodal status.The recurrence patterns between treatment groups were analysis in both pathological lymph node-negative and-positive patients,and the specific site of locoregional recurrence(LRR)were mapped.Results:A total of 1898 patients were taken into analysis.The cumulative probability of recurrence occurred progressively as the number of positive lymph nodes increased(HR=1.09,95%CI:1.06-1.12,p<0.001).The 2-year LRR rates for N0,N1,N2 and N3 stages were 24.2%,32.1%,41.3%and 47.1%,respectively(p<0.001),and the 2-year distant metastasis(DM)rates were 9.6%,18.6%,21.3%and 37.7%,respectively(p<0.001),with the 5-year OS rates of 60.8%,34.6%,20.7%and 8.6%,respectively(p<0.001).And multivariate regression analysis identified PORT as independent prognostic factors for both the node-negative(HR=0.60,95%CI:0.41-0.87,p<0.001)and positive patients(HR=0.61,95%CI:0.50-0.75,p<0.001).For node-negative patients,the 2-year recurrence rates in the supraclavicular,mediastinal,anastomosis and abdominal regions were 9.8%,16.5%,3.0%and 3.9%in the S group as compared with 4.4%(p=0.004),10.6%(p=0.032),0.9%(p=0.485)and 5.3%(p=0.321),respectively.For node-positive patients,the 2-year recurrence rates in the supraclavicular,mediastinal,anastomosis and abdominal regions were 11.9%,24.4%,4.0%and 10.6%in the S group as compared with 4.6%(p=0.001),10.5%(p<0.001),2.7%(p=0.418)and 5.9%(p=0.102),with the 2-year DM rates of 21.5%and 25.2%,respectively(p=0.073).The subgroup analysis found that the abdominal RT was found to have positive effects on reducing the abdominal recurrence in node-positive patients with low thoracic lesions(HR:0.42,95%CI:0.18-0.97,p=0.042).Conclusion:The reduction of target volumes did not increase the risk of recurrence within RT fields.Given the high incidence of DM in node-positive patients,our study provided a theoretical basis for reduction in the RT field and combination with chemotherapy or immunotherapy. |
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