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CORRESPONDENCE
Year : 2019  |  Volume : 15  |  Issue : 1  |  Page : 255-257

Successful definitive concurrent chemoradiotherapy in a patient with esophageal cancer and Child–Pugh B cirrhosis of the liver


Department of Radiology, The University of Tokyo Hospital, Tokyo, Japan

Date of Web Publication13-Mar-2019

Correspondence Address:
Dr. Hideomi Yamashita
Department of Radiology, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo 113-8655
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_338_17

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 > Abstract 


This case report demonstrates successful concurrent chemoradiotherapy for esophageal cancer without severe adverse events in a patient with cirrhotic disease. A 63-year-old Japanese male with alcoholic liver cirrhosis was referred to our hospital for treatment of superficial esophageal cancer. Endoscopic submucosal dissection was performed and the patient was diagnosed as having squamous cell carcinoma of the esophagus that was pathologically staged as pT1bN0M0. When a superficial tumor involves the submucosa, esophagectomy is usually recommended. However, the patient was at high risk of perioperative morbidity and mortality because of impaired liver function. As an alternative to esophagectomy, the patient received concurrent chemoradiotherapy, comprising nedaplatin 64 mg/m2 on days 1 and 34 and S-1 80 mg/body orally on days 1–14 and 34–47 with concurrent radiotherapy of 50 Gy in daily fractions of 2 Gy. He has shown no signs of recurrence in the 30 months since his treatment.

Keywords: Esophageal neoplasms, liver cirrhosis, radiation oncology


How to cite this article:
Katano A, Yamashita H, Nakagawa K. Successful definitive concurrent chemoradiotherapy in a patient with esophageal cancer and Child–Pugh B cirrhosis of the liver. J Can Res Ther 2019;15:255-7

How to cite this URL:
Katano A, Yamashita H, Nakagawa K. Successful definitive concurrent chemoradiotherapy in a patient with esophageal cancer and Child–Pugh B cirrhosis of the liver. J Can Res Ther [serial online] 2019 [cited 2019 Oct 18];15:255-7. Available from: http://www.cancerjournal.net/text.asp?2019/15/1/255/228636




 > Introduction Top


Approximately 3%–14% of patients with esophageal carcinoma are reported to have hepatic cirrhosis.[1],[2],[3] Although surgery is the treatment of choice for superficial esophageal cancers, only highly selected patients with cirrhotic liver disease should be offered esophagectomy. These patients have been reported to have significant morbidity and mortality rates of 83%–87% and 17%–30%, respectively.[4] Although Shimakawa et al. reported successful esophagectomy in a patient with Child–Pugh class B liver cirrhosis,[5] decompensated liver cirrhosis is considered a contraindication to esophageal resection in many centers.[6]

Surgery plays an essential role in the treatment of esophageal cancer. However, in spite of recent advances in surgical and intensive care, patients with decompensated cirrhosis still have a greater perioperative risk of morbidity and mortality because of immune system dysfunction, malnutrition, fluid imbalance, and a bleeding tendency. These patients may benefit from alternative nonsurgical therapies when available and appropriate. Herein, we report the favorable course of a patient with esophageal cancer and hepatic cirrhosis who underwent concurrent chemoradiotherapy.


 > Case Report Top


A 63-year-old Japanese male was referred on the suspicion of hepatic dysfunction in March 2014. He consumed 900 mL of rice wine per day and had smoked 20 cigarettes per day for the previous 40 years. Laboratory data revealed the following: aspartate aminotransferase 70 U/L (normal range: 9–38 U/L), alanine aminotransferase 57 U/L (normal range: 4–36 U/L), alkaline phosphatase 822 U/L (normal range: 115–359 U/L), gamma-glutamyl transpeptidase 427 U/L (normal range: 4–68 U/L), and ammonia 108 μg/dL (normal range: 12–66 μg/dL). A computed tomography (CT) scan and abdominal ultrasonography confirmed alcoholic liver cirrhosis. During gastrointestinal endoscopy screening for esophageal varices, an area of erythematous mucosa was found in the esophagus at 30–34 cm from the incisor teeth [Figure 1]. The mucosa was biopsied and diagnosed as squamous cell carcinoma.
Figure 1: Gastrointestinal endoscopy image of esophagus. Staining with Lugol's iodine shows an unstained pattern occupying approximately half of the esophageal circumference at 30–34 cm from the incisor teeth

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Endoscopic submucosal dissection was performed in May 2014, and pathological analysis revealed invasion of a moderately differentiated squamous cell carcinoma beyond the muscularis mucosa, reaching the middle third of the submucosa, with vascular invasion. He was pathologically staged as pT1bN0M0 according to the 7th edition of the American Joint Committee on Cancer tumor, node, and metastasis staging system and considered to need further treatment. However, he was not a candidate for surgery because of decompensated liver cirrhosis with mild symptoms of hepatic encephalopathy, including a shortened attention span and episodes of drowsiness. His Child–Pugh score was 7 and he was categorized as having Child–Pugh class B liver cirrhosis: Grade I encephalopathy, no ascites, an elevated serum bilirubin level of 1.1 mg/dL (normal range: 0.3–1.3 mg/dL), a prolonged prothrombin time-international normalized ratio of 1.19 (normal range: 0.85–1.15), and a low serum albumin level of 3.2 g/dL (normal range: 3.9–4.9 g/dL). Concurrent chemoradiotherapy with a multidrug regimen and careful assessment of liver function were considered tolerable.

After receiving a careful explanation of the risks and benefits of treatment, the patient opted for concurrent chemoradiotherapy, comprising nedaplatin 64 mg/m2 on days 1 and 34 and S-1 80 mg/body orally on days 1–14 and 34–47, with concurrently administered radiotherapy (four-field oblique box, parallel opposed pair, 10 MV X-ray beams and 50 Gy in daily fractions of 2 Gy), as shown in [Figure 2]. Chemotherapy was administered at 80% of the recommended dose. The patient experienced acute adverse events, including grade 2 fatigue, grade 1 esophagitis, grade 1 anemia (nadir hemoglobin 11.7 g/dL), grade 2 leukopenia (nadir white blood cell count 2.4 × 109/L), and grade 3 thrombocytopenia (nadir platelet count 42 × 109/L) as assessed by Common Terminology Criteria for Adverse Events version 4.0. Follow-up investigations included a physical examination, assessment of laboratory data, gastrointestinal endoscopy, and a CT scan.
Figure 2: Treatment plan for esophageal cancer. The sky blue line indicates the planning target volume. Radiation isodose lines are shown in the upper left corner. The red area is the 95% isodose of the prescribed dose

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Gastrointestinal endoscopy after the concurrent chemoradiotherapy revealed no obvious abnormalities, except for a scar-like lesion on the right wall of the esophagus at 30–35 cm from the incisor teeth. CT showed no definite recurrent lesions and sudden progression of liver dysfunction was not observed. However, the patient's Child–Pugh score increased gradually over time and his Child–Pugh grade progressed from B to C approximately 1 year after radiotherapy, which reflects the natural progression of cirrhosis [Figure 3]. He has shown no signs of recurrence of esophageal cancer in the 30 months since receiving concurrent chemoradiotherapy.
Figure 3: Changes in serum albumin (g/dL) and total bilirubin (mg/dL) levels from initial presentation until the present time. The solid line indicates the serum albumin level and the dotted line indicates the serum total bilirubin level

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 > Discussion Top


Concurrent chemoradiotherapy is a potentially useful alternative to esophagectomy in patients with superficial esophageal carcinoma.[7] One study has reported no significant difference in the 3-year survival rate between esophagectomy (87%) and concurrent chemoradiotherapy (78%), which consisted of radiotherapy comprising at least 50 Gy with concurrent 5-fluorouracil and cisplatin-based chemotherapy in patients with clinical T1bN0M0 esophageal cancer.[8] Further, in a retrospective case–control analysis, Trivin et al. reported the case of a patient with esophageal cancer and well-compensated cirrhosis who tolerated chemoradiotherapy as well as patients who only had esophageal cancer.[1]

A combination of cisplatin and continuously infused 5-fluorouracil is regarded as the standard regimen when embarking on concurrent chemoradiotherapy in patients with esophageal cancer. However, concurrent chemotherapy consisting of nedaplatin and oral S-1 was successful in our patient. S-1 is an oral prodrug of 5-fluorouracil that can be administered in the outpatient setting, and nedaplatin produces less nausea, vomiting, and nephrotoxicity than other platinum-containing drugs.[9] Tsuda et al. reported that S-1 and nedaplatin in combination with radiotherapy are feasible and that the toxicity is tolerable in the treatment of esophageal cancer.[10]

Our patient with Child–Pugh class B cirrhosis successfully received a course of concurrent chemoradiotherapy without severe adverse events. This treatment modality might be considered as one of the treatment options for patients with superficial esophageal carcinoma and liver cirrhosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Trivin F, Boucher E, Vauléon E, Cumin I, Le Prisé E, Audrain O, et al. Management of esophageal carcinoma associated with cirrhosis: A retrospective case-control analysis. J Oncol 2009;2009:173421.  Back to cited text no. 1
    
2.
Tachibana M, Kotoh T, Kinugasa S, Dhar DK, Shibakita M, Ohno S, et al. Esophageal cancer with cirrhosis of the liver: Results of esophagectomy in 18 consecutive patients. Ann Surg Oncol 2000;7:758-63.  Back to cited text no. 2
    
3.
Dagnini G, Caldironi MW, Marin G, Buzzaccarini O, Tremolada C, Ruol A, et al. Laparoscopy in abdominal staging of esophageal carcinoma. Report of 369 cases. Gastrointest Endosc 1986;32:400-2.  Back to cited text no. 3
    
4.
Mariette C. Is there a place for esogastric cancer surgery in cirrhotic patients? Ann Surg Oncol 2008;15:680-2.  Back to cited text no. 4
    
5.
Shimakawa T, Naritaka Y, Asaka S, Isohata N, Murayama M, Konno S, et al. Surgical treatment for superficial esophageal cancer with liver cirrhosis and esophageal varices: Report of a case. Anticancer Res 2007;27:3507-11.  Back to cited text no. 5
    
6.
Bartels H, Stein HJ, Siewert JR. Preoperative risk analysis and postoperative mortality of oesophagectomy for resectable oesophageal cancer. Br J Surg 1998;85:840-4.  Back to cited text no. 6
    
7.
Yamamoto S, Ishihara R, Motoori M, Kawaguchi Y, Uedo N, Takeuchi Y, et al. Comparison between definitive chemoradiotherapy and esophagectomy in patients with clinical stage I esophageal squamous cell carcinoma. Am J Gastroenterol 2011;106:1048-54.  Back to cited text no. 7
    
8.
Motoori M, Yano M, Ishihara R, Yamamoto S, Kawaguchi Y, Tanaka K, et al. Comparison between radical esophagectomy and definitive chemoradiotherapy in patients with clinical T1bN0M0 esophageal cancer. Ann Surg Oncol 2012;19:2135-41.  Back to cited text no. 8
    
9.
Ota K. Nedaplatin. Gan To Kagaku Ryoho 1996;23:379-87.  Back to cited text no. 9
    
10.
Tsuda T, Inaba H, Miyazaki A, Izawa N, Hirakawa M, Watanabe Y, et al. Prospective study of definitive chemoradiotherapy with S-1 and nedaplatin in patients with stage II/III (non-T4) esophageal cancer. Esophagus 2011;8:45-51.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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