Curative Effect And Prognosis Of Radiotherapy In Elder Patients With Esophagus Cancer

Background Esophageal carcinoma(EC) is the eighth most common cancer and the sixth most common cause of cancer death worldwide. In China, the morbidity of EC ranks sixth and is the fourth leading cause of cancer-related mortality. Squamous cell carcinoma(SCC) is the predominant histological type of EC worldwide, which accounts for >90% of all types of EC in China. For different types of EC, the risk increases with age, with a mean age at diagnosis of 67 years, and the incidence of SCC peaks in the seventh decade of life. Therefore, the control of EC is an urgent issue, especially in elderly patients. Esophagectomy remains the primary treatment for early stage EC, and a multimodal treatment with an neoadjuvant chemotherapy or a combined chemoradiotherapy followed by surgery or definitive chemoradiotherapy is recommended for locally advanced cancers. However, with lower performance status and more complications EC patients aged >70 years old are under-represented in most randomized trials and there are lack of evidence-based strategies for the elderly population with EC. Therefore, the current retrospective study was designed to evaluate the safety and efficacy of combined chemoradiotherapy or radiotherapy alone in elderly patients with EC to identify the best method of treatment. Most cancer is a deadly diseases, pose a serious threat to human survival, has become the first mortality in our country.The etiology of cancer is complex, clinical manifestations and changeful.Tumor tissue can take normal tissue protein breakdownproducts, synthesis of protein, needed for tumor itself lead to the consumption of the body in a serious state of cachexia, tumor cells have also taken place in the amino acid metabolism disorder. There is still lack of effective treatment for cancer, the early diagnosis of cancer to improve cancer overall therapeutic effect and survival is of great importance.Because cancer is polygene, being under the action of multiple factors, such as complex diseases.We need study from genome, transcriptome and proteomics research to fully understand the molecular mechanism. Metabonomics is a new discipline, which was developed from genome, transcriptome and proteomics. Metabonomics has unique advantages in describing the metabolic situation of medium and revealing small molecule metabolites tumor metabolic changes. Scientists have done a lot of research on early diagnosis, prognosis, monitoring and individualized treatment, etc. of many cancers.such as through relevant characteristic of small molecules in serum and urine in patients with metabolic marker for esophageal cancer, breast cancer, pancreatic cancer, prostate cancer, kidney cancer. At present, nuclear magnetic resonance(NMR) spectroscopy and mass spectrometry(MS) are the most commonly used two kinds of metabonomics analysis technology.Surface enhanced Raman spectroscopy(SERS) is developed in recent years,It can be used in detecting tumor markers or metabolites.Because of high sensitivity, high accuracy,easily with the various chromatographic qualitative and quantitative combination, identification ability, etc, it will become one of the important means of metabolomics research. This study can be divided into four parts.Firstly, we study from clinical point of view to reveal the clinical characteristics, efficacy and survival analysis of combined chemoradiotherapy or radiotherapy alone in elderly patients with esophageal carcinoma.Secordly, we conducted a retrospective analysis to assess the curative effects and side effects of involved field irradiation(IFI) and elective nodal irradiation(ENI) in elderly patients with esophageal squamous cell cancer(ESCC) and to evaluate the prognoses to identify the best method of treatment.Thirdly,we disscuss the surface enhanced raman spectra from perspective of laboratory which can be used to detecting tumor metabonomics amino acid high sensitively. And hope to provide new method and train of thought to early diagnosis and treatment of tumor like the digestive tract tumors and other system tumors in the future.At last, Based on the study of the thirdexperiment,we study the detection and analysis of prognosis of using dynamic substrate surface enhanced Raman spectra method for elder esophageal carcinoma patients after radiotherapy.PartⅠ The Characteristics and Curative Effect of Radiation Therapy of Elder Patients with Esophagus CancerPurposes To study the clinical characteristics and safety and efficacy of combined chemoradiotherapy or radiotherapy alone in elderly patients with esophageal carcinoma and to evaluate the prognoses to identify the best method of treatment.Methods A total of 285 patients with inoperable thoracic esophageal carcinoma between 2008 and 2014 were enrolled. The patients were divided into two groups: an elderly group(age ≥70 years) with 143(50.2%) patients and a non-elderly group(age <70years) with 142(49.8%) patients. The tumor position and stage, lymph node and distant metastases, and incidence and severity of treatment-related toxic recitation between elderly and non-elderly patients were compared. 150(52.6%) patients received radiochemotherapy for ESCC in curative intention and 49(17%) in all were old group patients. The median follow-up time was 30 months(range 5–68 months). There were 204(71.6%) male and 81(28.4%) female with a median age of 70 years(range 38-92 years). Selection criteria for radio(chemo)therapy were unfit for surgery and/or unresectable primary tumor or patients’ choice. The majority of the patients received a combination of cisplatin and 5-fluorouracil chemotherapy with radiotherapy. Median Survival Time(MST),Overall survival(OS), Progress Free Survival(PFS) and treatment-related toxicities were assessed.Results The median OS of the overall population was 22 months and PFS was 14 months. In elder group, The median OS and PFS was 18 months and 14 months respectively.For patients treated with CRT and radiotherapy alone, the median OS was 32 months, and 17 months respectively(P=0.000). Median OS for elder group patients treated with radiotherapy dose ≥60Gy and <60Gy was 23 months and 14 months respectively(P=0.001). By univariate analysis, age,clinical stage, chemoradiotherapy and radiotherapy dose ≥60Gy,recent effect were found to achieve higher survival rates. By multivariate analysis, chemoradiotherapy, radiotherapy dose ≥60Gy, have no compications and did not smoking were identified as independent prognostic factors of OS. 131patients(46%) suffered an in-field recurrence.102 patients(35%) undergone distant metastasis.42 patients(14%) experienced both of them.The most common acute toxicith such as radiation pneumonitis and esophagitis were under grade 2.There was no grade 4 toxicity observed during the study.Conclusions 1. The curative effect of radiotherapy was better to inoperable esophageal carcinoma patients aged 70 and older.The adverse event could be tolerated.Non-surgical clinical stage could guide prognosis betterly.Patients with stage I and II had a better prognosis over stage III patients. 2. As to elderly patients, compare to normal radiotherapy, accurate radiotherapy had no difference in PFS,but had advantages on OS. 3. As to elder group,CRT group had superiority in PFS and OS as compared to radiotherapy alone.But chemotherapy was not independent prognostic factor. 4. As to PFS and OS in elder group,Radiotherapy dose ≥60Gy group was better than <60Gy group. Accurate radiation had no different efficacy with usual radiotherapy in elder group,but had a better OS. 5. The location and length of had no significant correlation with survival.Clinical stage,radiotherapy dose, Presence of complications, the recent curative effect, smoke or not were the independent factors for survival, suggested that the elderpatients actively treatment of complications, advocated to stop smoking.PartⅡ Comparative study of Involved Field Irradiation(IFI) and Elective Nodal Irradiation(ENI) in Radiotherapy for the elderly patients with esophageal squamous cell cancerPurposes We conducted a retrospective analysis to assess the efficacy and side effects of involved field irradiation(IFI) and elective nodal irradiation(ENI) in elderly patients with esophageal squamous cell cancer(ESCC).Therefor,we wanted to provide a reference for elder patients choosing appropriate irradiation method.Methods We performed a retrospective review of the records of elderly patients(>70 years) with unresectable ESCC or no willing to accept surgery who received treatment with radiotherapy between January 2010 and June 2015.Male were 90,female were 36. The median follow-up time of 20 months.According to the irradiation volume, patients were allocated into either the elective nodal irradiation(ENI) group or the IFI group. Overall survival(OS), progression-free survival(PFS) and treatment-related toxicities were compared between the two groups.Results A total of 126 patients were enrolled.For the entire group, the median OS and PFS were 20 months and 12 months, respectively.The 1-, 2-, and 3-year OS rates for the entire population were 62.8%, 29.1%, and 21.2%, respectively. For the 79 patients in the IFI group, the 1-, 2-, and 3-year OS rates were,68.7%,39.2%,16.9%,respectively; for the 47 patients in the ENI group, 82%,64.1%, 40.7%, respectively. The MSTs of thepatients in the IFI and ENI groups were15 months and 20 months, respectively,(p = 0.141). Leukopenia, esophagitis and pneumonia were the major toxicities. No significant difference was found between ENI patients and IFI patients who experienced grade >3 treatment-related hematologic toxicities. The rate of grade ≥ 2 acute RE in the ENI group(33/47, 70.2%) was significantly higher than that in the IFI group(38/79, 48.7%), with a p value of 0.035. The incidence of grade1-2 acute irradiation pneumonitis(RP) was 63.8% in the ENI group(30/47) and 74.7% in the IFI group(59/79), The incidence of grade ≥3 acute irradiation pneumonitis(RP) was 14.9% in the ENI group(6/47) and 7.6% in the IFI group(6/47),but the difference was not significant(p = 0.356). However, 1 patient in the ENI group died from RP.Conclusions IFI resulted in decreased irradiation toxicities without sacrificing OS in elderly patients with ESCC.IFI was a appropriate treatment option for elderly patients.Part III A preliminary study of detecting amino acids high sensitively by the dynamic substrate surface enhanced Raman spectra methodPurposes The Raman scattering cross section of amino acids which are the important parts of protein is low, and normal Raman method is difficult to the detect them, so a simple method is needed to trace detection of the several amino acids by preparing the ultra sensitive dynamic surface enhanced Raman spectroscopy substrate, furthermore, the monitoring of the metabolism of amino acid in serum of cancer patients can be realized in simply, rapidly and highly sensitively, and it can provide new ideas and methods for the early diagnosis, treatment status monitoring and prognostic analysis to the tumors including esophageal carcinoma in the future.Methods This paper presented a novel and simple preparation method of 3D dynamic hotspots substrate to realize detection of amino acid by surface enhanced Raman spectroscopy. An Ag sol droplet connecting the sample to be detected has been dropped to a piece of super hydrophobic transparent glass plate,then the glass upside down, making the Ag sol droplet suspended in the glass at the bottom, the suspension of Ag sol drops as the substrate of surface enhanced Raman spectra, when the laser irradiated to the liquid droplet, under the interaction within the liquid adhesive, solvent evaporation and super hydrophobic effect, the nano-particles in the droplet were concentrated, 3D space was formatted with the distance of the nano-particles changing constantly is inside the droplet, the 3D space can be used as the surface enhanced Raman spectroscopy substrate for the trace detection of the amino acids.Results The 3D dynamic substrate prepared in the experiment has good stability and repeatability, so the trace analyte can be detected highly sensitively by surface enhanced Raman spectroscopy method using the 3D dynamic substrate, and the different amino acid can be detected simultaneously. For the Rhodamine 6G, which commonly used as the label molecular of surface enhanced Raman spectroscopy, the detection limit can be low to 0.01 fmol, moreover, the detection limit to the amino acids can be low to 0.5pmol, which is very difficultly detected by the conventional Raman method because of their lower Raman cross section, the detection to a variety of amino acids has been realized rapidly and sensitively, such as: tyrosine, cysteine, arginine, valine acid and phenyl alanine.Conclusions A new and effective method for the rapid and simultaneous detection of several trace amino acids by surface enhanced Raman spectroscopy. Based on the liquid adhesive and super hydrophobic condensation effect, an Ag nano-particle dynamic surface enhanced Raman substrate with 3D hotspot prepared by hanging droplet method,the detection for Rhodamine 6G which as the commonly used as surface enhanced Raman spectroscopy label molecule has been realized, moreover, the trace detection for amino acids which as the important part of protein with lower Raman cross section has also been realized.Part IV The detection and analysis of prognosis of using dynamic substrate surface enhanced Raman spectra method for elder esophageal carcinoma patients after radiotherapyPurposes On the basis of the using of 3D dynamic surface enhanced Raman scattering substrate to achieve the rapid detection of a variety of trace amino acids, the 3D dynamic Ag sols SERS substrate has been used to detect the serum of the esophageal carcinoma patients who after radiotherapy sensitively. Firstly, the difference of the serum SERS spectrums among the esophageal carcinoma patients with recurrence or metastasis after radiotherapy, the esophageal carcinoma patients who has good restoration after radiotherapy and the normal people will be analyzed comparatively, and the SERS experiments results of the serum of these three groups human will be analyzed with statistical methods, then the analysis and evaluation of the effect of radiotherapy for esophageal carcinoma is realized, which could be used to explore a new rapid, non-destructive and high sensitive evaluation method for the prognosis assessment of the radiotherapy effect of the esophageal carcinoma patients.Methods The serum samples of the 23 cases of the esophageal carcinoma patients with recurrence or metastasis after radiotherapy, and 20 cases of normal and 17 cases of the esophageal carcinoma patients who has good restoration after radiotherapy were used as the research object, and the mixture of Ag sol and serum used as the 3D dynamic SERSsubstrate, the high sensitive detection of the serum of these three groups of human is achieved by surface enhanced Raman method.Then, the origin of characteristic peaks in the surface enhanced Raman spectrum of the serum are analyzed, the three groups of human serum SERS spectra are statistical analyzed by principal component analysis(PCA) using the SPSS software, consequently, the fast and non-destructive analysis and evaluation on the effect and prognosis of radiotherapy for esophageal carcinoma has been realized.Results After the comparative analysis of the average curves of the three groups of serum SERS spectrum, it is found that in spite of the average curves of them has some similar parts, there are still some differences in these curves. The results of the spectrum analysis shows that compared with the normal and the esophageal carcinoma patients who has good restoration after radiotherapy, the protein main chain structure in serum of the esophageal carcinoma patients with recurrence or metastasis after radiotherapy has been destroyed, so the ordered conformation reduced, and the disordered conformation increased, moreover, the polypeptide chain space structure changed. However, the protein main chain structure and the polypeptide chain space structure in the serum of the esophageal carcinoma patients who has good restoration after radiotherapy close to normal people.The content of the tyrosine and phenylalanine in the serum of the esophageal carcinoma patients with recurrence or metastasis after radiotherapy are lower than that in the serum of the esophageal carcinoma patients who has good restoration after radiotherapy and normal people, while the content of tryptophan is higher than that in the serum of the esophageal carcinoma patients who has good restoration after radiotherapy and normal people, and the content of the aspartic acid in the serum of the three group people is nearly. Moreover, the contents of the tyrosine, phenylalanine and tryptophan in the serum of the esophageal carcinoma patients with good restoration after radiotherapy are between the normal people and the esophageal carcinoma patients with recurrence or metastasis after radiotherapy.The content of lipid and sugar environment in the serum of the esophageal carcinoma patients with recurrence or metastasis after radiotherapy are different to the normalpeople, while the content of lipid and sugar environment in the serum of the esophageal carcinoma patients who has good restoration after radiotherapy are between of them, and closed to the normal people. The statistical results of the serum SERS spectra of these three groups of human analyzed by using principal component analysis method show: the statistical method can distinguish the esophageal carcinoma patients with recurrence or metastasis after radiotherapy from the normal people and the esophageal carcinoma patients who has good restoration after radiotherapy accurately and effectively, the test sensitivity was 95.7%, the specificity was 91.9%, and the total test correct rate was 93.3%.Conclusions The partial compositions in the serum of the esophageal carcinoma patients with recurrence or metastasis after radiotherapy are obviously different to that of normal people and the esophageal carcinoma patients with good restoration after radiotherapy, such as protein, amino acids, lipids and sugar, while these in the serum of the esophageal carcinoma patients with good restoration after radiotherapy are closed to normal. The principal component analysis method can distinguish the esophageal carcinoma patients with recurrence or metastasis after radiotherapy from the normal people and the esophageal carcinoma patients with good restoration after radiotherapy accurately and effectively, the statistical analysis method has the high accuracy and good detecting effect. Therefore, the serum of the esophageal carcinoma patients has been detected and investigated by surface enhanced Raman method based on the three-dimensional dynamic substrate, and then the surface enhanced Raman spectroscopy data of the serum were analyzed using the principal component analysis method, which is expected to become a new, rapid, non-destructive and high sensitive analysis method for evaluating the effect of the radiotherapy for esophageal carcinoma.