| Objective: We analyzed the survival rates of189patients withesophageal carcinoma according to the changes in maximal esophageal wallthickness and in volume of metastatic lymph node estimated by CTexamination after radiotherapy, and compared the results with those obtainedby barium meal examination, thereby creating a new standard using bariummeal examination combined with CT for evaluating the radiotherapeuticeffect.Methods: Between January2004and December2010,189patients withesophageal carcinoma were retrospectively reviewed. All patients wererequired to be localized by CT simulator and the target area was delineatedunder a unified standard before three-dimensional conformal radiation therapy(3D-CRT). Prescription dose was54~69Gy,1.8~2.0Gy per fraction,5fractions per week. All patients subjected to a barium meal examination and aCT examination before radiotherapy, and were reexamined within3monthsafter radiotherapy. CT images were transmitted to the treatment planningsystem (Pinnacle7.6c/8.0m) by the local area network. Survival rates of thepatients were analyzed according to the changes in maximal esophageal wallthickness and in volume of metastatic lymph node estimated by CTexamination after radiotherapy, and compared the results with those obtainedby barium meal examination. SPSS16.0software package was applied forstatistical analysis.Results:(1)The overall1,3and5-year survival rates of the patientsafter radiotherapy were70.3%,39.4%and32.2%respectively.(2)Themaximal esophageal wall thickness was ranged from0.72cm to2.71cm(median value1.26cm) estimated by CT examination after radiotherapy. Single factor analysis by Cox regression showed that the maximal esophagealwall thickness after radiotherapy was the prognostic factor for esophagealcarcinoma patients (Wald=28.528, P=0.000).(3)With an increase intervalspace of0.10cm, survival rates were analyzed beginning from the group ofpatients with the maximal esophageal wall thickness≤0.90cm compared withthe group of patients with the maximal esophageal wall thickness ranged from0.91to1.00cm. The results showed that there was a statistically significantdifference between the group of patients with the maximal esophageal wallthickness≤1.20cm and the group with the maximal esophageal wall thicknessranged from1.21to1.30cm (χ~2=4.195, P=0.041), which suggested that1.20cm might be the suitable value. A similar result could be found whensurvival rates were analyzed with a decrease interval space of0.10cm. Theresults showed that there was a statistically significant difference between thegroup of patients with the maximal esophageal wall thickness>1.20cm andthe group with the maximal esophageal wall thickness ranged from1.11to1.20cm (χ~2=5.784, P=0.016). It also suggested that1.20cm might be thesuitable value for evaluating the radiotherapeutic effect.(4)Kappa statisticalanalysis between barium meal and CT examination in evaluating theradiotherapeutic effect showed that based on the maximal esophageal wallthickness of1.30cm, two methods had good consistency, Kappa value was0.435; secondly for1.40cm and1.20cm, Kappa value was0.376and0.369respectively.(5)Based on the maximal esophageal wall thickness of1.20cmestimated by CT examination,189patients (except the three patients evaluatedby barium meal as NR) were divided into4groups. The survival rates ofpatients evaluated by barium meal as CR with the maximal esophageal wallthickness≤1.20cm estimated by CT examination were significantly higherthan those evaluated as CR with the maximal esophageal wall thickness>1.20cm, than those evaluated as PR with the maximal esophageal wall thickness≤1.20cm and higher than those evaluated as PR with the maximal esophagealwall thickness>1.20cm (χ~2=25.479,11.179,24.034; P=0.000,0.001,0.000).And the log-rank test did not show any significant survival difference among the later three groups.(χ~2=1.175,0.127,0.487; P=0.278,0.722,0.485). The1,3and5-year survival rates of patients evaluated by barium meal as CR withthe maximal esophageal wall thickness≤1.20cm were95.1%,66.6%and59.3%respectively.(6)Among these patients, there were65cases ofesophageal carcinoma patients with lymph node metastasis,115cases withoutlymph node metastasis, and other9cases were uncertain.The volume ofresidual metastatic lymph node was in the range of0.18-52.23cm~3(medianvalue1.30cm~3) estimated by CT examination after radiotherapy. We did notfind a patient whose metastatic lymph node completely disappeared afterradiotherapy. Single factor analysis by Cox regression showed that the volumeof residual metastatic lymph node after radiotherapy was the prognostic factorfor esophageal carcinoma patients (Wald=4.126, P=0.042). Based on thevolume of residual metastatic lymph node of1.00cm~3(long-axis diameter of0.92cm, short-axis diameter of0.71cm) estimated by CT examination, thesurvival rates of the patients with the volume of residual metastatic lymphnode≤1.00cm~3were significantly higher than those with the volume ofresidual metastatic lymph node>1.00cm~3(χ~2=4.725, P=0.030). The1,3and4-year survival rates of the two groups were78.6%,51.7%and47.4%as wellas67.0%,34.8%and31.0%respectively.(7)65patients without lymph nodemetastasis were divided into CR group and PR group depending on theevaluation of radiotherapeutic effect by barium meal examination. The1,3and5-year local control rates of the CR group and PR group were77.8%,62.2%and62.2%as well as66.3%,36.2%and29.0%respectively. The localcontrol rates of CR group were significantly higher than those of PR group(χ~2=5.698, P=0.017). The1,3and5-year survival rates of the CR group andPR group were77.8%,56.4%and49.5%as well as63.0%,18.5%and14.8%respectively. The survival rates of CR group were significantly higher thanthose of PR group (χ~2=10.345, P=0.001).115patients with lymph nodemetastasis were divided into CR group and PR group depending on theevaluation of radiotherapeutic effect by barium meal examination. The1,3and4-year local control rates of the CR group and PR group were84.5%, 68.6%and68.6%as well as67.6%,48.2%and48.2%respectively. The localcontrol rates of CR group were significantly higher than those of PR group(χ~2=5.933, P=0.015). The1,3and4-year survival rates of the CR group andPR group were78.7%,45.3%and36.4%as well as62.8%,35.1%and35.1%respectively. There was no statistically significant difference of survival ratesbetween the two groups.(χ~2=1.734, P=0.188)(.8)The1,3and5-year survivalrates of the40patients evaluated by barium meal as CR with the maximalesophageal wall thickness≤1.20cm and the volume of residual metastaticlymph node≤1.00cm~3estimated by CT examination were97.5%,72.4%and61.4%respectively. The1,3and5-year survival rates of the133patientsevaluated by barium meal as PR or with the maximal esophageal wallthickness>1.20cm and those evaluated as CR with the maximal esophagealwall thickness≤1.20cm but the volume of residual metastatic lymph node>1.00cm~3estimated by CT examination were63.2%,31.4%and24.1%respectively. The log-rank test showed a significant survival differencebetween the two groups (χ~2=19.599,P=0.000).Conclusion: The maximal esophageal wall thickness after radiotherapywas the prognostic factor for esophageal carcinoma patients, suggesting that themaximal esophageal wall thickness of1.20cm might be the suitable value forevaluating the radiotherapeutic effect. As for the esophageal carcinoma patientswith lymph node metastasis, the volume of residual metastatic lymph node afterradiotherapy was the prognostic factor. The esophageal carcinoma patients withthe volume of residual metastatic lymph node≤1.00cm~3(long-axis diameter≤0.92cm, short-axis diameter≤0.71cm) afterradiotherapy had a betterprognosis. The local control and survival rates of patients without lymph nodemetastasis evaluated by barium meal as CR were significantly higher than thoseevaluated as PR. As for the esophageal carcinoma patients with lymph nodemetastasis, there was no significant survival difference between the patientsevaluated by barium meal as CR and those evaluated as PR. But the localcontrol rates of patients evaluated by barium meal as CR were significantlyhigher than those evaluated as PR. Thus simply using barium meal examination to evaluate the radiotherapeutic effect showed a certain limitation. We stronglyrecommend the standard for evaluating the early radiotherapeutic effect bybarium meal combined with CT examination as follow: patients evaluated bybarium meal as CR with the maximal esophageal wall thickness≤1.20cm andthe volume of residual metastatic lymph node≤1.00cm~3estimated by CTexamination were defined as complete response. Patients evaluated by bariummeal as PR or with the maximal esophageal wall thickness>1.20cm and thoseevaluated as CR with the maximal esophageal wall thickness≤1.20cm but thevolume of residual metastatic lymph node>1.00cm~3estimated by CTexamination were defined as partial response. Patients evaluated by bariummeal as NR, regardless of their maximal esophageal wall thickness andmetastatic lymph node, and patients with other new lymph node metastasis orwith distal metastasis detected by CT scan were defined as no response orprogress of disease. |
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