title: Patterns of failure after radical surgery among patients with thoracic esophageal squamous cell carcinoma: implications for the clinical target volume design of postoperative radiotherapy.
abstract: BACKGROUND
  This study evaluated patterns of treatment failure (especially locoregional failure; LRF) after radical esophagectomy and proposes a clinical target volume (CTV) for postoperative radiotherapy (PORT) among patients with thoracic esophageal squamous cell carcinoma (SCC).
  
  
  METHODS
  All patients who were followed up in our center after radical esophagectomy between 2007 and 2011 were retrospectively enrolled. The patterns of first discovered failure were assessed, and LRFs (including anastomotic and regional lymph node recurrences) were evaluated to determine whether our proposed PORT CTV encompassed these areas. The clinicopathologic factors predictive of lymphatic recurrence type were analyzed.
  
  
  RESULTS
  Of the 414 patients who underwent surgery and were followed up over the study, 207 experienced recurrent or metastatic diseases. The median time to progression was 11.0 months. Of the 173 patients with locoregional recurrence, nodal failure recurred in 160; supraclavicular and superior mediastinal lymph nodes had the highest metastasis rates. All 233 recurrent sites across the 160 patients were located in a standard CTV area, including the bilateral supraclavicular areas, the entire mediastinum, and the left gastric lymphatic drainage region. A total of 203 sites (87.2%) were located in either the bilateral supraclavicular areas or the entire mediastinum, and 185 sites (79.4%) were located in either the bilateral supraclavicular areas or the upper mediastinum. A multivariate analysis revealed the lymph node metastatic ratio (LNMR) and tumor differentiation were risk factors for nodal failure.
  
  
  CONCLUSIONS
  Locoregional recurrence (especially lymph node recurrence) was the most common and potentially preventable type of initial treatment failure after curative surgery among patients with thoracic esophageal SCC. The proposed PORT CTV covered most LRF sites. The lymphatic drainage regions for PORT are selective, and the supraclavicular and superior mediastinal areas should be considered. However, the value of PORT and the extent of CTV should be investigated in further prospective studies.
authors.affiliation: Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China.
authors.forename: Qi
authors.initials: Q
authors.lastname: Liu
authors.affiliation: Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China.
authors.forename: Xu-Wei
authors.initials: XW
authors.lastname: Cai
authors.affiliation: Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China; Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China.
authors.forename: Bin
authors.initials: B
authors.lastname: Wu
authors.affiliation: Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China.
authors.forename: Zheng-Fei
authors.initials: ZF
authors.lastname: Zhu
authors.affiliation: Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China; Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai, P.R. China.
authors.forename: Hai-Quan
authors.initials: HQ
authors.lastname: Chen
authors.affiliation: Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, P.R. China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, P.R. China.
authors.forename: Xiao-Long
authors.initials: XL
authors.lastname: Fu
mesh_terms: D000328:Adult; D000368:Aged; D002294:Carcinoma, Squamous Cell / Q000000981:diagnostic imaging / Q000532:radiotherapy* / Q000601:surgery*; D004938:Esophageal Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy* / Q000601:surgery*; D000077277:Esophageal Squamous Cell Carcinoma; D016629:Esophagectomy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011184:Postoperative Period; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D014057:Tomography, X-Ray Computed; D017211:Treatment Failure