Radiochemotherapy With and Without Dose Escalation in Patients Presenting Locally Advanced or Inoperable Carcinoma of the Oesophagus (CONCORDE)

Prodige 26: Radiochemotherapy With and Without Dose Escalation in Patients Presenting Locally Advanced or Inoperable Carcinoma of the Oesophagus

Exclusive concomitant radiochemotherapy (RCT) at a dose of 50 Gy delivered over 5 weeks, according to the RTOG 85-01 protocol, has led to improved 5-year survival in 25% of patients, whereas no patients survived for 5 years using radiotherapy alone for patients with esophageal cancer. Surgery, even when combined with preoperative RCT, also gives disappointing results for locally advanced tumors, which casts serious doubts on the usefulness of preoperative radiotherapy. By varying the fractionation schedule, the length of treatment or the radiotherapy volumes, it has become possible to obtain levels of loco-regional relapse of around 35 to 45%. After reviewing the results for loco-regional relapse according to the dose of radiation and the recommended radiotherapy volumes, we aimed to investigate why increasing the dose of radiation has no impact in esophageal cancers. Although INT-0123 phase III trial showed no benefit of dose escalation in esophageal cancer, some issues remain unclear as most of the patients who died in the experimental arm were treated above 50Gy. Moreover, only the tumor was treated up to 64Gy while involved nodes were not considered for dose escalation in this trial. In the RTOG 85-01phase III trial, an elective nodal irradiation from subclavicular fossa up to the esophagogastric junction was performed with a 2D technique, delivering 30Gy which could be considered as not appropriate.

In this randomized phase II/III trial, we aim to test an exclusive concomitant chemoradiotherapy for patients with non resectable esophageal cancer with a dose escalation up to 66Gy on the primary tumor as well as the involved nodes using a 3D conformal technique combined with a 40 Gy elective nodal irradiation on lymph node stations (as defined by the RTOG) with a risk of microscopic involvement ≥ 20%.

Study Overview

• Status: Completed
• Conditions: Esophageal Cancer
• Intervention / Treatment: Radiation: Conformal 3D Radiotherapy with " ENI "-type prophylactic irradiation of the lymph node; Radiation: Boost; Radiation: Boost; Drug: chemotherapy: FOLFOX 4

• Study Type: Interventional
• Enrollment (Actual): 196
• Phase: Phase 2; Phase 3

Contacts and Locations

Study Locations

• France
  • Dijon, France, 21000
    • Centre Georges François Leclerc

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 75 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Age> or = 18 and < 75 ans
2. WHO Status 0, 1 and 2
3. Enteral or parenteral feeding (> or = 1500 KCal) planned before the start of treatment
4. Histologically proven carcinoma of the oesophagus
5. Histological Types: adenocarcinomas and epidermoid carcinomas
6. T3, N0-N1-N2-N3, M0 (TNM version 7)
7. T1-T2, N0-N1-N2-N3, M0 with a contra-indication for surgery (TNM version 7)
8. Absence of trachea-oesophageal fistula
9. Written informed consent
10. Woman under appropriate contraception
11. Patient able to understand and complete, with help if necessary, a quality of life questionnaire

Exclusion Criteria:

1. Evolutive heart failure or myocardial necrosis for less than 6 months
2. Myocardial infarction of more than 6 months with ischemic sequelae on myocardial scintigraphy.
3. Patient cannot absorb at least 1500kcal/j before and/or during treatment
4. Left heart failure.
5. Stage II to IV arteriopathy in the Leriche and Fontaine classification
6. Creatinine > or = 1.25x N
7. PNN < 1,5.109 /l
8. Platelets < 100. 109 /l
9. Albumin < 30g/l
10. TP < 60% without anticoagulant
11. VEMS < 1l
12. History of cancer (except baso-cellular cutaneous epithelioma or in situ epithelioma of the cervix) that has relapsed in the 5 years preceding recruitment for the trial
13. Patient already enrolled in another therapeutic trial with an experimental molecule
14. Women who are pregnant or likely to be so, or who are breastfeeding
15. People who are in custody or under guardianship
16. Impossibility to adhere to the medical follow up for the trial for geographical,social or psychiatric reasons.
17. Presence of a history of radiotherapy to the chest or upper abdomen for another tumour
18. Peripheral neuropathy > or = grade 1 (CTC v3.0)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: ARM A; Conformal 3D Radiotherapy with " ENI "-type prophylactic irradiation of the lymph nodes: Radiotherapy 40 Gy, in 20 fractions / 4 weeks: PTV (1cm in every direction); Boost 10 Gy in 5 fr: PTV = +1cm.; Chemotherapy FOLFOX 4: 6 treatments in 3 courses concomitant to the radiotherapy (D1, D15, D29)	Radiation: Conformal 3D Radiotherapy with " ENI "-type prophylactic irradiation of the lymph node; 40 Gy in 20 fractions / 5 weeks, PTV (1cm in every direction); Radiation: Boost; Boost 10 Gy in 5 fr, PTV = +1cm.; Radiation: Boost; Boost 26 Gy in 13 fr, PTV = +1cm.; Drug: chemotherapy: FOLFOX 4; 6 treatments with 4 courses concomitant to radiotherapy (D1, D15, D29, D43) arm B or 3 courses concomitant to radiotherapy (D1, D15, D29) arm A.
Experimental: ARM B; Conformal 3D Radiotherapy with " ENI "-type prophylactic irradiation of the lymph nodes: 40 Gy in 20 fractions / 4 weeks, PTV (1cm in every direction); Boost 26 Gy in 13 fr: PTV = +1cm.; Chemotherapy: FOLFOX 4: 6 treatments with 4 courses concomitant to radiotherapy (D1, D15, D29, D43).	Radiation: Conformal 3D Radiotherapy with " ENI "-type prophylactic irradiation of the lymph node; 40 Gy in 20 fractions / 5 weeks, PTV (1cm in every direction); Radiation: Boost; Boost 10 Gy in 5 fr, PTV = +1cm.; Radiation: Boost; Boost 26 Gy in 13 fr, PTV = +1cm.; Drug: chemotherapy: FOLFOX 4; 6 treatments with 4 courses concomitant to radiotherapy (D1, D15, D29, D43) arm B or 3 courses concomitant to radiotherapy (D1, D15, D29) arm A.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Evaluate the rate of acute toxicity leading to cessation or temporary interruption of treatment of more than a total of 14 days or of 7 consecutive days during the whole treatment.	end of phase II (january 2014)
Evaluate the rate of completes endoscopic response at 3 months	for each patient 3 months after the end treatment
Survival without locoregional relapse at 2 years (time elapsed between date of randomisation and onset of local relapse and/or lymph node involvement)	after the end of phase III in january 2015 (anticipated)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Evaluate adherence		every 3 months until the end of phase II (january 2014)
Evaluate acute toxicity at 3 months		for each patient 3 months after the end treatment
Evaluate death due to toxicity		each month during all the study
Evaluate quality of life (QLQ-C30 [annex n° 2] + OG25 [annex n° 3])		after the completion of phase II (january 2014)
Compare according to treatment arm :Quality of life (QLQ-C30 [annex n° 2] + OG 25 [annex n° 3])		after the completion of phase III (january 2015-anticpated)
Compare according to treatment arm :Overall survival		after the completion of phase III (january 2015-anticpated)
Compare according to treatment arm :Disease-free survival		after the completion of phase III (january 2015-anticpated)
Compare according to treatment arm :Acute and late toxicity according to the CTCAE version 3.0 scale		after the completion of phase III (january 2015-anticpated)
Compare according to treatment arm :The number of palliative interventions, the time to the first palliative intervention		after the completion of phase III (january 2015-anticpated)
Compare according to treatment arm :The rate of dysphagia according to Atkinson's criteria		after the completion of phase III (january 2015-anticipated)
Compare according to treatment arm :Survival without local recurrence in responders		after the completion of phase III (january 2015-anticipated)
Compare according to treatment arm :Progression-free survival in non-responding patients		after the completion of phase III (january 2015-anticipated)
Evaluation of the post-operative morbi-mortalities	Evaluation of the post-operative morbi-mortalities (in 30 days) of the group of patients which will benefit from of a surgery of the tumoral residue.	after the completion of phase III (january 2015-anticipated)

Collaborators and Investigators

• Sponsor: Centre Georges Francois Leclerc
• Collaborators: Federation Francophone de Cancerologie Digestive; National Cancer Institute, France; UNICANCER; SFRO:French Society of Radiation Oncology
• Investigators: Principal Investigator: Gilles Créhange, MD, Centre Georges François Leclerc

Publications and helpful links

General Publications

• Bednarek C, Crehange G, Quivrin M, Cueff A, Vulquin N, Chevalier C, Cerda T, Petegnief Y, Mazoyer F, Maingon P, Bosset JF, Servagi Vernat S. Mapping of failures after radiochemotherapy in patients with non-metastatic esophageal cancer: A posteriori analysis of the dose distribution in the sites of loco-regional relapse. Radiother Oncol. 2015 Aug;116(2):252-6. doi: 10.1016/j.radonc.2015.07.019. Epub 2015 Jul 27.

Study record dates

Study Major Dates

• Study Start (Actual): May 6, 2011
• Primary Completion (Actual): June 7, 2011
• Study Completion (Actual): December 17, 2018

Study Registration Dates

• First Submitted: April 29, 2011
• First Submitted That Met QC Criteria: May 4, 2011
• First Posted (Estimate): May 5, 2011

Study Record Updates

• Last Update Posted (Actual): January 27, 2020
• Last Update Submitted That Met QC Criteria: January 24, 2020
• Last Verified: January 1, 2020

More Information

Terms related to this study

• Keywords: radiochemotherapy; unoperated cancers; oesophagus; with and without increased doses
• Additional Relevant MeSH Terms: Digestive System Diseases; Neoplasms; Neoplasms by Site; Gastrointestinal Neoplasms; Digestive System Neoplasms; Gastrointestinal Diseases; Head and Neck Neoplasms; Esophageal Diseases; Esophageal Neoplasms
• Other Study ID Numbers: 0291-1crgi09