According to clinical observations,

6 hours suffice for normal tissues with the exception of spinal cord, for which a dose below 4000 cGy is recommended in hyperfractionated accelerated RT. The maximum point dose received by the spinal cord in our study was 4110 cGy, with 10 patients receiving doses above 4000 cGy. Of these 10 patients, 5 died, and the median duration of follow up in the remaining 5 patients is 15 months (9-23 months). No patients in the study had L’Hermitte’s syndrome Inhibitors,research,lifescience,medical or myelitis. No cardiac toxicity occurred in 19 of our study subjects (95%). In only one currently patient (5%), pericardial effusion developed approximately 1.5 months after the treatment. DVH examination showed that the radiation dose received by the entire cardiac volume Inhibitors,research,lifescience,medical was 308 cGy. In the study by Ishikura et al. (20), 78 patients with esophageal cancer received concomitant CRT (6000 cGy plus brachytherapy) and 8 patients (10%) had Grade III pericarditis, 3 patients (4%) had radiation pneumonia, and 4 patients (5%) had esophageal strictures. In the study by Yamada et al. (21) where concomitant CRT (5500-6600 cGy with brachytherapy) was given to 63 patients with T1 N0 esophageal cancer, late toxicities included pericardial effusion in 3 cases,

and esophageal fistula (Grade IV and V) in 2 cases. Three-dimensional conformal RT, intensity-adjusted RT and proton treatment as well as Inhibitors,research,lifescience,medical avoidance from pre-load areas are recommended to avoid from cardiac side effects. In this study, Inhibitors,research,lifescience,medical four patients died due to gastrointestinal bleeding, which was probably due to esophageal perforation resulting from tumor necrosis. An additional five patients had grade III esophageal toxicity. A higher than expected rate of esophageal toxicity observed in this study may be due to the high radiation Inhibitors,research,lifescience,medical dose used. In addition, hyperfractionated dosing may not allow appropriate tissue repairing. In one patient, PET-CT showed metabolic complete response, but the patient died at week 5 before undergoing surgery. Early thorax computerized tomography images following

chemoradiotherapy did not allow an accurate distinction between edematous and tumor tissues due to Batimastat acute side effects. We believe that if surgery can be accomplished in patients with clinical response, it may be possible to minimize deaths due to esophageal perforation. Conclusions Improved radiation dose schedules and achievement of maximum possible pCR rates may improve survival and organ protection in patients with esophageal cancer. In these patients, HART may help to target local disease control and increased survival. However, several factors including the performance status, treatment compliance, and tumor dimensions also play an important role in patient selection. Further studies to improve neoadjuvant and radical chemoradiotherapy dose schedules are warranted for maximum local control rates with minimal toxicity. In particular, high esophageal toxicity should be addressed.