Patterns of Radiotherapy Practice, Dosimetric Exposure, and Treatment Outcomes in Esophageal Cancer:A Retrospective Cohort Study from a Tertiary Care Center

Patterns of Radiotherapy Practice, Dosimetric Exposure, and Treatment Outcomes in Esophageal Cancer:A Retrospective Cohort Study from a Tertiary Care Center | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Patterns of Radiotherapy Practice, Dosimetric Exposure, and Treatment Outcomes in Esophageal Cancer:A Retrospective Cohort Study from a Tertiary Care Center Rahul Modi, Samiran Chavan, Puneet Pareek, Bharti Devnani, Akanksha Solanki, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8689515/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Esophageal cancer frequently presents at an advanced stage in low- and middle-income countries, where radiotherapy plays a central role across curative and palliative settings. While survival outcomes are commonly reported, fewer studies describe real-world radiotherapy practice patterns and organ-at-risk dosimetric exposure. Objectives The primary objective was to evaluate patterns of radiotherapy practice and cardiopulmonary dosimetric exposure in patients with esophageal cancer treated at a tertiary care center. Secondary objectives included treatment completion, multimodality integration, and overall survival. Methods This retrospective cohort study included patients with biopsy-proven esophageal cancer treated with radiotherapy between 2018 and 2021. Demographic, tumor-related, treatment, and dosimetric parameters were extracted from institutional records. Overall survival was analyzed using the Kaplan–Meier method. Results Seventy-nine patients received radiotherapy. Squamous cell carcinoma was the predominant histology, and most patients presented with locally advanced disease. Radiotherapy was delivered across neoadjuvant, definitive, adjuvant, and palliative intents using 2D, 3DCRT, and VMAT techniques. Treatment completion was achieved in 88.6% of patients. Mean heart and lung doses were generally within accepted tolerance ranges. Survival analysis was feasible in 61 patients. The median overall survival was 18 months (95% CI: 12.5–23.4). TNM stage grouping and surgical intervention were significantly associated with overall survival. Among surgically treated thoracic esophageal cancers, neoadjuvant radiotherapy was associated with improved overall survival compared to adjuvant radiotherapy. Conclusion In routine clinical practice, radiotherapy for esophageal cancer can be delivered across diverse clinical intents with acceptable cardiopulmonary dosimetric exposure and high treatment completion rates. Overall survival is largely influenced by disease stage and the feasibility of multimodality treatment. Observed survival differences according to treatment sequencing should be interpreted as reflective of patient selection and disease characteristics rather than definitive treatment effects. Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Esophageal cancer remains a major cause of cancer-related mortality worldwide, particularly in low- and middle-income countries. In India, delayed diagnosis is common due to socioeconomic factors, limited access to early diagnostic services, nutritional deficiencies, and aggressive tumor biology. As a result, a large proportion of patients present with locally advanced or metastatic disease, limiting the feasibility of upfront surgical resection( 1 , 2 ). Radiotherapy plays a central role in the management of esophageal cancer across the disease spectrum. It is used as part of neoadjuvant multimodality therapy, as definitive treatment in inoperable disease, in the adjuvant setting following surgery in selected cases, and for palliation of dysphagia and pain. While randomized trials have established treatment standards for selected patient populations, these trials often exclude patients with poor performance status, advanced disease burden, or socioeconomic constraints, limiting their generalizability to real-world practice( 3 – 6 ). In routine clinical settings, radiotherapy delivery is influenced by multiple factors, including patient fitness, tumor extent, treatment intent, institutional resources, and access to advanced techniques. Additionally, thoracic radiotherapy inevitably exposes the heart and lungs to radiation. Although cardiopulmonary dose exposure has been implicated in treatment-related morbidity and survival in some studies, evidence remains inconsistent, particularly outside controlled trial settings( 7 – 9 ). There is limited literature describing real-world radiotherapy practice patterns, dosimetric exposure, and feasibility of multimodality treatment for esophageal cancer in tertiary care centers from resource-constrained regions. This study was therefore undertaken to systematically evaluate radiotherapy practice patterns, organ-at-risk dosimetry, treatment completion, and survival outcomes in patients with esophageal cancer treated at a tertiary care center, with the aim of providing pragmatic insight into routine care delivery. MATERIALS AND METHODS Study Design and Ethics This retrospective observational study was conducted in the Department of Radiation Oncology, AIIMS Jodhpur, following approval from the Institutional Ethics Committee. The study was conducted in accordance with the Declaration of Helsinki. Informed consent was waived due to the retrospective nature of the analysis. Patient Selection Patients with biopsy-proven esophageal cancer who received radiotherapy between January 2018 and December 2021 were included. Patients with hypopharyngeal malignancies, Siewert type III gastroesophageal junction tumors, gastric cancers, or incomplete treatment records were excluded. Data Collection Demographic characteristics, ECOG performance status, tumor location, histology, AJCC 8th edition staging, radiotherapy intent, technique, dose–fractionation, chemotherapy details, surgical intervention, pathological response, and treatment completion were extracted from institutional records. Radiotherapy Planning and Delivery Patients were simulated in the supine position with appropriate immobilization. Radiotherapy was delivered using two-dimensional radiotherapy (2D), three-dimensional conformal radiotherapy (3DCRT), or volumetric modulated arc therapy (VMAT). Prescribed doses ranged from palliative regimens (30 Gy) to definitive doses up to 66 Gy. Mean doses to the heart and lungs were recorded where available. Survival Analysis Overall survival (OS) was defined as the interval from initiation of radiotherapy to death from any cause or last follow-up. Survival was estimated using the Kaplan–Meier method and compared using the log-rank test. Multivariate analysis was not performed due to limited subgroup sizes and incomplete survival data. RESULTS Patient Demographics and Baseline Clinical Characteristics A total of 79 patients were treated during the study period. Baseline demographic and clinical characteristics are summarized in Table 1 . The median age was 59 years (range, 27–88), with a slight female predominance. Most patients were from rural backgrounds and presented with ECOG performance status 0–2. Table 1 Baseline demographic and clinical characteristics (n = 79) Variable n (%) Median age (range) 59 years (27–88) Male 36 (45.6) Female 43 (54.4) Rural 53 (67.1) Urban 26 (32.9) ECOG 0–1 34 (43.0) ECOG 2 29 (36.7) ECOG ≥ 3 6 (7.6) Data not available 10 (12.7) Tumor Characteristics and Stage at Presentation Tumor characteristics, including histology, anatomical location, and AJCC stage distribution, are detailed in Table 2 . Squamous cell carcinoma was the predominant histological subtype. The middle thoracic esophagus was the most common tumor location. A substantial proportion of patients presented with stage III or metastatic disease. Table 2 Tumor characteristics and AJCC stage distribution Parameter n (%) Squamous cell carcinoma 74 (93.7) Adenocarcinoma 3 (3.8) Not available 2 (2.5) Cervical esophagus 15 (20.0) Upper thoracic 8 (10.7) Middle thoracic 30 (40.0) Lower thoracic 22 (29.3) Stage I 1 (2.2) Stage II 13 (28.9) Stage III 11 (24.4) Stage IVA 17 (37.8) Stage IVB 3 (6.7) Radiotherapy Practice Patterns Radiotherapy intent, technique selection, and dose prescription are summarized in Table 3 . Neoadjuvant and definitive radiotherapy accounted for the majority of curative-intent treatments. VMAT was the most frequently employed technique, reflecting increasing adoption of advanced conformal radiotherapy. Table 3 Radiotherapy intent, technique, and dose Parameter Value Radiotherapy intent Neoadjuvant chemoradiotherapy 28 (35.4%) Definitive chemoradiotherapy 24 (30.4%) Adjuvant radiotherapy 8 (10.1%) Palliative radiotherapy 17 (21.5%) Radiotherapy technique VMAT 51 (64.6%) 3DCRT 12 (15.2%) 2D radiotherapy 16 (20.3%) Mean prescribed dose (Gy) Neoadjuvant 41.4 Definitive 55.3 ± 7.27 Adjuvant 47.0 ± 2.79 Palliative 27.4 ± 5.04 Dosimetric Exposure to Organs at Risk Mean cardiac and pulmonary dose exposure is presented in Table 4 . Overall, cardiopulmonary doses were within accepted tolerance ranges for thoracic radiotherapy across treatment intents. Table 4 Mean cardiac and pulmonary dose exposure Organ at risk Mean ± SD (Gy) Median (Gy) Range (Gy) Heart (n = 41) 20.8 ± 9.49 23.9 1.2–35.3 Right lung (n = 44) 11.3 ± 4.46 12.1 1.0–21.6 Left lung (n = 44) 12.2 ± 3.82 13.1 1.3–17.9 Treatment Completion and Multimodality Integration Treatment completion and multimodality integration are summarized in Table 5 . Radiotherapy was completed as planned in 88.6% of patients. Concurrent chemotherapy and surgical resection were feasible in selected patients with adequate performance status. Table 5 Treatment completion and multimodality therapy Parameter n (%) Radiotherapy completion Completed as planned 70 (88.6) Incomplete 9 (11.4) Concurrent chemotherapy Received 44 (57.2) Not received 35 (42.8) Surgical intervention * Surgery performed 27 (47.4) No surgery 30 (52.6) Pathological complete response (pCR) Achieved 5 (18.5% of surgical patients) Not achieved 22 (81.5%) Overall Survival Survival analysis was feasible in 61 patients. Prognostic factors associated with OS are summarized in Table 6. TNM stage grouping and the presence of distant metastasis were associated with inferior survival, while surgical intervention in thoracic esophageal cancer was associated with improved OS. Variable Effect on overall survival Log-rank p value cT stage No significant association NS cN stage No significant association NS Presence of distant metastasis Worse OS 0.034 TNM stage grouping Significant difference 0.049 Surgical intervention (thoracic tumors) Improved OS <0.001 The median OS for the entire cohort was 18 months (95% CI: 12.5–23.4). Kaplan–Meier survival curves are shown in: Impact of Timing of Radiotherapy on Overall Survival For this analysis, patients with cervical esophageal tumors were excluded. Only patients with thoracic esophageal cancer who underwent surgical resection as the definitive treatment were included. Kaplan–Meier analysis demonstrated that neoadjuvant radiotherapy was associated with improved overall survival compared to adjuvant radiotherapy administered postoperatively (log-rank p = 0.011). In patients receiving neoadjuvant chemoradiotherapy, the median OS was not reached, with a mean OS of approximately 50 months. Patients treated with adjuvant radiotherapy exhibited comparatively inferior survival outcomes. These findings should be interpreted cautiously, as they likely reflect differences in baseline disease characteristics, treatment selection, and patient fitness rather than a direct causal effect of radiotherapy timing. DISCUSSION This retrospective cohort study provides a comprehensive overview of real-world radiotherapy practice for esophageal cancer in a tertiary care setting. The findings highlight the heterogeneity of clinical presentation, treatment intent, and radiotherapy delivery in routine practice, particularly in a resource-constrained environment. The predominance of squamous cell carcinoma and advanced-stage disease at presentation in this cohort is consistent with epidemiological patterns reported from India and other Asian countries( 1 , 2 ). These factors significantly influence treatment selection, often necessitating non-surgical or multimodality approaches. The high proportion of patients treated with neoadjuvant or definitive radiotherapy reflects both disease extent and limitations in upfront surgical feasibility. A key observation of this study is the high rate of radiotherapy treatment completion despite advanced disease and variable performance status. This finding underscores the feasibility of delivering thoracic radiotherapy across diverse clinical intents when individualized planning and supportive care are employed. The widespread use of VMAT in this cohort suggests a transition toward advanced conformal techniques, even in routine clinical practice( 10 ). Cardiopulmonary dosimetric exposure remained within accepted tolerance limits for most patients( 8 , 11 ). Although increasing evidence suggests a potential relationship between cardiac dose and survival in esophageal cancer, particularly in trial settings, such associations remain inconsistent in real-world populations. In the present study, dosimetric parameters were reported descriptively without attempting to establish dose–response relationships, thereby avoiding overinterpretation( 9 ). Overall survival outcomes in this cohort followed expected stage-dependent patterns. The association between surgical intervention and improved survival in thoracic esophageal cancer likely reflects patient selection, tumor biology, and response to multimodality therapy rather than a direct treatment effect. Similarly, the observed association between neoadjuvant radiotherapy and improved survival compared to adjuvant radiotherapy in surgically treated patients should be interpreted with caution. Patients selected for neoadjuvant therapy are typically fitter, have potentially resectable disease at presentation, and are managed within structured multimodality pathways( 3 – 6 , 12 – 15 ). The strengths of this study include detailed documentation of radiotherapy practice patterns, explicit reporting of dosimetric exposure, and integration of treatment completion and survival outcomes. These features provide practical insights that complement evidence derived from randomized trials. However, the retrospective design, limited sample size in subgroups, incomplete survival data, and absence of multivariate analysis constrain causal inference. LIMITATIONS This study is limited by its retrospective nature, single-institution design, incomplete survival data in a subset of patients, and lack of multivariate survival modeling. Additionally, unmeasured confounders and selection bias inherent to real-world treatment decisions cannot be excluded. CONCLUSION In routine clinical practice, radiotherapy for esophageal cancer can be delivered across neoadjuvant, definitive, adjuvant, and palliative intents with acceptable cardiopulmonary dosimetric exposure and high treatment completion rates. Survival outcomes are primarily influenced by disease stage and the feasibility of multimodality treatment, particularly surgical resection in selected patients. Observed survival differences according to treatment sequencing should be interpreted as reflective of patient selection and disease characteristics rather than definitive treatment effects. Real-world evaluation of radiotherapy practice patterns provides valuable context for understanding care delivery in tertiary care settings without overstating therapeutic impact. Declarations Authors’ Contributions R.M. conceived the study concept, designed the analysis framework, performed data interpretation, and drafted the manuscript. S.C. and P.P. contributed to treatment planning review, clinical data verification, and acquisition of radiotherapy-related data. B.D. and A.S. contributed to data curation, literature review, and manuscript revision. A.K.G. and R.P. provided study supervision, critical evaluation of methodology, and intellectual review of the manuscript. All authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work. ADDITIONAL INFORMATION Licensing and Tool Use Statement No proprietary datasets, licensed materials, or third-party tools requiring special permission were used in the preparation of this manuscript. Language editing and formatting assistance, where applicable, did not influence the study design, data collection, data analysis, interpretation of results, or scientific conclusions. The authors take full responsibility for the content of the manuscript. Ethics Approval : Institutional Ethics Committee approval obtained Clinical trial number: not applicable. Conflicts of interest: In compliance with the ICMJE uniform disclosure requirements, all authors declare the following. Payment/services information : All authors declare that no financial support was received from any organization for the submitted work. Financial relationships : All authors declare that they have no financial relationships, either currently or within the previous three years, with any organizations that could be perceived to influence the submitted work. Other relationships: All authors declare that there are no other relationships or activities that could appear to have influenced the submitted work. Funding The authors received no financial support for the research, authorship, and/or publication of this article References Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424. Arnold M, Soerjomataram I, Ferlay J, Forman D. Global incidence of oesophageal cancer by histological subtype in 2012. Gut. 2015;64(3):381–7. Bedenne L, Michel P, Bouché O, Milan C, Mariette C, Conroy T, et al. Chemoradiation followed by surgery compared with chemoradiation alone in squamous cancer of the esophagus: FFCD 9102. J Clin Oncol Off J Am Soc Clin Oncol. 2007;25(10):1160–8. Minsky BD, Pajak TF, Ginsberg RJ, Pisansky TM, Martenson J, Komaki R, et al. INT 0123 (Radiation Therapy Oncology Group 94 – 05) phase III trial of combined-modality therapy for esophageal cancer: high-dose versus standard-dose radiation therapy. J Clin Oncol Off J Am Soc Clin Oncol. 2002;20(5):1167–74. Herskovic A, Martz K, al-Sarraf M, Leichman L, Brindle J, Vaitkevicius V, et al. Combined chemotherapy and radiotherapy compared with radiotherapy alone in patients with cancer of the esophagus. N Engl J Med. 1992 June;11(24):1593–8. Cooper JS, Guo MD, Herskovic A, Macdonald JS, Martenson JA, Al-Sarraf M, et al. Chemoradiotherapy of locally advanced esophageal cancer: long-term follow-up of a prospective randomized trial (RTOG 85 – 01). Radiation Therapy Oncol Group JAMA. 1999;281(17):1623–7. Mansour MA, El-Salamoni MAF, Mostafa HN. Long-term outcomes and radiation-induced complications following stereotactic radiosurgery for a left temporal arteriovenous malformation: illustrative case. 2025 May 26 [cited 2026 Jan 20]; Available from: https://thejns.org/caselessons/view/journals/j-neurosurg-case-lessons/9/21/article-CASE25201.xml Vošmik M, Hodek M, Buka D, Sýkorová P, Grepl J, Paluska P, et al. Cardiotoxicity of radiation therapy in esophageal cancer. Rep Pract Oncol Radiother. 2020;25(3):318–22. Gagliardi G, Constine LS, Moiseenko V, Correa C, Pierce LJ, Allen AM, et al. Radiation dose-volume effects in the heart. Int J Radiat Oncol Biol Phys. 2010;76(3 Suppl):S77–85. Lin SH, Wang L, Myles B, Thall PF, Hofstetter WL, Swisher SG, et al. Propensity score-based comparison of long-term outcomes with 3-dimensional conformal radiotherapy vs intensity-modulated radiotherapy for esophageal cancer. Int J Radiat Oncol Biol Phys. 2012;84(5):1078–85. Wang X, Palaskas NL, Yusuf SW, Abe JI, Lopez-Mattei J, Banchs J, et al. Incidence and Onset of Severe Cardiac Events After Radiotherapy for Esophageal Cancer. J Thorac Oncol Off Publ Int Assoc Study Lung Cancer. 2020;15(10):1682–90. Rohatgi PR, Swisher SG, Correa AM, Wu TT, Liao Z, Komaki R, et al. Failure patterns correlate with the proportion of residual carcinoma after preoperative chemoradiotherapy for carcinoma of the esophagus. Cancer. 2005;104(7):1349–55. Preoperative Chemoradiotherapy for Esophageal or Junctional Cancer. | New England Journal of Medicine [Internet]. [cited 2026 Jan 25]. Available from: https://www.nejm.org/doi/full/ 10.1056/NEJMoa1112088 Ando N, Kato H, Igaki H, Shinoda M, Ozawa S, Shimizu H, et al. A randomized trial comparing postoperative adjuvant chemotherapy with cisplatin and 5-fluorouracil versus preoperative chemotherapy for localized advanced squamous cell carcinoma of the thoracic esophagus (JCOG9907). Ann Surg Oncol. 2012;19(1):68–74. Waters J, Sewell M, Molena D. Multimodal Treatment of Resectable Esophageal Cancer. Ann Thorac Surg. 2025;119(1):70–82. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8689515","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":579934066,"identity":"324e185c-3a93-48df-9281-6c2463fdff55","order_by":0,"name":"Rahul Modi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYFACHgaGBwwMjG38je0fEiqAAszMDYS1JIC0SBw+xvDhDEgLI5FaGhjS0hhntoFECGgxbz97TCIxx0a2j+GM2WPeebXR/O1ALT8qtuHUInMmL00icVuacRtzj7kx77bjuTMOMzYw9py5jVOLBEOOGVDL4cQ2hjMG0rzbjuU2ALUwM7bh0cL/BqYlB6hlzrHc+QS1SMBtSUuTnNlQk7uBsJY3xhZgv0gcPmzw4diB3I1ALQfx+oU/x/DGx202svP7GxsfJNTU5c47f/jggx8VuLWgg8Ng8gDR6oGgjhTFo2AUjIJRMEIAAN7QXmsEFPs2AAAAAElFTkSuQmCC","orcid":"","institution":"All India Institute of Medical Sciences Jodhpur","correspondingAuthor":true,"prefix":"","firstName":"Rahul","middleName":"","lastName":"Modi","suffix":""},{"id":579934069,"identity":"02050f7b-9717-48a9-9496-c8c536829b8b","order_by":1,"name":"Samiran Chavan","email":"","orcid":"","institution":"All India Institute of Medical Sciences Jodhpur","correspondingAuthor":false,"prefix":"","firstName":"Samiran","middleName":"","lastName":"Chavan","suffix":""},{"id":579934072,"identity":"deb8e192-b01f-4fee-800f-9b7c6b2c49d6","order_by":2,"name":"Puneet Pareek","email":"","orcid":"","institution":"All India Institute of Medical Sciences Jodhpur","correspondingAuthor":false,"prefix":"","firstName":"Puneet","middleName":"","lastName":"Pareek","suffix":""},{"id":579934073,"identity":"e04791d2-a0d4-44f0-8016-429a0ffdd25b","order_by":3,"name":"Bharti Devnani","email":"","orcid":"","institution":"All India Institute of Medical Sciences Jodhpur","correspondingAuthor":false,"prefix":"","firstName":"Bharti","middleName":"","lastName":"Devnani","suffix":""},{"id":579934074,"identity":"167d1dff-ea91-42f4-a1fc-85b290191a7f","order_by":4,"name":"Akanksha Solanki","email":"","orcid":"","institution":"All India Institute of Medical Sciences Jodhpur","correspondingAuthor":false,"prefix":"","firstName":"Akanksha","middleName":"","lastName":"Solanki","suffix":""},{"id":579934075,"identity":"543d2441-23c8-4a5b-b691-12d2a694e1f0","order_by":5,"name":"Atul kumar Gupta","email":"","orcid":"","institution":"All India Institute of Medical Sciences Jodhpur","correspondingAuthor":false,"prefix":"","firstName":"Atul","middleName":"kumar","lastName":"Gupta","suffix":""},{"id":579934078,"identity":"6f8b1506-2fdd-4519-9e89-7ea033dcf790","order_by":6,"name":"Rishi Prem","email":"","orcid":"","institution":"All India Institute of Medical Sciences Jodhpur","correspondingAuthor":false,"prefix":"","firstName":"Rishi","middleName":"","lastName":"Prem","suffix":""}],"badges":[],"createdAt":"2026-01-25 00:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8689515/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8689515/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101214214,"identity":"6e6dae43-287e-41dd-adc2-1622fac0ddb0","added_by":"auto","created_at":"2026-01-27 10:34:09","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":172682,"visible":true,"origin":"","legend":"\u003cp\u003eOverall survival of the entire cohort\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8689515/v1/d1f75980ea87704b57af4357.jpeg"},{"id":101214283,"identity":"e21551ea-0d40-4a3d-90c7-244084a3b980","added_by":"auto","created_at":"2026-01-27 10:34:25","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":249170,"visible":true,"origin":"","legend":"\u003cp\u003eOverall survival stratified by TNM stage grouping\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8689515/v1/6ceb771c40cfa220eeb33bb4.jpeg"},{"id":101214365,"identity":"f71f0581-a2a9-464a-9bb2-2f2e566322a1","added_by":"auto","created_at":"2026-01-27 10:34:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":70932,"visible":true,"origin":"","legend":"\u003cp\u003eOverall survival according to surgical intervention in thoracic esophageal cancer\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8689515/v1/8b91970089d9a7b74287bad9.png"},{"id":101214212,"identity":"3a62fda1-ce3e-4fc6-8495-0bb5742aa69f","added_by":"auto","created_at":"2026-01-27 10:34:08","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":68100,"visible":true,"origin":"","legend":"\u003cp\u003eOverall survival according to timing of radiotherapy (neoadjuvant vs adjuvant) in surgically treated thoracic esophageal cancer\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-8689515/v1/f8fdf09bceae69b8acbbf031.png"},{"id":101640540,"identity":"4f99e953-af12-40fd-8e39-3872a75c7ea3","added_by":"auto","created_at":"2026-02-02 07:27:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1334043,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8689515/v1/938a8ee8-4da6-443c-922f-5301b210a14d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Patterns of Radiotherapy Practice, Dosimetric Exposure, and Treatment Outcomes in Esophageal Cancer:A Retrospective Cohort Study from a Tertiary Care Center","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eEsophageal cancer remains a major cause of cancer-related mortality worldwide, particularly in low- and middle-income countries. In India, delayed diagnosis is common due to socioeconomic factors, limited access to early diagnostic services, nutritional deficiencies, and aggressive tumor biology. As a result, a large proportion of patients present with locally advanced or metastatic disease, limiting the feasibility of upfront surgical resection(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRadiotherapy plays a central role in the management of esophageal cancer across the disease spectrum. It is used as part of neoadjuvant multimodality therapy, as definitive treatment in inoperable disease, in the adjuvant setting following surgery in selected cases, and for palliation of dysphagia and pain. While randomized trials have established treatment standards for selected patient populations, these trials often exclude patients with poor performance status, advanced disease burden, or socioeconomic constraints, limiting their generalizability to real-world practice(\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn routine clinical settings, radiotherapy delivery is influenced by multiple factors, including patient fitness, tumor extent, treatment intent, institutional resources, and access to advanced techniques. Additionally, thoracic radiotherapy inevitably exposes the heart and lungs to radiation. Although cardiopulmonary dose exposure has been implicated in treatment-related morbidity and survival in some studies, evidence remains inconsistent, particularly outside controlled trial settings(\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere is limited literature describing real-world radiotherapy practice patterns, dosimetric exposure, and feasibility of multimodality treatment for esophageal cancer in tertiary care centers from resource-constrained regions. This study was therefore undertaken to systematically evaluate radiotherapy practice patterns, organ-at-risk dosimetry, treatment completion, and survival outcomes in patients with esophageal cancer treated at a tertiary care center, with the aim of providing pragmatic insight into routine care delivery.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Ethics\u003c/h2\u003e \u003cp\u003e This retrospective observational study was conducted in the Department of Radiation Oncology, AIIMS Jodhpur, following approval from the Institutional Ethics Committee. The study was conducted in accordance with the Declaration of Helsinki. Informed consent was waived due to the retrospective nature of the analysis.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePatient Selection\u003c/h3\u003e\n\u003cp\u003ePatients with biopsy-proven esophageal cancer who received radiotherapy between January 2018 and December 2021 were included. Patients with hypopharyngeal malignancies, Siewert type III gastroesophageal junction tumors, gastric cancers, or incomplete treatment records were excluded.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eDemographic characteristics, ECOG performance status, tumor location, histology, AJCC 8th edition staging, radiotherapy intent, technique, dose\u0026ndash;fractionation, chemotherapy details, surgical intervention, pathological response, and treatment completion were extracted from institutional records.\u003c/p\u003e\n\u003ch3\u003eRadiotherapy Planning and Delivery\u003c/h3\u003e\n\u003cp\u003ePatients were simulated in the supine position with appropriate immobilization. Radiotherapy was delivered using two-dimensional radiotherapy (2D), three-dimensional conformal radiotherapy (3DCRT), or volumetric modulated arc therapy (VMAT). Prescribed doses ranged from palliative regimens (30 Gy) to definitive doses up to 66 Gy. Mean doses to the heart and lungs were recorded where available.\u003c/p\u003e\n\u003ch3\u003eSurvival Analysis\u003c/h3\u003e\n\u003cp\u003eOverall survival (OS) was defined as the interval from initiation of radiotherapy to death from any cause or last follow-up. Survival was estimated using the Kaplan\u0026ndash;Meier method and compared using the log-rank test. Multivariate analysis was not performed due to limited subgroup sizes and incomplete survival data.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003ePatient Demographics and Baseline Clinical Characteristics\u003c/h2\u003e\n \u003cp\u003eA total of 79 patients were treated during the study period. Baseline demographic and clinical characteristics are summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The median age was 59 years (range, 27\u0026ndash;88), with a slight female predominance. Most patients were from rural backgrounds and presented with ECOG performance status 0\u0026ndash;2.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBaseline demographic and clinical characteristics (n\u0026thinsp;=\u0026thinsp;79)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedian age (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e59 years (27\u0026ndash;88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36 (45.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43 (54.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53 (67.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (32.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eECOG 0\u0026ndash;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (43.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eECOG 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29 (36.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eECOG\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eData not available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eTumor Characteristics and Stage at Presentation\u003c/h3\u003e\n\u003cp\u003eTumor characteristics, including histology, anatomical location, and AJCC stage distribution, are detailed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Squamous cell carcinoma was the predominant histological subtype. The middle thoracic esophagus was the most common tumor location. A substantial proportion of patients presented with stage III or metastatic disease.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTumor characteristics and AJCC stage distribution\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSquamous cell carcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e74 (93.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdenocarcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCervical esophagus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUpper thoracic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMiddle thoracic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLower thoracic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22 (29.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStage I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStage II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13 (28.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStage III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11 (24.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStage IVA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17 (37.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStage IVB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eRadiotherapy Practice Patterns\u003c/h2\u003e\n \u003cp\u003eRadiotherapy intent, technique selection, and dose prescription are summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e. Neoadjuvant and definitive radiotherapy accounted for the majority of curative-intent treatments. VMAT was the most frequently employed technique, reflecting increasing adoption of advanced conformal radiotherapy.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eRadiotherapy intent, technique, and dose\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eValue\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRadiotherapy intent\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeoadjuvant chemoradiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28 (35.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDefinitive chemoradiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24 (30.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdjuvant radiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8 (10.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePalliative radiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17 (21.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eRadiotherapy technique\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVMAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51 (64.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3DCRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2D radiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16 (20.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean prescribed dose (Gy)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeoadjuvant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDefinitive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e55.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdjuvant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e47.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePalliative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e27.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eDosimetric Exposure to Organs at Risk\u003c/h2\u003e\n \u003cp\u003eMean cardiac and pulmonary dose exposure is presented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e. Overall, cardiopulmonary doses were within accepted tolerance ranges for thoracic radiotherapy across treatment intents.\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"char\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"char\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003cdiv align=\"char\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMean cardiac and pulmonary dose exposure\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOrgan at risk\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (Gy)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian (Gy)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRange (Gy)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeart (n\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.2\u0026ndash;35.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRight lung (n\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.0\u0026ndash;21.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeft lung (n\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e13.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.3\u0026ndash;17.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eTreatment Completion and Multimodality Integration\u003c/h2\u003e\n \u003cp\u003eTreatment completion and multimodality integration are summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e. Radiotherapy was completed as planned in 88.6% of patients. Concurrent chemotherapy and surgical resection were feasible in selected patients with adequate performance status.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eTreatment completion and multimodality therapy\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eRadiotherapy completion\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCompleted as planned\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e70 (88.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncomplete\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9 (11.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eConcurrent chemotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReceived\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44 (57.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot received\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35 (42.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical intervention\u003c/strong\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurgery performed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27 (47.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (52.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePathological complete response (pCR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAchieved\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5 (18.5% of surgical patients)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot achieved\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22 (81.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eOverall Survival\u003c/h2\u003e\n \u003cp\u003eSurvival analysis was feasible in 61 patients. Prognostic factors associated with OS are summarized in Table\u0026nbsp;6. TNM stage grouping and the presence of distant metastasis were associated with inferior survival, while surgical intervention in thoracic esophageal cancer was associated with improved OS.\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEffect on overall survival\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLog-rank p value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ecT stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo significant association\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ecN stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo significant association\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePresence of distant metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eWorse OS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTNM stage grouping\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSignificant difference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.049\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSurgical intervention (thoracic tumors)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eImproved OS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eThe median OS for the entire cohort was 18 months (95% CI: 12.5\u0026ndash;23.4).\u003c/p\u003e\n \u003cp\u003eKaplan\u0026ndash;Meier survival curves are shown in:\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eImpact of Timing of Radiotherapy on Overall Survival\u003c/h2\u003e\n \u003cp\u003eFor this analysis, patients with cervical esophageal tumors were excluded. Only patients with thoracic esophageal cancer who underwent surgical resection as the definitive treatment were included.\u003c/p\u003e\n \u003cp\u003eKaplan\u0026ndash;Meier analysis demonstrated that neoadjuvant radiotherapy was associated with improved overall survival compared to adjuvant radiotherapy administered postoperatively (log-rank p\u0026thinsp;=\u0026thinsp;0.011). In patients receiving neoadjuvant chemoradiotherapy, the median OS was not reached, with a mean OS of approximately 50 months. Patients treated with adjuvant radiotherapy exhibited comparatively inferior survival outcomes.\u003c/p\u003e\n \u003cp\u003eThese findings should be interpreted cautiously, as they likely reflect differences in baseline disease characteristics, treatment selection, and patient fitness rather than a direct causal effect of radiotherapy timing.\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis retrospective cohort study provides a comprehensive overview of real-world radiotherapy practice for esophageal cancer in a tertiary care setting. The findings highlight the heterogeneity of clinical presentation, treatment intent, and radiotherapy delivery in routine practice, particularly in a resource-constrained environment.\u003c/p\u003e \u003cp\u003eThe predominance of squamous cell carcinoma and advanced-stage disease at presentation in this cohort is consistent with epidemiological patterns reported from India and other Asian countries(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These factors significantly influence treatment selection, often necessitating non-surgical or multimodality approaches. The high proportion of patients treated with neoadjuvant or definitive radiotherapy reflects both disease extent and limitations in upfront surgical feasibility.\u003c/p\u003e \u003cp\u003eA key observation of this study is the high rate of radiotherapy treatment completion despite advanced disease and variable performance status. This finding underscores the feasibility of delivering thoracic radiotherapy across diverse clinical intents when individualized planning and supportive care are employed. The widespread use of VMAT in this cohort suggests a transition toward advanced conformal techniques, even in routine clinical practice(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCardiopulmonary dosimetric exposure remained within accepted tolerance limits for most patients(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Although increasing evidence suggests a potential relationship between cardiac dose and survival in esophageal cancer, particularly in trial settings, such associations remain inconsistent in real-world populations. In the present study, dosimetric parameters were reported descriptively without attempting to establish dose–response relationships, thereby avoiding overinterpretation(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOverall survival outcomes in this cohort followed expected stage-dependent patterns. The association between surgical intervention and improved survival in thoracic esophageal cancer likely reflects patient selection, tumor biology, and response to multimodality therapy rather than a direct treatment effect. Similarly, the observed association between neoadjuvant radiotherapy and improved survival compared to adjuvant radiotherapy in surgically treated patients should be interpreted with caution. Patients selected for neoadjuvant therapy are typically fitter, have potentially resectable disease at presentation, and are managed within structured multimodality pathways(\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e–\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e–\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe strengths of this study include detailed documentation of radiotherapy practice patterns, explicit reporting of dosimetric exposure, and integration of treatment completion and survival outcomes. These features provide practical insights that complement evidence derived from randomized trials. However, the retrospective design, limited sample size in subgroups, incomplete survival data, and absence of multivariate analysis constrain causal inference.\u003c/p\u003e "},{"header":"LIMITATIONS","content":"\u003cp\u003eThis study is limited by its retrospective nature, single-institution design, incomplete survival data in a subset of patients, and lack of multivariate survival modeling. Additionally, unmeasured confounders and selection bias inherent to real-world treatment decisions cannot be excluded.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn routine clinical practice, radiotherapy for esophageal cancer can be delivered across neoadjuvant, definitive, adjuvant, and palliative intents with acceptable cardiopulmonary dosimetric exposure and high treatment completion rates. Survival outcomes are primarily influenced by disease stage and the feasibility of multimodality treatment, particularly surgical resection in selected patients. Observed survival differences according to treatment sequencing should be interpreted as reflective of patient selection and disease characteristics rather than definitive treatment effects. Real-world evaluation of radiotherapy practice patterns provides valuable context for understanding care delivery in tertiary care settings without overstating therapeutic impact.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eAuthors’ Contributions\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eR.M. conceived the study concept, designed the analysis framework, performed data interpretation, and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eS.C. and P.P. contributed to treatment planning review, clinical data verification, and acquisition of radiotherapy-related data.\u003c/p\u003e\n\u003cp\u003eB.D. and A.S. contributed to data curation, literature review, and manuscript revision.\u003c/p\u003e\n\u003cp\u003eA.K.G. and R.P. provided study supervision, critical evaluation of methodology, and intellectual review of the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eADDITIONAL INFORMATION\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eLicensing and Tool Use Statement\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNo proprietary datasets, licensed materials, or third-party tools requiring special permission were used in the preparation of this manuscript. Language editing and formatting assistance, where applicable, did not influence the study design, data collection, data analysis, interpretation of results, or scientific conclusions. The authors take full responsibility for the content of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthics Approval\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Institutional Ethics Committee approval obtained\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eClinical trial number: not applicable.\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eConflicts of interest:\u003cbr\u003e\u0026nbsp;In compliance with the ICMJE uniform disclosure requirements, all authors declare the following.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003ePayment/services information\u003c/u\u003e:\u003cbr\u003e\u0026nbsp;All authors declare that no financial support was received from any organization for the submitted work.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFinancial relationships\u003c/u\u003e:\u003cbr\u003e\u0026nbsp;All authors declare that they have no financial relationships, either currently or within the previous three years, with any organizations that could be perceived to influence the submitted work.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eOther relationships:\u003cbr\u003e\u003c/u\u003eAll authors declare that there are no other relationships or activities that could appear to have influenced the submitted work.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, and/or publication of this article\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394\u0026ndash;424.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArnold M, Soerjomataram I, Ferlay J, Forman D. Global incidence of oesophageal cancer by histological subtype in 2012. Gut. 2015;64(3):381\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBedenne L, Michel P, Bouch\u0026eacute; O, Milan C, Mariette C, Conroy T, et al. Chemoradiation followed by surgery compared with chemoradiation alone in squamous cancer of the esophagus: FFCD 9102. J Clin Oncol Off J Am Soc Clin Oncol. 2007;25(10):1160\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinsky BD, Pajak TF, Ginsberg RJ, Pisansky TM, Martenson J, Komaki R, et al. INT 0123 (Radiation Therapy Oncology Group 94\u0026thinsp;\u0026ndash;\u0026thinsp;05) phase III trial of combined-modality therapy for esophageal cancer: high-dose versus standard-dose radiation therapy. J Clin Oncol Off J Am Soc Clin Oncol. 2002;20(5):1167\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHerskovic A, Martz K, al-Sarraf M, Leichman L, Brindle J, Vaitkevicius V, et al. Combined chemotherapy and radiotherapy compared with radiotherapy alone in patients with cancer of the esophagus. N Engl J Med. 1992 June;11(24):1593\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCooper JS, Guo MD, Herskovic A, Macdonald JS, Martenson JA, Al-Sarraf M, et al. Chemoradiotherapy of locally advanced esophageal cancer: long-term follow-up of a prospective randomized trial (RTOG 85\u0026thinsp;\u0026ndash;\u0026thinsp;01). Radiation Therapy Oncol Group JAMA. 1999;281(17):1623\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMansour MA, El-Salamoni MAF, Mostafa HN. Long-term outcomes and radiation-induced complications following stereotactic radiosurgery for a left temporal arteriovenous malformation: illustrative case. 2025 May 26 [cited 2026 Jan 20]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://thejns.org/caselessons/view/journals/j-neurosurg-case-lessons/9/21/article-CASE25201.xml\u003c/span\u003e\u003cspan address=\"https://thejns.org/caselessons/view/journals/j-neurosurg-case-lessons/9/21/article-CASE25201.xml\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVošmik M, Hodek M, Buka D, S\u0026yacute;korov\u0026aacute; P, Grepl J, Paluska P, et al. Cardiotoxicity of radiation therapy in esophageal cancer. Rep Pract Oncol Radiother. 2020;25(3):318\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGagliardi G, Constine LS, Moiseenko V, Correa C, Pierce LJ, Allen AM, et al. Radiation dose-volume effects in the heart. Int J Radiat Oncol Biol Phys. 2010;76(3 Suppl):S77\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin SH, Wang L, Myles B, Thall PF, Hofstetter WL, Swisher SG, et al. Propensity score-based comparison of long-term outcomes with 3-dimensional conformal radiotherapy vs intensity-modulated radiotherapy for esophageal cancer. Int J Radiat Oncol Biol Phys. 2012;84(5):1078\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang X, Palaskas NL, Yusuf SW, Abe JI, Lopez-Mattei J, Banchs J, et al. Incidence and Onset of Severe Cardiac Events After Radiotherapy for Esophageal Cancer. J Thorac Oncol Off Publ Int Assoc Study Lung Cancer. 2020;15(10):1682\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRohatgi PR, Swisher SG, Correa AM, Wu TT, Liao Z, Komaki R, et al. Failure patterns correlate with the proportion of residual carcinoma after preoperative chemoradiotherapy for carcinoma of the esophagus. Cancer. 2005;104(7):1349\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePreoperative Chemoradiotherapy for Esophageal or Junctional Cancer. | New England Journal of Medicine [Internet]. [cited 2026 Jan 25]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nejm.org/doi/full/\u003c/span\u003e\u003cspan address=\"https://www.nejm.org/doi/full/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMoa1112088\u003c/span\u003e\u003cspan address=\"10.1056/NEJMoa1112088\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndo N, Kato H, Igaki H, Shinoda M, Ozawa S, Shimizu H, et al. A randomized trial comparing postoperative adjuvant chemotherapy with cisplatin and 5-fluorouracil versus preoperative chemotherapy for localized advanced squamous cell carcinoma of the thoracic esophagus (JCOG9907). Ann Surg Oncol. 2012;19(1):68\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaters J, Sewell M, Molena D. Multimodal Treatment of Resectable Esophageal Cancer. Ann Thorac Surg. 2025;119(1):70\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8689515/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8689515/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eEsophageal cancer frequently presents at an advanced stage in low- and middle-income countries, where radiotherapy plays a central role across curative and palliative settings. While survival outcomes are commonly reported, fewer studies describe real-world radiotherapy practice patterns and organ-at-risk dosimetric exposure.\u003c/p\u003e\u003cp\u003e\u003cb\u003eObjectives\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe primary objective was to evaluate patterns of radiotherapy practice and cardiopulmonary dosimetric exposure in patients with esophageal cancer treated at a tertiary care center. Secondary objectives included treatment completion, multimodality integration, and overall survival.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis retrospective cohort study included patients with biopsy-proven esophageal cancer treated with radiotherapy between 2018 and 2021. Demographic, tumor-related, treatment, and dosimetric parameters were extracted from institutional records. Overall survival was analyzed using the Kaplan\u0026ndash;Meier method.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSeventy-nine patients received radiotherapy. Squamous cell carcinoma was the predominant histology, and most patients presented with locally advanced disease. Radiotherapy was delivered across neoadjuvant, definitive, adjuvant, and palliative intents using 2D, 3DCRT, and VMAT techniques. Treatment completion was achieved in 88.6% of patients. Mean heart and lung doses were generally within accepted tolerance ranges. Survival analysis was feasible in 61 patients. The median overall survival was 18 months (95% CI: 12.5\u0026ndash;23.4). TNM stage grouping and surgical intervention were significantly associated with overall survival. Among surgically treated thoracic esophageal cancers, neoadjuvant radiotherapy was associated with improved overall survival compared to adjuvant radiotherapy.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn routine clinical practice, radiotherapy for esophageal cancer can be delivered across diverse clinical intents with acceptable cardiopulmonary dosimetric exposure and high treatment completion rates. Overall survival is largely influenced by disease stage and the feasibility of multimodality treatment. Observed survival differences according to treatment sequencing should be interpreted as reflective of patient selection and disease characteristics rather than definitive treatment effects.\u003c/p\u003e","manuscriptTitle":"Patterns of Radiotherapy Practice, Dosimetric Exposure, and Treatment Outcomes in Esophageal Cancer:A Retrospective Cohort Study from a Tertiary Care Center","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-27 10:29:11","doi":"10.21203/rs.3.rs-8689515/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7129a3a7-3b8e-4317-87db-357c485fe412","owner":[],"postedDate":"January 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T07:26:09+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-27 10:29:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8689515","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8689515","identity":"rs-8689515","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}