Definitive chemoradiotherapy for T4 and/or M1 lymph node squamous cell carcinoma of the esophagus

Comparison of Aggressive Planned Salvage Surgery Versus Neoadjuvant Chemoradiotherapy Plus Surgery for Borderline Resectable T4 Squamous Cell Carcinoma

INTRODUCTION

We compare planned salvage surgery after definitive chemoradiotherapy (SALV) versus neoadjuvant chemoradiotherapy plus surgery (NCRS) for borderline resectable T4 esophageal squamous cell carcinoma.

PATIENTS AND METHODS

A total of 37 patients underwent planned SALV, and 20 underwent NCRS from 2004 to 2017. The short-term outcome measures were the R0 resection rate, complications, and treatment-related mortality. The long-term outcome measures were the 5-year overall survival rate and causes of death.

RESULTS

R0 resection rate was similar between the SALV and NCRS groups (81% versus 85%). The incidence of postoperative pneumonia (35% versus 18%) and treatment-related mortality rate (9% versus 0%) tended to be higher in the SALV. ypT grade 2-3 (65% versus 30%, p = 0.012) and Clavien-Dindo grade ≥ IIIb complications (32% versus 0%, p = 0.008) were significantly more frequent in the SALV group. The groups had similar 5-year overall survival (26% versus 27%). The causes of death in the SALV and NCRS groups were primary esophageal cancer in 35% and 55% of patients, respectively, and pulmonary-related mortality in 24% and 5%, respectively. Multivariable Cox regression analysis revealed the following significant poor prognostic factors: stable disease as the clinical response, preoperative body mass index (BMI) of < 18.5 kg/m², ypN stage 1-3, and R1-2 resection.

CONCLUSIONS

SALV was associated with a higher incidence of late pulmonary-related mortality but had a stronger antitumor effect than NCRS. Consequently, the survival rate was similar between the groups. Surgery is recommended for patients with a partial response and preoperative BMI of ≥ 18.5 kg/m².

Association of local complete response with prognosis after salvage photodynamic therapy for esophageal squamous cell carcinoma

OBJECTIVES

Photodynamic therapy (PDT) is an effective salvage endoscopic treatment for local failure at the primary site after chemoradiotherapy (CRT) in esophageal cancer patients. However, the contribution of local control by salvage PDT to the prognosis is unclear. We investigated whether complete response at primary site by salvage PDT could improve the prognosis.

METHODS

Between January 2008 and March 2016, 34 patients received salvage PDT for local failure of esophageal cancer limited to stage T1-2 after definitive CRT or radiotherapy. Local complete response (L-CR) rate, adverse events, overall survival (OS), and progression-free survival (PFS) were assessed retrospectively.

RESULTS

Local complete response rates after PDT were 68% (23/34; 95% CI, 50-83%) in all patients: 81% (17/21; 95% CI, 58-95%) for stage T1 and 46% (6/13; 95% CI, 19-75%) for stage T2 patients. Grade 3 esophageal stricture occurred in one patient. The median follow-up was 26.0 months (range, 3.7-93.6 months); 21 patients died. The median survival times were 54.3 months in patients who achieved L-CR after PDT (L-CR group) and 19.8 months in those who did not (non-CR group). The 2-year OS rates were 79% (95% CI, 54-92%) in the L-CR group and 40% (95% CI, 11-68%) in the non-CR group (P = 0.0389; log-rank test). The median PFS was 21.2 months in the L-CR group and 1.9 months in the non-CR group (P < 0.001; log-rank test).

CONCLUSION

Achieving L-CR by salvage PDT for local failure after CRT in esophageal cancer was associated with good prognosis.

Imaging biomarkers of contrast-enhanced computed tomography predict survival in oesophageal cancer after definitive concurrent chemoradiotherapy

BACKGROUND

This study aimed to evaluate the predictive potential of contrast-enhanced computed tomography (CT)-based imaging biomarkers (IBMs) for the treatment outcomes of patients with oesophageal squamous cell carcinoma (OSCC) after definitive concurrent chemoradiotherapy (CCRT).

METHODS

Altogether, 154 patients with OSCC who underwent definitive CCRT were included in this retrospective study. All patients were randomised to the training cohort (n = 99) or the validation cohort (n = 55). Pre-treatment contrast-enhanced CT scans were obtained for all patients and used for the extraction of IBMs. An IBM score, was constructed by using the least absolute shrinkage and selection operator with Cox regression analysis, which was equal to the log-partial hazard of the Cox model in the training cohort and tested in the validation cohort. IBM nomograms were built based on IBM scores for individualised survival estimation. Finally, a decision curve analysis was performed to estimate the clinical usefulness of the nomograms.

RESULTS

Altogether, 96 IBMs were extracted from each contrast-enhanced CT scan. IBM scores were constructed from 11 CT-based IBMs for overall survival (OS) and 8 IBMs for progression-free survival (PFS), using the LASSO-Cox regression method in the training cohort. Multivariate analysis revealed that IBM score was an independent prognostic factor correlated with OS and PFS. In the training cohort, the C-indices of IBM scores were 0.734 (95% CI 0.664-0.804) and 0.658 (95% CI 0.587-0.729) for OS and PFS, respectively. In the validation cohort, C-indices were 0.672 (95% CI 0.578-0.766) and 0.666 (95% CI 0.574-0.758) for OS and PFS, respectively. Kaplan-Meier survival analysis showed a significant difference between risk subgroups in the training and validation cohorts. Decision curve analysis confirmed the clinical usefulness of the IBM score.

CONCLUSIONS

The IBM score based on pre-treatment contrast-enhanced CT could predict the OS and PFS for patients with OSCC after definitive CCRT. Further multicentre studies with larger sample sizes are warranted.

Outcomes of Definitive Chemoradiotherapy for Stage IVa (T4b vs. N4) Esophageal Squamous Cell Carcinoma Based on the Japanese Classification System: A Retrospective Single-Center Study

The differences in prognoses or progression patterns between T4b non-N4 and non-T4b N4 esophageal squamous cell carcinoma post chemoradiotherapy (CRT) is unclear. This study compared the outcomes of CRT for stage IVa esophageal squamous cell carcinoma according to T/N factors. We retrospectively identified 66 patients with stage IVa esophageal squamous cell carcinoma who underwent definitive CRT at our center between January 2009 and March 2013. The treatment outcomes, i.e., progression patterns, prognostic factors, and toxicities based on version 5.0 of the National Cancer Institute Common Terminology Criteria for Adverse Events, were studied. The patients (56 men and 10 women) had a median age of 67 (range: 37-87) years. The T/N classifications were T4b non-N4 (28/66), non-T4b N4 (24/66), and T4b N4 (14/66). Objective response was achieved in 57 patients (86.4%, (95% confidence interval, 74.6-94.1%)). There were no significant differences between the T/N groups in terms of overall survival, progression-free survival, and progression pattern. We found no significant differences in prognoses or progression patterns among patients with T4b non-N4, non-T4b N4, and T4b N4 esophageal squamous cell carcinoma. Thus, it seems impractical to modify CRT regimens based on T/N factors.

Development of chemotherapeutics for unresectable advanced esophageal cancer

INTRODUCTION

The prognosis of unresectable advanced esophageal squamous cell carcinoma (ESCC) has gradually improved due to efforts for the development of systemic chemotherapy or concurrent chemoradiotherapy.

AREAS COVERED

Chemotherapeutic agents such as cytotoxic agents, molecular-targeted agents, and immune checkpoint inhibitors, sometimes used with irradiation, lead in the treatment of unresectable advanced ESCC. Here, we review the latest treatment strategies for unresectable advanced ESCC and discuss future perspectives.

EXPERT OPINION

Immunotherapeutic agents will be part of the treatment of unresectable advanced ESCC in the near future. However, definitive predictive biomarkers to determine good patient candidates remain unclear for immunotherapy in patients with ESCC. Further research is warranted to identify those biomarkers working individually and in combination. Moreover, genome-based therapeutics enable individualized and patient-specific treatment. The development of molecular-targeted drugs against actionable or druggable genes is in progress.

The first evidence for SLFN11 expression as an independent prognostic factor for patients with esophageal cancer after chemoradiotherapy

BACKGROUND

Schlafen 11 (SLFN11) was recently identified as a dominant determinant of sensitivity to DNA-targeting agents including platinum-based drugs. SLFN11 also reportedly enhances cellular radiosensitivity. In this study, we examined the prognostic value of SLFN11 expression in esophageal squamous cell carcinoma (ESCC) patients treated with definitive chemoradiotherapy (dCRT), including the platinum derivative nedaplatin.

METHODS

Seventy-three patients with ESCC who received dCRT were examined. SLFN11 expression was analyzed in pre-dCRT biopsies using immunohistochemistry and evaluated using a histo-score (H-score). Correlation between the H-score and overall survival was analyzed. An H-score ≥ 51 was provisionally defined as indicating high SLFN11 expression. Viability assays were performed using previously established isogenic human cell lines differentially expressing SLFN11 to test the usefulness of SLFN11 as marker of response to the dCRT regimen.

RESULTS

High SLFN11 expression was independently associated with better prognosis in ESCC patients (hazard ratio = 0.295, 95% CI = 0.143-0.605, p = 0.001 for multivariate analysis). Kaplan-Meier survival curves showed that the prognostic value of high SLFN11 expression was most evident in patients at clinical stages II and III (p = 0.004). In in vitro study, SLFN11-proficient cells were highly sensitive to platinum derivatives compared to SLFN11-deficient cells.

CONCLUSION

SLFN11 expression is an independent prognostic factor for ESCC patients treated with dCRT and a potential biomarker for treatment selection of ESCC. Examination of SLFN11 may be particularly useful for clinical Stage II-III patients who wish to choose dCRT (instead of surgery) to preserve esophageal function.

The association of primary tumor site with acute adverse event and efficacy of definitive chemoradiotherapy for cStage II/III esophageal cancer: an exploratory analysis of JCOG0909

BACKGROUND

JCOG0909 is a phase II trial of definitive chemoradiotherapy including salvage treatment for cStage II-III thoracic esophageal cancer; the radiation field for elective regional lymph node irradiation, which can affect patient outcome and adverse event, varied based on the primary tumor site, i.e., upper (Ut), middle (Mt), and lower thoracic (Lt) esophagus. The impact of different primary sites on the safety and efficacy of definitive chemoradiotherapy in JCOG0909 is not well characterized.

METHODS

Patients were categorized into three groups (Ut, Mt, and Lt) according to the primary tumor location. We compared acute adverse events during definitive chemoradiotherapy, complete response (CR) rate, 3-year progression-free survival (PFS), and overall survival (OS) among the 3 groups.

RESULTS

Out of the 96 patients enrolled in JCOG0909 between April 2010 and August 2014, 94 patients (16, 59, and 19 patients in the Ut, Mt, and Lt groups, respectively) were included in this exploratory analysis. The proportion of patients with cStage III was 25% in the Ut, 37% in the Mt, and 47% in the Lt group. Grade 3-4 leukopenia, neutropenia, and thrombocytopenia were more frequently observed in the Mt (66%, 54%, and 15%) and Lt groups (84%, 68%, and 16%) than in the Ut group (38%, 44%, and 0%). There was no significant between-group difference with respect to 3-year OS (73.3%, 77.9%, and 57.9%), 3-year PFS (60.0%, 59.3%, and 47.4%), or CR rate (62.5%, 62.7%, and 42.1%).

CONCLUSIONS

In JCOG0909, the incidence of severe hematological toxicity had a trend toward higher in the Mt and Lt than the Ut esophageal cancer; however, no remarkable difference by primary sites was observed with respect to efficacy endpoints.

Platelet-to-lymphocyte ratio is an independent predictor of chemoradiotherapy-related esophageal fistula in esophageal cancer patients

Background

Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR) are all markers of systemic inflammation response. The role of systemic inflammation in the development of esophageal fistula (EF) has yet to be defined. This study aimed to investigate the predictive value of hematologic measures of inflammation and to set up a predictive model.

Methods

The data of esophageal cancer (EC) patients who received chemoradiotherapy (CRT) in our institution between January, 2015 and January, 2018 were retrospectively collected. The NLR, PLR, and MLR of these enrolled patients were calculated. Univariate and multivariate analyses were performed to find the independent risk factors of EF. Moreover, a nomogram model was developed to predict the probability of fistula occurring in EC patients.

Results

For PLR, the optimal cut-off value was 153. Patients with PLR >153 had a higher probability of developing fistula than those with PLR ≤153 (P<0.001). Multivariate analyses revealed that esophageal stenosis, ulcerative tumor, and PLR were independent factors for EF. Subsequently, a novel nomogram was set up with the C-index of 0.77 to predict the risk of developing EF in EC patients who received CRT.

Conclusions

PLR is an independent predictive indicator for EC patients who receive CRT. These findings will help to facilitate individual risk stratification for the development of EF in patients with EC.

Cardiac tamponade in a long-term survival esophageal cancer patient after esophageal bypass and chemoradiotherapy: a case report

Esophageal bypass surgery is an effective treatment strategy for esophageal cancer with esophago-tracheobronchial fistula. We herein report an esophageal cancer patient with esophago-pulmonary fistula who achieved a long-term survival but died suddenly because of cardiac tamponade. A 70-year-old male patient with esophago-pulmonary fistula due to esophageal tumor invasion underwent definitive chemoradiotherapy as the initial treatment. Esophageal bypass surgery followed by additional chemotherapy was performed, and the patient survived for a long time. Four years and six months later, a small abscess in an esophago-pulmonary fistula was visualized on computed tomography. One month later, he suffered suddenly severe dyspnea and died. An autopsy suggested that the direct cause of death had been cardiac tamponade due to atrio-pericardial fistula. Definitive therapy for esophageal cancer with fistula after esophageal bypass is an effective treatment, but close special attention must be paid to the possibility of irradiation-related late toxicity.

Impact of Extracapsular Lymph Node Involving the Esophagus in Esophageal Perforation During and After Radiotherapy: A Propensity Score-Matched Analysis

Background

This study aimed to analyze the risk factors for esophageal squamous cell carcinoma (ESCC), especially extracapsular lymph node involving the esophagus (ECLNIE), occurring during or after radiotherapy (RT) in patients with esophageal perforation (EP).

Methods

In total, 306 patients with ESCC who received RT and/or chemotherapy between January 2016 and December 2017 in our hospital and who met the inclusion criteria of the study were recruited. The continuous variables were converted into classification variables using the receiver operating characteristic curve or common clinical parameters. Risk factors for EP were examined by univariable analysis using the chi-square test or Fisher’s exact and by multivariable analysis using logistic regression model. Propensity score matching (PSM) was used to compensate for the differences in baseline characteristics, and the incidence of EP was compared after matching.

Results

EP was observed in 26 patients (incidence rate, 8.5%). Univariable analysis revealed that age, BMI, T4 stage, tumor length, esophageal wall thickness, ECLNIE, necrotic areas, niche sign by esophagogram before RT, neutrophil-to-lymphocyte ratio, and prognostic nutritional index were significantly associated with EP among patients with ESCC who received radiotherapy. Multivariable analysis demonstrated that age, ECLNIE, esophageal wall thickness, and niche sign by esophagogram before RT were independent risk factors for EP. After PSM, compared with patients without ECLNIE, patients with ESCC and ECLNIE had a significantly higher risk of EP.

Conclusion

The presence of ECLNIE could be a strong risk factor of EP during and after RT.

Radiation Dose-escalated Chemoradiotherapy Using Simultaneous Integrated Boost Intensity-Modulated Radiotherapy for Locally Advanced Unresectable Thoracic Oesophageal Squamous Cell Carcinoma: A Single-institution Phase I Study

AIMS

About 80% of cases of locally advanced unresectable thoracic oesophageal squamous cell carcinoma recur within the irradiation fields after chemoradiotherapy. Radiation dose escalation using advanced radiotherapy techniques is expected to improve clinical outcomes by reducing local and regional recurrence. The current study aimed to determine the recommended escalated radiation dose for these patients.

MATERIALS AND METHODS

Patients with locally advanced unresectable thoracic oesophageal squamous cell carcinoma with good performance status underwent chemoradiotherapy using simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) with elective nodal irradiation. SIB-IMRT was delivered in five fractions per week. The radiation dose to the unresectable gross tumour was escalated from 66 Gy to a planned maximum dose of 72 Gy in 3 Gy increments in a standard 3 + 3 design. The doses to the resectable component, superficial tumours and elective nodal regions were fixed as 60, 51 and 48 Gy, respectively. Cisplatin and 5-fluorouracil were concurrently administered. Dose-limiting toxicity (DLT) was defined as acute grade 3 oesophagitis, grade 2 pneumonitis, grade 2 cardiac toxicity and a failure to complete planned radiotherapy within 60 days. Locoregional control and overall survival were estimated using the Kaplan-Meier method. Nine patients were enrolled.

RESULTS

DLTs occurred in one of six and two of three patients at doses of 66 and 69 Gy, respectively. All DLTs were grade 3 oesophagitis. The recommended dose was determined as 66 Gy delivered in 30 fractions based on the predefined criteria. With a median follow-up period of 23 months, the 1-year locoregional control and overall survival rates were 67 (95% confidence interval = 19-90) and 78% (95% confidence interval = 36-94), respectively.

CONCLUSION

The recommended radiation dose in chemoradiotherapy using SIB-IMRT with elective nodal irradiation was 66 Gy delivered in 30 fractions.

Long-Term Outcome of Patients with Locally Advanced Clinically Unresectable Esophageal Cancer Undergoing Conversion Surgery after Induction Chemotherapy with Docetaxel Plus Cisplatin and 5-Fluorouracil

BACKGROUND

Although definitive chemoradiotherapy (CRT) is recommended for patients with locally advanced unresectable esophageal cancer, the outcome is unsatisfactory. We previously demonstrated the safety and efficacy of induction chemotherapy with docetaxel plus cisplatin and 5-fluorouracil (DCF) and subsequent conversion surgery (CS) for patients with locally advanced unresectable esophageal cancer. However, whether or not induction DCF chemotherapy and subsequent CS improve the long-term outcomes of patients with locally advanced unresectable esophageal cancer is unclear.

METHODS

A total of 177 consecutive patients with locally advanced unresectable esophageal cancer without distant metastasis were included in this study. Of these, 55 patients received DCF induction chemotherapy, of whom 36 underwent CS. We divided these 36 patients into two groups according to clinical response, which was analyzed retrospectively.

RESULTS

The toxicities related to DCF chemotherapy were manageable. The response rate to induction DCF chemotherapy was 67%. R0 resection was achieved in 81% of the 36 patients who underwent subsequent CS. No serious postoperative complications were observed. Histopathological CR was achieved in 17% of the 36 patients, and the 3- and 5-year survival rates after CS were 61% and 54%, respectively. The outcomes of the patients who obtained good clinical response was better than the outcomes of patients who did not.

CONCLUSIONS

Induction DCF chemotherapy and subsequent CS show acceptable toxicity and offer the chance of long-term survival in patients with locally advanced clinically unresectable esophageal cancer.

Pegaspargase Combined with Concurrent Radiotherapy for Early-Stage Extranodal Natural Killer/T-Cell Lymphoma, Nasal Type: A Two-Center Phase II Study

Background

Concurrent chemoradiotherapy (CCRT) is expected to improve local and systemic disease control and has been established as a standard therapy for several types of solid tumors. Considering the benefits of frontline radiation and pegaspargase in localized extranodal natural killer (NK)/T‐cell lymphoma, nasal type (ENKTL), we conducted a phase II study on pegaspargase‐based CCRT to explore an effective treatment.

Materials and Methods

In this study, 30 patients with newly diagnosed nasal ENKTL in stages IE to IIE received CCRT (radiation 50 Gy and two cycles of pegaspargase 2,500 unit/m² every 3 weeks). Four courses of pegaspargase were performed after CCRT.

Results

The patients completed CCRT and four cycles of pegaspargase. The complete remission (CR) rate was 90%, with a 95% confidential interval (CI) of 73.5%–97.9% after CCRT. The CR rate was 100% (95% CI, 88.4%–100%) at the end of the treatment. The 2‐year overall survival and progression‐free survival rates were 90.9% (95% CI, 78.4%–100%) and 92.8% (95% CI, 83.2%–100%), respectively. The major adverse events were in grades 1–2.

Conclusion

Preliminary data indicate that pegaspargase combined with concurrent radiotherapy for newly diagnosed patients with nasal ENKTL was efficacious and well tolerated. Registered atwww.chictr.org. Clinical Trial Registration Number. ChiCTR‐OIC‐15007662.

Implications for Practice

This clinical trial, evaluating the efficacy and toxicity of concurrent chemoradiotherapy by using single‐drug pegaspargase for patients with extranodal natural killer/T‐cell lymphoma, nasal type (ENKTL) in stage IE to IIE, showed pegaspargase combined with concurrent radiotherapy was efficacious and well tolerated. Pegaspargase has a long half‐life and is easy to administer via intramuscular injection. Consequently, pegaspargase combined with concurrent radiotherapy for patients with ENKTL can be completed in the outpatient clinic.

This phase II clinical study evaluated the efficacy and toxicity of concurrent chemoradiotherapy using single‐drug pegaspargase for patients with nasal‐type extranodal NK/T‐cell lymphoma.

Successful Management of Esophageal Cancer With Perforation Using Bypass Surgery Followed by Definitive Chemoradiotherapy

BACKGROUND

Esophageal perforation in advanced esophageal cancer requires immediate treatment. However, no clear treatment protocol has been established for this condition. We report a case of advanced esophageal cancer with esophageal perforation treated with esophageal bypass surgery and definitive chemoradiotherapy (CRT).

CASE REPORT

A 45-year-old woman was diagnosed with locally advanced esophageal cancer with esophageal perforation. Although the patient's general condition was relatively stable, no improvement was expected through conservative treatment. Esophageal gastric bypass surgery was performed; her symptoms improved postoperatively and oral ingestion became possible. Definitive CRT with 66 Gy radiotherapy and chemotherapy with cisplatin and 5-fluorouracil was administered. A complete clinical response was achieved. The patient is alive and well without recurrence 20 months after treatment.

CONCLUSION

Definitive CRT after esophageal bypass surgery is a potential treatment option for locally advanced esophageal cancer with esophageal perforation to improve treatment response and quality of life.

Prognostic value of lymph node to primary tumor standardized uptake value ratio in unresectable esophageal cancer

Background

Unresectable esophageal cancer harbors high mortality despite chemoradiotherapy. Better patient selection for more personalized management may result in better treatment outcomes. We presume the ratio of maximum standardized uptake value (SUV) of metastatic lymph nodes to primary tumor (NTR) in 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography/computed tomography (FDG PET/CT) may provide prognostic information and further stratification of these patients.

Methods

The patients with non-metastatic and unresectable esophageal squamous cell carcinoma (SCC) receiving FDG PET/CT staging and treated by chemoradiotherapy were retrospectively reviewed. Receiver operating characteristic (ROC) analysis was performed to determine the optimal cut-off value for NTR. Kaplan-Meier method and Cox regression model were used for survival analyses and multivariable analyses, respectively.

Results

From 2010 to 2016, 96 eligible patients were analyzed. The median follow-up time was 10.2 months (range 1.6 to 83.6 months). Using ROC analysis, the best NTR cut-off value was 0.46 for prediction of distant metastasis. The median distant metastasis-free survival (DMFS) was significantly lower in the high-NTR group (9.5 vs. 22.2 months, p = 0.002) and median overall survival (OS) (9.5 vs. 11.6 months, p = 0.013) was also significantly worse. Multivariable analysis revealed that NTR was an independent prognostic factor for DMFS (hazard ratio [HR] 1.81, p = 0.023) and OS (HR 1.77, p = 0.014).

Conclusions

High pretreatment NTR predicts worse treatment outcomes and could be an easy-to-use and helpful prognostic factor to provide more personalized treatment for patients with non-metastatic and unresectable esophageal SCC.

T4 cervical esophageal cancer cured with modern chemoradiotherapy: A case report

BACKGROUND

T4 esophageal cancer portends a poor prognosis, particularly when it is complicated by a tracheoesophageal fistula (TEF) either resulting from disease or occurring as a complication of treatment. Patients with TEF that occurs during treatment are commonly treated with palliative intent because fistula-associated treatment complications such as aspiration pneumonia and mediastinitis are associated with high morbidity and mortality. To date, there is no clear evidence on the optimal treatment of T4 esophageal cancer, particularly when a TEF formation occurs.

CASE SUMMARY

A 67-year-old gentleman who presented with dysphagia and weight loss. Endoscopy and imaging revealed a T4N1M0 cervical esophageal squamous cell carcinoma. He received image-guided intensity-modulated radiation therapy, with concurrent weekly carboplatin (area under curve 2 mg/mL per minute) and paclitaxel (50 mg/m² of body surface area). One week after treatment initiation (16.2 Gy thus far), he developed cough on swallowing. A TEF was detected on image-guided radiation therapy using cone-beam computed tomography during the treatment course, for which a tracheal stent was inserted. After discussing the risks and morbidity of continuing treatment, he resumed chemoradiotherapy with an additional radiation dose of 45 Gy in 25 fractions. Three months after completion of chemoradiotherapy, he developed an esophageal stricture that required esophageal stenting and dilatation. The patient remains cancer-free at two year on follow-up. Complete response of esophageal cancer was evident on post-treatment endoscopy and computed tomography imaging, with successful closure of TEF.

CONCLUSION

This case highlights that successful curative treatment for esophageal cancer complicated by a TEF is possible using novel chemotherapeutic regimens and modern radiation technologies.

Definitive chemoradiotherapy for squamous cell carcinoma of the esophagus: outcomes for borderline-resectable disease

Definitive chemoradiotherapy (dCRT) is the standard treatment for unresectable esophageal cancer. Induction chemotherapy has been actively investigated for borderline-resectable and unresectable disease, but the superiority over dCRT has yet to be confirmed. The purpose of this study was to evaluate the outcome of dCRT with special interest in borderline-resectable disease. Patients with esophageal cancer treated with dCRT between January 2004 and November 2016 were included in this retrospective analysis. Chemotherapy consisted of two cycles of cisplatin (70-75 mg/m2) on day 1 and 5-fluorouracil (700-1000 mg/m2 per day) on days 1-4 or low-dose cisplatin (10 mg/m2 per day) and 5-fluorouracil (175 mg/m2 per day) for 20 days. Radiotherapy was given with a daily fraction of 1.8-2 Gy to a total dose of 50-70 Gy. A total of 104 patients were included: 34 were resectable, 35 were borderline-resectable and 35 were unresectable. Complete response was achieved in 44 patients (42%). Eighteen patients (17%) suffered Grade 2 or greater cardiopulmonary toxicity and seven patients (7%) suffered Grade 3 cardiopulmonary toxicity. At the time of this analysis, 59 patients were dead and 45 were censored. The 3-year overall survival proportions for resectable, borderline-resectable and unresectable patients were 64%, 46% and 21%, respectively. The overall survival for borderline-resectable patients with complete response and noncomplete response was significantly different (P < 0.001), with 3-year survival of 70% and 8%, respectively. The overall survival for complete response patients with borderline-resectable disease was encouraging. Further investigation to find a subgroup fit for esophagus-preserving treatment is warranted.

Tracheal resection and anterior mediastinal tracheostomy in the multidisciplinary treatment of esophageal cancer with tracheal invasion

Combined tracheal resection and anterior mediastinal tracheostomy (AMT) for esophageal cancer with tracheal invasion is a challenging treatment because of its high morbidity and the lack of evidence regarding long-term outcomes. The aim of this study was to assess the short- and long-term outcomes of AMT as part of the multidisciplinary treatment for esophageal cancer with tracheal invasion. This retrospective study included 27 consecutive patients with esophageal cancer with tracheal invasion who underwent combined tracheal resection and AMT in their multidisciplinary treatment for esophageal cancer. We evaluated postoperative complications, body weight loss, and survival and examined the prognostic value of preoperative factors. All patients underwent chemotherapy and/or chemoradiotherapy as prior treatment. R0 resection was achieved in all cases. Clavien-Dindo grade I or greater complications occurred in 17 patients (63%), and grade III or greater complications occurred in 12 (44%). Overall in-hospital mortality was 4%, with one patient dying on postoperative day 48 when the brachiocephalic artery ruptured from tracheal compression. The 30- and 90-day mortality rates were 0% and 4%, respectively. Median weight change in patients without recurrence in the year after surgery was -1.7% (-9.6-21%). All of these patients received nutrition by oral intake and were living independently at home without public assistance. The 3- and 5-year disease-free survival rates were 25.9% and 18.5%, respectively; 3- and 5-year overall survival rates were 38.6% and 25.7%, respectively. Multivariate analysis identified response to prior treatment as an independent prognostic factor in these patients. Combined tracheal resection and AMT may be adapted as part of the multidisciplinary treatment of esophageal cancer with tracheal invasion. Improving AMT safety and optimizing patient selection may improve prognosis among patients with this cancer.

Appropriate Candidates for Salvage Esophagectomy of Initially Unresectable Locally Advanced T4 Esophageal Squamous Cell Carcinoma

BACKGROUND

Standard treatment for unresectable locally advanced esophageal cancer is definitive chemoradiotherapy (dCRT). Although salvage esophagectomy is the only curative treatment available following dCRT failure, the appropriate candidates for salvage esophagectomy remain unclear.

PATIENTS AND METHODS

Three hundred seventeen patients who underwent dCRT from April 2004 to December 2016 were stratified into three study groups-a complete response (CR) group, chemotherapy or best supportive care (BSC) group, and salvage esophagectomy group-and compared. We also investigated the clinical outcomes and prognostic factors of salvage esophagectomy.

RESULTS

Seventy-one patients (22.4%) achieved CR after dCRT, 18 patients (5.7%) underwent salvage esophagectomy, and 228 patients (71.9%) underwent palliative chemotherapy or BSC. The 5-year overall survival (OS) rates of the CR group, salvage esophagectomy group, and chemotherapy or BSC group were 83.0%, 51.6%, and 1.3%, respectively. Salvage esophagectomy recipients had a worse OS rate than CR patients (p < 0.001) but a better OS rate than those in the chemotherapy or BSC group (p < 0.001). Incomplete resection was the only significant variable associated with poor OS on univariate Cox proportional-hazards analysis (hazard ratio: 7.633, 95% confidence interval: 1.692-34.482; p = 0.008). Patients with tumors in the upper thoracic esophagus were more likely to undergo incomplete resection (p = 0.011).

CONCLUSIONS

Patients who achieve R0 resection are good candidates for salvage esophagectomy regardless of their response to dCRT. Those with upper thoracic esophageal tumors are at risk of incomplete resection; careful attention is required when considering these patients for salvage esophagectomy.

TENERGY: multicenter phase II study of Atezolizumab monotherapy following definitive Chemoradiotherapy with 5-FU plus Cisplatin in patients with unresectable locally advanced esophageal squamous cell carcinoma

BACKGROUND

The standard treatment for patients with unresectable locally advanced esophageal squamous cell carcinoma (ESCC) is definitive chemoradiotherapy (CRT) using 5-FU plus cisplatin. However, complete response (CR) rates are low at 11-25%, resulting in 9-10 months of median overall survival (OS). An improved therapeutic efficacy by combining immunotherapy with radiation has been reported in patients with locally advanced non-small cell lung cancer. The results using ESCC cell lines suggest sequential treatment with anti-PD-L1 agents soon after completion of CRT is the most effective combination.

METHODS

TENERGY trial is a multicenter, phase II, proof-of-concept study to assess the efficacy and safety of atezolizumab following definitive CRT in patients with locally advanced ESCC. The main inclusion criteria are unresectable locally advanced ESCC without distant metastasis, completion of 60 Gy of radiation plus two concomitant cycles of chemotherapy (cisplatin 70 mg/m2 on day 1 and 5-FU 700 mg/m2 on days 1-4, every 28 days), and adequate organ function. Within 6 weeks after CRT, participants will start taking 1200 mg of atezolizumab every three weeks and continue until 12 months or disease progression. The primary endpoint is the confirmed CR rate by the investigator's assessment. Secondary endpoints include overall response rate, progression-free survival (PFS), OS, adverse events, and confirmed CR rate by central assessment. We will enroll 50 patients (40 with primary locally advanced ESCC and 10 with postoperative locoregionally recurrent ESCC). We will obtain biopsies from the primary site and will collect blood at 3 time points (before CRT, after CRT, and four weeks after the start of atezolizumab) for an exploratory biomarker study. We will analyze the phenotype of immune-competent cells, neoantigens, tumor mutational burden, PD-L1 status, and Human Leukocyte Antigen haplotyping.

DISCUSSION

The synergistic efficacies of the sequential combination of CRT and atezolizumab should improve the CR rate, resulting in survival improvement for patients with unresectable locally advanced ESCC. Because CRT is a standard treatment option for patients with early stage to locally advanced ESCC, the sequential combination of CRT and atezolizumab has the potential to change the standard ESCC treatments.

TRIAL REGISTRATION

UMIN000034373, 10/04/2018 and EPOC1802.

A study of concurrent chemoradiotherapy with weekly docetaxel and cisplatin for advanced esophageal squamous cell carcinoma with T4 and/or M1 lymph node metastasis or locoregional recurrence

Background

The improvement of survival outcomes and the reduction of toxicities for esophageal squamous cell carcinoma (SCC) are still needed. We conducted a pilot study of concurrent chemoradiotherapy with weekly docetaxel and cisplatin for the treatment of esophageal SCC with T4 and/or M1 lymph node metastasis (LNM) or locoregional recurrence.

Methods

Fifty-four patients with advanced thoracic esophageal SCC having a stage T4 tumor or M1 LNM and/or locoregional recurrence were enrolled. Docetaxel and cisplatin were both administered weekly at a dose of 25 mg/m² 5–6 times in total concurrently with a specific dose of radiation. The primary endpoint was overall survival (OS), and the secondary endpoints were progression-free survival (PFS), locoregional control and treatment-related toxicities.

Results

From October 2015 to December 2016, concurrent treatment with full-cycle docetaxel and cisplatin and radiotherapy was administered to 41 of 54 patients (75.9%). A total of 51 patients (94.4%) completed the radiation schedules. Twenty-one patients (44.4%) achieved a complete response, and 21 (44.4%) achieved a partial response after chemoradiotherapy. The median survival time was 18.2 months, and the median PFS time was 11.5 months. The 1-year and 3-year OS, locoregional control and PFS rates were 70.4, 80.6, 50.0 and 36.4%, 64.3, 31.5%, respectively. Grade 3 toxicities included neutropenia (13.0%), anemia (3.7%), thrombocytopenia (1.9%), fatigue (20.4%), anorexia (13.0%), esophagitis (11.1%), and pneumonitis (5.6%). Grade 4 neutropenia occurred in 16.7% of patients. Four patients (7.4%) died from grade 5 toxicities. There were no significant differences in both survival and grade 3 and higher toxicities between the newly diagnosed group and recurrent group.

Conclusions

Concurrent chemoradiotherapy with weekly docetaxel and cisplatin is a well-tolerated and effective treatment regimen for esophageal SCC with T4 or M1 LNM and/or locoregional recurrence. Clinical trials with larger sample size and comparisons with conventional fluorouracil and cisplatin regimens are needed.

Safety of thoracoscopic esophagectomy after induction chemotherapy for locally advanced unresectable esophageal squamous cell carcinoma

INTRODUCTION

Recent studies have reported that induction chemotherapy with docetaxel plus cisplatin and 5-fluorouracil (DCF) is an effective treatment for unresectable, locally advanced esophageal cancer. The aim of this study was to investigate the safety and feasibility of thoracoscopic esophagectomy (TE) after DCF for initially unresectable esophageal squamous cell carcinoma (ESCC).

METHODS

Twenty-three patients with initially unresectable T4 thoracic ESCC underwent TE after induction DCF.

RESULTS

The neighboring organs with tumors were the tracheobronchus in nine patients, thoracic aorta in 13, and pericardium and diaphragm in three each (concurrent overlapping invasion occurred in five patients). The mean total operation time was 556.3 ± 107.2 minutes, and the mean time of the thoracic procedure was 258.9 ± 83.9 minutes. The mean total blood loss was 166.2 ± 117.8 mL, and the loss during the thoracic procedure was 33.5 ± 24.6 mL. All patients achieved complete R0 resection under TE. No conversions to open thoracotomy were performed. The postoperative morbidity rate was 34.8%. The postoperative hospital stay was 24.3 (range, 13-38) days. Five patients had recurrence: four had distant metastasis (lung, two; liver, three; and one with overlap), and one had mediastinal lymph node recurrence. No local recurrence was noted at the site of the primary T4 tumor.

CONCLUSIONS

TE was safely performed in 23 patients after DCF therapy for locally advanced unresectable ESCC. Induction DCF, followed by TE, could be an alternative treatment for unresectable T4 ESCC.

Risk Factors Associated with Esophageal Fistula after Radiotherapy for Esophageal Squamous Cell Carcinoma

Purpose: The aim of this study was to investigate risk factors for esophageal squamous cell carcinoma (ESCC) treated with radiotherapy (RT) with or without chemotherapy to guide how to reduce the occurrence of esophageal fistula (EF).

Methods: 414 patients with ESCC who underwent RT with or without chemotherapy were collected in Shandong Cancer Hospital from February 2012 to June 2018 retrospectively. The clinical characters and dosimetric parameters were recorded. Univariate and multivariate logistic regression analyses were provided to determine the risk factors associated with EF.

Results: The cumulative incidences of EF were 11.1% (46/414 patients). The median follow-up period was 15.8 months (range: 0.2-82.6months). The median survival time (MST) of patients with EF was 5.3 months. In univariate analysis, age, T4 stage, N3 stage, chemotherapy regimens, re-RT, ulcerative esophageal cancer (EC), esophageal stenosis, the maximum thickness of the tumor and the length of tumor had a correlation with the prevalence of EF. In multivariable logistic regression analysis, T4 stage, N3 stage, re-RT, ulcerative EC, esophageal stenosis, the maximum thickness of the tumor was confirmed as risk factors for EF.

Conclusion: This study revealed that T4 stage, N3 stage, re-RT, ulcerative EC, esophageal stenosis, the maximum thickness of the tumor were risk factors associated with EF. We ought to attach importance to the prevention of EF. Patients with risk factors for EF should be paid close attention.

Metabolic Tumor Volume Change Predicts Long-term Survival and Histological Response to Preoperative Chemotherapy in Locally Advanced Esophageal Cancer

OBJECTIVE

Here, we assess the ability of metabolic tumor volume (MTV) as measured by F-fluorodeoxyglucose-positron emission tomography/computed tomography (F-FDG PET/CT) to evaluate neoadjuvant chemotherapy response for patients with locally advanced esophageal cancer (EC).

BACKGROUND

Optimal methods to evaluate treatment response for EC patients have not yet been established. Although previous studies have reported the value of standardized uptake value (SUV), the accuracy of predicting histological response or long-term survival in EC is limited.

METHODS

In all, 102 EC patients without distant metastasis who underwent F-FDG PET/CT both before and after the preoperative chemotherapy series were analyzed.

RESULTS

The median primary tumor MTV values before and after preoperative chemotherapy were 22.55 (range 0.4-183.1) and 2.75 (0-52.9), respectively, and the median MVT reduction rate was 86.5%. We found the most significant difference in survival between PET responders and nonresponders with a cut-off value of 60% MTV reduction, using a 10% stepwise cut-off analysis [2-year progression-free survival (PFS): 79.2 vs 44.4%; hazard ratio (HR) 3.397; P < 0.0001). With this cut-off value, histological response (P = 0.0091), tumor location (P = 0.0102), pT (P = 0.0011), and pN (P = 0.0110) were significantly associated with PET response. Univariate analysis of PFS indicated a correlation between PFS and tumor size, cT, decrease of primary lesion by CT, SUVmax reduction rate, MTV reduction rate, pT, pN, and pM. Multivariate analysis further identified pM (HR 3.063; P = 0.0279) and MTV reduction rate (HR 2.471; P = 0.0263) to be independent prognostic predictors, but not decrease of primary lesion by CT or SUVmax reduction rate.

CONCLUSION

MTV change is clinically useful in predicting both long-term survival and histological response to preoperative chemotherapy in EC patients, after determining the optimal cut-off value based on survival analysis.

Prognostic Impact of Postoperative Complications following Salvage Esophagectomy for Esophageal Cancer after Definitive Chemoradiotherapy

BACKGROUND

Recent studies have reported that the occurrence of postoperative complications after esophagectomy for esophageal cancer has a negative impact on long-term survival. Although salvage esophagectomy is associated with higher rates of morbidity and mortality, the impact of postoperative complications on long-term survival following salvage esophagectomy has not been fully investigated.

METHODS

We retrospectively analyzed 73 patients with thoracic esophageal cancer who underwent salvage esophagectomy between January 1997 and December 2017 after definitive chemoradiotherapy. We investigated the clinical impact of postoperative complications on long-term survival after salvage esophagectomy.

RESULTS

Postoperative complications, pulmonary complications, and anastomotic leakage occurred in 34 (47%), 14 (13%), and 14 (19%) of the patients, respectively. Patients with complications had significantly poorer survival than patients who did not have complications (HR [hazard ratio], 2.06; p = 0.017), but there were no significant differences in overall survival between patients with and those without pulmonary complications or anastomotic leakage (HR, 1.48, p = 0.318, and HR, 1.37, p = 0.377, respectively). Multivariate analysis revealed that pathological T3-4 disease (HR, 4.63; p = 0.001), residual disease (HR, 5.09; p = 0.001), and postoperative complications (HR, 3.85; p = 0.001) were significant independent prognostic factors. In particular, the frequency of death from other diseases among patients with postoperative complications was nonsignificantly higher than among patients without postoperative complications (26 vs. 10%; p = 0.071).

CONCLUSION

The occurrence of complications leads to a poor prognosis for patients with esophageal cancer after salvage esophagectomy. Prevention of postoperative complications and long-term postoperative general supportive care might be important for improving patients' prognosis.

Phase III study of tri-modality combination therapy with induction docetaxel plus cisplatin and 5-fluorouracil versus definitive chemoradiotherapy for locally advanced unresectable squamous-cell carcinoma of the thoracic esophagus (JCOG1510: TRIANgLE)

A randomized phase III trial commenced in Japan in February 2018. Definitive chemoradiotherapy (CRT) with cisplatin plus 5-fluorouracil is the current standard treatment for locally advanced unresectable esophageal carcinoma. The purpose of this study is to confirm the superiority of induction chemotherapy with docetaxel plus cisplatin and 5-fluorouracil (DCF) followed by conversion surgery or definitive CRT over definitive CRT alone for overall survival (OS) in patients with locally advanced unresectable squamous-cell carcinoma of thoracic esophagus. A total of 230 patients will be accrued from 47 Japanese institutions over 4.5 years. The primary endpoint is OS, and the secondary endpoints are progression-free survival, complete response rate of CRT, response rate of DCF, adverse events of DCF and CRT, late adverse events and surgical complications. This trial has been registered at the Japan Registry of Clinical Trials as jRCTs031180181.

Does chemoradiotherapy benefit elderly patients with esophageal squamous cell cancer? A propensity-score matched analysis on multicenter data (3JECROG R-03A)

BACKGROUND

The aim of the present study was to assess the efficacy of concurrent chemoradiotherapy (CRT) or radiotherapy alone (RT-alone) in elderly patients with esophageal squamous cell carcinoma (ESCC).

METHODS

The clinical data of patients with ESCC treated with RT-alone or CRT were collected and retrospectively reviewed. The 1-, 3- and 5-year overall survival (OS) rates and the clinical characteristics correlated with survival were analyzed statistically. Propensity score matching (PSM) analyses were used to compensate for differences in baseline characteristics between the CRT and RT-alone groups to confirm the survival difference.

RESULTS

A total of 729 patients fulfilling the inclusion criteria were reviewed. Diabetes, primary tumor volume (pTV), primary tumor location (pTLo), clinical T stage,(cT) clinical N stage (cN), clinical M stage (cM) and short-term response to RT were independent factors influencing OS (P = 0.002-0.044). The 5-year OS rate was 26.6, 26.0 and 30.1% in the whole cohort, RT-alone and CRT groups, respectively. The survival difference between RT alone and CRT was not significant before or following PSM. Compared with the corresponding subgroups treated with RT alone, CRT significantly benefited patients with diabetes (P = 0.003), cT4 (P = 0.030) and cN0 (P = 0.049), whereas no benefit was identified between CRT and RT alone in the other subgroups, including cT1-3, cN1, cM, pTLo, pTV, age and gender.

CONCLUSIONS

CRT with the current chemotherapy regimens may not improve the survival of elderly ESCC patients compared to RT-alone, except in patients with cT4 stage, cN0 stage or diabetes. However, due to the limitation of the retrospective nature of the current study, further clinical trials are required for confirmation.

Salvage esophagectomy for initially unresectable locally advanced T4 esophageal squamous cell carcinoma

BACKGROUND

Definitive chemoradiotherapy (dCRT) for esophageal squamous cell carcinoma (ESCC) is a potentially curative treatment modality, even for patients with unresectable T4 tumors. For patients who fail dCRT, salvage esophagectomy is known to be a high-risk procedure. However, the efficacy and safety of salvage surgery for these patients remain unclear.

METHODS

A total of 35 patients who underwent salvage esophagectomy after dCRT for initially unresectable locally advanced T4 ESCC were assessed, and both outcomes and prognostic factors after surgery were investigated.

RESULTS

Among the study population, R0 resection was achieved in 19 patients (54.3%). Postoperatively, 8 patients (22.9%) experienced Clavien-Dindo grade IIIb or higher complications, and 3 patients (8.6%) registered surgery-related mortality. Overall survival rates were 45.7%, 28.6%, and 5.7% at 1, 2, and 5 years, respectively. In Cox regression analysis, residual or relapsed tumor limited to T2 or less was an independent prognostic factor for better survival (P = 0.010). On the other hand, postoperative pneumonia and incomplete resection were negative prognostic factors (P < 0.001 and P = 0.019, respectively). Nodal involvement and extent of lymph node dissection did not impact patient survival.

CONCLUSIONS

Although salvage esophagectomy for initially unresectable T4 ESCC is considered a high-risk surgery with poor prognosis, long-term survival may be achieved in patients with ≤ T2 residual tumors. In addition, R0 resection and postoperative pneumonia prevention are crucial to improve patient survival.

Analysis of fistula formation of T4 esophageal cancer patients treated by chemoradiotherapy

BACKGROUND AND AIM

Fistula is one of the known complications of T4 esophageal cancer (T4-EC). The standard treatment for T4-EC is chemoradiotherapy, but detailed data about fistula resulting from chemoradiotherapy in this condition are limited. In particular, radiographic findings of T4-EC with fistula have not been reported. This study assessed the risk factors of fistula based on clinical information on patients with chemoradiotherapy for T4-EC.

METHODS

We retrospectively reviewed the clinical data of 59 T4-EC patients who had squamous cell carcinoma without any fistula before receiving definitive or palliative chemoradiotherapy.

RESULTS

A fistula was observed in 18 patients (31%) throughout their clinical course. The overall survival in the fistula group was significantly shorter than that in the non-fistula group (259 vs. 346 days; p = 0.0341). The axial tumor size on computed tomography (CT) was confirmed as an independent risk factor for esophageal fistula in multivariate analysis of stepwise methods [OR 1.226; 95% CI 1.109-1.411; p < 0.0001]. Twelve out of 14 patients with an axial tumor size of 50 mm or greater had developed a fistula.

CONCLUSIONS

A large tumor size on the axial plane on CT is a risk factor for fistula formation.

Risk Factors for Esophageal Fistula in Esophageal Cancer Patients Treated with Radiotherapy: A Systematic Review and Meta-Analysis

<b><i>Objective:</i></b> Esophageal fistula is a critical and fatal complication of esophageal cancer. The aim of this meta-analysis was to explore the risk factors for esophageal perforation in esophageal cancer patients treated with radiotherapy. <b><i>Methods:</i></b> Data from the PubMed and Embase databases were retrieved for clinical research published between 1990 and 2018. The Newcastle-Ottawa Scale was used to evaluate the quality of the articles. A meta-analysis was performed using the RevMan 5.3 software provided by the Cochrane Collaboration Network. <b><i>Results:</i></b> Seventeen articles were eligible for the meta-analysis. In these articles, over 35 risk factors for esophageal fistula formation were described and 17 risk factors were analyzed. Significant differences in the odds of developing an esophageal perforation were found with regard to age (OR 2.34, 95% CI 1.08–5.03, <i>p</i> = 0.001), ulcerative type (OR 2.72, 95% CI 1.43–5.16, <i>p</i> = 0.002), histology (OR 4.16, 95% CI 1.14–15.12, <i>p</i> = 0.03), T stage (OR 2.66, 95% CI 1.44–4.91, <i>p</i> = 0.002), short-term response (OR 2.21, 95% CI 1.06–4.62, <i>p</i> = 0.03), chemotherapy regimen (OR 2.80, 95% CI 1.38–5.68, <i>p</i> = 0.005), and stenosis (OR 2.00, 95% CI 1.03–3.89, <i>p</i> = 0.04). <b><i>Conclusions:</i></b> An age of &#x3c;60–65 years, ulcerative type, squamous cell cancer, T4 stage, incomplete response, fluorouracil-based regimen, and stenosis were associated with an increased risk of esophageal fistula during or after radiotherapy. However, further, large-scale prospective studies are needed to establish the validity of this associ­ation.

Recent progress in multidisciplinary treatment for patients with esophageal cancer

Esophageal cancer is one of the most aggressive gastrointestinal cancers. This review focuses on eight topics within the multidisciplinary approach for esophageal cancer. As esophagectomy is highly invasive and likely to impair quality of life, the development of less invasive strategies is expected. Endoscopic resection (ER) of early esophageal cancer is a less invasive treatment for early esophageal cancer. A recent phase II trial revealed that combined ER and chemoradiotherapy (CRT) is efficacious as an esophagus-preserving treatment for cT1bN0 squamous cell carcinoma (SCC). Esophagectomy and definitive CRT are equally effective for patients with clinical stage I SCC in terms of long-term outcome. For locally advanced resectable cancers, multidisciplinary treatment strategies have been established through several clinical trials of neoadjuvant or perioperative treatment. Minimally invasive esophagectomy may improve the outcomes of patients and CRT is a curative-intent alternative to esophagectomy. CRT with 50.4 Gy radiotherapy combined with salvage surgery is a promising option to preserve the esophagus. Induction chemotherapy followed by esophagectomy may improve the outcomes of patients with locally advanced unresectable tumors. Immune checkpoint inhibitors are effective for esophageal cancer, and their introduction to clinical practice is awaited.

Long-term outcomes of multimodal therapy combining definitive chemoradiotherapy and salvage surgery for T4 esophageal squamous cell carcinoma

BACKGROUND

Survival outcomes of patients with cT4 esophageal squamous cell carcinoma (ESCC) remain extremely poor. We aimed to investigate long-term outcomes and identify prognostic factors in patients treated by definitive chemoradiotherapy (dCRT) alone or with dCRT plus salvage surgery (SALV) for cT4 ESCC.

PATIENTS AND METHODS

In total, 73 patients completing dCRT were analyzed. Patients achieving clinical complete response (CR) received follow-up evaluations thereafter. For patients diagnosed with clinical partial response (PR), potentially curative SALV was generally performed. Possible prognostic factors included demographic data, tumor staging, blood chemistry profiles, and esophageal stenosis.

RESULTS

The 1- and 3-year overall survival (OS) rates of the 73 patients were 67.1% and 40.8%, respectively. Twenty-one patients (29%) achieved clinical CR with dCRT alone. Among 35 patients (48%) with clinical PR, 31 underwent SALV and 4 opted for non-surgical treatments. In the dCRT-alone group (n = 42), patients with clinical CR-PR (n = 25) showed significantly better 3-year OS than those who responded poorly to dCRT (stable or progressive) (n = 17) (67.5% vs. 0%, P < 0.001). In the SALV group (n = 31), curative SALV (n = 22, 73%) provided significantly better 3-year OS than non-curative SALV (58.7% vs. 0%, P < 0.001). Multivariable analysis revealed stenosis before dCRT (P = 0.02) and pretreatment elevated CRP (P = 0.02) to be independently associated with poor outcomes.

CONCLUSIONS

The multimodal treatment strategy combining dCRT and SALV is rational for treating cT4 ESCC patients. When curative resection is feasible, SALV can provide good long-term survival outcome for patients who responded to dCRT but did not achieve clinical CR with dCRT alone.

Development and validation of a risk prediction model for radiotherapy-related esophageal fistula in esophageal cancer

Objectives

We aimed to identify the risk factors and provide a nomogram for the prediction of radiotherapy-related esophageal fistula in patients with esophageal cancer (EC) using a case-control study.

Patients and methods

Patients with esophageal fistula who received radiotherapy or chemoradiotherapy between 2003 and 2017 were retrospectively collected in two institutions. In the training cohort (TC), clinical, pathologic, and serum data of 136 patients (cases) who developed esophageal fistula during or after radiotherapy were enrolled and compared with 272 controls (1:2 matched with the diagnosis time of EC, sex, marriage, and race). After the univariable and multivariable logistic regression analyses, the independent risk factors were identified and incorporated into a nomogram. Then the nomogram for the risk prediction was externally validated in the validation cohort (VC; 47 cases and 94 controls) using bootstrap resampling.

Results

Multivariable analyses demonstrated that ECOG PS, BMI, T4, N2/3 and re-radiotherapy were independent factors for esophageal fistula. Then a nomogram was constructed with the C-index of 0.805 (95% CI, 0.762–0.848) for predicting the risk of developing esophageal fistula in EC patients receiving radiotherapy. Importantly, the C-index maintained 0.764 (95% CI, 0.683–0.845) after the external validation.

Conclusions

We created and externally validated the first risk nomogram of esophageal fistula associated with radiotherapy. This will aid individual risk stratification of patients with EC developing esophageal fistula.

Feasibility of extended chemoradiotherapy plus surgery for patients with cT4b esophageal carcinoma

BACKGROUND

Treatment of cT4b esophageal carcinoma usually consists of definitive chemoradiotherapy (dCRT). However, outcome after dCRT in these patients is poor. Whether surgery should have a place in the treatment of cT4b esophageal cancer is still subject to debate. Goal of this study was to evaluate the feasibility of esophagectomy after extended chemoradiotherapy in patients with cT4b esophageal cancer.

METHODS

Patients with cT4b esophageal carcinoma, as determined by endoscopic ultrasound and (PET-)CT, were eligible for this phase-2 study. Patients were treated with weekly carboplatin + paclitaxel with 50.4 Gy radiotherapy in 28 fractions for 5.5 weeks followed by an explorative thoracotomy and esophagectomy if deemed feasible.

RESULTS

From July 2011 through March 2013, 16 patients were enrolled. Five patients did not undergo surgery because of detection of distant metastases during/after CRT (n = 3), unwillingness to undergo surgery (n = 1) or death before start of CRT (n = 1). Of the 13 patients who completed CRT, 3 patients experienced major hematologic toxicity (grade 3). A radical (R0) resection was achieved in 9 of 11 patients. Postoperative complications occurred in 9 patients. A reoperation was performed in 2 patients and 2 patients died in hospital after surgery. Three patients developed recurrent disease (1 locoregional and 2 systemic) after a mean interval of 17 months. Median overall survival of all included patients was 14.3 months.

CONCLUSIONS

In certain patients with cT4b esophageal carcinoma a radical resection can be accomplished after chemoradiotherapy. However, this treatment is associated with considerable complications and should therefore be reserved for physically fit patients.

NETHERLANDS TRIAL REGISTER NUMBER

NTR3060.

Role of photodynamic therapy in the treatment of esophageal cancer

Photodynamic therapy (PDT), a treatment of choice for cancer, induces a photochemical reaction, thereby eradicating tumor cells. This is achieved through the administration of a photosensitizer drug, which is activated with a laser after localization to the tumor mass, and is an approved curative endoscopic ablative treatment for superficial esophageal squamous cell carcinoma (ESCC) in Japan. PDT has been approved for dysplastic Barrett's esophagus and as a palliative treatment for patients with symptomatic obstructive esophageal cancer in US. However, its adverse events and complicated procedure and the development of alternative endoscopic procedures such as endoscopic submucosal dissection, radiofrequency ablation and cryotherapy, have largely limited the practice of PDT in esophageal cancer worldwide. Recently, owing to the invention of second-generation PDT using talaporfin sodium and diode laser, PDT can be performed with less phototoxicity and therefore has regained popularity in the treatment of ESCC. As a salvage treatment for patients with local failure after chemoradiotherapy (CRT), PDT has shown promising complete response with less phototoxicity and shorter sun shade period. In addition, the efficacy and safety of PDT in patients with local failure of ESCC after CRT were shown in several clinical trials. The direction of the study interest of the next-generation PDT is the safety and potential expansion of the indications for its application in the future. This review covers the PDT for the treatment of ESCC and dysplastic Barrett's esophagus, with special focus on the role of PDT in practice for esophageal cancer.

Clinical Implications of Conversion Surgery After Induction Therapy for T4b Thoracic Esophageal Squamous Cell Carcinoma

BACKGROUND

Definitive chemoradiation therapy or chemotherapy alone is generally recommended for patients with unresectable cT4b esophageal cancer. However, conversion surgery has emerged as a therapeutic option when downstaging is achieved by induction therapy.

METHODS

We studied 169 patients with cT4 esophageal cancer who underwent induction therapy. Survival and prognostic factors were examined.

RESULTS

Of 169 patients, 25 who achieved a clinical complete response (cCR) underwent surveillance, 72 patients underwent conversion surgery, while another 72 patients whose tumors were regarded as unresectable after induction therapy did not undergo surgery. Among 169 patients, the 3- and 5-year survival rates were 31.0% and 25.9%, respectively. Sixty-four patients who underwent curative resection showed better survival comparable with survival of 25 patients who achieved cCR (3- and 5-year survival; 56.8% and 48.6% versus 64.0% and 52.0%, respectively). However, the survival of eight patients who underwent noncurative resection was as dismal as that of patients who did not undergo conversion surgery. Multivariate analysis in 169 patients identified female sex and achieving cCR or R0 resection as independent prognostic factors. Multivariate analysis in 72 patients who underwent conversion surgery identified sex, lymph node status, and R0 resection as independent prognostic factors in patients with cT4b esophageal cancer.

CONCLUSIONS

The present study showed that conversion surgery after induction therapy can be a potentially curative treatment option for select patients with cT4b esophageal cancer. An important issue for further research is to establish a method for more accurately diagnosing tumor resectability after induction therapy for cT4b esophageal cancer.

The Benefits of Docetaxel Plus Cisplatin and 5-Fluorouracil Induction Therapy in Conversion to Curative Treatment for Locally Advanced Esophageal Squamous Cell Carcinoma

BACKGROUND

Definitive chemoradiotherapy (CRT), used for treatment of patients with an initial diagnosis of unresectable locally advanced esophageal cancer, has led to unsatisfactory long-term prognosis. Moreover, CRT can lead to esophageal fistula, perforation, and strictures. Therefore, strong induction chemotherapeutic treatments are necessary to reduce the tumor volume for subsequent radical esophagectomy. This study aimed to determine the oncological utility of docetaxel plus cisplatin and 5-fluorouracil (DCF) and the technical feasibility of subsequent esophagectomy for locally advanced esophageal cancer.

METHODS

Eighty-seven patients with clinical borderline unresectable T3 and T4 esophageal squamous cell carcinoma without distant metastases were included in this study. There were 44 patients in primary DCF group and 43 patients in definitive CRT group, and perioperative and long-term oncological outcomes were compared between the two groups.

RESULTS

Twenty-two patients (50%) achieved R0 resection in the DCF group. Albeit not significant, the rate of curative treatment was higher in the DCF group than the definitive CRT group (p = 0.099). The overall survival (OS) and progression-free survival (PFS) were better with DCF than with definitive CRT (median OS, 29 vs. 17 months, p = 0.206; median PFS, 10 vs. 6 months, p = 0.020). Specifically, the OS of patients with a Charlson score of less than 3 among the DCF-treated patients tended to be better than those among the definitive CRT-treated patients.

CONCLUSION

DCF and subsequent esophagectomy achieved R0 resection in 50% of the patients and was associated with better long-term oncological outcomes in patients with initially unresectable esophageal cancer if their systemic status is acceptable.

Association of preoperative inflammation-based prognostic score with survival in patients undergoing salvage esophagectomy

Salvage esophagectomy (SALV) is potentially beneficial for patients with residual or relapsed esophageal carcinoma after definitive chemoradiotherapy (dCRT), although preoperatively identifying good candidates for SALV remains difficult. We investigated the prognostic impacts of inflammatory and nutritional status in patients undergoing SALV after dCRT. Forty-seven SALV patients were retrospectively reviewed, of whom 46 (98%) had squamous cell carcinoma and 1 (2%) adenocarcinoma. Possible prognostic factors included patients' demographic data, physical status, blood chemistry profiles, and clinical/pathological tumor features. The Glasgow prognostic score (GPS) was derived from preoperative C-reactive protein (CRP) and albumin values. Thirty (64%), 11 (23%), and 6 (13%) patients were classified into the GPS 0, 1, and 2, respectively, groups. None of the possible prognostic factors showed significant correlations with GPS. Patients with GPS 0 had better outcomes than those with GPS 1 or GPS 2 (Median survivals: 37.8, 15.9, and 5.1 months, respectively, P < 0.001). In the multivariable Cox proportional hazards model, GPS 1 (HR 5.62, 95% CI 1.94-16.4, P = 0.002), GPS 2 (HR 9.10, 95% CI 2.60-31.8, P < 0.001), R1/2 resection (HR 16.3, 95% CI 3.62-86.7, P < 0.001) and incomplete response to dCRT (HR 3.53, 95% CI 1.12-12.5, P = 0.03) were all independent risk factors for a poor outcome. Preoperative GPS is potentially useful for predicting outcomes in esophageal cancer patients undergoing SALV.

Treatment and clinical outcome of clinical T4 esophageal cancer: A systematic review

BACKGROUND

Survival of patients with cT4 esophageal cancer is dismal. Although the optimal treatment strategy remains to be established, two treatment options are available for cT4 esophageal cancers: definitive chemoradiation (dCRT) and induction treatment followed by conversion surgery (CS). However, little is known concerning the differences in clinical outcome between patients with T4 esophageal tumors treated with dCRT and those eventually treated with CS.

METHODS

A systematic search of the scientific literature on PubMed/MEDLINE was carried out using the keywords "T4 esophageal cancer," "invading (involving) adjacent organ," "definitive chemoradiation," "induction therapy," "salvage surgery," and "conversion surgery," obtaining 28 reports published up to July 2018.

RESULTS/CONCLUSION

We found that CS was superior to dCRT with respect to local disease control and short-term survival; however, CS was associated with relatively higher perioperative mortality and morbidity. Alternatively, although dCRT might often cause fistula formation, a clinical complete response to dCRT is likely to lead to a better prognosis. Recent advances in chemotherapeutic agents have led to triple induction chemotherapy, with docetaxel, cisplatin, and 5-fluorouracil (DCF), which has shown promise as an initial induction treatment for cT4 esophageal cancer. Indeed, this regimen could control both local and systemic disease, which enables curative resection without preoperative CRT. Moreover, some appropriate changes in perioperative management and intensive systemic chemotherapy might enhance patient outcome. Randomized controlled trials with a large sample size are needed to establish the standard treatment for cT4 esophageal cancer.

Stenting in Palliation of Unresectable Esophageal Cancer

Background

The aim of this study was to analyze the safety and effectiveness of stenting using partially covered self-expandable stents in palliation of dysphagia in patients with unresectable esophageal cancer.

Methods

Retrospective analysis of hospital records of all patients who underwent esophageal stenting in the period 2008–2015 was performed. The study included patients with unresectable esophageal and esophagogastric cancer.

Results

There were 442 patients included. Mean age was 56 years (range 28–89), and 379 were males. In 40 (9.0%) patients, stenting was performed in the cervical, in 150 (39.3%)—in the middle thoracic, in 141 (31.9%)—in lower thoracic esophagus and in 111 (25.1%)—in the esophagogastric junction. Stenting resulted in significant alleviation of dysphagia grade (3.0 vs. 1.0, p = 0.00001). During the follow-up, 55 (12.4%) patients experienced recurrent dysphagia due to tumor or granulation tissue overgrowth, and in 18 (4.1%) patients, migration of the stent occurred, for which an independent risk factor was adjuvant chemo- and/or radiation therapy (p = 0.001). Minor complications included chest pain (54.5%), delayed complete stent expansion (12.0%), feeling of a foreign body (25.3%), hiccup (1.6%), gastroesophageal reflux (45.6%) and post-discharge pneumonia (2.5%). A feeling of a foreign body in the esophagus was significantly more common after stenting of the cervical esophagus (p = 0.0001), and hiccup was more common after stenting of the esophagogastric junction (p = 0.02). Major complications included bleeding (1.3%), respiratory insufficiency (0.7%), esophageal perforation (0.9%) and irregular heartburn (2.3%). Overall procedure-related mortality was 0.4%. The median survival time was 117.8 days (range 2–732).

Conclusions

Stenting is an effective procedure in relieving dysphagia in patients with unresectable malignant esophageal stenosis and is associated with low rate of postoperative and long-term complications.