A meta-analysis of randomized controlled trials that compared neoadjuvant chemoradiation and surgery to surgery alone for resectable esophageal cancer

Monitoring sputum culture in resected esophageal cancer patients with preoperative treatment

Pneumonia is a major cause of postesophagectomy mortality and worsens the long-term survival in resected esophageal cancer patients. Moreover, preoperative treatments such as chemotherapy or chemoradiotherapy (which have recently been applied worldwide) might affect the bacterial flora of the sputum. To investigate the association among preoperative treatments, the bacterial flora of sputum, and the clinical and pathological features in resected esophageal cancer patients, this study newly investigates the effect of preoperative treatments on the bacterial flora of sputum. We investigated the association among preoperative treatments, the bacterial flora of sputum, and clinical and pathological features in 163 resected esophageal cancer patients within a single institution. Pathogenic bacteria such as Candida (14.1%), Staphylococcus aureus (6.7%), Enterobacter cloacae (6.1%), Haemophilus parainfluenzae (4.9%), Klebisiella pneumoniae (3.7%), Methicillin-resistant Staphylococcus aureus (MRSA) (3.7%), Pseudomonas aeruginosa (2.5%), Escherichia coli (1.8%), Streptococcus pneumoniae (1.8%), and Haemophilus influenzae (1.2%) were found in the sputum. The pathogen detection rate in the present study was 34.3% (56/163). In patients with preoperative chemotherapy and chemoradiotherapy, the indigenous Neisseria and Streptococcus species were significantly decreased (P= 0.04 and P= 0.04). However, the detection rates of pathogenic bacteria were not associated with preoperative treatments (all P> 0.07). There was not a significant difference of hospital stay between the sputum-monitored patients and unmonitored patients (35.5 vs. 49.9 days; P= 0.08). Patients undergoing preoperative treatments exhibited a significant decrease of indigenous bacteria, indicating that the treatment altered the bacterial flora of their sputum. This finding needs to be confirmed in large-scale independent studies or well-designed multicenter studies.

Development of a novel biomarker model for predicting preoperative lymph node metastatic extent in esophageal squamous cell carcinoma1

The number and range of lymph node metastasis (LNM) are critical prognostic factors in esophageal squamous cell carcinoma (ESCC). Preoperative serum biomarkers are reported to be associated with LNM. However, whether these markers can precisely predict the extent of LNM is not known. The aim of this study was to evaluate the predictive value of preoperative serum SCC-Ag, Cyfra21-1, CEA, CA19-9 and CA72-4 for LNM number and range by retrospectively investigating 577 ESCC patients undergone esophagectomy from 2007-2010. In this study, the positive rate of SCC-Ag and CA19-9 were associated with pN stage. Significant differences were found in CEA and CA19-9 between pN0-1 stage patients and pN2-3 stage patients. However, in subgroup analysis (patients with pN0-1), significant difference was found only in SCC-Ag between pN0 and pN1 stage patients (P=0.003). Middle thoracic ESCC patients were Chosen to analyze the correlation between the range of LNM and biomarkers. SCC-Ag was correlated with paraesophageal and paracardial lymph nodes, but not correlated with subcarinal and left gastric artery lymph nodes. Interestingly, the results of CEA were opposite to that of SCC-Ag. CA19-9 was associated with subcarinal and paracardial LNM (P=0.000, P=0.038). Based on the results, a model incorporated SCC-Ag, CEA and CA19-9 was constructed. The rate of patients with pN2-3 stage was 15.4% and 54.4% in group 1 and 4 of our model.

In summary, SCC-Ag was associated with early lymph node metastatic stage, and CEA and CA19-9 have a close relationship with advanced lymph node metastatic stage. The model combining SCC-Ag, CEA and CA19-9 might help identify the preoperative extent of LNM for a subgroup of ESCC patients that can be benefited from neoadjuvant therapy.

Treatment results of neoadjuvant chemoradiotherapy followed by radical esophagectomy in patients with initially inoperable thoracic esophageal cancer

PURPOSE

We evaluated the effectiveness of neoadjuvant chemoradiotherapy (CRT) followed by esophagectomy for cT4 esophageal cancer or lymph node metastases (LNM) invading adjacent structures.

MATERIALS AND METHODS

We retrospectively evaluated 42 consecutive patients with thoracic esophageal cancer who underwent CRT followed by esophagectomy between 2008 and 2013. All were initially considered to be unresectable because of cT4 (n = 32) disease or LN invasion (n = 10). Radiotherapy was administered at 41.4 Gy/23 fr with concurrent chemotherapy. At completion of CRT, restaging was performed using computed tomography (CT).

RESULTS

All cT4 tumors were downstaged, LNM invading to adjacent structures were considered to be released, and subtotal esophagectomy was performed. The median follow-up period was 42 months. The curative resection (R0) rate was 94% in cT4 group and 70% in LN invasion group. The 3-year overall survival (OS) and 3-year locoregional control (LRC) rates were 65-80% in the cT4 group and 50-67% in LN invasion group, respectively.

CONCLUSIONS

The cT4 group showed good rates of R0, OS, and LRC. Surgical resection should be an effective option when downstaging is achieved by CRT for patients with initially inoperable thoracic esophageal cancer.

CT-based assessment of visceral adiposity and outcomes for esophageal adenocarcinoma

Background

Various methods of quantifying and correlating obesity to outcomes for patients with esophageal adenocarcinoma (EA) have been evaluated. Published data suggest that quantification of adiposity may be more accurate than body mass index (BMI) as a prognostic factor. We report our analysis of adiposity as a prognostic factor in a series of patients with EA.

Methods

This single institution retrospective review included patients with EA who underwent esophagectomy from 1994-2008. Patients with BMI <20 were excluded. Using the preoperative CT scan, the visceral (VFA), subcutaneous (SFA), and total abdominal fat (TFA) areas were calculated. Each was contoured on a Siemens Leonardo workstation at the level of the iliac crest (L4/5). The Hounsfield threshold was -30 to -130. Outcomes were analyzed using Kaplan-Meier method and log-rank analysis. Multivariate analysis (MVA) was performed using the Cox proportion hazard regression model.

Results

We identified 126 patients for the analysis. There were no statistically significant differences in overall survival or disease-free survival between groups above and below the medians for TFA, SFA, or VFA/SFA ratio. However, an increase in VFA was significantly associated with worsened OS and DFS when we further classified patients into quartiles. Patients with VFA ≥182 cm² had larger tumor size (P=0.016), fewer involved lymph nodes (P=0.047), longer operating times (P=0.032), and were more likely to be males (P=0.042).

Conclusions

Published data have demonstrated an association between treatment outcomes and degree of adiposity; our study found a correlation between VFA and OS and DFS in patients with EA. Median TFA, SFA, and VFA/SFA were not prognostic on MVA. While VFA >182 cm² was associated with larger tumors, there were also fewer lymph nodes harvested in this group.

Handgrip Strength Is Associated With Treatment Modifications During Neoadjuvant Chemoradiation in Patients With Esophageal Cancer

RATIONALE

It has been shown that early nutrition intervention improves nutrition status (NS) and treatment tolerance in patients with esophageal cancer. However, it remains unknown whether pretreatment parameters of NS are associated with treatment modifications (TMs) during neoadjuvant chemoradiation (CR) in patients who are intensively nutritionally supervised during treatment.

METHODS

All outpatients with esophageal cancer who were scheduled for CR in the VU medical center from 2006-2015 were included. NS was assessed by body mass index (BMI), weight loss in the past 6 months (WL), fat mass index (FMI) and fat-free mass index (FFMI), handgrip strength (HGS), and energy/protein intake. Logistic regression analyses, adjusted for age, sex, previous tumor, tumor stage, and physical status, were applied. TMs were defined as delay, dose reduction or discontinuation of chemotherapy and/or radiotherapy, hospitalization, or mortality (yes/no).

RESULTS

In total, 162 patients were included (73% male; mean age 65 ± 9 years). Mean BMI was 25.1 ± 4.5 kg/m2, and WL was 4.8 ± 5.1 kg. HGS and FFMI were below the 10th percentile of reference values in 21 and 37 patients, respectively. Thirty-five (22%) patients experienced at least 1 TM during CR; unplanned hospitalization (n = 18, 11%) was the most prevalent. After adjustments for confounders, only HGS was statistically significantly associated with TMs (odds ratio, 0.93; 95% confidence interval, 0.88-1.00).

CONCLUSION

In this group of intensively supervised patients with esophageal cancer, pretreatment parameters of NS had little influence on TMs during CR. Only a lower HGS was associated with TMs.

Effects of neoadjuvant chemotherapy combined with radiotherapy in patients with advanced esophageal carcinoma

We analyzed the improvement of survival time and the effects of neoadjuvant chemotherapy combined with radiotherapy on treating patients with advanced esophageal carcinoma. Retrospectively, 43 patients were selected with esophageal carcinoma who were administered neoadjuvant chemotherapy combined with radiotherapy. According to gender, and tumor staging, the nearest neighbor matching was carried out. Eighty-six patients (1:2) who received neoadjuvant chemotherapy and 129 patients (1:3) who underwent surgery only were taken and compared for clinical outcomes. It was found that in the combination group, the median survival time was prolonged and the 1-year survival rate improved. The diameter of tumors was significantly reduced, and the surgical resection, margin negative and total effective rates improved. In addition, the recurrence rate significantly decreased, whereas quality of life scores significantly increased (p<0.05). The comparison of overall incidence of complications was not statistically significant (p>0.05). Tumor staging, location, and diameter after neoadjuvant therapy, as well as therapeutic regimen, treatment cycle, margin negative rate and effective rate were independent risk factors for significantly influencing survival outcomes and time (p<0.05). In conclusion, neoadjuvant chemotherapy combined with radiotherapy can be utilized to treat advanced esophageal carcinoma improve survival time and promote prognosis.

Induction Therapy for Locally Advanced, Resectable Esophagogastric Cancer: A Phase I Trial of Vandetanib (ZD6474), Paclitaxel, Carboplatin, 5-Fluorouracil, and Radiotherapy Followed by Resection

OBJECTIVES

Preoperative chemotherapy and radiation for localized esophageal cancer produces cure rates near 30% when combined with surgical resection. Vandetanib, a small molecule receptor tyrosine kinase inhibitor of VEGFR-2, VEGFR-3, RET, and EGFR, demonstrated synergy with radiation and chemotherapy in preclinical models. We conducted a phase I study to assess the safety and tolerability of vandetanib when combined with preoperative chemoradiation in patients with localized esophageal carcinoma who were surgical candidates.

METHODS

Patients with stage II-III esophageal and gastroesophageal junction carcinoma without prior therapy were enrolled in a 3+3 phase I design. Patients received once-daily vandetanib (planned dosing levels of 100, 200, and 300 mg) with concomitant daily radiotherapy (1.8 Gy/d, 45 Gy total) and chemotherapy, consisting of infusional 5-FU (225 mg/m/d over 96 h, weekly), paclitaxel (50 mg/m, days 1, 8, 15, 22, 29) and carboplatin (AUC of 5, days 1, 29).

RESULTS

A total 9 patients were enrolled with 8 having either distal esophageal or gastroesophageal junction carcinomas. All patients completed the planned preoperative chemoradiation and underwent esophagectomy. Nausea (44%) and anorexia (44%) were the most common acute toxicities of any grade. One grade 4 nonhematologic toxicity was observed (gastrobronchial fistula). One additional patient suffered a late complication, a fatal aortoenteric hemorrhage, not definitively related to the investigational regimen. Five (56%) patients achieved a pathologic complete response. Three (33%) additional patients had only microscopic residual disease. Five (56%) patients remain alive and disease free with a median follow-up of 3.7 years and median overall survival of 3.2 years. The maximum tolerated dose was vandetanib 100 mg/d.

CONCLUSIONS

Vandetanib at 100 mg daily is tolerable in combination with preoperative chemotherapy (5-FU, paclitaxel, carboplatin) and radiation therapy with encouraging efficacy worthy of future study.

Neoadjuvant Therapy for Esophageal Adenocarcinoma in the Community Setting-Practice and Outcomes

There has been an alarming rise in the incidence of esophageal adenocarcinoma which continues to have poor survival rates primarily due to lack of effective chemotherapy and presentation at advanced stages. Over a dozen chemotherapeutic agents are FDA approved for esophageal cancer (EC), and a two or three-drug combination is typically prescribed as first-line therapy for the majority of EC patients, administered either pre or post-operatively with esophageal resection. We have noticed significant variability in adjuvant and neoadjuvant regimens used in the community setting. The aim of this study was to review the various drug regimens used in the neoadjuvant setting for EC patients with adenocarcinoma undergoing resection at a single tertiary referral center in the Midwest. A total of 123 patients (stage II–III) underwent esophageal resection after neoadjuvant treatment at the center. Overall, 18 distinct drug regimens were used in 123 patients including two patients who received targeted therapy. Median survival post-surgery for this group was 11.2 months with no single regimen offering a survival advantage. These results reveal an unclear algorithm of how accepted regimens are prescribed in the community setting as well as a dire need for agents that are more effective. Additionally, it was noted that although proteomic markers have been found to predict drug response to 92% of the FDA-approved drugs in EC (12 of 13), according to pathology reports, molecular diagnostic testing was not used to direct treatment in this cohort. We therefore propose potential strategies to improve clinical outcomes including the use of a robust molecular oncology diagnostic panel and discuss the potential role for targeted chemotherapy and/or immunotherapy in the management of EC patients.

Importance of positron emission tomography for assessing the response of primary and metastatic lesions to induction treatments in T4 esophageal cancer

BACKGROUND

There is no consensus strategy for treatment of T4 esophageal cancer, and because of this, a better evaluation of treatment response is crucial to establish personalized therapies. This study aimed to establish a useful system for evaluating treatment response in T4 esophageal cancer.

METHODS

This study included 130 patients with cT4 esophageal cancer without distant metastasis who underwent ¹⁸F-fluorodeoxyglucose-positron emission tomography before and after a series of induction treatments comprising chemoradiation or chemotherapy. We evaluated the maximal standardized uptake value and treatment response.

RESULTS

The mean ± standard deviation of standardized uptake value in the primary tumor before and after induction treatments were 13.8 ± 4.4 and 5.4 ± 4.1, respectively, and the mean standardized uptake value decrease was 58.4%. The most significant difference in survival between positron emission tomography-primary tumor responders and nonresponders was at a decrease of 60% standardized uptake value, based on every 10% stepwise cutoff analysis (2-year cause-specific survival: 60.2 vs 23.5%; hazard ratio = 2.705; P < .0001). With this cutoff value, the resectability (P = .0307), pathologic response (P = .0004), and pT stage (P < .0001) were associated with positron emission tomography-primary tumor response. Univariate analysis of 2-year cause-specific survival indicated a correlation between cause-specific survival and clinical stages according to TNM classification, esophageal perforation, positron emission tomography-primary tumor response, lymph node status evaluated by positron emission tomography before and after induction treatments, and operative resection. Multivariate analysis further identified positron emission tomography-primary tumor response (hazard ratio = 2.354; P = .0107), lymph node status evaluated by positron emission tomography after induction treatments (hazard ratio = 1.966; P = .0089), and operative resection (hazard ratio = 2.012; P = .0245) as independent prognostic predictors.

CONCLUSION

Positron emission tomography evaluation of the response of primary and metastatic lesions to induction treatments is important to formulate treatment strategies for cT4 esophageal cancer.

Value and application of trimodality therapy or definitive concurrent chemoradiotherapy in thoracic esophageal squamous cell carcinoma

BACKGROUND

Few large, prospective, randomized studies have investigated the value and optimal application of neoadjuvant chemoradiotherapy followed by surgery (trimodality therapy) or definitive concurrent chemoradiotherapy (CCRT) for patients with thoracic esophageal squamous cell carcinoma (TESCC).

METHODS

The authors analyzed data from patients with TESCC in the Taiwan Cancer Registry database. To compare their outcomes, patients with TESCC were enrolled and categorized into the following groups according to treatment modality: group 1, those who underwent surgery alone; group 2, those who received trimodality therapy; and group 3, those who received definitive CCRT. Group 1 was used as the control arm for investigating the risk of mortality after treatment.

RESULTS

In total, 3522 patients who had TESCC without distant metastasis were enrolled. Multivariate Cox regression analysis indicated that a Charlson comorbidity index score ≥3, American Joint Committee on Cancer stage ≥IIA, earlier year of diagnosis, alcohol consumption, cigarette smoking, and definitive CCRT were significant, independent predictors of a poor prognosis. After adjustment for confounders, adjusted hazard ratios and 95% confidence intervals (CIs) for overall mortality in patients with clinical stage I, IIA, IIB, IIIA, IIIB, and IIIC TESCC were 2.01 (95% CI, 0.44-6.18), 1.65 (95% CI, 0.99-2.70), 1.48 (95% CI, 0.91-2.42), 0.66 (95% CI, 1.08-1.14), 0.39 (95% CI, 0.26-0.57), and 0.44 (95% CI, 0.24-0.83), respectively, in group 2; and 2.06 (95% CI, 1.18-3.59), 2.65 (95% CI, 1.76-4.00), 2.25 (95% CI, 1.49-3.39), 1.34 (95% CI, 0.79-2.28), 0.82 (95% CI, 0.57-1.17), and 0.93 (95% CI, 0.51-1.71), respectively, in group 3.

CONCLUSIONS

Trimodality therapy may be beneficial for the survival of patients with advanced-stage (IIIA-IIIC) TESCC, and CCRT might be an alternative to surgery alone in these patients. Cancer 2017;123:3904-15. © 2017 American Cancer Society.

Histopathologic Features are more Important Prognostic Factors than Primary Tumour Location in Gastro-oesophageal Adenocarcinoma Treated with Preoperative Chemoradiation and Surgery

The aim of present study was to evaluate the impact of primary tumour location and other factors on the outcome of preoperative chemoradiation followed by surgery in adenocarcinomas of distal oesophagus, gastro-oesophageal junction and stomach. We retrospectively reviewed the institutional patient database. The therapeutic response was re-evaluated as a percentage of residual tumor cells in surgical resection specimens. Overall survival (OS) and disease-free survival (DFS) were assessed. The effect primary tumour location, clinical and pathological TNM stage, and histopathological factors (histological type, grade, angioinvasion, perineural invasion, tumour response) on treatment outcome were evaluated. A total of 108 patients underwent preoperative chemoradiation for adenocarcinoma of distal oesophagus, gastro-oesophageal junction or stomach. The median prescribed dose of radiation was 45 Gy. The concurrent chemotherapy consisted of 5-fluorouracil +/- cisplatin +/- taxanes. R0 resection was achieved in 80 patients (74%). The complete response was observed in 19%. The median follow-up was 50.8 months. Three-year and 5-year OS and DFS were 36.2% and 25.3%; and 28.1% and 23.7%, respectively. Pretreatment T-stage, pathological N-stage, radicality of resection, histological subtype, grade, angioinvasion and perineural invasion, were identified as statistical significant OS predictors in univariate analysis; pathological N-stage, radicality of resection and angioinvasion, in multivariate analysis. The primary tumor location did not influence the prognosis. The pathologic response to chemoradiation had borderline significance. In conclusion, no prognostic impact of primary tumour location, in contrast to other investigated factors, was evident in the present study. The most important predictors of prognosis were angioinvasion status and pN-stage.

Esophageal cancer's 100 most influential manuscripts: a bibliometric analysis

Bibliometric analysis highlights key topics and publications that have shaped the understanding and management of esophageal cancer (EC). Here, the 100 most cited manuscripts in the field of EC are analyzed. The Thomson Reuters Web of Science database with the search terms 'esophageal cancer' or 'esophageal carcinoma' or 'oesophageal cancer' or 'oesophageal carcinoma' or 'gastroscopy' was used to identify all English language full manuscripts for the study. The 100 most cited papers were further analyzed by topic, journal, author, year, and institution. A total of 121,556 eligible papers were returned and the median (range) citation number was 406.5 (1833 to 293). The most cited paper focused on the role of perioperative chemotherpy in EC (1833 citations). Gastroenterology published the highest number of papers (n = 15, 6362 citations) and The New England Journal of Medicine received the most citations (n = 12, 12125 citations). The country and year with the greatest number of publications were the USA (n = 50), and 1998, 1999, and 2000 (n = 7). The most ubiquitous topic was the pathology of EC (n = 66) followed by management of EC (n = 54), and studies related to EC prognosis (n = 44). The most cited manuscripts highlighted the pathology, management, and prognosis of EC and this bibliometirc review provides the most influential references serving as a guide to popular research themes.

NEOSCOPE: A randomised phase II study of induction chemotherapy followed by oxaliplatin/capecitabine or carboplatin/paclitaxel based pre-operative chemoradiation for resectable oesophageal adenocarcinoma

BACKGROUND

Oxaliplatin-capecitabine (OxCap) and carboplatin-paclitaxel (CarPac) based neo-adjuvant chemoradiotherapy (nCRT) have shown promising activity in localised, resectable oesophageal cancer.

PATIENTS AND METHODS

A non-blinded, randomised (1:1 via a centralised computer system), 'pick a winner' phase II trial. Patients with resectable oesophageal adenocarcinoma ≥ cT3 and/or ≥ cN1 were randomised to OxCapRT (oxaliplatin 85 mg/m2 day 1, 15, 29; capecitabine 625 mg/m2 bd on days of radiotherapy) or CarPacRT (carboplatin AUC2; paclitaxel 50 mg/m2 day 1, 8, 15, 22, 29). Radiotherapy dose was 45 Gy/25 fractions/5 weeks. Both arms received induction OxCap chemotherapy (2 × 3 week cycles of oxaliplatin 130 mg/m2 day 1, capecitabine 625 mg/m2 bd days 1-21). Surgery was performed 6-8 weeks after nCRT. Primary end-point was pathological complete response (pCR). Secondary end-points included toxicity, surgical morbidity/mortality, resection rate and overall survival.

STATISTICS

Based on pCR ≤ 15% not warranting future investigation, but pCR ≥ 35% would, 76 patients (38/arm) gave 90% power (one-sided alpha 10%), implying that arm(s) having ≥10 pCR out of first 38 patients could be considered for phase III trials. ClinicalTrials.gov: NCT01843829. Funder: Cancer Research UK (C44694/A14614).

RESULTS

Eighty five patients were randomised between October 2013 and February 2015 from 17 UK centres. Three of 85 (3.5%) died during induction chemotherapy. Seventy-seven patients (OxCapRT = 36; CarPacRT = 41) underwent surgery. The 30-d post-operative mortality was 2/77 (2.6%). Grade III/IV toxicity was comparable between arms, although neutropenia was higher in the CarPacRT arm (21.4% versus 2.6%, p = 0.01). Twelve of 41 (29.3%) (10 of first 38 patients) and 4/36 (11.1%) achieved pCR in the CarPacRT and OxcapRT arms, respectively. Corresponding R0 resection rates were 33/41 (80.5%) and 26/36 (72.2%), respectively.

CONCLUSION

Both regimens were well tolerated. Only CarPacRT passed the predefined pCR criteria for further investigation.

Radiation Therapy for Locally Advanced Esophageal Cancer

The treatment of locally advanced esophageal cancer is controversial. For patients who are candidates for surgical resection, multiple prospective clinical trials have demonstrated the advantages of neoadjuvant chemoradiation. For patients who are medically inoperable, definitive chemoradiation is an alternative approach with survival rates comparable to trimodality therapy. Although trials of dose escalation are ongoing, the standard radiation dose remains 50.4 Gy. Modern radiotherapy techniques such as image-guided radiation therapy with motion management and intensity-modulated radiation therapy are strongly encouraged with a planning objective to maximize conformity to the intended target volume while reducing dose delivered to uninvolved normal tissues.

Update on Neoadjuvant Regimens for Patients with Operable Oesophageal/Gastrooesophageal Junction Adenocarcinomas and Squamous Cell Carcinomas

Survival outcomes following multimodal treatment of operable oesophageal and gastrooesophageal cancer remain disappointingly poor. Although an appreciation of the impact of both tumour location and histological subtype is now shaping the design of clinical trials, there has been a lack of consensus of the optimal neoadjuvant treatment strategy. This update article will review recent advances in the use of both neoadjuvant chemotherapy and chemoradiotherapy. The emerging role of PET imaging to direct appropriate neoadjuvant treatment regimens and the additive benefit of biological agents are also discussed.

Prospective comparison of MR with diffusion-weighted imaging, endoscopic ultrasound, MDCT and positron emission tomography-CT in the pre-operative staging of oesophageal cancer: results from a pilot study

OBJECTIVE

To compare the diagnostic performance of MR and diffusion-weighted imaging (DWI), multidetector CT, endoscopic ultrasonography (EUS) and ¹⁸F-FDG (fluorine-18 fludeoxyglucose) positron emission tomography CT (PET-CT) in the pre-operative locoregional staging of oesophageal cancer.

METHODS

18 patients with oesophageal or Siewert I tumour (9 directly treated with surgery and 9 addressed to chemo-/radiotherapy before) underwent 1.5-T MR and DWI, 64-channel multidetector CT, EUS and PET-CT before (n = 18) and also after neoadjuvant treatment (n = 9). All images were analysed and staged blindly by dedicated operators (seventh TNM edition). Two radiologists calculated independently the apparent diffusion coefficient from the first scan. Results were compared with histopathological findings. After the population had been divided according to local invasion (T1-T2 vs T3-T4) and nodal involvement (N0 vs N+), sensitivity, specificity, accuracy, positive- and negative-predictive values were calculated and compared. Quantitative measurements from DWI and PET-CT were also analysed.

RESULTS

For T staging, EUS showed the best sensitivity (100%), whereas MR showed the highest specificity (92%) and accuracy (83%). For N staging, MR and EUS showed the highest sensitivity (100%), but none of the techniques showed adequate results for specificity. Overall, MR showed the highest accuracy (66%) for N stage, although this was not significantly different to the other modalities. The apparent diffusion coefficient was different between surgery-only and chemo-/radiotherapy groups (1.90 vs 1.30 × 10^-3 mm² s^-1, respectively; p = 0.005)-optimal cut off for local invasion: 1.33 × 10^-3 mm² s^-1 (p = 0.05). Difference in standardized uptake value was also very close to conventional levels of statistical significance (8.81 vs 13.97 g cm^-3, respectively; p = 0.05)-optimal cut off: 7.97 g cm^-3 (p = 0.44).

CONCLUSION

In this pilot study, we have shown that MR with DWI could enrich the current pre-operative work-up for oesophageal cancer and could be used for T and N staging. However, larger studies will need to be carried out before introducing this technique in the standard diagnostic pathway, in order to understand if MR with DWI could change its management and replace more costly or invasive tests such as PET-CT or EUS. Advances in knowledge: This pilot study represents the first effort where the four techniques have been prospectively compared together for oesophageal cancer staging. The combination of MR and DWI could provide important, additional information for staging and initial treatment decision-making.

Current status of proteomics of esophageal carcinoma

INTRODUCTION

Esophageal cancer (EC) is one of the most common causes of cancer-related death worldwide. Identifying suitable biomarkers for early diagnosis as well as predicting lymph node metastasis, prognosis and the therapeutic response of EC is essential for the effective and efficient management for EC. There is an urgent need to develop effective, novel approaches for patients who do not respond to conventional treatment. Areas covered: EC is characterized by the presence of two main histological types such as squamous cell carcinoma and adenocarcinoma, which differ in their response to treatments and prognosis. Thus, this review describes the latest research into biomarkers and novel treatment targets generated by cancer proteomics for the two main histological types. Finally, the main difficulties facing the translation of biomarkers and novel treatment targets into the clinical settings are discussed. Expert commentary: EC proteomics have provided useful results and, after their validation, novel clinical tools should be developed to improve the clinical outcomes for EC patients.

Overexpression of HSP47 in esophageal squamous cell carcinoma: clinical implications and functional analysis

Several biomarkers of esophageal squamous cell carcinoma (ESCC) have been explored to improve the prognosis of this disease. One of these, the 47-kDa heat shock protein (HSP47), has been screened as a potential biomarker by genomic profiling and is known to be overexpressed in some malignant diseases. In this study, we explored the role and evaluated the prognostic value of HSP47 expression in ESCC. The function of this protein was analyzed by assaying proliferation, wound healing, and colony formation in an HSP47-knockdown ESCC line. The prognostic implication of HSP47 expression was analyzed by immunohistochemical staining in 157 surgical specimens. HSP47 expression level and other clinical variables were analyzed using multivariate Cox proportional hazards models. Silencing of the HSP47 gene in the ESCC cell line inhibited cell proliferation and colony formation. HSP47 was highly expressed in ESCC tissue samples, compared with normal esophageal tissues. The level of immunohistochemical staining of HSP47 and pathologic stage were significantly correlated with overall and recurrence-free survival, as shown by multivariate analysis (P = 0.014 and 0.044, respectively). We found that overexpression of HSP47 is associated with poor prognosis in patients with ESCC and that this is consistent with the function of HSP47 in terms of increased cell proliferation and colony formation. These results suggest that HSP47 is a potential prognostic biomarker for ESCC and merits further research for novel diagnostic and therapeutic applications.

Outcome of neoadjuvant therapies for cancer of the oesophagus or gastro-oesophageal junction based on a national data registry

BACKGROUND

Randomized trials have shown that neoadjuvant treatment improves survival in the curative treatment of oesophageal and gastro-oesophageal junction cancer. Results from population-based observational studies are, however, sparse and ambiguous.

METHODS

This prospective population-based cohort study included all patients who had oesophagectomy for cancer in Sweden, excluding clinical T1 N0, recorded in the National Register for Oesophageal and Gastric Cancer, 2006-2014. Patients were stratified into three groups: surgery alone, neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy.

RESULTS

Neoadjuvant treatment was given to 521 patients (51·1 per cent) and 499 (48·9 per cent) received surgery alone. Neoadjuvant chemotherapy increased the risk of postoperative surgical complications compared with surgery alone (adjusted odds ratio 2·01, 95 per cent c.i. 1·24 to 3·25; P = 0·005). Postoperative mortality was significantly increased after neoadjuvant chemoradiotherapy compared with surgery alone (odds ratio 2·37, 1·06 to 5·29; P = 0·035). Survival improved in patients with squamous cell carcinoma after neoadjuvant chemotherapy, whereas after neoadjuvant chemoradiotherapy survival was significantly improved only in the subgroup with the highest performance status and without known co-morbidity. In adenocarcinoma there was a trend towards improved overall survival after neoadjuvant chemotherapy, but neoadjuvant chemoradiotherapy did not offer a survival benefit. Stratified analysis including only patients with adenocarcinoma in the highest performance category without known co-morbidity showed a strong trend towards improved survival after neoadjuvant chemotherapy compared with surgery alone (adjusted hazard ratio 0·47, 0·21 to 1·04; P = 0·061).

CONCLUSION

For patients with squamous cell carcinoma of the oesophagus or gastro-oesophageal junction, neoadjuvant treatments seemed to increase long-term survival, but also the risk of postoperative morbidity and mortality, compared with surgery alone. Neither neoadjuvant treatment option seemed to improve survival significantly among patients with adenocarcinoma, compared with surgery alone.

Impact of PET/CT on radiation treatment in patients with esophageal cancer: A systematic review

PURPOSE

With the advances in radiotracers, positron emission tomography/computed tomography (PET/CT) is recognized as a useful adjunct to anatomic imaging with CT, MRI and endoscopic ultrasonography (EUS). The objective of this review was to comprehensively analyze the roles of PET/CT for the radiotherapy of esophageal cancer.

METHODS

In this review, we focused on issues concerning the application of PET/CT in TNM staging, target volume delineation and response to therapy, both for the primary tumor and regional lymph nodes. Furthermore, the following questions were addressed: how does PET/CT guide appropriate treatment protocols, how does it allow accurate tumor delineation and how does it guide prognosis and future treatment decisions.

RESULTS AND CONCLUSION

For the staging of esophageal cancer, PET/CT played a crucial role in exploring distant malignant lymph nodes and metastasis with high sensitivity, specificity and accuracy. PET/CT using different radiotracer provided a serial of thresholding methods based on standardized uptake value (SUV) to assist in auto-contouring the gross tumor volume (GTV). The change in SUV may offer a potential paradigm of personalized treatment to definitive chemoradiotherapy (CRT). In total, PET/CT has sought to further optimize radiotherapy treatment planning for patients with esophageal cancer.

Potentially Curable Cancers of the Esophagus and Stomach

Gastric and gastroesophageal adenocarcinomas continue to be a major health burden globally and collectively represent the third leading cause of cancer death. Among patients with metastatic disease, most die of their cancer because of the limited number of modestly effective treatment regimens available today. The progress against these cancers has been slow compared with many other solid tumors despite many attempts. In-depth molecular profiling has also not been completed. Even when these cancers are localized, they impose considerable challenges for the patient, relatives, and treatment team alike. Localized gastric or gastroesophageal cancer is best managed with a multidisciplinary approach. This review focuses on the management of localized cancers by reviewing the current literature and explaining certain principles that help guide therapy for these patients. The future, however, will afford numerous opportunities, including exploitation of initial data from The Cancer Genome Atlas, to identify novel targets and drugs, harness the prowess of the immune system, and customize therapy for each patient.

Comparison of neoadjuvant versus a surgery first approach for gastric and esophagogastric cancer

Gastric cancer remains a significant worldwide health concern. While surgery is required for cure, all but the earliest of cancers will require multimodality therapy. Chemotherapy and chemoradiation in the neoadjuvant and adjuvant settings have shown to improve overall survival, but the sequencing of treatment is controversial. As healthcare expenses surge, it is increasingly important to impart value to these treatments. This review will look at the intersection of effective treatment and costs for gastric cancer. J. Surg. Oncol. 2016;114:296-303. © 2016 Wiley Periodicals, Inc.

Outcome after Transthoracic Resection of Carcinoma of the Oesophagus and Oesophago-Gastric Junction

Aims:

To assess the postoperative morbidity and mortality, length of stay and long-term survival after resection of carcinoma of the oesophagus and gastro-oesophageal junction, after establishment of a new surgical team unit between thoracic and gastroenterologic surgeons.

Methods:

We analysed the prospective collected data of 166 consecutive patients who underwent a transthoracic oesophageal resection between June 1997 and December 2003.

Results:

There were 119 men and 47 women. The median age was 63 years (range 36–81). Fifty-five patients (33 %) had squamous cell carcinoma and 111 (67 %) had adenocarcinoma. Postoperative complications occurred in a total of 60 patients (36 %). Ten patients (6 %) died postoperatively, eight (4.8 %) due to medical and two (1.2 %) due to surgical complications. The median postoperative length of stay was 11 days (range 6–75). The overall 3- and 5- years survival was 35.6 % and 30.6 % respectively. Survival was adversely affected by patient age and tumor stage.

Conclusions:

Concentrating resection for carcinoma of the oesophagus and oesophagogastric junction to a dedicated team of specialists, including both gastrointestinal and thoracic surgeons as well as thoracic-anaesthesiological know-how, results in acceptable complication rates as well as low mortality rates especially due to surgical complications.

Using the Comprehensive Complication Index to Assess the Impact of Neoadjuvant Chemoradiotherapy on Complication Severity After Esophagectomy for Cancer

Background

Neoadjuvant chemoradiotherapy (nCRT) followed by surgery for patients with esophageal or junctional cancer has become a standard of care. The comprehensive complication index (CCI) has recently been developed and accounts for all postoperative complications. Hence, CCI better reflects the burden of all combined postoperative complications in surgical patients than the Clavien–Dindo score alone, which incorporates only the most severe complication. This study was designed to evaluate the severity of complications in patients treated with nCRT followed by esophagectomy versus in patients who underwent esophagectomy alone using the comprehensive complication index.

Study-design

All patients included in the CROSS trial—a randomized, clinical trial on the value of nCRT followed by esophagectomy—were included. Complications were assessed and graded using the Clavien–Dindo classification. CCI was derived from these scores, using the CCI calculator available online (www.assessurgery.com). CCI of patients who underwent nCRT followed by surgery was compared with the CCI of patients who underwent surgery alone.

Results

In both groups 161 patients were included. The median (and interquartile range) CCI of patients with nCRT and surgery was 26.22 (17.28–42.43) versus 25.74 (8.66–43.01) in patients who underwent surgery alone (p = 0.58). There also was no difference in CCI between subgroups of patients with anastomotic leakage, pulmonary complications, cardiac complications, thromboembolic events, chyle leakage, and wound infections.

Conclusions

Neoadjuvant chemoradiotherapy according to CROSS did not have a negative impact on postoperative complication severity expressed by CCI compared with patients who underwent surgery alone for potentially curable esophageal or junctional cancer.

Intensity modulated radiation therapy with simultaneous integrated boost based dose escalation on neoadjuvant chemoradiation therapy for locally advanced distal esophageal adenocarcinoma

AIM: To evaluate impact of radiation therapy dose escalation through intensity modulated radiation therapy with simultaneous integrated boost (IMRT-SIB).

METHODS: We retrospectively reviewed the patients who underwent four-dimensional-based IMRT-SIB-based neoadjuvant chemoradiation protocol. During the concurrent chemoradiation therapy, radiation therapy was through IMRT-SIB delivered in 28 consecutive daily fractions with total radiation doses of 56 Gy to tumor and 5040 Gy dose-painted to clinical tumor volume, with a regimen at the discretion of the treating medical oncologist. This was followed by surgical tumor resection. We analyzed pathological completion response (pCR) rates its relationship with overall survival and event-free survival.

RESULTS: Seventeen patients underwent dose escalation with the IMRT-SIB protocol between 2007 and 2014 and their records were available for analysis. Among the IMRT-SIB-treated patients, the toxicity appeared mild, the most common side effects were grade 1-3 esophagitis (46%) and pneumonitis (11.7%). There were no cardiac events. The Ro resection rate was 94% (n = 16), the pCR rate was 47% (n = 8), and the postoperative morbidity was zero. There was one mediastinal failure found, one patient had local failure at the anastomosis site, and the majority of failures were distant in the lung or bone. The 3-year disease-free survival and overall survival rates were 41% (n = 7) and 53% (n = 9), respectively.

CONCLUSION: The dose escalation through IMRT-SIB in the chemoradiation regimen seems responsible for down-staging the distal esophageal with well-tolerated complications.

Delaying surgery after neoadjuvant chemoradiotherapy does not significantly influence postoperative morbidity or oncological outcome in patients with oesophageal adenocarcinoma

BACKGROUND

Patients with resectable oesophageal cancer are treated with neoadjuvant chemoradiotherapy (nCRT) followed by surgery within 3-8 weeks. In practice, surgery is often delayed for various reasons. The aim of this study was to evaluate whether delaying surgery beyond 8 weeks has an effect on postoperative morbidity, long-term survival, and pathologic response in patients treated for oesophageal ADC.

METHODS

Patients who underwent nCRT followed by surgery, for cT1-3, N0-3, M0 ADC between 2001 and 2014 were retrospectively included from a prospectively obtained database. Patients with a time from the end of nCRT to surgery (TTS) ≤8 weeks were compared with patients with a TTS >8 weeks.

RESULTS

Of 190 patients, 65 had a TTS ≤8 weeks, and 125 had a TTS >8 weeks. Patient characteristics were comparable for both groups, but patients with TTS >8 weeks exhibited higher ASA scores (p = 0.013) and more comorbidities (p = 0.007). Multivariate analysis revealed that TTS did not significantly influence postoperative morbidity, pathologic complete response rates, and five-year survival rates (42% in patients with TTS ≤8 weeks and 37% in patients with TTS >8 weeks).

CONCLUSIONS

Delaying surgery beyond 8 weeks after nCRT did not significantly influence postoperative morbidity, pathologic response, and survival in patients with non-metastatic ADC. Therefore, it appears reasonable to postpone surgery beyond 8 weeks in patients who have not yet recovered from nCRT. However, if the patient is fit for surgery, postponing surgery does not have any additional advantages.

Perioperative outcomes associated with robotic Ivor Lewis esophagectomy in patient's undergoing neoadjuvant chemoradiotherapy

BACKGROUND

Neoadjuvant chemoradiotherapy (NCR) for the treatment of esophageal cancer has been associated with increased perioperative morbidity and mortality. Minimally invasive procedures utilizing robotic techniques have been shown to reduce perioperative complications and length of hospitalization (LOH). The purpose of this study is to compare perioperative outcomes between patients undergoing NCR and robotic-assisted Ivor Lewis esophagectomy (RAIL) versus upfront RAIL.

METHODS

A database of esophagectomy patients was queried to identify RAIL patients. Differences in perioperative outcomes were analyzed between NCR and non NCR patients.

RESULTS

Eighty-nine patients were identified who underwent RAIL Seventy-seven patients (87%) had NCR and 22 patients did not (13%). The median age was 66 (range, 44-83). The median age of the patients treated with NCR was younger {69 [44-83] vs. 64 [46-81] years respectively, P=0.05}. The patients who underwent NCR had a higher BMI then those who went straight to esophagectomy (31 vs. 27; P=0.001). There were no conversions to open laparotomy or thoracotomy in either group. There were no statistically significant differences in the mean operative times and estimated blood loss (EBL) between both groups. Complications occurred in 17 (19.1%) patients. There were no statistically significant differences in the rates of any complications between patients receiving NCR and those that did not receive NCR (P=0.11). There were no deaths in either group. The total number of days in hospital and total number of intensive care unit (ICU) days were also similar in both groups (P=0.25). There was no statistically significant difference in the mean number of lymph nodes harvested in the patients treated with NCR compared with those treated without NCR.

CONCLUSIONS

We have demonstrated that RAIL is a safe and feasible option for patients with esophageal cancer. The administration of NCR to RAIL did not result in an increase in perioperative morbidity and mortality. The number of lymph nodes harvested and the completeness of resection was also similar between patients who received NCR and those who did not. Longer follow-up is required in order to determine long term oncologic outcome.

Comparison between surgery and definitive chemoradiotherapy for patients with resectable esophageal squamous cell carcinoma: a propensity score analysis

PURPOSE

Our intent was to compare survival following neoadjuvant chemotherapy followed by surgery versus chemoradiotherapy (CRT) among patients with potentially resectable esophageal squamous cell carcinoma.

METHODS

Information about 406 consecutive esophageal cancer patients with resectable disease who underwent surgery with neoadjuvant chemotherapy consisting of cisplatin plus 5-fluorouracil or who underwent definitive CRT was reviewed. The survival outcomes were analyzed using the Kaplan-Meier method and propensity score-adjusted Cox proportional hazards models. Relevant variables were included in the propensity score model.

RESULTS

Overall, 206 patients planned to undergo surgery (S group) and 200 patients planned to undergo CRT (CRT group). In the unadjusted situation, progression-free survival and overall survival did not differ statistically between the groups. After matching, both survival outcomes were better in the S group compared to the CRT group. Subanalysis showed both survival outcomes were better in the S group for patients with only stage III disease. However, survival outcomes for stages I, II, and IV were not significantly different between treatment groups.

CONCLUSIONS

Among patients with resectable disease, survival outcomes in the S group were favored over those of the CRT group. These results indicate that different therapeutic strategies should be used for stage III esophageal cancer than for other stages.

Genome-wide hypomethylation and specific tumor-related gene hypermethylation are associated with esophageal squamous cell carcinoma outcome

INTRODUCTION

Esophageal squamous cell carcinoma (ESCC) is a cancer of variable outcomes with limited effective treatments resulting in poor overall survival (OS). Epigenetic alterations contributing to this deadly cancer type that can be used as novel therapeutic or diagnostic targets are still poorly understood.

METHODS

We explored genome-wide DNA methylation data from The Cancer Genome Atlas project and identified a panel of tumor-related genes hypermethylated in ESCC. The methylation statuses of RASSF1, RARB, CDKN2A (p16INK4a, p14ARF), APC, and RUNX3 genes and long interspersed nucleotide element-1 (LINE-1) were validated in a large cohort (n = 140) of clinically well-annotated ESCC specimens and esophageal normal mucosa (n = 28) using a quantitative methylation-specific polymerase chain reaction.

RESULTS

Hypermethylation of RARB, p16INK4a, RASSF1, APC, RUNX3, and p14ARF were observed in 55%, 24%, 20%, 19%, 14%, and 8% of specimens, respectively. Hypermethylation of APC was significantly associated with tumor depth (p = 0.02) and American Joint Committee on Cancer stage (p = 0.03). Global DNA methylation level, assessed by LINE-1, was significantly lower in ESCC than in normal mucosa (p < 0.0001), and lower in greater than or equal to T2 (n = 69) than T1 tumors (n = 45; p = 0.03). There was a significant inverse correlation between LINE-1 and RARB methylation (p = 0.008). Importantly, hypermethylation of RASSF1 and APC genes was significantly associated with overall survival (OS; p = 0.006 and p = 0.007, respectively). In addition, patients with tumors containing a higher number of methylated genes (greater than two genes) presented worse OS (p = 0.003).

CONCLUSIONS

This study demonstrates that epigenetic alterations of a panel of tumor-related genes and the noncoding region LINE-1 can be used as prognostic indicators and help in clinical management of ESCC patients.

Combined Modality Therapy for Thoracic and head and Neck Cancers: A Review of Updated Literature Based on a Consensus Meeting

Purpose

Combined modality therapy is a mainstay option for thoracic malignancies and head and neck cancers. The integration of different strategies is based on the multidisciplinary approach of modern clinical oncology. Radiation oncologists have to be educated, trained, and updated to provide state-of-the-art care to cancer patients and thus educational meetings are crucial.

Methods

The Italian Association of Radiation Oncology Young Members Working Group (AIRO Giovani) organized its 8th national meeting, focused on combination therapy in lung, esophageal, and head and neck cancer (with a specific focus on larynx-preservation strategies for larynx/hypopharynx tumors), involving young professionals working in Italy. The meeting was addressed to young radiation oncologists, presenting state-of-the-art knowledge, based on the latest evidence in this field. We performed a review of the current literature based on the highlights of the Congress.

Results

The multimodality approach of head and neck and thoracic malignancies includes surgery, chemotherapy, and radiotherapy, but also has to take into account new information and data coming from basic and translational research and including molecular biology, genetics, and immunology. All these aspects are crucial for the treatment of non-small-cell lung cancer and esophageal, esophagogastric junction, and larynx/hypopharynx malignancies. The integration of different treatments in the clinical decision-making process to combine therapies is crucial.

Conclusions

Combination therapy has proved to be a consolidated approach in these specific oncologic settings, highlighting the importance of multimodality management in modern clinical oncology. Dedicated meetings on specific topics are helpful to improve knowledge and skills of young professionals in radiation oncology.

The Comparison of Computed Tomography Perfusion, Contrast-Enhanced Computed Tomography and Positron-Emission Tomography/Computed Tomography for the Detection of Primary Esophageal Carcinoma

OBJECTIVE

The purpose of this study was to investigate the efficiency of computed tomography perfusion (CTP), contrast-enhanced computed tomography (CECT) and 18F-fluoro-2-deoxy-D-glucose (18F-FDG) positron-emission tomography (PET/CT) in the diagnosis of esophageal cancer.

SUBJECTS AND METHODS

This prospective study consisted of 33 patients with pathologically confirmed esophageal cancer, 2 of whom had an esophageal abscess. All the patients underwent CTP, CECT and PET/CT imaging and the imaging findings were evaluated. Sensitivity, specificity and positive and negative predictive values were calculated for each of the 3 imaging modalities relative to the histological diagnosis.

RESULTS

Thirty-three tumors were visualized on CTP, 29 on CECT and 27 on PET/CT. Six tumors were stage 1, and 2 and 4 of these tumors were missed on CECT and PET/CT, respectively. Significant differences between CTP and CECT (p = 0.02), and between CTP and PET/CT (p = 0.04) were found for stage 1 tumors. Values for the sensitivity, specificity and positive and negative predictive values on CTP were 100, 100, 100 and 100%, respectively. Corresponding values on CECT were 93.94, 0, 93.94 and 0%, respectively, and those on PET/CT were 87.88, 0, 93.55 and 0%, respectively. Hence, the sensitivity, specificity and positive and negative predictive values of CTP were better than those of CECT and PET/CT.

CONCLUSION

CTP had an advantage over CECT and PET/CT in detecting small lesions. CTP was valuable, especially in detecting stage 1 tumors.

A clinical trial of neoadjuvant concurrent chemoradiotherapy followed by resection for esophageal carcinoma

Background:

Esophageal carcinoma is a common malignancy in the North East of Iran. Combined modality treatments have been adopted to improve survival in patients with esophageal carcinoma. In this trial, we evaluated the efficacy and toxicity of a preoperative concurrent chemoradiotherapy protocol in the patients with locally advanced esophageal carcinoma.

Materials and Methods:

Between 2006 and 2011, eligible patients with locally advanced esophageal carcinoma underwent concurrent radiotherapy and chemotherapy and 3-4 weeks later, esophagectomy. Pathologic response, overall survival rate, toxicity, and feasibility were evaluated.

Results:

One hundred ninety-seven patients with a median age of 59 (range: 27-70) entered the protocol. One hundred ninety-four cases (98.5%) had esophageal squamous cell carcinoma. Grades 3-4 of toxicity in patients undergoing neoadjuvant chemoradotherapy were as follows: Neutropenia in 21% and esophagitis in 2.5% of cases. There were 11 (5.6%) early death probably due to the treatment-related toxicities. One hundred twenty-seven patients underwent surgery with postsurgical mortality of 11%. In these cases, the complete pathological response was shown in 38 cases (29.9%) with a 5-year overall survival rates of 48.2% and median overall survival of 44 months (95% confidence interval, 24.46-63.54).

Conclusion:

The pathological response rate and the overall survival rate are promising in patients who completed the protocol as receiving at least one cycle of chemotherapy. However, the treatment toxicities were relatively high.

Patterns of nodal metastases on 18F-FDG PET/CT in patients with esophageal squamous cell carcinoma are useful to guide treatment planning of radiotherapy

BACKGROUND AND PURPOSES

The aim of the study was to examine the patterns of lymph node metastases from esophageal squamous cell carcinoma (ESCC) and compare the laterality of lymphatic metastasis in cervical, supraclavicular, and paratracheal areas using F-FDG PET/CT.

PATIENTS AND METHODS

The data of 75 patients who underwent F-FDG PET/CT for staging of ESCC between January 2011 and March 2012 were reviewed. Fourteen groups of lymph nodes from the neck to abdomen were defined. Lateralization of the upper thoracic lymph nodes was defined in reference to the midline of the trachea. Frequencies of positive lymph nodes were used to determine the pattern of lymphatic spread and compare the lateralization of metastases in the cervical and upper thoracic regions.

RESULTS

The right paratracheal region was the most frequent site of metastasis among all patients. Left paratracheal and paragastric nodes were more frequent in upper and lower third ESCC, respectively. Upward and downward lymphatic spread was equal in mid third ESCC. In all patients, there was a trend toward more frequent lymph node metastasis on the right side than the left side for the supraclavicular and paratracheal regions. Further stratified analysis with tumor location found that right paratracheal node metastasis was significantly associated with mid third ESCC (P = 0.03). Remote nodal metastasis was found in 10.5% of patients with upper third ESCC and 13% of patients with lower third ESCC, respectively. Remote nodal metastasis was associated with higher SUV of the primary tumor (P = 0.02) and worse survival (P = 0.03). Receiver operating characteristic analysis showed a cutoff SUV of 14.8 for predicting remote lymph node metastases.

CONCLUSIONS

PET/CT provides important information before radiotherapy planning. Mid and lower third ESCC tends to metastasize to the right paratracheal/supraclavicular lymph nodes. Remote nodal metastases on PET/CT correlated with higher primary tumor SUV and worse survival.

Does neoadjuvant treatment before oncologic esophagectomy affect the postoperative quality of life? A prospective, longitudinal outcome study

To evaluate the cancer patients' quality of life (QoL) following esophagectomy the focus was placed on the impact of neoadjuvant treatment before surgery. For patients undergoing oncologic surgery, the QoL is generally accepted as an important outcome parameter in addition to clinical parameters. This prospective nonrandomized study evaluated QoL in patients treated by preoperative chemo(radio)therapy followed by either surgery or surgery alone with special focus on the postoperative course. QoL was assessed in 131 consecutive patients who underwent surgery for esophageal cancer. The EORTC-QLQ-C30 and a tumor-specific module were administered before surgery, at discharge, 3, 6, 12, and 24 months after surgery. Clinical data were collected prospectively and a follow up was performed every 6 months. The histological type of cancer was squamous cell carcinoma in 49.6% and adenocarcinoma in 50.4%. There was no significant difference between patients that were treated neoadjuvantly and those that were first operated on with regard to morbidity, mortality, and survival rates (5-year survival rate of 34%). Most QoL scores dropped significantly below the baseline in the early postoperative period and recovered slowly during the follow-up period to almost preoperative levels in many scores. There was no statistically significant difference in any of the QoL scales between neoadjuvantly treated or primary operated patients. Esophageal resections are associated with significant deterioration of QoL, which slowly recovers during the follow-up period to an almost preoperative level. Neoadjuvant treatment seems to not further negatively affect the QoL deterioration.

Prognostic utility of diffusion-weighted MRI in oesophageal cancer: is apparent diffusion coefficient a potential marker of tumour aggressiveness?

PURPOSE

To investigate the role of the apparent diffusion coefficient (ADC) as a potential prognostic biomarker in the evaluation of the aggressiveness of oesophageal cancer.

MATERIALS AND METHODS

Between November 2009 and December 2013, 43 patients with evidence of oesophageal or oesophago-gastric junction cancer were referred to our institution and prospectively entered in our database. The final study population consisted of 23 patients (18 men; 5 women; mean age, 64.62 ± 10.91 years) who underwent diffusion-weighted Magnetic Resonance before surgical intervention. Specifically, 14 were directly treated with surgery and 9 were addressed to chemo/radiotherapy beforehand. Two radiologists independently measured mean tumour ADC and inter-observer agreement (Spearman's and intraclass correlation coefficient [ICC]) was assessed. In the univariate analysis, overall survival curves related to pathological ADC, pT, pN, tumour location and histotype were fitted using the Kaplan-Meier method. Survival curves were then compared using the log-rank test.

RESULTS

Inter-observer reproducibility was very good (Spearman's rho = 0.95; ICC = 0.94). At a total median follow-up of 19 months (2-49 months), 4 patients had died. The median follow-up was 18.50 months (5-49 months) for the surgery-only group (1/4 events, 25 %) and 24 months (2-34 months) for the chemo/radiotherapy group (3/4 events, 75 %). Survival time at 48 months for the overall population was 59 % (±0.11), while for the surgery-only group and the chemo/radiotherapy group was 90 % (±0.09) and 61 % (±0.34), respectively. In the univariate analysis, ADC values below or equal to 1.4 × 10(-3) mm(2)/s were associated with a negative prognosis both in the total population (P = 0.016) and in the surgery-only group (P < 0.001).

CONCLUSION

Despite the biggest limitation of our study (i.e. the small study population), we were able to show that pathological ADC could be considered a prognostic factor for oesophageal cancer. DWI might be introduced into clinical practice as a promising and reliable technique in the diagnostic pathway of this tumour.

Postoperative complications do not affect long-term outcome in esophageal cancer patients

BACKGROUND

As esophagectomy is associated with a considerable complication rate, the aim of this study was to assess the impact of postoperative complications and neoadjuvant treatment on long-term outcome of adenocarcinoma (EAC) and squamous cell carcinoma (SCC) patients.

METHODS

Altogether, 134 patients undergoing transthoracic esophagectomy between 2005 and 2010 with intrathoracic stapler anastomosis were included in the study. Postoperative complications were allocated into three main categories: overall complications, acute anastomotic insufficiency, and pulmonary complications. Data were collected prospectively and reviewed retrospectively for the purpose of this study.

RESULTS

SCC patients suffered significantly more often from overall and pulmonary complications (SCC vs. EAC: overall complications 67 vs. 45 %, p = 0.044; pulmonary complications 56 vs. 34 %, p = 0.049). The anastomotic insufficiency rates did not differ significantly (SCC 11%, EAC 15%, p = 0.69). Long-term survival of EAC and SCC patients was not affected by perioperative (overall/pulmonary) complications or by the occurrence of anastomotic insufficiency. Also, neoadjuvant treatment did not influence the incidence of complications or long-term survival.

CONCLUSIONS

This is the first time the patient population of a center experienced with esophageal cancer surgery was assessed for the occurrence of general and esophageal cancer surgery-specific perioperative complications. Our results indicated that these complications did not affect long-term survival of EAC and SCC patients. Our data support the hypothesis that neoadjuvant treatment might not affect the incidence of perioperative complications or long-term survival after treatment of these tumor subtypes.

A Dilemma in Staging of Esophageal Cancer: How Should We Stage ypT0 N2 M0 Esophageal Cancer after Neoadjuvant Therapy?

Background. Since neoadjuvant treatment in esophageal cancer began to become popular, a complete pathological response at the primary tumour site has been commonly reported. An issue of conflict is whether complete response in the esophageal lumen means that the esophagus is completely tumour-free. Another important issue is whether lymph nodes that are retrieved from pathologically complete response cases are also tumour-free or not. There is a gap in the esophageal cancer staging system for ypT0 N2 M0 tumours that have received neoadjuvant therapy. Here, we will discuss the problem about staging of esophageal cancer associated with neoadjuvant therapy. Case. A female aged 40 years complaining of dysphagia was diagnosed as having locally advanced thoracic esophageal cancer. Neoadjuvant therapy decision was taken by oncology committee. Six weeks after neoadjuvant therapy, with a curative intention, minimal invasive surgery was performed. The pathology report was as follows. "There were no neoplastic cells in the suspected area of the esophageal mucosa upon examination with all staining. There was no cancer at resection margins. Four metastatic lymph nodes were infiltrated with squamous cell cancer." Conclusion. Despite the growing use of neoadjuvant treatment in locally advanced esophageal cancer in world, we do not have a protocol for the evaluation of these patients' pathology reports. We believe that new studies and new ideas are needed to resolve this dilemma associated with neoadjuvant therapy.

[Long-term outcome of neoadjuvant radiochemotherapy followed by surgery for esophageal cancer: a single institution retrospective study of 102 patients]

PURPOSE AND OBJECTIVES

To report survival and morbidity of a large homogeneous cohort of patients with a locally advanced esophageal or cardia carcinoma and put in evidence predictive factors of locoregional control and survival.

PATIENTS AND METHODS

Hundred and two patients were treated at the university hospital of Tours between 1990 and 2010 and received neo-adjuvant chemoradiation therapy with external irradiation (40Gy-44Gy) and two courses of chemotherapy (5-fluoro-uracile and cisplatine). Esophagectomy associated with lymph node dissection was performed about ten weeks after the end of chemoradiation therapy.

RESULTS

The median follow-up was 22.4 months [6-185 months]. The overall survival rates at 2 and 5years were 53% and 27%, respectively. The median overall survival was estimated at 27months. The overall 2-year survival between patients "responders" and patients "non-responders" was 67% vs 26%, respectively (P<0.0001). In case of histological response, there was a benefit in terms of overall survival (P<0.0001), locoregional control (P<0.0036) and disease-free survival (P<0.001). Overall survival at 2years was 64% for ypN0 group vs 32% for ypN1 group (P<0.0001). The median survival was estimated at 37months against 15months in the absence of lymph node involvement (P<0.0001).

CONCLUSION

Our results in terms of survival, tolerance and morbidity and mortality were comparable to those in the literature. Complete histological response of lymph node was associated with an improvement of local control, disease-free survival and overall survival.

MicroRNA-330-5p as a Putative Modulator of Neoadjuvant Chemoradiotherapy Sensitivity in Oesophageal Adenocarcinoma

Oesophageal adenocarcinoma (OAC) is the sixth most common cause of cancer deaths worldwide, and the 5-year survival rate for patients diagnosed with the disease is approximately 17%. The standard of care for locally advanced disease is neoadjuvant chemotherapy or, more commonly, combined neoadjuvant chemoradiation therapy (neo-CRT) prior to surgery. Unfortunately, ~60-70% of patients will fail to respond to neo-CRT. Therefore, the identification of biomarkers indicative of patient response to treatment has significant clinical implications in the stratification of patient treatment. Furthermore, understanding the molecular mechanisms underpinning tumour response and resistance to neo-CRT will contribute towards the identification of novel therapeutic targets for enhancing OAC sensitivity to CRT. MicroRNAs (miRNA/miR) function to regulate gene and protein expression and play a causal role in cancer development and progression. MiRNAs have also been identified as modulators of key cellular pathways associated with resistance to CRT. Here, to identify miRNAs associated with resistance to CRT, pre-treatment diagnostic biopsy specimens from patients with OAC were analysed using miRNA-profiling arrays. In pre-treatment biopsies miR-330-5p was the most downregulated miRNA in patients who subsequently failed to respond to neo-CRT. The role of miR-330 as a potential modulator of tumour response and sensitivity to CRT in OAC was further investigated in vitro. Through vector-based overexpression the E2F1/p-AKT survival pathway, as previously described, was confirmed as a target of miR-330 regulation. However, miR-330-mediated alterations to the E2F1/p-AKT pathway were insufficient to significantly alter cellular sensitivity to chemotherapy (cisplatin and 5-flurouracil). In contrast, silencing of miR-330-5p enhanced, albeit subtly, cellular resistance to clinically relevant doses of radiation. This study highlights the need for further investigation into the potential of miR-330-5p as a predictive biomarker of patient sensitivity to neo-CRT and as a novel therapeutic target for manipulating cellular sensitivity to neo-CRT in patients with OAC.

Understanding Complete Pathologic Response in Oesophageal Cancer: Implications for Management and Survival

Despite significant improvement over recent decades, oesophageal cancer survival rates remain poor. Neoadjuvant chemoradiotherapy followed by oesophageal resection is mainstay of therapy for resectable oesophageal tumours. Operative morbidity and mortality associated with oesophagectomy remain high and complications arise in up to 60% of patients. Management strategies have moved towards definitive chemoradiotherapy for a number of tumour sites (head and neck, cervical, and rectal) particularly for squamous pathology. We undertook to perform a review of the current status of morbidity and mortality associated with oesophagectomy, grading systems determining pathologic response, and data from clinical trials managing patients with definitive chemoradiotherapy to inform a discussion on the topic.

International comparison of the German evidence-based S3-guidelines on the diagnosis and multimodal treatment of early and locally advanced gastric cancer, including adenocarcinoma of the lower esophagus

BACKGROUND

Clinical guidelines are essential in implementing and maintaining nationwide stage-specific diagnostic and therapeutic standards. In 2011, the first German expert consensus guideline defined the evidence for diagnosis and treatment of early and locally advanced esophagogastric cancers. Here, we compare this guideline with other national guidelines as well as current literature.

METHODS

The German S3-guideline used an approved development process with de novo literature research, international guideline adaptation, or good clinical practice. Other recent evidence-based national guidelines and current references were compared with German recommendations.

RESULTS

In the German S3 and other Western guidelines, adenocarcinomas of the esophagogastric junction (AEG) are classified according to formerly defined AEG I-III subgroups due to the high surgical impact. To stage local disease, computed tomography of the chest and abdomen and endosonography are reinforced. In contrast, laparoscopy is optional for staging. Mucosal cancers (T1a) should be endoscopically resected "en-bloc" to allow complete histological evaluation of lateral and basal margins. For locally advanced cancers of the stomach or esophagogastric junction (≥T3N+), preferred treatment is preoperative and postoperative chemotherapy. Preoperative radiochemotherapy is an evidence-based alternative for large AEG type I-II tumors (≥T3N+). Additionally, some experts recommend treating T2 tumors with a similar approach, mainly because pretherapeutic staging is often considered to be unreliable.

CONCLUSIONS

The German S3 guideline represents an up-to-date European position with regard to diagnosis, staging, and treatment recommendations for patients with locally advanced esophagogastric cancer. Effects of perioperative chemotherapy versus chemoradiotherapy are still to be investigated for adenocarcinoma of the cardia and the lower esophagus.

Impact of docetaxel in addition to cisplatin and fluorouracil as neoadjuvant treatment for resectable stage III or T3 esophageal cancer: a propensity score-matched analysis

PURPOSE

To investigate the influence of addition of docetaxel to neoadjuvant chemotherapy (NAC) with cisplatin plus 5-fluorouracil (CF) in patients with clinical stage III or T3 esophageal squamous cell carcinoma.

METHODS

Information about 209 esophageal cancer patients with stage III or T3 disease, who underwent NAC consisting of CF with or without docetaxel, was reviewed. The survival outcomes were analyzed using the Kaplan-Meier method and propensity score-adjusted Cox proportional hazards models. The relevant variables were included in the propensity score model.

RESULTS

NAC was administered to 149 patients in the CF group and 60 patients in the docetaxel plus CF (DCF) group. Overall, 129 patients treated with CF and 58 patients treated with DCF underwent surgery after NAC. The overall response rate was significantly higher in the DCF group compared with the CF group (61.0 vs. 43.2 %, p = 0.021). After matching, recurrence-free survival did not differ statistically between the CF and DCF groups [hazard ratio (HR) 0.83, 95 % confidence interval (CI) 0.50-1.37, p = 0.46]. After matching, the improvement in overall survival in the DCF group reached statistical significance (HR 0.49, 95 % CI 0.24-0.999, p = 0.050). No significant differences in rate of locoregional or distant recurrences were observed between the CF and DCF groups (53.0 vs. 48.3 %, p = 0.54).

CONCLUSIONS

NAC with DCF is superior to CF in patients with clinical stage III or T3 esophageal squamous cell carcinoma.

Radiation-induced liver disease as a mimic of liver metastases at serial PET/CT during neoadjuvant chemoradiation of distal esophageal cancer

PURPOSE

To determine the frequency and appearance of radiation-induced liver disease on PET/CT in patients undergoing serial imaging during neoadjuvant chemoradiation of distal esophageal cancer.

MATERIALS AND METHODS

In this IRB-approved, HIPAA-compliant retrospective analysis, we identified 112 patients with distal esophageal cancer treated by neoadjuvant chemoradiation who had serial PET/CT imaging available for review. Two readers reviewed all studies in consensus and recorded those cases where new foci of visually detectable increased FDG avidity appeared in the liver during therapy. The etiology of such foci was determined from corresponding findings at CT or MRI, by hepatic biopsy during surgery, by characteristic evolution on post-operative imaging, or by a combination of these methods.

RESULTS

New foci of FDG avidity developed in the liver during neoadjuvant therapy in 10 of 112 (9%) patients, of whom nine (8%) were determined to have radiation-induced liver disease based on further imaging and/or biopsy and one of whom had developed interval metastatic disease based on biopsy. In the cases of radiation-induced liver disease, the abnormal foci were found only in the caudate and left hepatic lobes, near the primary tumor, while the patient who developed interval metastatic disease had involvement of the inferior right hepatic lobe, remote from the radiation therapy field.

CONCLUSION

New foci of increased FDG avidity are commonly seen in the caudate and left hepatic lobes of the liver during neoadjuvant chemoradiation of distal esophageal cancer, and these findings generally reflect radiation-induced liver disease rather than metastatic disease.

Concurrent versus sequential chemoradiotherapy for esophageal cancer among Chinese population: a meta-analysis

AIMS AND BACKGROUND

Esophageal cancer can cause substantial mortality and there is controversy about the effectiveness of concurrent and sequential chemoradiotherapy (CRT) for this disease.

METHODS AND STUDY DESIGN

Based on established criteria, we searched electronic databases including PubMed, Excerpta Medica Database (Embase), China National Knowledge Infrastruction (CNKI), Wanfang, and Weipu databases up to March 2014 to collect eligible studies. Relative risks (RRs) and their 95% confidence intervals (CIs) were calculated. Q and I2 test were applied to test statistical heterogeneities among studies. Publication bias of total effective rate was evaluated through a funnel plot and sensitive analysis was conducted.

RESULTS

We identified 10 Chinese studies including 1024 esophageal cancer patients. The RRs of total effective rate and 1-, 2-, and 3-year survival rate for concurrent versus sequential CRT were 1.15 (95% CI 1.07 to 1.24), 1.15 (95% CI 1.05 to 1.26), 1.44 (95% CI 1.21 to 1.73), and 1.66 (95% CI 1.37 to 2.01), respectively, all with statistically significant differences (p&lt;0.05). With regards to incidence of leukocytopenia, the RR for concurrent versus sequential CRT was 1.14 (95% CI 1.03 to 1.26) with significant difference (p&lt;0.05). However, the RR of incidence of radiation esophagitis was 1.09 (95% CI 0.96 to 1.22) for concurrent versus sequential CRT without significant differences (p = 0.17).

CONCLUSIONS

Concurrent CRT was superior to sequential CRT for esophageal cancer management among Chinese people. Though higher toxic effects were revealed in concurrent CRT, it was tolerable. Therefore, concurrent CRT could be applied into esophageal cancer treatments for Chinese patients.