Randomized trial of preoperative chemoradiation versus surgery alone in patients with locoregional esophageal carcinoma

A rationale multidisciplinary approach for treatment of esophageal and gastroesophageal junction cancer: Accurate review of management and perspectives

Cancer of the esophagus and of gastroesophageal junction can be cured, even if with lacking cure rate. Different approaches have been developed, mostly when carcinoma has loco-regional pattern. Multimodality therapy showed a survival rate superior than 10% if compared to a single approach. This is a systematic review, carried to assess the following matters: Which therapeutic opportunities are available? Who could benefit of them? Which adverse reactions could possibly verify? How can physicians definitely choose the proper strategy? Which is the role of surgery? We mean to give either General Practitioner or specialists clear and efficient updates about current treatment of this tumour, starting from physical examination. Four eminent guidelines were consulted for our study: Cancer Care Ontario's Program in Evidence-Based Care, NCCN, Belgian Health Care Knowledge Centre and Esmo.

Does timing of esophagectomy following neoadjuvant chemoradiation affect outcomes? A meta-analysis

BACKGROUND

The optimal timing of esophagectomy after neoadjuvant chemoradiation treatment (nCRT) remains unclear. Here, a meta-analysis was conducted to determine whether prolonged interval between nCRT and surgery can affect the outcomes in esophageal cancer.

MATERIALS AND METHODS

The databases PubMed, Embase, Web of Science, and Cochrane were systematically searched for studies reporting the outcomes in esophageal cancer according to the length of interval between nCRT and surgery. The primary outcome was rate of pathologic complete response (pCR), and the secondary outcomes included R0 resection rate, incidence of anastomotic leak, postoperative mortality, and two or five-year overall survival (OS). The intervals were classified into dichotomous (≤7-8 weeks and >7-8 weeks) for the pooled analysis, and a combined relative risk (RR) was calculated.

RESULTS

A total of 13 studies involving 15,086 patients were analyzed. The overall results indicated that an interval longer than 7-8 weeks between the end of nCRT and the surgery was significantly associated with an improved pCR rate (RR, 1.13; 95% confidence interval [CI], 1.05-1.21; P = 0.001). However, it was related to a higher 30-day surgical mortality (RR, 1.51; 95% CI, 1.19-1.92; P = 0.0006). The subgroup analyses only detected a significant association of the extended interval with pCR and the surgical mortality rate in adenocarcinoma patients. Moreover, an increased time interval resulted in a lower 2-year (RR, 0.94; 95% CI, 0.90-0.98; P = 0.002) and 5-year OS (RR, 0.88; 95% CI, 0.82-0.95; P = 0.0009). No association with R0 resection rate or anastomotic complication resulting from delayed resection was detected.

CONCLUSIONS

Although increasing the time interval from nCRT to esophagectomy was associated with significantly higher pathologic complete response rates in esophageal cancer, delaying the surgery might be disadvantageous for the long-term survival.

Neoadjuvant Chemoradiotherapy Followed by Surgery Versus Surgery Alone for Locally Advanced Squamous Cell Carcinoma of the Esophagus (NEOCRTEC5010): A Phase III Multicenter, Randomized, Open-Label Clinical Trial

Purpose The efficacy of neoadjuvant chemoradiotherapy (NCRT) plus surgery for locally advanced esophageal squamous cell carcinoma (ESCC) remains controversial. In this trial, we compared the survival and safety of NCRT plus surgery with surgery alone in patients with locally advanced ESCC. Patients and Methods From June 2007 to December 2014, 451 patients with potentially resectable thoracic ESCC, clinically staged as T1-4N1M0/T4N0M0, were randomly allocated to NCRT plus surgery (group CRT; n = 224) and surgery alone (group S; n = 227). In group CRT, patients received vinorelbine 25 mg/m² intravenously (IV) on days 1 and 8 and cisplatin 75 mg/m² IV day 1, or 25 mg/m² IV on days 1 to 4 every 3 weeks for two cycles, with a total concurrent radiation dose of 40.0 Gy administered in 20 fractions of 2.0 Gy on 5 days per week. In both groups, patients underwent McKeown or Ivor Lewis esophagectomy. The primary end point was overall survival. Results The pathologic complete response rate was 43.2% in group CRT. Compared with group S, group CRT had a higher R0 resection rate (98.4% v 91.2%; P = .002), a better median overall survival (100.1 months v 66.5 months; hazard ratio, 0.71; 95% CI, 0.53 to 0.96; P = .025), and a prolonged disease-free survival (100.1 months v 41.7 months; hazard ratio, 0.58; 95% CI, 0.43 to 0.78; P < .001). Leukopenia (48.9%) and neutropenia (45.7%) were the most common grade 3 or 4 adverse events during chemoradiotherapy. Incidences of postoperative complications were similar between groups, with the exception of arrhythmia (group CRT: 13% v group S: 4.0%; P = .001). Peritreatment mortality was 2.2% in group CRT versus 0.4% in group S ( P = .212). Conclusion This trial shows that NCRT plus surgery improves survival over surgery alone among patients with locally advanced ESCC, with acceptable and manageable adverse events.

Stage selection for neoadjuvant radiotherapy in non-cervical esophageal cancer: A propensity score-matched study based on the SEER database

BACKGROUND

The effect of neoadjuvant radiotherapy (NRT) was controversial in non-cervical esophageal cancer. The aim of this study was to identify which stage of non-cervical esophageal cancer would get benefit from NRT using propensity score matching (PSM) and survival analysis based on the Surveillance Epidemiology, and End Results (SEER) database.

METHODS

A selection process was used for case screening from the SEER database. Seven baseline variables were included in PSM. The survival analysis were based on T stage (T2 and T3 ) and status of lymph node involvement (N0 and N+ ) using Kaplan-Meier method and log-rank test for comparing the overall survival of patient with NRT plus surgery versus those who with surgery alone (SA).

RESULTS

A total of 1631 cases were included in this study. After PSM, 225 cases of esophageal squamous cell carcinoma (ESCC) and 606 cases of esophageal adenocarcinoma (EAC) were enrolled in survival analysis. We found that only T3 N+ stage of EAC would got survival benefit from NRT (P = 0.0052), while NRT showed no significant benefit in overall survival in other stages of EAC and ESCC.

CONCLUSIONS

NRT followed by resection had a significant survival benefit in non-cervical EAC patients with T3 N+ stage. For patients with ESCC and other EAC stages, NRT versus SA did not demonstrate a statistical significant survival difference.

[Surgery after upfront radiochemotherapy for locally advanced esophageal cancer: To do or not to do?]

The treatment of locally advanced esophageal cancer is still evolving. Surgery was considered as the backbone of the therapeutic management for a long time. Nowadays, chemoradiation has taken a major place in the neoadjuvant setting or as an exclusive treatment. Although some patients benefit from esophagectomy after chemoradiotherapy, a large subset of patients has no benefit and morbi-mortality rates are increased with a trimodality strategy. Patients who will have a local failure are at high risk of distant metastases in the follow-up. A third group of patients will have persistent locoregional disease after chemoradiotherapy and may benefit from surgery, but only a minority of patients with locally advanced disease are eligible. The impact of surgery after upfront chemoradiotherapy on survival and the quality of life of patients with locally advanced squamous cell esophageal cancer remain uncertain. An active surveillance strategy after chemoradiation or salvage esophagectomy for a locally residual disease might improve the prognosis of these patients. An optimized bimodality such as chemoradiotherapy delivering at least 50Gy is still standard and salvage surgery for local persistent disease or a local failure must be discussed in the framework of a multidisciplinary group for selected patients only.

The role of definitive chemoradiotherapy versus surgery as initial treatments for potentially resectable esophageal carcinoma

Background

We performed a meta-analysis to compare the efficacy of definitive chemoradiotherapy (dCRT) and esophagectomy as initial treatments for potentially resectable esophageal cancer.

Methods

To assess both strategies, the combined odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Thirteen studies (N = 2071; dCRT = 869 and surgery = 1202) were included. In all, 90.39% of the patients were diagnosed with esophageal squamous cell carcinoma (ESCC).

Results

The 2-year (OR = 1.199, 95% CI 0.922–1.560; P = 0.177) and 5-year overall survival (OS) rates (OR = 0.947, 95% CI 0.628–1.429; P = 0.796) were not significantly different. No significant differences were identified in the 2-year OS among patients with stage I disease (OR = 1.397, 95% CI 0.740–2.638; P = 0.303) or stage II–III (OR = 0.418, 95% CI 0.022–7.833; P = 0.560). Patients with lymph node metastases tended to have a better 5-year OS when treated with dCRT than with surgery (OR = 0.226, 95% CI 0.044–1.169; P = 0.076); however, the difference between the two methods was not significant. Western patients who received dCRT had poorer prognoses than patients who underwent surgery (OR = 1.522, 95% CI 1.035–2.238; P = 0.033). dCRT and surgery led to similar 5-year progression-free survival rates (OR = 1.06, 95% CI 0.79–1.42; P = 0.70).

Conclusions

dCRT and surgery are equally effective as initial treatments for potentially resectable esophageal cancer. These results apply primarily to Asian populations as they have an increased incidence of ESCC.

Electronic supplementary material

The online version of this article (10.1186/s12957-018-1470-y) contains supplementary material, which is available to authorized users.

Drug-induced expression of EpCAM contributes to therapy resistance in esophageal adenocarcinoma

Background

With a less than 5% overall survival rate, esophageal adenocarcinoma (EAC) is one of the leading causes of death in the United States. Epithelial cell adhesion molecule (EpCAM) is a cancer stem cell (CSC) marker that is expressed in various epithelial carcinomas, including EAC. Accumulating evidence indicates that CSC subpopulations can initiate cancer development and, in addition, drive metastasis, recurrence and drug resistance. It has also been reported that EpCAM up-regulation in EAC may lead to an aggressive behavior and, thus, an adverse clinical outcome. Here, we aimed to determine whether treatment with standard chemotherapeutic agents may induce EpCAM expression and, concomitantly, increases in malignant potential and drug resistance in EAC.

Methods

EpCAM expression was assessed in 20 primary human EAC/adjacent normal tissues, as well as in a human EAC-derived cell line (OE-19), in a pre-malignant Barrett’s Esophagus cell line (Bar-T) and in a benign esophageal cell line (HET 1-A), using immunohistochemistry, Western blotting and qRT-PCR, respectively. Drug-induced resistance was investigated in OE-19-derived spheres treated with (a combination of) adriamycin, cisplatin and 5-fluorouracil (ACF) using survival, adhesion and flow cytometric assays, respectively, and compared to drug resistance induced by standard chemotherapeutic agents (CTA). Finally, ACF treatment-surviving cells were evaluated for their tumor forming capacities both in vitro and in vivo using spheroid formation and xenograft assays, respectively.

Results

High EpCAM expression was observed in esophageal cancer tissues and esophageal cancer-derived cell lines, but not in adjacent benign esophageal epithelia and benign esophageal cell lines (HET 1-A and Bar-T). The OE-19 cell spheres were drug resistant and EpCAM expression was significantly induced in the OE-19 cell spheres compared to the non-sphere OE-19 cells. When OE-19 cell spheres were challenged with ACF, the EpCAM mRNA and protein levels were further up-regulated up to 48 h, whereas a decreased EpCAM expression was observed at 72 h. EpCAM down-regulation by RNA interference increased the ACF efficacy to kill OE-19 cells. Increased EpCAM expression coincided with the CSC marker CD90 and was associated with an aggressive growth pattern of OE-19 cell spheres in vivo.

Conclusions

From our data we conclude that an ACF-induced increase in EpCAM expression reflects the selection of a CSC subpopulation that underlies tumor development and drug resistance in EAC.

The Comparison of the Advantages of Neoadjuvant Chemoradiotherapy versus Postoperative Chemoradiotherapy: Outcomes in Esophageal Cancer Patients

BACKGROUND AND OBJECTIVES

Esophageal cancer is the eighth most common type of cancer worldwide. For the treatment of which, surgical intervention alone or with neoadjuvant chemoradiotherapy or chemotherapy is recommended. In this study, we aimed to compare the benefits of neoadjuvant chemoradiotherapy versus postoperative chemoradiotherapy.

PATIENTS AND METHODS

We collected data regarding 325 patients admitted for esophageal cancer to Qaem Hospital, Mashhad, Iran, during 2006-2016. The participants were divided into two groups of neoadjuvant and postoperative adjuvant therapies. Chi-square, McNemar, Kaplan-Mayer, and multivariate regression tests were performed using SPSS.

RESULTS

Gender, age, stage of the disease, tumor grade and location, disease histopathology, and the recurrence showed no significant differences between the two groups (P ˃ 0.05), but there was a significant association between the two types of treatment in terms of postoperative complications (P = 0.03). We followed up 147 patients postoperatively and found no significant differences between the groups (P ˃ 0.05).

CONCLUSION

No conclusion can be drawn on whether there are any advantages in adjuvant chemoradiotherapy over neoadjuvant approaches. Further confirmatory trials, particularly randomized trials, are necessary before any recommendations can be made.

Histological changes of superficial esophageal squamous cell carcinoma after preoperative chemotherapy

INTRODUCTION

We aimed to analyze the clinical and histological effects of chemotherapy in superficial esophageal squamous cell carcinoma (SESCC).

METHODS

We analyzed tumor samples from five patients with cT1bN1M0 who underwent subtotal esophagectomy following two courses of a new triplet chemotherapy regimen including docetaxel, cisplatin, and 5-fluorouracil (DCF). To assess the histological effects of chemotherapy, resected specimens were analyzed by macroscopic examination, hematoxylin & eosin (HE) staining, immunohistochemical (IHC) staining (p53, Ki-67 and cytokeratin) and periodic acid-Schiff (PAS) staining.

RESULTS

All five patients had a pathological T stage of T0/1a-LPM/1a-MM/1b (1/2/1/1) and histological grade of grade1a/1b/2/3 (1/1/2/1). Endoscopic examination revealed substantial shrinkage of lugol-voiding lesions (LVLs) in all cases. One case showed complete LVL disappearance, and resected specimen examination confirmed pathological complete response (pCR). IHC and PAS staining revealed that most initial LVLs were PAS-negative. Obvious viable cells were confirmed in two cases. The other three cases exhibited nuclear atypia and strong expression of p53 and Ki-67 in the basal layer of mucosa or lamina propria mucosae, even though the superficial layer of mucosa showed no obvious LVLs with PAS-positive. p53-positive lesions were also observed in Ki-67-positive. This indicated discordance between the endoscopic findings and histopathological evaluation.

CONCLUSION

DCF chemotherapy alone had a substantial therapeutic effect on SESCC in all cases. However, despite the normal appearance of the mucosal surface, viable cancer cells remained below the basal layer of mucosa. Careful attention should be paid when diagnosing clinical CR, or securing a resection margin of SESCC after DCF chemotherapy.

Comparison of the prognosis of neoadjuvant chemoradiotherapy treatment with surgery alone in esophageal carcinoma: a meta-analysis

Background

Resection remains the best treatment for carcinoma of the esophagus in terms of local control, but local recurrence and distant metastasis remain an issue after surgery. Chemo-radiotherapy (CRT) followed by surgery was associated with significantly improved survival benefit, but the effectiveness of neoadjuvant therapy in patients with resectable esophageal carcinoma remains controversial. The aim of this study was to evaluate the effects of neoadjuvant chemoradiotherapy in resectable esophageal carcinoma compared to surgery alone (SA).

Methods

A search for publications that compared the efficacy of CRT with SA in resectable esophageal carcinoma was conducted. After a rigorous review of the quality, the data were extracted from eligible trials. The major outcomes measures were odds ratios (ORs). The ORs with their corresponding 95% confidence intervals were the principal measure of effects. For the meta-analysis, Revman 5.3 software was used to analyze the combined pooled ORs using fixed- or random-effects models according to the heterogeneity.

Results

Our findings revealed that, compared with SA, neoadjuvant CRT was associated with improved overall survival (OS) and progression-free survival times, but the 3- and 5-year OS did not show a statistical difference (P≥0.05). The adjuvant chemotherapy group did not show significant improvement on reference rate and metastasis rate compared with the control group.

Conclusion

CRT does significantly improve progression-free survival and OS in patients with esophageal cancer compared with SA. However, further assessment is still warranted on the role of CRT in future trials with well-selected patients.

Timing of esophagectomy after neoadjuvant chemoradiation treatment in squamous cell carcinoma

BACKGROUND

Time interval between neoadjuvant (combined) chemotherapy and radiation (nCRT) and surgery has been linked to pathologic response rates and outcomes in patients with various solid cancers. The optimal timing between nCRT and esophagectomy in patients with esophageal squamous cell carcinoma (SCC), however, is not known. Our aim was to analyze the relation between elapsed time from completion of nCRT to esophagectomy and postsurgical mortality and overall survival.

METHODS

We reviewed the National Cancer Database for patients with SCC (n = 1,244) of the esophagus diagnosed between 2003 and 2011 who were treated with nCRT followed by esophagectomy within 26 weeks after completion of nCRT.

RESULTS

Thirty-day mortality was 5.6% and 90-day mortality was 11.1%. The duration of post-nCRT interval was not a predictor of 30-day and 90-day postoperative mortality in multivariate models, but 30-day postoperative mortality was predictable based on increasing Charlson-Deyo comorbidities (adjusted odds ratio [aOR] 1.77, P = .054) and improved in academic institutions (aOR 0.66, P = .005). Similar findings were found for 90-day mortality (comorbidity index aOR 1.58, P = .046) and for treatment at an academic facility (0.82, P = .062). In a multivariate survival analysis, the duration of the post-nCRT interval was not found to be a predictor of overall survival (P = .769), whereas increasing age (hazard ratio [HR] 1.02, P = .005), increasing comorbidity score (HR 1.38, P = .005), treatment at an academic hospital (HR 0.84, P = .001), and post-treatment nodal status (HR 1.73, P < .001) were predictors.

CONCLUSION

Perioperative mortality and overall survival are not affected by the time interval between completion of nCRT and esophagectomy among patients with SCC histology.

Surgical resection after neoadjuvant chemoradiation for oesophageal adenocarcinoma: what is the optimal timing?

OBJECTIVES

The purpose of this study was to determine the optimal timing of surgical resection of oesophageal adenocarcinoma following neoadjuvant chemoradiotherapy (nCRT).

METHODS

nCRT before resection of oesophageal adenocarcinoma yields improved overall and progression-free survival. Despite the wide acceptance of tri-modal therapy, the optimal timing of surgical resection after nCRT is not well defined and existing studies are limited. Adults with Stage II/III oesophageal adenocarcinoma undergoing nCRT before surgery were identified from the National Cancer Database. Multivariable analysis using restricted cubic splines was used to identify an inflection point in clinical outcomes as a function of time between nCRT and surgery, dividing the cohort into short- and long-interval treatment groups, which were then compared. Adjusted rates of survival and margin status were compared between groups using multivariable analysis.

RESULTS

Among 2444 patients, restricted cubic splines identified an inflection point at 56 days, dividing our cohort into 1533 short-interval and 911 long-interval patients. Long-interval patients had a higher adjusted incidence of pathologic downstaging (odds ratio 1.38, confidence interval 1.02-1.85, P = 0.04) but no difference in margin positivity compared with short-interval patients (odds ratio 0.91, confidence interval 0.56-1.47, P = 0.69). Worse overall survival was noted in the long-interval subgroup (hazard ratio 1.44, confidence interval 1.22-1.71, P < 0.001), but 30-day postoperative mortality was not statistically different (odds ratio 1.56, confidence interval 0.9-2.72, P = 0.12).

CONCLUSIONS

Restricted cubic splines provides an objective mechanism to more accurately delineate optimum timing between nCRT and surgical resection. A time interval of 56 days represents an interval where increased pathologic downstaging is balanced by decreased overall survival.

Anti-tumoral effects of low molecular weight heparins: A focus on the treatment of esophageal cancer

Esophageal cancer is one of the most prevalent types of cancer globally. With current treatment options, the survival is poor, and there are ongoing efforts to find new and more efficient therapeutic approaches. There are several reports on the anti-tumoral effects of low-molecular-weight heparins (LMWH). We have assessed the possible survival benefits and underlying mechanisms of LMWHs in malignancies with a focus on esophageal cancer. We conclude that the effects of LMWHs on survival of cancer patients is probably due to a combination of direct anti-tumoral, anti-angiogenic, and immunomodulatory effects and indirect effects on the coagulation system.

Impact of postoperative TNM stages after neoadjuvant therapy on prognosis of adenocarcinoma of the gastro-oesophageal junction tumours

AIM

To compare prognostic relevance of postoperative tumour/node/metastasis (TMN) stages between patients with and without neoadjuvant treatment.

METHODS

Data from patients with adenocarcinoma of the gastro-oesophageal junction (AEG) who had undergone surgical resection at a single German university centre were retrospectively analysed. Patients with or without neoadjuvant preoperative treatment were selected by exact matching based on preoperative staging. Standard assessment of preoperative (c)TNM stage was based on endoscopic ultrasound and computed tomography of the thorax and abdomen, according to the American Joint Committee on Cancer/Union for International Cancer Control classification system. Patients with cT1cN0cM0 and cT2cN0cM0 stages were excluded from the study, as these patients are generally not recommended for pretreatment. Long-term survival among the various postoperative TNM stages was compared between the groups of patients with or without neoadjuvant treatment. For statistical assessments, a P-value of ≤ 0.05 was considered significant.

RESULTS

The study included a total of 174 patients. The group of patients who had received preoperative neoadjuvant treatment included more cases of AEG (Siewert) type 1 carcinoma (P < 0.001), and consequently oesophagectomy was performed more frequently among these patients (P < 0.001). The two groups (with or without preoperative neoadjuvant treatment) had comparable preoperative T stages, but the group of patients with preoperative neoadjuvant treatment presented a higher rate of preoperative N-positive disease (P = 0.020). Overall long-term survival was not different between the two groups of patients according to tumours of different AEG classifications, receipt of oesophagectomy or gastrectomy, nor between patients with similar postoperative TNM stage, resection margin and grading. However, an improvement of long-term survival was found for patients with nodal down-staging after neoadjuvant therapy (P = 0.053).

CONCLUSION

The prognostic relevance of postoperative TNM stages is similar for AEG in patients with or without neoadjuvant preoperative treatment, but treatment-related nodal down-staging prognosticates longer-term survival.

Intraluminal brachytherapy boost following external beam radiotherapy with concurrent chemotherapy of oesophagus carcinoma: Results of a prospective observational study

PURPOSE

The main objective of our study is to evaluate response and toxicity profile in patients receiving external beam radiotherapy with concurrent chemotherapy followed by intraluminal brachytherapy boost for a carcinoma of the oesophagus.

MATERIAL AND METHODS

Twenty patients with biopsy-proven carcinoma of the oesophagus received external beam radiotherapy (50Gy in 25 fractions) with concurrent chemotherapy (cisplatin: 40mg/m²). After a gap of two to three weeks, intraluminal brachytherapy (10Gy in two fractions each 1 week apart by a high dose rate ⁶⁰Co source) was given. Response was evaluated at 1 month and at 1 year of completion of treatment. In addition, acute and chronic toxicity was evaluated at 1 month and 6 months of treatment.

RESULTS

Complete response were seen in 80% of patients and partial response in 20% at 1 month. Moreover, there were 65% complete response, 10% local recurrences, 15% patients showed local control with distant metastasis and 10% patients died at 1 year. Grade 1, grade 2 and grade 3 oesophagitis were seen in 10%, 70% and 20% of patients respectively. Stricture was seen in 40% of patients and fistula in 10% of patients. There was no spinal cord, cardiac and nephrotoxicity found.

CONCLUSIONS

With the concept that high tumoricidal dose for adequate tumor control achieved by intraluminal brachytherapy as a mean of dose escalation, while sparing surrounding normal tissue and potentially improving therapeutic ratio, external beam radiotherapy followed by intraluminal brachytherapy could be a better choice for oesophagus carcinoma.

Prognosis of surgery combined with different adjuvant therapies in esophageal cancer treatment: a network meta-analysis

This network meta-analysis was conducted to assess whether the efficacy of surgery with adjuvant therapies, including radiotherapy (RT+S), chemotherapy (CT+S), and chemoradiotherapy (CRT+S) have better performance in esophageal cancer treatment and management. PubMed and EMBASE were used to search for relevant trials. Both conventional pair-wise and network meta-analyses were carried out. The surface under the cumulative ranking curve (SUCRA) was used to rank interventions based on the efficacy of the treatment method. As for 3-year overall survival (OS), CRT+S showed the highest efficacy (CRT+S vs.

SURGERY

HR=0.81, 95% CrI =0.73-0.90; CRT+S vs. CT+S: HR=0.82, 95% CrI =0.70-0.95; CRT+S vs. RT+S: HR=0.77, 95% CrI =0.62-0.95). For disease-free survival, CRT+S showed efficacy over CT+S ((HR =0.70, 95% CrI =0. 59-0.83). In conclusion, CRT+S showed a better performance for survival outcomes and ranks best among all therapies. The results of our study can provide guidance for medical decisions and treatment options that may help clinical practitioners improve the efficacy of EC treatment.

Neoadjuvant treatments for locally advanced, resectable esophageal cancer: A network meta-analysis

The relative survival benefits and postoperative mortality among the different types of neoadjuvant treatments (such as chemotherapy only, radiotherapy only or chemoradiotherapy) for esophageal cancer patients are not well established. To evaluate the relative efficacy and safety of neoadjuvant therapies in resectable esophageal cancer, a Bayesian network meta-analysis was performed. MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched for publications up to May 2016. ASCO and ASTRO annual meeting abstracts were also searched up to the 2015 conferences. Randomized controlled trials that compared at least two of the following treatments for resectable esophageal cancer were included: surgery alone, surgery preceded by neoadjuvant chemotherapy, neoadjuvant radiotherapy or neoadjuvant chemoradiotherapy. The primary outcome assessed from the trials was overall survival. Thirty-one randomized controlled trials involving 5496 patients were included in the quantitative analysis. The network meta-analysis showed that neoadjuvant chemoradiotherapy improved overall survival when compared to all other treatments including surgery alone (HR 0.75, 95% CR 0.67-0.85), neoadjuvant chemotherapy (HR 0.83. 95% CR 0.70-0.96) and neoadjuvant radiotherapy (HR 0.82, 95% CR 0.67-0.99). However, the risk of postoperative mortality increased when comparing neoadjuvant chemoradiotherapy to either surgery alone (RR 1.46, 95% CR 1.00-2.14) or to neoadjuvant chemotherapy (RR 1.58, 95% CR 1.00-2.49). In conclusion, neoadjuvant chemoradiotherapy improves overall survival but may also increase the risk of postoperative mortality in patients locally advanced resectable esophageal carcinoma.

Customization of therapy for gastroesophageal adenocarcinoma patients

Gastroesophageal adenocarcinomas (GEACs) remain a global health problem. These are most often diagnosed at advanced stage and the estimated 5-year relative survival rate is about 5%. Although cure is not possible for patients with advanced GEAC, systemic therapy (chemotherapy or biochemotherapy) can palliate symptoms, improve survival and provide a better quality of life. One of the most promising options for some patients with advanced stage GEAC is immunotherapy, which can result in durable responses. Numerous phase III trials evaluating targeted therapies in different lines are ongoing and it is hoped that better biomarkers will emerge to identify patients who can benefit from targeted agents and immunotherapy in the future. Surgery remains as the corner stone for localized GEAC and adjunctive therapies can increase the survival rates by about 10%. The high toxicity and low completion rates of adjuvant therapy led to the strategies of preoperative treatment. With the results of ongoing pre-operative therapy trials we will be able to determine the optimal adjunctive approach for resectable GEAC.

Low disabled-2 expression promotes tumor progression and determines poor survival and high recurrence of esophageal squamous cell carcinoma

Patients with esophageal squamous cell carcinomas (ESCCs) have poor survival and high recurrence rate, but lack a prognostic biomarker. Disabled-2 (DAB2) is a crucial tumor suppressor, but its roles in ESCCs are uncertain. We investigated whether low DAB2 expression in ESCCs could lead into tumor progression and poor prognosis. Our results found patients with low-DAB2 expression ESCCs had significantly larger tumor size, deeper tumor invasion depth, lymph node metastasis, worse survival, and higher recurrence rate (P<0.05). The Cox-regression model revealed low-DAB2 expression was an independent factor of poor survival (P<0.05), and also of tumor recurrence with the predictive performance superior to clinical TNM stage (P<0.05). Low-DAB2 cancer cells, validated by DAB2 knockdown or over-expression, had higher phosphorylated ERK and migration abilities, which could be suppressed by ERK inhibitor treatment. TGF-β-induced epithelial-to-mesenchymal transition (EMT) only existed in the high-DAB2 cells, and related to worse prognosis of high-DAB2 ESCCs (P<0.05). In conclusion, DAB2 can suppress the ERK signaling, but correlate to have TGF-β-induced EMT in ESCCs. DAB2 expression could be a biomarker to identify patients with worse survival and high recurrence. Our data suggest DAB2 expression can stratify patients in need of aggressive surveillance and with possible benefit from anti-ERK or anti-TGF-β therapies.

Multidisciplinary Approach to the Management of Esophageal Malignancies

INTRODUCTION

A multidisciplinary approach in the management of complex malignancies is becoming more common, and likewise, adopting such an approach to the care of patients with locally advanced esophageal is recommended in order to optimize clinical outcomes.

METHODS

In this review, we discuss both the surgical and medical oncology perspectives in the management of patients with locally advanced esophageal cancer. We review the data supporting the current standard-of-care approach, namely trimodality therapy with neoadjuvant chemo-radiotherapy followed by surgery. Other aspects of managing these patients including the control of dysphagia and pain as well as nutritional support are discussed. Finally, we review data that support the importance of incorporating a multidisciplinary streamlined approach in the management of these patients.

RESULTS

Rather than having patients see each provider separately, a multidisciplinary approach to esophageal cancer allows for the seamless flow of communication and proactive management of the patient's symptoms. These benefits include increasing the likelihood of evidence-based decision making, shorter time to treatment, and increased patient quality of life, all of which can result in improved patient outcomes.

CONCLUSION

The use of a multidisciplinary team can lead to a more accurate staging paradigm and thereby, better management decisions that translate to improved clinical outcomes. Therefore, optimizing the multidisciplinary approach for the care of patients with locally advanced esophageal cancer is essential for successful and individualized patient care.

Neoadjuvant Treatment for Locally Invasive Esophageal Cancer

Locally advanced esophageal carcinoma has a poor prognosis, and epidemiologic trends show that more patients are being diagnosed with locally advanced esophageal carcinoma and with adenocarcinoma histology. This prompts a review and evaluation of the field regarding standard of care treatment for patients with locally advanced esophageal carcinoma, both adenocarcinoma and squamous cell carcinoma. We review the evidence showing the moderate benefit of neoadjuvant chemoradiation followed by esophagectomy compared to perioperative chemotherapy plus esophagectomy in patients who are good operative candidates. Also, we summarize the emerging clinical trial landscape in the perioperative setting primarily seeking to apply targeted therapies against HER2 (trastuzumab or pertuzumab) or immune checkpoint inhibitors against programmed death 1 (PD-1; pembrolizumab and nivolumab) or programmed death ligand 1 (PD-L1; durvalumab). Understanding the foundations that have determined the current standard of care for patients with locally advanced esophageal carcinoma will aid in interpreting the clinical trial results that will soon appear with the novel treatment strategies.

Surveillance or resection after chemoradiation in esophageal cancer

The treatment of locally advanced esophageal cancer continues to evolve. Previously, surgery was considered the foundation of treatment, but chemoradiation (CRT) has taken on a larger role both in the neoadjuvant setting and as definitive treatment. It has become clear that although some patients benefit from esophagectomy after CRT, a large subset of patients likely derive no benefit, and may be harmed by surgery. Some patients are cured from CRT alone and therefore do not need surgery. Another group of patients likely have metastatic disease at the time of local therapy that is just undetected on imaging and also do not benefit from surgery. A third group of patients will have persistent locoregional disease only after CRT. This last group is the subset who will actually benefit from surgery, but this likely comprises only a minority of patients with locally advanced disease. A strategy to maximize survival while minimizing unnecessary surgery is a reasonable goal, but present technology does not allow us to do this with certainty. Thus, the decision of whether to pursue resection or surveillance after CRT can be difficult as clinicians and patients try to balance the goal of maximizing the likelihood of cure against the risk of surgery and its impact on quality of life.

Neoadjuvant chemoradiotherapy followed by minimally invasive esophagectomy: is it a superior approach for locally advanced resectable esophageal squamous cell carcinoma?

Background

Few studies reported the outcomes of minimally invasive esophagectomy (MIE) in treating patients with esophageal squamous cell carcinoma (ESCC) after neoadjuvant chemoradiotherapy (nCRT). The aim of the study was to investigate the feasibility and efficacy of nCRT plus MIE (RM) strategy in treating locally advanced resectable ESCC.

Methods

This retrospective study included 175 patients with ESCC undergoing surgical resection after neoadjuvant therapy in our institution from 2010 to 2016. Patients were stratified into three groups: RM, [neoadjuvant chemotherapy (nCT) plus MIE] (CM) and [nCT plus open esophagectomy (OE)] (CO).

Results

Seventy-six (43.4%), 42 (24%) and 57 (32.6%) patients received RM, CM and CO approach, respectively. Compared with CO approach, RM or CM approach had shorter operation duration (188±39, 185±37 vs. 209±45 minutes, P=0.004, P=0.009) and less blood loss (124±88, 122±79 vs. 166±92 mL, P=0.001, P=0.003). There was a trend with lower risk of postoperative non-surgical complications in RM and CM approach [odds ratio (OR) 0.45, 0.200-1.040; P=0.062; OR 0.41, 0.150-1.160; P=0.093]. There were no differences in 30- and 90-day mortality among all groups. RM approach was more likely to achieve pathological complete regression (27.6% vs. 4.8%, 1.8%, P=0.001, P=0.001) and fewer lymph node metastasis (25.0% vs. 57.1%, 61.4%, P=0.001, P=0.001) than CM or CO approach. Survival analysis revealed a potential trend towards improved overall survival in RM approach compared with CM or CO approach (P=0.098, P=0.166).

Conclusions

RM approach was a safe and efficient strategy in treating locally advanced resectable ESCC.

The frontline of esophageal cancer treatment: questions to be asked and answered

Achieving a good treatment for esophageal cancer is a great challenge. For early stage cancer, endoscopic treatment is considered the first line and a possible curative therapy. Chemotherapy, radiotherapy, and surgery are all used for the treatment of locally advanced esophageal cancer, administered either alone or combined. Some combinations have proven to be feasible, effective, and superior, such as neoadjuvant chemoradiation (CRT) plus surgery in the Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) trial. However, other strategies such as perioperative chemotherapy or definitive chemoradiation also have demonstrated substantial effectiveness. The current article addresses the following questions: (I) how can a choice between different multi-modality treatments be made; (II) is there enough evidence to compare the merits of the different strategies; and (III) is there any new evidence to improve the current practice. Moreover, in this article, existing evidence for treatment strategies for locally advanced esophageal cancer have been reviewed.

Radiation dose in neoadjuvant chemoradiation therapy for esophageal cancer: patterns of care and outcomes from the National Cancer Data Base

Background

Neoadjuvant chemoradiotherapy (CRT) for locally advanced esophageal cancer (EC) may utilize a wide variety of RT doses, without clear consensus to date. This study evaluated national practice patterns between lower dose (LD) (40-41.4 Gy) or higher dose (HD) (50-50.4 Gy) therapy, in addition to differences in survival and postoperative events.

Methods

The National Cancer Data Base (NCDB) was queried [2004-2013] for patients with newly-diagnosed cT1a-T4aN0/N+M0 EC that received neoadjuvant CRT followed by esophagectomy. Multivariable logistic regression determined factors predictive of receiving LD RT. Kaplan-Meier analysis evaluated overall survival (OS), and Cox proportional hazards modeling determined variables associated with OS. Propensity score matching assessed groups in a balanced manner while reducing indication biases.

Results

Altogether, 5,025 patients met inclusion criteria; 257 (5%) received LD RT, while 4,768 (95%) received HD RT. LD RT was more likely delivered at academic centers (P=0.038), in more recent years (2009-2013, P=0.011), and to squamous cell carcinomas (P=0.001). HD RT tended to be administered with higher T stage as well as node-positive disease (P<0.05). The median OS in the LD and HD cohorts was 39.0 vs. 35.6 months (P=0.072), and 39.0 vs. 42.7 months after propensity matching (P=0.812). Dose did not independently correlate with OS on multivariate analysis (P=0.069), but treatment at academic centers correlated with improved OS (P=0.028). There were no differences between groups in the rates of 30-day readmission (P=0.182), 30-day mortality (P=0.314), or length of postoperative hospital stay (P=0.665), but the LD group experienced lower 90-day mortality (P=0.007).

Conclusions

Although neoadjuvant LD CRT has been underutilized for EC in the United States, it is rising in more recent years. Dose did not significantly impact survival before or after propensity matching, nor did it independently predict for survival. Treatment at academic facilities independently correlated with higher survival, which has implications for patient counseling.

Neoadjuvant chemo-radiotherapy for locally advanced esophageal cancer: A monocentric study

Aims and background

Multimodal therapy is a keystone of care in advanced esophageal cancer. Although neoadjuvant chemoradiotherapy is known to provide a survival advantage in selected cases, reliable prognostic and response predictive factors remain elusive. We report the outcome in a series of esophageal cancer patients treated at our center and the results of a retrospective analysis of epidermal growth factor receptor (EGFR) expression and EGFR/HER2 gene copy numbers taken as possible prognostic and predictive factors.

Methods and study design

Between 2001 and 2009, a total of 40 consecutive patients (34 men and 6 women; median age, 59 years) were treated for esophageal cancer. Treatment: cisplatin, 80 mg/m2 day 1, and 5-fluorouracil, 800 mg/m2/24 h on days 1–5, every 21 days, concomitant with 3D-conformal radiotherapy (54–59.4 in 30–33 fractions) for three up to four cycles. Surgery was performed in eligible patients 6–8 weeks after chemoradiation. EGFR expression and EGFR/HER2 amplification and gene copy number were studied by immunohistochemical analysis and fluorescence in situ hybridization, respectively.

Results

Acceptable toxicity following chemoradiation was recorded, with G3–G4 hematological toxicity in 20% of patients and G3–G4 dysphagia in less than 10%; 14 (35%) patients achieved complete response and 19 (48%) partial response; 18 underwent surgery after chemoradiation, of which 8 (20%) achieved pathologic complete response. The median survival was 29 months (95% CI, 25.7–32.1): 42 months for the resected and 20 for the unresected patients. EGFR and HER2 analysis in 28 patients showed that 89% had immunohistochemical EGFR expression, with 5 cases of EGFR and 10 of HER2 gene gain without a significant difference in response rate and survival in these patient subgroups.

Conclusions

Our results suggest a better outcome in patients who underwent surgery after chemoradiation. A larger sample size is necessary to clarify the role of EGFR and HER2 gene gain in predict response and survival.

Pilot study of serial FLT and FDG-PET/CT imaging to monitor response to neoadjuvant chemoradiotherapy of esophageal adenocarcinoma: correlation with histopathologic response

OBJECTIVE

The aim of this prospective pilot study was to investigate the potential of serial FLT-PET/CT compared to FDG-PET/CT to provide an early indication of esophageal cancer response to concurrent neoadjuvant chemoradiation therapy.

METHODS

Five patients with biopsy-proven esophageal adenocarcinomas underwent neoadjuvant chemoradiation (Tx) prior to minimally invasive esophagectomy. The presence of residual tumor was classified histologically using the Mandard et al. criteria, categorizing patients as pathologic responders and non-responders. Participants underwent PET/CT imaging 1 h after intravenous administration of FDG and of FLT on two separate days within 48 h of each other. Each patient underwent a total of 3 scan "pairs": (1) pre-treatment, (2) during treatment, and (3) post-treatment. Image-based response to therapy was measured in terms of changes in SUVmax (ΔSUV) between pre- and post-therapeutic FLT- and FDG-PET scans. The PET imaging findings were correlated with the pathology results after surgery.

RESULTS

All tumors were FDG and FLT avid at baseline. Lesion FLT uptake was lower than with FDG. Neoadjuvant chemoradiation resulted in a reduction of tumor uptake of both radiotracers in pathological responders (n = 3) and non-responders (n = 2). While the difference in the reduction in mean tumor FLT uptake during Tx between responders (ΔSUV = - 55%) and non-responders (ΔSUV = - 29%) was significant (P = 0.007), for FDG it was not, [responders had a mean ΔSUV = - 39 vs. - 31% for non-responders (P = 0.74)]. The difference in the reduction in tumor FLT uptake at the end of treatment between responders (ΔSUV = - 62%) and non-responders (ΔSUV = - 57%) was not significant (P = 0.54), while for FDG there was a trend toward significance [ΔSUV of responders = - 74 vs. - 52% in non-responders (P = 0.06)].

CONCLUSION

The results of this prospective pilot study suggest that early changes in tumor FLT uptake may be better than FDG in predicting response of esophageal adenocarcinomas to neoadjuvant chemoradiation. These preliminary results support the need to corroborate the value of FLT-PET/CT in a larger cohort.

Definite intensity-modulated radiotherapy with concurrent chemotherapy more than 4 cycles improved survival for patients with locally-advanced or inoperable esophageal squamous cell carcinoma

We investigated which prognostic factor could improve survival for esophageal cancer patients who received definite concurrent chemoradiation (CCRT). Eighty patients with age ≥18, Karnofsky Performance Scale (KPS) ≥ 60, and clinical stage T1-4N0-3M0 esophageal squamous cell carcinoma were enrolled from July 2004 to December 2015. They underwent definite intensity-modulated radiotherapy (IMRT) with or without simultaneous integrated boost to the primary tumor, and reception of concurrent chemotherapy ≥ 1 cycle. The primary endpoints were overall survival (OS), locoregional progression-free survival (LRPFS) and distant metastasis-free survival (DMFS). The median follow-up duration for alive patients was 21.5 months. The rates of 2-, 3- and 5-year OS/LRPFS/DMFS were 23.8%/53.5%/49.3%, 19.1%/44.6%/49.3%, and 13.0%/44.6%/43.9%, respectively. Only the non-clinical complete response (non-cCR) after CCRT was an independent poor prognostic factor in OS (HR 3.101, 95% CI 1.535-6.265, p = 0.0016). Radiation dose >50.4 Gy and chemotherapy ≥4 cycles significantly predicted better LRPFS (p = 0.0361 and 0.0163, respectively). Poorly differentiated tumor and stage III disease have poor DMFS (p = 0.0336 and 0.0411, respectively), and chemotherapy ≥ 4 cycles was a better predictor (p = 0.0004). In subgroup analysis, patients who received radiation dose ≤50.4 Gy with concurrent chemotherapy ≥4 cycles had the best survival outcome with 1-, 2-, 3- and 5-year survival rates of 73.7%, 39.4%, 31.5% and 17.5%, respectively. In conclusion, definite radiotherapy with concurrent chemotherapy ≥4 cycles improved the survival for patients with inoperable or locally-advanced esophageal squamous cell carcinoma.

Management of Patients With Adenocarcinoma or Squamous Cancer of the Esophagus

Esophageal cancer is characterized by early and frequent metastasis. Surgery is the primary treatment for early-stage disease, whereas patients with patients with locally advanced disease receive perioperative chemotherapy or chemoradiotherapy. Squamous cancers can be treated with primary chemoradiotherapy without surgery, depending on their response to therapy and patient tolerance for subsequent surgery. Chemotherapy with a fluorinated pyrimidine and a platinum agent, followed by later treatment with taxanes and irinotecan, provides some benefit. Agents that inhibit the erb-b2 receptor tyrosine kinase 2 (ERBB2 or HER2), or vascular endothelial growth factor, including trastuzumab, ramucirumab, and apatinib, increase response and survival times. Esophageal adenocarcinomas have mutations in tumor protein p53 and mutations that activate receptor-associated tyrosine kinase, vascular endothelial growth factor, and cell cycle pathways, whereas esophageal squamous tumors have a distinct set of mutations. Esophageal cancers develop systems to evade anti-tumor immune responses, but studies are needed to determine how immune checkpoint modification contributes to esophageal tumor development.

Traditional and cumulative meta-analysis: Chemoradiotherapy followed by surgery versus surgery alone for resectable esophageal carcinoma

The role of neoadjuvant chemoradiotherapy followed by surgery (CRTS) compared with surgery alone (SA) for resectable esophageal carcinoma has been established by several randomized controlled trials (RCTs). The present study aimed to investigate the difference in survival between the two treatments by a review of meta-analyses. Related research indicators were extracted from RCTs investigating CRTS or SA for resectable esophageal carcinoma by searching electronic databases for eligible articles. Outcomes were synthesized by adopting a fixed- or random-effects model with 95% confidence interval (CI). A total of 22 RCTs including 3,419 patients were selected. The odds ratio (OR) (95% CI, P-value), expressed as CRTS vs. SA, was 1.06 (0.94-1.19, P=0.348) for 1-year overall survival rate (OSR1y), 1.38 (1.20-1.58, P<0.001) for 3-year overall survival rate (OSR3y), and 1.42 (1.22-1.66, P<0.001) for 5-year overall survival rate (OSR5y). The R0 resection rate increased in patients treated by CRTS (OR=2.76, 95% CI: 2.15-3.53, P<0.001). CRTS lowered the locoregional cancer recurrence (OR=0.49, 95% CI: 0.36-6.65, P<0.001) and distant metastasis rate (OR=0.76, 95% CI: 0.60-0.97, P=0.02). However, the incidence of postoperative mortality was similar between the two groups (OR=0.97, 95% CI: 0.72-1.32, P=0.87). The subgroup analysis revealed that OSR3y and OSR5y for Asian, European and American populations were significantly higher in the CRTS group compared with those in the SA group (P<0.05). When comparing the OSR1y between the two groups for patients in all three continents, there was no significant difference (P>0.05). Histological subgroup analysis indicated that patients with esophageal adenocarcinoma may benefit from CRTS in terms of OSR1y (OR=1.55, 95% CI: 1.09-2.20, P=0.01), OSR3y (OR=1.77, 95% CI: 1.34-2.36, P<0.0001) and OSR5y (OR=1.92, 95% CI: 1.34-2.75, P=0.0004). The pooled OR of squamous cell carcinoma in terms of OSR3y and OSR5y between the two groups was 1.57 (95% CI: 1.21-2.04, P=0.0006) and 1.69 (95% CI: 1.32-2.16, P<0.0001), respectively, but there was no statistical difference in terms of OSR1y (OR=1.13, 95% CI: 0.88-1.45, P=0.35). Thus, neoadjuvant CRT followed by surgery may improve long-term survival and surgical parameters, and reduce locoregional cancer recurrence and distant metastasis.

Adoption of evidence-based novel therapies in the treatment of gastric cancer: A national observational study

BACKGROUND

The adoption of novel and effective gastric cancer therapies into general clinical practice has crucial implications for patient outcomes. The current study explored trends in treatment use and overall survival in patients with gastric cancer in the United States.

METHODS

Patients with adenocarcinoma of the gastric cardia and noncardia were identified in the National Cancer Data Base between 2006 and 2014. Tumor stages were divided into early (IA), locally advanced (IB-IIIC), and metastatic (IV) stage. Treatment use was examined according to tumor stage and location. Time trend analyses of treatment use and overall survival were conducted.

RESULTS

A total of 89,098 patients with gastric adenocarcinoma were identified. In those with early-stage cancer, endoscopic treatment increased over time in patients with cardia and noncardia disease. In patients with locally advanced cardia disease, preoperative therapy use increased over time (2013-2014 [vs 2006-2008]: odds ratio [OR], 3.09; 95% confidence interval [95% CI], 2.80-3.41). In patients with locally advanced noncardia disease, the use of preoperative therapy also increased (2013-2014: OR, 3.32; 95% CI, 2.88-3.82) as did the use of perioperative therapy (2013-2014: OR, 4.21; 95% CI, 3.52-5.03) in lieu of postoperative treatment (2013-2014: OR, 0.66; 95% CI, 0.60-0.71). In patients with metastatic disease, approximately 34% of patients with cardia and 40% of patients with noncardia cancer did not receive treatment. Stage-specific and location-specific overall survival was found to improve over the study period.

CONCLUSIONS

Practice patterns for the treatment of gastric cancer in the United States reflect the increased adoption of evidence-based therapies, including endoscopic resection of early-stage cancer and preoperative therapy for patients with locally advanced disease. Treatment for metastatic disease remains markedly underused. Cancer 2018;124:1122-31. © 2017 American Cancer Society.

18FDG-PET/CT is useful in the follow-up of surgically treated patients with oesophageal adenocarcinoma

OBJECTIVE

The purpose of this study was to evaluate fludeoxyglucose-positron emission ;tomography/CT's (FDG-PET/CT) performance in the follow ;up of patients with surgically treated oesophageal adenocarcinoma.

METHODS

The follow-up FDG-PET/CT scans of 162 consecutive patients with surgically treated oesophageal adenocarcinoma were retrospectively reviewed. Histopathological and/or imaging examinations confirmed recurrent disease. The accuracy, sensitivity, specificity and negative and positive predictive values were calculated.

RESULTS

Recurrence occurred in 71 (43%) patients, usually within the first year following surgery (60%) and in more than one site (76%). The sensitivity, specificity, positive-predictive value, negative-predictive value and accuracy of FDG-PET/CT for anastomotic recurrence were 77, 76, 16, 98 and 76%; for regional nodal recurrence were 88, 85, 43, 97 and 86%; and for distant metastatic recurrence were: 97, 96, 91, 99 and 96%. In 5 of the 42 patients (12%) with distant metastases, the metastatic sites were outside the area covered by a conventional follow-up chest-abdomen CT and in 4 patients (9%) metastases were barely perceptible on the CT component of the FDG-PET/CT and consequently were unlikely to be detected without the aid of the FDG uptake.

CONCLUSION

FDG PET/CT is accurate in detecting oesophageal adenocarcinoma recurrence, especially within the first post-operative year when most recurrences occur, and is useful in identifying patients with a solitary metastasis. Advances in knowledge: FDG-PET/CT should be considered as a valuable tool in the routine follow ;up of surgically treated oesophageal cancer patients within the first 2 years after surgery.

Meta-analysis of microRNAs as potential biomarkers for detecting esophageal carcinoma in Asian populations

BACKGROUND:

An Increasing number of studies in the literature have shown that microRNAs (miRNAs) can be used as early diagnostic markers for esophageal carcinoma (EC), but their conclusions remain controversial. Hence, we performed this meta-analysis to evaluate the diagnostic accuracy of using miRNAs in EC and to provide an experimental basis for early diagnosis of the disease.

METHODS:

This meta-analysis included 39 Asian studies from 18 articles, which covered 3,708 EC patients and 2,689 healthy controls. We used a bivariate random-effects model, the chi-square test and the I² test to assess sensitivity and heterogeneity.

RESULTS:

Pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio of miRNAs for diagnosis of EC in Asians reached 0.798, 0.785, 3.705, 0.257 and 14.391, respectively. Additionally, the area under the summary receiver operating characteristic curve was 0.86. Subgroup analysis based on research country (China vs. Japan), sample types (plasma vs. serum) and miRNAs (single vs. multiple; singly reported miRNAs vs. repeatedly reported miRNAs) showed no significant difference in accuracy of diagnosis for each subgroup.

CONCLUSIONS:

MiRNAs can distinguish EC patients from healthy controls. Blood-based miRNAs have better diagnostic value in detecting EC than saliva-based miRNAs, whereas both serum and plasma are recommended for clinical specimens for miRNA detection.

Evaluating Factors for Prophylactic Feeding Tube Placement in Gastroesophageal Cancer Patients Undergoing Chemoradiotherapy

PURPOSE

Though better studied in head/neck cancers, there are currently no studies on timing of feeding tube (FT) placement in patients with gastroesophageal cancer. This study sought to discern characteristics of patients who used versus did not use a prophylactic FT (pFT), and also analyzed factors associated with placement of FTs during chemoradiotherapy (CRT).

METHODS/MATERIALS

From 1998 to 2013, 1,329 patients underwent neoadjuvant CRT, of which 323 received an FT. Patients for whom FTs were placed prior to treatment due to tumor occlusion or substantial weight loss (n = 130), and those with FTs placed following treatment (n = 43) were excluded. One hundred patients had pFTs placed, and 50 underwent placement during CRT. The following was collected for each patient: demographic/patient information, oncologic/treatment characteristics, and CRT tolerance.

RESULTS

No significant differences were found in any parameter between cohorts that used (n = 66) versus did not use a pFT (n = 34); on univariate and multivariate analyses, no pretreatment characteristic associated with using a pFT. When compared with patients who used a pFT (n = 66), those who required an FT during CRT (n = 50) had lower body mass index (p = 0.045), underwent higher-dose radiotherapy (p = 0.003), and received induction chemotherapy (p = 0.031). On multivariate analysis, receipt of induction chemotherapy and greater weight loss and esophagitis during treatment were associated with placement of FTs during CRT (p < 0.05).

CONCLUSION

Of our cohort who received pFTs, there were no clinical factors that predicted for their use. Patients must be closely monitored for weight loss and esophagitis when receiving CRT in order to intervene prior to further worsening of toxicities.

An Update on Randomized Clinical Trials in Gastric Cancer

The optimal treatment of esophageal cancer is still being defined. The timing of surgical management and the application of chemotherapy and radiation in the neoadjuvant and adjuvant settings have been studied in several prospective, randomized, controlled trials. This article outlines some of the historical as well as updated research that has been published regarding the management of esophageal cancer.

Concurrent neoadjuvant chemoradiotherapy could improve survival outcomes for patients with esophageal cancer: a meta-analysis based on random clinical trials

Background

The long-term survival benefit of concurrent neoadjuvant chemoradiotherapy in patients with resectable esophageal cancer remains controversial. In the present study, we conducted a meta-analysis to assess these effectiveness.

Methods

We searched for most relevant studies published up to the end of August 2016, using Pubmed and web of knowledge. And additional articles were identified from previous meta-analysis. The hazard ratio (HR, for overall survival and progression free survival) or risk ratio (RR, for R0 resection) with its corresponding 95 % confidence interval (CI) were used to assess the pooled effect.

Results

Twelve articles including 1756 patients were included in the meta-analysis. Concurrent neoadjuvant chemoradiotherapy followed by surgery was associated with significantly improved overall survival (HR=0.76 , 95% CI= 0.68-0.86), progression survival (HR =0.69, 95% CI= 0.59-0.81), and R0 resection rate(RR =1.17, 95% CI= 1.03-1.33). Subgroup analysis suggested that concurrent neoadjuvant chemoradiotherapy could improve overall survival outcome for squamous cell carcinoma (HR=0.73, 95%CI=0.61-0.88) but not those for adenocarcinoma (HR=0.72, 95%CI=0.48-1.04).

Conclusion

Our findings suggested that concurrent neoadjuvant chemoradiotherapy was associated with a significant survival benefit in patients with esophageal cancer.

Neoadjuvant cisplatin and fluorouracil versus epirubicin, cisplatin, and capecitabine followed by resection in patients with oesophageal adenocarcinoma (UK MRC OE05): an open-label, randomised phase 3 trial

BACKGROUND

Neoadjuvant chemotherapy before surgery improves survival compared with surgery alone for patients with oesophageal cancer. The OE05 trial assessed whether increasing the duration and intensity of neoadjuvant chemotherapy further improved survival compared with the current standard regimen.

METHODS

OE05 was an open-label, phase 3, randomised clinical trial. Patients with surgically resectable oesophageal adenocarcinoma classified as stage cT1N1, cT2N1, cT3N0/N1, or cT4N0/N1 were recruited from 72 UK hospitals. Eligibility criteria included WHO performance status 0 or 1, adequate respiratory, cardiac, and liver function, white blood cell count at least 3 × 109 cells per L, platelet count at least 100 × 109 platelets per L, and a glomerular filtration rate at least 60 mL/min. Participants were randomly allocated (1:1) using a computerised minimisation program with a random element and stratified by centre and tumour stage, to receive two cycles of cisplatin and fluorouracil (CF; two 3-weekly cycles of cisplatin [80 mg/m2 intravenously on day 1] and fluorouracil [1 g/m2 per day intravenously on days 1-4]) or four cycles of epirubicin, cisplatin, and capecitabine (ECX; four 3-weekly cycles of epirubicin [50 mg/m2] and cisplatin [60 mg/m2] intravenously on day 1, and capecitabine [1250 mg/m2] daily throughout the four cycles) before surgery, stratified according to centre and clinical disease stage. Neither patients nor study staff were masked to treatment allocation. Two-phase oesophagectomy with two-field (abdomen and thorax) lymphadenectomy was done within 4-6 weeks of completion of chemotherapy. The primary outcome measure was overall survival, and primary and safety analyses were done in the intention-to-treat population. This trial is registered with the ISRCTN registry (number 01852072) and ClinicalTrials.gov (NCT00041262), and is completed.

FINDINGS

Between Jan 13, 2005, and Oct 31, 2011, 897 patients were recruited and 451 were assigned to the CF group and 446 to the ECX group. By Nov 14, 2016, 327 (73%) of 451 patients in the CF group and 302 (68%) of 446 in the ECX group had died. Median survival was 23·4 months (95% CI 20·6-26·3) with CF and 26·1 months (22·5-29·7) with ECX (hazard ratio 0·90 (95% CI 0·77-1·05, p=0·19). No unexpected chemotherapy toxicity was seen, and neutropenia was the most commonly reported event (grade 3 or 4 neutropenia: 74 [17%] of 446 patients in the CF group vs 101 [23%] of 441 people in the ECX group). The proportions of patients with postoperative complications (224 [56%] of 398 people for whom data were available in the CF group and 233 [62%] of 374 in the ECX group; p=0·089) were similar between the two groups. One patient in the ECX group died of suspected treatment-related neutropenic sepsis.

INTERPRETATION

Four cycles of neoadjuvant ECX compared with two cycles of CF did not increase survival, and cannot be considered standard of care. Our study involved a large number of centres and detailed protocol with comprehensive prospective assessment of health-related quality of life in a patient population confined to people with adenocarcinomas of the oesophagus and gastro-oesophageal junction (Siewert types 1 and 2). Alternative chemotherapy regimens and neoadjuvant chemoradiation are being investigated to improve outcomes for patients with oesophageal carcinoma.

FUNDING

Cancer Research UK and Medical Research Council Clinical Trials Unit at University College London.

Chemoradiotherapy versus chemoradiotherapy plus surgery for esophageal cancer

BACKGROUND

Please see Appendix 4 for a glossary of terms.The outcome of patients with esophageal cancer is generally poor. Although multimodal therapy is standard, there is conflicting evidence regarding the addition of esophagectomy to chemoradiotherapy.

OBJECTIVES

To compare the effectiveness and safety of chemoradiotherapy plus surgery with that of chemoradiotherapy alone in people with nonmetastatic esophageal carcinoma.

SEARCH METHODS

We performed a computerized search for relevant studies, up to Feburary 2017, on the CENTRAL, MEDLINE, and Embase databases using MeSH headings and keywords. We searched five online databases of clinical trials, handsearched conference proceedings, and screened reference lists of retrieved papers.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing chemoradiotherapy plus esophagectomy with chemoradiotherapy alone for localized esophageal carcinoma. We excluded RCTs comparing chemotherapy or radiotherapy alone with esophagectomy.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data, and assessed risk of bias and the quality of the evidence, using standardized Cochrane methodological procedures. The primary outcome was overall survival (OS), estimated with Hazard Ratio (HR). Secondary outcomes, estimated with risk ratio (RR), were local and distant progression-free survival (PFS), quality of life (QoL), treatment-related mortality and morbidity, and use of salvage procedures for dysphagia. Data were analyzed using a random effects model in Review Manager 5.3 software.

MAIN RESULTS

From 2667 references, we identified two randomized studies, in six reports, that included 431 participants. All participants were clinically staged to have at least T3 and/or node positive thoracic esophageal carcinoma, 93% of which was squamous cell histology. The risk of methodological bias of the included studies was low to moderate.High-quality evidence found the addition of esophagectomy had little or no difference on overall survival (HR 0.99, 95% CI 0.79 to 1.24; P = 0.92; I² = 0%; two trials). Neither study reported PFS, therefore, freedom from loco-regional relapse was used as a proxy. Moderate-quality evidence suggested that the addition of esophagectomy probably improved freedom from locoregional relapse (HR 0.55, 95% CI 0.39 to 0.76; P = 0.0004; I² = 0%; two trials), but low-quality evidence suggested it may increase the risk of treatment-related mortality (RR 5.11, 95% CI 1.74 to 15.02; P = 0.003; I² = 2%; two trials).The other pre-specified outcomes (quality of life, treatment-related toxicity, and use of salvage procedures for dysphagia) were reported by only one study, which found very low-quality evidence that use of esophagectomy was associated with reduced short-term QoL (MD 0.93, 95% CI 0.24 to 1.62), and low-quality evidence that it reduced use of salvage procedures for dysphagia (HR 0.52, 95% CI 0.36 to 0.75). Neither study compared treatment-related morbidity between treatment groups.

AUTHORS' CONCLUSIONS

Based on the available evidence, the addition of esophagectomy to chemoradiotherapy in locally advanced esophageal squamous cell carcinoma, provides little or no difference on overall survival, and may be associated with higher treatment-related mortality. The addition of esophagectomy probably delays locoregional relapse, however, this end point was not well defined in the included studies. It is undetermined whether these results can be applied to the treatment of adenocarcinomas, tumors involving the distal esophagus and gastro-esophageal junction, and to people with poor response to chemoradiation.

Recurrence patterns and associated factors of locoregional failure following neoadjuvant chemoradiation and surgery for esophageal cancer

BACKGROUND

Despite neoadjuvant chemoradiation (nCRT) followed by esophagectomy for locally advanced esophageal cancer, locoregional recurrence (LRR) is common and factors associated with LRR have not been clearly identified.

METHODS

Patients were identified from a single institution, prospectively maintained database (1996-2013). Patterns of recurrence were described and associated factors of LRR were analyzed using competing risks regression models.

RESULTS

Of the 456 patients treated with nCRT and surgery, 167 patients developed recurrence. Locoregional and distant recurrences were observed in 69 (15.1%) and 140 (30.9%) patients, respectively. Time to recurrence (13.6 vs 10.4 months, P = 0.20) and median overall survival (29.3 vs 19.1 months, P = 0.12) were no different among the 27 patients (6%) who developed a solitary LRR compared to patients who developed distant recurrence. Univariable analysis identified lymphovascular invasion (HR 1.46, P = 0.07), lymph node ratio >0.5 (HR 2.16, P = 0.02), positive margin (HR 1.95, P = 0.05), lack of response to neoadjuvant therapy (HR 1.99, P < 0.01), clinical T stage (HR 2.62, P < 0.01) and final T3/4 stage (HR 2.06, P < 0.01) as factors significantly associated with LRR. Clinical T stage and response to neoadjuvant treatment were independently associated with LRR on multivariable analysis.

CONCLUSIONS

Although aggressive tumor biology plays a significant role in LRR, optimizing neoadjuvant treatments to obtain a complete pathologic response may lead to improved locoregional control.

A Phase II Study with Lead-In Safety Cohort of 5-Fluorouracil, Oxaliplatin, and Lapatinib in Combination with Radiation Therapy as Neoadjuvant Treatment for Patients with Localized HER2-Positive Esophagogastric Adenocarcinomas

Lessons Learned.

Neoadjuvant 5‐fluorouracil, oxaliplatin, and lapatinib in combination with radiation therapy is safe for neoadjuvant treatment for patients with localized human epidermal growth receptor 2‐positive esophagogastric adenocarcinoma.

Evaluation of this drug combination in a larger patient pool would allow for more accurate analysis of its efficacy.

Background.

The optimal design of neoadjuvant chemoradiation for the treatment of localized esophagogastric cancers is the subject of much debate. In this nonrandomized trial, we evaluated neoadjuvant 5‐fluorouracil (5‐FU), oxaliplatin, and lapatinib in combination with radiation therapy as neoadjuvant treatment for patients with localized human epidermal growth receptor 2 (HER2)‐positive esophagogastric adenocarcinomas.

Methods.

Patients received neoadjuvant 5‐FU (225 mg/m² continuous intravenous infusion, days 1–42), oxaliplatin (85 mg/m² intravenously [IV], days 1, 15, and 29), and lapatinib (six patients, 1,000 mg p.o., days 1–42; six patients, 750 mg p.o., days 1–42) plus radiation (1.8 Gy/day Monday through Friday for 50.4 Gy total). Following restaging, eligible patients underwent definitive resection, and pathologic response to neoadjuvant therapy was assessed. Planned enrollment was 42 patients. The primary endpoint was the pathologic complete response (pCR) rate.

Results.

Twelve patients (median age 64 years; 67% male) received a median of 5.6 weeks of treatment (range: 1.1–8.4). The pCR rate was 8%; four of the 12 patients underwent tumor resection and one patient had a pCR, with pathologic partial response in the remaining three. The most common lapatinib‐related adverse events included (all grades) nausea (67%) and diarrhea (58%), although these were all grade 1 or 2. Enrollment was halted due to low accrual.

Conclusion.

The treatment regimen was determined to be safe. The study was terminated early due to low accrual.

PET/Computed Tomography Scanning and Precision Medicine: Esophageal Cancer

Esophageal cancer commonly has a poor prognosis, which requires an accurate diagnosis and early treatment to improve outcome. Other modalities for staging, such as endoscopic ultrasound imaging and computed tomography (CT) scans, have a role in diagnosis and staging. However, PET with fluorine-18 fluoro-2-deoxy-d-glucose/CT (FDG PET/CT) scanning allows for improved detection of distant metastatic disease and can help to prevent unnecessary interventions that would increase morbidity. FDG PET/CT scanning is valuable in the neoadjuvant chemotherapy assessment and predicting survival outcomes subsequent to surgery. FDG PET/CT scanning detects recurrent disease and metastases in follow-up.

Neoadjuvant twice daily chemoradiotherapy for esophageal cancer: Treatment-related mortality and long-term outcomes

OBJECTIVE

Because of the short potential doubling time of esophageal cancer, there is a theoretical benefit to using an accelerated radiation treatment schedule. This study evaluates outcomes and treatment-related mortality and morbidity of patients treated with neoadjuvant hyperfractionated accelerated chemoradiation for resectable esophageal cancer.

METHODS AND MATERIALS

Outcomes from 250 consecutive patients with resectable esophageal cancer treated with preoperative hyperfractionated accelerated chemoradiotherapy (45 Gy in 30 twice-daily fractions over 3 weeks) followed by planned transhiatal esophagectomy were analyzed. Grade 3 or greater treatment related toxicity, surgical complications, and treatment-related mortality were determined. Additionally, available surgical specimens were graded for pathological response to chemoradiation. Overall survival (OS) and locoregional control were calculated using the Kaplan-Meier method. The log rank test was used to determine statistical significance.

RESULTS

Median follow-up was 59 months for surviving patients; 87% of patients had adenocarcinoma and 13% had squamous cell carcinoma. Eleven percent of patients did not have surgery because of the development of metastases, declining performance status, or refusal. Twenty-seven patients were found to have unresectable and/or metastatic disease at the time of surgery. Overall, 10 of 223 operated patients died within 3 months, resulting in a perioperative mortality rate of 4%. Median OS was 28.4 months (95% confidence interval, 22.3-35.6 months) for all patients and 35.1 months (95% confidence interval, 27.4-47 months) for patients who underwent esophagectomy. There were 32 isolated locoregional failures with a 3-year locoregional control rate of 83%. Of 129 patients who had independent pathology review, 29% had complete response to treatment. This group had a median OS of 98.9 months and 3-year OS of 74%.

CONCLUSION

Neoadjuvant twice-daily chemoradiation for esophageal cancer is a safe and effective alternative to daily fractionation with low treatment-related mortality and long-term outcomes similar to standard fractionation courses.

Dose escalated neoadjuvant chemoradiotherapy with dose-painting intensity-modulated radiation therapy and improved pathologic complete response in locally advanced esophageal cancer

We compared pathologic complete response (pCR) rate, toxicity, and postoperative complications between patients treated preoperatively with 50.4 Gy versus dose escalation with dose-painting intensity-modulated radiation therapy (dp-IMRT) to 56 Gy in locally advanced esophageal cancer. We evaluated esophageal cancer patients treated between 2006 and 2014 with preoperative IMRT chemoradiation to a dose of 50.4 Gy versus 56 Gy. The endpoints were pCR and toxicity. We identified 113 patients (50.4 Gy: n = 40; 56 Gy: n = 73). There were no significant differences in tumor or patient characteristics. Patients treated with 56 Gy demonstrated a higher pCR rate (56.2% vs. 30.0%) and lower pathologic nonresponse rate (4.1% vs. 20.0%) compared to patients treated to 50.4 Gy (P = 0.008). This remained significant on multivariate analysis (OR 3.375 95%CI 1.3-8.8, P = 0.013). Patients treated to 56 Gy also had an improved 3-year locoregional control rate compared to those treated to 50.4 Gy (93.8% vs. 78.5%; P = 0.022). The estimated 3-year freedom from failure was also superior in the 56 Gy arm (73.7% vs. 52.2%; P = 0.051), approaching significance. There were no differences in treatment related grade ≥3 toxicities, hospital admissions, feeding tube, esophageal stent placement, or dilation. There was, however, a statistically significant increase in postoperative atrial fibrillation in patients treated with 56 Gy (30.1% vs. 12.5%; P = 0.036). There was no difference in postoperative 30 or 60 day mortality. Dose escalation to 56 Gy with dp-IMRT is safe and results in significantly higher complete pathologic response rates in esophageal cancer without an increase in treatment-related toxicity. Prospective trials using dp-IMRT are needed to address the role of dose escalation on pCR rate and survival in esophageal cancer.

Outcome of proximal esophageal cancer after definitive combined chemo-radiation: a Swiss multicenter retrospective study

Objective

To report oncological outcomes and toxicity rates, of definitive platin-based chemoradiadiationtherapy (CRT) in the management of proximal esophageal cancer.

Methods

We retrospectively reviewed the medical records of patients with cT1-4 cN0-3 cM0 cervical esophageal cancer (CEC) (defined as tumors located below the inferior border of the cricoid cartilage, down to 22 cm from the incisors) treated between 2004 and 2013 with platin–based definitive CRT in four Swiss institutions. Acute and chronic toxicities were retrospectively scored using the National Cancer Institute’s Common Terminology Criteria for Adverse Events, version 4.0 (CTCAE-NCI v.4.0). Primary endpoint was loco-regional control (LRC). We also evaluated overall survival (OS) and disease-free survival (DFS) rates. The influence of patient- and treatment related features have been calculated using the Log-rank test and multivariate Cox proportional hazards model.

Results

We enrolled a total of 55 patients. Median time interval from diagnosis to CRT was 78 days (6–178 days). Median radiation dose was 56Gy (28–72Gy). Induction chemotherapy (ICHT) was delivered in 58% of patients. With a median follow up of 34 months (6–110months), actuarial 3-year LRC, DFS and OS were 52% (95% CI: 37–67%), 35% (95% CI: 22–50%) and 52% (95% CI: 37–67%), respectively. Acute toxicities (dysphagia, pain, skin-toxicity) ranged from grade 0 – 4 without significant dose-dependent differences. On univariable analyses, the only significant prognostic factor for LRC was the time interval > 78 days from diagnosis to CRT. On multivariable analysis, total radiation dose >56Gy (p <0.006) and ICHT (p < 0.004) were statistically significant positive predictive factors influencing DFS and OS.

Conclusion

Definitive CRT is a reliable therapeutic option for proximal esophageal cancer, with acceptable treatment related toxicities. Higher doses and ICHT may improve OS and DFS and. These findings need to be confirmed in further prospective studies.