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Survival After Neoadjuvant and Adjuvant Treatments Compared to Surgery Alone for Resectable Esophageal Carcinoma: A Network Meta-analysis. Ann Surg 2017; 265:481-491. [PMID: 27429017 DOI: 10.1097/sla.0000000000001905] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This network meta-analysis compared overall survival after neoadjuvant or adjuvant chemotherapy (CT), radiotherapy (RT), or combinations of both (chemoradiotherapy, CRT) or surgery alone to identify the most effective approach. SUMMARY BACKGROUND DATA The optimal treatment for resectable esophageal cancer is unknown. METHODS A search for randomized controlled trials reporting on neoadjuvant and adjuvant therapies was conducted. Using a network meta-analysis, treatments were ranked based on their effectiveness for improving survival. RESULTS In 33 eligible randomized controlled trials, 6072 patients were randomized to receive either surgery alone (N = 2459) or neoadjuvant CT (N = 1332), RT (N = 58), and CRT (N = 1196) followed by surgery or surgery followed by adjuvant CT (N = 542), RT (N = 383), and CRT (N = 102). Twenty-one comparisons were generated. Neoadjuvant CRT followed by surgery compared with surgery alone was the only treatment to significantly improve survival [hazard ratio (HR) = 0.77, 95% confidence interval (CI): 0.68-0.87]. When trials were grouped considering neoadjuvant and adjuvant therapies and surgery alone, neoadjuvant therapies combined with surgery compared with surgery alone showed a survival advantage (HR = 0.83, 95% CI 0.76-0.90), whereas surgery along with adjuvant therapies showed no significant survival advantage (HR = 0.87, 95% CI 0.67-1.14). A subgroup analysis of neoadjuvant therapies showed a superior effectiveness of neoadjuvant CRT and surgery compared with surgery alone (HR = 0.77, 95% CI 0.68-0.87). CONCLUSIONS This network meta-analysis showed neoadjuvant CRT followed by surgery to be the most effective strategy in improving survival of resectable esophageal cancer. Resources should be focused on developing the most effective neoadjuvant CRT regimens for both adenocarcinomas and squamous cell carcinomas of the esophagus.
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Reynolds JV, Preston SR, O’Neill B, Baeksgaard L, Griffin SM, Mariette C, Cuffe S, Cunningham M, Crosby T, Parker I, Hofland K, Hanna G, Svendsen LB, Donohoe CL, Muldoon C, O’Toole D, Johnson C, Ravi N, Jones G, Corkhill AK, Illsley M, Mellor J, Lee K, Dib M, Marchesin V, Cunnane M, Scott K, Lawner P, Warren S, O’Reilly S, O’Dowd G, Leonard G, Hennessy B, Dermott RM. ICORG 10-14: NEOadjuvant trial in Adenocarcinoma of the oEsophagus and oesophagoGastric junction International Study (Neo-AEGIS). BMC Cancer 2017; 17:401. [PMID: 28578652 PMCID: PMC5457631 DOI: 10.1186/s12885-017-3386-2] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 05/25/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Neoadjuvant therapy is increasingly the standard of care in the management of locally advanced adenocarcinoma of the oesophagus and junction (AEG). In randomised controlled trials (RCTs), the MAGIC regimen of pre- and postoperative chemotherapy, and the CROSS regimen of preoperative chemotherapy combined with radiation, were superior to surgery only in RCTs that included AEG but were not powered on this cohort. No completed RCT has directly compared neoadjuvant or perioperative chemotherapy and neoadjuvant chemoradiation. The Neo-AEGIS trial, uniquely powered on AEG, and including comprehensive modern staging, compares both these regimens. METHODS This open label, multicentre, phase III RCT randomises patients (cT2-3, N0-3, M0) in a 1:1 fashion to receive CROSS protocol (Carboplatin and Paclitaxel with concurrent radiotherapy, 41.4Gy/23Fr, over 5 weeks). The power calculation is a 10% difference in favour of CROSS, powered at 80%, two-sided alpha level of 0.05, requiring 540 patients to be evaluable, 594 to be recruited if a 10% dropout is included (297 in each group). The primary endpoint is overall survival, with a minimum 3-year follow up. Secondary endpoints include: disease free survival, recurrence rates, clinical and pathological response rates, toxicities of induction regimens, post-operative pathology and tumour regression grade, operative in-hospital complications, and health-related quality of life. The trial also affords opportunities for establishing a bio-resource of pre-treatment and resected tumour, and translational research. DISCUSSION This RCT directly compares two established treatment regimens, and addresses whether radiation therapy positively impacts on overall survival compared with a standard perioperative chemotherapy regimen Sponsor: Irish Clinical Research Group (ICORG). TRIAL REGISTRATION NCT01726452 . Protocol 10-14. Date of registration 06/11/2012.
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Affiliation(s)
- JV Reynolds
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - SR Preston
- Royal Surrey County Hospital, Guildford, UK
| | | | | | | | - C Mariette
- University Hospital C. Huriez Place de Verdun, Lille, France
| | - S Cuffe
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - M Cunningham
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - T Crosby
- Velindre Cancer Centre, Cardiff, Wales UK
| | - I Parker
- St Mary’s Hospital and Imperial College London, London, UK
| | | | - G Hanna
- St Mary’s Hospital and Imperial College London, London, UK
| | | | - CL Donohoe
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - C Muldoon
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - D O’Toole
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - C Johnson
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - N Ravi
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - G Jones
- Velindre Cancer Centre, Cardiff, Wales UK
| | - AK Corkhill
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - M Illsley
- Royal Surrey County Hospital, Guildford, UK
| | - J Mellor
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - K Lee
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - M Dib
- University Hospital C. Huriez Place de Verdun, Lille, France
| | - V Marchesin
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
| | - M Cunnane
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
| | - K Scott
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
| | - P Lawner
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
| | - S Warren
- St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
| | - S O’Reilly
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
| | - G O’Dowd
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
| | - G Leonard
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
| | - B Hennessy
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
| | - R Mc Dermott
- Irish Clinical Oncology Research Group (ICORG), Dublin, Ireland
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153
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Ronellenfitsch U, Schwarzbach M, Hofheinz R, Kienle P, Nowak K, Kieser M, Slanger TE, Burmeister B, Kelsen D, Niedzwiecki D, Schuhmacher C, Urba S, van de Velde C, Walsh TN, Ychou M, Jensen K. Predictors of overall and recurrence-free survival after neoadjuvant chemotherapy for gastroesophageal adenocarcinoma: Pooled analysis of individual patient data (IPD) from randomized controlled trials (RCTs). Eur J Surg Oncol 2017; 43:1550-1558. [PMID: 28551325 DOI: 10.1016/j.ejso.2017.05.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 05/02/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Neoadjuvant chemotherapy improves prognosis of patients with locally advanced gastroesophageal adenocarcinoma. The aim of this study was to identify predictors for postoperative survival following neoadjuvant therapy. These could be useful in deciding about postoperative continuation of chemotherapy. METHODS This meta-analysis used IPD from RCTs comparing neoadjuvant chemotherapy with surgery alone for gastroesophageal adenocarcinoma. Trials providing IPD on age, sex, performance status, pT/N stage, resection status, overall and recurrence-free survival were included. Survival was calculated in the entire study population and subgroups stratified by supposed predictors and compared using the log-rank test. Multivariable Cox models were used to identify independent survival predictors. RESULTS Four RCTs providing IPD from 553 patients fulfilled the inclusion criteria. (y)pT and (y)pN stage and resection status strongly predicted postoperative survival both after neoadjuvant therapy and surgery alone. Patients with R1 resection after neoadjuvant therapy survived longer than those with R1 resection after surgery alone. Patients with stage pN0 after surgery alone had better prognosis than those with ypN0 after neoadjuvant therapy. Patients with stage ypT3/4 after neoadjuvant therapy survived longer than those with stage pT3/4 after surgery alone. Multivariable regression identified resection status and (y)pN stage as predictors of survival in both groups. (y)pT stage predicted survival only after surgery alone. CONCLUSION After neoadjuvant therapy for gastroesophageal adenocarcinoma, survival is determined by the same factors as after surgery alone. However, ypT stage is not an independent predictor. These results can facilitate the decision about postoperative continuation of chemotherapy in pretreated patients.
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Affiliation(s)
- U Ronellenfitsch
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - M Schwarzbach
- Department of General, Visceral, Vascular, and Thoracic Surgery, Klinikum Frankfurt Höchst, Gotenstraße 6-8, 65929 Frankfurt am Main, Germany.
| | - R Hofheinz
- Day Treatment Center (TTZ), Interdisciplinary Tumor Center Mannheim (ITM) & 3rd Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - P Kienle
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - K Nowak
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - M Kieser
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130, 69120 Heidelberg, Germany.
| | - T E Slanger
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - B Burmeister
- University of Queensland, Princess Alexandra Hospital, Brisbane, QLD 4102, Australia.
| | - D Kelsen
- Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, NY 10021, USA.
| | - D Niedzwiecki
- The Alliance for Clinical Trials in Oncology (Alliance) Statistics and Data Center, Duke University Medical Center, Hock Plaza, 2424 Erwin Rd, Room 8040, Durham, NC 27705, USA.
| | - C Schuhmacher
- Department of Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany.
| | - S Urba
- Division of Hematology/Oncology, University of Michigan Medical Center, 1500 E Medical Center Drive, C347, SPC 5848, Ann Arbor, MI 48109, USA.
| | - C van de Velde
- Department of Surgery, Leiden University Medical Center, K6-R, P.O. Box 9600, 2300 RC Leiden, The Netherlands.
| | - T N Walsh
- Department of Surgery, Connolly Hospital, Blanchardstown, Dublin 15, Ireland.
| | - M Ychou
- Centre Régional de Lutte Contre le Cancer, Val d'Aurelle, Montpellier Cedex 05, France.
| | - K Jensen
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130, 69120 Heidelberg, Germany.
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Yamashita H, Seto Y, Takenaka R, Okuma K, Kiritooshi T, Mori K, Yamada K, Fukuda T, Kaminishi M, Abe O, Nakagawa K. Survival comparison between radical surgery and definitive chemoradiation in 267 esophageal squamous cell carcinomas in a single institution: A propensity-matched study. PLoS One 2017; 12:e0177133. [PMID: 28486551 PMCID: PMC5423615 DOI: 10.1371/journal.pone.0177133] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 04/21/2017] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To compare radical surgery with definitive chemoradiation (CRT) for esophageal squamous cell carcinoma using propensity score (PS) matching at our single institution. MATERIALS AND METHODS A total of 386 consecutive, surgically treated and 243 CRT-treated cases between 2001 and 2014 were analyzed. PS was calculated using multivariable analysis (logistic regression) for pairs of variables such as treatment time, age, sex, primary tumor location, clinical stage, and clinical T- and N-stage for patients after excluding clinical T4 and M1 cases. According to PS, 133 surgically-treated and 134 CRT-treated cases were selected randomly by software. RESULTS The patients' median age was 68 years in the CRT group and 71 years in the surgery group. Clinical stage II-III, T3, N0 (according to the 7th American Joint Committee on Cancer-2009), and upper plus middle thoracic esophageal disease were seen in 68%, 44%, 54%, and 59%, respectively, in the CRT group and 64%, 47%, 55%, and 64%, respectively, in the surgery group. The 3- and 5-year overall survival was 47.1% and 34.0% in the CRT group and 68.3% and 54.4% in the surgery group (p = 0.0019). The 3- and 5-year progression-free survival was 45.3% and 38.8% in the CRT group and 61.1% and 54.4% in the surgery group (p = 0.022). CONCLUSION CRT may be inferior to surgery in survival, although a selection bias for patients selected for a non-operative approach cannot be excluded, especially since surgery is the standard of care at this institution. A prospective randomized clinical trial will be necessary to draw a definite conclusion.
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Affiliation(s)
- Hideomi Yamashita
- Department of Radiology, University of Tokyo Hospital, Tokyo, Japan
- * E-mail:
| | - Yasuyuki Seto
- Department of Gastrointestinal Surgery, University of Tokyo Hospital, Tokyo, Japan
| | | | - Kae Okuma
- Department of Radiology, University of Tokyo Hospital, Tokyo, Japan
| | | | - Kazuhiko Mori
- Department of Gastrointestinal Surgery, Mitui Memorial Hospital, Tokyo, Japan
| | - Kazuhiko Yamada
- Department of Gastrointestinal Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takashi Fukuda
- Department of Gastrointestinal Surgery, Saitama Cancer Center, Saitama, Japan
| | - Michio Kaminishi
- Department of Gastrointestinal Surgery, Showa General Hospital, Tokyo, Japan
| | - Osamu Abe
- Department of Radiology, University of Tokyo Hospital, Tokyo, Japan
| | - Keiichi Nakagawa
- Department of Radiology, University of Tokyo Hospital, Tokyo, Japan
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155
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Petrelli F, Tomasello G, Barni S. Surrogate end-points for overall survival in 22 neoadjuvant trials of gastro-oesophageal cancers. Eur J Cancer 2017; 76:8-16. [DOI: 10.1016/j.ejca.2017.01.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/07/2017] [Accepted: 01/29/2017] [Indexed: 02/07/2023]
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156
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Tomasello G, Ghidini M, Barni S, Passalacqua R, Petrelli F. Overview of different available chemotherapy regimens combined with radiotherapy for the neoadjuvant and definitive treatment of esophageal cancer. Expert Rev Clin Pharmacol 2017; 10:649-660. [PMID: 28349718 DOI: 10.1080/17512433.2017.1313112] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Neoadjuvant chemoradiotherapy (CTRT) is the current standard of care for treatment of locally advanced cancer of the esophagus or gastroesophageal junction. Many efforts have been made over the last years to identify the best chemotherapy and radiotherapy combination regimen, but specific randomized trials addressing this issue are still lacking. Areas covered: A systematic review of the literature was performed searching in PubMed all published studies of combinations CTRT regimens for operable or unresectable esophageal cancer to describe activity and toxicity. Studies considered were prospective series or clinical phase II-III trials including at least 40 patients and published in English language. Expert commentary: Long-term results of CROSS trial have established RT combined with carboplatin plus paclitaxel chemotherapy as the preferred neoadjuvant treatment option for both squamous and adenocarcinoma of the esophagus. More effective multimodal treatment strategies integrating novel biological agents including immunotherapy and based on an extensive molecular tumor characterization are eagerly awaited.
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Affiliation(s)
- Gianluca Tomasello
- a Oncology Unit, Oncology Department , ASST Ospedale di Cremona , Cremona , Italy
| | - Michele Ghidini
- a Oncology Unit, Oncology Department , ASST Ospedale di Cremona , Cremona , Italy
| | - Sandro Barni
- b Oncology Unit, Oncology Department , ASST Bergamo Ovest , Treviglio (BG) , Italy
| | - Rodolfo Passalacqua
- a Oncology Unit, Oncology Department , ASST Ospedale di Cremona , Cremona , Italy
| | - Fausto Petrelli
- b Oncology Unit, Oncology Department , ASST Bergamo Ovest , Treviglio (BG) , Italy
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157
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Powell AGMT, Hughes DL, Brown J, Larsen M, Witherspoon J, Lewis WG. Esophageal cancer's 100 most influential manuscripts: a bibliometric analysis. Dis Esophagus 2017; 30:1-8. [PMID: 28375483 DOI: 10.1093/dote/dow039] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- A G M T Powell
- Division of Cancer and Genetics, Cardiff University, University Hospital of Wales, Cardiff, UK.,Department of Surgery, University Hospital of Wales, Cardiff, UK
| | - D L Hughes
- Department of Surgery, University Hospital of Wales, Cardiff, UK
| | - J Brown
- Department of Surgery, University Hospital of Wales, Cardiff, UK
| | - M Larsen
- Department of Surgery, University Hospital of Wales, Cardiff, UK
| | - J Witherspoon
- Department of Surgery, University Hospital of Wales, Cardiff, UK
| | - W G Lewis
- Department of Surgery, University Hospital of Wales, Cardiff, UK
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158
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Controversies and Consensus in Preoperative Therapy of Esophageal and Gastroesophageal Junction Cancers. Surg Oncol Clin N Am 2017; 26:241-256. [DOI: 10.1016/j.soc.2016.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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159
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Tiesi G, Park W, Gunder M, Rubio G, Berger M, Ardalan B, Livingstone A, Franceschi D. Long-term survival based on pathologic response to neoadjuvant therapy in esophageal cancer. J Surg Res 2017; 216:65-72. [PMID: 28807215 DOI: 10.1016/j.jss.2017.03.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 03/06/2017] [Accepted: 03/23/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neoadjuvant treatment is standard for locally advanced esophageal cancer. However, whether the addition of radiation to neoadjuvant regimen improves survival remains unclear. The aim of this study was to compare survival in locally advanced esophageal cancer treated with neoadjuvant chemotherapy versus chemoradiation. MATERIALS AND METHODS A prospectively maintained database of esophagectomies (1999-2012) was analyzed. We identified 297 patients with locally advanced esophageal cancer that underwent either neoadjuvant chemotherapy (n = 231) or chemoradiation (n = 66) followed by esophagectomy. Pretreatment and pathologic staging were compared to assess response. Overall survival was recorded. RESULTS Most patients in the chemotherapy and chemoradiation groups had pretreatment stage III disease (66.7% versus 65.2%; P = 0.44). Median follow-up was 79.3 and 64.9 mo for chemotherapy and chemoradiation cohorts, respectively. Complete response rate was higher in chemoradiation than chemotherapy groups (30.3% versus 13.8%; P < 0.001). Overall survival was similar between complete responders in both groups (median not reached versus 121.1 mo; chemotherapy versus chemoradiation). However, partial responders in the chemotherapy cohort had improved median survival (147.2 mo) versus those in the chemoradiation cohort (83.7 mo, P < 0.03). Within the chemotherapy-only group, partial responders had improved survival compared with nonresponders (P = 0.041); however, there was no difference in survival between partial and complete responders (P = 0.36). CONCLUSIONS In patients undergoing esophagectomy for locally advanced esophageal cancer, neoadjuvant chemotherapy was associated with an equivalent overall survival, when compared with neoadjuvant chemoradiotherapy. Adding neoadjuvant radiation may enhance complete response rates but does not appear to be associated with improved survival.
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Affiliation(s)
- Gregory Tiesi
- Division of Surgical Oncology, Department of General Surgery, University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Sylvester Comprehensive Cancer Center, University of Miami Hospital, Miami, Florida.
| | - Wungki Park
- Division of Hematology-Oncology, Department of Medicine, University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Sylvester Comprehensive Cancer Center, University of Miami Hospital, Miami, Florida
| | - Meredith Gunder
- Division of Surgical Oncology, Department of General Surgery, University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Sylvester Comprehensive Cancer Center, University of Miami Hospital, Miami, Florida
| | - Gustavo Rubio
- Division of Surgical Oncology, Department of General Surgery, University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Sylvester Comprehensive Cancer Center, University of Miami Hospital, Miami, Florida
| | - Michael Berger
- Division of Surgical Oncology, Department of General Surgery, University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Sylvester Comprehensive Cancer Center, University of Miami Hospital, Miami, Florida
| | - Bach Ardalan
- Division of Hematology-Oncology, Department of Medicine, University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Sylvester Comprehensive Cancer Center, University of Miami Hospital, Miami, Florida
| | - Alan Livingstone
- Division of Surgical Oncology, Department of General Surgery, University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Sylvester Comprehensive Cancer Center, University of Miami Hospital, Miami, Florida
| | - Dido Franceschi
- Division of Surgical Oncology, Department of General Surgery, University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Sylvester Comprehensive Cancer Center, University of Miami Hospital, Miami, Florida
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160
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Multimodality treatment of locally advanced squamous cell carcinoma of the oesophagus: A comprehensive review and network meta-analysis. Crit Rev Oncol Hematol 2017; 114:24-32. [PMID: 28477744 DOI: 10.1016/j.critrevonc.2017.03.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 03/21/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Surgery is the mainstay of treatment for oesophageal squamous-cell carcinoma (OSCC) but with poor results. Attempts to improve patient outcome have been made by introducing chemotherapy (CT), radiotherapy (RT), or both (CRT). However, randomized comparisons for all these strategies are not always available. PATIENTS AND METHODS We conducted an extensive literature search for studies comparing surgery with multimodality treatment (i.e. [neo-]adjuvant CT or RT or CRT or definitive CRT). Network meta-analysis was performed in a Bayesian framewor and node-split models were built to assess inconsistency. RESULTS Twenty-five trials including a total of 3866 OSCC patients were included. Neoadjuvant CRT was associated with the most robust survival advantage across different multimodality treatment options (HR 0.73; 95% credible interval [CrI] 0.63-0.86). Definitive CRT was also significantly more effective than surgery but with greater uncertainties (HR 0.62; 95%CrI 0.41-0.96). Neoadjuvant CT (HR 0.90; 95%CrI 0.76-1.07) and adjuvant CRT (HR 1.00; 95%CrI 0.70-1.40) are associated with a non-significant benefit. CONCLUSIONS To date, neoadjuvant CRT seems to represent the best approach to maximize the benefit of a multimodality approach.
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161
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Lertbutsayanukul C, Tharavej C, Klaikeaw N, Prayongrat A, Lowanitchai C, Sriuranpong V. High dose radiation with chemotherapy followed by salvage esophagectomy among patients with locally advanced esophageal squamous cell carcinoma. Thorac Cancer 2017; 8:219-228. [PMID: 28322515 PMCID: PMC5415457 DOI: 10.1111/1759-7714.12427] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 01/29/2017] [Accepted: 02/03/2017] [Indexed: 12/21/2022] Open
Abstract
Background Locoregional failure is a major problem associated with chemoradiation treatment for squamous cell esophageal carcinoma. The aim of this study was to assess the feasibility, efficacy, and toxicity of preoperative radiation (dose > 50 Gy) with platinum‐based chemotherapy followed by esophagectomy in locally advanced squamous cell carcinoma. Methods Data of patients with cT2‐cT4 or node positive squamous cell carcinoma of the esophagus who received trimodality treatment between February 2006 and June 2015 were reviewed. Results Forty‐four patients were treated with intensity‐modulated radiation therapy, volumetric‐modulated arc therapy or three‐dimensional radiation therapy. The median radiation dose was 60 Gy. The average volume of the lungs receiving 10 Gy was 48.1%, 20 Gy was 24.5%, and the average mean lung dose was 14 Gy. After chemoradiation, R0 resection was achieved in 31 patients (71%). Patients who received >60 Gy had a higher pathologic complete remission rate than those in the lower dose group (59.1% vs. 36.4%). R0 resection and radiation dose >60 Gy were associated with better overall survival in Cox proportional hazards regression analysis. The median follow‐up duration was 22.4 months and median survival was 25.6 months. Two‐year overall, progression‐free survival and locoregional control rates were 55.9%, 28.6%, and 56%, respectively. The most common grade 3–4 toxicities were esophagitis (63.6%) and neutropenia (25%). Grade 3–4 postoperative morbidities included surgical wound infection (2.3%), acute renal failure (2.3%), and anastomosis stricture (2.3%). Conclusion Trimodality treatment with a high preoperative radiation dose and chemotherapy yielded a good pathologic complete response rate, and long‐term survival with low toxicities.
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Affiliation(s)
| | - Chadin Tharavej
- Faculty of Medicine, Department of Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Naruemon Klaikeaw
- Faculty of Medicine, Department of Pathology, Chulalongkorn University, Bangkok, Thailand
| | - Anussara Prayongrat
- Faculty of Medicine, Department of Radiology, Chulalongkorn University, Bangkok, Thailand
| | - Chutinan Lowanitchai
- Faculty of Medicine, Department of Radiology, Chulalongkorn University, Bangkok, Thailand
| | - Virote Sriuranpong
- Medical Oncology Unit, Faculty of Medicine, Department of Internal Medicine, Chulalongkorn University, Bangkok, Thailand
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162
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So B, Marcu L, Olver I, Gowda R, Bezak E. Oesophageal cancer: Which treatment is the easiest to swallow? A review of combined modality treatments for resectable carcinomas. Crit Rev Oncol Hematol 2017; 113:135-150. [PMID: 28427503 DOI: 10.1016/j.critrevonc.2017.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 12/17/2016] [Accepted: 03/08/2017] [Indexed: 01/31/2023] Open
Abstract
Oesophageal cancer is a relatively uncommon malignancy, but with poor prognosis. Despite several treatment options that are available, the 5-year survival rates rarely exceed 40%. This review discusses the main challenges of oesophageal cancer, the available treatment options, and the most effective treatment in terms of overall survival. The outcomes of clinical trials show that neo-adjuvant chemo-radiotherapy using cisplatin and 5-fluorouracil followed by oesophagectomy results in the greatest survival. However, the optimal chemotherapy and radiotherapy schedule remains unclear. There is no satisfactory treatment to date, particularly for patients with co-morbidities or advanced tumours.
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Affiliation(s)
- Bianca So
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; School of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Loredana Marcu
- Faculty of Science, University of Oradea, Oradea 410087, Romania; School of Physical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Ian Olver
- Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - Raghu Gowda
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Eva Bezak
- School of Health Sciences, University of South Australia, Adelaide, SA, Australia; School of Physical Sciences, University of Adelaide, Adelaide, SA, Australia; Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia.
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163
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Altorki N, Harrison S. What is the role of neoadjuvant chemotherapy, radiation, and adjuvant treatment in resectable esophageal cancer? Ann Cardiothorac Surg 2017; 6:167-174. [PMID: 28447006 DOI: 10.21037/acs.2017.03.16] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The majority of patients with operable esophageal cancers present with locally advanced disease, for which surgical resection as a sole treatment modality has been historically associated with poor survival. Even following radical resection, most of these patients will eventually succumb to their disease due to distant metastasis. For this reason, there has been intense interest in the role of neoadjuvant therapy. Neoadjuvant therapy primarily consists of either chemotherapy, radiation therapy, or a combination of the two. Multiple studies of variable scope, design, and patient characteristics have been conducted to determine whether neoadjuvant therapy is warranted, and-if so-what is the best modality of treatment. Despite nearly three decades of study, decisions regarding neoadjuvant therapy for esophageal cancer remain controversial. Regardless, the available evidence provided by large, prospective studies supports preoperative chemotherapy as opposed to surgery alone. Therefore, in our opinion, there is no longer any question as to whether induction therapy is appropriate for locally advanced esophageal cancer. Less clear, however, is the evidence that the addition of radiation to chemotherapy in the preoperative setting is superior to neoadjuvant chemotherapy alone. Our group generally advocates for neoadjuvant chemotherapy alone followed by radical esophageal resection. The data for adjuvant therapy are soft, and particularly troubling is the high rate of treatment drop out in trials studying adjuvant therapy. Therefore, we strongly prefer neoadjuvant chemotherapy and reserve adjuvant chemotherapy for those rare, highly selected patients-patients with T1 tumors, for example-who do not receive neoadjuvant treatment and are found to have occult nodal disease at the time of surgery.
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Affiliation(s)
- Nasser Altorki
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
| | - Sebron Harrison
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, USA
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164
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Liu S, Qiu B, Luo G, Liang Y, Zheng Y, Chen Z, Luo K, Xi M, Liu Q, Hu Y, Li Q, Fu J, Liu M, Yang H, Liu H. TNM Staging Matched-pair Comparison of Surgery After Neoadjuvant Chemoradiotherapy, Surgery Alone and Definitive Chemoradiotherapy for Thoracic Esophageal Squamous Cell Carcinoma. J Cancer 2017; 8:683-690. [PMID: 28367248 PMCID: PMC5370512 DOI: 10.7150/jca.17048] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 11/16/2016] [Indexed: 01/02/2023] Open
Abstract
Introduction: We used the TNM staging matched-pair approach to compare the efficacies of surgery after neoadjuvant chemoradiotherapy (NCT), surgery alone and definitive chemoradiotherapy (CCRT) in patients with localized advanced thoracic esophageal squamous cell carcinoma (ESCC). Methods: A total of 642 patients with ESCC from previous studies were studied. Patients whose treatment involved NCT + surgery and surgery alone were compared with patients receiving CCRT. Prospensity score matched-pair comparison based on pre-treatment TNM staging was developed to assess the efficacies of these treatment options. Results: Prospensity score matched-pair comparison to control for bias generated a cohort of 274 patients who were eligible for comparison. The 3-year OS rate was 70.0% in the NCT + surgery group, compared to 51.7% in the surgery group (p=0.000) and 61.9% in the CCRT group (p=0.082). With the TNM staging matched-pair approach, the CCRT group had more upper thoracic ESCC patients (43/92, 46.7%), while the surgery group had more lower thoracic ESCC patients (37/92, 40.2%). The 3-year OS rates were comparable between the surgery alone group and CCRT group (p=0.109). Conclusions: NCT plus surgery was superior in OS to surgery alone or CCRT. The 3-year OS rates were comparable between the surgery alone group and CCRT group with TNM staging matched-pair approach. Further investigation is warranted to confirm these findings.
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Affiliation(s)
- ShiLiang Liu
- State Key Laboratory of Oncology in South China;; Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, P.R. China;; Department of Radiation Oncology
| | - Bo Qiu
- State Key Laboratory of Oncology in South China;; Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, P.R. China;; Department of Radiation Oncology
| | - GuangYu Luo
- State Key Laboratory of Oncology in South China;; Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, P.R. China;; Department of Endoscopy
| | - Ying Liang
- State Key Laboratory of Oncology in South China;; Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, P.R. China;; Department of Medical Oncology
| | - YuZhen Zheng
- State Key Laboratory of Oncology in South China;; Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, P.R. China;; Department of Thoracic Surgery
| | - ZhaoLin Chen
- State Key Laboratory of Oncology in South China;; Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, P.R. China;; Department of Radiation Oncology
| | - KongJia Luo
- State Key Laboratory of Oncology in South China;; Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, P.R. China;; Department of Thoracic Surgery
| | - Mian Xi
- State Key Laboratory of Oncology in South China;; Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, P.R. China;; Department of Radiation Oncology
| | - Qing Liu
- State Key Laboratory of Oncology in South China;; Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, P.R. China;; Department of Clinical Statistics, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P.R. China
| | - YongHong Hu
- State Key Laboratory of Oncology in South China;; Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, P.R. China;; Department of Radiation Oncology
| | - Qun Li
- State Key Laboratory of Oncology in South China;; Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, P.R. China;; Department of Radiation Oncology
| | - JianHua Fu
- State Key Laboratory of Oncology in South China;; Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, P.R. China;; Department of Thoracic Surgery
| | - MengZhong Liu
- State Key Laboratory of Oncology in South China;; Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, P.R. China;; Department of Radiation Oncology
| | - Hong Yang
- State Key Laboratory of Oncology in South China;; Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, P.R. China;; Department of Thoracic Surgery
| | - Hui Liu
- State Key Laboratory of Oncology in South China;; Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, P.R. China;; Department of Radiation Oncology
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165
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Chun SG, Skinner HD, Minsky BD. Radiation Therapy for Locally Advanced Esophageal Cancer. Surg Oncol Clin N Am 2017; 26:257-276. [PMID: 28279468 DOI: 10.1016/j.soc.2016.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Stephen G Chun
- Division of Radiation Oncology, The University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA.
| | - Heath D Skinner
- Division of Radiation Oncology, The University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Bruce D Minsky
- Division of Radiation Oncology, The University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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166
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Franco P, Arcadipane F, Strignano P, Spadi R, Trino E, Martini S, Iorio GC, Satolli MA, Airoldi M, Romagnoli R, Camandona M, Ricardi U. Pre-operative treatments for adenocarcinoma of the lower oesophagus and gastro-oesophageal junction: a review of the current evidence from randomized trials. Med Oncol 2017; 34:40. [PMID: 28176241 DOI: 10.1007/s12032-017-0898-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 01/31/2017] [Indexed: 01/03/2023]
Abstract
Adenocarcinomas of the lower oesophagus and gastro-oesophageal junction are a complex clinico-pathological setting. Multimodality therapy is considered mandatory in most disease presentations. Nevertheless, the most appropriate treatment package has yet to be established. We herein summarize the evidence derived from randomized phase III trials on pre-operative treatments in this oncological scenario.
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Affiliation(s)
- Pierfrancesco Franco
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy.
| | - Francesca Arcadipane
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy
| | - Paolo Strignano
- Department of Surgical Sciences, General Surgery 2U and Liver Transplantation Center, University of Turin, Turin, Italy
| | - Rosella Spadi
- Department of Oncology, Medical Oncology 1, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Elisabetta Trino
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy
| | - Stefania Martini
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy
| | - Giuseppe Carlo Iorio
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy
| | | | - Mario Airoldi
- Department of Oncology, Medical Oncology 2, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Renato Romagnoli
- Department of Surgical Sciences, General Surgery 2U and Liver Transplantation Center, University of Turin, Turin, Italy
| | - Michele Camandona
- Department of Surgical Sciences, General Surgery 1U, University of Turin, Turin, Italy
| | - Umberto Ricardi
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy
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167
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Hagen PV, Heijl MV, van Berge Henegouwen MI, Boellaard R, Bossuyt PMM, Kate FJWT, Dekken HV, Hoekstra OS, Sloof GW, Lanschot JJBV. Prediction of disease-free survival using relative change in FDG-uptake early during neoadjuvant chemoradiotherapy for potentially curable esophageal cancer: A prospective cohort study. Dis Esophagus 2017; 30:1-7. [PMID: 27001344 DOI: 10.1111/dote.12479] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
18F-Fluorodeoxyglucose positron emission tomography (FDG-PET) has been investigated as a tool for monitoring response to neoadjuvant chemo- and chemoradiotherapy (CT and CRT, respectively) and as a predictor for survival in patients with esophageal cancer. In contrast to patients who undergo neoadjuvant CT, it is not known whether patients who are clinically identified as responders after neoadjuvant CRT show better disease-free survival (DFS) than patients identified as nonresponders. The aim of the study was to determine the predictive value of FDG-uptake measured prior to and early during neoadjuvant CRT. Patients treated with neoadjuvant CRT between 2004 and 2009 within a randomized trial were included. FDG-uptake was measured at baseline and after 14 days of CRT. According to the PERCIST-criteria, patients were allocated to have metabolic response, stable disease, or progression. Patients were followed until recurrence of disease or death. The predictive value of FDG-PET was determined with univariable and multivariable analysis in patients who underwent potentially curative surgery. One-hundred and six patients were included in the analysis. Minimal follow-up for surviving patients was 60 months. No significant differences in DFS were found between patients with metabolic response, stable disease, or progression, with 5-year DFS rates of 66%, 53%, and 67%, respectively (P = 0.39). Relative change in FDG uptake after 14 days of CRT is not associated with DFS in patients with esophageal cancer undergoing neoadjuvant chemoradiotherapy followed by surgery. These measurements should not be used for prognostication in this specific group of patients.
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Affiliation(s)
- P V Hagen
- Department of Surgery, Erasmus Medical Center, Rotterdam
| | - M V Heijl
- Department of Surgery, Academic Medical Center, Amsterdam
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - R Boellaard
- Department of Nuclear Medicine and PET research, VU Medical Center, Amsterdam
| | - P M M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam
| | - F J W T Kate
- Department of Pathology, Academic Medical Center, Amsterdam
- Department of Pathology, Erasmus Medical Center, Rotterdam
| | - H V Dekken
- Department of Pathology, Erasmus Medical Center, Rotterdam
- Department of Pathology, Sint Lucas Andreas Hospital, Amsterdam
| | - O S Hoekstra
- Department of Nuclear Medicine and PET research, VU Medical Center, Amsterdam
| | - G W Sloof
- Department of Nuclear Medicine, Academic Medical Center, Amsterdam
- Department of Nuclear Medicine, Groene Hart Hospital, Gouda
| | - J J B V Lanschot
- Department of Surgery, Erasmus Medical Center, Rotterdam
- Department of Surgery, Academic Medical Center, Amsterdam
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168
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Wahl DR, Lawrence TS. Integrating chemoradiation and molecularly targeted therapy. Adv Drug Deliv Rev 2017; 109:74-83. [PMID: 26596559 DOI: 10.1016/j.addr.2015.11.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/27/2015] [Accepted: 11/08/2015] [Indexed: 12/25/2022]
Abstract
While the advent of combined chemoradiation has improved outcomes for innumerable patients with locally advanced cancers, further improvements are urgently needed. Escalation of either chemotherapy or radiotherapy is associated with unacceptable toxicity. An alternative strategy is the integration of chemoradiation and molecularly targeted therapies, which exploits biological differences between cancer and normal tissue and should therefore increase efficacy while maintaining tolerable toxicity. Combining chemoradiation with agents that modulate tumor-specific pathways such as cell cycle checkpoints, PARP signaling, EGFR signaling, the PI3K/AKT/mTOR axis and androgen signaling has shown immense promise in preclinical and clinical studies, as have combinations with environmentally-targeted agents against the immune system and angiogenesis. The optimal application of these strategies will likely require consideration of molecular heterogeneity between patients and within individual tumors.
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169
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Cox SJ, O'Cathail SM, Coles B, Crosby T, Mukherjee S. Update on Neoadjuvant Regimens for Patients with Operable Oesophageal/Gastrooesophageal Junction Adenocarcinomas and Squamous Cell Carcinomas. Curr Oncol Rep 2017; 19:7. [PMID: 28213876 PMCID: PMC5315732 DOI: 10.1007/s11912-017-0559-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Samantha J Cox
- Cardiff University, Cardiff, CF10 3XQ, UK.
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, UK.
| | - Sean M O'Cathail
- Department of Clinical Oncology, Oxford University NHS Trust, Oxford, UK
| | | | - Tom Crosby
- Department of Clinical Oncology, Velindre Cancer Centre, Cardiff, UK
| | - Somnath Mukherjee
- MRC/CRUK Oxford Institute for Radiation Oncology, University of Oxford, Oxford, UK
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170
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Meta-Analysis for the Therapeutic Effect of Neoadjuvant Therapy in Resectable Esophageal Cancer. Pathol Oncol Res 2016; 23:657-663. [PMID: 28013492 DOI: 10.1007/s12253-016-0164-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022]
Abstract
We aimed to review the therapeutic effects of neoadjuvant chemoradiotherapy (NCRT), chemotherapy (NCT), and radiotherapy (NRT) on patients with resectable Esophageal cancer (EsC) by comparison with surgery alone (SA). PubMed, EMBASE and Cochrane were searched for eligible studies published up to March 2015. Cochrane reviews were used for quality assessment. Eight primary outcomes were analyzed. Risk ratios (RRs)/ hazard ratios (HRs) and corresponding 95% confidence intervals (95% CIs) were calculated using the random- or fixed- effects model. Heterogeneity was assessed using the Chi-square-based Q statistic and the I 2 test. Publication bias was examined by the Begg's funnel plot. Totally 24 articles including 4718 EsC cases were eligible for this meta-analysis. The quality of the literatures was relatively high. Significant difference was found in five-year survival rate (RR = 1.45, 95% CI: 1.17-1.79, P < 0.01) between patients treated with NCT and SA, while the eight enrolled primary outcomes were all statistically different between NCRT and SA, and significant difference was identified in three-year survival between NCRT and NCT (RR = 1.35, 95% CI: 1.14-1.60, P < 0.01). No obvious publication bias was observed. NCRT and NCT provide an obvious benefit for EsC treatment over SA, and NCRT possesses a clear advantage compared with NCT.
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171
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Wang DB, Sun ZY, Deng LM, Zhu DQ, Xia HG, Zhu PZ. Neoadjuvant Chemoradiotherapy Improving Survival Outcomes for Esophageal Carcinoma: An Updated Meta-analysis. Chin Med J (Engl) 2016; 129:2974-2982. [PMID: 27958230 PMCID: PMC5198533 DOI: 10.4103/0366-6999.195464] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The effectiveness of neoadjuvant chemoradiotherapy (NCRT) treatment for patients with esophageal carcinoma (EC) remains controversial. The aim of this study was to compare the effect of NCRT followed by surgery (NCRTS) with surgery alone (SA) for EC. METHODS The PubMed, EMBASE, and the Cochrane Library databases were electronically searched up to August 2015 for all the published studies that investigated EC patients receiving either NCRTS or SA, and the reference lists were also manually examined for the eligible studies. The risk ratio (RR) with 95% confidence intervals (CI s) as effective size was determined to assess the 1-, 3-, 5-year survival rates (SRs), postoperative morbidity, and postoperative mortality. Heterogeneity was determined using the Q-test. The Begg's test and Egger's test were used for assessing any potential publication bias. RESULTS Of 1120 identified studies, 16 eligible studies were included in this analysis (involving 2549 patients). Overall, the pooled results suggested that NCRTS was associated with significantly improved 1-year (RR: 1.07, 95% CI: 1.02-1.13), 3-year (RR: 1.26, 95% CI: 1.14-1.39), and 5-year (RR: 1.36, 95% CI: 1.18-1.56) SRs. However, the results also indicated that NCRTS had no or little effect on postoperative morbidity (RR: 0.93, 95% CI: 0.82-1.05) and postoperative mortality (RR: 1.17, 95% CI: 0.56-2.44). CONCLUSIONS Compared with SA, NCRTS can increase 1-, 3-, and 5-year SRs in patients with EC.
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Affiliation(s)
- Dong-Bin Wang
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, China
| | - Zhong-Yi Sun
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, China
| | - Li-Min Deng
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, China
| | - De-Qing Zhu
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, China
| | - Hong-Gang Xia
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, China
| | - Peng-Zhi Zhu
- Department of Cardiothoracic Surgery, Tianjin Hospital, Tianjin 300211, China
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172
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Huang X, Liu C, Cui Y, Zhang H, Liu Y, Zhou X, Luo J. Association between XRCC1 and ERCC1 single-nucleotide polymorphisms and the efficacy of concurrent radiochemotherapy in patients with esophageal squamous cell carcinoma. Oncol Lett 2016; 13:704-714. [PMID: 28356949 PMCID: PMC5351381 DOI: 10.3892/ol.2016.5496] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 09/30/2016] [Indexed: 12/20/2022] Open
Abstract
The aim of the present study was to investigate the association between single-nucleotide polymorphisms (SNPs) in X-ray repair cross-complementing 1–399 (XRCC1-399) or excision repair cross-complementation group 1–118 (ERCC1-118) and the short-term efficacy of radiochemotherapy, tumor metastasis and relapse, as well as the survival time in patients with esophageal squamous cell carcinoma (ESCC). TaqMan probe-based quantitative polymerase chain reaction (qPCR) was conducted to examine the levels of XRCC1-399 and ERCC1-118 SNPs in the peripheral blood of 50 patients with pathologically confirmed ESCC. In addition, the associations between different genotypes and short-term therapeutic efficacy [the complete remission (CR) rate], tumor metastasis and relapse, as well as the survival time following concurrent radiochemotherapy, were determined. A total of 50 ESCC patients who received concurrent radiochemotherapy were enrolled. It was found that the short-term therapeutic efficacy (CR rate) was higher in the group of patients carrying the homozygous mutation of XRCC1-399 (A/A genotype) than in the group of patients without the XRCC1-399 mutation (G/G genotype). In addition, the CR rate was significantly increased in patients carrying one or two ERCC1-118 C alleles (C/C or C/T genotype) compared with patients lacking the C allele (T/T genotype). The differences were statistically significant (A/A vs. G/G, P=0.014; TT vs. C/T+C/C, P=0.040). During the follow-up period, the group of patients carrying the homozygous mutation of XRCC1-399 (A/A genotype) exhibited a markedly reduced risk of metastasis and relapse compared with the group of patients carrying non-mutated XRCC1-399 (G/G genotype; P=0.031). By contrast, ERCC1-118 SNP was not associated with the risk of metastasis and recurrence (P>0.05). The combined results of univariate and multivariate Cox regression analysis showed that the SNP in ERCC1-118 was closely associated with survival time. The mean survival time was significantly prolonged in patients carrying 1 or 2 C alleles (C/C or C/T genotype) compared with patients lacking the C allele (T/T genotype) [T/T vs. C/C, HR=12.96, 95% confidence interval (CI)=3.08–54.61, P<0.001; TT vs. C/T+C/C, HR=11.71, 95% CI=3.06–44.83, P<0.001]. However, XRCC1-399SNP had no effect on survival time (P>0.05). XRCCl-399 SNP was associated with the short-term therapeutic efficacy (the CR rate) and tumor metastasis/relapse in ESCC patients who received the docetaxel plus cisplatin (TP) regimen-based concurrent radiochemotherapy. By contrast, ERCC1-118 SNP was significantly associated with the short-term therapeutic efficacy (the CR rate) and survival time in ESCC patients who received TP regimen-based concurrent radiochemotherapy.
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Affiliation(s)
- Xue Huang
- Department of Radiation Oncology, Changzhou Tumor Hospital Affiliated to Soochow University, Changzhou, Jiangsu 213001, P.R. China
| | - Changmin Liu
- Department of Oncology, Affiliated Hospital of Binzhou Medical College, Binzhou, Shandong 256603, P.R. China
| | - Yayun Cui
- Department of Radiation Oncology, Anhui Provincial Hospital, Hefei, Anhui 230001, P.R. China
| | - Heping Zhang
- Department of Radiation Oncology, Changzhou Tumor Hospital Affiliated to Soochow University, Changzhou, Jiangsu 213001, P.R. China
| | - Yongping Liu
- Department of Radiation Oncology, Changzhou Tumor Hospital Affiliated to Soochow University, Changzhou, Jiangsu 213001, P.R. China
| | - Xifa Zhou
- Department of Radiation Oncology, Changzhou Tumor Hospital Affiliated to Soochow University, Changzhou, Jiangsu 213001, P.R. China
| | - Judong Luo
- Department of Radiation Oncology, Changzhou Tumor Hospital Affiliated to Soochow University, Changzhou, Jiangsu 213001, P.R. China
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173
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Comments on Radical Esophagectomy after Neoadjuvant Chemoradiation: Single Institutional Experience from Tertiary Cancer Centre in India. Indian J Surg Oncol 2016; 7:373-374. [DOI: 10.1007/s13193-016-0561-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 09/12/2016] [Indexed: 10/20/2022] Open
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174
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Al-Sukhni E, Gabriel E, Attwood K, Kukar M, Nurkin SJ, Hochwald SN. No Survival Difference with Neoadjuvant Chemoradiotherapy Compared with Chemotherapy in Resectable Esophageal and Gastroesophageal Junction Adenocarcinoma: Results from the National Cancer Data Base. J Am Coll Surg 2016; 223:784-792.e1. [DOI: 10.1016/j.jamcollsurg.2016.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 08/31/2016] [Accepted: 09/01/2016] [Indexed: 12/28/2022]
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175
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Victorzon M, Tolonen P, Kohonen M, Salmo M. Outcome of Surgery for Oesophageal Carcinoma in a Low Volume Centre, with and without Preoperative Chemoradiotherapy. Scand J Surg 2016; 93:37-42. [PMID: 15116818 DOI: 10.1177/145749690409300108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Aims: To critically assess the outcome of surgery for oesophageal carcinoma, with or without neoadjuvant chemoradiotherapy. Methods: Since April 1998 until August 2002 resectable oesophageal cancer patients referred to us have received multimodal treatment, consisting of two courses of fluorouracil, cisplatin and hydroxyurea and 20 Gy of radiotherapy followed by surgery. The outcome of this treatment was compared to the outcome of a historical group of oesophageal cancer patients, treated with surgery alone in the time period 1994 to 1998. The patients represent a consecutive series of 20 resectable oesophageal carcinomas, referred to us since 1994. Four patients (20 %) were treated for squamocellular carcinoma, 16 (80 %) patients for adenocarcinoma. Results: Treatment related toxicity was low and there was no death attributable to the chemoradiotherapy. Postoperative hospital mortality (< 30 days) and morbidity rates were 10 % and 50 %, respectively. A complete pathological response (T0) occurred in two of the nine patients in the multimodal group (22 %). Overall median survival was 11 months. Median survival among patients in the multimodal group was 14 months, as compared with 7 months in the group treated with surgery alone (P = 0.041). Conclusions: Despite low volume, outcome of surgery for oesophageal carcinoma was acceptable.
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Affiliation(s)
- M Victorzon
- Department of Gastrointestinal Surgery, Vasa Central Hospital, Vasa, Finland.
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176
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Liu S, Anfossi S, Qiu B, Zheng Y, Cai M, Fu J, Yang H, Liu Q, Chen Z, Fu J, Liu M, Burks JK, Lin SH, Reuben J, Liu H. Prognostic Factors for Locoregional Recurrence in Patients with Thoracic Esophageal Squamous Cell Carcinoma Treated with Radical Two-Field Lymph Node Dissection: Results from Long-Term Follow-Up. Ann Surg Oncol 2016; 24:966-973. [PMID: 27804027 DOI: 10.1245/s10434-016-5652-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To aim of this study was to determine the clinical and biological prognostic factors for locoregional recurrence (LRR) in patients with thoracic esophageal squamous cell carcinoma (ESCC) undergoing radical two-field lymph node dissection (2FLD). METHODS A total of 462 patients diagnosed with thoracic ESCC underwent radical esophagectomy between March 2001 and May 2010 at Sun Yat-Sen University Cancer Center. Clinical characteristics, CD44 expression, and tumor-infiltrating lymphocyte (TIL) levels were evaluated in 198 patients who underwent R0 dissection with long-term follow-up. Partial Cox regression analysis with leave-one-out cross-validation was performed to validate the selected risk factors. RESULTS With a median follow-up of 54 months, the 5-year local failure-free survival (LFFS) rate of 198 patients was 62.5%. Multivariate analysis revealed that T stage (p = 0.043), pathological positive tumor above the carina (p = 0.000), CD44 expression level (p = 0.045) and TIL level (p = 0.007) were prognostic factors for LFFS, while the Cox model with risk scores had an area under the curve value of 83.6% for the prediction of 5-year LFFS. The best cut-off value (sum score = 11.19) was used to determine the high- and low-risk groups, with patients at high risk having a significantly shorter 5-year LFFS than patients at low risk (p = 0.000). The LRR pattern revealed significantly high incidences of recurrent disease at the supraclavicular and cervical sites, mediastinum (above the carina), and anastomosis. CONCLUSIONS Our predictive model was able to distinguish between patients at high risk for LRR and patients at low risk for LRR. LRR primarily involved the upper thorax and this area must be considered in future study designs for radical trimodality treatment.
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Affiliation(s)
- ShiLiang Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, People's Republic of China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, People's Republic of China.,Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, People's Republic of China
| | - Simone Anfossi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bo Qiu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, People's Republic of China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, People's Republic of China.,Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, People's Republic of China
| | - YuZhen Zheng
- Department of Thoracic Surgery, Fujian Provincial Tumor Hospital, Fuzhou, People's Republic of China
| | - MuYan Cai
- Department of Pathology, Sun Yat-Sen University Cancer Center, Guangzhou, Guangdong, People's Republic of China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, People's Republic of China.,Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, People's Republic of China
| | - Jia Fu
- Department of Pathology, Sun Yat-Sen University Cancer Center, Guangzhou, Guangdong, People's Republic of China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, People's Republic of China.,Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, People's Republic of China
| | - Hong Yang
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, Guangdong, People's Republic of China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, People's Republic of China.,Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, People's Republic of China
| | - Qing Liu
- Department of Clinical Statistics, Sun Yat-Sen University Cancer Center, Guangzhou, Guangdong, People's Republic of China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, People's Republic of China.,Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, People's Republic of China
| | - ZhaoLin Chen
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, People's Republic of China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, People's Republic of China.,Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, People's Republic of China
| | - JianHua Fu
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, Guangdong, People's Republic of China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, People's Republic of China.,Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, People's Republic of China
| | - MengZhong Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, People's Republic of China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, People's Republic of China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, People's Republic of China.,Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, People's Republic of China
| | - Jared K Burks
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - James Reuben
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hui Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, People's Republic of China. .,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, People's Republic of China. .,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, People's Republic of China. .,Guangdong Esophageal Cancer Research Institute, Guangzhou, Guangdong, People's Republic of China.
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177
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Predictors of Survival in Esophageal Squamous Cell Carcinoma with Pathologic Major Response after Neoadjuvant Chemoradiation Therapy and Surgery: The Impact of Chemotherapy Protocols. BIOMED RESEARCH INTERNATIONAL 2016; 2016:6423297. [PMID: 27777949 PMCID: PMC5061941 DOI: 10.1155/2016/6423297] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 08/23/2016] [Indexed: 12/02/2022]
Abstract
Tumor recurrence is an important problem threatening esophageal cancer patients after surgery, even when they achieve a pathologic major response (pMR) after neoadjuvant concurrent chemoradiation therapy (CCRT). The predictors related to overall survival and disease progression for these patients remain elusive. We aimed to identify factors that predict disease progression and overall survival in esophageal squamous cell carcinoma (SCC) patients who achieve a pMR after neoadjuvant CCRT followed by surgery. We conducted a retrospective study to analyze the factors influencing survival and disease progression after esophagectomy for esophageal cancer patients who had a major response to CCRT, which is defined by complete pathological response or microscopic residual disease without lymph node metastasis. From our study cohort, 285 patients underwent CCRT and subsequent esophagectomy; 171 (60%) of these patients achieved pMR. After excluding patients with lymph node metastases, incomplete clinical data, and adenocarcinomas, we enrolled 117 patients in this study. We found that the CCRT regimen was the only factor that influenced overall survival. The overall survival of the patients receiving taxane-incorporated CCRT was superior to that of patients receiving traditional cisplatin and 5-fluorouracil (PF) (P = 0.011). The CCRT regimen can significantly influence the clinical outcome of esophageal SCC patients who achieve pMR after neoadjuvant CCRT and esophagectomy. Incorporation of taxanes into cisplatin-based CCRT may be associated with prolonged survival.
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178
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Verma V, Moreno AC, Lin SH. Advances in Radiotherapy Management of Esophageal Cancer. J Clin Med 2016; 5:E91. [PMID: 27775643 PMCID: PMC5086593 DOI: 10.3390/jcm5100091] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 09/30/2016] [Accepted: 10/17/2016] [Indexed: 01/25/2023] Open
Abstract
Radiation therapy (RT) as part of multidisciplinary oncologic care has been marked by profound advancements over the past decades. As part of multimodality therapy for esophageal cancer (EC), a prime goal of RT is to minimize not only treatment toxicities, but also postoperative complications and hospitalizations. Herein, discussion commences with the historical approaches to treating EC, including seminal trials supporting multimodality therapy. Subsequently, the impact of RT techniques, including three-dimensional conformal RT, intensity-modulated RT, and proton beam therapy, is examined through available data. We further discuss existing data and the potential for further development in the future, with an appraisal of the future outlook of technological advancements of RT for EC.
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Affiliation(s)
- Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE 68198, USA.
| | - Amy C Moreno
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA.
| | - Steven H Lin
- Department of Radiation Oncology, University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA.
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179
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Swisher SG, Moughan J, Komaki RU, Ajani JA, Wu TT, Hofstetter WL, Konski AA, Willett CG. Final Results of NRG Oncology RTOG 0246: An Organ-Preserving Selective Resection Strategy in Esophageal Cancer Patients Treated with Definitive Chemoradiation. J Thorac Oncol 2016; 12:368-374. [PMID: 27729298 DOI: 10.1016/j.jtho.2016.10.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/08/2016] [Accepted: 10/01/2016] [Indexed: 01/09/2023]
Abstract
INTRODUCTION The impact of selective surgical resection for patients with esophageal cancer treated with definitive chemoradiation has not been clearly evaluated long-term. METHODS NRG (National Surgical Adjuvant Breast and Bowel Project, Radiation Therapy Oncology Group, Gynecologic Oncology Group) Oncology Radiation Therapy Oncology Group 0246 was a multi-institutional, single-arm, open-label, nonrandomized phase II study that enrolled 43 patients from September 2003 to March 2008 with clinical stage T1-4N0-1M0 squamous cell or adenocarcinoma of the esophagus or gastroesophageal junction from 19 sites. Patients received induction chemotherapy with fluorouracil (650 mg/m2/d), cisplatin (15 mg/m2/d), and paclitaxel (200 mg/m2/d) for two cycles followed by concurrent chemoradiation consisting of 50.4 Gy of radiation (1.8 Gy per fraction) and daily fluorouracil (300 mg/m2/d) with cisplatin (15 mg/m2/d) over the first 5 days. After definitive chemoradiation, patients were evaluated for residual disease. Selective esophagectomy was considered only for patients with residual disease after chemoradiation (clinical incomplete response) or recurrent disease on surveillance. RESULTS This report looks at the long-term outcome of this selective surgical strategy. With a median follow-up of 8.1 years (minimum to maximum for 12 alive patients 7.2-9.8 years), the estimated 5- and 7-year survival rates are 36.6% (95% confidence interval [CI]: 22.3-51.0) and 31.7% (95% CI: 18.3-46.0). Clinical complete response was achieved in 15 patients (37%), with 5- and 7-yearr survival rates of 53.3% (95% CI: 26.3-74.4) and 46.7% (95% CI: 21.2-68.7). Esophageal resection was not required in 20 of 41 patients (49%) on this trial. CONCLUSIONS The long-term results of NRG Oncology Radiation Therapy Oncology Group 0246 demonstrate promising efficacy of a selective surgical resection strategy and suggest the need for larger randomized studies to further evaluate this organ-preserving approach.
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Affiliation(s)
| | - Jennifer Moughan
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Ritsuko U Komaki
- University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Jaffer A Ajani
- University of Texas M. D. Anderson Cancer Center, Houston, Texas
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180
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Klevebro F, Lindblad M, Johansson J, Lundell L, Nilsson M. Outcome of neoadjuvant therapies for cancer of the oesophagus or gastro-oesophageal junction based on a national data registry. Br J Surg 2016; 103:1864-1873. [PMID: 27689845 DOI: 10.1002/bjs.10304] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/24/2016] [Accepted: 07/25/2016] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- F Klevebro
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institute, and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - M Lindblad
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institute, and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - J Johansson
- Department of Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - L Lundell
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institute, and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - M Nilsson
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institute, and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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181
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Kapoor R, Bansal A, Kumar S, Miriyala RT. Factors Influencing Compliance to Radical Treatment of Middle Thoracic Esophageal Cancer: An Audit from a Regional Cancer Centre. Indian J Palliat Care 2016; 22:288-94. [PMID: 27559257 PMCID: PMC4973489 DOI: 10.4103/0973-1075.185037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The aim of this study is to identify the factors responsible for interruption of planned treatment in patients of carcinoma mid-thoracic esophagus and also discuss the strategies for improving treatment completion rates. MATERIALS AND METHODS Patients with nonmetastatic mid-thoracic esophageal cancer who received treatment by multimodality approach using chemotherapy, radiation, and/or surgery were retrospectively analyzed. Factors influencing compliance with planned treatment completion were evaluated, and their significance was determined using multivariate Cox regression analysis. RESULTS Ninety-one patients were reviewed. Median follow-up period was 11 months. Of 15 patients planned with neoadjuvant chemoradiation followed by surgery (Group 1), only 6 (40%) could complete the treatment. Similarly, only 19 out of 36 patients (52.8%) completed the planned definitive chemoradiation (Group 2). Furthermore, of forty patients planned with definitive radiotherapy (Group 3), 29 patients only (72.5%) completed this schedule. The rate of completion of therapy was worst in Group 1. The most common reason for noncompletion of planned treatment was nutritional inadequacy and excessive weight loss in all groups. In addition, chemotherapy-induced myelosuppression (P = 0.05) was the factor leading to treatment interruption in Group 2 and radiation-induced acute mucositis (P = 0.02) and lost to follow-up (P = 0.02) were the factors in Group 3. CONCLUSIONS Rate of treatment completion significantly impacts survival rates. Nutritional inadequacy was the most common factor for noncompletion of planned treatment. A well-trained management team consisting of oncologist, dietitian, and psychotherapist can help overcome these factors and thereby improve the treatment completion rates.
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Affiliation(s)
- Rakesh Kapoor
- Department of Radiotherapy, PGIMER, Chandigarh, India
| | | | - Shikhar Kumar
- Department of Radiotherapy, PGIMER, Chandigarh, India
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Abstract
Survival for esophageal cancer has improved over the past four decades, probably as a result of a combination of more accurate staging, improved surgical outcomes, advances in adjuvant and neoadjuvant therapies, and the increasing implementation of multimodality treatment. Surgical resection still remains the mainstay in the treatment of localized esophageal adenocarcinoma. Multiple techniques have been described for esophagectomy, which are based on either a transthoracic or transhiatal approach. Despite proponents of each technique touting potential advantages such as superior oncologic resection with more extensive transthoracic lymphadenectomy compared to the relatively limited morbidity and mortality with a transhiatal resection, the superiority of one technique over another is not clear and may be relegated to a topic of historical significance in the era of minimally invasive surgery. With the increased acceptance of neoadjuvant multimodality therapy, both approaches have been shown to have acceptable outcomes. And in the hands of experienced surgeons, both techniques can provide excellent short-term results. Moreover, surgeon and hospital volume have shown to be strongly associated with improved operative morbidity and oncologic outcomes, which may supersede the type of approach selected for an individual patient.
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Affiliation(s)
- Jukes P Namm
- 1 Department of Surgery, Loma Linda University Health , Loma Linda, California
| | - Mitchell C Posner
- 2 Department of Surgery, University of Chicago Medicine , Chicago, Illinois
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183
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Brower JV, Chen S, Bassetti MF, Yu M, Harari PM, Ritter MA, Baschnagel AM. Radiation Dose Escalation in Esophageal Cancer Revisited: A Contemporary Analysis of the National Cancer Data Base, 2004 to 2012. Int J Radiat Oncol Biol Phys 2016; 96:985-993. [PMID: 27869098 DOI: 10.1016/j.ijrobp.2016.08.016] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 08/08/2016] [Accepted: 08/15/2016] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate the effect of radiation dose escalation on overall survival (OS) for patients with nonmetastatic esophageal cancer treated with concurrent radiation and chemotherapy. METHODS AND MATERIALS Patients diagnosed with stage I to III esophageal cancer treated from 2004 to 2012 were identified from the National Cancer Data Base. Patients who received concurrent radiation and chemotherapy with radiation doses of ≥50 Gy and did not undergo surgery were included. OS was compared using Cox proportional hazards regression and propensity score matching. RESULTS A total of 6854 patients were included; 3821 (55.7%) received 50 to 50.4 Gy and 3033 (44.3%) received doses >50.4 Gy. Univariate analysis revealed no significant difference in OS between patients receiving 50 to 50.4 Gy and those receiving >50.4 Gy (P=.53). The dose analysis, binned as 50 to 50.4, 51 to 54, 55 to 60, and >60 Gy, revealed no appreciable difference in OS within any group compared with 50 to 50.4 Gy. Subgroup analyses investigating the effect of dose escalation by histologic type and in the setting of intensity modulated radiation therapy also failed to reveal a benefit. Propensity score matching confirmed the absence of a statistically significant difference in OS among the dose levels. The factors associated with improved OS on multivariable analysis included female sex, lower Charlson-Deyo comorbidity score, private insurance, cervical/upper esophagus location, squamous cell histologic type, lower T stage, and node-negative status (P<.01 for all analyses). CONCLUSIONS In this large national cohort, dose escalation >50.4 Gy did not result in improved OS among patients with stage I to III esophageal cancer treated with definitive concurrent radiation and chemotherapy. These data suggest that despite advanced contemporary treatment techniques, OS for patients with esophageal cancer remains unaltered by escalation of radiation dose >50.4 Gy, consistent with the results of the INT-0123 trial. Furthermore, these data highlight that many radiation oncologists have not embraced the concept that dose escalation does not improve OS. Although local control, not investigated in the present study, might benefit from dose escalation, novel therapies are needed to improve the OS of patients with esophageal cancer.
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Affiliation(s)
- Jeffrey V Brower
- Department of Human Oncology, University of Wisconsin Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Shuai Chen
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Michael F Bassetti
- Department of Human Oncology, University of Wisconsin Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Menggang Yu
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Paul M Harari
- Department of Human Oncology, University of Wisconsin Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Mark A Ritter
- Department of Human Oncology, University of Wisconsin Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Andrew M Baschnagel
- Department of Human Oncology, University of Wisconsin Carbone Cancer Center, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin.
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Neri A, Marrelli D, Voglino C, Di Mare G, Ferrara F, Marini M, Roviello F. Recurrence after surgery in esophago-gastric junction adenocarcinoma: Current management and future perspectives. Surg Oncol 2016; 25:355-363. [PMID: 27916166 DOI: 10.1016/j.suronc.2016.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 08/10/2016] [Accepted: 08/12/2016] [Indexed: 02/07/2023]
Abstract
Recurrent esophago-gastric junction adenocarcinoma is not a rare event and its correct management is still debated. Many approaches for the treatment of these patients exist, but only few studies compare the different techniques. Most of the studies are retrospectives series and describe the experiences of single institutions in the treatment of recurrent esophageal and esophago-gastric junction cancers. Nowadays surgery is still the main and only curative treatment. Other alternative palliative therapies could be endoscopic stent placement and balloon dilation, photodynamic therapy, thermal tumor ablation (laser photoablation and Argon plasma coagulation), radiation therapy and brachytherapy, and chemotherapy. The aim of this review is to investigate the different rates, patterns and timings of recurrence of this tumor, and to explain the various approaches used for the treatment of recurrent esophago-gastric junction cancer.
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Affiliation(s)
- Alessandro Neri
- Department of Medicine, Surgery and Neurosciences - Unit of General Surgery and Surgical Oncology, University of Siena, Viale Bracci - Policlinico "Le Scotte" 53100, Siena, Italy
| | - Daniele Marrelli
- Department of Medicine, Surgery and Neurosciences - Unit of General Surgery and Surgical Oncology, University of Siena, Viale Bracci - Policlinico "Le Scotte" 53100, Siena, Italy
| | - Costantino Voglino
- Department of Medicine, Surgery and Neurosciences - Unit of General Surgery and Surgical Oncology, University of Siena, Viale Bracci - Policlinico "Le Scotte" 53100, Siena, Italy.
| | - Giulio Di Mare
- Department of Medicine, Surgery and Neurosciences - Unit of General Surgery and Surgical Oncology, University of Siena, Viale Bracci - Policlinico "Le Scotte" 53100, Siena, Italy
| | - Francesco Ferrara
- Department of Medicine, Surgery and Neurosciences - Unit of General Surgery and Surgical Oncology, University of Siena, Viale Bracci - Policlinico "Le Scotte" 53100, Siena, Italy
| | - Mario Marini
- Department of Medicine, Surgery and Neurosciences - Unit of Gastroenterology and Digestive Endoscopy, University of Siena, Viale Bracci - Policlinico "Le Scotte" 53100, Siena, Italy
| | - Franco Roviello
- Department of Medicine, Surgery and Neurosciences - Unit of General Surgery and Surgical Oncology, University of Siena, Viale Bracci - Policlinico "Le Scotte" 53100, Siena, Italy
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185
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The Benefit of Chemotherapy in Esophageal Cancer Patients With Residual Disease After Trimodality Therapy. Am J Clin Oncol 2016; 39:136-41. [PMID: 24487417 DOI: 10.1097/coc.0000000000000036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The objective of this retrospective study was to determine the potential benefits of chemotherapy in esophageal cancer patients treated with chemoradiation followed by surgery. MATERIALS AND METHODS At our institution, 145 patients completed trimodality therapy from 1993 to 2009. Neoadjuvant treatment predominantly consisted of 5-fluorouracil and cisplatin with a concurrent median radiation dose of 50.4 Gy. Sixty-two patients received chemotherapy postoperatively. The majority (49/62) received 3 cycles of docetaxel. RESULTS Within the entire cohort, a 5-year overall survival (OS) benefit was found in those who received postoperative chemotherapy, OS 37.1% versus 18.0% (P=0.024). The response after neoadjuvant chemoradiation was as follows: 33.8% had a pathologic complete response and 62.8% with residual disease. A 5-year OS and cause-specific survival (CSS) advantage were associated with postoperative chemotherapy among those with macroscopic residual disease after neoadjuvant therapy: OS 38.7% versus 13.9% (P=0.016), CSS 42.8% versus 18.8% (P=0.048). This benefit was not seen in those with a pathologic complete response or those with microscopic residual. A stepwise multivariate Cox regression model evaluating the partial response group revealed that postoperative chemotherapy and M stage were independent predictors of overall and CSS. CONCLUSIONS This analysis revealed that patients with gross residual disease after trimodality therapy for esophageal cancer who received postoperative chemotherapy had an improved overall and CSS. These data suggest that patients with residual disease after trimodality therapy and a reasonable performance status may benefit from postoperative chemotherapy. Prospective trials are needed to confirm these results to define the role of postoperative treatment after trimodality therapy.
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Phase II study of neoadjuvant therapy with nab-paclitaxel and cisplatin followed by surgery in patients with locally advanced esophageal squamous cell carcinoma. Oncotarget 2016; 7:50624-50634. [PMID: 27244882 PMCID: PMC5226608 DOI: 10.18632/oncotarget.9562] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 04/26/2016] [Indexed: 02/07/2023] Open
Abstract
Background We carried out a phase II study to evaluate the efficiency and safety of the combination of nanoparticle albumin bound-paclitaxel (nab-paclitaxel) and cisplatin as preoperative chemotherapy for locally advanced esophageal squamous cell carcinoma (ESCC) Results From Oct 2011 to Dec 2012, 35 patients were enrolled and received neoadjuvant chemotherapy. Thirty patients underwent surgery and achieved a 100% R0 resection. Pathological complete response (pCR) rate was 13.3% and near pCR rate was 6.7%. Down-staging was achieved in 19 patients. With median follow-up of 37.8 months, 16 patients were still alive. One-, 2- and 3- year overall survival (OS) rate was 90.0%, 70.0% and 43.3%, respectively. This treatment resulted in a median disease-free survival (DFS) of 34.7 months and a median OS of 37.8 months. Median DFS and OS of down-staged patients were significantly longer than those of non-downstaged patients. The grade 4 toxicities during neoadjuvant chemotherapy were limited to neutropenia (2.9%) and vomiting (2.9%). Methods Patients with locally advanced ESCC (stage IIA to IIIC) and performance status 0-1 were enrolled and received two cycles of nab-paclitaxel (100 mg/m2) on day 1, 8, 22 and 29, and cisplatin (75 mg/m2) on day 1 and 22, followed by resection. Two cycles of adjuvant chemotherapy with the same regimen were given. Postoperative radiotherapy was permitted and decided by radiation therapist. Conclusion Weekly nab-paclitaxel with three-weekly cisplatin seems effective and safe as a neoadjuvant chemotherapy strategy for locally advanced ESCC. Down-staged patients have favorable outcome. ClinicalTrials.gov Identifier NCT01258192
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187
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Nabavizadeh N, Shukla R, Elliott DA, Mitin T, Vaccaro GM, Dolan JP, Maggiore RJ, Schipper PH, Hunter JG, Thomas CR, Holland JM. Preoperative carboplatin and paclitaxel-based chemoradiotherapy for esophageal carcinoma: results of a modified CROSS regimen utilizing radiation doses greater than 41.4 Gy. Dis Esophagus 2016; 29:614-20. [PMID: 26043837 DOI: 10.1111/dote.12377] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Trimodality therapy for resectable esophageal and gastroesophageal junction cancers utilizing preoperative radiotherapy with concurrent carboplatin and paclitaxel-based chemotherapy is being increasingly utilized secondary to the results of the phase III CROSS trial. However, there is a paucity of reports of this regimen as a component of chemoradiotherapy in North America. We aim to report on our clinical experience using a modified CROSS regimen with higher radiotherapy doses. Patients with advanced (cT2-cT4 or node positive) esophageal or gastroesophageal junction carcinoma who received preoperative carboplatin/paclitaxel-based chemoradiotherapy with radiation doses of greater than 41.4 Gray (Gy) followed by esophagectomy were identified from an institutional database. Patient, imaging, treatment, and tumor response characteristics were analyzed. Twenty-four patients were analyzed. All but one tumor had adenocarcinoma histology. The median radiation dose was 50.4 Gy. Pathologic complete response was achieved in 29% of patients, with all receiving 50.4 Gy. Three early postoperative deaths were seen, due in part to acute respiratory distress syndrome and all three patients received 50-50.4 Gy. With a median follow-up of 9.4 months (23 days-2 years), median survival was 24 months. Trimodality therapy utilizing concurrent carboplatin/paclitaxel with North American radiotherapy doses appeared to have similar pathologic complete response rates compared with the CROSS trial, but may be associated with higher toxicity. Although the sample size is small and further follow-up is necessary, radiation doses greater than 41.4 Gy may not be warranted secondary to a potentially increased risk of severe radiation-induced acute lung injury.
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Affiliation(s)
- N Nabavizadeh
- Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - R Shukla
- Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - D A Elliott
- Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - T Mitin
- Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - G M Vaccaro
- Division of Medical Oncology, Department of Internal Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - J P Dolan
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - R J Maggiore
- Division of Medical Oncology, Department of Internal Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - P H Schipper
- Division of Cardiothoracic and General Thoracic Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - J G Hunter
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - C R Thomas
- Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - J M Holland
- Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon, USA
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Chemoradiotherapy in tumours of the oesophagus and gastro-oesophageal junction. Best Pract Res Clin Gastroenterol 2016; 30:551-63. [PMID: 27644904 DOI: 10.1016/j.bpg.2016.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/14/2016] [Accepted: 06/18/2016] [Indexed: 01/31/2023]
Abstract
Oesophageal cancer remains a malignancy with a poor prognosis. However, in the recent 10-15 years relevant progress has been made by the introduction of chemoradiotherapy (CRT) for tumours of the oesophagus or gastro-oesophageal junction. The addition of neo-adjuvant CRT to surgery has significantly improved survival and locoregional control, for both adenocarcinoma and squamous cell carcinoma. For irresectable or medically inoperable patients, definitive CRT has changed the treatment intent from palliative to curative. Definitive CRT is a good alternative for radical surgery in responding patients with squamous cell carcinoma and those running a high risk of surgical morbidity and mortality. For patients with an out-of-field solitary locoregional recurrence after primary curative treatment, definitive CRT can lead to long term survival.
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189
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Berry MF. The Role of Induction Therapy for Esophageal Cancer. Thorac Surg Clin 2016; 26:295-304. [PMID: 27427524 DOI: 10.1016/j.thorsurg.2016.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Survival of esophageal cancer generally is poor but has been improving. Induction chemoradiation is recommended before esophagectomy for locally advanced squamous cell carcinoma. Both induction chemotherapy and induction chemoradiation are found to be beneficial for locally advanced adenocarcinoma. Although a clear advantage of either strategy has not yet been demonstrated, consensus-based guidelines recommend induction chemoradiation for locally advanced adenocarcinoma.
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Affiliation(s)
- Mark F Berry
- Department of Cardiothoracic Surgery, Stanford University, 870 Quarry Road, Falk Cardiovascular Research Building, 2nd Floor, Stanford, CA 94305, USA.
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190
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Matsuda S, Takeuchi H, Kawakubo H, Ando N, Kitagawa Y. Current Advancement in Multidisciplinary Treatment for Resectable cStage II/III Esophageal Squamous Cell Carcinoma in Japan. Ann Thorac Cardiovasc Surg 2016; 22:275-283. [PMID: 27384595 DOI: 10.5761/atcs.ra.16-00111] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Multidisciplinary treatment comprising surgery, chemotherapy, and radiotherapy for resectable esophageal squamous cell carcinoma (ESCC) is widely used with improved prognosis. Transthoracic esophagectomy (TTE) with extended lymph node (LN) dissection, known as three field LN dissection, has been recommended for ESCC using open thoracotomy or the thoracoscopic approach. The Japan Clinical Oncology Group (JCOG) trial (JCOG1409) is investigating the patients' long term survival using the thoracoscopic approach that has been shown to reduce the incidence of postoperative respiratory complication. For perioperative treatment, neoadjuvant chemotherapy using cisplatin plus 5-fluorouracil (5-FU), has been accepted as the standard of care in Japan based on the JCOG9907 trial. In Western countries, neoadjuvant chemoradiotherapy was shown to prolong overall survival for esophageal cancer, including ESCC. Although surgery has been recognized as an initial curative treatment for esophageal cancer, definitive chemoradiotherapy is an alternative treatment for patients who are unable to undergo thoracotomy or who decline to undergo surgery. This article reviews multidisciplinary treatment advances for ESCC. However, current standard treatments are country dependent and the ongoing trial may help standardize ESCC treatment across various societies.
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Affiliation(s)
- Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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191
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Ng T. For esophageal cancer, biology is still king. J Thorac Cardiovasc Surg 2016; 152:761-2. [PMID: 27325491 DOI: 10.1016/j.jtcvs.2016.05.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 05/26/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Thomas Ng
- Department of Surgery, The Warren Alpert Medical School of Brown University, Providence, RI.
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192
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Sathornviriyapong S, Matsuda A, Miyashita M, Matsumoto S, Sakurazawa N, Kawano Y, Yamada M, Uchida E. Impact of Neoadjuvant Chemoradiation on Short-Term Outcomes for Esophageal Squamous Cell Carcinoma Patients: A Meta-analysis. Ann Surg Oncol 2016; 23:3632-3640. [PMID: 27278203 DOI: 10.1245/s10434-016-5298-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiation (NCRT) has emerged as a component of the standard treatment for esophageal squamous cell carcinoma (SCC). The primary benefit of NCRT is an improvement in long-term survival; however, the impact of NCRT on short-term outcomes is unclear. METHODS A comprehensive electronic literature search was performed via the MEDLINE (PubMed), Cochrane Library, and Google Scholar databases through November 2015 for the inclusion of randomized controlled trials (RCTs) that evaluated short-term outcomes of patients administered NCRT followed by surgery compared with surgery alone for resectable esophageal SCC. The main outcome measures were postoperative mortality and morbidity. A meta-analysis was performed using random-effects models to calculate odds ratios (ORs) with 95 % confidence intervals (CIs). RESULTS Eight RCTs were included, for a total of 1058 patients. Meta-analysis of the overall postoperative mortality and cardiopulmonary complication rates showed that there was a significant increase for patients administered NCRT followed by surgery compared with surgery alone (OR 1.87, 95 % CI 1.07-3.28, p = 0.03, number of patients needed to harm = 33.3; and OR 2.12, 95 % CI 1.03-4.35, p = 0.04, respectively). Dropout before surgery was higher for patients in the NCRT followed by surgery group compared with patients in the surgery-alone group. NCRT has no statistically impact on anastomosis and other complications compared with surgery alone. CONCLUSIONS NCRT for esophageal SCC significantly increases postoperative mortality and cardiopulmonary complications.
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Affiliation(s)
- Suun Sathornviriyapong
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan.,Department of Surgery, Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand
| | - Akihisa Matsuda
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan.
| | - Masao Miyashita
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Satoshi Matsumoto
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Nobuyuki Sakurazawa
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Yoichi Kawano
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Marina Yamada
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Eiji Uchida
- Department of Surgery, Nippon Medical School, Tokyo, Japan
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Kleinberg L, Brock M, Gibson M. Management of Locally Advanced Adenocarcinoma of the Esophagus and Gastroesophageal Junction: Finally a Consensus. Curr Treat Options Oncol 2016; 16:35. [PMID: 26112428 DOI: 10.1007/s11864-015-0352-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Opinion statement: Adenocarcinoma of the esophagus is increasing in incidence in Western nations leading to increased interest in and opportunity to study optimal management. Randomized trials have now robustly demonstrated the preoperative therapy with chemoradiotherapy and chemotherapy alone improves survival outcome for the bulk of curable patients, those with locally advanced T1N1M0 and T2-3 N0-1 M0 disease. Evidence suggests but does not confirm that radiation-containing regimens are more beneficial. Clinical staging is designed to exclude patients with T1N0M0 disease who may be treated with surgery alone and those with metastatic disease who may not benefit from intensive local therapy. The approach to clinical staging includes endoscopy with ultrasound and fine needle aspirate to assess local and regional disease, supplemented by CT and PET scanning primarily to exclude metastatic disease. Minimally invasive approaches to esophagectomy may be used with the goal of reducing complications, but there is no evidence that mortality or ultimate outcome is improved.
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Affiliation(s)
- Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, 401 North Broadway, Suite 1440, Baltimore, MD, 21231, USA,
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194
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Neoadjuvant therapy for advanced esophageal cancer: the impact on surgical management. Gen Thorac Cardiovasc Surg 2016; 64:386-94. [DOI: 10.1007/s11748-016-0655-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 04/28/2016] [Indexed: 12/18/2022]
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195
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Lee A, Wong AT, Schwartz D, Weiner JP, Osborn VW, Schreiber D. Is There a Benefit to Prolonging the Interval Between Neoadjuvant Chemoradiation and Esophagectomy in Esophageal Cancer? Ann Thorac Surg 2016; 102:433-8. [PMID: 27154156 DOI: 10.1016/j.athoracsur.2016.02.058] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 12/23/2015] [Accepted: 02/16/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Evidence suggests that delaying surgical procedures may increase the rate of pathologic complete response (pCR) and that pCR is associated with improved overall survival (OS). In this study, the National Cancer Data Base (NCDB) was analyzed to evaluate this relationship in a large hospital-based registry. METHODS We identified patients diagnosed with esophageal adenocarcinoma or squamous cell carcinoma who received neoadjuvant chemoradiation (CRT) followed by esophagectomy from 2003 to 2012. Patients were stratified into quartiles based on the interval between the completion of CRT to operative treatment (≤40 days, 41-50 days, 51-63 days, and ≥64 days), and those with pT0N0M0 were classified as having pCR. Multivariate logistic regression was used to assess the impact of covariates on pCR, and multivariate Cox regression was used to assess their impact on OS. RESULTS The study population included 5,393 patients. Increasing the time interval to the surgical procedure was associated with an increased pCR rate (12.3% for ≤40 days to 18.3% for ≥64 days; p < 0.001). On multivariate analysis, a time interval greater than or equal to 51 days was associated with an increased likelihood of pCR (p = 0.009 for 51-63 days; p < 0.001 for ≥64 days), as was an increased radiation dose ≥50 Gy (p = 0.046 for 50-50.4 Gy; p = 0.02 for >50.4 Gy). Increasing the time interval was not associated with an improvement in OS for any quartile on multivariate analysis. In addition, OS was worse for those who underwent operation ≥64 days after completion of radiation therapy (hazard ratio [HR], 1.16; 95% confidence interval [CI], 1.01-1.33; p = 0.03). CONCLUSIONS Although increasing the time interval from CRT to surgical intervention was associated with a higher pCR rate, there was no improvement in survival.
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Affiliation(s)
- Anna Lee
- Department of Radiation Oncology, SUNY Downstate Medical Center and Department of Veterans Affairs, New York Harbor Healthcare System, Brooklyn, New York.
| | - Andrew T Wong
- Department of Radiation Oncology, SUNY Downstate Medical Center and Department of Veterans Affairs, New York Harbor Healthcare System, Brooklyn, New York
| | - David Schwartz
- Department of Radiation Oncology, SUNY Downstate Medical Center and Department of Veterans Affairs, New York Harbor Healthcare System, Brooklyn, New York
| | - Joseph P Weiner
- Department of Radiation Oncology, SUNY Downstate Medical Center and Department of Veterans Affairs, New York Harbor Healthcare System, Brooklyn, New York
| | - Virginia W Osborn
- Department of Radiation Oncology, SUNY Downstate Medical Center and Department of Veterans Affairs, New York Harbor Healthcare System, Brooklyn, New York
| | - David Schreiber
- Department of Radiation Oncology, SUNY Downstate Medical Center and Department of Veterans Affairs, New York Harbor Healthcare System, Brooklyn, New York
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196
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Kathiravetpillai N, Koëter M, van der Sangen MJC, Creemers GJ, Luyer MDP, Rutten HJT, Nieuwenhuijzen GAP. Delaying surgery after neoadjuvant chemoradiotherapy does not significantly influence postoperative morbidity or oncological outcome in patients with oesophageal adenocarcinoma. Eur J Surg Oncol 2016; 42:1183-90. [PMID: 27134188 DOI: 10.1016/j.ejso.2016.03.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 02/13/2016] [Accepted: 03/31/2016] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
| | - M Koëter
- Department of Surgery, Catharina Hospital Eindhoven, The Netherlands
| | | | - G J Creemers
- Department of Oncology, Catharina Hospital Eindhoven, The Netherlands
| | - M D P Luyer
- Department of Surgery, Catharina Hospital Eindhoven, The Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital Eindhoven, The Netherlands
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197
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McNamara MJ, Rybicki LA, Sohal D, Allende DS, Videtic GMM, Rodriguez CP, Stephans KL, Murthy SC, Raja S, Raymond D, Ives DI, Bodmann JW, Adelstein DJ. The relationship between pathologic nodal disease and residual tumor viability after induction chemotherapy in patients with locally advanced esophageal adenocarcinoma receiving a tri-modality regimen. J Gastrointest Oncol 2016; 7:196-205. [PMID: 27034786 DOI: 10.3978/j.issn.2078-6891.2015.097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND A complete pathologic response to induction chemo-radiotherapy (CRT) has been identified as a favorable prognostic factor for patients with loco-regionally advanced (LRA) adenocarcinoma (ACA) of the esophagus and gastro-esophageal junction (E/GEJ). Nodal involvement at the time of surgery has been found to be prognostically unfavorable. Less is known, however, about the prognostic import of less than complete pathologic regression and its relationship to residual nodal disease after induction chemotherapy. METHODS Between February 2008 and January 2012, 60 evaluable patients with ACA of the E/GEJ enrolled in a phase II trial of induction chemotherapy, surgery, and post-operative CRT. Eligibility required a clinical stage of T3-T4 or N1 or M1a (AJCC 6(th)). Induction chemotherapy with epirubicin 50 mg/m(2) d1, oxaliplatin 130 mg/m(2) d1, and fluorouracil 200 mg/m(2)/day continuous infusion for 3 weeks, was given every 21 days for three courses and was followed by surgical resection. Adjuvant CRT consisted of 50-55 Gy at 1.8-2.0 Gy/d and two courses of cisplatin (20 mg/m(2)/d) and fluorouracil (1,000 mg/m(2)/d) over 4 days during weeks 1 and 4 of radiotherapy. Residual viability (RV) was defined as the amount of remaining tumor in relation to acellular mucin pools and scarring. RESULTS Of the 60 evaluable patients, 54 completed induction therapy and underwent curative intent surgery. The Kaplan-Meier projected 3-year overall survival (OS) for patients with pathologic N0 (n=20), N1 (n=12), N2 (n=13), and N3 (n=9) disease is 73%, 57%, 35%, and 0% respectively (P<0.001). The Kaplan-Meier projected 3-year OS of patients with low (0-25%, n=19), intermediate (26-75%, n=26), and high (>75%, n=9) residual tumor viability was 67%, 42%, and 17% respectively (P=0.004). On multivariable analysis (MVA), both the pN descriptor and RV were independently prognostic for OS. In patients with less nodal dissemination (N0/N1), RV was prognostic for OS [3-year OS 85% (0-25% viable) vs. 51% (>25% viable), P=0.028]. Outcomes were poor, however, for patients with advanced nodal disease (N2/N3) regardless of RV [3-year OS 20% (0-25% viable) vs. 21% (>25% viable), P=0.55]. CONCLUSIONS RV and the pN descriptor after induction chemotherapy are independent pathologic prognostic factors for OS in patients with LRA ACA of the E/GEJ. Patients with extensive nodal disease, however, have poor outcomes irrespective of residual tumor viability.
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Affiliation(s)
- Michael J McNamara
- 1 Hematology and Oncology, Taussig Cancer Institute, 2 Quantitative Health Sciences, 3 Department of Pathology, 4 Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA ; 5 Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA 98109, USA ; 6 Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Lisa A Rybicki
- 1 Hematology and Oncology, Taussig Cancer Institute, 2 Quantitative Health Sciences, 3 Department of Pathology, 4 Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA ; 5 Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA 98109, USA ; 6 Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Davendra Sohal
- 1 Hematology and Oncology, Taussig Cancer Institute, 2 Quantitative Health Sciences, 3 Department of Pathology, 4 Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA ; 5 Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA 98109, USA ; 6 Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Daniela S Allende
- 1 Hematology and Oncology, Taussig Cancer Institute, 2 Quantitative Health Sciences, 3 Department of Pathology, 4 Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA ; 5 Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA 98109, USA ; 6 Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Gregory M M Videtic
- 1 Hematology and Oncology, Taussig Cancer Institute, 2 Quantitative Health Sciences, 3 Department of Pathology, 4 Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA ; 5 Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA 98109, USA ; 6 Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Cristina P Rodriguez
- 1 Hematology and Oncology, Taussig Cancer Institute, 2 Quantitative Health Sciences, 3 Department of Pathology, 4 Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA ; 5 Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA 98109, USA ; 6 Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Kevin L Stephans
- 1 Hematology and Oncology, Taussig Cancer Institute, 2 Quantitative Health Sciences, 3 Department of Pathology, 4 Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA ; 5 Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA 98109, USA ; 6 Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Sudish C Murthy
- 1 Hematology and Oncology, Taussig Cancer Institute, 2 Quantitative Health Sciences, 3 Department of Pathology, 4 Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA ; 5 Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA 98109, USA ; 6 Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Siva Raja
- 1 Hematology and Oncology, Taussig Cancer Institute, 2 Quantitative Health Sciences, 3 Department of Pathology, 4 Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA ; 5 Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA 98109, USA ; 6 Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Daniel Raymond
- 1 Hematology and Oncology, Taussig Cancer Institute, 2 Quantitative Health Sciences, 3 Department of Pathology, 4 Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA ; 5 Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA 98109, USA ; 6 Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Denise I Ives
- 1 Hematology and Oncology, Taussig Cancer Institute, 2 Quantitative Health Sciences, 3 Department of Pathology, 4 Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA ; 5 Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA 98109, USA ; 6 Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Joanna W Bodmann
- 1 Hematology and Oncology, Taussig Cancer Institute, 2 Quantitative Health Sciences, 3 Department of Pathology, 4 Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA ; 5 Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA 98109, USA ; 6 Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
| | - David J Adelstein
- 1 Hematology and Oncology, Taussig Cancer Institute, 2 Quantitative Health Sciences, 3 Department of Pathology, 4 Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA ; 5 Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA 98109, USA ; 6 Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
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Shridhar R, Abbott AM, Doepker M, Hoffe SE, Almhanna K, Meredith KL. Perioperative outcomes associated with robotic Ivor Lewis esophagectomy in patient's undergoing neoadjuvant chemoradiotherapy. J Gastrointest Oncol 2016; 7:206-12. [PMID: 27034787 DOI: 10.3978/j.issn.2078-6891.2015.104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Ravi Shridhar
- 1 Department of Radiation Oncology, Florida Hospital Orlando, Orlando, FL, USA ; 2 Department of Surgical Oncology, 3 Department of Radiation Oncology, 4 Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA ; 5 Department of Gastrointestinal and Surgical Oncology, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Andrea M Abbott
- 1 Department of Radiation Oncology, Florida Hospital Orlando, Orlando, FL, USA ; 2 Department of Surgical Oncology, 3 Department of Radiation Oncology, 4 Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA ; 5 Department of Gastrointestinal and Surgical Oncology, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Matthew Doepker
- 1 Department of Radiation Oncology, Florida Hospital Orlando, Orlando, FL, USA ; 2 Department of Surgical Oncology, 3 Department of Radiation Oncology, 4 Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA ; 5 Department of Gastrointestinal and Surgical Oncology, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Sarah E Hoffe
- 1 Department of Radiation Oncology, Florida Hospital Orlando, Orlando, FL, USA ; 2 Department of Surgical Oncology, 3 Department of Radiation Oncology, 4 Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA ; 5 Department of Gastrointestinal and Surgical Oncology, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Khaldoun Almhanna
- 1 Department of Radiation Oncology, Florida Hospital Orlando, Orlando, FL, USA ; 2 Department of Surgical Oncology, 3 Department of Radiation Oncology, 4 Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA ; 5 Department of Gastrointestinal and Surgical Oncology, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Kenneth L Meredith
- 1 Department of Radiation Oncology, Florida Hospital Orlando, Orlando, FL, USA ; 2 Department of Surgical Oncology, 3 Department of Radiation Oncology, 4 Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA ; 5 Department of Gastrointestinal and Surgical Oncology, Sarasota Memorial Hospital, Sarasota, FL, USA
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Saeed N, Shridhar R, Hoffe S, Almhanna K, Meredith KL. AKT expression is associated with degree of pathologic response in adenocarcinoma of the esophagus treated with neoadjuvant therapy. J Gastrointest Oncol 2016; 7:158-65. [PMID: 27034781 DOI: 10.3978/j.issn.2078-6891.2015.067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Neoadjuvant chemoradiation (NCRT) has become standard in the treatment of locally advanced esophageal adenocarcinoma (EAC) with survival correlated to degree of pathologic response. The phosphatidyl inositol 3 kinase (PI3K)/protein kinase B (AKT)/mTOR pathway plays an important role in tumorgenesis and resistance. We sought to elucidate the role of this pathway in patients with EAC who received NCRT. METHODS After IRB approval, a prospective trial was initiated in which patients with EAC underwent endoscopic biopsies of normal and tumor tissue prior to instituting NCRT. Patients then proceeded to esophagectomy. The pre-treatment tissues underwent gene expression profiling. SAM method was used to analyze expression of AKT within normal and tumor tissue. Expression was then correlated to degree of pathologic response. RESULTS One-hundred patients were consented for the study, of which 67 met final eligibility. Nineteen patient's tumors ultimately underwent gene expression profiling via microarray. The differential expression of all AKT isoforms in tumor tissue was markedly overexpressed compared to normal tissue (P=6×10(-5)). There were 3 patients designated as pNR, 6 as pPR, and 10 as pCR. Partial and non-responders had higher expressions of AKT compared to pCR with the non-responders consistently illustrated the highest expression of AKT (P=0.02). There was a significant correlation between individual isoforms of AKT-1, AKT-2, and AKT-3 and degree of pathologic response (P=0.002, 0.04, and 0.04 respectively). CONCLUSIONS AKT is overexpressed in patients with AC of the esophagus. Moreover, pathologic response to NCRT may be correlated with degree of AKT expression. Additional data is needed to clarify this relationship to potentially add targeted therapies to the neoadjuvant regimen.
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Affiliation(s)
- Nadia Saeed
- 1 Department of Gastrointestinal Oncology, 2 Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA ; 3 Department of Surgery, College of Medicine Florida State University, FL, USA
| | - Ravi Shridhar
- 1 Department of Gastrointestinal Oncology, 2 Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA ; 3 Department of Surgery, College of Medicine Florida State University, FL, USA
| | - Sarah Hoffe
- 1 Department of Gastrointestinal Oncology, 2 Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA ; 3 Department of Surgery, College of Medicine Florida State University, FL, USA
| | - Khaldoun Almhanna
- 1 Department of Gastrointestinal Oncology, 2 Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA ; 3 Department of Surgery, College of Medicine Florida State University, FL, USA
| | - Kenneth L Meredith
- 1 Department of Gastrointestinal Oncology, 2 Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA ; 3 Department of Surgery, College of Medicine Florida State University, FL, USA
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Yip SSF, Coroller TP, Sanford NN, Mamon H, Aerts HJWL, Berbeco RI. Relationship between the Temporal Changes in Positron-Emission-Tomography-Imaging-Based Textural Features and Pathologic Response and Survival in Esophageal Cancer Patients. Front Oncol 2016; 6:72. [PMID: 27066454 PMCID: PMC4810033 DOI: 10.3389/fonc.2016.00072] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 03/14/2016] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Although change in standardized uptake value (SUV) measures and PET-based textural features during treatment have shown promise in tumor response prediction, it is unclear which quantitative measure is the most predictive. We compared the relationship between PET-based features and pathologic response and overall survival with the SUV measures in esophageal cancer. METHODS Fifty-four esophageal cancer patients received PET/CT scans before and after chemoradiotherapy. Of these, 45 patients underwent surgery and were classified into complete, partial, and non-responders to the preoperative chemoradiation. SUVmax and SUVmean, two cooccurrence matrix (Entropy and Homogeneity), two run-length matrix (RLM) (high-gray-run emphasis and Short-run high-gray-run emphasis), and two size-zone matrix (high-gray-zone emphasis and short-zone high-gray emphasis) textures were computed. The relationship between the relative difference of each measure at different treatment time points and the pathologic response and overall survival was assessed using the area under the receiver-operating-characteristic curve (AUC) and Kaplan-Meier statistics, respectively. RESULTS All Textures, except Homogeneity, were better related to pathologic response than SUVmax and SUVmean. Entropy was found to significantly distinguish non-responders from the complete (AUC = 0.79, p = 1.7 × 10(-4)) and partial (AUC = 0.71, p = 0.01) responders. Non-responders can also be significantly differentiated from partial and complete responders by the change in the run-length and size-zone matrix textures (AUC = 0.71-0.76, p ≤ 0.02). Homogeneity, SUVmax, and SUVmean failed to differentiate between any of the responders (AUC = 0.50-0.57, p ≥ 0.46). However, none of the measures were found to significantly distinguish between complete and partial responders with AUC <0.60 (p = 0.37). Median Entropy and RLM textures significantly discriminated patients with good and poor survival (log-rank p < 0.02), while all other textures and survival were poorly related (log-rank p > 0.25). CONCLUSION For the patients studied, temporal changes in Entropy and all RLM were better correlated with pathological response and survival than the SUV measures. The hypothesis that these metrics can be used as clinical predictors of better patient outcomes will be tested in a larger patient dataset in the future.
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Affiliation(s)
- Stephen S F Yip
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School , Boston MA , USA
| | - Thibaud P Coroller
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School , Boston MA , USA
| | - Nina N Sanford
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School , Boston MA , USA
| | - Harvey Mamon
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School , Boston MA , USA
| | - Hugo J W L Aerts
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Boston MA, USA; Department of Radiology, Dana-Farber Cancer Institute, Harvard Medical School, Boston MA, USA
| | - Ross I Berbeco
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School , Boston MA , USA
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