Association Between Clinically Staged Node-Negative Esophageal Adenocarcinoma and Overall Survival Benefit From Neoadjuvant Chemoradiation

Nomogram based on multimodal magnetic resonance combined with B7-H3mRNA for preoperative lymph node prediction in esophagus cancer

BACKGROUND

Accurate preoperative prediction of lymph node metastasis (LNM) in esophageal cancer (EC) patients is of crucial clinical significance for treatment planning and prognosis.

AIM

To develop a clinical radiomics nomogram that can predict the preoperative lymph node (LN) status in EC patients.

METHODS

A total of 32 EC patients confirmed by clinical pathology (who underwent surgical treatment) were included. Real-time fluorescent quantitative reverse transcription-polymerase chain reaction was used to detect the expression of B7-H3 mRNA in EC tissue obtained during preoperative gastroscopy, and its correlation with LNM was analyzed. Radiomics features were extracted from multi-modal magnetic resonance imaging of EC using Pyradiomics in Python. Feature extraction, data dimensionality reduction, and feature selection were performed using XGBoost model and leave-one-out cross-validation. Multivariable logistic regression analysis was used to establish the prediction model, which included radiomics features, LN status from computed tomography (CT) reports, and B7-H3 mRNA expression, represented by a radiomics nomogram. Receiver operating characteristic area under the curve (AUC) and decision curve analysis (DCA) were used to evaluate the predictive performance and clinical application value of the model.

RESULTS

The relative expression of B7-H3 mRNA in EC patients with LNM was higher than in those without metastasis, and the difference was statistically significant (P < 0.05). The AUC value in the receiver operating characteristic (ROC) curve was 0.718 (95%CI: 0.528-0.907), with a sensitivity of 0.733 and specificity of 0.706, indicating good diagnostic performance. The individualized clinical prediction nomogram included radiomics features, LN status from CT reports, and B7-H3 mRNA expression. The ROC curve demonstrated good diagnostic value, with an AUC value of 0.765 (95%CI: 0.598-0.931), sensitivity of 0.800, and specificity of 0.706. DCA indicated the practical value of the radiomics nomogram in clinical practice.

CONCLUSION

This study developed a radiomics nomogram that includes radiomics features, LN status from CT reports, and B7-H3 mRNA expression, enabling convenient preoperative individualized prediction of LNM in EC patients.

Delayed esophagectomy for adenocarcinoma is associated with a negative impact on long-term survival and an increased risk of perioperative morbidity

OBJECTIVE

Delayed esophagectomy (DE) following chemoradiation therapy (CXRT) for esophageal carcinoma is undertaken in selected patients. This study aimed to assess both short-term outcomes and long-term survival for patients with adenocarcinoma undergoing DE.

METHODS

The National Cancer Database was queried for patients with American Joint Committee on Cancer clinical stage II-III esophageal adenocarcinoma undergoing esophagectomy after CXRT. Patients were categorized as (1) DE, ≥90 days between completion of CXRT and surgery or (2) nondelayed esophagectomy (NDE), <90 days. Cox regression was performed to identify factors associated with mortality.

RESULTS

A total of 8157 patients met criteria. Age >69, nonwhite race, Medicare/Medicaid insured patients preferentially underwent DE. Five-year overall survival (OS) favored NDE (36% vs. 31%, p = 0.008). Cox regression identified DE, clinical stage >T2, or >N0 as factors associated with mortality. Within the DE group, OS favored early cT-status. DE fared worse than NDE in 30- and 90-day mortality (4.5%/11.1% vs. 2.9%/6.5%, p < 0.01/p < 0.001) and margin positive resection (7.1% vs. 4.2%, p < 0.001).

CONCLUSIONS

For esophageal adenocarcinoma, DE is associated with decreased OS compared to NDE. For DE, cT-status is prognostic for OS, while cN-status was not. Increased 30-/90-day mortality and margin positive resection rates for DE question whether patients with locally advanced (cT3/T4) primary esophageal adenocarcinoma should undergo intentional DE.

Is There a Role for Neoadjuvant Systemic Therapy for cT4bM0 Colon Cancer? A Propensity Score-Matched Analysis of the National Cancer Database

BACKGROUND

Nonmetastatic T4b colon cancer has been traditionally treated with upfront surgery, often requiring technically challenging multiorgan resection. Neoadjuvant chemotherapy can potentially downsize these tumors and improve their resectability.

OBJECTIVE

This study aimed to explore trends and outcomes of neoadjuvant chemotherapy use compared to upfront surgery in patients with nonmetastatic T4b colon cancer. This study also sought to determine factors associated with increased neoadjuvant chemotherapy use and with overall survival.

DESIGN

Retrospective cohort study.

SETTINGS

Conducted using the National Cancer Database.

PATIENTS

Patients with nonmetastatic T4b colon cancer who underwent colectomy (2006-2016) were included in the study. Patients receiving neoadjuvant chemotherapy were propensity-matched (1:2) to those who underwent upfront surgery in either clinically node-negative or node-positive disease.

MAIN OUTCOME MEASURES

Postoperative outcomes (length of stay, 30-d readmission, 30/90-d mortality), oncologic resection adequacy (R0 rate, number of resected/positive nodes), and overall survival were the main outcome measures.

RESULTS

Neoadjuvant chemotherapy was used in 7.7% of the patients. Neoadjuvant chemotherapy use increased over the study period from 4% to 16% in the entire cohort, from 3% to 21% in patients with clinically node-positive disease, and from 6% to 12% in patients with clinically node-negative disease. Factors associated with increased use of neoadjuvant chemotherapy included younger age (OR 0.97; 95% CI, 0.96-0.98; p < 0.001), male sex (OR 1.35; 95% CI, 1.11-1.64; p = 0.002), recent diagnosis year (OR 1.16; 95% CI, 1.12-1.20; p < 0.001), academic centers (OR 2.65; 95% CI, 2.19-3.22; p < 0.001), clinically node-positive (OR 1.23; 95% CI, 1.01-1.49; p = 0.037), and tumor located in the sigmoid colon (OR 2.44; 95% CI, 1.97-3.02; p < 0.001). Patients who received neoadjuvant chemotherapy had significantly higher R0 resection compared with upfront surgery (87% vs 77%; p < 0.001). On multivariable analysis, neoadjuvant chemotherapy was associated with higher overall survival (HR 0.76; 95% CI, 0.64-0.91; p = 0.002). On propensity-matched analyses, neoadjuvant chemotherapy was associated with a higher 5-year overall survival compared to upfront surgery in patients with clinically node-positive disease (57% vs 43%; p = 0.003) but not in patients with clinically node-negative disease (61% vs 56%; p = 0.090).

LIMITATIONS

Retrospective design.

CONCLUSION

Neoadjuvant chemotherapy use for nonmetastatic T4b has increased significantly on the national level, more so in patients with clinically node-positive disease. Patients with node-positive disease treated with neoadjuvant chemotherapy had higher overall survival compared to those who underwent upfront surgery. See Video Abstract at http://links.lww.com/DCR/C228 .

EXISTE LUGAR PARA LA TERAPIA SISTMICA NEOADYUVANTE PARA EL CNCER DE COLON CTBM UN ANLISIS EMPAREJADO DE PUNTAJE DE PROPENSIN DE LA BASE DE DATOS NACIONAL DEL CNCER

ANTECEDENTES:El cáncer de colon T4b no metastásico se ha tratado tradicionalmente con cirugía inicial, que frecuentemente requiere de una resección multiorgánica técnicamente desafiante. La quimioterapia neoadyuvante puede potencialmente reducir el tamaño y mejorar la resecabilidad de esos tumores.OBJETIVO:Explorar las tendencias y los resultados del uso de quimioterapia neoadyuvante en pacientes con cáncer de colon T4b no metastásico, en comparación con la cirugía inicial. Determinar los factores asociados con el aumento del uso de quimioterapia neoadyuvante y con la supervivencia general.DISEÑO:Estudio de cohorte retrospectivo.AJUSTES:Utilizando de la Base de Datos Nacional del Cáncer.PACIENTES:Pacientes con cáncer de colon T4b no metastásico sometidos a colectomía (2006-2016). Los pacientes que recibieron quimioterapia neoadyuvante fueron emparejados por propensión (1:2) con aquellos sometidos a cirugía inicial, ya sea en enfermedad clínica con ganglios negativos o ganglios positivos.PRINCIPALES MEDIDAS DE RESULTADO:Resultados posoperatorios (duración de la hospitalización, reingreso a los 30 días, mortalidad a los 30/90 días), adecuación de la resección oncológica (tasa R0, número de ganglios resecados/positivos) y supervivencia general.RESULTADOS:La quimioterapia neoadyuvante se utilizó en el 7,7% de los pacientes. El uso de quimioterapia neoadyuvante aumentó durante el período de estudio del 4% al 16% en toda la cohorte; del 3% al 21% en pacientes con enfermedad clínica y ganglios positivos; y del 6% al 12% en pacientes con enfermedad clínica y ganglios negativos. Los factores asociados con un mayor uso de quimioterapia neoadyuvante incluyeron, edad más joven (OR 0,97, IC del 95 %: 0,96-0,98, p < 0,001), sexo masculino (OR 1,35, IC del 95 %: 1,11-1,64, p = 0,002), año de diagnóstico mas reciente (OR 1,16, 95% IC: 1,12-1,20, p < 0,001), centros académicos (OR 2,65, 95% IC: 2,19-3,22, p < 0,001), enfermedad clínica con ganglios positivos (OR 1,23, 95% IC: 1,01-1,49, p = 0,037), y tumor localizado en colon sigmoide (OR 2,44, 95% IC: 1,97-3,02, p < 0,001). Los pacientes que recibieron quimioterapia neoadyuvante tuvieron una resección R0 significativamente mayor en comparación con la cirugía inicial (87 % frente a 77 %, p < 0,001). En análisis multivariable, la quimioterapia neoadyuvante se asoció con una mayor supervivencia global (HR 0,76, IC del 95%: 0,64-0,91, p = 0,002). En los análisis de propensión pareada, la quimioterapia neoadyuvante se asoció con una mayor supervivencia general a los 5 años en comparación con la cirugía inicial en pacientes con enfermedad clínica con ganglios positivos (57% frente a 43%, p = 0,003), pero no en pacientes con enfermedad clínica y ganglios negativos (61% vs 56%, p = 0,090).LIMITACIONES:Diseño retrospectivo.CONCLUSIÓN:El uso de quimioterapia neoadyuvante para T4b no metastásico ha aumentado significativamente a nivel nacional, más aún en pacientes con enfermedad clínica y ganglios positivos. Los pacientes con enfermedad y ganglios positivos tratados con quimioterapia neoadyuvante tuvieron una mayor supervivencia general en comparación con la cirugía inicial. Consulte Video Resumen en http://links.lww.com/DCR/C228 . (Traducción-Dr. Fidel Ruiz Healy ).

Association of survival with adjuvant radiotherapy for pN0 esophageal cancer

INTRODUCTION

This study was conducted to elucidate the link between adjuvant radiotherapy and survival in pathologic node-negative (pN0) esophageal cancer patients with upfront esophagectomy.

METHODS

From 2000 to 2016, patients with pN0 esophageal cancer who underwent upfront esophagectomy were selected from the Surveillance, Epidemiology, and End Results (SEER) database. The association of high-risk covariates with survival after adjuvant radiotherapy was evaluated using propensity score matching and multivariate analysis.

RESULTS

We identified 3197 patients, 321 (10.0%) underwent postoperative radiotherapy and 2876 (90.0%) underwent esophagectomy alone. In the unmatched cohort, postoperative radiotherapy was associated with a statistically significant but modest absolute decrease in survival outcomes (P < 0.001). In the matched cohort, the survival differences disappeared. Additionally, adjuvant radiotherapy was linked to a 5-year overall survival (OS) benefit for patients with the pT3-4N0 disease (34.8% vs. 27.7%; P = 0.008). Adjuvant radiotherapy for pT3-4N0 disease with tumor length ≥3 cm, adenocarcinoma, and evaluated lymph node count <12 was shown to independently function as a risk factor for improved OS, as per a multivariate analysis (P < 0.01).

CONCLUSIONS

This population-based trial showed that high-risk patients with pT3-4N0 esophageal cancer had better OS following upfront esophagectomy followed by radiotherapy therapy. This discovery may have major significance in the use of adjuvant radiotherapy following upfront esophagectomy in patients with pN0 esophageal cancer.

Human intravital microscopy in the study of sarcomas: an early trial of feasibility

Sarcomas comprise a vast and heterogenous group of rare tumors. Because of their diversity, it is challenging to study sarcomas as a whole with regard to their biological and molecular characteristics. This diverse set of tumors may also possess differences related to their tumor-associated vasculature, which in turn may impact the ability to deliver systemic therapies (e.g., chemotherapy, targeted therapies, and immunotherapy). Consequently, response to systemic treatment may also be variable as these depend on the ability of the therapy to reach the tumor target via the tumor-associated vasculature. There is a paucity of data regarding sarcoma-related tumor vessels, likely in part to the rarity and heterogeneity of this cancer as well as the previously limited ability to image tumor-associated vessels in real time. Our group has previously utilized confocal fluorescent imaging technology to observe and characterize tumor-associated vessels in real time during surgical resection of tumors, including cutaneous melanoma and carcinomatosis implants derived from gastrointestinal, gynecological, or primary peritoneal (e.g., mesothelioma) tumors. Our prior studies have demonstrated the feasibility of real-time, human intravital microscopy in the study of these tumor types, leading to early but important new data regarding tumor vessel characteristics and their potential implications on drug delivery and efficacy. In this brief report, we present our latest descriptive findings in a cohort of patients with sarcoma who underwent surgical resection and real-time, intravital microscopy of their tumors. Overall, intravital imaging was feasible during the surgical resection of large sarcomas.

Clinical trial registrations

ClinicalTrials.gov, identifier NCT03517852; ClinicalTrials.gov, identifier NCT03823144.

Effect of preoperative radiotherapy on the prognosis of patients with stage cTxN0M0 esophageal squamous cell carcinoma: propensity score matching analysis based on SEER database

Objective

The aim of this study was to investigate the effect of preoperative radiotherapy (RT) on overall survival (OS) in patients with stage cTxN0M0 esophageal squamous cell carcinoma (ESCC).

Methods

A total of 467 patients with ESCC diagnosed as cTxN0M0 and undergoing esophagectomy between 2004 and 2016 were downloaded from the Surveillance, Epidemiology, and End Results (SEER) database. According to the presence or absence of preoperative RT, the patients were divided into preoperative RT group and non-preoperative RT group. Propensity score matching (PSM) was performed to equalize baseline levels between groups. Univariate and multivariate Cox regression analyses were used to compare the survival differences between the two groups.

Results

Using PSM, 162 pairs of patients were selected. Preoperative RT was not a prognostic factor for OS in all patients with cTx stage. After PSM, for patients with cT1-2 stage, univariate Cox regression analysis showed that preoperative RT was an influencing factor of OS, and multivariate Cox regression analysis confirmed that preoperative RT was an independent predictor of OS. Compared with non-preoperative RT, preoperative RT significantly decreased OS (HR = 1.556, 95%CI 1.008-2.464, p = 0.046). For patients with cT3-4, univariate Cox regression analysis showed that preoperative RT was an influencing factor for OS, and multivariate Cox regression analysis determined that preoperative RT was independent predictors of survival. Compared with non-preoperative RT, preoperative RT significantly improved the OS (HR = 0.479, 95%CI 0.272-0.841, p = 0.010).

Conclusion

For ESCC, preoperative RT can improve the OS of patients with cT3-4N0M0. However, preoperative RT is not suitable for patients with cT1-2N0M0.

Prediction of Individual Lymph Node Metastatic Status in Esophageal Squamous Cell Carcinoma Using Routine Computed Tomography Imaging: Comparison of Size-Based Measurements and Radiomics-Based Models

BACKGROUND

Lymph node status is vital for prognosis and treatment decisions for esophageal squamous cell carcinoma (ESCC). This study aimed to construct and evaluate an optimal radiomics-based method for a more accurate evaluation of individual regional lymph node status in ESCC and to compare it with traditional size-based measurements.

METHODS

The study consecutively collected 3225 regional lymph nodes from 530 ESCC patients receiving upfront surgery from January 2011 to October 2015. Computed tomography (CT) scans for individual lymph nodes were analyzed. The study evaluated the predictive performance of machine-learning models trained on features extracted from two-dimensional (2D) and three-dimensional (3D) radiomics by different contouring methods. Robust and important radiomics features were selected, and classification models were further established and validated.

RESULTS

The lymph node metastasis rate was 13.2% (427/3225). The average short-axis diameter was 6.4 mm for benign lymph nodes and 7.9 mm for metastatic lymph nodes. The division of lymph node stations into five regions according to anatomic lymph node drainage (cervical, upper mediastinal, middle mediastinal, lower mediastinal, and abdominal regions) improved the predictive performance. The 2D radiomics method showed optimal diagnostic results, with more efficient segmentation of nodal lesions. In the test set, this optimal model achieved an area under the receiver operating characteristic curve of 0.841-0.891, an accuracy of 84.2-94.7%, a sensitivity of 65.7-83.3%, and a specificity of 84.4-96.7%.

CONCLUSIONS

The 2D radiomics-based models noninvasively predicted the metastatic status of an individual lymph node in ESCC and outperformed the conventional size-based measurement. The 2D radiomics-based model could be incorporated into the current clinical workflow to enable better decision-making for treatment strategies.

Quantitative RECIST derived from multiparametric MRI in evaluating response of esophageal squamous cell carcinoma to neoadjuvant therapy

OBJECTIVE

To develop a quantitative Response Evaluation Criteria in Solid Tumors (qRECIST) for evaluating response to neoadjuvant therapy (nT) in ESCCs relying on multiparametric (mp) MRI.

METHODS

Patients with cT2-T4a/N0-N3/M0 ESCC undergoing pre-nT and post-nT esophageal mpMRI before radical resection were prospectively included. Images were reviewed by two experienced radiologists. qRECIST was redefined using four methods including conventional criterion (cRECIST) and three model-dependent RECIST relying on quantitative MRI measurements at pre-nT, post-nT, and delta pre-post nT, respectively. Pathological tumor regression grades (TRGs) were used as a reference standard. The rates of agreement between four qRECIST methods and TRGs were determined with a Cronbach's alpha test, area under the curve (AUC), and a diagnostic odds ratio meta-analysis.

RESULTS

Ninety-one patients were enrolled. All four methods revealed high inter-reader agreements between the two radiologists, with a Kappa coefficient of 0.96, 0.87, 0.88, and 0.97 for cRECIST, pre-nT RECIST, post-nT RECIST, and delta RECIST, respectively. Among them, delta RECIST achieved the highest overall agreement rate (67.0% [61/91]) with TRGs, followed by post-nT RECIST (63.8% [58/91]), cRECIST (61.5% [56/91]), and pre-nT RECIST (36.3% [33/91]). Especially, delta RECIST achieved the highest accuracy (97.8% [89/91]) in distinguishing responders from non-responders, with 97.3% (34/35) for responders and 98.2% (55/56) for non-responders. Post-nT RECIST achieved the highest accuracy (93.4% [85/91]) in distinguishing complete responders from non-pCRs, with 77.8% (11/18) for pCRs and 94.5% (69/73) for non-pCRs.

CONCLUSION

The qRECIST with mpMRI can assess treatment-induced changes and may be used for early prediction of response to nT in ESCC patients.

KEY POINTS

• Quantitative mpMRI can reliably assess tumor response, and delta RECIST model had the best performance in evaluating response to nT in ESCCs, with an AUC of 0.98, 0.95, 0.80, and 0.82 for predicting TRG0, TRG1, TRG2, and TRG3, respectively. • In distinguishing responders from non-responders, the rate of agreement between delta RECIST and pathology was 97.3% (34/35) for responders and 98.2% (55/56) for non-responders, resulting in an overall agreement rate of 97.8% (89/91). • In distinguishing pCRs from non-pCR, the rate of agreement between MRI and pathology was 77.8% (11/18) for pCRs and 94.5% (69/73) for non- pCRs, resulting in an overall agreement rate of 91.2% (83/91).

The Impact of Adjuvant Therapy on Survival After Esophagectomy for Node-negative Esophageal Adenocarcinoma

OBJECTIVE

Determine whether adjuvant chemotherapy is associated with a survival benefit in high risk T2-4a, pathologically node-negative distal esophageal adenocarcinoma.

SUMMARY OF BACKGROUND DATA

There is minimal literature to substantiate the NCCN guidelines recommending adjuvant therapy for patients with distal esophageal adenocarcinoma and no pathologic evidence of nodal disease.

METHODS

The National Cancer Database was used to identify adult patients with pT2-4aN0M0 esophageal adenocarcinoma who underwent definitive surgery (2004-2015) and had characteristics considered high risk by the NCCN. Patients were stratified by receipt of adjuvant chemotherapy with or without radiation. The primary outcome was overall survival, which was evaluated using Kaplan-Meier and multivariable Cox Proportional Hazards models. A 1:1 propensity score-matched analysis was also performed to compare survival between the groups.

RESULTS

Four hundred three patients met study criteria: 313 (78%) without adjuvant therapy and 90 who received adjuvant chemotherapy with or without radiation (22%). In both unadjusted and multivariable analysis, adjuvant chemotherapy with or without radiation was not associated with a significant survival benefit compared to no adjuvant therapy. In a subgroup analysis of 335 patients without high risk features by NCCN criteria, adjuvant chemotherapy was not independently associated with a survival benefit.

CONCLUSION

In this analysis, adjuvant chemotherapy with or without radiation was not associated with a significant survival benefit in completely resected, pathologically node-negative distal esophageal adenocarcinoma, independent of presence of high risk characteristics. The risks and benefits of adjuvant therapy should be weighed before offering it to patients with completely resected pT2-4aN0M0 esophageal adenocarcinoma.

Machine Learning and Radiomics Applications in Esophageal Cancers Using Non-Invasive Imaging Methods-A Critical Review of Literature

Esophageal cancer (EC) is of public health significance as one of the leading causes of cancer death worldwide. Accurate staging, treatment planning and prognostication in EC patients are of vital importance. Recent advances in machine learning (ML) techniques demonstrate their potential to provide novel quantitative imaging markers in medical imaging. Radiomics approaches that could quantify medical images into high-dimensional data have been shown to improve the imaging-based classification system in characterizing the heterogeneity of primary tumors and lymph nodes in EC patients. In this review, we aim to provide a comprehensive summary of the evidence of the most recent developments in ML application in imaging pertinent to EC patient care. According to the published results, ML models evaluating treatment response and lymph node metastasis achieve reliable predictions, ranging from acceptable to outstanding in their validation groups. Patients stratified by ML models in different risk groups have a significant or borderline significant difference in survival outcomes. Prospective large multi-center studies are suggested to improve the generalizability of ML techniques with standardized imaging protocols and harmonization between different centers.

Staging esophageal cancer: low EUS accuracy in t2n0 patients

Background and study aims  Esophageal cancer (EC) is one of the most lethal malignancies worldwide. Staging of EC is performed with computed tomography (CT), positron-emission tomography (PET), and endoscopic ultrasonography (EUS). Patient management mostly depends on lymph node status. Compared to histopathology, the accuracy of EUS for T and N parameters is about 85 % and 75 %, respectively. Errors in staging may change prognosis. The aim of this study was to assess the role of EUS in T2-N0 EC considering the experience of two high-volume digestive endoscopic centers. Methods  Two prospectively collected databases were queried to identify all patients with EC, staged as cT2N0 by EUS, with no distant metastases at CT/PET scan and who underwent transthoracic esophagectomy. Preoperative EUS staging (cTNM) was compared to histopathology of the surgical specimen (pTNM) to evaluate accuracy. Results  Of 729 consecutive patients with EC between January 2011 and September 2018, 72 (49 men) had cT2N0 disease. CT and PET scans confirmed the absence of distant metastasis. In 43 of 72 patients (60 %), the evaluation was correct, 23 of 72 (31,7 %) were understaged, and six of 72 patients (8,3 %) were overstaged. Among the understaged patients, eight were understaged by tumor depth (35 %), seven by nodal involvement (30 %), and eight by both (35 %). All six patients who were overstaged had T1b-N0 disease. EUS accuracy was 77 % in staging for tumor depth and 82 % in staging for nodal metastases. The positive predictive value (PPV) for cT2N0 EC was 60 % (43 pT2N0 /72 cT2N). Conclusions  The accuracy of EUS staging of T2N0 EC is low, with only 60 % of patients undergoing appropriate therapy based on histopathology.

Staging Concordance and Guideline-Concordant Treatment for Esophageal Adenocarcinoma

BACKGROUND

Treatment selection for patients with esophageal adenocarcinoma is predicated on clinical staging information, which is inaccurate in 20% to 30% of cases and could impact the delivery of guideline-concordant treatment. We aimed to evaluate the association between staging concordance at the patient and hospital levels with the delivery of guideline-concordant treatment among esophageal adenocarcinoma patients.

METHODS

This was a national cohort study of resected esophageal adenocarcinoma patients in the National Cancer Data Base (2006 to 2015) treated either with upfront resection or neoadjuvant therapy followed by surgery. Patient- and hospital-level clinical and pathologic staging concordance and deviations from treatment guidelines were ascertained. For neoadjuvant therapy patients, staging concordance was predicted through Bayesian analysis. Reliability adjustment was used when evaluating hospital-level concordance.

RESULTS

Among 9393 esophageal adenocarcinoma patients treated at 927 hospitals, 41% had upfront surgery. Among upfront surgery patients, staging concordance was 85.1% for T1N0 and 86.9% for T3-T4N+ disease, but less than 50% for all others. Among patients treated with neoadjuvant therapy, treatment downstaging was observed in 33.9%. Deviations from treatment guidelines were identified in 38.5% of upfront surgery patients and 3.3% of neoadjuvant therapy patients. The proportion of concordantly staged patients ranged from 60.1% to 87.9%, and deviations from treatment guidelines were observed among 14.9% to 22.7% of the patients. Patient staging concordance increased, and deviations from guidelines decreased, as hospital-level concordance increased (trend test, P values less than .001 for all).

CONCLUSIONS

Deviations from treatment guidelines in esophageal adenocarcinoma patients appear to be a function of inaccurate clinical staging information, which should be a new focus for quality improvement efforts.

Clinical characteristics and survival of 5283 esophageal cancer patients: A multicenter study from eighteen hospitals across six regions in China

Objective

This study aimed to investigate the potential determining epidemiological and clinical risk factors affecting the survival of esophageal cancer (EC) patients across multiple hospitals in China.

Methods

This was a multicenter study comprising of newly diagnosed EC cases from Beijing, Hebei, Henan, Hubei, Zhejiang, and Guangdong Province of China. Their baseline characteristics and treatment methods data were collected from their medical records. The EpiData software was used for data quality control. The Kaplan‐Meier method was used to estimate their overall survival (OS), and the Cox's proportional hazard regression model was used to estimate hazard ratios (HR) and 95% confidence interval (CI).

Results

The 3‐ and 5‐year OS rates of the 5283 investigated EC patients were 49.98% and 39.07%, respectively. Their median survival was 36.00 months. The median survival time of females was longer than that of males (females vs. males: 45.00 vs. 33.00, P < 0.001). The 5‐year OS rate of patients who never‐smoked was higher than that of smokers (never‐smokers vs smokers: 40.73% vs. 37.84%, P = 0.001). There was no significant difference in the 5‐year OS rate between drinkers and never‐drinkers (drinkers vs never‐drinkers: 34.22% vs. 29.65%, P = 0.330). In multivariate analysis, pathological stage (stage II: HR = 1.80, 95% CI = 1.40‐2.31; stage III: HR = 2.62, 95% CI = 2.06‐3.34; stage IV: HR = 3.90, 95% CI = 2.98‐5.09), poor differentiation/undifferentiated (HR = 1.34, 95% CI = 1.11‐1.63), not married status (HR = 2.45, 95% CI = 1.49‐4.04), production and service personnel (HR = 1.36, 95% CI = 1.01‐1.83) and farming/fishing (HR = 1.40, 95% CI = 1.12‐1.76) were independent prognostic risk factors for poor EC survival. Tumors in the thoracic or abdominal part of the esophagus, female and family history of any cancer were independent factors predictive of a good EC OS.

Conclusion

Gender, marital status, occupation, family history of any cancer, tumor topographical site, differentiation status, and pathological stage were associated with the survival rate of EC. This study reveals important clinical characteristics of esophageal cancer patients in China and provides helpful information for their clinical management and surveillance.

Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for clinical node-negative esophageal carcinoma

Background

The impact of neoadjuvant chemoradiotherapy (nCRT) on early stage esophageal cancer is unknown. Here, we compared the outcomes after esophagectomy alone or nCRT plus surgery for clinically staged node‐negative esophageal cancer.

Methods

We searched the Surveillance, Epidemiology, and End Results database for patients with clinically node‐negative (cN0) esophageal cancer from 2004 to 2016 who underwent surgery alone or nCRT plus surgery. Propensity score matching and Cox regression analysis were used to identify covariates associated with overall survival and cancer‐specific survival.

Results

A total of 1587 patients were retrospectively identified, of whom 49.8% (n = 791) received nCRT and 80.2% (n = 1273) were truly node‐negative diseases. For the entire cohort, surgery alone was associated with a statistically significant but modest absolute increase in survival outcomes (P < 0.01). After matching, nCRT was associated with improved five‐year overall survival for pT3‐4N0 (localized) disease (59.6% vs. 37.7%; P < 0.001) and pathological node‐positive disease (60.5% vs. 40.7%; P = 0.002). Cox multivariate regression analysis revealed that the addition of nCRT for truly node‐negative patients with tumor length ≥ 3 cm, pT1‐2N0 (early‐staged) and localized disease were independent risk factors for survival than surgery alone (P < 0.01).

Conclusions

Compared with surgery alone, patients with cN0 esophageal cancer with pathological node‐positive or localized true node‐negative disease gain a significant survival benefit from nCRT. However, nCRT plus surgery was associated with decreased survival for early‐staged true node‐negative patients. This finding may have significant implications on the use of neoadjuvant chemoradiation in patients with cN0 disease.

Role of Perioperative Chemotherapy in Lymph Node-negative Esophageal Cancer After Resection: A Population-based Study With Propensity Score-matched Analysis

BACKGROUND

Multimodality treatment is increasingly accepted and becoming the standard care for local advanced esophageal cancer (EC) patients. However, for early stage lymph node-negative EC patients, surgery alone is still the primary treatment approach, and the role of perioperative chemotherapy remains unclear.

METHODS

Patients with lymph node-negative EC were identified from the Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2013. Survival was compared by the log-rank test. Cox proportional hazards analysis was used to identify covariates associated with overall survival (OS). Propensity score-matched analysis was also performed to control for confounding.

RESULTS

A total of 3071 patients (T1-4N0M0) were identified, 1363 (44.4%) of which received perioperative chemotherapy. The effect of chemotherapy on OS was remarkably dependent on the T stage. For stage T1 patients, chemotherapy was inversely associated with OS (hazard ratio [HR]=1.54; 95% confidence interval [CI], 1.27-1.86), and no impact of chemotherapy on OS was found for T2 patients (HR=0.92; 95% CI, 0.712-1.18), whereas a significant improvement in OS was observed with the addition of chemotherapy for patients with stages T3 (HR=0.52; 95% CI, 0.43-0.62) and T4 (HR=0.60; 95% CI, 0.36-0.98) disease. Multivariable analysis with demonstrated that chemotherapy usage, age, sex, tumor grade, and T stage (P<0.05) were significantly associated with OS in T3-T4 patients. The results were similar in subgroup analyses stratified by confounding covariates, and the propensity score-matched analysis.

CONCLUSIONS

This population-based study indicates perioperative chemotherapy is associated with improved survival in stage T3-4N0M0 patients with EC, which needs to be further validated by randomized trials.

The overall metastatic rate in early esophageal adenocarcinoma: long-time follow-up of surgically treated patients

The overall metastatic potential of surgically treated early esophageal adenocarcinoma has not been studied in detail. This paper therefore assessed lymph node metastases at surgery, loco regional and distant metastases, in order to assess the metastatic potential of early esophageal adenocarcinoma. Two hundred and seventeen patients (53 T1a, 164 T1b; median follow-ups 87 and 75 months, 187 males) diagnosed with early esophageal adenocarcinoma and treated with esophagectomy in our tertiary center's database between July 2000 and December 2015 were included. All metastatic events were retrospectively analyzed, their topographic distribution was assessed, and the overall metastatic rate was calculated. Lymph node metastases occurred in 39 patients (18%) and 29 (13.4%) developed recurrences. Lymph node metastases were absent in m1 and m2 tumors and rare in m3 (1/18), m4 (5/21), and sm1 (4/42), but more frequent in sm2 (11/44) and sm3 tumors (18/78). Locoregional recurrences were exceedingly rare in m3 (2/18), m4 (1/21), sm1 (1/42), and sm2 (2/44), but frequent in sm3 (12/78). In contrast, distant metastases were more frequent with 2/18 in m3, 1/21 in m4, 4/42 in sm1, 4/44 in sm2, and 13/78 in sm3. Overall metastatic rates of 11.9% in sm1 (submucosal layer divided into equal thirds), 27.3% in sm2, and 32.1% in sm3 tumors were calculated. This first report of the metastatic potential of early esophageal adenocarcinoma provides a meticulous assessment of the overall metastatic risk. Metastatic events pose a relevant risk in surgically treated patients with esophageal adenocarcinoma with distant metastases being more frequent than locoregional recurrences.

Reliability of clinical nodal status regarding response to neoadjuvant chemoradiotherapy compared with surgery alone and prognosis in esophageal cancer patients

Background: Clinical nodal (cN) staging is a key element in treatment decisions in patients with esophageal cancer (EC). The reliability of cN status regarding the effect on response and survival after neoadjuvant chemoradiotherapy (nCRT) with esophagectomy was evaluated in determining the up- and downstaged pathological nodal (pN) status after surgery alone. Material and methods: From a prospective database, we included all 395 EC patients who had surgery with curative intent with or without nCRT between 2000 and 2015. All patients were staged by a standard pretreatment protocol: 16-64 mdCT, 18 F-FDG-PET or 18 F-FDG-PET/CT and EUS ± FNA. After propensity score matching on baseline clinical tumor and nodal (cT/N) stage and histopathology, a surgery-alone and nCRT group (each N = 135) were formed. Clinical and pathological N stage was scored as equal (cN = pN), downstaged (cN > pN) or upstaged (cN < pN). Prognostic impact on disease free survival (DFS) was assessed with multivariable Cox regression analysis (factors with p value <.1 on univariable analysis). Results: The surgery-alone and nCRT group did not differ in cT/N status. Pathologic examination revealed equal staging (32 vs. 27%), nodal up (43 vs. 16%) and downstaging (25 vs. 56%), respectively (p < .001). Nodal up-staging was common in cT3-4a tumors and adenocarcinomas in the surgery-alone group, while nodal downstaging was found in half of cT1-2 and cT3-4 regardless of tumortype after nCRT. Prognostic factors for DFS were pN (p = .002) and lymph-angioinvasion (p = .016) in surgery-alone, and upper abdominal cN metastases (p = .012) and lymph node ratio (p = .034) in the nCRT group. Conclusions: Despite modern staging methods, correct cN staging remains difficult in EC. Nodal overstaging (cN > pN) occurred more often than understaging impeding an adequate assessment of pathologic complete response and prognosis after nCRT.

Accuracy of Clinical Staging and Outcome With Primary Resection for Local-Regionally Limited Esophageal Adenocarcinoma

OBJECTIVE

The aim of this study was to determine the accuracy of clinical staging, to assess survival with surgical resection alone, and to determine factors associated with understaging in patients with esophageal adenocarcinoma thought to have limited local-regional disease.

BACKGROUND

Primary surgical resection is the preferred treatment in patients with esophageal adenocarcinoma clinically staged to have limited nodal disease. This approach requires reliable clinical staging.

METHODS

A retrospective chart review was performed of all patients who had primary esophagectomy for clinical stage T1-3 N0-1 adenocarcinoma (seventh edition AJCC) from January 2002 to May 2013. Clinical and pathologic stages were compared and overall survival was analyzed.

RESULTS

There were 88 patients who met inclusion criteria. Final pathology confirmed appropriate clinical staging (≤T3N1) in 76% of patients (67/88). There were 21 patients who were understaged (>T3N1), and in all cases, understaging was based on the presence of advanced nodal (N2 or N3) disease. Factors independently associated with understaging were the presence of dysphagia, tumor length >3 cm, and poor differentiation. At a median follow-up of 35 months, 63% of all patients (55/88) remain alive. The 5-year survival in correctly staged patients was 67%, compared with 33% for those who were understaged (P < 0.0001).

CONCLUSIONS

Modern clinical staging will accurately identify the majority of patients with esophageal adenocarcinoma and limited local-regional disease (≤pT3N1). Survival with surgery alone in correctly staged patients was excellent and unlikely to be improved with neoadjuvant therapy. A combination of dysphagia, poor differentiation, and tumor length >3 cm was associated with understaging in 92% of patients. Patients with these factors are likely to have more advanced disease than clinically suspected and may benefit from neoadjuvant therapy before resection.

Preoperative lymph node status on computed tomography influences the survival of pT1b, T2 and T3 esophageal squamous cell carcinoma

PURPOSE

The preoperative lymph node status is critical for tailoring optimal treatments for esophageal squamous cell carcinoma (ESCC). This study aimed to evaluate the prognostic impact of a diagnostic criterion based solely on the short-axis diameters of lymph nodes depicted on computed tomography (CT) in ESCC patients undergoing upfront esophagectomy.

METHODS

We retrospectively reviewed 246 pT1b-T3 ESCC patients undergoing upfront esophagectomy. Clinically positive lymph node metastasis (cN+) was defined as nodes with a short-axis diameter of at least 8 mm on CT.

RESULTS

Ninety-three patients had a cN+ status according to this criterion. The overall and recurrence-free survival rates were significantly lower in the cN+ group than in the cN- group (P < 0.001). The overall survival rate was markedly lower in the "pN2/3 and cN+" group than in the other groups (vs. pN0: P < 0.001, vs. pN1: P = 0.002, vs. "pN2/3 and cN-": P < 0.001). However, the overall survival rate of the "pN2/3 and cN-" group was similar to that of the pN0-1 groups. A multivariate analysis showed that cN+ (P = 0.002), major complications (P = 0.001), and pT3 (P = 0.021) were independently associated with a poor prognosis.

CONCLUSION

A diagnostic criterion based solely on the short-axis diameters of lymph nodes depicted on CT was useful for stratifying the survival in ESCC patients.

Disparities in major surgery for esophagogastric cancer among hospitals by case volume

Background

The purpose of this study was to characterize disparities among centers performing major surgery for esophageal or gastric cancer stratified by case volume.

Methods

The National Cancer Data Base (NCDB) was queried for cases of esophagectomy or total gastrectomy. Centers were compared based on number of cases during 2004-2013: low volume [1-99], middle [100-200], and high [>200].

Results

For esophagectomy, 17,547 patients were included; 73.5% were treated in low volume centers, 14.6% in middle, and 11.9% in high. For gastrectomy, 20,059 patients were included, with 87.5%, 8.3%, and 4.3%, respectively. Patients treated at low volume centers were more likely to be of racial/ethnic minorities, uninsured, and have lower socioeconomic status. Overall survival (OS) was superior for patients treated at high volume centers. On multivariable analysis for either procedure, a higher number of disparate factors was identified in the low and middle volume centers compared to the high volume centers, which were associated with poorer OS.

Conclusions

This study identified higher numbers of disparate patient factors associated with low/middle volume centers compared to high volume centers, which were associated with worse OS, and further makes the case for performance of esophagectomy and total gastrectomy at high volume centers.

Complete pathologic response is independent of the timing of esophagectomy following neoadjuvant chemoradiation for esophageal cancer

Background

The relationship of complete pathologic response (cPR) with the timing of esophagectomy after neoadjuvant chemoradiation (nCRT) is not well defined. We sought to determine if a delay in esophagectomy after nCRT would result in increased likelihood of cPR and improved survival.

Methods

This is a retrospective analysis of a prospectively maintained database of all patients treated with nCRT and esophagectomy between 2004 and 2014. Patients were divided into two groups based on timing of esophagectomy (≤50 vs. >50 days) after completion of nCRT. Survival outcomes were compared using standard Kaplan-Meier curves, and multivariable analyses were performed using Cox regression models.

Results

This study included 226 patients (males, 211 and median age, 61 years) for analysis. Fifty-two patients (23%) in the early group (≤50 days) were compared to 174 patients (77%) in the delayed group (>50 days). The two groups were similar with respect to age, gender, comorbid conditions, ECOG status, location, grade, and tumor histology. There was no statistically significant difference in cPR rate between the early and late groups (26.9% vs. 19.0%, respectively, P=0.24). On multivariable analysis, lower age, absence of signet cell histology, better ECOG status, shorter length of stay and cPR were independent predictors of improved survival. The median follow-up was 52 months (range, 2-110 months), and there was no difference in the median overall survival (OS) between the early and late groups (48.9 vs. 42.6 months, respectively, P=0.73).

Conclusions

This analysis of a large cohort of patients with esophageal cancer undergoing multi-modality therapy shows that cPR is independent of the timing of esophagectomy. Other considerations for the timing of surgery, including recovery from nCRT and patient performance, may have more relevant roles than cPR when deciding when to perform esophagectomy.

Pathologic assessment of gastrointestinal tract and pancreatic carcinoma after neoadjuvant therapy

Neoadjuvant therapy is increasingly used to treat patients with a wide variety of malignancies. Histologic evaluation of treated specimens provides important prognostic information and may guide subsequent chemotherapy. Neoadjuvant therapy is commonly employed in the treatment of locally advanced rectal adenocarcinoma, hepatic colorectal metastases, esophageal/esophagogastric junction carcinoma, and pancreatic ductal adenocarcinoma. Numerous tumor regression schemes have been used in these tumors and standardized approaches to evaluate these specimens are needed. In this review, the various tumor regression scoring systems that have been used in these organs are described and their associations with clinical outcomes are discussed. Recommendations regarding how to handle and report the histologic findings in these resections specimens are provided.

Induction therapy before surgery improves survival in patients with clinical T3N0 esophageal cancer: a nationwide study in Taiwan

The utility of induction therapy (IT) in patients with resectable esophageal cancer remains controversial, especially when clinical evidence of nodal metastases is lacking. We sought to compare the survival impact of IT versus upfront surgery (US) in patients with cT3N0 esophageal cancer. We searched the Taiwan Cancer Registry for patients with cT3N0 esophageal cancer who underwent US or IT between 2008 and 2013. Multivariate Cox regression analysis was used to analyze the potential benefits of IT in terms of overall survival (OS) and disease-free survival (DFS). Of the 11752 patients with esophageal cancer included in the nationwide database, 762 (6.5%) had cT3N0 disease. Most cases (720 [94.5%]) had a histological diagnosis of squamous cell carcinoma. Of them, 135 received IT (the IT group) and 237 received surgery first (the US group). In the US group, pretreatment clinical staging was accurate in 47.9% of patients. Twenty-one (8.97%) were clinically overstaged (pT1-2N0), whereas 101 (43.17%) were clinically understaged (pT4N0 or pTanyN1-3). The presence of unexpected nodal metastases was identified in 92.1% of clinically understaged patients. In the IT group, 28 (20.74%) patients did not proceed to surgery after IT. The use of IT was associated with higher R0 resection rates and fewer pathological nodal metastases, despite unexpected M1 disease being more common (all P< 0.05). The 5-year OS rate was significantly higher (42%) in the IT group than in the US group (33%, P= 0.032). Similar findings were observed in terms of 5-year DFS (37% in the IT group versus 29% in the US group, P= 0.009). Multivariate analysis identified US (hazard ratio: 1.42, P= 0.03) and non-R0 resection (hazard ratio: 1.58, P= 0.03) as independent adverse prognostic factors. We found that 43.17% of patients with cT3N0 disease undergoing primary surgery had their disease understaged. The use of IT before esophagectomy significantly improves OS and DFS in patients with clinical T3N0 esophageal squamous cell carcinoma.

Remnant lymph node metastases after neoadjuvant therapy and surgery in patients with pathologic T0 esophageal carcinoma impact on prognosis: A systematic review and meta-analysis

BACKGROUND

The aim of this study was to evaluate the outcomes of patients with pathologic T0 esophageal carcinoma after neoadjuvant therapy and surgery.

METHODS

We searched PubMed, Embase, Cochrane Library, and Medline databases from inception up to November 12, 2016. The meta-analysis was performed to compare odds ratios (OR) for overall survival (OS), disease-free survival (DFS), local control (LC), and distant control (DC).

RESULTS

Eight published studies of 837 patients were included in the meta-analysis. Data showed that the ypT0N1 group was associated with worse outcomes compared with the ypT0N0 group. The pooled OR and 95% confidence interval (CI) for 3-year and 5-year OS were 3.08 [2.07, 4.57] and 4.27 [2.76, 6.59], respectively. Whereas, the pooled OR and 95% CI for 3-year and 5-year DFS were 3.90 [2.08, 7.34] and 5.17 [1.93, 13.87], respectively. The pooled OR and 95% CI for LR and DR were 4.52 [1.72, 11.91] and 2.65 [1.38, 5.09], respectively.

CONCLUSIONS

Remnant lymph node metastases after neoadjuvant therapy and surgery in patients with pathologic T0 esophageal carcinoma portend poor survival, and it is an important prognostic factor.

Novel Calculator to Estimate Overall Survival Benefit from Neoadjuvant Chemoradiation in Patients with Esophageal Adenocarcinoma

BACKGROUND

Our group reported that patients with clinically node-negative esophageal adenocarcinoma do not derive overall survival (OS) benefit from neoadjuvant chemoradiation (nCRT) compared with clinically node-positive patients. The aim of this study was to develop a calculator that could more easily identify which patients derive OS benefit from nCRT.

STUDY DESIGN

Using the National Cancer Data Base (2006 to 2012), patients with clinical status T1b to T4a, N-/+, M0 adenocarcinoma of the esophagus who underwent resection were selected. Of this cohort, 80% were randomly selected to develop and test the prediction model using Cox regression. The remaining 20% were used to internally validate the model, and performance was evaluated using receiver operating characteristic curves and area under the curves.

RESULTS

A total of 8,974 patients met study criteria. Using the model testing cohort (7,179 patients), variables that were independently associated with OS in multivariable analysis were included in the model. These variables included Charlson-Deyo comorbidity score, tumor grade, clinical T and N status, and nCRT before surgery. Factors associated with increased risk of death were higher grade and higher T or N status. Receipt of nCRT was associated with improved OS. After validation, model performance showed an area under the curve of 0.630 and 0.682 for 1-year and 3-year OS, respectively.

CONCLUSIONS

A novel OS calculator was developed for esophageal adenocarcinoma that reasonably predicts which patients are expected to derive OS benefit from nCRT. This tool can be helpful in determining OS benefit from nCRT to assist with treatment decision making.

Neoadjuvant therapy versus upfront surgery for resected pancreatic adenocarcinoma: A nationwide propensity score matched analysis

BACKGROUND

Neoadjuvant therapy is an emerging paradigm in pancreatic cancer care; however, its role for resectable disease remains controversial in the absence of conclusive randomized controlled trials. The purpose of the present study is to assess the impact of neoadjuvant therapy on survival in resected pancreatic cancer patients by clinical stage.

METHODS

A retrospective cohort study using the National Cancer Data Base from 2004 to 2012 including nonmetastatic pancreatic adenocarcinoma patients who underwent pancreatectomy and initiated chemotherapy. Propensity score matching within each stage was used to account for potential selection bias between patients undergoing neoadjuvant therapy and upfront surgery. Overall survival was compared by the Kaplan-Meier method.

RESULTS

In the study, 1,541 and 7,159 patients received neoadjuvant therapy followed by surgery and upfront surgery succeeded by adjuvant therapy, respectively. In clinical stage III pancreatic cancer (n = 486), neoadjuvant therapy was associated with significant survival benefit after matching (median survival 22.9 vs 17.3 months; log-rank P < .0001) compared with conventional upfront surgery followed by adjuvant therapy; however, no survival difference was found between the 2 treatment sequences in patients with clinical stage I (n = 3,149; median survival, 26.2 vs 25.7 months; P = .4418) and II (n = 5,065; median survival, 23.5 vs 23.0 months; P = .7751) disease after matching.

CONCLUSION

The survival impact of neoadjuvant therapy is stage-dependent. Neoadjuvant therapy does not disadvantage survival compared with conventional upfront surgery followed by adjuvant therapy in any stage, and is associated with a significant survival advantage in stage III pancreatic cancer.