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Tamamura H, Hasatani K, Matsumoto S, Asahi S, Tatebe H, Sato Y, Matsusita K, Tameshige Y, Maeda Y, Sasaki M, Takamatsu S, Yamamoto K. Evaluation of Exposure Doses of Elective Nodal Irradiation in Chemoradiotherapy for Advanced Esophageal Cancer. Cancers (Basel) 2023; 15:cancers15030860. [PMID: 36765818 PMCID: PMC9913169 DOI: 10.3390/cancers15030860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/22/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
We evaluated elective nodal irradiation (ENI) doses during radical chemoradiotherapy (CRT) for esophageal cancer (EC). A total of 79 patients (65 men and 14 women) aged 52-80 years with T1-3, N0-3, and M0 (including M1ly) who underwent CRT for EC during November 2012-September 2019 were eligible for this retrospective analysis. Patients were divided into two groups: the high-dose group (HG), including 38 patients who received ≥40 Gy as ENI; and the low-dose group (LG), including 41 patients who received <40 Gy. The median doses were 40.0 and 36.0 Gy in HG and LG, respectively. During the follow-up (median: 36.7 months), no lymph node recurrence was observed in the ENI field in all patients. Lymph node recurrence near the ENI field was observed in six patients. No significant differences were observed between the two groups in median overall survival, progression-free survival, and local control. Grade 3-4 acute and late adverse events were observed in five patients of HG and six patients of LG, respectively. No ulceration or stricture was observed in the ENI field on endoscopy examined with 58 Gy irradiation. In conclusion, an ENI dose of 36 Gy could be considered to control the elective nodes of EC.
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Affiliation(s)
- Hiroyasu Tamamura
- Proton Therapy Center, Fukui Prefectural Hospital, 2-8-1 Yotsui, Fukui City 910-8526, Fukui Prefecture, Japan
- Correspondence: ; Tel.: +81-0776-57-2981; Fax: +81-0776-57-2987
| | - Kenkei Hasatani
- Department of Gastroenterology, Fukui Prefectural Hospital, 2-8-1 Yotsui, Fukui City 910-8526, Fukui Prefecture, Japan
| | - Sae Matsumoto
- Proton Therapy Center, Fukui Prefectural Hospital, 2-8-1 Yotsui, Fukui City 910-8526, Fukui Prefecture, Japan
| | - Satoko Asahi
- Proton Therapy Center, Fukui Prefectural Hospital, 2-8-1 Yotsui, Fukui City 910-8526, Fukui Prefecture, Japan
| | - Hitoshi Tatebe
- Proton Therapy Center, Fukui Prefectural Hospital, 2-8-1 Yotsui, Fukui City 910-8526, Fukui Prefecture, Japan
| | - Yoshitaka Sato
- Proton Therapy Center, Fukui Prefectural Hospital, 2-8-1 Yotsui, Fukui City 910-8526, Fukui Prefecture, Japan
| | - Keiichiro Matsusita
- Proton Therapy Center, Fukui Prefectural Hospital, 2-8-1 Yotsui, Fukui City 910-8526, Fukui Prefecture, Japan
| | - Yuji Tameshige
- Proton Therapy Center, Fukui Prefectural Hospital, 2-8-1 Yotsui, Fukui City 910-8526, Fukui Prefecture, Japan
| | - Yoshikazu Maeda
- Proton Therapy Center, Fukui Prefectural Hospital, 2-8-1 Yotsui, Fukui City 910-8526, Fukui Prefecture, Japan
| | - Makoto Sasaki
- Proton Therapy Center, Fukui Prefectural Hospital, 2-8-1 Yotsui, Fukui City 910-8526, Fukui Prefecture, Japan
| | - Shigeyuki Takamatsu
- Department of Radiotherapy, Kanazawa University Hospital, Kanazawa 920-8641, Ishikawa, Japan
| | - Kazutaka Yamamoto
- Proton Therapy Center, Fukui Prefectural Hospital, 2-8-1 Yotsui, Fukui City 910-8526, Fukui Prefecture, Japan
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Lewis S, Lukovic J. Neoadjuvant Therapy in Esophageal Cancer. Thorac Surg Clin 2022; 32:447-456. [DOI: 10.1016/j.thorsurg.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Silva ALD, Nunes TA, Cunha CA, Carvalho MGD, Watty AJ, Silveira Filho LD, Souza AFD, Martins ALOR, Dourado C, Martins MM. Câncer de esôfago: radioterapia pré-operatória. REVISTA BRASILEIRA DE CANCEROLOGIA 2022. [DOI: 10.32635/2176-9745.rbc.1996v42n1.2884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Um estudo realizado no Instituto Mineiro de Oncologia, no período de 1986 a 1992, envolveu 158 pacientes com câncer de esôfago. Destes, 47 (29,74%) foram submetidos a radioterapia (4400 cGy) e, um mês após, à esofagectomia. A histopatologia das peças ressecadas revelou a presença de tumor residual em 34 (72,34%) delas.
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Bao Y, Ma Z, Yuan M, Wang Y, Men Y, Hui Z. Comparison of different neoadjuvant treatments for resectable locoregional esophageal cancer: A systematic review and network meta-analysis. Thorac Cancer 2022; 13:2515-2523. [PMID: 35891585 PMCID: PMC9436699 DOI: 10.1111/1759-7714.14588] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/02/2022] [Accepted: 07/08/2022] [Indexed: 01/09/2023] Open
Abstract
PURPOSE The best pattern of neoadjuvant therapy for resectable locoregional esophageal cancer has not been determined. Our study evaluated the efficacy and postoperative events of different treatments using the Bayesian network meta-analysis. METHODS We systematically tracked randomized clinical trials from the Medline, EMBASE, and Cochrane Library databases. The following treatments were included: neoadjuvant chemoradiation followed by surgery (NCRT + S), neoadjuvant chemotherapy followed by surgery (NCT + S), neoadjuvant radiotherapy followed by surgery (NRT + S), and surgery alone (S). The Revised Cochrane risk-of-bias tools were used to assess the quality of included trials. Overall survival (OS) and progression-free survival or disease-free survival (PFS/DFS) were assessed through hazard ratios (HR). Locoregional recurrence, distant metastasis, postoperative mortality, and postoperative morbidity were assessed through odds ratios (OR). These outcomes were compared between different treatments through Bayesian network meta-analysis. RESULTS Twenty trials with 4384 patients were included. Compared with S, only NCRT + S could significantly improve OS for patients with esophageal cancer (HR = 0.78, 95% confidence interval [CI] 0.68-0.88). NCRT + S and NCT + S significantly improved PFS/DFS compared with S (NCRT + S vs. S, HR = 0.72, 95% CI 0.63-0.81; NCT + S vs. S, HR = 0.81, 95% CI 0.69-0.97). NCRT + S significantly reduced both locoregional recurrence (OR = 0.67, 95% CI 0.51-0.88) and distant metastasis (OR = 0.63, 95% CI 0.45-0.90) compared with S. There were no differences in postoperative morbidity between the four treatments. However, NCRT + S also increased postoperative mortality compared with S (OR = 1.77, 95% CI 1.09-2.82) and NCT + S (OR = 1.96, 95% CI 1.11-3.51). CONCLUSION NCRT + S is the most efficient neoadjuvant treatment for resectable locoregional esophageal cancer. However, NCRT + S increases the risk of postoperative mortality but not morbidity.
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Affiliation(s)
- Yongxing Bao
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Zeliang Ma
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Meng Yuan
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Yang Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Yu Men
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina,Department of VIP Medical Services, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Zhouguang Hui
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina,Department of VIP Medical Services, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
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Ma Z, Yuan M, Bao Y, Wang Y, Men Y, Hui Z. Survival of Neoadjuvant and Adjuvant Therapy Compared With Surgery Alone for Resectable Esophageal Squamous Cell Carcinoma: A Systemic Review and Network Meta-Analysis. Front Oncol 2021; 11:728185. [PMID: 34745950 PMCID: PMC8564474 DOI: 10.3389/fonc.2021.728185] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/23/2021] [Indexed: 01/02/2023] Open
Abstract
Objective The optimal treatment for resectable esophageal squamous cell carcinoma (ESCC) remains controversial. Surgery is the primary treatment but with poor results. Attempts to improve patient survival have been made by introducing chemotherapy, radiotherapy, or both. However, randomized comparisons for all these strategies are not always available. This network meta-analysis compared the overall survival of neoadjuvant and adjuvant therapy with surgery alone to identify the most effective approach. Methods We systematically searched electronic databases (PubMed, Embase, and Cochrane Library) for relevant studies published before April 2021. Only phase II and III randomized controlled trials comparing the following treatments were included: surgery alone, neoadjuvant chemotherapy (NCT), radiotherapy (NRT) or chemoradiotherapy (NCRT), adjuvant chemotherapy (ACT), radiotherapy (ART), or chemoradiotherapy (ACRT). The hazard ratios (HR) and 95% confidence intervals (CIs) of overall survival (OS) was identified as the measurement of effectiveness. A network meta-analysis was conducted to synthesize the evidence under the Bayesian framework, and the relative effects of all possible comparisons were made. The ranking analysis was performed to support the decision in clinical practice. Results A total of 19 relevant trials with 3,749 patients were identified. Compared with surgery alone, NCRT (HR 0.76, 95% CI 0.65–0.89) and NCT (HR 0.81, 95% CI 0.70–0.94) significantly improved OS, while other treatments, including NRT (HR 0.86, 95% CI 0.66–1.08), ACRT (HR 0.73, 95% CI 0.49–1.08), ACT (HR 0.96, 95% CI 0.75–1.21), and ART (HR 0.86, 95% CI 0.66–1.14), provided no significant survival advantage. None of the neoadjuvant and adjuvant treatments showed a statistically significant difference in OS to each other when compared in pairs. Conclusion For resectable esophageal squamous cell carcinoma, this network meta-analysis showed that NCRT may be the optimal strategy, NCT may be the second choice, while other multimodality treatments could not improve OS compared with surgery alone. It remains unclear whether ESCC will benefit from adding radiotherapy into the neoadjuvant treatment. Systematic Review Registration We registered this meta-analysis protocol at the prospective register of systematic reviews, PROSPERO https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=172745 (Identification code: CRD42020172745).
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Affiliation(s)
- Zeliang Ma
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Meng Yuan
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongxing Bao
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Men
- Department of VIP Medical Services, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhouguang Hui
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of VIP Medical Services, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Peng J, Lv Y, Wu C. Radiation-resistance increased by overexpression of microRNA-21 and inhibition of its target PTEN in esophageal squamous cell carcinoma. J Int Med Res 2021; 48:300060519882543. [PMID: 32268810 PMCID: PMC7153193 DOI: 10.1177/0300060519882543] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objective Overexpression of microRNA-21 (miR-21) increases the radiation resistance of esophageal squamous cell carcinoma (ESCC). However, the molecular mechanism responsible for this action is still unclear. In the present study, we investigated the role of phosphatase and tensin homolog deleted on chromosome 10 (PTEN) in miR-21-enhanced radiation resistance in patients with ESCC. Methods We evaluated the association between miR-21 levels and radiation resistance in patients with ESCC. We also investigated the role of PTEN in the proliferation and apoptosis of ESCC cells transfected with miR-21 inhibitor during irradiation, using PTEN small interfering RNA (siRNA). Results MiR-21 levels were significantly higher in radiation-resistant patients. Downregulation of miR-21 during irradiation suppressed the radiation resistance of ESCC cells, demonstrated by decreased cell proliferation and increased cell apoptosis. PTEN siRNA attenuated miR-21-induced suppression of radiation resistance in ESCC cells. Conclusions These results suggest that miR-21 enhanced the radiation resistance of ESCC by inhibiting PTEN. MiR-21 and PTEN are potential therapeutic biotargets for ESCC.
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Affiliation(s)
- Jun Peng
- Department of Research, Hangzhou Biozon Medical institute Co Ltd, Zhejiang, China
| | - Yinxiang Lv
- Department of oncology, People's Hospital of XinChang County, Zhejiang, China
| | - Chaochao Wu
- Department of Research, Hangzhou Biozon Medical institute Co Ltd, Zhejiang, China
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Yuan M, Bao Y, Ma Z, Men Y, Wang Y, Hui Z. The Optimal Treatment for Resectable Esophageal Cancer: A Network Meta-Analysis of 6168 Patients. Front Oncol 2021; 11:628706. [PMID: 33777777 PMCID: PMC7988076 DOI: 10.3389/fonc.2021.628706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 01/27/2021] [Indexed: 12/14/2022] Open
Abstract
The optimal treatment for resectable esophageal cancer remains unclear. This network meta-analysis compares the efficacy of different treatments. PubMed, Embase, and the Cochrane library were systematically screened. Randomized controlled trials comparing the efficacy of different treatments for resectable esophageal cancer were included. Hazard ratios (HR) for overall survival (OS), progression-free survival, or disease-free survival, and odds ratios for locoregional recurrence and distant metastasis rates were identified as the measurements of efficacy. A Bayesian network meta-analysis was performed. In this study, 26 studies were included. Patients received either surgery alone; neoadjuvant chemotherapy (CT), neoadjuvant radiotherapy (RT), or neoadjuvant chemoradiotherapy (CRT) followed by surgery; or surgery followed by adjuvant CT, adjuvant RT, or adjuvant CRT. Neoadjuvant CRT followed by surgery (pooled HR = 0.76, 95% credible interval: 0.67–0.85) and neoadjuvant CT followed by surgery compared with surgery alone were the only two showing statistically confident improvement on OS. Ranking analysis showed that neoadjuvant CRT with surgery was likely to be the best option in terms of efficacy. Therefore, for patients with resectable esophageal cancer, neoadjuvant CRT with surgery is the optimal treatment. Future studies should focus on the optimization of neoadjuvant CRT regimens.
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Affiliation(s)
- Meng Yuan
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongxing Bao
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zeliang Ma
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Men
- Department of VIP Medical Services, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yang Wang
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhouguang Hui
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Department of VIP Medical Services, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Cummings D, Wong J, Palm R, Hoffe S, Almhanna K, Vignesh S. Epidemiology, Diagnosis, Staging and Multimodal Therapy of Esophageal and Gastric Tumors. Cancers (Basel) 2021; 13:582. [PMID: 33540736 PMCID: PMC7867245 DOI: 10.3390/cancers13030582] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/14/2021] [Accepted: 01/25/2021] [Indexed: 02/06/2023] Open
Abstract
Gastric and esophageal tumors are diverse neoplasms that involve mucosal and submucosal tissue layers and include squamous cell carcinomas, adenocarcinomas, spindle cell neoplasms, neuroendocrine tumors, marginal B cell lymphomas, along with less common tumors. The worldwide burden of esophageal and gastric malignancies is significant, with esophageal and gastric cancer representing the ninth and fifth most common cancers, respectively. The approach to diagnosis and staging of these lesions is multimodal and includes a combination of gastrointestinal endoscopy, endoscopic ultrasound, and cross-sectional imaging. Likewise, therapy is multidisciplinary and combines therapeutic endoscopy, surgery, radiotherapy, and systemic chemotherapeutic tools. Future directions for diagnosis of esophageal and gastric malignancies are evolving rapidly and will involve advances in endoscopic and endosonographic techniques including tethered capsules, optical coherence tomography, along with targeted cytologic and serological analyses.
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Affiliation(s)
- Donelle Cummings
- Division of Gastroenterology and Hepatology, Department of Medicine, New York Medical College, New York City Health and Hospitals Corporation-Metropolitan Hospital Center, 1901 First Avenue, New York, NY 10029, USA;
| | - Joyce Wong
- Division of Surgery, Mid Atlantic Kaiser Permanente, 700 2nd St. NE, 6th Floor, Washington, DC 20002, USA;
| | - Russell Palm
- Department of Radiation Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (R.P.); (S.H.)
| | - Sarah Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (R.P.); (S.H.)
| | - Khaldoun Almhanna
- Division of Hematology/Oncology, Lifespan Cancer Institute, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, 593 Eddy St, George 312, Providence, RI 02903, USA;
| | - Shivakumar Vignesh
- Division of Gastroenterology and Hepatology, Department of Medicine, SUNY Downstate Health Sciences University, MSC 1196, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
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Kumar T, Pai E, Singh R, Francis NJ, Pandey M. Neoadjuvant strategies in resectable carcinoma esophagus: a meta-analysis of randomized trials. World J Surg Oncol 2020; 18:59. [PMID: 32199464 PMCID: PMC7085863 DOI: 10.1186/s12957-020-01830-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 02/27/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The survival benefit of neoadjuvant therapy in resectable carcinoma esophagus has been elucidated. We performed a meta-analysis in light of new studies and long-term results of past trials. The search strategy was refined to include only "neoadjuvant" so that any bias by adjuvant treatment is eliminated. METHODS A detailed search of MEDLINE, Embase, and Cochrane Library was done. Only published randomized English language trials were included. Data were categorized as neoadjuvant concurrent chemoradiation (NACRT), neoadjuvant chemotherapy (NACT), neoadjuvant radiotherapy (NART), and neoadjuvant sequential chemoradiotherapy (SCRT). Meta-analysis was done using odds ratio (OR) and 95% CI using fixed/random effects model. Heterogeneity was tested by chi-square and I2 test. Z probability calculated significant difference across subgroups. Outcomes assessed were overall survival (OS) and disease-free survival (DFS) at 3 and 5 years, respectively, mortality (30/90 day) and failures (local/systemic). RESULTS Twenty-five randomized trials involving 5272 patients were included for quantitative analysis. NACRT was evaluated in 12 studies (2676 patients). Superior 3-year OS (OR = 0.68 CI 0.52-0.90, p = 0.007), 3-year DFS (OR = 0.55 CI 0.45-0.68, p = 0.00001), and 5-year DFS (OR = 0.59 CI 0.47-0.74, p = 0.00001), with lower failures (OR = 0.52 CI 0.37-0.73, p = 0.0001), were seen in favor of NACRT at the cost of increased perioperative mortality (OR = 1.79 CI 1.15-2.80, p = .01). However, 5-year OS (OR = 0.78 CI 0.60-0.1.01, p = 0.06) was not found to be significantly superior. NACT, NART, and SCRT were not found to have any benefit over surgery alone. CONCLUSION This meta-analysis presents strong evidence favoring NACRT over upfront surgery. It also shows no survival advantage of neoadjuvant chemotherapy.
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Affiliation(s)
- Tarun Kumar
- Department of Surgical Oncology, Banaras Hindu University, Varanasi, 221005, India.
| | - Esha Pai
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, 400012, India
| | - Rajesh Singh
- Department of Surgical Oncology, Asian Institute of Oncology, Mumbai, 400022, India
| | - Neville J Francis
- Department of Surgical Oncology, Banaras Hindu University, Varanasi, 221005, India
| | - Manoj Pandey
- Department of Surgical Oncology, Banaras Hindu University, Varanasi, 221005, India
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Zhang N, Zhang SW. Long-term effects of radiation prior to surgery and chemotherapy on survival of esophageal cancer undergoing surgery. Medicine (Baltimore) 2019; 98:e17617. [PMID: 31651875 PMCID: PMC6824783 DOI: 10.1097/md.0000000000017617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Esophageal cancer (EC) is one of the most common cancers in the world, with continuously growing diagnoses and morbidity. Because it is still unclear how to choose the best treatment for EC patients, a multimodal treatment is necessary to improve the prospect of the malignancy, including a sequence of surgery, chemotherapy, and radiotherapy, whether alone or combination. Therefore, this paper aims to analyze the effect of the sequence of chemotherapy, radiotherapy, and surgery on the prognosis and survival rate of patients with EC.The Surveillance, Epidemiology, and End Results (SEER) database was used to extract a dataset of patients who were diagnosed with EC from 1973 to 2015, with follow-up data for 6 years after diagnosis. The data were analyzed using correlation analysis, logistic regression Cox regression, and Kaplan-Meier analysis.EC patients who had radiation prior to surgery and chemotherapy had a better prognosis than the cases without chemotherapy. Based on univariate logistic regression, the odds radios of vital status recoded for "radiation prior to surgery combined with chemotherapy" is the lowest one among the 8 groups classified by radiation sequence with surgery and chemotherapy (P < .001). Further, radiation prior to surgery and chemotherapy is an independent prognostic factor for better survival among EC patients.In conclusion, in the treatment of EC, administering radiation prior to surgery and chemotherapy is better than no radiotherapy, perioperative radiotherapy, postoperative radiotherapy, and other combinations without chemotherapy.
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Zhang A, Deek MP, Kim S, Sayan M, Grann A, Wagman RT, Malhotra U, Hathout L, Biswal N, Zhang Y, Langenfeld J, Kennedy T, August DA, Jabbour SK. Vertebral body irradiation during chemoradiation therapy for esophageal cancer contributes to acute bone marrow toxicity. J Gastrointest Oncol 2019; 10:513-522. [PMID: 31183202 PMCID: PMC6534715 DOI: 10.21037/jgo.2019.01.20] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 01/22/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Hematologic toxicity (HT) commonly occurs during chemoradiation therapy (CRT) for esophageal cancer. We sought to determine radiation doses that correlate with declines in blood counts due to vertebral body (VB) irradiation during CRT. METHODS We analyzed 53 esophageal cancer patients who were treated with weekly neoadjuvant carboplatin, paclitaxel and RT with weekly complete blood counts (CBC) available during treatment. HTs were graded according to the Common Terminology Criteria for Adverse Events version 4.0 (CTCAE v4.0). Dose volume histogram (DVH) parameters of Vx, defined as percentage of entire bony vertebra (body, pedicles, laminae, processes) receiving at least x Gy of radiation, were collected for VB V5 (VBV5), VBV10-VBV60 in increments of 10, and mean vertebral dose (MVD). Linear and logistic regressions were performed to identify associations between leukopenia nadirs and DVH parameters. Receiver operator curves identified thresholds to avoid grade ≥3 leukopenia. RESULTS A proportion of 32.1% of patients (n=17) developed grade 3 leukopenia and 5.7% (n=3) developed grade 4 leukopenia. VBV5, VBV10, VBV20, VBV30, and MVD were significantly associated with worsening leukopenia on univariate and multivariate analysis. Associations with leukopenia were not seen with VBV40 and VBV50 DVH values. Thresholds to avoid grade ≥3 leukopenia were VBV10 <49.1%, VBV20 <45.6%, and MVD <17.2 Gy. CONCLUSIONS VBV5, VBV10, VBV20, VBV30 associate with leukopenia during CRT for esophageal cancer patients. Improved radiation sparing of the VB may decrease HT and may improve tolerability of concurrent chemotherapy and allow for intensification of systemic therapy during RT.
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Affiliation(s)
- Andrew Zhang
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Matthew P. Deek
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Sinae Kim
- Department of Biostatistics, School of Public Health, Rutgers University, Piscataway, NJ, USA
| | - Mutlay Sayan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Alison Grann
- Department of Radiation Oncology, Saint Barnabas Medical Center, Livingston, NJ, USA
| | - Raquel T. Wagman
- Department of Radiation Oncology, Saint Barnabas Medical Center, Livingston, NJ, USA
| | - Usha Malhotra
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Lara Hathout
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Nrusingh Biswal
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Yin Zhang
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - John Langenfeld
- Division of Surgery, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Timothy Kennedy
- Division of Surgery, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - David A. August
- Division of Surgery, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Salma K. Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
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Ma K, Yang Y, Wang S, Yang X, Lu T, Xi J, Jiang W, Zhan C, Zhu Y, Wang Q. Stage selection for neoadjuvant radiotherapy in non-cervical esophageal cancer: A propensity score-matched study based on the SEER database. Thorac Cancer 2018; 9:1111-1120. [PMID: 29961955 PMCID: PMC6119609 DOI: 10.1111/1759-7714.12794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 05/26/2018] [Accepted: 05/27/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The effect of neoadjuvant radiotherapy (NRT) was controversial in non-cervical esophageal cancer. The aim of this study was to identify which stage of non-cervical esophageal cancer would get benefit from NRT using propensity score matching (PSM) and survival analysis based on the Surveillance Epidemiology, and End Results (SEER) database. METHODS A selection process was used for case screening from the SEER database. Seven baseline variables were included in PSM. The survival analysis were based on T stage (T2 and T3 ) and status of lymph node involvement (N0 and N+ ) using Kaplan-Meier method and log-rank test for comparing the overall survival of patient with NRT plus surgery versus those who with surgery alone (SA). RESULTS A total of 1631 cases were included in this study. After PSM, 225 cases of esophageal squamous cell carcinoma (ESCC) and 606 cases of esophageal adenocarcinoma (EAC) were enrolled in survival analysis. We found that only T3 N+ stage of EAC would got survival benefit from NRT (P = 0.0052), while NRT showed no significant benefit in overall survival in other stages of EAC and ESCC. CONCLUSIONS NRT followed by resection had a significant survival benefit in non-cervical EAC patients with T3 N+ stage. For patients with ESCC and other EAC stages, NRT versus SA did not demonstrate a statistical significant survival difference.
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Affiliation(s)
- Ke Ma
- Department of Thoracic SurgeryZhongshan Hospital, Fudan UniversityShanghaiChina
| | - Yong Yang
- Department of Thoracic SurgeryThe Affiliated Suzhou Hospital of Nanjing Medical University SuzhouJiangsuChina
| | - Shuai Wang
- Department of Thoracic SurgeryZhongshan Hospital, Fudan UniversityShanghaiChina
| | - Xiaodong Yang
- Department of Thoracic SurgeryZhongshan Hospital, Fudan UniversityShanghaiChina
| | - Tao Lu
- Department of Thoracic SurgeryZhongshan Hospital, Fudan UniversityShanghaiChina
| | - Junjie Xi
- Department of Thoracic SurgeryZhongshan Hospital, Fudan UniversityShanghaiChina
| | - Wei Jiang
- Department of Thoracic SurgeryZhongshan Hospital, Fudan UniversityShanghaiChina
| | - Cheng Zhan
- Department of Thoracic SurgeryZhongshan Hospital, Fudan UniversityShanghaiChina
| | - Yimeng Zhu
- Department of Thoracic SurgeryThe Affiliated Suzhou Hospital of Nanjing Medical University SuzhouJiangsuChina
| | - Qun Wang
- Department of Thoracic SurgeryZhongshan Hospital, Fudan UniversityShanghaiChina
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13
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Doosti-Irani A, Holakouie-Naieni K, Rahimi-Foroushani A, Mansournia MA, Haddad P. A network meta-analysis of the treatments for esophageal squamous cell carcinoma in terms of survival. Crit Rev Oncol Hematol 2018; 127:80-90. [PMID: 29891115 DOI: 10.1016/j.critrevonc.2018.05.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 03/18/2018] [Accepted: 05/09/2018] [Indexed: 01/30/2023] Open
Abstract
We aimed to compare treatments for patients with esophageal squamous cell carcinoma (SCC) in terms of survival. Medline, Web of Science, Scopus, the Cochrane Library and Embase were searched. Randomized controlled trials (RCT) that had compared esophageal SCC treatments were included. The hazard ratio (HR) with 95% credible interval (CrI) was used to summarize the effect measures in the Bayesian network meta-analysis. Out of 23,256 references, 43 RCTs with 34 treatments were included. Carboplatin and paclitaxel plus radiotherapy plus surgery (carbo-pacli + RT + S) compared with surgery alone decreased risk of death (HR = 0.49; 95% CrI: 0.26, 0.90). The HRs for carbo-pacli + RT + S versus surgery plus cisplatin and fluorouracil and surgery plus cisplatin and vindesine were 0.44 (0.22, 0.86) and 0.41 (0.20, 0.83), respectively. Among all treatments in network, carbo-pacli + RT + S ranked as first treatment. It seems carbo-pacli + RT + S was a better treatment among available treatments in network in terms of survival in patients with esophageal SCC.
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Affiliation(s)
- Amin Doosti-Irani
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran; Department of Epidemiology, School of Public Health, Hamadan University of Medical Sciences, Hamadan, Iran.
| | - Kourosh Holakouie-Naieni
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
| | - Abbas Rahimi-Foroushani
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mohammad Ali Mansournia
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
| | - Peiman Haddad
- Radiation Oncology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran.
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Prognosis of surgery combined with different adjuvant therapies in esophageal cancer treatment: a network meta-analysis. Oncotarget 2018; 8:36339-36353. [PMID: 28423740 PMCID: PMC5482659 DOI: 10.18632/oncotarget.16193] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 02/20/2017] [Indexed: 12/22/2022] Open
Abstract
This network meta-analysis was conducted to assess whether the efficacy of surgery with adjuvant therapies, including radiotherapy (RT+S), chemotherapy (CT+S), and chemoradiotherapy (CRT+S) have better performance in esophageal cancer treatment and management. PubMed and EMBASE were used to search for relevant trials. Both conventional pair-wise and network meta-analyses were carried out. The surface under the cumulative ranking curve (SUCRA) was used to rank interventions based on the efficacy of the treatment method. As for 3-year overall survival (OS), CRT+S showed the highest efficacy (CRT+S vs. SURGERY HR=0.81, 95% CrI =0.73-0.90; CRT+S vs. CT+S: HR=0.82, 95% CrI =0.70-0.95; CRT+S vs. RT+S: HR=0.77, 95% CrI =0.62-0.95). For disease-free survival, CRT+S showed efficacy over CT+S ((HR =0.70, 95% CrI =0. 59-0.83). In conclusion, CRT+S showed a better performance for survival outcomes and ranks best among all therapies. The results of our study can provide guidance for medical decisions and treatment options that may help clinical practitioners improve the efficacy of EC treatment.
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Abstract
Esophageal carcinoma has, over the past decade, undergone a sea of change, not only in its pathological distribution, but also in the diagnosis, staging and subsequent management. Although the advent of better imaging techniques has helped in diagnosing patients at an earlier period, the majority of them have unresectable disease at the time of presentation. Despite aggressive treatment protocols involving either one or a combination of the options of surgery, radiation, and chemotherapy, the five-year survival remains dismal in the order of 10 to 15%. The two most commonly used surgical techniques for resecting the esophagus, the Ivor Lewis and the trans-hiatal esophagectomy, have similar results in terms of morbidity, mortality and, more importantly, five-year survival following resection. There has been an increasing interest in the surgical treatment of carcinoma esophagus by a minimally invasive approach, as meta-analysis of clinical series have shown that a faster recovery time without any statistically significant difference in the in-hospital mortality or morbidity when compared to conventional surgery. Nonrandomized studies suggest that patients receiving neoadjuvant chemo-radiation have a five year survival advantage compared with those treated with surgery alone, especially if they had a complete histological response to the preoperative regimen. Lastly, palliative procedures, form the mainstay of management of patients with non-resectable disease.
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Affiliation(s)
- Adil Sadiq
- General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kamal A Mansour
- General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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16
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Abstract
BACKGROUND In recent years research which conforms to evidence-based medicine (EBM) has been required even in surgery. Prospective, randomized studies are carried out in order to provide justification for the benefits of new procedures. OBJECTIVE The acquisition of special features in surgery with respect to the application of EBM. MATERIAL AND METHODS The investigation period selected was from1933 to 2013; therefore, all disciplines within the German Society of Surgery were questioned on the achievement of revolutionary innovations. The investigation was carried out utilizing personal interviews and a questionnaire. Only novel methods which were developed in Germany were considered. The survey was completed by carrying out research in database files. RESULTS During the past 80 years 15 pioneering innovations have been published in surgical research, although the prerequisites of EBM were only partly met. They appear to be based on the lowest level of evidence as these methods were mostly published as case reports or case series in journals with a low impact factor. DISCUSSION In general, innovative surgical procedures through top level research are still being published in the form of case reports or case series. This allows a rapid distribution of research results to the surgical community. Controlled studies still do not represent an alternative for the introduction of pioneering surgical innovations.
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Affiliation(s)
- S Weber
- Klinik für Thorax-, Herz- und Gefäßchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - A Haverich
- Klinik für Thorax-, Herz- und Gefäßchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
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17
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Noordman BJ, Wijnhoven BPL, Lagarde SM, Biermann K, van der Gaast A, Spaander MCW, Valkema R, van Lanschot JJB. Active surveillance in clinically complete responders after neoadjuvant chemoradiotherapy for esophageal or junctional cancer. Dis Esophagus 2017; 30:1-8. [PMID: 28881890 DOI: 10.1093/dote/dox100] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Indexed: 12/11/2022]
Abstract
Neoadjuvant chemoradiotherapy (nCRT) followed by surgery is standard of care for locally advanced esophageal cancer in many countries. After nCRT up to one third of all patients have a pathologically complete response in the resection specimen, posing an ethical imperative to reconsider the necessity of standard surgery in all operable patients after nCRT. An active surveillance strategy following nCRT, in which patients are subjected to frequent clinical investigations after the completion of neoadjuvant therapy, has been evaluated in other types of cancer with promising results. In esophageal cancer, both patients who are cured by neoadjuvant therapy alone as well as patients with subclinical disseminated disease at the time of completion of neoadjuvant therapy may benefit from such an organ sparing approach. Active surveillance is currently applied in selected patients with esophageal cancer who refuse surgery or are medically unfit for major surgery after completion of nCRT, but this strategy is not (yet) adopted as an alternative to standard surgery or definitive chemoradiation. The available literature is scarce, but suggests that long-term oncological outcomes after active surveillance are noninferior compared to standard surgical resection, providing justification for comparison of both treatments in a phase III trial. This review gives an overview of the current knowledge regarding active surveillance after completion of nCRT in esophageal cancer and outlines future research perspectives.
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Affiliation(s)
| | | | | | | | | | | | - R Valkema
- Department of Radiology and Nuclear Medicine, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
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18
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An Update on Randomized Clinical Trials in Gastric Cancer. Surg Oncol Clin N Am 2017; 26:621-645. [PMID: 28923222 DOI: 10.1016/j.soc.2017.05.003] [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: 11/21/2022]
Abstract
The optimal treatment of esophageal cancer is still being defined. The timing of surgical management and the application of chemotherapy and radiation in the neoadjuvant and adjuvant settings have been studied in several prospective, randomized, controlled trials. This article outlines some of the historical as well as updated research that has been published regarding the management of esophageal cancer.
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Shaikh T, Meyer JE, Horwitz EM. Optimal Use of Combined Modality Therapy in the Treatment of Esophageal Cancer. Surg Oncol Clin N Am 2017; 26:405-429. [DOI: 10.1016/j.soc.2017.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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20
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Jeong Y, Kim JH. Multimodality treatment for locally advanced esophageal cancers. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2015. [DOI: 10.18528/gii1400019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Yuri Jeong
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Hoon Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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21
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Noordman BJ, Shapiro J, Spaander MC, Krishnadath KK, van Laarhoven HW, van Berge Henegouwen MI, Nieuwenhuijzen GA, van Hillegersberg R, Sosef MN, Steyerberg EW, Wijnhoven BP, van Lanschot JJB. Accuracy of Detecting Residual Disease After Cross Neoadjuvant Chemoradiotherapy for Esophageal Cancer (preSANO Trial): Rationale and Protocol. JMIR Res Protoc 2015; 4:e79. [PMID: 26121676 PMCID: PMC4526968 DOI: 10.2196/resprot.4320] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 04/03/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Results from the recent CROSS trial showed that neoadjuvant chemoradiotherapy (nCRT) significantly increased survival as compared to surgery alone in patients with potentially curable esophageal cancer. Furthermore, in the nCRT arm 49% of patients with a squamous cell carcinoma (SCC) and 23% of patients with an adenocarcinoma (AC) had a pathologically complete response in the resection specimen. These results provide a rationale to reconsider and study the timing and necessity of esophagectomy in (all) patients after application of the CROSS regimen. OBJECTIVE We propose a "surgery as needed" approach after completion of nCRT. In this approach, patients will undergo active surveillance after completion of nCRT. Surgical resection would be offered only to those patients in whom residual disease or a locoregional recurrence is highly suspected or proven. However, before a surgery as needed approach in oesophageal cancer patients (SANO) can be tested in a randomized controlled trial, we aim to determine the accuracy of detecting the presence or absence of residual disease after nCRT (preSANO trial). METHODS This study is set up as a prospective, single arm, multicenter, diagnostic trial. Operable patients with potentially curable SCC or AC of the esophagus or esophagogastric junction will be included. Approximately 4-6 weeks after completion of nCRT all included patients will undergo a first clinical response evaluation (CRE-I) including endoscopy with (random) conventional mucosal biopsies of the primary tumor site and of any other suspected lesions in the esophagus and radial endo-ultrasonography (EUS) for measurement of tumor thickness and area. Patients in whom no locoregional or disseminated disease can be proven by cytohistology will be offered a postponed surgical resection 6-8 weeks after CRE-I (ie, approximately 12-14 weeks after completion of nCRT). In the week preceding the postponed surgical resection, a second clinical response evaluation (CRE-II) will be planned that will include a whole body PET-CT, followed again by endoscopy with (random) conventional mucosal biopsies of the primary tumor site and any other suspected lesions in the esophagus, radial EUS for measurement of tumor thickness and area, and linear EUS plus fine needle aspiration of PET-positive lesions and/or suspected lymph nodes. The main study parameter is the correlation between the clinical response assessment during CRE-I and CRE-II and the final pathological response in the resection specimen. RESULTS The first patient was enrolled on July 23, 2013, and results are expected in January 2016. CONCLUSIONS If this preSANO trial shows that the presence or absence of residual tumor can be predicted reliably 6 or 12 weeks after completion of nCRT, a randomized trial comparing nCRT plus standard surgery versus chemoradiotherapy plus "surgery as needed" will be conducted (SANO trial). TRIAL REGISTRATION Netherlands Trial Register: NTR4834; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4834 (archived by Webcite at http://www.webcitation.org/6Ze7mn67B).
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Affiliation(s)
- Bo Jan Noordman
- Erasmus MC - University Medical Center Rotterdam, Department of Surgery, Rotterdam, Netherlands.
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22
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Burmeister BH. Role of radiotherapy in the pre-operative management of carcinoma of the esophagus. World J Gastrointest Oncol 2015; 7:1-5. [PMID: 25610538 PMCID: PMC4295172 DOI: 10.4251/wjgo.v7.i1.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 12/16/2014] [Accepted: 12/29/2014] [Indexed: 02/05/2023] Open
Abstract
The use of radiotherapy in the management of carcinoma of the esophagus and gastro-esophageal junction has undergone much evolution over the past 2 decades. Advances to define its role have been slow with meta-analyses often providing the most useful data. In spite of this many institutions around the world are divided about the role of radiotherapy in this disease and attribute different roles to radiotherapy based on clinical stage, tumor site and histology. The purpose of this review is to try to define the role of radiotherapy given our current knowledge base and to review which current and future trials may fill the gaps of knowledge that we currently have. It will also highlight the difficulties in making firm recommendations about the use of radiotherapy especially in a time when technology and treatments are rapidly evolving.
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Affiliation(s)
- Bryan H Burmeister
- Bryan H Burmeister, Division of Cancer Services, Princess Alexandra Hospital, University of Queensland, Brisbane 4012, Australia
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23
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WITHDRAWN: Multimodality treatment for locally advanced esophageal cancers. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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24
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Perioperative therapy for esophageal cancer. Gen Thorac Cardiovasc Surg 2014; 62:531-40. [DOI: 10.1007/s11748-014-0458-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Indexed: 10/25/2022]
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Intraluminal brachytherapy in oesophageal cancer: defining its role and introducing the technique. J Contemp Brachytherapy 2014; 6:236-41. [PMID: 25097567 PMCID: PMC4105652 DOI: 10.5114/jcb.2014.43780] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 06/10/2014] [Accepted: 06/26/2014] [Indexed: 01/10/2023] Open
Abstract
Intraluminal brachytherapy plays an important role in the treatment of oesophageal tumours. This article aims to define this role in the curative as well as in the palliative treatment settings drawing on data from the literature, and also emphasizing its potential for harm when used inexpertly. It also provides a short introduction to practical aspects of the treatment procedure and treatment planning.
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26
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Baba Y, Watanabe M, Yoshida N, Baba H. Neoadjuvant treatment for esophageal squamous cell carcinoma. World J Gastrointest Oncol 2014; 6:121-8. [PMID: 24834142 PMCID: PMC4021328 DOI: 10.4251/wjgo.v6.i5.121] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 02/25/2014] [Accepted: 04/17/2014] [Indexed: 02/05/2023] Open
Abstract
Squamous cell carcinoma and adenocarcinoma are types of esophageal cancer, one of the most aggressive malignant diseases. Since both histological types present entirely different diseases with different epidemiology, pathogenesis and tumor biology, separate therapeutic strategies should be developed against each type. While surgical resection remains the dominant therapeutic intervention for patients with operable esophageal squamous cell carcinoma (ESCC), alternative strategies are actively sought to reduce the frequency of post-operative local or distant disease recurrence. Such strategies are particularly sought in the preoperative setting. Currently, the optimal management of resectable ESCC differs widely between Western and Asian countries (such as Japan). While Western countries focus on neoadjuvant or definitive chemoradiotherapy, neoadjuvant chemotherapy followed by surgery is the standard treatment in Japan. Importantly, each country and region has established its own therapeutic strategy from the results of local randomized control trials. This review discusses the current knowledge, available data and information regarding neoadjuvant treatment for operable ESCC.
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27
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Naughton P, Walsh TN. Multimodality therapy for cancers of the esophagus and gastric cardia. Expert Rev Anticancer Ther 2014; 4:141-50. [PMID: 14748664 DOI: 10.1586/14737140.4.1.141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The role of multimodal treatment in the management of esophageal cancer is controversial. There are conflicting results from studies on the effect of neoadjuvant and/or adjuvant treatment on long-term survival. Following a search of the Medline database, the authors examine the results of randomized studies on the various treatment protocols available and discuss future therapeutic improvements.
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Affiliation(s)
- Peter Naughton
- Department of Surgery, James Connolly Memorial Hospital, Blanchardstown, Dublin 15, Ireland.
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28
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Almhanna K, Shridhar R, Meredith KL. Neoadjuvant or adjuvant therapy for resectable esophageal cancer: is there a standard of care? Cancer Control 2013; 20:89-96. [PMID: 23571699 DOI: 10.1177/107327481302000202] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Carcinoma of the esophagus is an aggressive and lethal disease with an increasing incidence worldwide. Despite changes in the treatment approach over the past two decades and even following complete resection, most patients will eventually relapse and die as a result of their disease. Several clinical trials evaluated different modalities in treating locally advanced esophageal cancer; however, because of stage migration and the changes in disease epidemiology, applying these trials to clinical practice has become a daunting task. METHODS We searched Medline and conference abstracts for randomized studies published in the past three decades. We restricted our search to articles published in English. RESULTS Neoadjuvant chemoradiotherapy followed by surgical resection is an accepted standard of care in the United States for patients with locally advanced esophageal cancer. Esophagectomy remains an essential component of treatment and can lead to improved overall survival, especially when performed at high-volume institutions. The role of adjuvant chemotherapy following curative resection in patients who underwent neoadjuvant chemotherapy and radiation remains unclear. CONCLUSIONS Several questions still need to be answered regarding the use of neoadjuvant or adjuvant therapy for patients with resectable esophageal cancer. The optimal chemotherapy regimen has not yet been identified for these patients, although newer therapies show promise.
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Affiliation(s)
- Khaldoun Almhanna
- Gastrointestinal Tumor Program, H Lee Moffitt Cancer Center, Tampa, FL 33612, USA.
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29
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Nakajima M, Kato H. Treatment options for esophageal squamous cell carcinoma. Expert Opin Pharmacother 2013; 14:1345-54. [DOI: 10.1517/14656566.2013.801454] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Shridhar R, Almhanna K, Meredith KL, Biagioli MC, Chuong MD, Cruz A, Hoffe SE. Radiation Therapy and Esophageal Cancer. Cancer Control 2013; 20:97-110. [DOI: 10.1177/107327481302000203] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background Squamous cell carcinoma and adenocarcinoma account for more than 90% of all esophageal cancer cases. Although the incidence of squamous cell carcinoma has declined, the incidence of adenocarcinoma has risen due to increases in obesity and gastroesophageal reflux disease. Methods The authors examine the role of radiation therapy alone (external beam and brachytherapy) for the management of esophageal cancer or combined with other modalities. The impact on staging and appropriate stratification of patients referred for curative vs palliative intent with modalities is reviewed. The authors also explore the role of emerging radiation technologies. Results Current data show that neoadjuvant chemoradiotherapy followed by surgical resection is the accepted standard of care, with 3-year overall survival rates ranging from 30% to 60%. The benefit of adjuvant radiation therapy is limited to patients with node-positive cancer. The survival benefit of surgical resection after chemoradiotherapy remains controversial. External beam radiation therapy alone results in few long-term survivors and is considered palliative at best. Radiation dose-escalation has failed to improve local control or survival. Brachytherapy can provide better long-term palliation of dysphagia than metal stent placement. Although three-dimensional conformal treatment planning is the accepted standard, the roles of IMRT and proton therapy are evolving and potentially reduce adverse events due to better sparing of normal tissue. Conclusions Future directions will evaluate the benefit of induction chemotherapy followed by chemoradiotherapy, the role of surgery in locally advanced disease, and the identification of responders prior to treatment based on microarray analysis.
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Affiliation(s)
- Ravi Shridhar
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | | | | | | | | | - Alex Cruz
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Sarah E. Hoffe
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Villaflor VM, Allaix ME, Minsky B, Herbella FA, Patti MG. Multidisciplinary approach for patients with esophageal cancer. World J Gastroenterol 2012; 18:6737-46. [PMID: 23239911 PMCID: PMC3520162 DOI: 10.3748/wjg.v18.i46.6737] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 11/19/2012] [Accepted: 11/24/2012] [Indexed: 02/06/2023] Open
Abstract
Patients with esophageal cancer have a poor prognosis because they often have no symptoms until their disease is advanced. There are no screening recommendations for patients unless they have Barrett's esophagitis or a significant family history of this disease. Often, esophageal cancer is not diagnosed until patients present with dysphagia, odynophagia, anemia or weight loss. When symptoms occur, the stage is often stage III or greater. Treatment of patients with very early stage disease is fairly straight forward using only local treatment with surgical resection or endoscopic mucosal resection. The treatment of patients who have locally advanced esophageal cancer is more complex and controversial. Despite multiple trials, treatment recommendations are still unclear due to conflicting data. Sadly, much of our data is difficult to interpret due to many of the trials done have included very heterogeneous groups of patients both histologically as well as anatomically. Additionally, studies have been underpowered or stopped early due to poor accrual. In the United States, concurrent chemoradiotherapy prior to surgical resection has been accepted by many as standard of care in the locally advanced patient. Patients who have metastatic disease are treated palliatively. The aim of this article is to describe the multidisciplinary approach used by an established team at a single high volume center for esophageal cancer, and to review the literature which guides our treatment recommendations.
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Abstract
The incidence of esophageal cancer is increasing in the developed world, with a relative increase in adenocarcinoma compared with squamous cell carcinoma. The distensible nature of the esophagus results in delayed development of symptoms associated with esophageal cancer; hence many patients have locally advanced or metastatic cancer at the time of initial presentation. Although resection remains the treatment of choice for early-stage esophageal cancer, the best treatment strategy for locally advanced esophageal cancer is debatable and, consequently, varies at different centers. This article discusses the published literature on various available therapeutic options for the treatment of locally advanced esophageal cancer.
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Affiliation(s)
- Ankit Bharat
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, St Louis, MO 63110-1013, USA
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33
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Almhanna K, Strosberg JR. Multimodality approach for locally advanced esophageal cancer. World J Gastroenterol 2012; 18:5679-87. [PMID: 23155307 PMCID: PMC3484335 DOI: 10.3748/wjg.v18.i40.5679] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 06/25/2012] [Accepted: 08/14/2012] [Indexed: 02/06/2023] Open
Abstract
Carcinoma of the esophagus is an aggressive and lethal malignancy with an increasing incidence worldwide. Incidence rates vary internationally, with the highest rates found in Southern and Eastern Africa and Eastern Asia, and the lowest in Western and Middle Africa and Central America. Patients with locally advanced disease face a poor prognosis, with 5-year survival rates ranging from 15%-34%. Recent clinical trials have evaluated different strategies for management of locoregional cancer; however, because of stage migration and changes in disease epidemiology, applying these trials to clinical practice has become a daunting task. We searched Medline and conference abstracts for randomized studies published in the last 3 decades. We restricted our search to articles published in English. Neoadjuvant chemoradiotherapy followed by surgical resection is an accepted standard of care in the United States. Esophagectomy remains an essential component of treatment and can lead to improved overall survival, especially when performed at high volume institutions. The role of adjuvant chemotherapy following curative resection is still unclear. External beam radiation therapy alone is considered palliative and is typically reserved for patients with a poor performance status.
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34
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Vallbohmer D, Oh DS, Peters JH. The role of lymphadenectomy in the surgical treatment of esophageal and gastric cancer. Curr Probl Surg 2012; 49:471-515. [PMID: 22793506 DOI: 10.1067/j.cpsurg.2012.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Xu Y, Yu X, Chen Q, Mao W. Neoadjuvant versus adjuvant treatment: which one is better for resectable esophageal squamous cell carcinoma? World J Surg Oncol 2012; 10:173. [PMID: 22920951 PMCID: PMC3495900 DOI: 10.1186/1477-7819-10-173] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Accepted: 07/27/2012] [Indexed: 02/06/2023] Open
Abstract
Esophageal cancer is the eighth most common cancer worldwide, and especially in some areas of China is the fourth most common cause of death and is of squamous cell carcinoma (SCC) histology in >90% of cases. Surgery alone was the mainstay of therapeutic intervention in the past, but high rates of local and systemic failure have prompted investigation into multidisciplinary management. In this review, we discuss the key issues raised by the recent availability of esophageal SCC treatment with the addition of chemotherapy, radiotherapy, and chemoradiotherapy to the surgical management of resectable disease and discuss how clinical trials and meta-analysis inform current clinical practice. None of the randomized trials that compared neoadjuvant radiotherapy or chemotherapy with surgery alone in esophageal SCC has demonstrated an increase in overall survival in those patients treated with neoadjuvant radiotherapy or chemotherapy. Neoadjuvant chemoradiotherapy has been accepted recently for esophageal cancer because such a regimen offers great opportunity for margin negative resection, improved loco-regional control and increased survival. The majority of the available evidence currently reveals that only selected locally advanced esophageal SCC are more likely to benefit from the adjuvant therapy. The focus of future trials should be on identification of the optimum regimen and should aim to minimize treatment toxicities and effect on quality of life, as well as attempt to identify and select those patients most likely to benefit from specific treatment options.
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Affiliation(s)
- Yaping Xu
- Department of Thoracic Surgery, Zhejiang Cancer Hospital, Hangzhou, Zhejiang, People's Republic of China
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36
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Herskovic A, Russell W, Liptay M, Fidler MJ, Al-Sarraf M. Esophageal carcinoma advances in treatment results for locally advanced disease: review. Ann Oncol 2012; 23:1095-1103. [PMID: 22003242 DOI: 10.1093/annonc/mdr433] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The treatment results of patients with locally advanced esophageal carcinomas have evolved since the publication of the first trial of concurrent mitomycin C and 5-fluorouracil with radiotherapy (RT) in 1983. Subsequent studies refined and improved on the concurrent chemotherapy (chemo) with administration of cisplatin and 5-fluorouracil infusion (PF). Chemo (PF) before surgery improved overall survival (OS) in those patients in most of the randomized trials and in meta-analyses. Two courses of PF concurrent with irradiation followed by additional two courses of PF were superior to RT alone without surgery for both groups. Concurrent chemoradiotherapy followed by surgery was found to have statistically improved OS as compared with surgery only in randomized trials and meta-analyses. In most of these studies, it was found that those patients with pathologic complete response to the initial treatment(s) did better than those who had no improvement at all. Current treatment outcome for these diseases is disappointing; newer strategies including induction chemo with the optimal combination, proper dosage of each drug, and proper number of courses before concurrent chemoradiotherapy; improvement in RT; and immunotherapy with or without subsequent surgery are exciting and definitely need to be investigated in prospective randomized trial(s).
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Affiliation(s)
| | | | | | - M J Fidler
- Department of Section of Medical Oncology, Rush University Medical Center, Chicago
| | - M Al-Sarraf
- Department of Medicine, Wm Beaumont Hospital, Royal Oak, USA
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37
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Hölscher AH, Bollschweiler E. Choosing the best treatment for esophageal cancer : criteria for selecting the best multimodal therapy. Recent Results Cancer Res 2012; 196:169-77. [PMID: 23129373 DOI: 10.1007/978-3-642-31629-6_11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The best multimodal therapy in esophageal cancer comprises neoadjuvant radiochemotherapy in patients with adenocarcinoma or squamous cell carcinoma whereas neoadjuvant chemotherapy is only appropriate for patients with adenocarcinoma. However, the 2-year survival benefit by this induction therapy compared to surgery alone is only 5-9 %. Targeted drugs seem to be promising in order to improve the response rate. The choice of the best multimodal therapy by response prediction seems only to be possible in patients during chemotherapy for adenocarcinoma, whereas during neoadjuvant radiochemotherapy a response prediction by FDG-PET is not possible. The principle item of multimodal therapy is still transthoracic en bloc esophagectomy which should be performed in high volume centers in order to guarantee stable and good results.
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Affiliation(s)
- A H Hölscher
- Department of General, Visceral and Cancer Surgery, University of Cologne, Köln, Germany.
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Abstract
INTRODUCTION Worldwide, esophageal cancer (EC) is the seventh leading cause of cancer-related death, with its incidence increasing in the US, where a change in its epidemiology has been noted. Most patients present with regional or distant disease and, therefore, have a very poor prognosis. AREAS COVERED Progress made over the last 20 years in the diagnosis, staging and management of EC is focused on in this review, with the emphasis on locally-advanced disease treated with curative intent. Evidence is reviewed from prospective randomized trials and meta-analyses and data are presented regarding new therapy with targeted agents. Although surgery has been the mainstay of treatment for EC, survival with this approach alone remains disappointing. As a result, combined modality treatment (CMT) including chemotherapy and radiation has been incorporated into the treatment paradigm for both operable and inoperable disease. The evidence supporting CMT for EC, the role of surgery at different stages, and how treatment strategies differ based on histology are outlined. EXPERT OPINION Trends in 5-year overall survival rates over the last 30 years have increased (from 5 to 17%), suggesting that small, yet significant, improvements in diagnosis, staging, treatment and supportive care are being made. Clearly, the choice of treatment should be guided by disease stage, histology and patient co-morbidities.
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Affiliation(s)
- Deirdre J Cohen
- NYU Langone Medical Center, Division of Medical Oncology, New York University Cancer Institute, 160 East 34th Street, New York, NY 10016, USA.
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Mukherjee K, Chakravarthy AB, Goff LW, El-Rifai W. Esophageal adenocarcinoma: treatment modalities in the era of targeted therapy. Dig Dis Sci 2010; 55:3304-14. [PMID: 20300841 PMCID: PMC2890301 DOI: 10.1007/s10620-010-1187-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Accepted: 03/01/2010] [Indexed: 12/16/2022]
Abstract
Esophageal adenocarcinoma is an aggressive malignancy with a poor outcome, and its incidence continues to rise at an alarming rate. Current treatment strategies combining chemotherapy, radiation, and surgery are plagued with high rates of recurrence and metastasis. Multiple molecular pathways including the epidermal growth factor receptor, vascular endothelial growth factor, v-erb-b2 erythroblastic leukemia viral oncogene homolog (ERBB2), and Aurora kinase pathways are activated in many esophageal adenocarcinomas. In many cases, these pathways have critical roles in tumor progression. Research on the mechanisms by which these pathways contribute to disease progression has resulted in numerous biologic agents and small molecules with the potential to improve outcome. The promise of targeted therapy and personalized medicine in improving the clinical outcome is now closer than it has ever been.
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Affiliation(s)
- Kaushik Mukherjee
- Department of Surgery, Vanderbilt University Medical Center and Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - A. Bapsi Chakravarthy
- Department of Radiation Oncology, Vanderbilt University Medical Center and Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Laura W. Goff
- Division of Medical Oncology, Vanderbilt University Medical Center and Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Wael El-Rifai
- Department of Surgery, Vanderbilt University Medical Center and Vanderbilt-Ingram Cancer Center, Nashville, TN, Department of Cancer Biology, Vanderbilt University Medical Center and Vanderbilt-Ingram Cancer Center, Nashville, TN
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Park JW, Kim JH, Choi EK, Lee SW, Yoon SM, Song SY, Lee YS, Kim SB, Park SI, Ahn SD. Prognosis of esophageal cancer patients with pathologic complete response after preoperative concurrent chemoradiotherapy. Int J Radiat Oncol Biol Phys 2010; 81:691-7. [PMID: 20888705 DOI: 10.1016/j.ijrobp.2010.06.041] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Revised: 05/31/2010] [Accepted: 06/27/2010] [Indexed: 11/16/2022]
Abstract
PURPOSE To define failure patterns and predictive factors in esophageal cancer patients who had a pathologic complete response (pCR) after preoperative concurrent chemoradiotherapy (PCRT). METHODS AND MATERIALS We performed a retrospective analysis of 61 esophageal cancer patients who were enrolled in prospective studies and showed pCR after PCRT. All of the patients had squamous cell carcinoma. Of the patients, 40 were treated with hyperfractionated radiotherapy (4,560 cGy in 28 fractions) with 5-fluorouracil (5-FU) and cisplatin (FP), and 21 patients received conventional fractionation radiotherapy with capecitabine and cisplatin (XP). RESULTS The median follow-up time was 45.2 months (range, 6.5-162.3 months). The 5-year overall survival (OS) and disease-free survival rates (DFS) were 60.2% and 80.4%, respectively. In univariate analysis, age and lymph node (LN) metastasis were poor prognostic factors for OS, and pretreatment weight loss (>2 kg) was a poor prognostic factor for DFS. In multivariate analysis, lymph node metastasis and pretreatment weight loss were independent prognostic factors for OS and DFS. Nine patients (15%) had disease recurrence. Of the nine patients, 5 patients had locoregional failure, 1 patients had distant metastasis, and 3 patients had distant and locoregional failure. In-field failure occurred in 5 patients; out-of-field failure occurred in 1 patient; both in-field and out-of-field failure occurred in 2 patients; and both marginal and out-of-field failure occurred in 1 patient. CONCLUSIONS Even in pCR patients, the most common failure site was within the radiation field, which suggests that more efficient local treatment is needed. Tumor recurrence was more common in patients with older age and with pretreatment weight loss.
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Affiliation(s)
- Jae Won Park
- Department of Radiation Oncology, Division of Oncology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
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41
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Abstract
The management of esophageal cancer has been evolving over the past 30 years. In the United States, multimodality treatment combining chemotherapy and radiotherapy (RT) prior to surgical resection has come to be accepted by many as the standard of care, although debate about its overall effect on survival still exists, and rightfully so. Despite recent improvements in detection and treatment, the overall survival of patients with esophageal cancer remains lower than most solid tumors, which highlights why further advances are so desperately needed. The aim of this article is to provide a complete review of the history of esophageal cancer treatment with the addition of chemotherapy, RT, and more recently, targeted agents to the surgical management of resectable disease.
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42
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Hyngstrom JR, Posner MC. Neoadjuvant strategies for the treatment of locally advanced esophageal cancer. J Surg Oncol 2010; 101:299-304. [PMID: 20187065 DOI: 10.1002/jso.21479] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Patients with locally advanced esophageal carcinoma have consistently poor survival following surgery with associated high systemic and local-regional failure rates. Neoadjuvant therapeutic strategies have been employed in an attempt to improve outcome with variable success. Randomized trials of either neoadjuvant chemotherapy or chemoradiotherapy have shown conflicting results regarding survival and local-regional control. Future efforts should focus on identifying novel agents and targets to improve therapeutic efficacy.
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Affiliation(s)
- John R Hyngstrom
- Section of General Surgery, Department of Surgery, University of Chicago Medical Center, Chicago, Illinois 60637, USA
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Abstract
BACKGROUND Most studies regarding esophageal cancer are based on a selection of patients, influencing the prognosis as well as other variables measured. Sweden may be unique in that it has registries that cover the whole population, permitting population based studies regarding diseases such as esophageal cancer. This also makes it possible to study the true nature of a population of patients and to describe changes in that population over time. METHOD Retrospective analysis of the files of all 1284 patients diagnosed with esophageal cancer in Stockholm County 1978-1995. The study period was divided into three six-year intervals (periods I, II and III). RESULTS A total of 201 patients were diagnosed at autopsy. They were only analyzed regarding histopathological and demographic parameters. A statistically significant increased survival for the whole group of patients was found, but this improvement in survival was not found among resected patients. No survival benefit was noted for patients operated on at large centers compared to patients operated on at surgical clinics with few yearly resections performed. The well-known increase in the incidence of adenocarcinoma in the esophagus among men was documented. A tendency (non-significant) of an increase in the incidence of adenocarcinoma among women was also noted. CONCLUSIONS Survival seems to have increased among esophageal cancer patients, but this survival benefit is not dependent on improved surgery. The number of yearly operations in a clinic did not correlate to long-term survival in this study.
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Affiliation(s)
- Dag Stockeld
- Department of Surgery, Danderyd Hospital, Stockholm, Sweden.
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44
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Abstract
Oesophageal and gastric cancers are amongst the most frequent and lethal of cancers worldwide. In the US alone, some 13 000 individuals are affected each year, and mortality is particularly high in elderly patients with advanced stage disease and multiple co-morbidities. Patients usually do not present until later in the disease when symptoms occur, once the tumour is sufficiently large to cause obstruction or invasion of adjacent structures. Oesophageal cancer can metastasize to almost any organ, and widespread distant metastases are almost always present at the time of death. Overall mortality from this cancer is around 80-90%. Curative treatment of oesophageal cancer must achieve local control of the primary lesion as well as control and/or prevention of metastases. These are important contributors to overall results when therapy is undertaken in elderly patients, as are the significant risks of adverse effects such as morbidity from chemoradiation and the morbidity and mortality of oesophagectomy. Surgical resection affords the best chance for local control and the best means of palliation of dysphagia for most patients with localized disease, although both local and systemic recurrence of disease are common when surgery is used alone. Because of the low cure rates associated with the use of surgery alone, other modalities have been added to the treatment regimen. Elderly patients with significant cardiac and pulmonary co-morbidity are candidates for nonoperative therapy, even at an early disease stage. There are few data to support a survival advantage from adjuvant radiotherapy or chemotherapy following complete resection, in the absence of documented metastatic disease. Chemotherapy and radiotherapy have both been reported to improve survival when administered preoperatively in patients with oesophageal cancer, while current data using trimodal therapy show a trend towards increased treatment-related mortality with only a slight increase in overall survival. There is currently no completely reliable preoperative method for restaging patients following neoadjuvant chemoradiation in order to assess pathological complete response. Novel restaging techniques are therefore required, in addition to further study of the risks and benefits of neoadjuvant chemoradiotherapy for this disease.
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Affiliation(s)
- Mark J Krasna
- Saint Joseph Cancer Institute, St Joseph Medical Center, Towson, Maryland 21204, USA.
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Ekman S, Dreilich M, Lennartsson J, Wallner B, Brattström D, Sundbom M, Bergqvist M. Esophageal cancer: current and emerging therapy modalities. Expert Rev Anticancer Ther 2008; 8:1433-48. [PMID: 18759695 DOI: 10.1586/14737140.8.9.1433] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
During the last few years, there has been a gradual increase in treatment options for patients with esophageal malignancies. Several clinical studies have been performed, covering not only radiation and chemotherapy, but also the introduction of novel biological agents into the treatment arsenal. Patients with esophageal carcinoma are now offered second-line and sometimes even third-line treatments, and the number of research protocols is increasing. Despite the newly awakened interest in this malignancy, the overall 5-year survival rate has remained at approximately 10% since the 1980s. This review contains a compilation of available studies of esophageal malignancies and discusses current treatment options as well as newly developed therapies targeted at growth factor receptors.
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Affiliation(s)
- Simon Ekman
- Department of Oncology, Uppsala University Hospital, S-751 85 Uppsala, Sweden.
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46
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Abstract
Primary treatment of carcinoma of the esophagus and cardia rests on surgical resection. Although recent advances have shown the suitability of endoscopic treatment in selected patients with very early cancers, and preliminary studies have suggested that responders to primary chemoradiation may be equivalent to resection in selected patients with squamous cell carcinoma, surgical resection remains the mainstay of therapy, as it has for the past 50 years. Various changes support highly individualized treatment decisions, in which each patient receives the treatment with the best chance of eliminating all disease.
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47
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Lu JJ. Esophageal Cancer. Radiat Oncol 2008. [DOI: 10.1007/978-3-540-77385-6_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Moon S, Kim H, Chie E, Kim J, Park C. Positive impact of radiation dose on disease free survival and locoregional control in postoperative radiotherapy for squamous cell carcinoma of esophagus. Dis Esophagus 2008; 22:298-304. [PMID: 19021683 DOI: 10.1111/j.1442-2050.2008.00882.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The effect of total radiation dose (TRD) on the outcome of patients with postoperative radiotherapy (RT) for squamous cell carcinoma of esophagus was assessed. Sixty-seven patients with esophagectomy, followed by postoperative RT for squamous cell carcinoma of esophagus from June 1984 through February 2001, were retrospectively reviewed. Of these, 13 patients were excluded. No patient had chemotherapy. Patients were classified into two groups based on TRD delivered: TRD of less than 50 Gy (Group A, n = 16) and at least 50 Gy (Group B, n = 38). Follow-up duration of all patients ranged from 4 to 140 months (median, 14). Median TRD of Group A and B were 45 Gy (range, 45-48.6) and 54 Gy (range, 50-59.6), respectively. Median overall survival (OS) and disease-free survival (DFS) of all patients were 15 and 10 months, respectively. Although the TRD of 50 Gy or higher was marginally significant for improved OS (hazard ration [HR] 0.559, P = 0.066), it was statistically significant for improved DFS (HR 0.398, P = 0.011), and locoregional recurrence-free survival (HR 0.165, P = 0.001) with multivariate analysis. Three patients in group A and two in group B experienced a complication of grade 3 or higher. Our study suggests a positive impact of TRD of 50 Gy or higher on DFS and locoregional control, with acceptable morbidity in postoperative RT for patients with squamous cell carcinoma of esophagus. According to the present analysis, TRD should be at least 50 Gy in postoperative RT alone setting.
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Affiliation(s)
- S Moon
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
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49
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Lerut T, Moons J, Coosemans W, Decaluwé H, Decker G, De Leyn P, Nafteux P, Van Raemdonck D. Multidisciplinary treatment of advanced cancer of the esophagus and gastroesophageal junction: a European center's approach. Surg Oncol Clin N Am 2008; 17:485-502, vii-viii. [PMID: 18486879 DOI: 10.1016/j.soc.2008.02.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Tremendous progress has been made in surgery for cancer of the esophagus and gastroesophageal junction. After primary surgery, overall 5-year survival rates of 35% or more are obtained in high-volume units, and for advanced stage III cancer, 5-year survival reaches 25%. Multimodality therapy, in particular induction chemotherapy with or without radiotherapy, results in a complete response rate in up to 25% of the patients. Approximately 50% of the patients receiving such treatment do not respond, however, and their outcome is dismal. Therefore, further efforts are needed to elaborate more precise algorithms for selecting candidates for induction therapy versus primary surgery.
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Affiliation(s)
- Toni Lerut
- Department of Thoracic Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
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50
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Radiation as an Adjunct to Surgery. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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