Esophagectomy: Is It Necessary after Chemoradiotherapy for a Locally Advanced T4 Esophageal Cancer? Prospective Nonrandomized Trial Comparing Chemoradiotherapy with Surgery versus without Surgery

Induction Immunochemotherapy Yields a Higher Conversion Rate and Better Overall Survival than Chemotherapy in Initially Unresectable Esophageal Squamous Cell Carcinoma

INTRODUCTION

This study compared the surgical conversion rate and overall survival (OS) between induction chemotherapy (iC) and induction immunochemotherapy (iIC) for patients with initially unresectable esophageal squamous cell carcinoma (iuESCC).

METHODS

In this multicenter, retrospective cohort study, patients from four high-volume institutions with unresectable diseases were included. The primary endpoints were the conversion surgery rate and OS. A multivariate Cox regression analysis was used to identify the independent significant prognostic factors associated with OS. The stabilized inverse probability of treatment weighting was applied to confirm the survival comparison between the iIC and iC cohorts.

RESULTS

A total of 309 patients (150 in the iIC cohort and 159 in the iC cohort) were included. A significantly higher conversion surgical rate was observed in the iIC cohort (iIC vs. iC: 127/150, 84.7% vs. 79/159, 49.7%, P < 0.001). The pathological complete response rates were 22.0% and 5.1% in the iIC and the iC cohorts, respectively (P = 0.001). A significant difference in the OS was observed between the iIC (not reached) and iC cohorts (median 95% CI 36.3 [range 27.2-45.5]). The stabilized inverse probability of treatment weighting yielded similar results. Regimen (iIC vs. iC, HR 0.215, 95% CI 0.102-0.454, P < 0.001) and operation (yes vs. no, HR 0.262, 95% CI 0.161-0.427, P < 0.001) were the significant prognostic factors for OS.

CONCLUSIONS

Immunochemotherapy plus conversion surgery in the induction setting may be a better treatment option to achieve high pathological responses and improve OS in iuESCC patients.

Efficacy and Safety of Immune Checkpoint Inhibitor Combination Therapy for Dysphagia in Patients with Advanced Esophageal Cancer

Background/Objectives: Recently, pembrolizumab plus 5-fluorouracil and cisplatin (FP), nivolumab plus FP, and nivolumab plus ipilimumab have become the first-line treatments for patients with advanced esophageal cancer. However, the treatment efficacy in primary tumors has not been reported. We assessed the outcomes of these treatments in advanced esophageal cancer, specifically focusing on esophageal dysphagia improvements and the primary tumor response. Methods: This retrospective study was conducted between October 2021 and November 2023. We investigated 23 patients with esophageal cancer and dysphagia who received an immune checkpoint inhibitor (ICI) plus FP or nivolumab plus ipilimumab. Results: The median progression-free survival (PFS) was 10.6 months (95% confidence interval [CI]: 9.0-12.5), and the median overall survival was not reached (95%CI: 13.0-NA). Improvement in dysphagia was observed in 19/23 (82.6%) patients, with a median time to improvement of 26 days (range: 15-77 days) and a median dysphagia PFS of 12.6 months (range: 8.1-NA months). Ten patients experienced immune-related adverse events (irAEs): seven had interstitial pneumonia, and three had thyroid dysfunction, pituitary dysfunction, and rash, respectively. Conclusions: Although there was a high frequency of irAEs, ICI for esophageal cancer achieved high response rates and prolonged survival. The observed improvement in dysphagia suggests the potential efficacy of the treatment against primary tumors.

Locally Advanced Adenocarcinoma of the Esophagus: Is Esophagectomy Associated with Improved Overall Survival?

BACKGROUND

Esophagectomy in locally advanced esophageal adenocarcinoma is challenging and carries risk. The value of esophagectomy in locally advanced esophageal adenocarcinoma is not well-defined.

STUDY DESIGN

The National Cancer Database was used to identify patients with cT4 esophageal adenocarcinoma from 2004 to 2020. Multivariable regression was used to identify factors associated with use of esophagectomy. Cox modeling was used to identify factors associated with all-cause mortality. Patients undergoing esophagectomy were 1:1 propensity score-matched to patients treated nonsurgically. Kaplan-Meier analysis was used to compare 5-year overall survival (OS).

RESULTS

A total of 3,703 patients met inclusion criteria. Of those, 541 (15%) underwent esophagectomy, and 3,162 (85%) did not. Age 65 years or less (adjusted odds ratio [aOR] 1.69, 95% CI 1.33 to 2.14), White race (aOR 2.98, 95% CI 2.24 to 3.96), treatment in academic centers (aOR 1.64, 95% CI 1.33 to 2.02), private insurance (aOR 1.88, 95% CI 1.50 to 2.36), and tumors less than 6 cm (aOR 1.86, 95% CI 1.44 to 2.40) were associated with use of esophagectomy. Government of lack of insurance (hazard ratio [HR] 1.23, 95% CI 1.12 to 1.35), income <$46,000 (HR 1.11, 95% CI 1.03 to 1.20), treatment in nonacademic centers (HR 1.16, 95% CI 1.07 to 1.25), Charlson-Deyo Comorbidity Index 1 or more (HR 1.22, 95% CI 1.12 to 1.32), and tumors 6 cm or more (HR 1.20, 95% CI 1.09 to 1.32) were associated with risk of all-cause mortality. Esophagectomy (HR 0.50, 95% CI 0.44 to 0.56) and systemic therapy (HR 0.40, 95% CI 0.37 to 0.43) were associated with decreased risk of all-cause mortality. Patients undergoing esophagectomy had higher rates of 5-year OS (27.4% vs 13.2%, p < 0.0001) and longer median OS (24.71 vs 10.09 months, p < 0.0001). Among cT4b patients, those who underwent esophagectomy had higher rates of 5-year OS (24.5% vs 12.3%, p < 0.0001) and longer median OS (25.53 vs 11.01 months, p < 0.0001).

CONCLUSIONS

In cT4 esophageal adenocarcinoma, esophagectomy is associated with improved rates of 5-year OS compared with nonsurgical treatment.

Role of surgery in T4N0-3M0 esophageal cancer

BACKGROUND

This study aimed to investigate an unsettled issue that whether T4 esophageal cancer could benefit from surgery.

METHODS

Patients with T4N0-3M0 esophageal cancer from 2004 to 2015 from the Surveillance, Epidemiology, and End Results (SEER) database were included in this study. Kaplan-Meier method, Cox proportional hazard regression, and propensity score matching (PSM) were used to compare overall survival (OS) between the surgery and no-surgery group.

RESULTS

A total of 1822 patients were analyzed. The multivariable Cox regression showed the HR (95% CI) for surgery vs. no surgery was 0.492 (0.427-0.567) (P < 0.001) in T4N0-3M0 cohort, 0.471 (0.354-0.627) (P < 0.001) in T4aN0-3M0 cohort, and 0.480 (0.335-0.689) (P < 0.001) in T4bN0-3M0 cohort. The HR (95% CI) for neoadjuvant therapy plus surgery vs. no surgery and surgery without neoadjuvant therapy vs. no surgery were 0.548 (0.461-0.650) (P < 0.001) and 0.464 (0.375-0.574) (P < 0.001), respectively. No significant OS difference was observed between neoadjuvant therapy plus surgery and surgery without neoadjuvant therapy: 0.966 (0.686-1.360) (P = 0.843). Subgroup analyses and PSM-adjusted analyses showed consistent results.

CONCLUSION

Surgery might bring OS improvement for T4N0-3M0 esophageal cancer patients, no matter in T4a disease or in T4b disease. Surgery with and without neoadjuvant therapy might both achieve better OS than no surgery.

Chemoradiotherapy versus triplet chemotherapy as initial therapy for T4b esophageal cancer: survival results from a multicenter randomized Phase 2 trial

BACKGROUND

We report the long-term results as primary endpoint in a multicentre randomized prospective Phase 2 trial which compared chemoradiotherapy (CRT) and triplet chemotherapy (CT) as the initial therapy for conversion surgery (CS) in T4b esophageal cancer (EC).

METHODS

Patients with T4b EC were randomly assigned to the CRT group or CT group as initial treatment. CS was performed if resectable after initial or secondary treatment. The primary endpoint was 2-year overall survival, analysed by intention-to-treat.

RESULTS

The median follow-up period was 43.8 months. The 2-year survival rate was higher in the CRT group (55.1%; 95% CI: 41.1-68.3%) compared to the CT group (34.7%; 95% CI: 22.8-48.9%), although the difference was not significant (P = 0.11). Local and regional lymph node recurrence in patients undergoing R0 resection was significantly higher in the CT group compared to the CRT group (local: 30% versus 8%, respectively, P = 0.03; regional: 37% versus 8%, respectively, P = 0.002).

CONCLUSIONS

Upfront CT was not superior to upfront CRT as induction therapy for T4b EC in terms of 2-year survival and was significantly inferior to upfront CRT in terms of local and regional control.

REGISTRATION

The Japan Registry of Clinical Trials (s051180164).

A retrospective study comparing definitive chemoradiotherapy vs. chemoradiotherapy followed by surgery in T4 esophageal squamous cell carcinoma patients who were downstaged after neochemoradiotherapy

Background

The outcome of patients with T4 esophageal squamous cell carcinoma (ESCC) is extremely poor. Two distinct therapeutic options are currently available for T4 esophageal cancers: neochemoradiotherapy followed by surgery (CRT-S) and definitive chemoradiotherapy (D-CRT). This study aimed to investigate the clinicopathologic characteristics of T4 ESCC in Chinese patients and compare the survival between the two therapeutic options.

Methods

We retrospectively analyzed 125 patients with clinically unresectable T4 ESCC in Tianjin Medical University Cancer Institute and Hospital from January 2010 to December 2020. Overall survival (OS), progression-free survival (PFS) and associated factors were analyzed.

Results

A total of 106 of 125 T4 ESCC patients were downstaged of the tumor by neoadjuvant CRT. Among 106 patients, 32 patients underwent CRT-S, and 74 patients underwent D-CRT. Patients in the CRT-S group had a higher OS (20.4 months vs. un-reached median OS, p = 0.037) and PFS (8.6 months vs. 21.0 months, p = 0.008) than those in the D-CRT group. In multivariate analysis, treatment was an independent predictor of PFS. After propensity score matching (PSM), 50 patients (CRT-S = 25; D-CRT = 25) were matched. Among these 50 patients, patients in the CRT-S group had a higher OS (15.6 months vs. un-reached median OS, p = 0.025) and PFS (7.2 months vs. 18.8 months, p = 0.026) than those in the D-CRT group. In multivariate analysis, treatment was an independent predictor for PFS.

Conclusion

We demonstrated that CRT-S was superior to D-CRT for T4 ESCC patients who were downstaged by neo-CRT with respect to longer OS and PFS. Randomized controlled trials involving large population samples are needed to define the standard treatment for T4 ESCC.

Survival rates and safety associated with chemoradiotherapy followed by surgery and chemoradiotherapy alone for patients with T4 esophageal cancer: a systematic review and meta-analysis

BACKGROUND

The optimal treatment approach for T4 esophageal cancer is not well established. We aimed to perform a systematic review and meta-analysis to determine the survival rates and safety of chemoradiotherapy followed by surgery (CRT-S) and chemoradiotherapy alone (CRT) in patients with T4 N_any M0 esophageal cancer.

MATERIALS AND METHODS

We searched databases for eligible prospective or retrospective studies. The outcomes of interest were overall survival (OS) at 1, 3 and 5 years, treatment-related fistula formation and mortality rates. Meta-analyses were performed using the random effects models separately for studies evaluating CRT-S and CRT. Subgroup analyses were performed based on histology, radiation dose, chemotherapy regimen and duration of the interval between CRT and surgery.

RESULTS

We identified 23 studies including 1,119 patients with predominantly squamous cell carcinoma (93%) and adenocarcinoma (3%) histology. The OS rates of patients receiving CRT-S were 65%, 36% and 20% at 1, 3 and 5 years, respectively. The OS rates of patients receiving CRT were 30%, 11% and 10% at 1, 3 and 5 years, respectively. Treatment-related fistula formation rates were 4% for CRT-S and 9% for CRT. Treatment-related mortality rates were 3% for both groups. Subgroup analyses showed that the interval of >2 months between CRT and surgery was associated with significantly improved OS rates at 1, 3 and 5 years.

CONCLUSION

Chemoradiotherapy is an efficacious treatment approach for T4 esophageal cancer, with clinically acceptable rates of treatment-related fistula formation and mortality. Tri-modality approach with surgery can be considered in carefully selected patients. Our study findings should be interpreted with caution due to the lack of high-quality evidence. Randomized controlled trials are warranted to confirm these findings.

Chemoradiotherapy for Locally Advanced Esophageal Squamous Cell Carcinoma

PURPOSE

Few studies have reported the impact of chemoradiotherapy (CRT) on the objective response of patients with locally advanced unresectable esophageal squamous cell carcinoma (ESCC). We evaluated the factors predicting therapeutic effectiveness and the short- and long-term outcomes in patients with T4b ESCC treated with CRT.

METHODS

We included 155 patients with T4b ESCC who underwent CRT at the Department of Surgery, Gastroenterological Center, Yokohama City University, between January 2000 and December 2018. Responders were defined as patients who demonstrated a complete response (CR) or partial response (PR). Multivariate analysis for objective response was performed using a logistic regression model, and prognostic factors were evaluated by univariate and multivariate analyses.

RESULTS

Among the 155 patients included, 20 and 84 patients demonstrated a CR and PR, respectively, resulting in a response rate of 67.1%. The median overall survival (OS) was 15.2 months, and the 3-year survival rate was 32.1%. High Glasgow prognostic score (GPS) and advanced N-category independently predicted the objective response to CRT. GPS and objective response were independent prognostic factors for OS. There was no significant difference in the long-term survival of responders who received subsequent chemotherapy or salvage surgery.

CONCLUSIONS

High GPS and advanced N-category predicted a poor objective response to CRT in patients with T4b ESCC. Therefore, chemotherapeutic regimens with a higher efficacy are required. The indications for salvage surgery for responders should be carefully considered, with care taken to avoid complications. To confirm this, prospective randomized controlled studies are necessary.

Survival benefit of surgery in patients with clinical T4 esophageal cancer who achieved complete or partial response after neoadjuvant chemoradiotherapy or radiotherapy

Objective:

This study aimed to determine the long-term survival of patients with cT4 esophageal cancer (EC) and whether neoadjuvant chemoradiotherapy/radiotherapy plus surgery (nCRT/RT + S) is superior to definitive CRT(dCRT)/RT in terms of survival in cT4 EC downstaged after nCRT/RT.

Summary background data:

Treatment options for cT4 EC include dCRT/RT and nCRT/RT + S, but it is not clear whether the latter provides survival benefit in patients downstaged after nCRT/RT.

Methods:

From 2002 to 2017, 726 patients with cT4 esophageal squamous cell carcinoma (ESCC) were retrospectively analyzed. Patients achieving clinical complete response (cCR) or partial response (PR) after 4-week RT (median dose, 40.7 Gy) and considered fit for surgery were offered esophagectomy. Of the 726 patients, 308 (42.4%) achieved cCR/PR, while 74 patients received subsequent surgery (nCRT/RT + S group), 234 patients received dCRT/RT.

Results:

Median follow-up was 58 months. The 3-year overall survival (OS) and progression-free survival (PFS) rates for all patients were 33.3% and 35.6%, respectively. The corresponding OS and PFS rates were 54.8% and 48.5% in the nCRT/RT + S group versus 30.0% and 22.1% in the dCRT/RT group (both p < 0.0001). After adjusting the confounding variables with inverse probability of treatment weighting, the adjusted 3-year OS rates were 50.4% in the nCRT/RT + S group versus 50.8% in the dCRT/RT group (p = 0.15). However, the adjusted 3-year PFS rates were significantly different between the two groups (49.0% and versus 38.3%, p = 0.004). Postoperative complications occurred in 18 (24.3%) patients.

Conclusion:

The long-term survival of cT4 ESCC was improved after the use of three-dimensional CRT. In cT4, EC responded to nCRT/RT, surgery improves PFS but not OS.

Surgical strategies for treatment of clinical T4 esophageal cancer in Japan

Definitive chemoradiation (dCRT) is the mainstay treatment for cStage IVa esophageal squamous cell carcinoma (ESCC) with good performance status (PS), according to standard practice guidelines. Salvage surgery may incur operation complications and risk of mortality. According to the esophageal cancer practice guidelines outlined by the Japan Esophageal Society, when a tumor is residual and recurrent, chemotherapy and palliative symptomatic treatment is continued. However, salvage operation has been selected as a therapeutic option for recurrent or residual tumors after dCRT. There is weak evidence for not recommending surgery for cStage IVa ESCC exhibiting residual disease following dCRT. It has been reported that during salvage surgery the only prognostic factor that is thought to be performed is complete resection (R0), but at the same time, salvage esophagectomy increases the incidence of postoperative complications and mortality. The phase II chemoselection study by Yokota T et al. in Japan showed that multidisciplinary treatment initiated by induction therapy, in which docetaxel is added to cisplatin and 5-fluorouracil, resulted in a good prognosis in the short term. In this review, we discuss the surgical strategy and future of unresectable clinical T4 (cT4) ESCC.

Multicenter Randomized Phase 2 Trial Comparing Chemoradiotherapy and Docetaxel Plus 5-Fluorouracil and Cisplatin Chemotherapy as Initial Induction Therapy for Subsequent Conversion Surgery in Patients With Clinical T4b Esophageal Cancer: Short-term Results

OBJECTIVE

We conducted a multicenter randomized prospective phase 2 trial of chemoradiotherapy (CRT) versus chemotherapy (CT) as initial induction therapy for conversion surgery (CS) in clinical T4b esophageal cancer. We compared treatment effects and adverse events (AEs).

SUMMARY BACKGROUND DATA

Although induction followed by CS is potentially curative for T4b esophageal cancer, the optimal initial induction treatment is unclear.

METHODS

Ninety-nine patients with T4b esophageal cancer were randomly allocated to chemoradiotherapy (Group A, n = 49) or CT (Group B, n = 50) as initial induction treatment. CRT consisted of radiation (50.4 Gy) with cisplatin and 5-fluorouracil. CT consisted of 2 cycles of docetaxel plus cisplatin and 5-fluorouracil (DCF). CRT or CT was followed by CS if resectable. If unresectable, the patient received the other treatment as secondary treatment. CS was performed if resectable after secondary treatment. The primary end point was 2-year overall survival.

RESULTS

In Group A, CS was performed in 34 (69%) and 7 patients (14%) after initial and secondary treatment. In Group B, CS was performed in 25 (50%) and 17 patients (34%) after initial and secondary treatment. The R0 resection rate after initial and secondary treatment was similar (78% vs 76%, P = 1.000). AEs including leukopenia, neutropenia, febrile neutropenia, and diarrhea were significantly more frequent in Group B. Group A had better histological complete response of the primary tumor (40% vs 17%, P = 0.028) and histological nodal status (P = 0.038).

CONCLUSION

Upfront CRT was superior to upfront CT in terms of pathological effects and AEs. The Japan Registry of Clinical Trials (s051180164).

Recent Progress in the Neoadjuvant Treatment Strategy for Locally Advanced Esophageal Cancer

Neoadjuvant therapies, primarily chemotherapy and chemoradiotherapy, are able to improve the overall survival (OS) in patients with locally advanced resectable esophageal cancer (EC) based on the results of several randomized clinical trials. The advantage of neoadjuvant therapy is chiefly attributed to the decreased risk of local-regional recurrence and distant metastasis. Thus, it has been recommended as standard treatment for patients with resectable EC. However, several fundamental problems remain. First, the combination of neoadjuvant chemotherapy (nCT), neoadjuvant chemoradiotherapy (nCRT), and surgery for EC patients with different histological types remain controversial. Furthermore, to reduce the toxicity of preoperative chemotherapy and the risk of complications caused by preoperative radiation therapy, the treatment protocols of nCT and nCRT still need to be investigated and optimized by prospective trials. Moreover, for patients with complete clinical response following neoadjuvant therapy, it is worth ascertaining whether a "watch and wait" surveillance plus surgery-as-needed policy is more favorable, as well as, in addition to preoperative chemoradiotherapy, whether immunotherapy, especially when combined with the traditional neoadjuvant therapy regimens, brings new prospects for EC treatment. In this review, we summarize the recent insights into the research progress and existing problems of neoadjuvant therapy for locally advanced resectable EC.

Post-Neoadjuvant Surveillance and Surgery as Needed Compared with Post-Neoadjuvant Surgery on Principle in Multimodal Treatment for Esophageal Cancer: A Scoping Review

Simple Summary

A substantial fraction of patients with esophageal cancer show post-neoadjuvant pathological complete response (pCR). Principal esophagectomy after neoadjuvant treatment is the standard of care for all patients, including those with pCR. Surveillance and surgery as needed may be a treatment alternative for these patients. We performed a scoping review and described all relevant clinical studies addressing these two treatment approaches. We identified three completed randomized controlled trials (RCTs) including 468 participants, three planned/ongoing RCTs with a planned sample size of 752 participants, one non-randomized controlled study with 53 participants, ten retrospective cohort studies (2228 participants) and one survey on patients’ preferences (100 participants). The current scoping review reveals that although surveillance and surgery as needed has been investigated within different study designs, the available study pool show methodological limitations and clinical results are heterogeneous. A thoroughly planned RCT considering these limitations will be of great importance to provide these patients with the best treatment.

Abstract

Background: A substantial fraction of patients with esophageal cancer show post-neoadjuvant pathological complete response (pCR). Principal esophagectomy after neoadjuvant treatment is the standard of care for all patients, although surveillance and surgery as needed in case of local recurrence may be a treatment alternative for patients with complete response (CR). Methods: We performed a scoping review to describe key characteristics of relevant clinical studies including adults with non-metastatic esophageal cancer receiving multimodal treatment. Until September 2020, relevant studies were identified through systematic searches in the bibliographic databases Medline, Web of Science, Cochrane Library, Science Direct, ClinicalTrials, the German study register, and the WHO registry platform. Results: In total, three completed randomized controlled trials (RCTs, with 468 participants), three planned/ongoing RCTs (with a planned sample size of 752 participants), one non-randomized controlled study (NRS, with 53 participants), ten retrospective cohort studies (with 2228 participants), and one survey on patients’ preferences (with 100 participants) were identified. All studies applied neoadjuvant chemoradiation protocols. None of the studies examined neoadjuvant chemotherapeutic protocols. Studies investigated patient populations with esophageal squamous cell carcinoma, adenocarcinoma, and mixed cohorts. Important outcomes reported were overall, disease-free and local recurrence-free survival. Limitations of the currently available study pool include heterogeneous chemoradiation protocols, a lack of modern neoadjuvant treatment protocols in RCTs, short follow-up times, the use of heterogeneous diagnostic methods, and different definitions of clinical CR. Conclusion: Although post-neoadjuvant surveillance and surgery as needed compared with post-neoadjuvant surgery on principle has been investigated within different study designs, the currently available results are based on a wide variation of diagnostic tools to identify patients with pCR, short follow-up times, small sample sizes, and variations in therapeutic procedures. A thoroughly planned RCT considering the limitations in the currently available literature will be of great importance to provide patients with CR with the best and less harmful treatment.

Definitive chemoradiotherapy for clinical T4b esophageal cancer - Treatment outcomes, failure patterns, and prognostic factors

PURPOSE

The management of cT4b thoracic esophageal cancer (EC) is challenging. The optimal treatment remains unclear, and prospective or large-scale retrospective reports on treatment outcomes are lacking. The present study was conducted to investigate the treatment outcomes, failure patterns, treatment responses, and prognostic factors focusing on cT4b thoracic EC treated by definitive concurrent chemoradiotherapy (dCRT).

METHODS

A retrospective review of cT4b thoracic EC patients treated with curative intent dCRT at our institution between 2009 and 2017 was conducted. Survival analysis was calculated using the Kaplan-Meier method, and prognostic factors were examined by the Cox proportional hazards model.

RESULTS

A total of 95 cT4b EC patients were included, and the median survival was 11.4 months. The 1-year, 3-year, and 5-year survival rates were 49.4%, 22.2%, and 19.0%, respectively. Forty-six patients (48.4%) experienced locoregional failure, 3 patients (3.2%) developed distant metastasis, and 11 patients had synchronous locoregional and distant failure. The corresponding 1-year, 3-year, and 5-year locoregional failure rates were 62.6%, 74.5%, and 79.2%, respectively. The treatment response rate was 76.9%, and clinical complete response was achieved in 25.3% of patients. Multivariable analysis revealed that age ≤ 65 (p = 0.003), pre-dCRT body mass index (BMI) > 21 (p < 0.001), clinical N stage 0-1 (p = 0.014), and tumor length ≤ 6 cm (p = 0.026) were independent prognosticators for better survival.

CONCLUSION

Our study revealed that long-term survival is achievable for cT4b EC patients treated by dCRT, with a 3-year survival rate of more than 20%. Locoregional recurrence was the most common failure pattern. Age, BMI, N stage, and tumor length were significant prognosticators for survival in this group of patients.

Long-term results of definitive chemoradiotherapy for unresectable locally advanced esophageal squamous cell carcinoma

PURPOSE

The present study aimed to evaluate the long-term results of definitive chemoradiotherapy (CRT) for unresectable locally advanced esophageal squamous cell carcinoma (LA-ESCC).

MATERIALS AND METHODS

We analyzed eighty patients with unresectable LA-ESCC, who underwent definitive CRT between 2001 and 2014. The 5-year overall survival (OS), cause-specific survival (CSS), and progression-free survival (PFS) rates were calculated, and we investigated the prognostic factors and adverse events.

RESULTS

The median age was 66 years (range, 41-83 years). Histologically, all patients had squamous cell carcinoma. The most common tumor site was the middle thoracic esophagus in 43 (54%) patients. According to the eighth edition of the Union for International Cancer Control TNM classification, sixty-six patients (83%) had T4 disease, 59 (74%) had regional lymph node (LN) metastases, and 35 (44%) had distant LN metastases beyond the regional LN (M1 LYM) disease. Forty-five (56%) and 35 (44%) patients belong to clinical stages IVA and IVB, respectively. The median follow-up period for survivors was 86 months. The 5-year OS, CSS, and PFS rates were 20.2%, 25.7%, and 18.4%, respectively. On univariate analysis, only the performance status score was significantly associated with better overall survival (p = 0.026). Grade 3 or higher late adverse events were observed in 12 (15%) patients, and these included cardiopulmonary adverse events in 6 (8%) patients. Treatment-related death occurred in 3 (4%) patients.

CONCLUSION

We showed the long-term results of definitive CRT for unresectable LA-ESCC. The survivals are still poor and new treatment strategies need to be developed.

Salvage Robot-Assisted Minimally Invasive Esophagectomy (RAMIE) for T4b Esophageal Cancer After Definitive Chemoradiotherapy

Background

Patients  with esophageal cancer  that invades adjacent structures (cT4b) are precluded from surgery and usually treated with definitive chemoradiotherapy (dCRT). dCRT might result in sufficient downstaging to enable a radical resection, possibly improving survival. This study aimed to assess the perioperative and oncologic outcomes of a salvage robot-assisted minimally invasive esophagectomy (RAMIE) in patients with cT4b esophageal cancer after dCRT.

Methods

Between June 2012 and November 2019, patients who underwent a RAMIE with a gastric conduit reconstruction after completion of dCRT for cT4b esophageal carcinoma were identified from a prospectively maintained surgical database at the University Medical Center Utrecht.

Results

In total, 24 patients with a histopathologically confirmed T4b adenocarcinoma or squamous cell carcinoma of the esophagus were included. The adjacent organs involved were the tracheobronchial tree (67%), aorta (21%) or both (13%). No conversions or major intraoperative complications were observed. A radical resection was achieved in 22 patients (92%), and a pathologic complete response was observed in 13 (54%) patients. Postoperative grade 2 or higher complications occurred in 20 patients (83%). The disease-free survival at 24 months was 68% for the patients in whom a radical resection was achieved.

Conclusion

In patients with cT4b esophageal cancer treated with dCRT followed by a salvage RAMIE, a radical resection rate of 92% was achieved, with acceptable complications and promising survival rates. These results demonstrate the feasibility of a curative surgical treatment for patients with initially irresectable esophageal cancer but underscore the importance of a proper preoperative patient selection.

Successful Management of Esophageal Cancer With Perforation Using Bypass Surgery Followed by Definitive Chemoradiotherapy

BACKGROUND

Esophageal perforation in advanced esophageal cancer requires immediate treatment. However, no clear treatment protocol has been established for this condition. We report a case of advanced esophageal cancer with esophageal perforation treated with esophageal bypass surgery and definitive chemoradiotherapy (CRT).

CASE REPORT

A 45-year-old woman was diagnosed with locally advanced esophageal cancer with esophageal perforation. Although the patient's general condition was relatively stable, no improvement was expected through conservative treatment. Esophageal gastric bypass surgery was performed; her symptoms improved postoperatively and oral ingestion became possible. Definitive CRT with 66 Gy radiotherapy and chemotherapy with cisplatin and 5-fluorouracil was administered. A complete clinical response was achieved. The patient is alive and well without recurrence 20 months after treatment.

CONCLUSION

Definitive CRT after esophageal bypass surgery is a potential treatment option for locally advanced esophageal cancer with esophageal perforation to improve treatment response and quality of life.

Long-term outcomes of multimodal therapy combining definitive chemoradiotherapy and salvage surgery for T4 esophageal squamous cell carcinoma

BACKGROUND

Survival outcomes of patients with cT4 esophageal squamous cell carcinoma (ESCC) remain extremely poor. We aimed to investigate long-term outcomes and identify prognostic factors in patients treated by definitive chemoradiotherapy (dCRT) alone or with dCRT plus salvage surgery (SALV) for cT4 ESCC.

PATIENTS AND METHODS

In total, 73 patients completing dCRT were analyzed. Patients achieving clinical complete response (CR) received follow-up evaluations thereafter. For patients diagnosed with clinical partial response (PR), potentially curative SALV was generally performed. Possible prognostic factors included demographic data, tumor staging, blood chemistry profiles, and esophageal stenosis.

RESULTS

The 1- and 3-year overall survival (OS) rates of the 73 patients were 67.1% and 40.8%, respectively. Twenty-one patients (29%) achieved clinical CR with dCRT alone. Among 35 patients (48%) with clinical PR, 31 underwent SALV and 4 opted for non-surgical treatments. In the dCRT-alone group (n = 42), patients with clinical CR-PR (n = 25) showed significantly better 3-year OS than those who responded poorly to dCRT (stable or progressive) (n = 17) (67.5% vs. 0%, P < 0.001). In the SALV group (n = 31), curative SALV (n = 22, 73%) provided significantly better 3-year OS than non-curative SALV (58.7% vs. 0%, P < 0.001). Multivariable analysis revealed stenosis before dCRT (P = 0.02) and pretreatment elevated CRP (P = 0.02) to be independently associated with poor outcomes.

CONCLUSIONS

The multimodal treatment strategy combining dCRT and SALV is rational for treating cT4 ESCC patients. When curative resection is feasible, SALV can provide good long-term survival outcome for patients who responded to dCRT but did not achieve clinical CR with dCRT alone.

Feasibility of extended chemoradiotherapy plus surgery for patients with cT4b esophageal carcinoma

BACKGROUND

Treatment of cT4b esophageal carcinoma usually consists of definitive chemoradiotherapy (dCRT). However, outcome after dCRT in these patients is poor. Whether surgery should have a place in the treatment of cT4b esophageal cancer is still subject to debate. Goal of this study was to evaluate the feasibility of esophagectomy after extended chemoradiotherapy in patients with cT4b esophageal cancer.

METHODS

Patients with cT4b esophageal carcinoma, as determined by endoscopic ultrasound and (PET-)CT, were eligible for this phase-2 study. Patients were treated with weekly carboplatin + paclitaxel with 50.4 Gy radiotherapy in 28 fractions for 5.5 weeks followed by an explorative thoracotomy and esophagectomy if deemed feasible.

RESULTS

From July 2011 through March 2013, 16 patients were enrolled. Five patients did not undergo surgery because of detection of distant metastases during/after CRT (n = 3), unwillingness to undergo surgery (n = 1) or death before start of CRT (n = 1). Of the 13 patients who completed CRT, 3 patients experienced major hematologic toxicity (grade 3). A radical (R0) resection was achieved in 9 of 11 patients. Postoperative complications occurred in 9 patients. A reoperation was performed in 2 patients and 2 patients died in hospital after surgery. Three patients developed recurrent disease (1 locoregional and 2 systemic) after a mean interval of 17 months. Median overall survival of all included patients was 14.3 months.

CONCLUSIONS

In certain patients with cT4b esophageal carcinoma a radical resection can be accomplished after chemoradiotherapy. However, this treatment is associated with considerable complications and should therefore be reserved for physically fit patients.

NETHERLANDS TRIAL REGISTER NUMBER

NTR3060.

Surgery Is Associated With Survival Benefit in T4a Esophageal Adenocarcinoma: A National Analysis

BACKGROUND

The National Comprehensive Cancer Network guidelines recommend consideration of surgery for clinical T4a esophageal adenocarcinoma. There are limited data on the outcomes of patients with T4a adenocarcinoma treated with surgery vs definitive chemoradiation, however.

METHODS

The National Cancer Database was used to identify patients from 2010-2015 with clinical T4aN0-3M0 esophageal adenocarcinoma, and grouped by receipt of surgery (with or without perioperative therapy) or definitive, concurrent chemoradiation. Patients receiving incomplete definitive therapy or with missing survival information were excluded. Overall survival was evaluated with Kaplan-Meier and Cox proportional hazard analyses.

RESULTS

Of 182 patients in the study, 85 (47%) underwent esophagectomy and 97 (53%) underwent chemoradiation. In the surgery cohort, 79 patients (93%) received perioperative chemotherapy. Unadjusted and multivariable analyses demonstrated a significant survival benefit associated with surgery compared with definitive chemoradiotherapy (adjusted hazard ratio 0.32; 95% confidence interval 0.21, 0.50). A 1:1 propensity score-matched analysis of 63 patient pairs also revealed a significant overall survival benefit with surgery compared with chemoradiotherapy alone (hazard ratio 0.26; 95% confidence interval 0.16, 0.43).

CONCLUSIONS

In this national analysis, surgery for cT4a esophageal adenocarcinoma was associated with improved outcomes when compared with definitive chemoradiation. Surgery should be considered for medically fit patients with cT4aN0-3M0 esophageal adenocarcinoma.

Neoadjuvant chemotherapy with irinotecan and nedaplatin in a single cycle followed by esophagectomy on cT4 resectable esophageal squamous cell carcinoma: a prospective nonrandomized trial for short-term outcomes

Neoadjuvant chemotherapy (NAC) significantly extends survival in advanced esophageal squamous cell carcinoma (ESCC), but the short-term outcomes for cT4 ESCC remain controversial. Many NAC regimens have been previously reported, although no study has reported a regimen of irinotecan and nedaplatin for cT4 potential resectable ESCC. We evaluated the short-term outcomes of NAC with irinotecan and nedaplatin in a single cycle followed by esophagectomy on cT4 resectable ESCC. A total of 51 patients with cT4 potentially resectable ESCC were eligible for this study. Twenty of these patients underwent NAC, and the other 31 patients underwent surgery alone. The toxicities and response of NAC were evaluated. The clinicopathologic characteristics, responses, toxicities, surgical outcomes, postoperative complications, and survival time between the two groups were analyzed. No significant differences were found in clinicopathologic characteristics between the groups (P > 0.05). The response rate of NAC was 75% (15/20). The differences in the long-axis diameter of the tumor and cT stage between pre- and post-NAC were significant (P < 0.05). Twenty-four toxic events occurred in 11 patients of the NAC group, and 20/24 of these were mild. The R0 resection rates in the NAC group and the surgery alone group were 85% and 64.5%, with no statistically significant difference (P > 0.05). Differences in the pathological T stage and pathological tumor-node-metastasis (TNM) stage were significant (P < 0.05). The overall survival (OS) time and mortality in the NAC group versus the surgery alone group were 31.57 ± 3.06 months versus 15.24 ± 1.46 months and 25% versus 61.3%, respectively. The differences in OS and mortality were significant (P < 0.05). The NAC group and R0 resection were significant and independent predictors of positive prognosis. NAC with irinotecan and nedaplatin in a single cycle followed by esophagectomy on cT4 resectable ESCC as a new NAC is safe and effective.

Treatment and clinical outcome of clinical T4 esophageal cancer: A systematic review

BACKGROUND

Survival of patients with cT4 esophageal cancer is dismal. Although the optimal treatment strategy remains to be established, two treatment options are available for cT4 esophageal cancers: definitive chemoradiation (dCRT) and induction treatment followed by conversion surgery (CS). However, little is known concerning the differences in clinical outcome between patients with T4 esophageal tumors treated with dCRT and those eventually treated with CS.

METHODS

A systematic search of the scientific literature on PubMed/MEDLINE was carried out using the keywords "T4 esophageal cancer," "invading (involving) adjacent organ," "definitive chemoradiation," "induction therapy," "salvage surgery," and "conversion surgery," obtaining 28 reports published up to July 2018.

RESULTS/CONCLUSION

We found that CS was superior to dCRT with respect to local disease control and short-term survival; however, CS was associated with relatively higher perioperative mortality and morbidity. Alternatively, although dCRT might often cause fistula formation, a clinical complete response to dCRT is likely to lead to a better prognosis. Recent advances in chemotherapeutic agents have led to triple induction chemotherapy, with docetaxel, cisplatin, and 5-fluorouracil (DCF), which has shown promise as an initial induction treatment for cT4 esophageal cancer. Indeed, this regimen could control both local and systemic disease, which enables curative resection without preoperative CRT. Moreover, some appropriate changes in perioperative management and intensive systemic chemotherapy might enhance patient outcome. Randomized controlled trials with a large sample size are needed to establish the standard treatment for cT4 esophageal cancer.

Prognostic Factors of Salvage Esophagectomy for Residual or Recurrent Esophageal Squamous Cell Carcinoma After Definitive Chemoradiotherapy

BACKGROUND

The aim of this study was to confirm prognostic factors for salvage esophagectomy for remnant or recurrent esophageal squamous cell carcinoma after definitive chemoradiotherapy.

STUDY DESIGN

We retrospectively analyzed clinicopathological backgrounds of 50 patients who underwent salvage esophagectomy between April 2005 and January 2016. Salvage esophagectomy comprised 40 three-incision esophagectomies, two transhiatal esophagectomies and eight pharyngolaryngoesophagectomies. Independent prognostic factors for overall survival were assessed using Cox regression analysis of the factors.

RESULTS

Salvage esophagectomy remains a highly invasive surgery and correlated with a higher incidence of all morbidities of Clavien-Dindo classification (CDc) ≥II, severe morbidities of CDc ≥ IIIb, any pulmonary morbidities and chylorrhea, compared with those in patients without preoperative definitive chemoradiotherapy. Cox regression analysis suggested that R0 resection (hazard ratio [HR] 6.39; 95% confidence interval [CI] 2.03-9.68, P = 0.002), absence of severe complications (HR 4.97; 95% CI 1.70-14.81, P = 0.004) and early pStage (0-II) (HR 3.42; 95% CI 1.24-10.12, P = 0.018) were independent prognostic factors for salvage esophagectomy.

CONCLUSIONS

Salvage esophagectomy remains correlated with a high incidence of postoperative complications. Avoiding non-curative surgery and reducing the incidence of severe postoperative complications are important if patients are to receive prognostic benefit of this highly invasive surgery.

The current optimal multimodality treatments for oesophageal squamous-cell carcinoma: A systematic review and meta-analysis

BACKGROUND

Multimodality treatments including definitive chemoradiotherapy (dCRT) and neoadjuvant chemoradiotherapy (nCRT) or chemotherapy (nCT) followed by surgery (S) are frequently used to improve prognosis in locally advanced oesophageal squamous-cell carcinoma (LAESCC), while the optimal multimodality regimen has yet to be defined; therefore, this systematic review and meta-analysis aimed to find out the current best multimodality regimen for LAESCC.

METHODS

We conducted a systematic search of PubMed, Embase, Ovid and Cochrane Library databases for studies comparing nCRT + S with nCT + S or dCRT. The primary outcome was overall survival. The secondary outcomes were the rates of R0 resection, pathologic complete response (pCR), tumor-free lymph nodes (pN0) and postoperative recurrence.

RESULTS

Five studies comparing nCRT + S with nCT + S and fourteen studies comparing nCRT + S with dCRT were finally included. Meta-analysis showed that nCRT + S had higher rates of R0 resection (OR 1.84, 95% CI 1.03-3.29), pCR (OR: 2.90 95% CI 1.37-6.14) and pN0 (OR: 2.55 95% CI 1.54-4.24) with a significant survival advantage (HR 0.72; 95% CI 0.52-0.99) when compared with nCT + S in LAESCC. When nCRT + S was compared with dCRT, nCRT + S yielded a significant survival benefit (HR 0.65; 95% CI 0.56-0.76) and had a significantly lower rate of local recurrence (OR: 0.35 95% CI 0.22-0.57).

CONCLUSION

Current evidence suggests that CRT + S may be the optimal potential curative treatment mode for patients with LAESCC as long as they are suitable for this multimodality regimen.

Long-Term Outcome of Definitive Chemoradiotherapy and Induction Chemoradiotherapy Followed by Surgery for T4 Esophageal Cancer with Tracheobronchial Invasion

BACKGROUND

T4 esophageal cancer (EC) that invades the trachea or bronchus often has poorer prognosis than other T4 ECs. We investigated the long-term results of definitive chemoradiotherapy (dCRT) or induction chemoradiotherapy followed by surgery (iCRT-S) in patients with T4 EC with tracheobronchial invasion (TBI).

PATIENTS AND METHODS

From 2003 to 2013, 71 patients with T4 EC with TBI were treated in our institution; 58 underwent dCRT, and 13 underwent iCRT-S. The long-term results associated with survival were retrospectively analyzed, and prognostic factors were examined by univariable and multivariable analysis.

RESULTS

The 1-, 2-, and 5-year overall survival for all patients with T4 EC with TBI treated by dCRT or iCRT-S was 57, 29, and 19%, respectively. Multivariable analysis revealed that clinical lymph node (LN) metastasis and the treatment period were significant prognostic factors. Clinical LN positivity had significantly poorer prognosis than LN negativity. The treatment outcome in the later period was significantly better than that in the earlier period. In particular, the outcome after dCRT revealed significantly better prognosis in the later compared with the earlier period, whereas the outcome after iCRT-S did not show such a difference. With respect to treatment modality, no significant difference in survival was observed between dCRT and iCRT-S.

CONCLUSIONS

Clinical LN negativity and later treatment period were significantly good prognostic factors for T4 EC with TBI. The recent improvements in dCRT outcomes may help to achieve survival comparable to that of iCRT-S.

Utility of initial induction chemotherapy with 5-fluorouracil, cisplatin, and docetaxel (DCF) for T4 esophageal cancer: a propensity score-matched analysis

Although no consensus is available on the treatment of esophageal squamous cell carcinoma (ESCC) invading adjacent organs (T4), establishing effective induction treatments is crucial to altering an unresectable status and achieving curative resection. Here, we evaluated the efficacy of chemotherapy using 5-fluorouracil, cisplatin, and docetaxel (DCF) as the initial induction treatment for T4 ESCC. Fifty patients without distant metastasis who underwent initial induction chemotherapy using DCF for T4 ESCC were propensity score-matched with 50 patients who underwent radiotherapy concurrent with cisplatin and 5-fluorouracil (CRT). In the DCF group, 24 (48.0%) patients underwent surgery, achieving a 64% clinical response rate compared to 72.0% for induction CRT. CRT was also performed in another 24 (48.0%) patients in the DCF group in whom surgical resection was not indicated. The DCF group had significantly higher overall resectability than the CRT group (78.0% vs. 48.0%, P = 0.0017). The esophageal perforation rate during induction treatments was significantly lower in the DCF group than the CRT group (4.0% vs. 18.0%, P = 0.0205). Prognosis was significantly better in the DCF group than the CRT group (5-year cancer-specific survival 42.1% vs. 22.2%, P = 0.0146). Thus, induction DCF chemotherapy in patients with T4 ESCC reduced esophageal perforation and increased overall resectability, leading to better survival than CRT alone. Therefore, DCF chemotherapy may be an effective and safe option for initial induction treatment of T4 ESCC.

A case of separation surgery with drainage tube-less (DRESS) esophagostomy for advanced cancer with a respiratory fistula

INTRODUCTION

An esophagorespiratory fistula (ERF) can cause severe pneumonia or a lung abscess which progresses to life-threatening sepsis. A case of a patient with esophageal cancer and an esophagopulmonary fistula (EPF) who underwent separation surgery with drainage tube-less (DRESS) esophagostomy and was promptly started on definitive chemoradiotherapy (CRT) is reported.

PRESENTATION OF CASE

A 79-year-old man visited a clinic with a month-long history of dysphagia. Esophageal cancer at the middle thoracic esophagus was detected, and invasion of the left main bronchus and lower lobe of the right lung was seen on contrast-enhanced computed tomography (CT). Three weeks later, the patient was transferred to our hospital. CT showed a lung abscess in the lower lobe of the right lung that continued into the adjacent esophageal cancer. Due to the EPF, the patient underwent emergency surgery that consisted of esophageal separation surgery and double bilateral esophagostomy and enterostomy. Definitive CRT for the esophageal cancer was started from postoperative day 25. At six-month follow-up, the patient achieved relapse-free survival.

DISCUSSION

Separation surgery with a DRESS esophagostomy provides good control of inflammation because of division of the respiratory tract from the alimentary tract, which allows prompt initiation of CRT. Alternatively, a DRESS esophagostomy allows patients to be free from any tube trouble.

CONCLUSION

Separation surgery with a DRESS esophagostomy for an ERF is a promising method to improve patient quality of life that is less invasive, controls inflammation, and facilitates subsequent definitive CRT.

Esophageal stenosis and the Glasgow Prognostic Score as independent factors of poor prognosis for patients with locally advanced unresectable esophageal cancer treated with chemoradiotherapy (exploratory analysis of JCOG0303)

BACKGROUND

The aim of this study was to investigate the possible prognostic factors and predictive accuracy of the Glasgow Prognostic Score (GPS) for patients with unresectable locally advanced esophageal squamous cell carcinoma (LAESCC) treated with chemoradiotherapy.

METHODS

One hundred forty-two patients were enrolled in JCOG0303 and assigned to the standard cisplatin and 5-fluorouracil (PF)-radiotherapy (RT) group or the low-dose PF-RT group. One hundred thirty-one patients with sufficient data were included in this analysis. A Cox regression model was used to analyze the prognostic factors of patients with unresectable LAESCC treated with PF-RT. The GPS was classified based on the baseline C-reactive protein (CRP) and serum albumin levels. Patients with CRP ≤1.0 mg/dL and albumin ≥3.5 g/dL were classified as GPS0. If only CRP was increased or only albumin was decreased, the patients were classified as GPS1, and the patients with CRP >1.0 mg/dL and albumin <3.5 g/dL were classified as GPS2.

RESULTS

The patients' backgrounds were as follows: median age (range), 62 (37-75); male/female, 119/12; ECOG PS 0/1/2, 64/65/2; and clinical stage (UICC 5th) IIB/III/IVA/IVB, 3/75/22/31. Multivariable analyses indicated only esophageal stenosis as a common factor for poor prognosis. In addition, overall survival tended to decrease according to the GPS subgroups (median survival time (months): GPS0/GPS1/GPS2 16.1/14.9/8.7).

CONCLUSIONS

Esophageal stenosis was identified as a candidate stratification factor for randomized trials of unresectable LAESCC patients. Furthermore, GPS represents a prognostic factor for LAESCC patients treated with chemoradiotherapy.

CLINICAL TRIAL INFORMATION

UMIN000000861.

Is 18F-FDG-PET useful for predicting R0 resection after induction therapy for initially unresectable locally advanced esophageal carcinoma?

OBJECTIVE

Induction therapy followed by surgery is a promising strategy for esophageal cancer patients with invasion of the trachea/bronchus or aorta. However, no diagnostic criteria have been established to diagnose whether R0 resection can be performed. We investigated whether ¹⁸F-2-deoxy-D-glucose positron emission tomography (¹⁸F-FDG-PET) and other modalities are useful for predicting R0 resection.

METHODS

Fifty-seven patients with esophageal cancer invading the trachea/bronchus or aorta who underwent induction therapy followed by surgery were enrolled. We divided the participants into two groups, an R0 resection group (n = 43) and a non-R0 resection group (n = 14), and then compared the between-group results of three modalities, including computed tomography (CT), endoscopy and ¹⁸F-FDG-PET, before and after induction therapy.

RESULTS

The post-maximal standardized uptake value (SUV_max) after induction therapy in the R0 resection group was significantly lower than that in the non-R0 resection group (4.4 vs. 6.6, p = 0.005). The receiver operating characteristic curve analysis showed that the cut-off value for the post-SUV_max based on ¹⁸F-FDG-PET prediction of R0 resection was 4.7. Furthermore, a tumor reduction rate of ≥44% on CT, no residual stenosis, and no deep ulcer on endoscopy were associated with R0 resection after induction therapy (p = 0.002, p = 0.091, and p = 0.059, respectively). Multivariate logistic analyses revealed that the tumor reduction rate on CT and post-SUV_max <4.7 in ¹⁸F-FDG-PET were independent factors for R0 resection.

CONCLUSIONS

The post-SUV_max determined by ¹⁸F-FDG-PET and the volume reduction rate based on CT scans were useful for predicting R0 resection after induction therapy for initially unresectable locally advanced esophageal carcinoma.

Inter-evaluator heterogeneity of clinical diagnosis for locally advanced esophageal squamous cell carcinoma

BACKGROUND

Identifying clinical resectability of locally advanced esophageal squamous cell carcinoma (ESCC) is important, although inter-evaluator heterogeneity (IEH) could exist, especially in borderline resectable (BLR) cases. To investigate the extent of heterogeneity, we conducted clinical diagnostic imaging questionnaires.

MATERIALS AND METHODS

Five cases with clinical T3 or T4 cases, which were treated with neo-adjuvant triplet chemotherapy followed by surgery, were selected as the model. These cases were divided into two groups: curative resected cases (#1-#3) and non-curative resected cases (#4 and #5). Only imaging slides were shown without any information about patient characteristics or clinical course. The evaluators consisted of surgeons (staff and non-staff), medical oncologists, and an imaging radiologist; a total of 25 medical staff answered the questionnaire. Two questions (1: clinical T stage before chemotherapy, 2: resectability after chemotherapy) were answered. Occupational differences were assessed by comparing the results to the imaging radiologist.

RESULTS

IEH was observed for clinical diagnosis before chemotherapy in one case (clinical T4: 52%, clinical T3: 48%). In the other cases, most evaluators diagnosed them as clinical T4, with 76-88% agreement. IEH for clinical resectability after chemotherapy was relatively small. Occupational IEH was observed in both before and after chemotherapy.

CONCLUSION

IEH in decisions about treating BLR cases in ESCC should be considered in clinical practice. Multi-disciplinary teams are essential to overcome this problem.

Risk Factors for Esophageal Fistula Associated With Chemoradiotherapy for Locally Advanced Unresectable Esophageal Cancer: A Supplementary Analysis of JCOG0303

Esophageal fistula is a critical adverse event in patients treated with chemoradiotherapy (CRT) for locally advanced esophageal cancer. However, risk factors associated with esophageal fistula formation in patients receiving CRT have not yet been elucidated.We retrospectively analyzed data obtained from 140 patients who were enrolled in a phase II/III trial comparing low-dose cisplatin with standard-dose cisplatin administered in combination with 5-flurouracil and concomitant radiotherapy. Inclusion criteria were performance status (PS) 0 to 2 and histologically proven thoracic esophageal cancer clinically diagnosed as T4 and/or unresectable lymph node metastasis for which definitive CRT was applicable. Risk factors for esophageal fistula were examined with univariate analysis using Fisher exact test and multivariate analysis using logistic regression models.Esophageal fistula was observed in 31 patients (22%). Of these, 6 patients developed fistula during CRT. Median time interval between the date of CRT initiation and that of fistula diagnosis was 100 days (inter quartile range, 45-171). Esophageal stenosis was the only significant risk factor for esophageal fistula formation both in univariate (P = 0.026) and in multivariate analyses (odds ratio, 2.59; 95% confidence interval, 1.13-5.92, P = 0.025). Other clinicopathological factors, namely treatment arm, age, sex, PS, primary tumor location, T stage, lymph node invasion to adjacent organs, blood cell count, albumin level, and body mass index, were not risk factors fistula formation.Esophageal stenosis was a significant risk factor for esophageal fistula formation in patients treated with CRT for unresectable locally advanced thoracic esophageal squamous cell carcinoma.

Inter-institutional survival heterogeneity in chemoradiation therapy for esophageal cancer: exploratory analysis of the JCOG0303 study

It is important to examine variation in the treatment effects of patients with esophageal cancer in order to generalize treatment outcomes. We aimed to investigate the range of prognostic differences among hospitals in the treatment of locally advanced esophageal cancer. The JCOG0303 study compared the efficacy of radiotherapy plus low-dose cisplatin and 5-fluorouracil with that of high-dose cisplatin and 5-fluorouracil for unresectable esophageal cancer. Of 32 institutions participating in the JCOG0303 study, the 18 institutions that enrolled three or more patients were included in this study. We predicted the 1-year survival in each institution by using a mixed-effect model. We found that the predicted 1-year survival in the 18 institutions with three or more patients was a median of 60.9%, with a range of 60.9-60.9%. This study is the first to investigated heterogeneity of survival in patients who received definitive chemoradiotherapy for locally advanced esophageal squamous cell carcinoma.

Is the outcome of a salvage surgery for T4 thoracic esophageal squamous cell carcinoma really poor?

BACKGROUND

Among patients with T4 thoracic esophageal squamous cell carcinoma (TESCC), it is unclear whether the outcomes of late responders who undergo high-dose chemoradiotherapy (CRT) followed by salvage esophagectomy differs from those of early responders who undergo low-dose CRT followed by esophagectomy.

METHODS

A total of 153 patients with T4 TESCC were treated with CRT. The first evaluation was performed after 40 Gy of CRT for downstaging. Of these, 28 patients could be downstaged, and underwent subsequent surgery (early responders). For the remaining patients, additional CRT was administered, and patients were re-evaluated after treatment and underwent salvage surgery. In total, 40 patients (early + late responders) were analyzed.

RESULTS

The primary tumors exhibited a grade 3 response in six (21.4 %) of the early responders and two (16.7 %) of the late responders (p = 1.000). The rate of residual tumor in the primary tumor was 80 % (32/40 patients). The proportions of resected lymph nodes and positive metastatic nodes were similar between early and late responders (p = 0.406 and p = 0.859, respectively). The 5-year overall survival rates among the early and late responders were 25.9 and 36.5 %, respectively, and the median survival times were 24.8 and 24.3 months (p = 0.925), respectively. The 5-year cause-specific survival rates in the early and late responder groups were 61.5 and 72.9 % (p = 0.425), respectively.

CONCLUSION

The outcomes of both early and late responders to CRT were similar, and salvage surgery for T4 TESCC outweighs the risks in patients with T4 TESCC.

Randomized study of low-dose versus standard-dose chemoradiotherapy for unresectable esophageal squamous cell carcinoma (JCOG0303)

Low-dose cisplatin and 5-fluorouracil (LDPF) chemotherapy with daily radiotherapy (RT) is used as an alternative chemoradiotherapy regimen for locally advanced esophageal carcinoma. We evaluated whether RT plus LDPF chemotherapy had an advantage in terms of survival and/or toxicity over RT plus standard-dose cisplatin and 5-fluorouracil (SDPF) chemotherapy in this study. This multicenter trial included esophageal cancer patients with clinical T4 disease and/or unresectable regional lymph node metastasis. Patients were randomly assigned to receive RT (2 Gy/fraction, total dose of 60 Gy) with SDPF (arm A) or LDPF (arm B) chemotherapy. The primary endpoint was overall survival (OS). A total of 142 patients (arm A/B, 71/71) from 41 institutions were enrolled between April 2004 and September 2009. The OS hazard ratio in arm B versus arm A was 1.05 (80% confidence interval, 0.78-1.41). There were no differences in toxicities in either arm. Arm B was judged as not promising for further evaluation in the phase III setting. Thus, the Data and Safety Monitoring Committee recommended that the study be terminated. In the updated analyses, median OS and 3-year OS were 13.1 months and 25.9%, respectively, for arm A and 14.4 months and 25.7%, respectively, for arm B. Daily RT plus LDPF chemotherapy did not qualify for further evaluation as a new treatment option for patients with locally advanced unresectable esophageal cancer. This study was registered at the UMIN Clinical Trials Registry as UMIN000000861.

Chemoradiotherapy and surgery for T4 esophageal cancer in Japan

Esophageal cancer is thought to be the most malignant neoplasm due to its biological aggressiveness. The most effective treatment modality for esophageal cancer, particularly T4 esophageal cancer, is chemoradiotherapy (CRT). Some T4 patients show long-term survival after receiving CRT, suggesting that even T4 esophageal cancer can be cured with this modality. Although surgery is performed after CRT in some T4 cases, its prognostic benefit is controversial. In this paper, we review the status of CRT and conversion surgery as well as the development of new regimens and discuss the future prospects of CRT in the treatment of T4 esophageal cancer in Japan.

Complications of the rescue esophagectomy in advanced esophageal cancer

BACKGROUND

Even though the esophageal cancer has innumerous treatment options its prognosis is still unsettled. Because esophagectomy is rarely curative, new and emerging therapies come to light such as isolated chemotherapy and radiotherapy or combined chemoradiation, followed or not by surgery. The rescue esophagectomy is an alternative for those patients with recurrent or advanced disease.

AIM

To evaluate the results of the rescue esophagectomy in patients with esophageal cancer who had previously undergone chemoradiation and describe local and systemic complications of the procedure.

METHODS

Eighteen patients with unresectable esophageal squamous cell carcinoma were treated with chemoradiation followed by rescue esophagectomy. All of them presented the preoperative clinical conditions required to indicate the surgical procedure. Transthoracic esophagectomy with right side thoracotomy plus midline laparotomy was performed. Patients were evaluated with regard to any postoperative complications.

RESULTS

There were five patients with evidence of fistula at the level of the anastomosis, and four of them progressed satisfactorily. Postoperative dilation was needed in five out of eighteen patients due to stenosis of the esophagogastric suture line. Seven patients did develop pulmonary infection with a fatal outcome for two of them. Among the patients who were available for a five-year follow-up, there was a rate of 53.8% of disease-free survival.

CONCLUSIONS

These patients presented an elevated morbidity of the procedure related to many factors such as the long period between chemoradiation and surgery, which leads to tissue injury resulting in anastomotic fistulas. Nevertheless, esophagectomy seems to be valuable in cases without any other therapeutic option.

Induction chemotherapy or chemoradiotherapy followed by radical esophagectomy for T4 esophageal cancer: results of a prospective cohort study

BACKGROUND

We hypothesized that the survival rate of patients undergoing R0 esophagectomy after induction chemotherapy or chemoradiotherapy for unresectable T4 esophageal cancer (URT4) would be similar to that of patients undergoing esophagectomy for immediately resectable esophageal cancer with no unfavorable prognostic factors (RNU).

METHODS

Between April 2002 and June 2012, 87 of 283 patients with esophageal cancer who presented at the University Hospital of the Ryukyus were enrolled in this prospective cohort study. Tumors were classified as RNU and URT4 in 44 and 43 of the 87 patients, respectively. Outcomes of treatment for URT4 patients were compared with those of RNU patients.

RESULTS

The R0 resection rate (61 %) and in-hospital mortality rate (20 %) of URT4 patients were significantly poorer than those of RNU patients (98 and 2.3 %, respectively), although the morbidity rate was similar in the two groups (63 and 52 %, respectively). The 5-year survival rate (35 %) of URT4 patients was significantly poorer than that of RNU patients (67 %) in the intention-to-treat analysis. However, no significant difference was noted between the two survival curves for cases of R0 resection (5-year survival rate, 60 % vs. 69 %). Multivariate analysis revealed R status as the only significant independent prognostic factor for URT4 patients (P < 0.001; hazard ratio = 8.279).

CONCLUSIONS

Satisfactory survival rates can be achieved if R0 resection is performed after induction treatment in patients with T4 esophageal cancer, although secondary radical esophagectomy is associated with a higher risk of in-hospital mortality.

A history of surgery for locally-advanced (T4) cancer of the thoracic esophagus in Japan and a personal perspective

The history of esophageal surgery in Japan can be divided into three periods, an era of safety from 1930 to 1980, an era of radicality from 1980 to 2000, and the era of quality of life (QOL) from 2000 to the present. The treatment for T4 cancers of the thoracic esophagus has also changed over time from preoperative radiotherapy, combined resection of the neighboring organs with esophagectomy, and to definitive chemoradiotherapy (dCRT) with salvage surgery. At present, almost all patients with an unresectable T4 esophageal cancer receives dCRT. However, there are many patients with a residual or recurrent tumor after dCRT. Salvage surgery for such patients often results in incomplete resection of the tumor because the tumor involves the trachea and/or aorta. New techniques to enable the resection of such neighboring organs even during salvage surgery are needed. In the future, the mainstay of treatment for esophageal cancer will be CRT with the foreseeable progress in new drugs and new techniques of radiotherapy. Surgery will be indicated for a local failure after CRT, while combined resection of the neighboring organs will be necessary to treat a local failure after CRT for T4 cancers. New surgical techniques have to be developed through some application of new devices and equipment.

Esophageal bypass operation prior to definitive chemoradiotherapy in advanced esophageal cancer with tracheobronchial invasion

BACKGROUND

In T4 esophageal cancer with tracheobronchial invasion, an esophagorespiratory fistula (ERF) often occurs during or after chemoradiotherapy. We have performed esophageal bypass operations prior to definitive chemoradiotherapy for these patients to increase the chemoradiotherapy completion rate by minimizing the potential effect of an ERF. The aim of this study was to examine the clinical outcome of esophageal bypass surgery prior to chemoradiotherapy.

METHODS

Between 1997 and 2010, 17 patients underwent esophageal bypass surgery followed by definitive chemoradiotherapy for esophageal cancer with tracheobronchial invasion (bypass group). Ten patients in the same circumstances were treated with chemoradiotherapy alone (control group). Overall survival, the clinical effect of chemoradiotherapy, the ERF incidence rate, and the safety of esophageal bypass surgery were assessed.

RESULTS

The overall response rate to chemoradiotherapy was 64.7% in the bypass group and 90.0% in the control group. Except for 2 patients with ERF at initial diagnosis, 4 (26.7%) of the 15 patients developed ERF in the bypass group, and 3 (30.0%) of the 10 patients developed ERF in the control group during or after chemoradiotherapy. The 2-year and 3-year overall survival rates were 17.6% and 17.6% in the bypass group and 20.0% and 0% in the control group, respectively (p = 0.924); long-term survival of more than 3 years was seen only in the bypass group.

CONCLUSIONS

Esophageal bypass surgery prior to definitive chemoradiotherapy could be performed safely, and this strategy contributed to long-term survival in the patients who achieved a good response to chemoradiotherapy but developed an ERF.

Tailoring esophageal cancer surgery

Esophageal cancer is a significant source of major mortality worldwide and is increasing dramatically in incidence. Without treatment this disease leads rapidly to death, but intervention also carries significant risk, so a carefully tailored approach must be used to maximize oncological efficacy while minimizing the negative consequences of intervention. Careful patient selection based on histologic and anatomic staging, consideration of each patient's clinical variables, appropriately timing chemo- and radiation therapy, and minimizing the morbidity of surgical intervention may significantly improve a patient's chances of surviving this disease, but each must be carefully orchestrated with a tailored approach to treatment. This review will serve as a guide to tailoring surgery for esophageal cancer.

President's address of the 65th annual scientific meeting of the Japanese Association for Thoracic Surgery: challenges for advanced esophageal cancer

Advanced esophageal tumors have been a challenge for surgery since the very beginning, and these challenges continue still today. In the early period of three-field lymphadenectomy (late 1980s), there was no special attention paid to tracheal necrosis after such an extended operation. In 1988, we reported functional mediastinal dissection preserving the right bronchial artery to prevent such complications. In 1993, we reported that the survival after three-field lymphadenectomy was better than that after en-bloc esophagectomy, and then the lymph node compartment classification based on the metastatic rate and the survival rate. This concept was introduced into the 9th edition of the Guidelines for Clinical and Pathologic Studies on Carcinoma of the Esophagus published in 1999. In early 1980s, combined resection of the neighboring organs was initiated for a locally advanced esophageal cancer. Almost all patients who underwent such an operation, however, died of metastasis in the short-term after surgery without any additional treatment. In 1987, we reported several types of tracheal repair using the latissimus dorsi muscle flap, as a less-invasive surgery that enabled adjuvant or additive therapy, after resection of the trachea involved by cancer. Then in 2004, we demonstrated that the canine aorta could be resected even immediately after aortic stenting. This suggests that an esophageal cancer involving the aorta can be resected using a new technique. To meet the challenges posed by advanced esophageal cancer, the help of other specialized fields besides esophageal surgery is needed: "The specialist must know everything of something, something of everything."

Management of advanced-stage operable esophageal cancer

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.

Clinical relevance of induction triplet chemotherapy for esophageal cancer invading adjacent organs

BACKGROUND AND OBJECTIVES

There is no consensus on treatment for esophageal cancer invading adjacent organs (T4), but induction multidrug chemotherapy may be a beneficial, especially when surgery is considered as adjuvant treatment.

METHODS

We classified 169 patients with T4 esophageal cancer without distant metastasis into those undergoing chemotherapy using cisplatin and 5-FU (CF) plus adriamycin or CF plus docetaxel (79 patients) and those undergoing chemoradiotherapy using CF (90 patients). For the former group, chemoradiation was subsequently applied when surgical resection was not indicated.

RESULTS

Thirty-four patients in the chemotherapy group (43.0%) received chemoradiotherapy following chemotherapy. Although the response rate tended to be higher in the chemoradiotherapy group, there was no significant difference in the response rate between the groups (63.3% vs. 68.9%). Esophageal perforation during treatment was more frequent among the chemoradiotherapy group than the chemotherapy group (16.7% vs. 6.3%, P=0.0379). The rate of surgical resection was consequently higher for the induction chemotherapy group compared to the chemoradiotherapy group (72.1% vs. 45.6%, P=0.0005).

CONCLUSIONS

Induction triplet chemotherapy reduced esophageal perforation and increased the resectability of T4 esophageal cancers by combining second-line chemoradiotherapy. This strategy might increase the chance of curative resection for patients with T4 esophageal cancer.

Treatment of T4 esophageal cancer. Definitive chemo-radiotherapy vs chemo-radiotherapy followed by surgery

The outcome of patients with T4 esophageal cancer, defined as a tumor that invades neighboring structures (e.g., aorta, trachea, bronchus, and lung), is extremely poor. Despite recent advances in surgical techniques, these tumors are usually considered inoperable. Two distinct therapeutic options are currently available for T4 esophageal cancers: chemo-radiotherapy followed by surgery (CRT-S), which comprises esophagectomy following down-staging of the tumor by CRT, and definitive chemo-radiotherapy (D-CRT), which is designed to avoid esophagectomy by using maximum doses of irradiation. CRT-S is superior to D-CRT with respect to local control and short-term survival although CRT-S is associated with relatively higher perioperative mortality and morbidity. On the other hand, it is sometimes difficult to achieve local control with D-CRT and the treatment often results in fistula formation, though a complete response to CRT is often associated with better prognosis. Admittedly, the difference in the survival rate between the two modalities is marginal at long-term follow-up due to operative morbidity and inadequate control of distant metastasis in CRT-S. Changes in perioperative management and intensive systemic chemotherapy may enhance the outcome. Randomized controlled trials involving large population samples are needed to define the standard treatment for T4 esophageal cancer.