Prognostic significance of total disease length in esophageal cancer

The prognostic impact of tumor length on pathological stage IA-IC esophageal adenocarcinoma

This study was completed to evaluate the relationship between tumor length and the prognosis of patients with pathological stage IA-IC esophageal adenocarcinoma (EAC). Patients were identified from the Surveillance, Epidemiology, and End Results Program database (United States, 2006-2015). X-tile software and ROC analysis were mainly used to explore the best threshold of tumor length for dividing patients into different groups, and then propensity score matching (PSM) was used to balance other variables between groups. The primary outcome assessed was overall survival (OS). A total of 762 patients were identified, and 500 patients were left after PSM. Twenty millimeters were used as the threshold of tumor length. Patients with longer tumor lengths showed worse OS (median: 93 vs. 128 months; P = 0.006). Multivariable Cox regression analysis showed that longer tumor length was an independent risk factor (hazard ratio 1.512, 95% confidence interval, 1.158-1.974, P = 0.002). Tumor length has an impact on patients with pathological stage IA-IC EAC who undergo surgery alone. The prognostic value of the pathological stage group may be improved after combining it with tumor length and age.

Tumour length as an independent prognostic factor in resectable oesophageal carcinoma

INTRODUCTION

Oesophageal longitudinal tumour length has been investigated as a prognostic indicator for disease recurrence and overall survival in resectable oesophageal carcinoma. However, there is conflicting evidence regarding its use in clinical practice. This study aims to assess the prognostic significance of histological tumour length in potentially curative oesophageal resections for cancer.

MATERIALS AND METHODS

Patients with locally advanced oesophageal carcinoma (squamous or adenocarcinoma) were identified in a single centre between July 2000 and December 2016. Patient demographics, tumour characteristics and survival outcomes were assimilated. Unifactorial and multifactorial analysis was performed to assess tumour length correlation with oncological outcomes.

RESULTS

A total of 281 patients were included; 226 (80.4%) male and 55 (19.6%) female, with a median age of 66 years; 39 patients (13.9%) developed local recurrence and 104 (37%) distant metastases. Disease progression rate was 44.8% with a median progression-free survival of 21 months and median overall survival of 30 months. Median tumour length was 3cm (interquartile range 2-4.5cm). Multivariate analysis demonstrated longer tumours to be significantly associated with a higher rate of local recurrence (p=0.028), metastases (p=0.016), disease progression (p=0.001) and shorter progression-free survival (p=0.001).

DISCUSSION

This study demonstrates histological tumour length as an independent prognostic factor for local recurrence, metastases, disease progression and progression-free survival. Further larger multicentre studies are required to define the role of longitudinal tumour length as a marker to identify patients who are at higher risk of poor oncological outcomes following surgery.

Prognostic relevance of serial endoscopic ultrasound after chemoradiation in esophageal cancer

The objective of this study is the feasibility of sequential endoscopic and endosonographic measurement of locoregional tumor load for the prediction of tumor recurrence in patients after neoadjuvant or definitive chemoradiotherapy, treated in curative intent for locally advanced esophageal carcinoma. In 67 patients with esophageal cancer, serial endoscopic ultrasound was performed before and after neoadjuvant (25) or definitive (42) chemoradiotherapy. Rate of complete endoscopic and endosonographic tumor response, reduction in tumor length or circumferential tumorous extension, maximal tumor thickness, lymph node size, and endosonographic uT- and uN-stage shift was measured. Results were correlated with tumor recurrence rate. After chemoradiotherapy, endosonography revealed a complete response of the primary tumor in 27 patients, and complete resolution of suspicious lymph nodes in 24 patients. According to uTN-stage, 43 patients showed a therapeutic response, with stage shift to a lower tumor stage. In patients with macroscopic residual disease, mean tumor thickness decreased from 13 to 9 mm, with nine patients presenting with a decrease of >50%. Mean tumor length decreased from 5.6 to 4.6 cm, with 10 patients showing a decrease of >50%. Mean lymph node size decreased from 14.5 to 12 mm, with four patients having a reduction in size of >50%. Tumor response was generally more pronounced after definitive than after neoadjuvant chemoradiotherapy. During follow-up, 33 patients developed a tumor recurrence. None of the endoscopic and endosonographic parameter analyzed was predictive for patient's prognosis, irrespective of the kind of chemoradiotherapy (neoadjuvant or definitive). Sequential measurement of locoregional tumor load with endoscopic ultrasound before and after chemoradiotherapy is not suitable for the prediction of tumor recurrence risk.

Significance of baseline FDG-PET/CT scan as a method of staging regional lymph nodes in patients with operable distal oesophageal or gastroesophageal junction adenocarcinoma

BACKGROUND

The new American Joint Committee on Cancer eighth edition (AJCC8) staging is the first to describe separate clinical and pathology staging systems, but still has low performance to predict prognosis in patients with oesophageal/gastroesophageal junction (O/GOJ) adenocarcinoma, who are candidates for surgery. Recent studies have demonstrated that O/GOJ cancer patients with 18F-fluorodeoxyglucose (FDG) avid regional lymph nodes (RLNs) may have poor prognosis. The aim of our study was to examine whether the baseline assessment of the FDG uptake of RLN improves the prognostic accuracy of the new AJCC8 staging.

PATIENTS AND METHODS

This single-centre retrospective study included patients with operable FDG avid O/GOJ adenocarcinoma treated with perioperative chemotherapy. All patients were reclassified according to the new AJCC8 clinical staging. Prognostic factors for time-to-progression (TTP) and overall survival (OS) were explored.

RESULTS

Of 430 patients included in the study, 180 (41.9%) had FDG avid RLN at baseline PET/CT scan before starting perioperative chemotherapy. The presence of FDG avid RLN was significantly and independently associated with shorter TTP and OS, especially in clinical stage III patients (p < .001 in both cases). Stage III patients with FDG avid RLN had similar TTP and OS to those with stage IVA. Classifying stage III patients with FDG avid RLN into stage IVA led to a significant improvement of the prognostic accuracy of the new AJCC8 clinical staging system (Harrell's concordance index improved from 0.555 to 0.588, p < .001). Of 430 patients starting perioperative chemotherapy, 332 underwent radical tumour resection. The presence of FDG avid RLN before starting perioperative chemotherapy could additionally predict a significantly shorter postoperative time-to-relapse and OS (p < .001 in both cases).

CONCLUSIONS

We propose that the incorporation of RLN status (by FDG PET/CT scan) into the AJCC8 staging system of O/GOJ adenocarcinoma improves its prognostic accuracy and may also improve treatment stratification.

Prognostic and predictive significance of tumor length in patients with esophageal squamous cell carcinoma undergoing radical resection

Background

The objective of this study was to investigate the prognostic and predictive significance of tumor length in patients with esophageal squamous cell carcinoma undergoing radical resection.

Methods

Tumor length and other clinicopathological variables were retrospectively evaluated in 1435 patients with squamous cell carcinoma treated with radical resection between 2003 and 2010. Tumor length was analyzed as categorical and continuous variable. Associations with overall survival were assessed with Cox proportional hazards models. Model-based nomograms were constructed. Predictive accuracy was measured with C-index. Decision curve analysis was used to evaluate clinical usefulness of prediction models.

Results

Both categorically and continuously coded tumor length were independent prognostic factors in multivariable analysis. Adding categorically and continuously coded tumor length to TNM staging model increased predictive accuracy by 0.2 and 0.4 % respectively. Decision curve analysis revealed that the models built by the addition of categorically or continuously coded tumor length did not perform better than TNM staging model.

Conclusions

Tumor length is an independent prognostic factor in patients with esophageal squamous cell carcinoma treated with radical resection. It increases predictive accuracy of TNM staging system for overall survival in these patients. But it does not increase clinical usefulness of TNM staging system as a prediction model.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2417-8) contains supplementary material, which is available to authorized users.

Prognostic factors in patients after definitive chemoradiation using involved-field radiotherapy for esophageal cancer in a phase II study

BACKGROUND

A prospective study was performed on the use of chemoradiotherapy (CRT) for esophageal cancer (EC) with involved-field radiation therapy (IFRT), based on 18-fluorodeoxyglucose positron-emission tomography. Prognostic factors for overall survival (OS) were analyzed.

METHODS

Eligible patients included 63 adults with newly diagnosed, untreated, inoperable stage I-IV EC with lymph node metastases. Patients received 80 mg/m² nedaplatin per day on day 1, 800 mg/m² 5-fluorouracil on days 1-4 intravenously repeated every 28 days for two to four cycles, and combined IFRT. Irradiation was applied only to the primary tumor and positive lymph nodes.

RESULTS

Three-year progression-free survival and OS rates were 44.9% and 47.5%, respectively. The median survival time was 31.5 months. In univariate analyses for OS, Karnofsy Performance Scale <90% (P = 0.027), initial stage (P = 0.0087), T stage (P = 0.066), N stage (P = 0.000086), M stage of M1 (P = 0.0042), dysphagia score (P = 0.00017), tumor marker squamous cell carcinoma antigen >1.5 ng/mL (P = 0.0054), gross tumor volume (GTV) > 60 cc (P = 0.00011), and relative dose intensity (RDI) of chemotherapy ≤50% (P = 0.063) were found to be associated with significantly or marginally worse OS. In multivariate analyses for OS, GTV ≥ 60 cc (P = 0.00040), RDI < 50% (P = 0.00034), and cN2-3 (P = 0.0020) were associated with significantly worse OS.

CONCLUSION

GTV, RDI and N grading, were associated with OS after definitive CRT using IFRT for EC.

Prediction of survival by tumor area on endosonography after definitive chemoradiotherapy for locally advanced squamous cell carcinoma of the esophagus

BACKGROUND

Definitive chemoradiotherapy (CRT) is a reasonable approach for patients with locally advanced esophageal cancer who are not surgical candidates. This study was performed to investigate whether endosonography (EUS) assessment of tumor area response is a useful prognostic marker in patients with squamous cell carcinoma (SCC) of the esophagus who receive definitive CRT.

METHODS

A total of 33 patients who received definitive CRT for locally advanced esophageal SCC were enrolled. The maximal transverse cross-sectional area of the tumor was measured before and after definitive therapy. EUS response was defined as a ≥50% reduction of the tumor area after definitive CRT.

RESULTS

Based on EUS evaluation, there were 20 nonresponders (60.6%) and 13 responders (39.4%). The median progression-free survival (PFS) was significantly longer in EUS responders than EUS nonresponders (p = 0.005). However, there was no statistical significance in overall survival according to EUS response (p = 0.120). During multivariate analysis, EUS response to definitive CRT was the only significant factor associated with PFS (p = 0.045), whereas EUS response to definitive CRT was not associated with overall survival (p = 0.221).

CONCLUSIONS

A reduction of the maximal cross-sectional tumor area measured by EUS correlates with a superior prognosis in patients with locally advanced SCC of the esophagus after definitive CRT.

Impact of tumor length on survival for patients with resected esophageal cancer

BACKGROUND

Tumor length in patients with esophageal cancer (EC) has recently received great attention. However, its prognostic role for EC is controversial. The purpose of our study was to characterize the prognostic value of tumor length in EC patients and offer the optimum cut-off point of tumor length by reliable statistical methods.

MATERIALS AND METHODS

A retrospective analysis was conducted on 71 consecutive patients with EC who underwent surgery. ROC curve analysis was used to determine the optimal cut-off point for tumor length, measured with a handheld ruler after formalin fixation. Correlations between tumor length and other factors were surveyed, and overall survival (OS) rates were compared between the two groups. Potential prognostic factors were evaluated by univariate Kaplan-Meier survival analysis. A P value less than 0.05 was considered significant.

RESULTS

There were a total of 71 patients, with a male/ female divide of 43/28 and a median age of 59. Characteristics were as follows: squamous/adenocarcinoma, 65/6; median tumor length, 4 (0.9-10); cut-off point for tumor length, 4cm. Univariate analysis prognostic factors were tumor length and modality of therapy. One, three and five year OS rates were 84, 43 and 43% for tumors with ≤4cm length, whereas the rates were 75, 9 and 0% for tumors >4 cm. There was a significant association between tumor length and age, sex, weight loss, tumor site, histology, T and N scores, differentiation, stage, modality of therapy and longitudinal margin involvement.

CONCLUSIONS

Future studies for modification of the EC staging system might consider tumor length too as it is an important prognostic factor. Further assessment with larger prospective datasets and practical methods (such as endoscopy) is needed to establish an optimal cut-off point for tumor length.

Feasibility RCT of definitive chemoradiotherapy or chemotherapy and surgery for oesophageal squamous cell cancer

Background:

The optimal treatment for localised oesophageal squamous cell carcinoma (SCC) is uncertain. We assessed the feasibility of an RCT comparing neoadjuvant treatment and surgery with definitive chemoradiotherapy.

Methods:

A feasibility RCT in three centres examined incident patients and reasons for ineligibility using multi-disciplinary team meeting records. Eligible patients were offered participation in the RCT with integrated qualitative research involving audio-recorded recruitment appointments and interviews with patients to inform recruitment training for staff.

Results:

Of 375 patients with oesophageal SCC, 42 (11.2%) were eligible. Reasons for eligibility varied between centres, with significantly differing proportions of patients excluded because of total tumour length (P=0.002). Analyses of audio-recordings and patient interviews showed that recruiters had challenges articulating the trial design in simple terms, balancing treatment arms and explaining the need for randomisation. Before analyses of the qualitative data and recruiter training no patients were randomised. Following training in one centre 5 of 16 eligible patients were randomised.

Conclusions:

An RCT of surgical vs non-surgical treatment for SCC of the oesophagus is not feasible in the UK alone because of the low number of incident eligible patients. A trial comparing diverse treatment approaches may be possible with investment to support the recruitment process.

Prognostic significance of novel ¹⁸F-FDG PET/CT defined tumour variables in patients with oesophageal cancer

PURPOSE

(18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) combined with computed tomography (PET/CT) is now established as a routine staging investigation of oesophageal cancer (OC). The aim of the study was to determine the prognostic significance of PET/CT defined tumour variables including maximum standardised uptake value (SUVmax), tumour length (TL), metastatic length of disease (MLoD), metabolic tumour volume (MTV), total lesion glycolysis (TLG) and total local nodal metastasis count (PET/CT LNMC).

MATERIALS AND METHODS

103 pre-treatment OC patients (76 adenocarcinoma, 25 squamous cell carcinoma, 1 poorly differentiated and 1 neuroendocrine tumour) were staged using PET/CT. The prognostic value of the measured tumour variables were tested using log-rank analysis of the Kaplan-Meier method and Cox's proportional hazards method. Primary outcome measure was survival from diagnosis.

RESULTS

Univariate analysis showed all variables to have strong statistical significance in relation to survival. Multivariate analysis demonstrated three variables that were significantly and independently associated with survival; MLoD (HR 1.035, 95% CI 1.008-1.064, p=0.011), TLG (HR 1.002, 95% CI 1.000-1.003, p=0.018) and PET/CT LNMC (HR 0.048-0.633, 95% CI 0.005-2.725, p=0.015).

CONCLUSION

MLoD, TLG, and PET/CT LNMC are important prognostic indicators in OC. This is the first study to demonstrate an independent statistical association between TLG, MLoD and survival by multivariable analysis, and highlights the value of staging OC patients with PET/CT using functional tumour variables.

Analysis of the tumor length and other prognosis factors in pT1-2 node-negative esophageal squamous cell carcinoma in a Chinese population

BACKGROUND

Tumor length is an important prognostic factor for many carcinomas, but its role in esophageal cancer remained undetermined. The aim of this study was to investigate the effect of tumor length on survival for patients with confined tumors (grade pT1-2) without lymph-node metastases in esophageal squamous cell carcinoma.

METHODS

We enrolled 201 patients with esophageal squamous cell carcinoma (SCC) who had undergone surgical resection and been confirmed as pT1-2N0M0. The relationship of tumor length with overall survival was assessed and compared with other factors detailed in the American Joint Committee on Cancer (AJCC) tumor, node, metastasis (TNM) staging system published in 2009.

RESULTS

The overall survival (OS) rates at 1, 3, and 5 years were 93.0%, 83.7%, and 69.2%, respectively. The tumor length adversely affected OS, with the 5-year rate being 93.5%, 82.0%, 68.6%, 67.9%, 55.3% and 41.1%, respectively for tumor lengths of less than 10 mm, 10 to 20 mm, 20 to 30 mm, 30 to 40 mm, 40 to 50 mm, and greater than 50 mm (P< 0.001). Multivariate analyses showed that the pathologic T classification and grade of tumor was significantly associated with OS. Tumor length of 30 mm or more remained an independent prognostic factor (P = 0.04), as did the other current TNM factors.

CONCLUSION

Tumor length appears to affect the OS of patients with early-stage esophageal squamous cell carcinoma. It may provide additional prognostic information for the current TNM staging system.

Prognostic significance of 18-FDG PET/CT and EUS-defined tumour characteristics in patients with oesophageal cancer

AIM

To determine the correlation between 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography/computed tomography (PET/CT) defined maximum standardized uptake value (SUVmax) and endoluminal ultrasound-defined tumour volume (EDTV) in patients with oesophageal cancer (OC) and their relative prognostic significance.

MATERIALS AND METHODS

One hundred and eighty-five consecutive patients with OC were staged using CT, endoscopic ultrasound (EUS), and PET/CT. The maximum potential EDTV was calculated (πr(2)L, where r = tumour thickness and L = total length of disease including proximal and distal lymph node metastases). Primary outcome measure was survival from diagnosis.

RESULTS

Ninety-one percent of patients (168/185) had FDG-avid tumours on PET/CT. SUVmax correlated positively and significantly with EDTV (Spearman's rho = 0.339, p = 0.001). On univariate analysis, survival was inversely related to the PET/CT lymph node metastasis count (LNMC, p = 0.015), EUS N stage (p = 0.002), EDTV (<48 cm(3), p = 0.001), EUS total length of disease (p = 0.001), SUVmax (p = 0.002), PET/CT N stage (p < 0.0001), and EUS LNMC (p < 0.0001). On multivariate analysis two factors were significantly and independently associated with survival: EDTV (HR, 3.118; 95% CI: 1.357-7.167; p = 0.007), and PET/CT N stage (HR, 0.496; 95% CI: 0.084-1.577; p = 0.022).

CONCLUSION

EDTV and PET/CT N stage were important predictors of survival and further research is needed to identify critical prognostic values.