Cervical Esophageal Cancers: Challenges and Opportunities

Combined Chemotherapy and Immunotherapy Induction for Screening of Patients with Cervical Esophageal Carcinoma for Subsequent Local Treatment: A New Treatment Paradigm

BACKGROUND

Definitive chemoradiotherapy is recommended as the primary treatment for cervical esophageal carcinoma (CEC). However, local control rates remain unsatisfactory for some patients. Therefore, in this study, we introduced a new treatment paradigm for individuals with CEC, customizing the choice between subsequent local treatments based on their response to induction chemotherapy and immunotherapy.

PATIENTS AND METHODS

Induction treatment comprised two to four cycles of chemotherapy combined with programmed cell death protein 1 (PD-1) inhibitors. Patients achieving complete response (CR) or near CR after induction treatment underwent definitive chemoradiotherapy (dCRT), while those not achieving CR or near CR underwent surgical resection.

RESULTS

Among the 40 eligible patients, 14 (35.0%) achieved a CR or near CR after induction treatment. Of the ten patients achieving a CR or near CR, one developed an esophageal fistula after dCRT (10.0%). Among the eight non-CR or non-near CR patients receiving chemoradiotherapy, six developed esophageal fistula (75.0%). Among the 26 patients who did not achieve CR or near CR after induction treatment, the 1-year cancer specific survival (CSS) rates were 93.3% [95% confidence interval (CI) 0.815-1%] for the 18 patients in the surgery group, and 71.4% (95% CI 0.447-1%) for the 8 patients in the chemoradiotherapy group (p = 0.027). The overall laryngeal preservation rate was 85.0% (34/40), with a functional laryngeal preservation rate of 77.5% (31/40).

CONCLUSION

The approach consisting of combined immunotherapy and chemotherapy successfully identified patients who were responding well to induction treatment and who were sensitive to radiotherapy, for chemoradiotherapy; thus, improving laryngeal preservation rates. In addition, it also identified patients with poor responses to induction treatment and radiotherapy, for timely surgery; hence, reducing radiotherapy complications and enhancing survival.

Treatment and Outcomes of Proximal Esophageal Squamous Cell Carcinoma

INTRODUCTION

This study evaluated the treatment of proximal (cervical or upper thoracic) esophageal squamous cell carcinoma (SCC), for which chemoradiation is the recommended therapy.

METHODS

Treatment and outcomes of patients with cT1-3N0-1M0 proximal esophageal SCC in the National Cancer Database between 2004 and 2016 was evaluated using logistic regression, Kaplan-Meier analysis, and propensity-score matching.

RESULTS

Therapy of 2159 patients was chemoradiation (n = 1500, 69.5%), no treatment (n = 205, 9.5%), surgery (n = 203, 9.4%), radiation alone (n = 190, 8.8%), and chemotherapy alone (n = 61, 2.8%). Factors associated with definitive therapy with either chemoradiation or surgery were younger age, non-Black race, being insured, cervical tumor location, clinical T2 and T3 stage, clinical nodal involvement, and treatment at a research/academic program. Five-year survival was significantly better in patients treated with definitive therapy than patients not treated definitively (34.0% vs. 13.3%, p < 0.001). In multivariable survival analysis, receiving definitive therapy (hazard ratio [HR] 0.39, p = 0.017) was associated with improved survival, while increasing age, male sex, clinical T3 stage, positive clinical nodal involvement, and increasing Charlson Comorbidity Index were associated with worse survival. Esophagectomy was not associated with improved survival in multivariable analysis of the definitive therapy cohort (HR 0.84, p = 0.08) or propensity matched analysis. However, the pathologic complete response was only 33.3% (40/120) for patients who did have an esophagectomy after chemoradiation.

CONCLUSIONS

This national analysis supports definitive chemoradiation for not only cervical but also proximal thoracic esophageal SCC. Routine surgery does not appear to be necessary but may have a role in patients with residual disease after chemoradiation.

Oncological outcomes of cervical esophageal cancer treated primarily with surgery: a systematic review and meta-analysis

PURPOSE

To determine the oncological outcomes of cervical esophageal cancer (CEC) treated primarily with surgery.

METHODS

A systematic review and meta-analysis was performed according to the PRISMA guidelines.

RESULTS

A total of 868 patients were included from 18 studies. Estimated pooled Overall Survival (OS) rates (95% Confidence Interval, CI) at 1 and 5 years were 74.4% (66.5-83.3), and 26.6% (20.3-34.7), respectively. Larynx non-preserving surgery (n = 229) showed an estimated pooled OS rates (95% CI) at 1 and 5 years of 59.3% (51.5-68.2) and 14.6% (8.8-24.3), respectively. On the other hand, larynx preserving surgery (n = 213) showed an estimated pooled OS rates (95% CI) at 1 and 5 years of 83.6% (78.2-89.4) and 35.1% (24.9-49.6), respectively.

CONCLUSIONS

Primary larynx-preserving surgery remains a valuable option for the management of CEC, with similar survival outcomes compared to primary chemoradiotherapy (CRT). On the other hand, larynx non-preserving surgery showed a significantly reduced survival, that may reflect the more advanced T classification of these tumors. Further studies are mandatory to directly compare primary surgery and primary CRT, distinguishing larynx preserving and non-preserving surgery.

Prognostic values of the gross volume of metastatic lymph nodes in patients with esophageal squamous cell carcinoma treated with definitive concurrent chemoradiotherapy

Purpose

We aim to explore whether the gross volume of metastatic lymph nodes (GTVnd) and the gross volume of primary tumor (GTVp) could be prognostic factors for esophageal squamous cell carcinoma (ESCC) patients treated with definitive concurrent chemoradiotherapy (dCCRT).

Methods

We retrospectively analyzed 252 ESCC patients treated with dCCRT in the era of intensity-modulated radiation therapy (IMRT) at our institution. The cut-off value for the GTVnd derived from the restricted cubic splines (RCS) was determined. Univariate and multivariate Cox proportional hazard models were performed to determine the association between GTVnd and prognosis. we performed recursive partitioning analysis (RPA) method using GTVnd to develop a new risk stratification (TGTVndM). Moreover, the linear trend χ2, likelihood ratio χ2, and akaike information criterion (AIC) were used to determine the prognostic value between the TNM and TGTVndM staging systems.

Results

The five-year overall survival (OS) rate was 30.6%, with a median follow-up of 38 months. The cut-off value of GTVnd determined by the RCS was 4.35 cm3. GTVnd≥4.35 cm3 was an independent and significant negative prognostic factor for OS (HR=1.949, P&lt;0.001), progression free survival (PFS) (HR=1.425, P=0.048), and distance metastasis free survival (DMFS) (HR=2.548, P=0.001). In multivariable analysis, gender, clinical T stage, and GTVnd were independently associated with OS. RPA segregated patients into 3 prognostic groups: high risk (T1-4 GTVnd≥4.35, n=126, III stage), intermediate risk (T4 GTVnd&lt;4.35,n=38,II stage), and low risk(T1-3GTVnd&lt;4.35, n=88, I stage). The 5-year OS(P&lt;0.001), PFS (P=0.002), and DMFS (P=0.001) were significantly worse in high-risk group in comparison with the intermediate and low risk groups. Compared with the TNM staging system, the clinical T stage combined with GTVnd (TGTVndM) had a higher linear trend χ2 (26.38 versus 25.77), higher likelihood ratio χ2 (24.39 versus 20.69), and lower AIC (1255.07 versus 1260.06).

Conclusions

GTVnd may serve as a good prognostic factor in predicting distant metastasis and death for ESCC patients treated with dCCRT. The TGTVndM staging system demonstrated superior accuracy for predicting OS and could serve as a more effective prognostic guidance for unresectable ESCC patients.

A modified tracheal transection approach for cervical esophageal lesion treatment: A report of 13 cases

Background

Surgical interventions for tumors in the cervical esophageal region are complicated and laryngeal function is frequently sacrificed. Therefore, we attempted the tracheal transection approach to resect the tumor while preserving laryngeal function.

Methods

Three patients with papillary thyroid cancer (PTC), six with cervical esophageal cancer (CEC), and four with CEC mixed with thoracic esophageal cancer (TEC) were enrolled. The esophagus was exposed after the trachea was transected between the second and third tracheal rings. CEC/TEC: Resection of the esophagus or/and a portion of the hypopharynx with acceptable safety margins and repair with free jejunum or tubular stomach. PTC: Suture the small esophageal incision immediately after removing the tumor. The tracheal dissection was repaired with interrupted sutures throughout the entire layer after the esophageal lesion was resected. The status of the recurrent laryngeal nerve (RLN) determined whether a tracheotomy was necessary.

Results

All 13 patients had effective esophageal lesion excision, with six of them requiring intraoperative tracheotomy. Postoperative complications included a tracheoesophageal fistula (one case, 7.7%), postoperative RLN paralysis (two cases, 15.4%), and aspiration (three cases, 23.1%). Except for two patients with distant metastases, there was no recurrence in the remaining patients after 5-92 months of follow-up.

Conclusion

The tracheal transection approach, as a new surgical technique, can retain laryngeal function while ensuring appropriate exposure and satisfactory surgical resection. Before surgery, the feasibility of this approach must be carefully assessed. The RLN should be protected during the procedure. The operation is both safe and effective, with a wide range of applications.

Real-world treatment patterns and outcomes in Japanese patients with cervical esophageal cancer

BACKGROUND

Cervical esophageal cancer (CEC) carries a poor prognosis; however, due to its low incidence, optimal treatment for CEC remains to be established. The purpose of this study was to clarify the current status of treatment of CEC in Japan and obtain evidence for establishing the appropriate treatment method.

PATIENTS AND METHODS

We asked specialist training facilities accredited by the Japanese Broncho-Esophageal Society to register data on CEC cases that received curative treatment from January 2009 to December 2014, and conducted a retrospective review of the clinical data of 302 cases registered from 27 facilities.

RESULTS

In regard to the initial therapy, of the 302 patients, 33 had undergone endoscopic resection, 41 had undergone surgery, 67 had received induction chemotherapy (IC), and 143 had received chemoradiotherapy (CRT). There were no significant differences in the 5-year overall survival rates among the patient groups that had received surgery, IC or CRT as the initial treatment; advanced stage and recurrent nerve invasion were identified as independent poor prognostic factors. Among the patients who had received IC or CRT as laryngeal-preserving surgery was not indicated at the time of the initial diagnosis, the functional laryngeal preservation rate at the end of the observation period was 34.8%.

CONCLUSION

Even in patients with advanced CEC, there is the possibility of preserving the larynx by adopting IC or CRT. However, if the laryngeal function cannot be preserved, there is a risk of complications from aspiration pneumonia, so that the choice of treatment should be made carefully.

Surgical outcomes of oro-intestinal continuity reconstruction after total esophagectomy in patients with cervicothoracic malignancy: a thoracic surgeon's perspective

Background

Oro-intestinal continuity reconstruction following total esophagectomy in patients with head-neck or esophageal cancer is rare and results in high operative morbidity and mortality. This case series aimed to investigate the perioperative surgical outcomes of oro-intestinal continuity reconstruction after total esophagectomy in selected patients with advanced head/neck or esophageal cancer.

Methods

From 2011 to 2018, 14 patients who underwent oro-intestinal reconstruction after total esophagectomy were assessed. We analyzed perioperative mortality, postoperative complications, oncologic outcomes, and recovery of dietary function.

Results

The median age of the patients was 61 (range, 42–72) years old and median follow-up time was 18.6 (range, 0–52.9) months. For conduit selection, 11 cases of oro-gastrostomy (78.6%), 2 of oro-colo-gastrostomy (14.3%), and 1 of oro-jejuno-gastrostomy (7.1%) were performed. Complete resection was pathologically confirmed in 10 patients (71.4%). Anastomosis site leakage was observed in three patients (21.4%) and conduit necrosis in two (14.3%). Postoperative mortality within 30 days, 90 days, and 1 year was 7.1%, 28.6%, and 42.8%, respectively.

Conclusions

Oro-intestinal continuity reconstruction following total esophagectomy showed acceptable morbidity and mortality in selected patients with advanced head/neck cancer or esophageal cancer. Careful selection of surgical candidates and multidisciplinary collaboration of experienced surgical teams are essential to minimize the surgical risk.

Oncological results and morbidity following intended curative resection and free jejunal graft reconstruction of cervical esophageal cancer: a retrospective Danish consecutive cohort study

BACKGROUND

The role of surgery in treatment of locally advanced cervical esophageal cancer (CEC) remains debated. In the European and American treatment guidelines, definitive chemoradiotherapy (dCRT) is preferred over surgery, while in the Danish guidelines, the two treatment modalities are equally recommended. Surgical treatment of CEC is centralized at our center in Denmark. We present our outcomes following neoadjuvant chemoradiotherapy (nCRT) when possible and resection as first-line therapy for CEC and compare with recent published dCRT results.

METHOD

We retrospectively reviewed the medical charts of patients treated for cervical esophageal cancer at Aarhus University Hospital from 2001-2018 with nCRT when possible and pharyngolaryngectomy followed by reconstruction with a free jejunal graft.

RESULTS

Forty consecutive patients were included. About, 45% received nCRT. The median survival was 21 months. The overall, disease-specific and disease-free 5-year survival was 43.6%, 53.2%, and 47.4%, respectively. The rate of microscopically radical resection was 85%. The recurrence rate was 47% and 81% of recurrences were locoregional. The in-hospital and 30-day mortality rate was 0%. Major complications occurred in 27.9%. Anastomotic leakage, graft failure, fistulas and strictures occurred in 10%, 7.5%, 30%, and 30%, respectively.

CONCLUSION

Our treatment offers equal oncological results compared to the best internationally published results for dCRT for CEC. Results vary considerably between dCRT studies. Morbidity appears more pronounced following surgery. Future studies are warranted to investigate the Danish national outcomes following dCRT as first-line treatment for curable locally advanced CEC.

Update on Management of Squamous Cell Esophageal Cancer

PURPOSE OF THE REVIEW

Esophageal cancer is the sixth most common cause of cancer death globally. Squamous cell carcinoma of the esophagus (ESCC) is the predominant histologic type in the world. Treatment strategies have evolved in the last decade and new paradigms are replacing traditional approaches at all stages of cancer. This review will summarize the epidemiology, diagnosis, staging, and treatment of esophageal squamous cell carcinoma.

RECENT FINDINGS

Novel approaches to screening may be cost-effective in regions with a high incidence of ESCC. Multi-disciplinary evaluation and treatment has become the standard of care. Endoscopic resection may be an option for early stage ESCC. Minimally invasive esophagectomy can be performed safely as a primary therapy or after-induction chemoradiation. Several recent studies have found a survival benefit to immunotherapy for patients with metastatic or persistent disease. Multi-disciplinary evaluation and multi-modal therapy including cytotoxic chemotherapy, radiation, surgery, and immunotherapy have improved survival compared to surgery alone.

Impact of invasion into cervical esophagus for patients with hypopharyngeal squamous cell carcinoma

OBJECTIVES

The invasion into cervical esophagus (ICE) sometimes could be encountered in patients with hypopharyngeal squamous cell carcinoma (HypoSCC). However, the incidence, predictive factors, and prognostic impact of ICE on the patients with HypoSCC remain unclear.

MATERIALS AND METHODS

Patient diagnosis with HypoSCC at the National Taiwan University Hospital between January 2007 and December 2018 were reviewed. All patients were classified into two groups: with and without ICE. The curative treatment included upfront laryngectomy or pharyngo-laryngo-esophagectomy (PLE) with adjuvant chemoradiation, or definite organ-sparing chemoradiation.

RESULTS

We analyzed 527 HypoSCC patients, 71 (13.47%) with and 456 (86.53%) without ICE. ICE presented more frequently in females (odds ratio (OR) = 3.01, p = 0.03) and posterior pharyngeal wall (OR = 2.34, p = 0.04). The 5-year disease-free survival of patients with and without ICE were 21.7% and 54.1%, respectively (p < 0.0001) and the 5-year overall survival were 13.1% and 53.8%, respectively (p < 0.0001). Among patients with ICE, the disease-free and overall survival of patients with upfront PLE were worse than the patients without upfront PLE (p = 0.21 and p = 0.27, respectively). After multivariant cox analysis, ICE was an independent risk factor for disease-free survival (p < 0.001) and overall survival (p < 0.001).

CONCLUSION

ICE was occasionally present (13.47%) in HypoSCC patients. Unfortunately, the presence of ICE had a significant impact on disease-free and overall survival. For the HypoSCC patients with ICE, organ-sparing chemoradiation should be considered first as upfront PLE had no additional benefit.

Treatment and Prognosis of Resectable Cervical Esophageal Cancer: A Population-based Study

BACKGROUND

The optimal treatment strategy for resectable cervical esophageal cancer (CEC) remains controversial. This study aimed to explore prognostic factors and optimal treatment strategies in the context of staging.

METHODS

In this population-based study, 1371 patients with resectable CEC were identified in the SEER database. Univariate analysis and multivariable Cox regression model were performed to evaluate factors related to overall survival (OS). Subgroup analysis based on staging was performed to assess the effect of treatments on survival and propensity score matching (PSM) was conducted to adjust confounding factors.

RESULTS

Univariate and multivariable analyses revealed that age, sex, year of diagnosis, histological type, tumor size, cN stage, surgery, radiotherapy and chemotherapy are independent prognostic factors. After PSM, patients with local disease (cT_1-2N₀M₀) who received surgery alone had a higher 10-year OS rate than those received chemoradiotherapy (CRT) (20.7% vs. 11.4%, p = 0.023). Compared with CRT, surgery-based multimodal therapy did not increase the OS rate of patients (14.8% vs. 11.1%, p = 0.084). For regional disease (cT_3-4aN₀M₀/cT_1-4aN_1-3M₀), although surgery alone did not improve the OS rate of patients compared with CRT (7.3% vs. 8.2%, p = 0.18), we observed a significant difference in 10-year OS among patients who underwent surgery-based multimodal therapy versus those who underwent CRT (20.4% vs. 9.0%, p = 0.031).

CONCLUSIONS

Compared with CRT, surgery alone improves the long-term survival of patients with localized disease, and surgery-based multimodal therapy increases the survival rate of patients with regional disease. Further studies are required to confirm our findings.

Nomogram to predict overall survival for patients with non-metastatic cervical esophageal cancer: a SEER-based population study

Background

Cervical esophageal cancer (CEC) is an uncommon malignancy with poor prognosis, and there is no specific model that can be used to accurately predict the survival of patients with CEC.

Methods

The Surveillance, Epidemiology, and End Results (SEER) database was searched for patients with non-metastatic CEC from 2004 to 2015. Overall survival (OS) and disease-specific survival (DSS) rates were calculated using the Kaplan-Meier method. Predictive factors were analyzed by Cox's proportional hazards regression, and a nomogram was created to predict survival probability using R software.

Results

We identified 601 patients with CEC, 94.3% of whom had squamous cell carcinoma (SCC). The median follow-up time was 71 months. The median OS and DSS for the overall population were 15 and 18 months, respectively. There was a statistically significant decrease in surgical rates over time, from 16.7% in 2004 to 8% in 2015 (P=0.035). Comprehensive strategies consisting of two or three treatment modalities were correlated with significantly better OS and DSS (P<0.001 for both). We randomly assigned half of the patients to the training cohort (n=300) and the other half to the validation cohort (n=301). Multivariate Cox regression analysis was performed using the training cohort. Age, sex, tumor size, stages in the 7th edition of the American Joint Committee on Cancer (AJCC) staging system, and treatment with surgery, radiotherapy, or chemotherapy were identified as independent risk factors for OS. These factors were incorporated into the development of a nomogram for predicting 1-, 3-, and 5-year OS rates. The C-index of the nomogram was 0.743, which was statistically higher than that of the AJCC staging system. The internal validation, using bootstrap resampling and external validation, demonstrated the accuracy of the nomogram.

Conclusions

We developed and validated the first nomogram for CEC. This nomogram could be used to predict the OS of CEC patients with a relatively high accuracy.