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Depypere L, Thomas M, Moons J, Coosemans W, Lerut T, Prenen H, Haustermans K, Van Veer H, Nafteux P. Analysis of patients scheduled for neoadjuvant therapy followed by surgery for esophageal cancer, who never made it to esophagectomy. World J Surg Oncol 2019; 17:89. [PMID: 31133018 PMCID: PMC6537364 DOI: 10.1186/s12957-019-1630-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 05/14/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Neoadjuvant treatment followed by esophagectomy is standard practice in locally advanced esophageal cancer. However, not all patients who started neoadjuvant treatment will undergo esophageal resection. The purpose of our study was to investigate the group of patients, scheduled for neoadjuvant treatment followed by esophagectomy, who never made it to esophageal resection. METHODS We retrospectively analyzed patients treated between 2002 and 2015 for locally advanced esophageal cancer, who did not undergo esophagectomy after neoadjuvant treatment. Subanalysis was performed according to time period (2002-2010 versus 2011-2015) and histology (adenocarcinoma versus squamous cell carcinoma). RESULTS In 114 of 679 patients (16.8%), surgery was not performed after neoadjuvant treatment. Reasons for cancelation were disease progression (50 patients, 43.9%), poor general condition (26 patients, 22.8%), irresectability (14 patients, 12.3%), patients' own decision (15 patients, 13.2%), and death during neoadjuvant treatment (9 patients, 7.9%). In the second time period, there were less irresectable tumors (17.7% versus 5.8%; p = 0.044). Median overall survival was not different over time (9.2 versus 12.5 months; p = 0.937). Irresectability (p = 0.032), patients' refusal (p = 0.012), and poor general condition (p = 0.002) were more frequent as reasons for cancelation in squamous cell carcinoma patients. Median overall survival was, respectively, 12.5 and 9.9 months for adenocarcinoma and squamous cell carcinoma patients (p = 0.441). The majority of patients refusing surgery had a clinical complete response (73.3%). They had a median overall survival of 33.2 months. CONCLUSIONS One in six patients starting neoadjuvant treatment for locally advanced esophageal cancer never made it to esophagectomy, more than half of them for oncological reasons, but also 1.3% because of death during treatment. Over time, irresectability as reason decreased. As a result, the relative weight of medical inoperability increased, indicating the importance of upfront testing of medical operability. Cancelation of surgery was significantly more common in patients with a squamous cell carcinoma, and this histology seems to represent a more complex oncological and functional entity. Refusal of esophagectomy based on clinical complete response showed a significant survival benefit compared to those who did not undergo esophagectomy because of other reasons.
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MESH Headings
- Adenocarcinoma/mortality
- Adenocarcinoma/pathology
- Adenocarcinoma/surgery
- Adenocarcinoma/therapy
- Adult
- Aged
- Aged, 80 and over
- Carcinoma, Squamous Cell/mortality
- Carcinoma, Squamous Cell/pathology
- Carcinoma, Squamous Cell/surgery
- Carcinoma, Squamous Cell/therapy
- Chemoradiotherapy, Adjuvant/mortality
- Combined Modality Therapy
- Esophageal Neoplasms/mortality
- Esophageal Neoplasms/pathology
- Esophageal Neoplasms/surgery
- Esophageal Neoplasms/therapy
- Esophagectomy/statistics & numerical data
- Female
- Follow-Up Studies
- Humans
- Male
- Middle Aged
- Neoadjuvant Therapy/mortality
- Neoplasm Recurrence, Local/mortality
- Neoplasm Recurrence, Local/pathology
- Neoplasm Recurrence, Local/surgery
- Neoplasm Recurrence, Local/therapy
- Prognosis
- Retrospective Studies
- Survival Rate
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Affiliation(s)
- Lieven Depypere
- Department of Thoracic Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Melissa Thomas
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, KU Leuven, Leuven, Belgium
| | - Johnny Moons
- Department of Thoracic Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Willy Coosemans
- Department of Thoracic Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Toni Lerut
- Department of Thoracic Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Hans Prenen
- Department of Oncology, University Hospital Antwerp, Edegem, Belgium
| | - Karin Haustermans
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
- Department of Oncology, KU Leuven, Leuven, Belgium
| | - Hans Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
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Depypere LP, Moons J, Lerut TE, Coosemans W, Van Veer H, Nafteux PR. Palliative esophagectomy in unexpected metastatic disease: sense or nonsense? Asian Cardiovasc Thorac Ann 2018; 26:552-557. [PMID: 30185072 DOI: 10.1177/0218492318797228] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Despite integrated positron emission tomography and computed tomography screening before and after neoadjuvant treatment in patients with locally advanced esophageal cancer, unexpected metastatic disease is still found in some patients during surgery. Should then esophagectomy be aborted or is there a place for palliative resection? Methods Between 2002 and 2015, 681 patients with potentially resectable esophageal cancer were sheduled for neoadjuvant therapy and subsequent esophagectomy. In 552 patients, a potentially curative esophagectomy was performed. In 12 patients, unexpected disease was discovered during surgery but esophagectomy was performed with synchronous resection of metastases; 10 of them had oligometastatic disease (≤4 single-organ metastases). Esophagectomy was not performed in 117 patients (because of disease progression in 50); 14 were also single-organ oligometastatic. Data of 10 single-organ oligometastatic patients who underwent esophageal resection (group 1) were compared those of 10 non-resected but treated counterparts (group 2) and with 228 patients who underwent potentially curative esophagectomy with persistent pathological lymph nodes (group 3). Results Five oligometastatic esophagectomy patients had lung metastases: 1 peritoneal, 2 adrenal, 1 pleural, and 1 pancreatic. Two oligometastatic non-resected patients had lung, 5 liver, and 3 brain metastases. Median overall survival was 21.4, 12.1, and 20.2 months in the respective groups (group 1 vs. group 2 p = 0.042; group 2 vs. group 3 p = 0.002; group 1 vs. group 3 p = 0.88). Conclusions Survival is longer in patients undergoing palliative esophagectomy with unexpected single-organ oligometastatic disease and comparable to survival in patients with persistent pathological lymph nodes. Palliative resection in these patients seems to be justified.
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Affiliation(s)
- Lieven P Depypere
- Department of Thoracic Surgery, University Hospitals, Leuven, Belgium
| | - Johnny Moons
- Department of Thoracic Surgery, University Hospitals, Leuven, Belgium
| | - Toni E Lerut
- Department of Thoracic Surgery, University Hospitals, Leuven, Belgium
| | - Willy Coosemans
- Department of Thoracic Surgery, University Hospitals, Leuven, Belgium
| | - Hans Van Veer
- Department of Thoracic Surgery, University Hospitals, Leuven, Belgium
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Badakhshi H, Kaul D, Zhao KLE. Association between the inflammatory biomarker, C-reactive protein, and the response to radiochemotherapy in patients with esophageal cancer. Mol Clin Oncol 2016; 4:643-647. [PMID: 27073683 DOI: 10.3892/mco.2016.753] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 01/20/2016] [Indexed: 12/11/2022] Open
Abstract
Locally advanced esophageal cancer has been treated by a multimodality regimen encompassing combined radiochemotherapy (RCT). The tumor response to neoadjuvant RCT is a major determinant of further therapeutic strategies, whether surgery or a continuation of RCT, and therefore, also of the patient's overall prognosis. The present study included patients with histologically proven squamous cell esophageal carcinoma. The C-reactive protein (CRP) level was measured prior to and following the completion of neoadjuvant RCT. Only CRP measurements taken within 2 weeks of the start of RCT were analyzed. Further measurements were then taken at 6, 12, 18, 24, 30, 36 and 40 weeks following RCT. CRP levels were high prior to treatment; however, eventually decreased and normalized following the therapy. In univariate analysis, pre-therapeutic CRP levels had a significant influence on the response rate (P=0.033), whilst post-therapeutic CRP levels had no significant influence (P=0.383). Pre-therapeutic CRP levels, however, not post-therapeutic CRP levels were significantly correlated with the response rate (P=0.045 and P=0.444, respectively), and no association was observed between CRP levels and survival. This preliminary data indicated that the pre-therapeutic serum CRP level is a possible indicator of treatment response to RCT.
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Affiliation(s)
- Harun Badakhshi
- Department of Clinical Radiation Oncology, Ernst von Bergmann Medical Center, D-14467 Potsdam, Germany
| | - David Kaul
- Department of Clinical Radiation Oncology, Ernst von Bergmann Medical Center, D-14467 Potsdam, Germany
| | - Kuai-LE Zhao
- Department of Radiation Oncology, Fudan University, Shanghai Cancer Center, Shanghai 200240, P.R. China
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Bollschweiler E, Hölscher AH, Schmidt M, Warnecke-Eberz U. Neoadjuvant treatment for advanced esophageal cancer: response assessment before surgery and how to predict response to chemoradiation before starting treatment. Chin J Cancer Res 2015; 27:221-30. [PMID: 26157318 DOI: 10.3978/j.issn.1000-9604.2015.04.04] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 03/20/2015] [Indexed: 12/22/2022] Open
Abstract
Patients with advanced esophageal cancer (T3-4, N) have a poor prognosis. Chemoradiation or chemotherapy before esophagectomy with adequate lymphadenectomy is the standard treatment for patients with resectable advanced esophageal carcinoma. However, only patients with major histopathologic response (regression to less than 10% of the primary tumor) after preoperative treatment will have a prognostic benefit of preoperative chemoradiation. Using current therapy regimens about 40% to 50% of the patients show major histopathological response. The remaining cohort does not benefit from this neoadjuvant approach but might benefit from earlier surgical resection. Therefore, it is an aim to develop tools for response prediction before starting the treatment and for early response assessment identifying responders. The current review discusses the different imaging techniques and the most recent studies about molecular markers for early response prediction. The results show that [(18)F]-fluorodeoxyglucose-positron emission tomography (FDG-PET) has a good sensitivity but the specificity is not robust enough for routine clinical use. Newer positron emission tomography detector technology, the combination of FDG-PET with computed tomography, additional evaluation criteria and standardization of evaluation may improve the predictive value. There exist a great number of retrospective studies using molecular markers for prediction of response. Until now the clinical use is missing. But the results of first prospective studies are promising. A future perspective may be the combination of imaging technics and special molecular markers for individualized therapy. Another aspect is the response assessment after finishing neoadjuvant treatment protocol. The different clinical methods are discussed. The results show that until now no non-invasive method is valid enough to assess complete histopathological response.
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Affiliation(s)
- Elfriede Bollschweiler
- 1 Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany ; 2 Institute of Nuclear Medicine, University of Cologne, Cologne, Germany
| | - Arnulf H Hölscher
- 1 Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany ; 2 Institute of Nuclear Medicine, University of Cologne, Cologne, Germany
| | - Matthias Schmidt
- 1 Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany ; 2 Institute of Nuclear Medicine, University of Cologne, Cologne, Germany
| | - Ute Warnecke-Eberz
- 1 Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany ; 2 Institute of Nuclear Medicine, University of Cologne, Cologne, Germany
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Outcomes of patients with squamous cell carcinoma of esophagus who did not receive surgical resection after neoadjuvant radiochemotherapy. TUMORI JOURNAL 2015; 101:263-7. [PMID: 25908044 DOI: 10.5301/tj.5000266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2014] [Indexed: 11/20/2022]
Abstract
AIMS AND BACKGROUND The primary objective was to assess the different reasons for refusal of surgical resection (SR) in patients with esophageal squamous cell cancer (ESCC), who were initially planned for neoadjuvant radiochemotherapy (N-RCT) + SR, but SR was not performed after N-RCT. METHODS AND STUDY DESIGN From 1988 to 2011, 311 patients with ESCC were treated with N-RCT in a tertiary referral center for esophageal diseases. Fifty-three patients were analyzed who received RCT with 40-45 Gy and concomitant chemotherapy in neoadjuvant intention, but in whom the treatment was stopped or switched to definitive RCT due to progression, patient decision, or new findings. RESULTS The reasons for refusal of SR for these 53 patients were as follows: (1) patients' or physicians' preference for the planned treatment was changed during the N-RCT, such that RCT was continued to a curative dose without a break (group 1, n = 23, 44%); (2) patients were restaged after 4 weeks, and the tumor board decided to continue RCT because R0 resection was unlikely and/or patients were medically unfit (group 2, n = 15, 28%); (3) patients refused continuation of any treatment (group 3, n = 15, 28%). Refusal of SR was significantly more likely in patients with longitudinal tumor dimension >8 cm and those with an Eastern Cooperative Oncology Group performance status score of 2. Median follow-up time from the start of N-RCT was 57 months (range 1-137 months). The survival rates at 2 and 5 years were 36 ± 7% and 27 ± 7%, respectively. Group 1 had significantly longer survival. CONCLUSIONS The planned N-RCT+SR could not be completed in a considerable number of patients in a tertiary referral center. More strict selection criteria for multimodality treatment including SR could spare some of these patients an incomplete treatment and probably lead to increased utilization of definitive RCT.
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