Are Patients with Esophageal Cancer Who Become PET Negative after Neoadjuvant Chemoradiation Free of Cancer?

Treatment Response to Neoadjuvant Therapy in Squamous Esophageal Cancer-Correlation Between Metabolic Response and Histopathology

PURPOSE

Esophageal cancer is among the leading causes of cancer-related mortality worldwide. Patients presenting with localized and loco-regionally advanced cancer without distant metastases have reasonable survival with multimodality management. Adequate and comprehensive staging is the backbone for proper selection of patients fit for curative treatment. Positron emission tomography (PET) in combination with contrast-enhanced computed tomography (CECT) is utilized as the standard staging modality. Multimodality treatment has been able to achieve evaluable tumor responses including pathological complete response (pCR). It is, therefore, necessary to understand whether the impact of neoadjuvant therapy can be evaluated on imaging, i.e., standardized uptake value (SUV) on PET scan done for response assessment and if this can be correlated with histopathological response and later, with survival. Squamous cell carcinoma (SCC) is more common globally and in the Indian subcontinent; hence, we chose this subgroup to evaluate our hypothesis.

METHODS

This is a single institution, retrospective study. Out of the 1967 patients who were treated between 2009 and 2019, 1369 (78.54%) patients had SCC. Out of these, 44 received NACTRT, whereas 1325 received NACT followed by curative surgery. The standardized uptake value (SUV) of 18-fluorodeoxyglucose was recorded during pre- and post-neoadjuvant treatment (NAT) using positron emission tomography (PET). The histopathology of the final resection specimen was evaluated using the Mandard tumor regression grade (TRG) criteria with response being graded from 0 to 5 as no residual tumor (NRT), scanty residual tumor (SRT), and residual tumor We attempted to find a cut-off value of the post neoadjuvant SUV of the primary tumor site which correlated with achievement of better histopathological response.

RESULTS

Out of 1325 patients of SCC esophagus who underwent surgery, 943 patients had available data of TRG, and it was categorized into the 0-2 category which had 325 patients (34.5%) and 3-5 category, 618 patients (65.5%). The SUV was taken only from the PET scans done at our institution, so as to achieve a more homogenous cohort, and this was available for 186 patients, 151 from the NACT group and 35 from the NACTRT group. The ROC method was used to find the cut-off for SUV (5.05) in the NACT cohort, which depicted significant difference in the outcome. Out of these, 93 patients who underwent NACT had SUV > 5.05 and 58 had SUV < 5.05. It was found that the subjective and objective histopathological scores correlated at a p value of < 0.0001. Specifically, the majority of cases with SRT tended to be in the 3-5 category of TRG, whereas cases with NRT are predominantly in the 0-2 category. In the ≥ 5.05 category of SUV, there were 76 cases with SRT. In the NACT cohort, the < 5.05 category of SUV, there are 26 cases with SRT and 32 cases with NRT. Among cases with SRT, 74.5% had SUV ≥ 5.05, while 25.5% had SUV < 5.05. Among cases with NRT, 34.7% had SUV ≥ 5.05, while 65.3% had SUV < 5.05 (p value 0.007). No significant association was found in the radio-pathological correlation in the NACTRT group.

CONCLUSION

Our study confirms the correlation of post neoadjuvant chemotherapy PET SUV with histopathological response, the cut-off of SUV being 5.05 in our cohort. This confirms the predictive value of FDG PET as demonstrated in other studies. Furthermore, its prognostic value with respect to survival has been verified in multiple other studies. With larger scale randomized studies, we may be able to identify the group of patients who have borderline operability anatomically as well as physiologically, where alternative treatment regimens may be indicated to improve outcomes.

Quantitative RECIST derived from multiparametric MRI in evaluating response of esophageal squamous cell carcinoma to neoadjuvant therapy

OBJECTIVE

To develop a quantitative Response Evaluation Criteria in Solid Tumors (qRECIST) for evaluating response to neoadjuvant therapy (nT) in ESCCs relying on multiparametric (mp) MRI.

METHODS

Patients with cT2-T4a/N0-N3/M0 ESCC undergoing pre-nT and post-nT esophageal mpMRI before radical resection were prospectively included. Images were reviewed by two experienced radiologists. qRECIST was redefined using four methods including conventional criterion (cRECIST) and three model-dependent RECIST relying on quantitative MRI measurements at pre-nT, post-nT, and delta pre-post nT, respectively. Pathological tumor regression grades (TRGs) were used as a reference standard. The rates of agreement between four qRECIST methods and TRGs were determined with a Cronbach's alpha test, area under the curve (AUC), and a diagnostic odds ratio meta-analysis.

RESULTS

Ninety-one patients were enrolled. All four methods revealed high inter-reader agreements between the two radiologists, with a Kappa coefficient of 0.96, 0.87, 0.88, and 0.97 for cRECIST, pre-nT RECIST, post-nT RECIST, and delta RECIST, respectively. Among them, delta RECIST achieved the highest overall agreement rate (67.0% [61/91]) with TRGs, followed by post-nT RECIST (63.8% [58/91]), cRECIST (61.5% [56/91]), and pre-nT RECIST (36.3% [33/91]). Especially, delta RECIST achieved the highest accuracy (97.8% [89/91]) in distinguishing responders from non-responders, with 97.3% (34/35) for responders and 98.2% (55/56) for non-responders. Post-nT RECIST achieved the highest accuracy (93.4% [85/91]) in distinguishing complete responders from non-pCRs, with 77.8% (11/18) for pCRs and 94.5% (69/73) for non-pCRs.

CONCLUSION

The qRECIST with mpMRI can assess treatment-induced changes and may be used for early prediction of response to nT in ESCC patients.

KEY POINTS

• Quantitative mpMRI can reliably assess tumor response, and delta RECIST model had the best performance in evaluating response to nT in ESCCs, with an AUC of 0.98, 0.95, 0.80, and 0.82 for predicting TRG0, TRG1, TRG2, and TRG3, respectively. • In distinguishing responders from non-responders, the rate of agreement between delta RECIST and pathology was 97.3% (34/35) for responders and 98.2% (55/56) for non-responders, resulting in an overall agreement rate of 97.8% (89/91). • In distinguishing pCRs from non-pCR, the rate of agreement between MRI and pathology was 77.8% (11/18) for pCRs and 94.5% (69/73) for non- pCRs, resulting in an overall agreement rate of 91.2% (83/91).

Can Clinical Response Predict Pathologic Response Following Neoadjuvant Chemoradiation for Esophageal Cancer?

OBJECTIVES

Approximately 20-40% of patients with locally advanced esophageal cancer will achieve a pathologic complete response (ypCR) following neoadjuvant chemoradiotherapy (nCRT). Predicting ypCR based on a clinical complete response (ycCR) has been a challenge. This study assessed the correlation between ycCR and ypCR, as determined from esophagectomy specimens.

METHODS

Patients undergoing esophagectomy following nCRT at three major institutions between 2005 and 2018 were reviewed. Restaging, including PET/CT, endoscopy with biopsy, and esophageal ultrasound (EUS), was performed to determine ycCR.

RESULTS

Six hundred sixty patients were included, with 93.3% with esophageal adenocarcinoma histology. Six hundred fifty-eight of these patients underwent PET, 304 EUS, and 584 underwent a biopsy. Following nCRT, 148 (22.4%) were found to have a ypCR. Only 12/32 (37.5%) determined to have a ycCR were found to have a ypCR, while 136/628 (21.6%) with a non-ycCR were found to have a ypCR (p 0.075). Individual modality PPV was 28% for PET, 54% for EUS, and 26% for biopsy. When PET was combined with EUS, 168 reports were concordant and the PPV of ypCR was 50%, though the number of patients was low (1/2). With all 3 re-staging modalities combined, the PPV and NPV both rose to 100%.

CONCLUSIONS

Current restaging tools cannot reliably predict ypCR after nCRT. While multimodal restaging appears to be a more accurate predictor of ypCR than any testing modality alone, patients cannot reliably be advised to avoid an esophagectomy on the assumption that ycCR predicts ypCR at this time.

18F-FDG-PET/CT-measured parameters as potential predictors of residual disease after neoadjuvant chemoradiotherapy in patients with esophageal carcinoma

Objective

To evaluate the maximum and mean standardized uptake values, together with the metabolic tumor value and the total lesion glycolysis, at the primary tumor site, as determined by ¹⁸F-fluorodeoxyglucose positron-emission tomography/computed tomography (¹⁸F-FDG-PET/CT), performed before and after neoadjuvant chemoradiotherapy (nCRT), as predictors of residual disease (RD) in patients with esophageal cancer.

Materials and Methods

The standardized uptake values and the volumetric parameters (metabolic tumor value and total lesion glycolysis) were determined by ¹⁸F-FDG-PET/CT to identify RD in 39 patients before and after nCRT for esophageal carcinoma. We used receiver operating characteristic curves to analyze the diagnostic performance of ¹⁸F-FDG-PET/CT parameters in the definition of RD. The standard of reference was histopathological analysis of the surgical specimen.

Results

Eighteen patients (46%) presented RD after nCRT. Statistically significant areas under the curve (approximately 0.72) for predicting RD were obtained for all four of the variables evaluated after nCRT. Considering the presence of visually detectable uptake (higher than the background level) at the primary tumor site after nCRT as a positive result, we achieved a sensitivity of 94% and a specificity of 48% for the detection of RD.

Conclusion

The use of ¹⁸F-FDG-PET/CT can facilitate the detection of RD after nCRT in patients with esophageal cancer.

Accuracy of Detecting Residual Disease After Neoadjuvant Chemoradiotherapy for Esophageal Cancer: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of this study was to perform a meta-analysis on the accuracy of endoscopic biopsies, EUS, and 18F-FDG PET(-CT) for detecting residual disease after neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer.

SUMMARY OF BACKGROUND DATA

After nCRT, one-third of patients have a pathologically complete response in the resection specimen. Before an active surveillance strategy could be offered to these patients, clinically complete responders should be accurately identified.

METHODS

Embase, Medline, Cochrane, and Web-of-Science were searched until February 2018 for studies on accuracy of endoscopic biopsies, EUS, or PET(-CT) for detecting locoregional residual disease after nCRT for squamous cell- or adenocarcinoma. Pooled sensitivities and specificities were calculated using random-effect meta-analyses.

RESULTS

Forty-four studies were included for meta-analyses. For detecting residual disease at the primary tumor site, 12 studies evaluated endoscopic biopsies, 11 qualitative EUS, 14 qualitative PET, 8 quantitative PET using maximum standardized uptake value (SUVmax), and 7 quantitative PET using percentage reduction of SUVmax (%ΔSUVmax). Pooled sensitivities and specificities were 33% and 95% for endoscopic biopsies, 96% and 8% for qualitative EUS, 74% and 52% for qualitative PET, 69% and 72% for PET-SUVmax, and 73% and 63% for PET-%ΔSUVmax. For detecting residual nodal disease, 11 studies evaluated qualitative EUS with a pooled sensitivity and specificity of 68% and 57%, respectively. In subgroup analyses, sensitivity of PET-%ΔSUVmax and EUS for nodal disease was higher in squamous cell carcinoma than adenocarcinoma.

CONCLUSIONS

Current literature suggests insufficient accuracy of endoscopic biopsies, EUS, and 18F-FDG PET(-CT) as single modalities for detecting residual disease after nCRT for esophageal cancer.

Phase II Feasibility and Biomarker Study of Neoadjuvant Trastuzumab and Pertuzumab With Chemoradiotherapy for Resectable Human Epidermal Growth Factor Receptor 2-Positive Esophageal Adenocarcinoma: TRAP Study

PURPOSE

Approximately 15% to 43% of esophageal adenocarcinomas (EACs) are human epidermal growth factor receptor 2 (HER2) positive. Because dual-agent HER2 blockade demonstrated a survival benefit in breast cancer, we conducted a phase II feasibility study of trastuzumab and pertuzumab added to neoadjuvant chemoradiotherapy (nCRT) in patients with EAC.

PATIENTS AND METHODS

Patients with resectable HER2-positive EAC received standard nCRT with carboplatin and paclitaxel and 41.4 Gy of radiotherapy, with 4 mg/kg of trastuzumab on day 1, 2 mg/kg per week during weeks 2 to 6, and 6 mg/kg per week during weeks 7, 10, and 13 and 840 mg of pertuzumab every 3 weeks. The primary end point was feasibility, defined as ≥ 80% completion of treatment with both trastuzumab and pertuzumab. An exploratory comparison of survival with a propensity score-matched cohort receiving standard nCRT was performed, as were exploratory pharmacokinetic and biomarker analyses.

RESULTS

Of the 40 enrolled patients (78% men; median age, 63 years), 33 (83%) completed treatment with trastuzumab and pertuzumab. No unexpected safety events were observed. R0 resection was achieved in all patients undergoing surgery, with pathologic complete response in 13 patients (34%). Three-year progression-free and overall survival (OS) were 57% and 71%, respectively (median follow-up, 32.1 months). Compared with the propensity score-matched cohort, a significantly longer OS was observed with HER2 blockade (hazard ratio, 0.58; 95% CI, 0.34 to 0.97). Results of pharmacokinetic analysis and activity on [18F]fluorodeoxyglucose positron emission tomography scans did not correlate with survival or pathologic response. Patients with HER2 3+ overexpression or growth factor receptor-bound protein 7 (Grb7) -positive tumors at baseline demonstrated significantly better survival (P = .007) or treatment response (P = .016), respectively.

CONCLUSION

Addition of trastuzumab and pertuzumab to nCRT in patients with HER2-positive EAC is feasible and demonstrates potentially promising activity compared with historical controls. HER2 3+ overexpression and Grb7 positivity are potentially predictive for survival and treatment response, respectively.

Detecting Pathological Complete Response in Esophageal Cancer after Neoadjuvant Therapy Based on Imaging Techniques: A Diagnostic Systematic Review and Meta-Analysis

INTRODUCTION

Up to 32% of patients with esophageal cancer show a pathological complete response (ypCR) after neoadjuvant therapy. To prevent overtreatment, the indication to perform esophagectomy in these patients should be reconsidered. Implementing an organ-preserving strategy for patients with ypCR requires an accurate assessment of residual disease after neoadjuvant treatment. The aim of this study was to systematically review the effectiveness of imaging techniques used for detection of ypCR after neoadjuvant therapy but before resection in patients with esophageal cancer.

METHODS

A systematic literature search of the Medline, Embase, and Cochrane Library databases was performed from January 1, 2000, to December 13, 2017. Eligible studies were diagnostic studies that compared results of imaging modalities after neoadjuvant therapy to histopathological findings in the resection specimen after esophagectomy. Methodological quality was assessed by the Cochrane Quality Assessment of Diagnostic Accuracy Studies, version 2, model. Primary outcome measures were true positive, false-positive, false-negative, and true negative values of imaging techniques predicting ypCR. A meta-analysis was performed by pooling sensitivities and specificities by using a bivariate model.

RESULTS

A total of 4420 articles were identified. After exclusion of irrelevant titles and abstracts, 360 articles were reviewed in full text. In total, four imaging modalities (computed tomography [CT], positron emission tomography [PET-CT], endoscopic ultrasound [EUS], and magnetic resonance imaging [MRI]) were used for restaging. The meta-analysis was conducted with data from 56 studies involving 3625 patients. The pooled sensitivities of CT, PET-CT, EUS, and MRI for detecting ypCR were 0.35, 0.62, 0.01 and 0.80, respectively, whereas the pooled specificities were 0.83, 0.73, 0.99, and 0.83, respectively. The positive predictive value in detecting ypCR was 0.47 for CT, 0.41 for PET-CT, not applicable for EUS, and 0.61 for MRI.

CONCLUSION

Current imaging modalities such as CT, PET-CT, and EUS seem to be insufficiently accurate to identify complete responders. More accurate diagnostic tests are needed to improve restaging accuracy for patients with esophageal cancer.

Accuracy of 18F-FDG PET/CT in Predicting Residual Disease After Neoadjuvant Chemoradiotherapy for Esophageal Cancer

Our purpose was to prospectively investigate optimal evaluation of qualitative and quantitative ¹⁸F-FDG PET/CT in response evaluations 12-14 wk after neoadjuvant chemoradiotherapy (nCRT) in esophageal cancer patients. Methods: This was a side study of the prospective diagnostic pre-SANO trial. ¹⁸F-FDG PET/CT scans at baseline and at 12-14 wk after nCRT were qualitatively assessed for the presence of tumor. Maximum SUVs normalized for lean body mass (SUL_max) were measured in all scans. The primary endpoint was the proportion of false-negative patients with tumor regression grade (TRG) 3-4 (>10% vital residual tumor) in qualitative and quantitative analyses. Receiver-operating-characteristic curve analysis for TRG1 versus TRG3-4 using SUL_max, SUL_max tumor-to-esophagus ratio, and Δ%SUL_max was performed to define optimal cutoffs. Secondary endpoints were sensitivity, specificity, negative predictive value, and positive predictive value for TRG1 versus TRG2-4. Results: In total, 129 of 219 patients were analyzed. Qualitative ¹⁸F-FDG PET/CT was unable to detect TRG3-4 in 15% of patients. Sensitivity, specificity, negative predictive value, and positive predictive value in qualitative analysis for detecting TRG1 versus TRG2-4 was 80%, 37%, 42%, and 77%, respectively. In 18 of 190 patients (10%) with follow-up scans after nCRT, ¹⁸F-FDG PET/CT identified new interval metastases. Quantitative parameters did not detect TRG3-4 tumor in 27%-61% of patients. The optimal cutoff for detecting TRG1 versus TRG2-4 was a post-nCRT SUL_max of 2.93 (area under receiver-operating-characteristic curve, 0.70). Conclusion: Qualitative and quantitative analyses of ¹⁸F-FDG PET/CT are unable to accurately detect TRG3-4 and to discriminate substantial residual disease from benign inflammation-induced ¹⁸F-FDG uptake after nCRT. However, ¹⁸F-FDG PET/CT is useful for the detection of interval metastases and might become useful in an active surveillance strategy with serial ¹⁸F-FDG PET/CT scanning.

Dose-escalated radiotherapy improved survival for esophageal cancer patients with a clinical complete response after standard-dose radiotherapy with concurrent chemotherapy

Purpose

For esophageal cancer patients with a clinical complete response (cCR) after standard-dose radiotherapy with concurrent chemotherapy, data on the survival outcomes and recurrence patterns remain scarce. To evaluate the impact of dose escalation on overall survival for this subset of patients, we carried out the current investigation.

Materials and methods

Medical records of 80 esophageal cancer patients with a cCR after standard-dose radiotherapy with concurrent chemotherapy at our center from 2010 to 2014 were allocated into the standard-dose group (50.4 Gy, observation group) or the radiation dose-escalation group (59.4 Gy, control group). In this cohort study, we compared the outcomes between the 2 groups.

Results

There were no differences in patient characteristics between the 2 groups. The median recurrence-free survival and overall survival times for all patients were 38 and 54 months, respectively. Patients in the control group had significantly better 5-year recurrence-free survival rate (12% vs 0%, p=0.019) and 5-year overall survival rate (42.8% vs 21.0%, p=0.028) than the observation group. Additionally, local control rate was significantly higher in the control group (p=0.04), and ~60% of treatment failures were local failures even for patients achieving cCR after chemoradiotherapy. There were no significant differences in treatment-related toxicities between the groups.

Conclusion

The results of the current study suggest that for esophageal cancer patients with a cCR after standard-dose radiotherapy with concurrent chemotherapy, those with dose-escalated radiotherapy showed significantly better local control, recurrence-free survival, and overall survival than patients receiving 50.4 Gy radiotherapy.

Safety and feasibility of robotic-assisted Ivor-Lewis esophagectomy

Esophagectomy is associated with substantial morbidity. Robotic surgery allows complex resections to be performed with potential benefits over conventional techniques. We applied this technology to transthoracic esophagectomy to assess safety, feasibility, and reliability of this technology. A retrospective cohort study of all patients undergoing robotic-assisted Ivor-Lewis esophagectomy (RAIL) from 2009 to 2014 was conducted. Clinicopathologic factors and surgical outcomes were recorded and compared. All statistical tests were two-sided and a P-value of <0.05 was considered statistically significant. We identified 147 patients with an average age 66 ± 10 years. Neoadjuvant therapy was administered to 114 (77.6%) patients, and all patients underwent a R0 resection. The mean operating room (OR) time was 415 ± 84.6 minutes with a median estimated blood loss (EBL) of 150 (25-600) mL. Mean intensive care unit (ICU) stay was 2.00 ± 4.5 days, median length of hospitalization (LOH) was 9 (4-38) days, and readmissions within 90 days were low at 8 (5.5%). OR time decreased from 471 minutes to 389 minutes after 20 cases and a further decrease to mean of 346 minutes was observed after 120 cases. Complications occurred in 37 patients (25.2%). There were 4 anastomotic (2.7%) leaks. Thirty and 90-day mortality was 0.68% and 1.4%, respectively. This represents to our knowledge the largest series of robotic esophagectomies. RAIL is a safe surgical technique that provides an alternative to standard minimally invasive and open techniques. In our series, there was no increased risk of LOH, complications, or death and re-admission rates were low despite earlier discharge.

Surveillance versus esophagectomy in esophageal cancer patients with a clinical complete response after induction chemoradiation

There currently exists an area of controversy in treatment of esophageal cancer for patients who have an apparent clinical complete response (cCR) after induction chemoradiation. A standard treatment is to offer these patients an esophagectomy, but increasingly there is interest from both the patient and provider for active surveillance with so-called "salvage" esophagectomies for local recurrence as an alternative treatment paradigm. In this article, we review the existing evidence that stakeholders should consider for clinical decision-making in this specific patient population, including: the accuracy of post-induction clinical restaging, the reliability of operative risk assessment, the feasibility and adherence to surveillance strategies, and the observed outcomes in these patients after salvage esophagectomy or continued active surveillance. We also briefly discuss quality of life and future directions for this field.

The predictive value of 18F-FDG PET for pathological response of primary tumor in patients with esophageal cancer during or after neoadjuvant chemoradiotherapy: a meta-analysis

OBJECTIVE

We want to review the value of 18-fluoro-deoxy-glucose positron emission tomography for response prediction of primary tumor in patients with esophageal cancer during or after neoadjuvant chemoradiotherapy.

METHODS

Studies were searched in Pubmed, Embase and Cochrane Library with specific search strategy. The published articles were included according to the criteria established in advance. The included studies were divided into two groups according to the time of the repeat positron emission tomography: during (Group A) or after neoadjuvant chemoradiotherapy (Group B). The studies that performed the repeat positron emission tomography after neoadjuvant chemoradiotherapy were graded Quality Assessment of Diagnostic Accuracy Studies. The pooled sensitivity, specificity and diagnostic odds ratio were obtained for both groups on the basis of no-existing of threshold effect.

RESULTS

Fifteen studies were included in the present study. The threshold effect did not exist in both groups. The pooled sensitivity, specificity and diagnostic odds ratio were 85%, 59%, 6.82 with 95% confidence interval 76-91%, 48-69%, 2.25-20.72 in Group A. The equivalent values were 67%, 69%, 6.34 with 95% confidence interval 60-73%, 63-74%, 2.08-19.34 in Group B. The pooled sensitivity was 90% in four studies that enrolled patients with esophageal squamous cell carcinoma merely in Group B.

CONCLUSIONS

According to the present data, positron emission tomography should not be used routinely to guide treatment strategy in esophageal cancer patients. We speculated that positron emission tomography could be used as a tool to predict treatment response after neoadjuvant chemoradiotherapy in patients with esophageal squamous cell carcinoma.

Accuracy of Detecting Residual Disease After Cross Neoadjuvant Chemoradiotherapy for Esophageal Cancer (preSANO Trial): Rationale and Protocol

BACKGROUND

Results from the recent CROSS trial showed that neoadjuvant chemoradiotherapy (nCRT) significantly increased survival as compared to surgery alone in patients with potentially curable esophageal cancer. Furthermore, in the nCRT arm 49% of patients with a squamous cell carcinoma (SCC) and 23% of patients with an adenocarcinoma (AC) had a pathologically complete response in the resection specimen. These results provide a rationale to reconsider and study the timing and necessity of esophagectomy in (all) patients after application of the CROSS regimen.

OBJECTIVE

We propose a "surgery as needed" approach after completion of nCRT. In this approach, patients will undergo active surveillance after completion of nCRT. Surgical resection would be offered only to those patients in whom residual disease or a locoregional recurrence is highly suspected or proven. However, before a surgery as needed approach in oesophageal cancer patients (SANO) can be tested in a randomized controlled trial, we aim to determine the accuracy of detecting the presence or absence of residual disease after nCRT (preSANO trial).

METHODS

This study is set up as a prospective, single arm, multicenter, diagnostic trial. Operable patients with potentially curable SCC or AC of the esophagus or esophagogastric junction will be included. Approximately 4-6 weeks after completion of nCRT all included patients will undergo a first clinical response evaluation (CRE-I) including endoscopy with (random) conventional mucosal biopsies of the primary tumor site and of any other suspected lesions in the esophagus and radial endo-ultrasonography (EUS) for measurement of tumor thickness and area. Patients in whom no locoregional or disseminated disease can be proven by cytohistology will be offered a postponed surgical resection 6-8 weeks after CRE-I (ie, approximately 12-14 weeks after completion of nCRT). In the week preceding the postponed surgical resection, a second clinical response evaluation (CRE-II) will be planned that will include a whole body PET-CT, followed again by endoscopy with (random) conventional mucosal biopsies of the primary tumor site and any other suspected lesions in the esophagus, radial EUS for measurement of tumor thickness and area, and linear EUS plus fine needle aspiration of PET-positive lesions and/or suspected lymph nodes. The main study parameter is the correlation between the clinical response assessment during CRE-I and CRE-II and the final pathological response in the resection specimen.

RESULTS

The first patient was enrolled on July 23, 2013, and results are expected in January 2016.

CONCLUSIONS

If this preSANO trial shows that the presence or absence of residual tumor can be predicted reliably 6 or 12 weeks after completion of nCRT, a randomized trial comparing nCRT plus standard surgery versus chemoradiotherapy plus "surgery as needed" will be conducted (SANO trial).

TRIAL REGISTRATION

Netherlands Trial Register: NTR4834; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4834 (archived by Webcite at http://www.webcitation.org/6Ze7mn67B).

Value of CT–PET after neoadjuvant chemoradiation in the prediction of histological tumour regression, nodal status and survival in oesophageal adenocarcinoma

Background

The role of CT–PET after neoadjuvant chemoradiation (nCRT) for prediction of pathological response and oncological outcome in oesophageal and junctional adenocarcinoma (OAC) is unclear. The relationship between complete metabolic response (cMR), pathological complete response (pCR) and nodal status has not been clarified.

Methods

Patients with locally advanced OAC selected to receive nCRT and surgery with curative intent, on the basis of staging that included CT–PET positivity, were included. Repeat scanning (PET2) with an identical protocol was performed 2–4 weeks after completion of nCRT (cisplatin and 5-fluorouracil plus 44 Gy radiation). Changes in [18F]fluorodeoxyglucose uptake, considered as either a maximum standardized uptake value (SUVmax) or a relative reduction (%ΔSUVmax), and PET-predicted nodal status following nCRT were compared with histopathological response, histological node positivity and survival.

Results

One hundred consecutive patients with PET-positive OAC were studied. Following nCRT, PET2 identified M1 disease in 2·0 per cent of patients. There were no significant associations between PET2 SUVmax or %ΔSUVmax with respect to primary tumour stage (ypT) (P = 0.216 and P = 0·975 respectively), tumour regression grade (P = 0·109 and P = 0·232), pCR (P = 0·633 and P = 0·870) or complete resection (R0) (P = 0·440 and P = 0·235). The sensitivity of PET2 for ypN was 10 per cent. %ΔSUVmax was not associated with disease-free or overall survival (P = 0·162 and P = 0·154 respectively). Of 46 patients with a cMR on PET2, 37 (80 per cent) had histological evidence of residual tumour in the resected specimen, and cMR was not associated with overall survival benefit (P = 0·478).

Conclusion

CT–PET following nCRT for OAC has poor prognostic and discriminatory value for clinical application.

Curative treatment of esophageal cancer; an evidenced based review

BACKGROUND

In 2013, roughly 18,000 cases of esophageal cancer will be diagnosed in the United States with more than 15,000 people dying from the disease. Worldwide, an estimated 482,300 new esophageal cancer cases were diagnosed with 406,800 deaths in 2008. Squamous cell carcinoma (SCC) and adenocarcinoma (AC) account for >90% of all esophageal cancer cases.

METHODS

The authors will examine the role of radiation therapy, chemotherapy, and surgery in the curative management of esophageal cancer by examining randomized control data, single arm phase II trials, several recently published meta-analyses, as well as retrospective data where there is no clinical trial data available. The role of positron emission tomography (PET) will be reviewed as well.

RESULTS

Current data support the role of neoadjuvant chemoradiotherapy followed by surgical resection for locally advanced esophageal cancer with 3-year overall survival ranging from 30% to 60%. The benefit of adjuvant chemoradiation therapy is limited to margin positive and/or node positive patients. There is emerging data questioning the survival benefit of surgical resection after chemoradiotherapy. External beam radiation therapy alone results in very few long-term survivors and is considered palliative at best. Radiation dose-escalation has failed to improve local control or survival. PET scanning is vital in staging and has become a strong predictor of response and survival.

CONCLUSIONS

Preoperative or definitive concurrent chemoradiotherapy is the established standard of care for locally advanced cancers of the esophagus. While preoperative chemotherapy is supported by level 1 evidence, the true benefit of induction chemotherapy before chemoradiotherapy has not been established in a prospective randomized control trial. The role of surgery in the management of SCC is still a hotly debated subject, however, it is still recommended for AC. There is no data to support adjuvant chemotherapy after preoperative chemoradiotherapy. The benefit of neoadjuvant chemotherapy seems to be limited AC. Radiation without chemotherapy is palliative and never curative. PET continues to be integrated into treatment decisions and predicts for response and survival after therapy.

Complete pathological response after neoadjuvant treatment in locally advanced esophageal cancer predicts long term survival: a retrospective cohort study

BACKGROUND AND OBJECTIVES

Esophageal cancer incidence is gradually increasing worldwide. Studies have looked at the pathological stage rather than clinical stage as predictor of survival. We looked at patients with complete pathological response to compare their survival outcomes to those who had residual disease after neoadjuvant treatment.

MATERIALS AND METHODS

All patients with esophageal cancer who underwent neoadjuvant treatment followed by resection at our institute were retrospectively reviewed. Overall survival and disease free survival were calculated for patients with complete pathological response and compared to those with residual disease using log rank test.

RESULTS

Mean age of our patients was 51.08 years with standard deviation of 10.17 years. 39% belong to stage IIa while 5% belong to Stage IIb. 56% were Stage III. Final histopathological stage was recorded and both disease free and overall survival were calculated. 45% of our patients had complete pathological response. Patients with complete pathological response had mean survival of 62.73 months ± 17.02 compared to 41.42 months for patients who had residual disease. 5 year disease free survival was 58%.

CONCLUSION

Complete Pathological response significantly improves overall and disease free survival. It is also the predictor of long term survival.

Has integrated 18F FDG PET/CT improved staging, reduced early recurrence or increased survival in oesophageal cancer?

BACKGROUND

Survival in oesophageal cancer remains poor with high post-operative recurrence rates. PET/CT was introduced to the Three-Counties Cancer Network (3CCN) in 2006 to detect 'occult' metastatic disease not seen with conventional staging modalities. This study aims to determine whether the introduction of Integrated fluorodeoxyglucose (18F) Positron Emission Tomography (PET/CT) has changed the management, improved survival or reduced the rate of early post-operative recurrence in patients with operable oesophageal cancer.

METHODS

A retrospective review was undertaken of all patients diagnosed with oesophageal cancer in the 3CCN from 2005 to 2009. Early recurrence was defined as proven recurrence locally or at a distant site within one year of resection.

RESULTS

725 patients were identified. 200 (27.6%) patients underwent staging PET/CT. PET/CT altered treatment intent in 19 (9.5%) patients. 128 (17.7%) patients underwent oesophageal resection, 90 (70.3%) of which had a staging PET/CT. No significant difference was noted in post-operative mortality (4.4% Vs 5.3%, p = 0.8) or early recurrence where PET/CT was performed when adjusted for age, sex, stage or neo-adjuvant chemotherapy (p = 0.761, OR 1.136[95% CI 0.499-2.585]). PET/CT had no significant effect on survival (log-rank test; Chi-square 0.710, p = 0.4).

CONCLUSION

PET/CT has improved the accuracy of oesophageal cancer staging avoiding potentially unnecessary surgery. Ultimately however, its use has had no effect on early recurrence or survival rates. Inaccurate identification of occult metastatic disease prior to the introduction of staging PET/CT does not appear to be the primary cause of early recurrence in patients with oesophageal cancer.

Clinical complete responders to definite chemoradiation or radiation therapy for oesophageal cancer: predictors of outcome

Background

To identify predictors of long-term outcome for patients with clinical complete response (cCR) after definite chemoradiotherapy (CRT) or radiation therapy (RT) for oesophageal cancer (EC).

Methods

In this retrospective study, we reviewed the files of all patients from our institution that underwent definitive RCT or RT for EC, from January 1998 to December 2003. Among 402 consecutive patients with EC, 110 cCR responses were observed, i.e. without evidence of tumour on morphological examination of the biopsy specimens, 8 to 10 weeks after radiation. Baseline patient and tumour characteristics were as follows: male = 98/110, median age = 60, squamous histology = 103/110, tumour site (upper/middle/lower third) = 41/50/19, weight loss none/<10%/≥10% = 36/45/29, dysphagia grade 1/2/≥3 = 30/14/66. Patients were staged according to endosonography and/or computed tomography. There were 9 stage I, 31 stage IIA, 15 stage IIB, 41 stage III, 6 stage IV. Post treatment nutritional characteristics were as follows: weight loss during treatment none/<10% ≥ 10% = 35/38/37, remaining dysphagia grade 1/2/≥3 = 54/24/32. Univariate and multivariate analyses were performed using log-rank and Cox proportional hazards models, and survival curves were estimated using the Kaplan-Meier method.

Results

During follow up (median: 6 [0.4–9.8] years), 16 patients had salvage surgery. Median OS was 2.5 years, and 5-year OS was 33.5%. Histological type, stage, age, gender, and treatment characteristics had no significant impact on outcome. The risk of death was increased two-fold for patients with grade ≥ 3 dysphagia after treament (HR = 1.9 [1.2–3.1], p = 0.007). Weight loss ≥10% during treatment also negatively affected outcome (HR = 1.8 [1.0–3.2], p = 0.040).

Conclusion

One EC patient among 3 with cCR after definite CRT/RT is still alive at 5 years. Variables related to reduced OS were: remaining significant dysphagia after treatment and weight loss ≥10% during treatment.

Comparison of survival among neoadjuvant chemoradiation responders, non-responders and patients receiving primary resection for locally advanced oesophageal squamous cell carcinoma: does neoadjuvant chemoradiation benefit all?

OBJECTIVES

While neoadjuvant chemoradiation followed by surgery has been shown to improve the survival of patients with locally advanced oesophageal cancer, it is not known whether neoadjuvant chemoradiation has a beneficial or harmful effect on the non-responders. We aimed to compare the outcomes among neoadjuvant chemoradiation responders, non-responders and patients receiving primary oesophagectomies for resectable locally advanced oesophageal squamous cell carcinoma.

METHODS

Eighty-four non-T1-2N0 oesophageal squamous cell carcinoma patients were included. Thirty-eight patients received primary resection and 46 patients received neoadjuvant chemoradiation. The overall survival of chemoradiation responders (<50% residual tumour), non-responders (>50% residual tumour and those who shifted to definitive chemoradiation instead of surgery due to tumour progression) and patients receiving primary resection were compared. Clinical parameters were also compared between responders and non-responders.

RESULTS

There was no overall difference in survival between neoadjuvant chemoradiation and primary resection groups (2-year overall survival rates: 45.6 vs 54.3%, P = 0.442). In patients receiving neoadjuvant chemoradiation followed by surgery, pathological responders had significantly higher 2-year overall survival rates than non-responders (64.5 vs 38.9%, P = 0.043). While the pathological responders had the highest survival rate, clinicopathological non-responders (pathological non-responders and patients with tumour progression during the neoadjuvant chemoradiation period) demonstrated significantly worse outcomes than those receiving primary resection (32.0 vs 54.3%, P = 0.036). However, none of the clinical parameters, including blood profiles, images and baseline tumour characteristics, predicted the response to chemoradiation before treatment.

CONCLUSIONS

Neoadjuvant chemoradiation non-responders demonstrated no benefit and an even worse outcome compared with those receiving primary resection for locally advanced oesophageal squamous cell carcinoma. However, no significant clinical parameters could be implemented in the clinics to predict the response to neoadjuvant chemoradiation before treatment.

Complete metabolic response is not uniformly predictive of complete pathologic response after induction therapy for esophageal cancer

BACKGROUND

Positron emission tomography scanning is used to assess response to induction therapy after treatment of esophageal cancer. A decrease in standardized uptake value has been correlated with response to therapy, with a standardized uptake value of zero often assumed to indicate complete absence of disease. We hypothesize that a significant number of patients may have residual esophageal cancer despite complete metabolic response (CMR).

METHODS

A prospective database was reviewed for esophageal cancer patients receiving induction therapy followed by esophagectomy on whom both preinduction and postinduction positron emission tomography scans were obtained. Patients with a postinduction SUV of 0 (or "no uptake") were categorized as complete metabolic responders. Survival was calculated by the Kaplan-Meier statistic.

RESULTS

Among 120 patients, 32 (27%) had postinduction CMR after chemotherapy (21 of 81, 26%) or chemoradiation (11 of 39, 28%). At surgery, 19 patients (59%) with CMR had residual disease, including 12 (38%) with nodal metastases. Even among patients with a negative postinduction biopsy, 4 of 10 (40%) had residual disease. Final pathologic stages of patients with CMR were yp0 (complete pathologic response) in 13 (41%), ypI in 4 (12%), ypII in 9 (28%), and ypIII in 6 (19%). Three-year survival was 83% in the CMR group versus 41% in the remainder of the cohort (p = 0.02).

CONCLUSIONS

A CMR on postinduction positron emission tomography scan predicts but should not be assumed to be synonymous with complete pathologic response in esophageal cancer patients. The presence of residual disease should be strongly considered despite CMR and negative biopsy in patients receiving induction therapy.

Radiation Therapy and Esophageal Cancer

Background

Squamous cell carcinoma and adenocarcinoma account for more than 90% of all esophageal cancer cases. Although the incidence of squamous cell carcinoma has declined, the incidence of adenocarcinoma has risen due to increases in obesity and gastroesophageal reflux disease.

Methods

The authors examine the role of radiation therapy alone (external beam and brachytherapy) for the management of esophageal cancer or combined with other modalities. The impact on staging and appropriate stratification of patients referred for curative vs palliative intent with modalities is reviewed. The authors also explore the role of emerging radiation technologies.

Results

Current data show that neoadjuvant chemoradiotherapy followed by surgical resection is the accepted standard of care, with 3-year overall survival rates ranging from 30% to 60%. The benefit of adjuvant radiation therapy is limited to patients with node-positive cancer. The survival benefit of surgical resection after chemoradiotherapy remains controversial. External beam radiation therapy alone results in few long-term survivors and is considered palliative at best. Radiation dose-escalation has failed to improve local control or survival. Brachytherapy can provide better long-term palliation of dysphagia than metal stent placement. Although three-dimensional conformal treatment planning is the accepted standard, the roles of IMRT and proton therapy are evolving and potentially reduce adverse events due to better sparing of normal tissue.

Conclusions

Future directions will evaluate the benefit of induction chemotherapy followed by chemoradiotherapy, the role of surgery in locally advanced disease, and the identification of responders prior to treatment based on microarray analysis.

Evaluation of response to neoadjuvant chemotherapy for esophageal cancer: PET response criteria in solid tumors versus response evaluation criteria in solid tumors

Recently, PET response criteria in solid tumors (PERCIST) have been proposed as a new standardized method to assess chemotherapeutic response metabolically and quantitatively. The aim of this study was to evaluate therapeutic response to neoadjuvant chemotherapy for locally advanced esophageal cancer, comparing PERCIST with the currently widely used response evaluation criteria in solid tumors (RECIST).

METHODS

Fifty-one patients with locally advanced esophageal cancer who received neoadjuvant chemotherapy (5-fluorouracil, adriamycin, and cisplatin), followed by surgery were studied. Chemotherapeutic lesion responses were evaluated using (18)F-FDG PET and CT according to the RECIST and PERCIST methods. The PET/CT scans were obtained before chemotherapy and about 2 wk after completion of chemotherapy. Associations were statistically analyzed between survival (overall and disease-free survival) and clinicopathologic results (histology [well-, moderately, and poorly differentiated squamous cell carcinoma], lymphatic invasion, venous invasion, clinical stage, pathologic stage, resection level, reduction rate of tumor diameter, reduction rate of tumor uptake, chemotherapeutic responses in RECIST and PERCIST, and pathologic response).

RESULTS

There was a significant difference in response classification between RECIST and PERCIST (Wilcoxon signed-rank test, P < 0.0001). Univariate analysis showed that lymphatic invasion, venous invasion, resection level, pathologic stage, and PERCIST were significant factors associated with disease-free or overall survival in this study. Although multivariate analysis demonstrated that venous invasion (disease-free survival: hazard ratio [HR] = 4.519, P = 0.002; overall survival: HR = 5.591, P = 0.003) and resection level (disease-free survival: HR = 11.078, P = 0.001) were the significant predictors, PERCIST was also significant in noninvasive therapy response assessment before surgery (disease-free survival: HR = 4.060, P = 0.025; overall survival: HR = 8.953, P = 0.034).

CONCLUSION

RECIST based on the anatomic size reduction rate did not demonstrate the correlation between therapeutic responses and prognosis in patients with esophageal cancer receiving neoadjuvant chemotherapy. However, PERCIST was found to be the strongest independent predictor of outcomes. Given the significance of noninvasive radiologic imaging in formulating clinical treatment strategies, PERCIST might be considered more suitable for evaluation of chemotherapeutic response to esophageal cancer than RECIST.

Tissue and serum mesothelin are potential markers of neoplastic progression in Barrett's associated esophageal adenocarcinoma

BACKGROUND

Mesothelin is overexpressed in several malignancies and is purportedly a specific marker of malignant transformation. In this pilot study, we investigated whether tissue and serum mesothelin are potential markers of neoplastic progression in Barrett's esophagus (BE) and in esophageal adenocarcinoma (EAC).

METHODS

Mesothelin expression was retrospectively evaluated in normal, BE, and EAC tissue from surgically resected esophageal specimens (n = 125). In addition, soluble mesothelin-related peptide (SMRP) levels were measured in serum.

RESULTS

Normal esophageal mucosa did not express mesothelin. BE tissue with high-grade dysplasia specifically expressed mesothelin, whereas BE tissue with low-grade or without dysplasia did not. Fifty-seven (46%) EAC tumors were positive for mesothelin. EAC tumors with BE expressed mesothelin more often than those without BE (58% vs. 35%, P = 0.01). SMRP levels were elevated in 70% of EAC patients (mean = 0.89 nmol/L; range: 0.03-3.77 nmol/L), but not in patients with acid reflux and/or BE.

CONCLUSIONS

Mesothelin is commonly expressed in BE-associated EAC. On the basis of this pilot study, a prospective study is under way to evaluate tissue and serum mesothelin which are potential markers of neoplastic progression in BE and in EAC (NCT01393483).

IMPACT

Current surveillance methods in Barrett's esophagus are invasive and neither cost-effective nor sensitive. This pilot study suggests that serum mesothelin is a marker of neoplastic transformation in BE and may provide a noninvasive method to improve identification of malignant transformation.

Pathologic nonresponders after neoadjuvant chemoradiation for esophageal cancer demonstrate no survival benefit compared with patients treated with primary esophagectomy

BACKGROUND

Neoadjuvant chemoradiation (NCRT) has become the preferred treatment for patients with locally advanced esophageal cancer. Survival often is correlated to degree of pathologic response; however, outcomes in patients who are found to be pathologic nonresponders (pNR) remain uninvestigated. This study was designed to evaluate survival in pNR to NCRT compared with patients treated with primary esophagectomy (PE).

METHODS

Using our comprehensive esophageal cancer database, we identified patients treated with NCRT and deemed pNR along with patients who proceeded to PE. Clinical and pathologic data were compared using Fisher's exact and χ(2), whereas Kaplan-Meier estimates were used for survival analysis.

RESULTS

We identified 63 patients treated with NCRT and were found to have a pNR, and 81 patients who underwent PE. Disease-free (DFS) and overall survival (OS) were significantly decreased in the pNR group compared with those treated with PE (10 vs. 50 months (0-152), P < 0.001 and 13 vs. 50 months (0-152), P < 0.001, respectively). For patients with stage II disease, DFS and OS were similarly decreased in pathologic nonresponders (13 vs. 62 months (0-120), P < 0.001 and 31 vs. 62 months (0-120), P = 0.024, respectively). There were no differences in DFS or OS for patients with stage III disease (10 vs. 14 months (0-152), P = 0.29 and 10 vs. 19 months (0-152), P = 0.16, respectively).

CONCLUSIONS

Pathologic nonresponders to NCRT for esophageal cancer receive no benefit in DFS or OS compared with patients treated with PE. For patients with stage II disease, DFS and OS are, in fact, significantly decreased in the pNR.

Barrett's esophagus: treatments of adenocarcinomas II

The following topics are explored in this collection of commentaries on treatments of adenocarcinomas related to Barrett's esophagus: the importance of intraoperative frozen sections of the margins for the detection of high dysplasia; the preferable way for sentinel node dissection; the current role of robotic surgery and of video-endoscopic approach; the value of the Siewert's classification of adenocarcinomas; the indications of two-step esophagectomy; the evaluation of pathological complete response; the role of PET scan in staging and response assessment; the role of p53 in the selection of adenocarcinomas patients; chemotherapy regimens for adenocarcinomas; the use of monoclonal antibodies in the control of cell proliferation; he attempt to define a stage-specific strategy, and the possible indications of selective therapy; and changes in mortality rates from esophageal cancer.

Metabolic response evaluation by PET during neoadjuvant treatment for adenocarcinoma of the esophagus and esophagogastric junction

Following several randomized trials, neoadjuvant therapy in adenocarcinoma of esophagus and the esophagogastric junction can be seen as an international standard. However, in a large proportion of patients the objective response achieved is unsatisfactory. These patients do not benefit from neoadjuvant therapy, but do suffer from toxic side effects; sometimes progressive and appropriate surgical therapy is delayed. For this reason, a diagnostic test that can accurately assess tumor response to neoadjuvant therapy might be of crucial importance. Response evaluation using CT scan, endoluminal ultrasound, or rebiopsy is not reliable. In recent times, response evaluation using 18FGD PET after and during neoadjuvant treatment is in the focus of clinical and scientific interest. Most studies have evaluated the diagnostic modalities for response to neoadjuvant treatment after completion of the treatment. Following the published data so far, FDG-PET seems to be less accurate after and during chemoradiation than after chemotherapy alone. The data of early response evaluation (14 days after the onset of chemotherapy) are very much encouraging; however, they have to be evaluated in an international randomized trial. Standardization of PET technology as well as defining the thresholds used for the estimation of early response is mandatory. So far, FDG-PET does not change treatment in esophageal and gastric cancer.

Outcomes of patients with esophageal cancer staged with [¹⁸F]fluorodeoxyglucose positron emission tomography (FDG-PET): can postchemoradiotherapy FDG-PET predict the utility of resection?

PURPOSE

To determine whether [(18)F]fluorodeoxyglucose positron emission tomography (FDG-PET) can delineate patients with esophageal cancer who may not benefit from esophagectomy after chemoradiotherapy.

PATIENTS AND METHODS

We reviewed records of 163 patients with histologically confirmed stage I to IVA esophageal cancer receiving chemoradiotherapy with or without resection with curative intent. All patients received surgical evaluation. Initial and postchemoradiotherapy FDG-PET scans and prognostic/treatment variables were analyzed. FDG-PET complete response (PET-CR) after chemoradiotherapy was defined as standardized uptake value ≤ 3.

RESULTS

Eighty-eight patients received trimodality therapy and 75 received chemoradiotherapy. Surgery was deferred primarily due to medical inoperability or unresectable/metastatic disease after chemoradiotherapy. A total of 105 patients were evaluable for postchemoradiotherapy FDG-PET response. Thirty-one percent achieved a PET-CR. PET-CR predicted for improved outcomes for chemoradiotherapy (2-year overall survival, 71% v 11%, P < .01; 2-year freedom from local failure [LFF], 75% v 28%, P < .01), but not trimodality therapy. On multivariate analysis of patients treated with chemoradiotherapy, PET-CR is the strongest independent prognostic variable (survival hazard ratio [HR], 9.82, P < .01; LFF HR, 14.13, P < .01). PET-CR predicted for improved outcomes regardless of histology, although patients with adenocarcinoma achieved a PET-CR less often.

CONCLUSION

Patients treated with trimodality therapy found no benefit with PET-CR, likely because FDG-PET residual disease was resected. Definitive chemoradiotherapy patients achieving PET-CR had excellent outcomes equivalent to trimodality therapy despite poorer baseline characteristics. Patients who achieve a PET-CR may not benefit from added resection given their excellent outcomes without resection. These results should be validated in a prospective trial of FDG-PET-directed therapy for esophageal cancer.

Systematic review of the benefits and risks of neoadjuvant chemoradiation for oesophageal cancer

Background

Surgery alone for locally advanced oesophageal cancer is associated with low cure rates. The benefits and risks of neoadjuvant chemoradiation for patients with oesophageal cancer were evaluated.

Methods

A systematic review of publications between 2000 and 2008 on neoadjuvant chemoradiation for oesophageal cancer was undertaken.

Results

Thirty-eight papers comprising 3640 patients met the inclusion criteria. Chemoradiation regimens varied widely with a predominance of 5-fluorouracil/cisplatin chemotherapy. Chemoradiation-related toxicity was reported in only ten studies and consisted mainly of neutropenia. The chemoradiation-related mortality rate was 2·3 per cent. The mean R0 resection rate and pathological complete response (pCR) rate were 88·4 and 25·8 per cent respectively. Postoperative morbidity was not uniformly reported. The in-hospital mortality rate after oesophagectomy following chemoradiation was 5·2 per cent. Five-year survival rates varied from 16 to 59 per cent in all patients and from 34 to 62 per cent in those with a pCR. Chemoradiation had a temporary negative effect on quality of life.

Conclusion

Neoadjuvant chemoradiation regimens for oesophageal cancer vary widely. Besides traditional outcome variables (such as survival), other parameters should be analysed (for example toxicity) to assess whether the risks of chemoradiation are sufficiently compensated for by the benefits.

Prediction of tumor response to neoadjuvant therapy in patients with esophageal cancer with use of 18F FDG PET: a systematic review

PURPOSE

To systematically review the accuracy of fluorine 18 ((18)F) fluorodeoxyglucose (FDG) positron emission tomography (PET) in the prediction of tumor response to neoadjuvant therapy in patients with esophageal cancer.

MATERIALS AND METHODS

The MEDLINE and EMBASE databases were systematically searched for relevant studies. Methodologic quality of the included studies was assessed. Sensitivities and specificities of (18)F FDG PET in individual studies were calculated and underwent meta-analysis with a random effects model. A summary receiver operating characteristic curve (sROC) was constructed with the Moses-Shapiro-Littenberg method. A chi(2) test was performed to test for heterogeneity (defined as P < .10). Potential sources for heterogeneity were explored by assessing whether certain covariates significantly (P < .05) influenced the relative diagnostic odds ratio.

RESULTS

Twenty reports, comprising a total of 849 patients with esophageal cancer, were included. Overall, the studies were of moderate methodologic quality. Sensitivity and specificity of (18)F FDG PET ranged from 33% to 100% and from 30% to 100%, respectively, with pooled estimates of 67% (95% confidence interval: 62%, 72%) and 68% (95% confidence interval: 64%, 73%), respectively. The area under the sROC curve was 0.7815. There was significant heterogeneity in both the sensitivity and specificity of the included studies (P < .0001). Spearman rho between the logit of sensitivity and the logit of 1-specificity was 0.086 (P = .719), which suggested that there was no threshold effect. Studies performed outside of the United States and studies of higher methodologic quality yielded significantly higher overall accuracy.

CONCLUSION

On the basis of current evidence, (18)F FDG PET should not yet be used in routine clinical practice to guide neoadjuvant therapy decisions in patients with esophageal cancer.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.09091324/-/DC1.

Pathologic response after neoadjuvant therapy is the major determinant of survival in patients with esophageal cancer

BACKGROUND

Esophageal cancer remains a malignancy with high morbidity and mortality despite improvements to diagnosis, staging, chemotherapy, radiation, and surgery. Neoadjuvant therapy (NT) may improve oncologic outcome in many patients, however the degree to which patients benefit remains unclear. We examined the relationship between pathologic response to NT and magnitude of benefit in patients with esophageal cancer.

METHODS

Using a comprehensive esophageal cancer database, we identified patients who underwent esophagectomy between 1994 and 2008. Pathologic response was denoted as complete (pCR), partial (pPR), and nonresponse (NR). Clinical and pathologic data were compared using Fisher's exact and chi-square when appropriate, while Kaplan-Meier estimates were used for survival analysis.

RESULTS

We identified 347 patients who underwent esophagectomy, and 262 (75.5%) were treated with NT. The median age was 66 years (28-86 years) with median follow-up of 20 months (1-177 months). There were 106 (40.5%) patients exhibiting pCR, 95 (36.3%) with pPR, and 61 (23.3%) with NR. The rate of R0 resections was higher amongst pCR (100%) compared with 94.7% in pPR (P = 0.02) and 87.5% in NR (P = 0.0007). There were 15 (14.2%) recurrences in pCR, 22 (23.7%) in pPR, and 17 (28.8%) in NR (P = 0.04). Patients achieving pCR had 5-year disease-free survival (DFS) and overall survival (OS) of 52% and 52%, respectively, compared with 36% and 38% in pPR and 22% and 19% in NR (P < 0.0001, P < 0.0001).

CONCLUSIONS

Esophageal cancer patients frequently succumb to their disease. However, patients treated with neoadjuvant therapy who achieve pCR have a higher rate of R0 resections, fewer recurrences, and improved 5-year OS and DFS.

The higher the decrease in the standardized uptake value of positron emission tomography after chemoradiation, the better the survival of patients with gastroesophageal adenocarcinoma

BACKGROUND

Postchemoradiation percentage decrease in standardized uptake value (SUV) of positron emission tomography (PET) from baseline correlates with overall survival (OS) and pathologic response. Analyses of dichotomized data are commonly reported. The authors analyzed percentage SUV decrease as both dichotomized and continuous variables.

METHODS

The authors assessed 151 consecutive patients with gastroesophageal adenocarcinoma who had chemoradiation and surgery. Baseline and postchemoradiation PET/computed tomography imaging was performed. The log-rank test and Cox proportional hazards models were used to associate percentage SUV changes and OS, and logistic regression models were used to detect the association between percentage SUV changes and pathologic response.

RESULTS

A >52% SUV decrease (dichotomized analysis) was associated with a longer OS (log-rank test, P = .023). The univariate Cox proportional hazards model indicated that greater percentage SUV decrease (as a continuous variable) was associated with a lower risk of death (hazard ratio [HR], 0.99; P = .01). Pathologic response (< or =50% residual cancer) was associated with longer OS (P = .003). Patients with chemoradiation resistance (>50% residual cancer) tended to have a higher risk of death than those with chemoradiation sensitivity (0-50% residual cancer; HR, 2.12; P = .099). In the multivariate model, the percentage SUV decrease (as a continuous variable) was the only prognosticator of OS (P = .01). The percentage SUV decrease was nonsignificantly associated with pathologic complete response (univariate odds ratio [OR], 1.01; P = .06 and multivariate OR, 1.03; P = .07).

CONCLUSIONS

The greater the decline in SUV after chemoradiation, the longer is the OS of gastroesophageal adenocarcinoma patients. The percentage SUV decrease as a continuous variable is a better prognosticator of OS than its dichotomized assessments.

Positron emission tomography’s changing significance in the treatment of esophageal cancer

Incidence of esophageal cancer has been rising, and Positron Emission Tomography (PET) is one tool that has shown utility and promise as a tool for staging, treatment response, and prognosis. PET delivery has evolved over time and is now frequently registered with a CT scan at the time of acquisition. However, resolution and confounders such as post-treatment radiation changes may limit clinical utility. PET has been shown to be helpful in staging, especially in evaluating for distant metastases. PET acquired after chemoradiation may give important prognostic information that can guide additional treatment decisions. Studies have had substantial variability in recommendations for the timing and manner of using PET for this purpose, and additional study is needed.

Positron emission tomography for monitoring response to neoadjuvant therapy in patients with oesophageal and gastro-oesophageal junction carcinoma

AIMS

The aim of this review is to consolidate our knowledge on an important and rapidly expanding area of expertise. Numerous methods for predicting response (in terms of pathological response and survival) to neoadjuvant therapy (chemotherapy/chemo-radiotherapy) in oesophageal and junctional cancers have been proposed. This review concerns itself only with the use of positron emission tomography for such a purpose. At present there are no standardised criteria amongst PET trials as to what determines a response according to PET, what is the optimal time to perform PET in relation to the timing of neoadjuvant therapy, and what is the ideal method of quantifying PET tracer uptake.

METHODS

An electronic search was performed of PubMed, Ovid and Embase websites to identify studies, in the English language, using the search terms: PET; oesophageal; oesophago-gastric; survival; cancer; response; chemotherapy and chemo-radiotherapy. The reference lists were searched manually to identify further relevant studies.

RESULTS

Twenty-two studies were identified, all using (18)FDG as the tracer, using PET to predict response in terms of pathological response and survival following neoadjuvant therapy (chemotherapy/chemo-radiotherapy). PET had a varying degree of success in predicting both pathological response and survival outcomes, with only one study using PET to influence management decisions.

CONCLUSIONS

PET seems a promising technique, but large-scale conclusions are hindered by small study numbers, lack of criteria as to what constitutes a response and markedly differing PET imaging times. A large randomised trial concerning a homogeneous group of patients and tumours is required before PET might be used to influence management.