Localized squamous-cell cancer of the esophagus: retrospective analysis of three treatment schedules

Computed tomography-based radiomics analysis to predict lymphovascular invasion in esophageal squamous cell carcinoma

OBJECTIVE

The present study explored the value of preoperative CT radiomics in predicting lymphovascular invasion (LVI) in esophageal squamous cell carcinoma (ESCC).

METHODS

A retrospective analysis of 294 pathologically confirmed ESCC patients undergoing surgical resection and their preoperative chest-enhanced CT arterial images were used to delineate the target area of the lesion. All patients were randomly divided into a training cohort and a validation cohort at a ratio of 7:3. Radiomics features were extracted from single-slice, three-slice, and full-volume regions of interest (ROIs). The least absolute shrinkage and selection operator (LASSO) regression method was applied to select valuable radiomics features. Radiomics models were constructed using logistic regression method and were validated using leave group out cross-validation (LGOCV) method. The performance of the three models was evaluated using the receiver characteristic curve (ROC) and decision curve analysis (DCA).

RESULTS

A total of 1218 radiomics features were separately extracted from single-slice ROIs, three-slice ROIs, and full-volume ROIs, and 16, 13 and 18 features, respectively, were retained after optimization and screening to construct a radiomics prediction model. The results showed that the AUC of the full-volume model was higher than that of the single-slice and three-slice models. According to LGOCV, the full-volume model showed the highest mean AUC for the training cohort and the validation cohort.

CONCLUSION

The full-volume radiomics model has the best predictive performance and thus can be used as an auxiliary method for clinical treatment decision making.

ADVANCES IN KNOWLEDGE

LVI is considered to be an important initial step for tumor dissemination. CT radiomics features correlate with LVI in ESCC and can be used as potential biomarkers for predicting LVI in ESCC.

Age plays an important role in the decision of definitive concurrent chemoradiotherapy (CCRT) for esophageal squamous cell carcinoma (ESCC): a propensity-score matched analysis of multicenter data (3JECROG R-02A)

BACKGROUND

To examine the survival benefit of definitive concurrent chemoradiotherapy (CCRT) compared to radiotherapy alone in patients with esophageal squamous cell carcinoma (ESCC) using a real-world patient population.

METHODS

This retrospective study included 2,762 patients with ESCC across ten medical centers in China from 2001 to 2017. A total of 1,133 patients received radiotherapy alone and 815 patients were treated with CCRT. The patient survival rates were assessed by propensity-score matching (PSM) and subgroup analysis.

RESULTS

The baseline characteristics were significantly different between the two groups, with the CCRT group showing a higher proportion of males, younger patients, cervical/upper thoracic cancers, and worse T and N stages. There were no significant differences in the clinical characteristics between the two groups after PSM. Before PSM, the median overall survival (OS) rates were 31.2 and 24.1 months in the CCRT and RT alone groups, respectively, demonstrating the superior therapeutic effects (TEs) of the CCRT. However, the median OS rates were not significantly different between the two groups after PSM (32.6 and 39.4 months in the CCRT and radiotherapy alone groups, respectively). The subgroup analyses revealed that the median OS was significantly better in the CCRT group compared to the radiotherapy alone group (37.5 vs. 25.1 months, respectively) in patients less than 70 years of age [hazard ratio (HR) 0.782, 95% confidence interval (CI): 0.657 to 0.932]. In contrast, in patients 70 years of age and older, the 5-year survival rate was poorer in the CCRT group (34.8%) compared to the radiotherapy alone group (73.4%). Therefore, CCRT was an independent poor prognostic risk factor (HR 3.206, 95% CI: 2.168 to 4.740).

CONCLUSIONS

CCRT may not be suitable for all patients with localized ESCC. Younger patients less than 70 years of age might benefit significantly from CCRT. However, in patients aged 70 years and older, the potential survival benefit of CCRT and the optimal combination treatment regimens require further investigation.

Clinical Evaluation of Transarterial Infusion Chemotherapy for Advanced Esophageal Cancer

Background: Most esophageal cancer patients are diagnosed at an advanced stage when there are few effective treatments. Transarterial infusion chemotherapy is a local chemotherapy method wherein chemotherapeutic drugs are directly injected into tumor vessels.

Methods: Transarterial infusion chemotherapy was performed on advanced esophageal cancer patients once a month, and each patient underwent 1-3 treatments. The clinical results, complications, and effectiveness rates of each treatment episode were recorded and analyzed.

Results: Transarterial infusion chemotherapy was successfully performed in all patients, and no severe complications such as paraplegia or death were noted. Complete response, partial response, and stable disease were noted in 17.3% (13/75), 77.3% (58/75), and 5.3% (4/75) of cases after transarterial infusion chemotherapy, respectively. The total treatment efficacy (complete response + partial response) was 94.7%. All cases exhibited improvement in clinical stage, with a marked decrease in dysphagia. Subsequent treatments were administered to 13 patients, including radical radiation in 7 and chemotherapy in 6. During follow-up, death was caused by progressive carcinoma in 20, tumor-related pneumatic infection and respiratory failure in 11, and gastrointestinal hemorrhage in 17. The median survival time was 15 months and the 1-year survival rate was 58.1%.

Conclusions: Transarterial infusion chemotherapy may be safely and effectively used for treatment of advanced esophageal cancer.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical Study of Concurrent Chemoradiotherapy or Radiotherapy Alone for Esophageal Cancer Patients with Positive Lymph Node Metastasis

Aims and Background

Esophageal cancer patients with pathologic lymph node involvement generally have a poor prognosis. Many randomized controlled trials have not achieved consistent results similar to those of the RTOG8501 trial, and the long-term survival rate has not increased. The present study aimed to compare the efficacy and toxic side effects of concurrent chemoradiotherapy and radiotherapy alone to treat N1 esophageal carcinoma.

Methods and Study Design

A total of 130 N1 esophageal carcinoma patients were enrolled and randomly divided into two groups: concurrent chemoradiotherapy group (n = 65) and radiotherapy group (n = 65). Both groups received three-dimensional conformal radiotherapy with a total dose of 64–66 Gy. Meanwhile, to the concurrent chemoradiotherapy group, an additional chemotherapy protocol (nedaplatin, 20 mg/m2/d, 5-FU, 500 mg/m2/d for four days) was given from day 1, and such treatment was repeated until day 29. From day 21 after radiotherapy, two cycles of a consolidated chemotherapy protocol were given at an interval of 28 days.

Results

The survival rates at one, two, and three years were 72.3%, 55.3%, and 40% in the concurrent chemoradiotherapy group, respectively, and 75.3%, 38.5%, and 18.5% in the radiotheray group (P = 0.007), respectively. The survival rates of the patients in the concurrent chemoradiotherapy group who completed one to two cycles and three to four cycles at one, two, and three years were 70%, 53.3%, and 30%, and 74.2%, 57.1%, 48.6% (P = 0.128), respectively. Three-year distant metastasis rates were 10.7% in the concurrent chemoradiotherapy group and 16.9% in the radiotherapy group. Acute toxicity in the concurrent chemoradiotherapy group was higher than in the radiotherapy group. Late toxic side effects were similar in the two groups.

Conclusions

Compared with radiotherapy alone, concurrent chemoradiotherapy in the treatment of esophageal carcinoma with local lymph node enlargement can improve the three-year survival rate. Moreover, completion of three to four cycles of chemotherapy may have better efficacy than one to two cycles.

Oesophageal cancer: Which treatment is the easiest to swallow? A review of combined modality treatments for resectable carcinomas

Oesophageal cancer is a relatively uncommon malignancy, but with poor prognosis. Despite several treatment options that are available, the 5-year survival rates rarely exceed 40%. This review discusses the main challenges of oesophageal cancer, the available treatment options, and the most effective treatment in terms of overall survival. The outcomes of clinical trials show that neo-adjuvant chemo-radiotherapy using cisplatin and 5-fluorouracil followed by oesophagectomy results in the greatest survival. However, the optimal chemotherapy and radiotherapy schedule remains unclear. There is no satisfactory treatment to date, particularly for patients with co-morbidities or advanced tumours.

Effect of Remote Internet Follow-Up on Postradiotherapy Compliance Among Patients with Esophageal Cancer: A Randomized Controlled Study

BACKGROUND

To explore the effects of using remote Internet follow-up on postradiotherapy compliance with medical advice provided to patients with esophageal cancer.

PATIENTS AND METHODS

Between January 1 and August 1, 2013, in total, 128 patients with esophageal squamous cell cancer treated with radiotherapy were randomly assigned to either an observation group (n=64) or a control group (n=64). The control group received routine outpatient follow-up, whereas the observation group received additional remote Internet follow-up for 6 months after discharge from the hospital. The treatment effects and compliance were investigated using a questionnaire.

RESULTS

At 3 months and 6 months after discharge, patients in the observation group had sought significantly more consultations and undergone more periodic re-examinations than patients in the control group (all p<0.001). Furthermore, both the disease-free survival rate and the symptom reduction rate were significantly higher in the observation group compared with the control group (all p<0.001).

CONCLUSIONS

Remote Internet follow-up is an easy and fast method for improving postradiotherapy compliance with medical instructions and promoting normalization among patients with esophageal cancer.

Radio(chemo)therapy for locally advanced squamous cell carcinoma of the esophagus: long-term outcome

PURPOSE

The purpose of this work is to report the long-term outcomes of three-dimensional conformal radio(chemo)therapy in the curative management of esophageal squamous cell carcinoma (ESCC).

PATIENTS AND METHODS

A retrospective analysis of patients treated with radio(chemo)therapy between 1988 and 2011 at Klinikum rechts der Isar, Technische Universität München was performed. In all, 168 patients received radio(chemo)therapy for ESCC in curative intention. The median follow-up time was 91 months (range 1-212 months). There were 128 men and 40 women with a median age of 63 years. Selection criteria for radio(chemo)therapy were unfit for surgery and/or unresectable primary tumor (n = 146, 87 %) or patients' choice (n = 22, 13 %). The majority of the patients received a combination of cisplatin and 5-fluorouracil chemotherapy with 54 Gy in 30 fractions of radiotherapy.

RESULTS

The median overall survival (OS) was 20 months (95 % confidence interval 17-23 months). The OS at 2 and 5 years for the whole cohort was 41 ± 4 % and 22 ± 3 %, respectively. Forty patients (24 %) suffered an in-field recurrence. The most common acute nonhematologic toxicity >grade 2 was dysphagia in 35 % of the patients. Acute hematologic toxicity > grade 2 was recorded in 14 % of the patients. There was no grade 5 toxicity observed during the study. Poor ECOG performance status (0-1 vs. 2-3, HR = 1.70, p = 0.002) and weight loss ≥ 10 % before the start of therapy (HR = 1.99, p = 0.001) were among the factors significantly associated with poor OS in multivariate analysis.

CONCLUSION

Three-dimensional conformal definitive radio(chemo)therapy is well tolerated and leads to long-term survival in more than 20 % of patients with advanced disease and/or contraindication to surgery. However, 24 % in-field recurrence remains a major concern. Prospective trials are warranted to assess if a well-tailored conformal radiochemotherapy can improve the local control and obviate the need for surgical resection in patients with good general condition and potentially resectable tumors.

Prognosis of patients with esophageal carcinoma after radiotherapy: an analysis of 85 cases

AIM: To investigate the efficacy of radiotherapy for esophageal carcinoma and to analyze prognostic factors for esophageal carcinoma after radiotherapy.

METHODS: Eighty-five patients with esophageal carcinoma who underwent comprehensive non-surgical treatment from April 2004 to April 2009 were enrolled in this study. Clinical factors influencing prognosis were evaluated. Survival was analyzed by Kaplan-Meier method. Univariate analysis was completed by using log-rank test (Log-rank test method), and multivariate analysis was performed using Cox proportional hazards regression model.

RESULTS: The follow-up rate was 100%. The 1- and 3-year survival rates were 65.9% and 29.4%, respectively. Univariate analysis showed that age, tumor site, lesion length, clinical stage, treatment mode, radiation techniques, and short-term effect were prognostic factors for esophageal carcinoma. Multivariate Cox regression analysis revealed that treatment mode, clinical stage and short-term effect were independent prognostic factors.

CONCLUSION: The long-term survival of patients with esophageal carcinoma after radiotherapy is poor. Treatment mode, clinical stage and short-term effect are main factors affecting the prognosis of esophageal carcinoma.

The enhancement of radiosensitivity in human esophageal carcinoma cells by thalidomide and its potential mechanism

To investigate the effects of thalidomide on the radiosensitivity of human esophageal cancer cells (TE1 cells) and the potential mechanism underlying these effects. The effects of thalidomide on proliferation of TE1 cells were determined by Methyl thiazolyl tetrazolium assay. The multitarget click model was used to delineate the survival curve using a colony-forming assay, and the radiosensitivity was determined after TE1 cells were treated by thalidomide and/or X-ray radiation. The cell cycle was detected using flow cytometry. Our results are as follows: thalidomide alone suppressed the proliferation of TE1 cells in a dose- and time-dependent manner. The suppressive effects were enhanced by prolonged duration or elevated concentration of thalidomide. However, thalidomide did not affect the cell cycle of TE1 cells. The expression of vascular endothelial growth factor (VEGF) mRNA and protein was suppressed after treatment with thalidomide alone in a dose-dependent manner. Synergistic suppressive effects on VEGF expression were observed after administration of thalidomide and X-ray exposure. In conclusion, thalidomide was able to enhance the radiosensitivity of TE1 cells in vitro, which could be closely related to its suppressive effects on the expression of VEGF in TE1 cells, but had no obvious effects on the cell cycle.

Esophagectomy compared with chemoradiation for early stage esophageal cancer in the elderly

BACKGROUND

: Esophagectomy has been the traditional treatment of choice for early stage esophageal cancer. However, esophagectomy is associated with high mortality and morbidity in the elderly, and these patients often receive chemoradiation instead. The authors of this report compared outcomes of esophagectomy versus chemoradiation in a population-based sample of elderly patients with early stage esophageal cancer.

METHODS

: The Surveillance, Epidemiology, and End Results-Medicare database was used to identify patients aged > or =65 years who were diagnosed with stage I or II esophageal cancer from 1991 to 2002. The associations of treatment with esophagectomy or chemoradiation were assessed along with demographic and clinical variables. A survival analyses was performed to compare outcomes with treatment modality and was adjusted for potential confounders.

RESULTS

: Seven hundred thirty patients with stage I or II esophageal cancer were identified who underwent esophagectomy (n = 341; 46.7%) or chemoradiation (n = 389; 53.3%). Older age, squamous cell histology, and lower socioeconomic status were associated with increased odds of receiving chemoradiation. In multivariate analyses, chemoradiation was associated with worse disease-specific survival (hazard ratio [HR], 2.08; 95% confidence interval [CI], 1.64-2.64) and overall survival (HR, 1.92; 95%CI, 1.58-2.34). The receipt of chemoradiation was associated with worse survival for patients with adenocarcinoma (HR, 3.01; 95%CI, 2.24-4.04), but there was no significant difference for patients with squamous cell carcinoma (HR, 1.33; 95%CI, 0.98-1.80).

CONCLUSIONS

: Compared with chemoradiation, esophagectomy may be associated with improved survival for early stage esophageal cancer in the elderly. The current results suggest that there also may be a subset of patients with squamous cell carcinoma for whom chemoradiation is adequate therapy. A randomized trial would be useful to determine the optimal treatment for elderly patients with early stage esophageal cancer. Cancer 2009. (c) 2009 American Cancer Society.

Outcomes from salvage esophagectomy post definitive chemoradiotherapy compared with resection following preoperative neoadjuvant chemoradiotherapy

Chemoradiotherapy (CRT) as a definitive treatment for esophageal cancer, is being used with increasing frequency and as a result, surgeons will be required to assess more patients who have residual or recurrent local malignancy. This article aimed to assess outcomes after esophagectomy following definitive CRT (dCRT) and compare any difference between them and patients who had preoperative neoadjuvant CRT (nCRT) using a similar regimen of chemotherapy. From a prospective database the details of patients who had a resection following nCRT and dCRT were analyzed. The main therapeutic difference between the groups was the dose of radiotherapy (35 vs 60 Gy) and the timing of the resection following completion of the CRT (median 4 vs 28 weeks). Fourteen patients had an esophagectomy following a dCRT and 53 had one following a nCRT. Preoperatively, the dCRT group had worse respiratory function and more ECG abnormalities. Preoperative tumor length, pathological TNM staging and R0 resection rates were the same in both groups. Post resection, the dCRT group had greater morbidity than the nCRT group, spending longer in the intensive care unit (median 48 vs 24 h), more days in hospital (median 31 vs 13) and having more severe respiratory complications (37%vs 6%). The operative mortality was higher in the dCRT group (7%vs 0%). The three-year survival was 24% after dCRT. Patients selected for salvage esophagectomy following dCRT are a major challenge in postoperative care. However, some patients survive for a reasonable period of time, making resection a worthwhile option.

High dose rate brachytherapy (HDR-BT) in locally advanced oesophageal cancer. Clinic response and survival related to biological equivalent dose (BED)

INTRODUCTION

Ninety percent of oesophageal cancers are locally advanced at diagnosis, and treatment yields discouraging results. High dose rate brachytherapy (HDR-BT) permits an increment of local doses without a significant increment of toxicity. The goal of our study is to compare different HDR-BT fractions and assess global survival (GS) and cause-specific survival (CSS).

MATERIAL AND METHODS

Twenty-six patients were treated for locally advanced oesophageal cancer with chemotherapy concomitant with conformal three-dimensional radiotherapy (C3DR) from January 1994 to December 2000. Of this group, 96.2% were males, mean age 63.08 years; the most frequent location was medium third, for 50% of cases. Eighty-four percent of cases were G2-3 epidermoid carcinomas. The administration consisted of 44.2 Gy with C3DR and 5 applications of HDR-BT of 500 cGy each.

RESULTS

Actuarial GS and CSS at 5 years is 10.18% and 12.96%, a mean survival of 25.68 and 29.14 months respectively. The following factors (C3DR total dose, fraction dose and total dose of HDR-BT, number of applications, active length of application, total dose of C3DR plus HDR-BT, and BED of HDR-BT) are evaluated to find if they have an influence on treatment response, GS and actuarial CSS. The only result that yields statistical significance, in univariant analysis, is the active length in HDR-BT, thus for a greater active length of application, a minor response is obtained and GS diminishes (p=0.05). We grouped BT fractions on biological equivalent dose (BED) into: <28, 28-33 and >33 Gy; mean survival and GS at 5 years increases with BED>or=28 Gy (p=0.016).

CONCLUSION

Tumour response increases (complete and partial) when BED on HDR-BT is increased, regardless of the fraction employed. A BED higher than 28 Gy yields a significant increase of mean survival and GS at 5 years (p=0.016).

Surgery alone in the curative treatment of localised oesophageal carcinoma

AIM

To document the results of surgery alone in patients with localised oesophageal carcinoma.

METHODS

Between January 1982 and 2002, 179 consecutive patients who underwent curative oesophagectomy for stage 0, I or II oesophageal carcinoma, without neo-adjuvant treatment, were analysed retrospectively.

RESULTS

Postoperative mortality and morbidity rates were 2.8 and 30.7%, respectively. The overall actuarial survival rate at 5 years was 59%. No patients with more than four invaded lymph nodes survived 5 years. A lymph node ratio more than 0.2, more than four invaded lymph nodes and an advanced pTNM stage were predictors of poor prognosis.

CONCLUSION

Long-term survival after surgery alone for localised oesophageal carcinoma can be achieved in some 2/3rds of patients. These results should be considered before designing neo-adjuvant therapeutic regimen or embarking into exclusive treatment alternate to oesophagectomy.