Cancer of the esophagus and gastro-esophageal junction: potentially curative therapies

Assessment of Field-in-Field, 3-Field, and 4-Field Treatment Planning Methods for Radiotherapy of Gastro-Esophageal Junction Cancer

Background

Gastro-esophageal (GE) junction cancer is the fastest-growing tumor, particularly in the United States (US).

Objective

This study aimed to compare dosimetric and radiobiological factors among field-in-field (FIF), three-field (3F), and four-field box (4FB) radiotherapy planning techniques for gastro-esophageal junction cancer.

Material and Methods

In this experimental study, thirty patients with GE junction cancer were evaluated, and three planning techniques (field-in-field (FIF), three-field (3F), and four-field box (4FB)) were performed for each patient for a 6-MV photon beam. Dose distribution in the target volume, the monitor units (MUs) required, and the dose delivered to organs at risk (OARs) were compared for these techniques using the paired-sample t-test.

Results

A significant difference was measured between the FIF and 3F techniques with respect to conformity index (CI), dose homogeneity index (HI), and tumor control probability (TCP) for the target organ, as well as the D_mean for the heart, kidneys, and liver. For the spinal cord, the FIF technique showed a slight reduction in the maximum dose compared to the other two techniques. In addition, the V_{20 Gy} of the lungs and the normal tissue complication probability (NTCP) of all OARs were reduced with FIF method.

Conclusion

The FIF technique showed better performance for treating patients with gastro-esophageal junction tumors, in terms of dose homogeneity in the target, conformity of the radiation field with the target volume, TCP, less dose to healthy organs, and fewer MU.

New frontiers in esophageal radiology

Esophageal cancer is the sixth most common cause of cancer related mortality worldwide. Advances in treatment have translated into steadily improving survival rates. Accurate preoperative staging of esophageal cancer is imperative in order to provide an accurate prognosis and direct patients to the most appropriate treatment. Current preoperative staging relies on imaging, most commonly endoscopic ultrasound (EUS), computed tomography (CT) and positron emission tomography (PET). A combination of these modalities should be used in preoperative staging, as each has advantages over another. Magnetic resonance imaging (MRI) has always shown promise in its ability to accurately stage esophageal cancer, though it has not been consistently adopted as a common tool for this purpose. Recent research has demonstrated that MRI can become an integral part of esophageal cancer clinical staging. Advances in MR technology that utilize radial sampling allow for shorter, free breathing techniques without degradation of image quality, resulting in improved capability for T and N staging of esophageal cancer. MRI enhanced with superparamagnetic iron oxide (SPIO) and ultrasmall SPIO (USPIO) nanoparticles has been shown to be useful for the detection of metastatic disease in lymph nodes. This article will review the current evidence in the role that imaging plays in staging esophageal cancer.

Current surgical treatment standards for esophageal and esophagogastric junction cancer

A number of different surgical techniques for the treatment of cancer of the esophagus and the esophagogastric junction have been proposed. Guidelines generally recommend a transthoracic approach for esophageal cancer, including Siewert type I tumors. In tumors of the proximal esophageal third, transthoracic esophagectomy may be extended to a three-field approach, including resection of cervical lymph nodes. However, the choice between transthoracic esophagectomy with intrathoracic anastomosis (Ivor Lewis esophagectomy) and the three-incision approach with cervical esophago-gastrostomy (McKeown esophagectomy) remains controversial, with guidelines varying among different countries. Furthermore, it is commonly accepted that Siewert type III tumors should be treated by extended total gastrectomy with transhiatal resection of the lower esophagus, whereas currently no consensus exists regarding the optimal surgical approach for the treatment of Siewert type II adenocarcinoma. Likewise, there is a major controversy regarding palliative and potentially curative treatment modalities in oligometastatic disease. This review deals with current surgical treatment standards for cancer of the esophagus and the eosphagogastric junction, including discussion of ongoing trials.

Primary malignant melanoma of the esophagus with multiple lymph node metastases: A case report and literature review

RATIONALE

Primary malignant melanoma of the esophagus (PMME) is a very rare malignancy accounting for only 0.1% to 0.2% of all malignant esophageal lesions. Presently, there are no standard strategies or clear guidelines for PMME treatment.

PATIENT CONCERNS

Herein, we report a patient who had PMME with multiple lymph node metastases (LNMs) who was treated successfully by esophagectomy. In March 2018, a 74-year-old man with symptoms of continuous dysphagia was referred to our hospital.

DIAGNOSIS

Upper gastrointestinal endoscopic examination revealed melanin pigmentation in the middle thoracic esophagus and a pigmented polypoid mass in the lower esophagus. Histopathological examination of the endoscopic biopsy specimen revealed malignant melanoma. Contrast-enhanced computed tomography showed a 3 cm tumor lesion with several enlarged lymph nodes without distant metastasis. The preoperative diagnosis based on the TNM classification was cT2N2M0 stage III.

INTERVENTIONS

The patient underwent esophagectomy with lymph node dissection.

OUTCOMES

Histopathological examination showed that the tumor extended to the submucosal layer of the esophageal wall, with multiple LNMs. Although multiple LNMs were detected, computed tomography scan 15 months after surgery showed no recurrence. Additionally, we analyzed the relationship between the overall survival and the clinicopathological factors including LNMs in 48 previously reported cases of PMME that were surgically treated.

LESSONS

To our knowledge, this is the first report on the effect of LNMs on the prognosis of PMME patients. The analysis revealed the prognostic value of the TNM stage. Early tumor detection and esophagectomy with lymph node dissection may play as key factors for achieving a better overall survival of PMME patients.

Advantages of 99mTc-3PRGD2 SPECT over CT in the preoperative assessment of lymph node metastasis in patients with esophageal cancer

BACKGROUND

Our study was designed to compare the diagnostic efficacies of integrated ^99mTc-HYNIC-PEG4-E[PEG4-c(RGDfK)]2 (^99mTc-3PRGD₂) single-photon emission computed tomography (SPECT) images and computed tomography (CT) images in lymph node metastasis in the patients with esophageal cancer.

METHODS

From September 2015 and May 2018, 32 patients with histologically proven primary esophageal carcinoma underwent both ^99mTc-3PRGD₂ SPECT and CT scans followed by esophagectomy with lymph node dissection. The results of reviewing ^99mTc-3PRGD₂ SPECT and CT images for the lymph node metastasis were compared in relation with pathologic findings.

RESULTS

During surgery, a total of 168 lymph nodes were dissected in 32 patients, of which 42 node groups in 18 patients were malignant on histologic examination. Preoperative nodal staging was compared with postoperative histopathological staging, The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of ^99mTc-3PRGD₂ SPECT for lymph nodes were 80.95%, 86.51%, 85.12%, 66.67%, and 93.16% on per-node basis, respectively; compared with 59.52%, 73.02%, 69.64%, 42.37%, and 84.40% for CT (p = 0.034, 0.008, 0.005, 0.011, and 0.038, respectively). 70.59% (12/17) false-negative interpretations and 50% (17/34) false-positive interpretations on CT were corrected by ^99mTc-3PRGD₂ SPECT. 37.5% false-negative interpretations on ^99mTc-3PRGD₂ SPECT were corrected by CT. 11.90% (5/42) positive lymph nodes and 13.49% (17/126) negative nodes at pathology were incorrectly diagnosed both by ^99mTc-3PRGD₂ SPECT and CT. The accuracy of ^99mTc-3PRGD₂ SPECT (87.50%, 28/32) was significantly higher than that of CT (62.50, 20/32; p = 0.022) on per-patient basis. ^99mTc-3PRGD₂ SPECT showed significantly higher sensitivity and accuracy in the neck and upper thoracic regions than CT. For nodal staging, ^99mTc-3PRGD₂ SPECT was correct in 78.12% (25/32) of the patients, whereas CT was correct in 53.12% (17/32), p = 0.037.

CONCLUSION

^99mTc-3PRGD₂ SPECT is more accurate than CT for preoperative assessment of lymph node metastasis in esophageal cancer and may be helpful in determining the therapeutic plan.

Prognostic significance of the size and number of lymph nodes on pre and post neoadjuvant chemotherapy CT in patients with pN0 esophageal squamous cell carcinoma: a 5-year follow-up study

The prognosis of patients with esophageal cancer improves by using neoadjuvant chemotherapy (NAC). More patients obtain pathological N0 staging (pN0) after surgery. The heterogeneity of prognosis of these patients poses a great challenge of customizing therapeutic strategies for individual patients. The signs of lymph nodes on both pre and post NAC computer tomography (CT) scan can provide more information for evaluation. Therefore, we investigated a new approach to lymph node (LN)-survival analysis by using pre-/post-NAC CT in pN0 esophageal cancer. 79 patients undergone curative resection after NAC obtained pN0 staging. The long and short axis diameter of maximal lymph node (MaxLN) and LN number on pre-/post-NAC CT scans were recorded and assessed for predicting survival by univariate and multivariate survival analysis. The prognosis of patients with esophageal cancer was correlated with the LN size and number on pre-/post-NAC CT. The LN number on pre-NAC CT and short-axis diameter of MaxLN on post-NAC CT remained the independent predictor of overall survival. By using these two factors as classification criterion, N0b group included patients with LN number>4 on pre-NAC CT or short-axis diameter of MaxLN >7 mm on post-NAC CT and the rest patients were included in N0a group. N0a group had a significantly better overall survival than N0b group (5-year survival rate: 75.2% vs. 32.6%). The size and number of lymph node on pre-/post-NAC CT were reliable and important prognostic factors in patients with pN0 esophageal cancer. This new criterion could distinguish these patients into N0a and N0b, according to different prognosis.

Expression and clinical significance of Apollon in renal carcinoma

Apollon, namely baculoviral inhibitor of apoptosis proteins (IAP) repeat containing 6, is an unusually large member of the IAP family, and may be important in oncogenesis. The aim of the present study was to assess the association between renal carcinoma (RC) and Apollon expression, and to highlight the link between Apollon expression and the occurrence, development and prognosis of RC. Apollon expression was detected by immunohistochemistry, western blotting and reverse transcription-quantitative polymerase chain reaction in RC tissues, adjacent non-cancerous tissues and paired normal tissues, respectively, in order to analyze the association between Apollon expression and clinicopathological features of RC. Kaplan-Meier survival estimate was used to assess the prognostic significance. It was observed that Apollon expression was higher in carcinoma tissues than in adjacent non-cancerous tissues and normal control tissues at the protein and messenger RNA level (P<0.001). There was a significant difference in T-stage (P=0.006), nodal involvement (P=0.007) and tumor-node-metastasis-stage (P=0.035) in patients categorized according to different Apollon expression levels. A prognostic significance of Apollon was also identified by the Kaplan-Meier method. The results of the present study indicate that Apollon expression is associated with the biological characteristics of renal cancer, and is potentially a valuable predictor and novel target for RC.

Expression and clinical significance of Apollon in esophageal squamous cell carcinoma

Apollon, an unusually large member of the inhibitors of apoptosis protein family, may be important for oncogenesis development. The aim of the present study was to assess the association between esophageal squamous cell carcinoma (ESCC) and Apollon expression levels, and to highlight the association between Apollon and the occurrence, development and prognosis of ESCC. Apollon expression was detected by immunohistochemical staining and reverse transcription-quantitative polymerase chain reaction in ESCC tissues, adjacent non-cancerous tissues and paired normal tissues respectively, in order to analyze the association between Apollon expression and the clinicopathological features of ESCC. Survival analysis was used to assess the prognostic significance of Apollon expression. It was determined that the mRNA and protein expression levels of Apollon were significantly higher in the carcinoma tissues compared with the adjacent non-cancerous tissues and normal control tissues (P<0.001). There was a significant difference in lymph node involvement and the tumor, nodes, and metastases stage in patients categorized according to different Apollon expression levels. The prognostic significance of Apollon was also determined using the log-rank method. The overexpression of Apollon was associated with shorter overall survival and disease-free survival rates. The present study indicates that Apollon expression is associated with the biological characteristics of ESCC, and may be a valuable prognostic factor and a novel chemotherapeutic target for ESCC treatment.

Esophageal Cancer: Role of Imaging in Primary Staging and Response Assessment Post Neoadjuvant Therapy

Advances in the early detection and treatment of esophageal cancer have meant improved survival rates for patients with esophageal cancer. Accurate pretreatment and post-neoadjuvant treatment staging of esophageal cancer is essential for assessing operability and determining the optimum treatment plan. This article reviews the multimodality imaging approach in the diagnosis, staging, and assessment of treatment response in esophageal cancer.

New TNM staging system for esophageal cancer: what chest radiologists need to know

Esophageal cancer is a leading cause of cancer-related deaths worldwide, and the 5-year relative survival rate remains less than 20% in the United States. The treatment of esophageal cancer should be stage specific for better clinical outcomes. Recent treatment paradigms tend to involve a multimodality approach to management, which includes surgical resection and preoperative or definitive chemoradiation therapy. Accurate pretreatment staging of esophageal cancer is integral for assessing operability and determining a suitable treatment plan. The American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC) have published the seventh edition of the staging manual for cancer in the esophagus and esophagogastric junction. Unlike the sixth edition, the revised staging manual is data driven and harmonized with the staging of stomach cancer. Improvements include new definitions for the anatomic classifications Tis, T4, regional lymph node, N, and M and the addition of nonanatomic cancer characteristics (histopathologic cell type, histologic grade, and cancer location). Given the recent increase in the incidence of adenocarcinoma of the distal esophagus, esophagogastric junction, and gastric cardia, the staging of tumors in the esophagogastric junction has been addressed. Radiologists must understand the details of the seventh edition of the AJCC-UICC staging system for esophageal cancer and use appropriate imaging modalities, such as computed tomography (CT), endoscopic ultrasonography, and positron emission tomography/CT, for initial staging.

Significance of 18F-Fluorodeoxyglucose Uptake at the Gastroesophageal Junction: Comparison of PET to Esophagogastroduodenoscopy

BACKGROUND

Positron emission tomography-computed tomography (PET/CT) occasionally reveals unexpected uptake of (18)F-fluorodeoxyglucose ((18)F-FDG) at the gastroesophageal junction (GEJ). The aim of this study was to determine the importance of unexpected (18)F-FDG uptake at the GEJ on PET/CT by correlating this finding with endoscopy results.

METHODS

We reviewed medical records from June 2009 to October 2012 to identify patients in our Veterans Affairs Medical Center who had an esophagogastroduodenoscopy (EGD) performed within 6 months of a PET/CT. Metabolic activity at the GEJ was quantified with standardized uptake values (SUV) and correlated with EGD and histopathology results.

RESULTS

A total of 219 patients were identified and assigned to one of five groups based upon EGD findings: esophageal malignancy (n = 34), esophagitis (n = 21), Barrett's esophagus (n = 8), other non-malignant disorders (n = 5), and normal (n = 151). The mean SUV Max for the groups was 6.72, 2.47, 2.40, 3.48, and 2.06, respectively. SUV Max and SUV Mean were significantly higher in the esophageal malignancy group than in all other groups (p < 0.001). SUV for patients with high-grade esophagitis was greater than in patients with low-grade esophagitis. A SUV Max ≥ 3.5 was found to predict necessity for EGD with a positive predictive value of 79 %. A SUV Max ≤ 2.2 yielded a negative predictive value of 86 %.

CONCLUSION

Differentiation between benign and potentially significant disease at the GEJ may be possible with quantification of incidental (18)F-FDG uptake at PET/CT. Our results suggest thresholds that may help determine need for further endoscopic evaluation in patients with abnormal metabolic activity at the GEJ.

Tumor suppression by miR-31 in esophageal carcinoma is p21-dependent

microRNA regulation network is important for the cancer genetic heterogeneity. Relative to the increasing numbers of microRNA's targets identified, upstream regulatory mechanisms that control functional microRNAs are less well-documented. Here, we investigated the function of miR-31, a pleiotropically-acting microRNA, in esophageal squamous cell cancer (ESCC). We demonstrated that miR-31 only exerted tumor-suppressive effects in TE-7 ESCC cells, but not in TE-1 ESCC cells, although both of these cell lines harbor inactive p53. Interestingly, TE-1 cells highly expressed p21, while p21 levels were virtually undetectable in TE-7 cells, suggesting a p21-dependent mechanism of miR-31-mediated tumor suppression. Accordingly, knockdown of p21 in TE-1 cells reversed the tumor suppressive actions of miR-31. In patient ESCC specimens, real-time RT-PCR analysis revealed that expression of E2F2 and STK40, two known miR-31 target oncogenes, was negatively correlated with the expression of miR-31 in a p21-dependent manner, supporting the conclusion that miR-31 only downregulates its target oncogenes when p21 levels are low. Collectively, these data suggest a novel mechanism through which the tumor-suppressive effect of miR-31 is p21-dependent. In addition, we speculate that delivery of miR-31 could provide therapeutic benefit in the personalized management of a subgroup of ESCC patients with p21-deficient tumors.

Maximum standardized uptake value on PET/CT in preoperative assessment of lymph node metastasis from thoracic esophageal squamous cell carcinoma

The presence of lymph node metastasis is an important prognostic factor for patients with esophageal cancer. Accurate assessment of lymph nodes in thoracic esophageal carcinoma is essential for selecting appropriate treatment and forecasting disease progression. Positron emission tomography combined with computed tomography (PET/CT) is becoming an important tool in the workup of esophageal carcinoma. Here, we evaluated the effectiveness of the maximum standardized uptake value (SUVmax) in assessing lymph node metastasis in esophageal squamous cell carcinoma (ESCC) prior to surgery. Fifty-nine surgical patients with pathologically confirmed thoracic ESCC were retrospectively studied. These patients underwent radical esophagectomy with pathologic evaluation of lymph nodes. They all had ¹⁸F-FDG PET/CT scans in their preoperative staging procedures. None had a prior history of cancer. The pathologic status and PET/CT SUVmax of lymph nodes were collected to calculate the receiver operating characteristic (ROC) curve and to determine the best cutoff value of the PET/CT SUVmax to distinguish benign from malignant lymph nodes. Lymph node data from 27 others were used for the validation. A total of 323 lymph nodes including 39 metastatic lymph nodes were evaluated in the training cohort, and 117 lymph nodes including 32 metastatic lymph nodes were evaluated in the validation cohort. The cutoff point of the SUVmax for lymph nodes was 4.1, as calculated by ROC curve (sensitivity, 80%; specificity, 92%; accuracy, 90%). When this cutoff value was applied to the validation cohort, a sensitivity, a specificity, and an accuracy of 81%, 88%, and 86%, respectively, were obtained. These results suggest that the SUVmax of lymph nodes predicts malignancy. Indeed, when an SUVmax of 4.1 was used instead of 2.5, FDG-PET/CT was more accurate in assessing nodal metastasis.

Discovery of stage-related proteins in esophageal squamous cell carcinoma using proteomic analysis

Esophageal squamous cell carcinoma (ESCC) is the major subtype of esophageal cancers in China, and characterized with high morbidity and mortality. So far, the diagnosis of ESCC is mainly dependent on the alterations in esophageal histology, but most cases of ESCC with low stage do not display visible histological abnormalities. Therefore, a deep understanding of the mechanism of ESCC progression and seeking stage-specific molecules might improve the diagnosis and therapy for ESCC. In this study, we used proteomics to analyze ESCC tissues with classification by TNM stage, and determined the proteomic features correlated with ESCC progression (from stages I to III). Proteins that exhibited significantly different expression patterns between ESCC and corresponding normal esophageal tissues were identified using MS. The identified proteins with differentiated expression mainly fell into three protein categories (i.e. cytoskeleton system-associated proteins, metabolism enzymes, and heat shock proteins). In addition, real-time PCR highlighted some molecules that were associated with tumor stages at the mRNA level, such as enolase 1, chromosome 1 ORF 10, elastase inhibitor, α B crystalline, stress-induced phosphoprotein 1, and squamous cell carcinoma antigen 1. Altogether, these data provided further information on ESCC progression and potential drug targets for ESCC clinical therapy.

[The role of neoadjuvant therapy in the treatment of locally advanced squamous cell cancer of the cervical oesophagus]

INTRODUCTION

Cervical oesophagus represents a critical location for squamous cell carcinoma, which usually requires extensive surgery (pharyngo-laryngo-oesophagectomy). In the last decade, neoadjuvant chemo-radiotherapy was reported to be beneficial in the treatment of locally advanced squamous cell oesophageal cancer.

METHODS

Between November 1997 and January 2012, 55 patients with locally advanced (T3-4) squamous cell oesophageal cancer received preoperative chemo-radiotherapy, where the tumour was localized in the upper third. Patients received preoperative irradiation of 3960 cGy in 180 cGy fractions and simultaneously Cisplatin and 5-FU chemotherapy. Restaging was carried out after four weeks and patients considered operable were underwent surgery.

RESULTS

In patients with cervical oesophageal cancer 35 of 55 (64%) underwent oesophageal resection or pharyngo-laryngectomy. In 16 out of 35 resected specimens (46%) complete histopathological remission (pCR) was observed. Perioperative mortality and anastomotic leaks were the same: 5/35 (14%). R0 resection rate was 82% and the 2- and 5 years survival rates were 41% and 18%. In 19 cases a larynx preserving pharyngo-oesophagectomy was performed and a free jejunal graft was used for reconstruction after a pharyngo-laryngectomy in 11 cases.

CONCLUSION

The high rate of pCR (46%) confirmed that upper third oesophageal cancer has superior sensitivity to multimodal treatment. In 30 cases neoadjuvant chemo-radiotherapy was able to achieve tumour regression and render pharyngo-laryngo-oesophagectomy unnecessary.

Role of F18-FDG PET/CT in the Staging and Restaging of Esophageal Cancer: A Comparison with CECT

Esophageal cancer is one of the most fatal cancers principally because of its late presentation. CECT plays an important role in the staging of esophageal cancer but has some limitations. PET/CT which provides physiological information along with anatomical information and is a whole body imaging technique may therefore be a better alternative and thereby can facilitate selection or exclusion of patients for resection. The aim was to evaluate the performance of F18 FDG PET/CT in the staging and restaging of esophageal carcinoma compared to CECT using histopathologic findings and clinical follow-up as gold standard. Twenty eight patients with proven esophageal carcinoma, both preoperative and postoperative, were studied with CECT and F18 FDG PET/CT scan within an interval of 2 weeks. The PET/CT scan was acquired after injection of 370 MBq (10 mCi) F18-FDG and was evaluated for areas of increased focal uptake. CECT scan of chest and abdomen was done after injection of iodinated non-ionic contrast media. CECT findings suggested stage-IV disease in 16/28 (57.14%) patients and non stage-IV disease in 12/28 (42.86%) patients, whereas PET/CT suggested stage-IV disease in 23/28 (82.14%) patients and non stage-IV disease in 5/28 (17.86%) patients. Total nine patients were upstaged by PET/CT compared to CECT, out of which 7 (25%) were correctly upstaged and 2 (7.14%) were falsely upstaged. PET/CT improved our ability to detect distant metastases in 25% of patients that was missed by CECT. So, the use of F18 FDG PET/CT in esophageal cancer can alter management in significant number of patients.

Neoadjuvant concurrent chemoradiotherapy with capecitabine and oxaliplatin in patients with locally advanced esophegeal cancer

Evaluation of the feasibility and efficacy of neoadjuvant concurrent chemoradiotherapy (CRT) with capecitabine and oxaliplatin in patients with locally advanced esophageal cancer. Forty-two patients were eligible for the study. The chemotherapy during CRT consisted of two cycles of intravenous oxaliplatin of 120 mg/m(2) on day 1 and oral capecitabine 825 mg/m(2) twice daily on days 1-14 at 3-week intervals. The radiotherapy (1.8 Gy/fraction/day to a total dose of 45 Gy) was delivered to the primary tumor site and regional lymph node. All patients completed the planned treatment. Overall clinical response rate was 54.8% with complete response in 16.7% while pathological response rate was 38%. Anemia was the commonest hematologic toxicity (52.3%) with grade 3 in 4.7%, and esophagitis was the commonest non-hematologic toxicity 59.5% with grade 3 and 4 in 9.5%. No treatment-related death was observed. After a median follow-up duration of 19 months, the 2-year survival rate was 42%, median survival time was 20 months (95%CI: 13.802-26.198), while 2-year progression-free survival (PFS) rate was 32.5% with median PFS time of 15 months (95%CI: 10.042-19.958). Neoadjuvant concurrent CRT with capecitabine and oxaliplatin was found to be well tolerated and effective in patients with locally advanced esophageal cancer; however, these results should be further evaluated in a phase III study.

Risk factors for development of benign cervical strictures after esophagectomy

OBJECTIVE

To identify independent risk factors for development of benign cervical anastomotic strictures in general and specifically for refractory strictures after esophagectomy in a large series of patients.

SUMMARY BACKGROUND DATA

Benign strictures develop frequently when a cervical anastomosis is performed after esophagectomy, causing burdensome symptoms and poor quality of life.

METHODS

From 1996 to 2006, all patients in the Academic Medical Center prospective database undergoing esophagectomy with a cervical anastomosis were included. Stricture was defined as dysphagia requiring endoscopic dilation of the anastomosis. Prediction of stricture was assessed using uni- and multivariate logistic regression analysis. Evaluation of risk factors was also performed for refractory strictures (>2 times the median number of dilations in all patients with stricture) in a similar fashion.

RESULTS

A total of 607 patients underwent potentially curative esophagectomy, with an in-hospital mortality of 2.5%. During follow-up, 253 (41.7%) patients developed a stricture after a median time of 74 days, requiring a median number of 5 dilations. Cardiovascular disease (P = 0.002), gastric tube compared with colonic interposition (P = 0.03), and anastomotic leakage (P = 0.002) were predictive for development of stricture in multivariate analysis. Development of stricture within 90 days after surgery (P = 0.001), chemoradiotherapy (P = 0.02), and anastomotic leakage (P = 0.03) were independent predictors for refractory strictures requiring over 10 dilations.

CONCLUSIONS

The benign cervical stricture rate after esophagectomy was relatively high. Cardiovascular disease, gastric tube compared with colonic interposition and postoperative anastomotic leakage were independent predictors for development of benign anastomotic stricture. Anastomotic leakage, chemoradiotherapy and early development of stricture were independently associated with the development of refractory strictures, requiring a higher number of dilations. Prevention of anastomotic stricture formation should be focused on prevention of anastomotic leakage.

Clinical staging of adenocarcinoma of the esophagogastric junction

Tumors of the esophagogastric junction are among the most frequent and cause lethal cancers. Patients often do not present until late in the disease when the tumor is sufficiently large to cause obstruction or invasion of the adjacent structures, and thus becomes symptomatic. Preoperative staging is critical to select those patients whose disease is still locally confined for curative surgery. Ideally, clinical staging should accurately predict tumor invasion, lymph node involvement, and distant metastases. Upper endoscopy establishes the tumor diagnosis by multiple biopsies and defines the tumor type (Siewert I-III), based on tumor localization in relation to the endoscopic cardia. Preoperative TNM staging has a strong impact on treatment strategy. Endoscopic Ultrasound (EUS) determines the T category, and to a lesser extent, the presence of lymph node metastases. Multislice Computed Tomography (CT) and 18Fluorode-ocx-glucose Positron Emission Computed Tomography (18FDG-PET-CT) provide further information, especially about systemic metastases. Diagnostic laparascopy is suggested in advanced (CT3/4) Siewert type II-III tumors to exclude peritoneal carcinomatosis. This chapter summarizes current staging modalities and their accuracy in clinical practice.

Lymph node staging in esophageal adenocarcinoma with PET-CT based on a visual analysis and based on metabolic parameters

BACKGROUND

In order to investigate the value of FDG positron emission tomography-computed tomography (PET-CT), FDG PET (reviewed side-by-side with CT), and metabolic parameters in the assessment of lymph node status and prognosis.

METHODS

Fifty-five subjects with lymph node positive (N1) and 26 subjects with lymph node negative (N0) disease were included. In the slice with the maximum FDG uptake of the tumor, the axial area of the primary tumor, the maximum diameter of the tumor, and the mean and maximum standardized uptake values were measured.

RESULTS

Fused PET-CT correctly characterized 289 of 325 lymph node groups (accuracy 89%) compared to 273 of 325 with PET (accuracy 84%). In lymph node staging (N0 vs. N1), PET-CT (accuracy 83%) was more accurate than PET (accuracy 78%). Among the metabolic parameters, the tumor diameter measured on PET-CT was the best predictor of lymph node stage (N0 vs. N1: accuracy 86%; threshold 25.5 mm) and overall survival. However, the highest accuracy of lymph node staging (N0 vs. N1) was achieved with the synergistic combination of visual analysis and primary tumor diameter measurements (accuracy 95%).

CONCLUSIONS

PET-CT increases accuracy of lymph node staging in esophageal adenocarcinoma compared to PET. The primary tumor diameter further improves accuracy in lymph node staging and was shown to be an independent predictor of overall survival.

Impact of fluorodeoxyglucose PET on the management of esophageal cancer

Esophageal cancer is the third most common malignancy of the alimentary tract. The incidence of esophageal cancer has steadily increased over the past three decades. Almost all therapeutic modalities for esophageal cancer are associated with a considerable mortality and morbidity. Consequently, there has been growing concern regarding effective management of esophageal cancer. 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) is playing an increasing role in the management of esophageal cancer, offering potential advantages in the accuracy of disease assessment at a number of decision points in the management pathway. This review evaluates the critical role of FDG-PET in (i) diagnosis, (ii) preoperative staging, (iii) monitoring of response to neoadjuvant therapy, (iv) assessment of recurrence and (v) prediction of prognosis of esophageal cancer. We have also compared diagnostic performance of FDG-PET and other current technologies such as computed tomography scan and endoscopic ultrasonography based on available evidence.

Value of bronchoscopy after EUS in the preoperative assessment of patients with esophageal cancer at or above the carina

INTRODUCTION

Esophageal cancer is an aggressive disease with a strong tendency to infiltrate into surrounding structures. The aim of the present study is to determine the additional value of bronchoscopy for detecting invasion of the tracheobronchial tree after endoscopic ultrasonography (EUS) in the preoperative assessment of patients with esophageal cancer at or above the carina.

MATERIALS AND METHODS

Between January 1997 and December 2006, 104 patients were analyzed for histologically proven esophageal cancer at or above the carina. All patients underwent both EUS and bronchoscopy (with biopsy on indication) in the preoperative assessment of local resectability.

RESULTS AND DISCUSSION

After extensive diagnostic workup, 58 of 104 patients (56%) were eligible for potentially curative esophagectomy; nine of these 58 patients (9/58, 15%) appeared to be incurable peroperatively because of ingrowth in the tracheobronchial tree (five patients), ingrowth in other vital structures (two patients) or distant metastases (two patients). Of the 46 non-operable patients, local irresectability (T-stage 4) was identified in 26 patients (26/46, 57%) due to invasion of vital structures on EUS: invasion of the aorta in six patients, invasion of the lung in 11 patients; in 12 patients invasion of the tracheobronchial tree was described, which was confirmed by bronchoscopy in only five patients. No patients with T4 were identified by bronchoscopy alone.

CONCLUSION

For patients with esophageal tumors at or above the carina, no additional value of bronchoscopy (with biopsy on indication) to exclude invasion of the tracheobronchial tree was seen after EUS in a specialized centre. Although based on relatively small numbers, we conclude that bronchoscopy is not indicated if no invasion of the airways is identified on EUS.

Impact of the introduction of integrated PET-CT into the preoperative staging pathway of patients with potentially operable oesophageal carcinoma

AIM

To retrospectively evaluate the role of integrated positron emission tomography computed tomography (PET-CT) in oesophageal carcinoma staging, in predicting prognosis and its influence on surgical management.

MATERIALS AND METHODS

Twenty-five consecutive patients with potentially operable, biopsy-proven oesophageal malignancy who undergoing PET-CT from September 2004 to April 2007 were included in this study. Chi-square and Fisher's exact tests were used to compare the accuracy of N staging with PET-CT and CT/endoscopic ultrasound (EUS) using postoperative loco-regional nodal histology as the reference standard. The prognostic value of primary tumour maximum standardized uptake value (SUVmax) was derived using logistic regression.

RESULTS

Seventeen men and eight women with a mean age of 62 years were studied. All tumours showed abnormal 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) uptake. Fifteen patients underwent surgical resection. There was high concordance between N staging at CT/EUS (14/15) and final histology. PET-CT N staging was discordant with final nodal histology in over half of the patients (8/15). PET-CT detected occult metastases in three patients (12%) that were not identified on CT and new synchronous tumours in two patients (8%). Patient management was altered in 10 patients (40%) as a direct result of PET-CT. No statistically significant association was observed between SUVmax and clinical outcome (p=0.65).

CONCLUSION

Integrated PET-CT has a significant incremental value over conventional staging investigations mainly in the detection of distant metastases and synchronous tumours and frequently impacts on patient management.

[The effect of preoperative chemo-radiotherapy in the treatment of locally advanced squamous cell carcinoma in the upper- and middle-thirds of the esophagus]

AIM

The aim of this study was to compare the efficiency of the preoperative combined chemo-radiotherapy in the treatment of locally advanced squamous cell carcinoma in different locations of the oesophagus.

METHODS

Between 1997 and 2005, 102 patients with locally advanced (T3-4) squamous cell oesophageal cancer received preoperative chemo-radiotherapy. In 40 cases, the tumour was localised in the upper-third (Group I), while in 62 cases, in the middle-third of the oesophagus (Group II). Survival rates of patients receiving neoadjuvant therapy were compared with a historical control group. In addition, Group I and Group II were compared to each other, as well.

RESULTS

survival rate was significantly better after neoadjuvant therapy (p:0.0042) Resection was performed in 70% of the patients from Group I, and in 50% of those complete pathological remission (pCR) was observed. The perioperative morbidity and mortality rates were 43% and 14%, respectively. As far as Group II, 69% of the patients underwent oesophageal resection, with a perioperative mortality of 18% and morbidity rate of 62%. pCR was observed only in 7% of the cases. The median survivals (21 and 22 months) and the R0 resection rates (82 and 84%) were similar in the two groups. The pCR subgroup showed a significantly better survival rate.

CONCLUSION

In this study, we demonstrated that preoperative chemo-radiotherapy increases survival in locally advanced oesophageal cancer. A significantly higher rate of complete response was observed in patients with upper-third oesophageal cancer. It seems that this group has superior sensitivity to multimodal treatment; therefore, our results support a new prognostic factor in oesophageal cancer treatment.

Clinical and psychometric validation of a questionnaire module, the EORTC QLQ-OG25, to assess health-related quality of life in patients with cancer of the oesophagus, the oesophago–gastric junction and the stomach

AIM

To combine and test the EORTC questionnaires for assessing quality of life (HRQL) for oesophageal (QLQ-OES18) and stomach cancer (QLQ-STO22), into a single questionnaire for tumours of the oesophagus, oesophago-gastric junction or stomach.

METHODS

The QLQ-OES18, QLQ-STO22 and seven modified items were administered to 300 patients with oesophageal (n=148), junctional (n=66), or gastric cancer (n=86). Semi-structured interviews assessed item and scale preference and multi-trait scaling analyses confirmed the scale structure of the new module (QLQ-OG25). This was further tested for validity.

RESULTS

The QLQ-OG25 has six scales, dysphagia, eating restrictions, reflux, odynophagia, pain and anxiety. Scales have good reliability (alpha range 0.67-0.87) and they distinguish between tumour sites and disease stage. Scales do not correlate highly with scores from the core questionnaire, thus indicating that the module was addressing separate HRQL aspects.

CONCLUSION

The QLQ-OG25 is recommended to supplement the EORTC QLQ-C30 when assessing HRQL in patients with oesophageal, junctional or gastric cancer.

Evolving role of (18)F-fluorodeoxyglucose positron emission tomography in the management of esophageal carcinoma

Positron emission tomography (PTE) and PET/CT imaging with (18)F-fluorodeoxyglucose are metabolic imaging modalities that depict tissues based on their level of glucose uptake. PET provides useful information in the primary staging of disease. PET performance in detecting locoregional nodal metastases is limited; however, it is the most accurate single noninvasive modality for detecting distant metastases. It is the imaging modality of choice for whole-body scanning in high-risk patients or patients who have clinically suspected recurrence, and is particularly helpful in determining which patients are the best candidates for surgical cure.

Neoadjuvant chemotherapy for locally advanced carcinoma of the lower oesophagus and oesophago-gastric junction

AIMS

To evaluate a single unit's experience with neoadjuvant chemotherapy for treating locally advanced non-metastatic initially resectable and unresectable oesophago-gastric cancer.

METHODS

The medical records of all patients with either locally advanced carcinoma of the lower oesophagus or cardia treated with neoadjuvant chemotherapy between August 1999 and January 2003 were reviewed.

RESULTS

Sixty-four patients with initially resectable tumours (T2-3 or N+) and 38 patients with initially unresectable tumours (T4 or M1a) received neoadjuvant chemotherapy (83% combination Epirubicin, Cisplatin and 5-Fluorouracil). Symptomatic grade III/IV toxicity was observed in 33% of patients. Chemotherapy was not completed in 20 patients because of death (5.9%) and inadequate tumour response/toxicity (13.7%). Forty-three patients (67.3%) with initially resectable tumours and 19 patients (50%) with initially unresectable tumours underwent surgery.

CONCLUSIONS

Chemotherapy in this study was associated with appreciable toxicity. Patients with initially unresectable locally advanced disease can be downstaged with neoadjuvant chemotherapy.

Validation of the functional assessment of cancer therapy esophageal cancer subscale

BACKGROUND

To develop and validate a quality of life subscale for patients with esophageal cancer to be used with the Functional Assessment of Cancer Therapy-General (FACT-G).

METHODS

Prospective cohort study of patients with esophageal cancer treated with surgery alone or neoadjuvant chemoradiotherapy and surgery evaluating the validity, internal consistency, and responsiveness to change of the FACT-Esophageal (FACT-E) when comparing it with the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ 30) and esophageal (OES 24) as well as clinical factors.

RESULTS

The FACT-E demonstrated very good convergent and divergent validity when compared with the EORTC QLQ30 and OES 24 and clinical variables. Internal consistency was also good with coefficient alpha > 0.70 for all subscales and individual items. Stability coefficients were > 0.80. Changes in clinical status were reflected in changes in FACT-E scores demonstrating responsiveness to change, particularly in patients receiving neoadjuvant chemoradiotherapy before surgery.

CONCLUSIONS

The FACT-E met or exceeded all standards for validity, providing an option to measure health-related quality of life for different treatment strategies for esophageal cancer.

Neoadjuvant chemotherapy for oesophageal cancer: The need for accurate response prediction and evaluation

Primary surgical resection for locally advanced oesophageal cancer is associated with systemic failure and poor survival due to presence of micrometastatic disease at the time of diagnosis. Neoadjuvant chemotherapy prior to surgical resection aims to downstage these locally advanced tumours. A review of reported randomised controlled trials has shown only one sufficiently powered trial with a survival advantage for cisplatin-based chemotherapy. Published meta-analyses of neoadjuvant chemotherapy trials have shown little or no overall survival benefit. A subgroup of patients with biologically favourable tumours who respond to this treatment have been consistently shown to have a survival advantage. These patients need to be differentiated from non-responders preferably at an early stage of this potentially toxic treatment. Current clinical, endoscopic and radiological methods of response evaluation are all unreliable. Response evaluation with 18FDG-PET has been shown to accurately assess the pathological response and also to predict the risk of local recurrence and overall survival. The development of integrated PET/CT imaging may enhance the accuracy of this response evaluation. In the future, molecular markers of response prediction prior to initiation of treatment may allow the development of individualised treatment strategies. New emerging chemotherapeutic agents may prove to be more effective in eradicating micrometastatic disease.

Neoadjuvant chemoradiotherapy for esophageal carcinoma

SUMMARY. Neoadjuvant chemoradiotherapy is often administered to patients with esophageal carcinoma in the belief that this will improve survival. However, its role in the management of esophageal carcinoma remains controversial. In this study we evaluated our experience with neoadjuvant chemoradiotherapy for the treatment of esophageal carcinoma. The study group was 115 patients who underwent esophagectomies between January 1999 and January 2004. Eighty-nine patients had adenocarcinoma and 26 had squamous cell carcinoma. Fifty-six patients underwent neoadjuvant chemoradiotherapy (two cycles of cisplatin and 5-fluorouracil with 45 Gy radiation) followed by esophagectomy. The other 59 patients proceeded directly to esophagectomy. Outcomes were determined prospectively, and follow-up was available for all patients. Neoadjuvant chemoradiotherapy achieved down-staging of the esophageal cancer in 43%, 43% and 46% of patients, according to T, N and TNM classifications, respectively. Neoadjuvant chemoradiotherapy resulted in a complete pathological response in seven (13%) patients. The surgical morbidity rate was 37% (42/115), and in-hospital mortality was 5% (6/115). There were no differences between patients who did and did not undergo neoadjuvant chemoradiotherapy in regard to completeness of resection, perioperative mortality and postoperative morbidity. Four-year survival was 33% following neoadjuvant chemoradiotherapy, compared with 19% for patients undergoing surgery alone. The administration of neoadjuvant chemoradiotherapy in patients with esophageal carcinoma down-staged nearly 50% of tumors, and a complete pathological response occurred in some of these patients. It was not associated with any increase in postoperative morbidity or perioperative mortality. In this non-randomized study, it was also associated with a trend towards a better survival outcome.

Prevention and management of early esophageal cancer

Early esophageal cancer is defined by its limitation to the esophageal mucosa and submucosa. It has become a curable malignant disease, in sharp contrast to the dismal prognosis of esophageal cancer at advanced stages, which still represents the majority of patients. Understanding the risk factors, establishing surveillance programs for patients at risk, and developing preventative interventions such as dietary and lifestyle changes or pharmacologic interventions hold the potential of reducing the incidence of the disease and of shifting the stage distribution toward early cancer. Endoscopic ultrasound examination is pivotal for distinguishing early from advanced stages of the disease because it allows for accurate assessment of tumor infiltration and regional lymph node involvement. The therapeutic mainstay for early esophageal cancer remains surgery. New, less invasive surgical techniques are being tested that are associated with less morbidity and mortality than standard radical esophagectomies. For patients who are not candidates for surgery, definitive chemoradiation is a viable alternative. New endoscopic ablation techniques, such as endoscopic mucosa resection and photodynamic therapy, are potential alternatives to surgery in patients with cancers limited to the mucosa. For patients with adenocarcinoma of the gastroesophageal junction with submucosal involvement, adjuvant chemoradiation should be considered because of its potential to increase survival.

Alveolar and plasma concentrations of interleukin-8 and vascular endothelial growth factor following oesophagectomy

The acute respiratory distress syndrome occurs in approximately 10% of all patients undergoing elective oesophagectomy. Local increases in lung pro-inflammatory cytokines have been previously detected in high-risk patients before the development of the acute respiratory distress syndrome. We hypothesised that similar changes would occur following oesophagectomy. Two groups of patients were studied. In the collapsed lung group (n = 11), interelukin-8 and vascular endothelial growth factor were measured in bronchoalveolar lavage samples obtained from the intra-operative collapsed lung after operation. In the ventilated lung group (n = 10), bronchoalveolar lavage was performed after operation from the ventilated lung and cytokines measured. Cytokines were also measured in peripheral blood samples before and after operation. Bronchoalveolar lavage cytokine levels in both lungs were of an order of magnitude greater than in peripheral blood. Pulmonary pro-inflammatory cytokine release occurs following oesophageal surgery and may indicate subclinical lung injury.

Neoplasms of the esophagus and stomach

Esophageal cancer is one of the most lethal of all neoplasms. During the last two decades, there have been significant changes in the epidemiology and treatment of esophageal cancer. The incidence of adenocarcinoma is increasing whereas that of squamous cancer is decreasing. Surgery, the mainstay of treatment of esophageal cancer, has been used with neoadjuvant chemoradiotherapy to improve prognosis in patients with localized disease. Accurate staging is essential for selection of the best mode of therapy and to predict prognosis. In addition, with widespread use of neoadjuvant therapy, accurate assessment of response to therapy has become very important because responders have better a prognosis than nonresponders. Anatomical imaging methods, such as computed tomography and endoscopic ultrasonography, that are commonly used to evaluate esophageal cancer have shortcomings in demonstrating the true extent of disease and in assessing or predicting response to therapy. Positron emission tomography (PET) with 2-[(18)F]fluoro-2-deoxy-d-glucose (FDG) has been shown to be a useful adjunct to anatomical imaging methods. For initial staging of esophageal cancer, the combination of PET and endoscopic ultrasonography with fine-needle aspiration biopsy has been suggested to be the most effective strategy. For restaging and monitoring response to therapy, FDG-PET has been shown to be superior to conventional imaging. The incidence of gastric cancer is decreasing worldwide, but it is also a highly lethal cancer. Similar to esophageal cancer, noninvasive staging of this cancer is unsatisfactory. Approximately one-third of the patients thought to have limited disease and to be candidates for surgery by conventional staging methods, are found to have advanced disease at surgery. Only a few published studies have evaluated gastric cancer with FDG-PET. These studies suggest that FDG-PET may be useful in evaluating gastric cancers of intestinal type and nonmucinous tumors.

Molecular markers and staging of early esophageal cancer

BACKGROUND

Patients with early esophageal cancer experience varying clinical outcomes despite identical tumor staging by standard diagnostic methods because clinical and histopathological staging fail to reveal the underlying complex biology of cancer.

METHODS AND FOCUS

This review discusses some of the current concepts of molecular staging with the potential to enhance the current staging methods of patients with early esophageal cancer.

CONCLUSIONS

Understanding the molecular biology of esophageal cancer has increased substantially, and clinicians anticipate the translation of the gained knowledge into patient care. Numerous molecular techniques are potentially available for analyzing biological aspects of the individual tumor for improved staging.