Adjuvant and neoadjuvant therapy for esophageal cancer: a critical reappraisal

Combined modality therapy for patients with esophageal squamous cell carcinoma: Radiation dose and survival analyses

BACKGROUND

We aimed to analyze the radiation dose and compare survival among combined modality therapy using modern radiation techniques for patients with esophageal squamous cell carcinoma (ESCC).

METHODS

This retrospective study included patients with clinically staged T1-4N0-3M0 ESCC from 2014 to 2018. Patients who received combined modality therapies with curative intent were enrolled. The overall survival (OS) rates among combined modality therapy were compared. The clinical variables and impacts of radiation dose on survival were analyzed by the Kaplan-Meier method and Cox regression model.

RESULTS

Of the 259 patients, 141 (54.4%) received definitive concurrent chemoradiotherapy (DCCRT); 67 (25.9%) underwent neoadjuvant chemoradiotherapy followed by surgery (NCRT+S); 51 (19.7%) obtained surgery followed by adjuvant chemoradiotherapy (S+ACRT). Two-year OS rates of the DCCRT, NCRT+S and S+ACRT group were 48.9, 61.5 and 51.2%. In the subgroup analysis of DCCRT group, the 2-year OS of patients receiving radiation dose 55-60 Gy was 57.1%. Multivariate analyses showed that clinical stage (p = 0.004), DCCRT with 55-60 Gy (p = 0.043) and NCRT+S with pathological complete response (pCR) (p = 0.014) were significant prognostic factors for better OS. The radiation dose-survival curve demonstrated a highly positive correlation between higher radiation dose and better survival.

CONCLUSION

Our results suggest that NCRT+S can provide a favorable survival for patients with ESCC, especially in patients who achieved pCR. The optimal radiation dose might be 55-60 Gy for patients receiving DCCRT via modern radiation techniques. Further randomized clinical studies are required to confirm the survival benefits between NCRT+S and DCCRT with escalated dose.

Survival benefit of neoadjuvant versus adjuvant radiotherapy in lymph node positive esophageal cancer: a population based analysis

Background

The impact of radiotherapy on the survival of patients with locally advanced esophageal cancer (EC) is presently insufficiently explored. Thus, using data from the Surveillance, Epidemiology, and End Results (SEER) Registry, this study aimed to compare the survival rates of patients with lymph node (LN) positive EC who received curative resection and were treated by neoadjuvant and adjuvant radiotherapy (RT), respectively.

Methods

Retrospectively collected data from the SEER database using all 18 SEER registries on patients that underwent esophagectomy for EC was evaluated. All patients with LN positive pathology who received either neoadjuvant or adjuvant RT and curative intent esophagectomy from 2004 to 2007 were included. A comparison of 5-year relative survival outcome among groups categorized by sex, race, age, histology, and tumor size was performed.

Results

A total of 933 patients were evaluated; 636 (69%) and 297 (31%) received RT in neoadjuvant and adjuvant setting respectively. Their overall 5-year relative survival rates were 32.8% (95% CI: 28.7-36.9) and 26.5% (95% CI: 21-32.3) (P=0.058). Patients in the neoadjuvant RT group who underwent curative resection for squamous cell carcinoma (SCC) of EC had an improved 5-year relative survival rate of 43.4% (95% CI: 32.5-53.8) compared to 26.5% (95% CI: 15.4-38.9) measured for the adjuvant RT group (P=0.03). The results further revealed a significant increase in the 5-year relative survival rates for stage T3 and Tx when RT was given in neoadjuvant setting compared to adjuvant RT group (T3 28.5% vs. 20.2%, P=0.011; Tx 46.3% vs. 8.9%, P=0.021). When the patients were grouped according to race, sex or age, or based on the timing of radiation relative to surgery, in the other histological or T stage groups, there were no statistically significant differences in the 5-year survival rates.

Conclusions

Compared to adjuvant radiotherapy, neoadjuvant radiotherapy results in a better 5-year relative survival in patients with squamous cell neoplasms and/or T3, Tx stage disease.

Evaluation of the germline single nucleotide polymorphism rs583522 in the TNFAIP3 gene as a prognostic marker in esophageal cancer

Most esophageal cancer patients die because of disease relapse, hence an accurate prognosis of disease relapse and survival is essential. Genetic variations in cancer patients may serve as important indicators. Three genotypes (GG, AG, and AA) are displayed by the single nucleotide polymorphism (SNP) rs583522, which maps to the TNFAIP3 gene on chromosome 6. Evaluation of the potential prognostic value of the TNFAIP3-SNP in esophageal cancer (EC) was the aim of this study. A total of 158 patients underwent complete surgical resection of the esophagus for EC. None of them received any neoadjuvant or adjuvant treatment. Peripheral blood was sampled, and genomic DNA was extracted from leukocytes before each operation. Clinicopathologic parameters, tumor cell dissemination in bone marrow, and clinical outcome were correlated with the TNFAIP3-SNP. A-allele carriers showed advanced tumor stages compared with those of homozygous G-allele carriers (P<0.001). Patients with an A-allele genotype (AA or AG) were significantly more likely to experience a relapse (P=0.003). Survival analysis (log-rank test) revealed a significant difference in overall survival between the three groups (P=0.039); however, none of the genotypes was identified as a disease stage-independent prognostic marker. In conclusion, TNFAIP3-SNP stratifies patients into different risk groups; however, it could not be identified as an independent prognostic marker.

An A/C germline single-nucleotide polymorphism in the TNFAIP3 gene is associated with advanced disease stage and survival in only surgically treated esophageal cancer

Prognostication of disease relapse and survival is essential for cancer patients and genetic variations in cancer patients may serve as important indicators. A single-nucleotide polymorphism (SNP) mapping to the tumor necrosis factor, alpha-induced protein 3 (TNFAIP3) gene at position 138241110 displays three genotypes (AA, AC and CC). The aim of this study was to evaluate the potential prognostic value of the TNFAIP3-SNP in esophageal cancer (EC). Genomic DNA was extracted from peripheral blood leukocytes of 173 patients who underwent complete surgical resection for EC and did not receive any neoadjuvant or adjuvant therapy. For SNP detection, a 260- bp fragment was PCR amplified, purified and sequenced with tested primers. The product was analyzed by automatic DNA sequencer.The TNFAIP3 genotypes were correlated with clinico-pathological parameters, tumor cell dissemination in bone marrow and clinical outcome. The C-allele carrier presented with higher disease stage (P<0.001). This was predominantly because of the presence of lymph node metastasis (P<0.001). The recurrence rate was higher in C-allele carriers (AC and CC genotype; P=0.004). Kaplan-Meier plots for disease-free (P=0.017) and overall survival (P<0.001) displayed a gene dosage-associated outcome with AA genotype patients presenting the longest and CC genotype patients the poorest survival. In disease stage-adjusted multivariate analysis the TNFAIP3-SNP was identified as an independent prognostic factor for survival (hazard ratio 1.9; P=0.008). The TNFAIP3-SNP allows risk stratification of EC patients and may be a useful tool to identify patients eligible for multimodal therapy concepts.

Adjuvant chemotherapy after esophagectomy: is there a role in the treatment of the lymph node positive thoracic esophageal squamous cell carcinoma?

BACKGROUND

Esophageal squamous cell carcinoma (ESCC) patients with regional lymph node metastases have poor prognosis after surgery. The purpose of this study was to investigate the impact of various treatment modalities on survival in these patients.

METHODS

We retrospectively reviewed data from 349 patients who had undergone left transthoracic esophagectomy for thoracic ESCC from January 2008 to December 2010 at our institute. All patients had lesions in the mid or lower third of the thoracic segment and had pathological positive lymph node metastasis. Of these patients, 143 patients received surgery alone, 154 patients underwent postoperative radiotherapy alone, and 52 patients underwent taxane-based chemotherapy. Univariate and multivariate Cox regression analyses were used to analyze prognostic factors and survival.

RESULTS

At a median follow-up of 53.1 months, the 3-year OS were 47.7% for the patients with surgery alone, 44.0% for the patients with adjuvant radiotherapy, and 58.9% for the patients with adjuvant chemotherapy. Multivariate analysis showed that postoperative therapy with adjuvant chemotherapy was significant positive predictor of survival.

CONCLUSIONS

Postoperative taxane-based adjuvant chemotherapy improved survival of patients with lymph node positive thoracic ESCC compared with surgery alone. Further randomized prospective studies to confirm these findings are warranted.

Survival benefits of postoperative chemoradiation for lymph node-positive esophageal squamous cell carcinoma

BACKGROUND

Little is known about the efficacy of chemoradiation therapy after surgery for patients with esophageal squamous cell carcinoma. This retrospective study aimed to determine whether postoperative chemoradiation improves survival compared with surgery alone.

METHODS

Of 290 patients with esophageal squamous cell carcinoma, 104 received postoperative chemoradiation therapy (CRT group) and 186 underwent surgery alone (S group). Propensity score matching analysis was used to identify 56 well-balanced pairs of patients to compare outcomes.

RESULTS

For N0 patients, overall survival (OS) and disease-free survival (DFS) were similar in both groups. For N+ patients, the median OS (31.0 versus 16.0 months) and the 3-year OS rate (45.8% versus 14.1%) were significantly higher in the CRT group than in the S group (p<0.001). Similarly, the median DFS (16.0 versus 9.0 months) and the 3-year DFS rate (24.1% versus 11.5%) were significantly higher in the CRT group than in the S group (p=0.002). In propensity-matched patients, a survival benefit was observed for N+ patients receiving postoperative chemoradiation (CRT versus S group: median OS 29.0 versus 16.0 months, 3-year OS rate 48.6% versus 16.8%; p=0.003). Disease-free survival (median DFS 11.0 versus 8.0 months, 3-year DFS rate 21.3% versus 12.5%) tended to be better in the CRT group than in the S group (p=0.057).

CONCLUSIONS

Postoperative chemoradiation therapy provided a survival benefit for patients with lymph node-positive esophageal squamous cell carcinoma.

The GNAS1 T393C single nucleotide polymorphism predicts the natural postoperative course of complete resected esophageal cancer

BACKGROUND

Genetic variations in cancer patients may serve as important prognostic indicators of clinical outcome. The GNAS1 T393C single nucleotide polymorphism (SNP) diversely correlates with the clinical outcome in cancer. The aim of this study was to evaluate the potential prognostic value of T393C-SNP in complete resected only surgically treated esophageal cancer (EC).

METHODS

Genomic DNA was extracted from peripheral blood leucocytes of 190 patients who underwent only complete surgical resection for EC. T393C-SNP was correlated with clinic-pathological parameters, tumor cell dissemination in bone marrow (DTC) and clinical outcome.

RESULTS

T-allele carriers had more advanced disease due to presence of lymph node metastasis (P < 0.0001) and DTC (P = 0.01) and higher recurrence rate (P = 0.01) compared to CC genotype. The disease-free (P < 0.001) and overall survival (P < 0.001) was better in CC compared to TT and TC patients. In the multivariate Cox regression disease-stage adjusted analysis the T393C-SNP was identified as a strong independent prognostic factor for recurrence (hazard ratio 1.8, P = 0.01) and survival (hazard ratio 2.5, P < 0.001) in EC patients.

CONCLUSION

Determination of T393C-SNP preoperatively will allow allocation of EC patients into different risk profiles which may help to stratify patients eligible for neoadjuvant and or adjuvant therapy.

Effects of small interfering RNAs targeting fascin on human esophageal squamous cell carcinoma cell lines

BACKGROUND

Fascin induces membrane protrusions and cell motility. Fascin overexpression was associated with poor prognosis, and its downregulation reduces cell motility and invasiveness in esophageal squamous cell carcinoma (ESCC). Using a stable knockdown cell line, we revealed the effect of fascin on cell growth, cell adhesion and tumor formation.

METHODS

We examined whether fascin is a potential target in ESCC using in vitro and in vivo studies utilizing a specific siRNA. We established a stable transfectant with downregulated fascin from KYSE170 cell line.

RESULTS

The fascin downregulated cell lines showed a slower growth pattern by 40.3% (p < 0.01) and detachment from collagen-coated plates by 53.6% (p < 0.01), compared to mock cells, suggesting that fascin plays a role in cell growth by maintaining cell adhesion to the extracellular matrix. In vivo, the tumor size was significantly smaller in the tumor with fascin knockdown cells than in mock cells by 95% at 30 days after inoculation.

CONCLUSIONS

These findings suggest that fascin overexpression plays a role in tumor growth and progression in ESCC and that cell death caused by its downregulation might be induced by cell adhesion loss. This indicates that targeting fascin pathway could be a novel therapeutic strategy for the human ESCC.

Neoadjuvant chemoradiation therapy for the treatment of esophageal carcinoma

An esophagectomy with three-field lymph node dissection is the standard therapy for esophageal cancer in many countries, including Japan. However, the results of esophagectomy are still unsatisfactory in comparison to the results of surgical treatment for gastric cancer or colon cancer. On the other hand, definitive chemoradiation therapy has recently shown progress as a treatment modality for resectable esophageal cancer, with data indicating the potential efficacy of combination therapy with chemoradiation and an esophagectomy. In fact, preoperative chemoradiotherapy for resectable esophageal cancer is becoming a standard therapy in Europe and North America. The latest metaanalysis concerning neoadjuvant chemoradiotherapy for resectable esophageal cancer concluded that a significant survival benefit was evident with preoperative chemoradiotherapy. However, there are still no supportive data for neoadjuvant chemoradiation and surgery from a well-designed large-scale randomized control trial (RCT). A well-designed large-scale RCT is needed to determine the utility of neoadjuvant chemoradiation. Future trials based on precise diagnosis and surgical procedures are required for the adequate interpretation of the results of treatment for resectable esophageal cancer. Of course, quality control of the operation is a very important factor, because operative mortality influences these results.

Long-term survivorship of esophageal cancer patients treated with radical intent

To investigate the recent trends in definitive management of esophageal cancer, the records of 138 consecutive patients treated with radical intent in a single institution between 1995 and 2003 were reviewed and analyzed. The median follow-up period was 5.7 years (range 1.1 to 10.4 years). Seventy-seven patients were treated with radiation therapy (RT) only and 61 with combined regimens (CRT), in which RT was combined with either radical surgery or chemotherapy, or both. The overall survival of the entire cohort was 32% over two years and 20% over five years. The survivorship in the RT group was 17% over two years and 5% over five years. In the CRT group, 51% and 35% survived over two and five years, respectively. From all the potential prognostic factors examined by univariate and multivariate analyses, only male sex and use of CRT were strongly associated with better survivorship. There was no significant difference in the outcomes among the different regimens of CRT. Survivorship was not affected by the location or histology of the tumour, clinical stage, dose of RT or use of endoluminal brachytherapy in addition to external beam RT. There was a greater tendency to use RT only more often in older patients, but patient age did not affect survivorship. The proportion of patients treated with CRT did not change significantly over the last versus the first four years of the observed period. Combined regimens are undoubtedly superior to RT as a single modality. The long-term survivorship of patients in a subgroup of our patients treated with combined modality protocols compared favourably with the previously reported results in the literature and specifically in prospective randomized trials. However, the optimal combined modality regimen is yet to be defined.

Gankyrin oncoprotein overexpression as a critical factor for tumor growth in human esophageal squamous cell carcinoma and its clinical significance

To elucidate the possible involvement of gankyrin in ESCC progression and the effect of its down-regulation in ESCC, we investigated the expression of gankyrin in ESCC tissues comparing it with the corresponding normal esophageal epithelia and tested a short-hairpin RNA (shRNA) expression vector for gankyrin in ESCC cell lines. Gankyrin protein expression in 11 ESCC cell lines (KYSE series) was examined by RT-PCR and western blot. The expression of gankyrin mRNA in 30 ESCC tissues was compared with the corresponding normal epithelia by Real-time PCR. Expression of gankyrin protein was immunohistochemically analyzed in the ESCC of 103 patients. A gankyrin-shRNA vector was stably transfected into KYSE 170 cells to assess the role of gankyrin in cell motility, invasion and proliferation in vitro and tumor formation in vivo. Gankyrin expression increased in all 11 ESCC cell lines. Real-time PCR revealed that gankyrin expression was higher in the cancerous tissue for all 30 patients. In immunohistochemistry, gankyrin overexpression was correlated with lower survival rate (p = 0.0001), extent of the primary tumor, lymph node metastasis, distant lymph node metastasis and stage (p = 0.0072, p = 0.0004, p = 0.0172 and p = 0.0002, respectively). A shRNA vector against gankyrin repressed growth, cell motility, invasiveness in vitro and tumor formation in vivo. Gankyrin overexpression is associated with poor prognosis. It may play an important role in ESCC tumor progression and could be a potentially important therapeutic gene target in ESCC.

[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.

Prevalence of bone marrow micrometastases in esophagogastric cancer patients with and without neoadjuvant chemoradiotherapy

BACKGROUND

Bone marrow micrometastases are present in a high proportion of patients undergoing curative resection for esophagogastric cancer. The incorporation of preoperative systemic therapies into these patients' treatment is widely practiced. This study investigates the effect of neoadjuvant chemoradiotherapy (CRT) on the incidence of micrometastases and the viability of detected tumor cells.

MATERIALS AND METHODS

Rib bone marrow was obtained from patients (n = 106) in three centers, who were selected for potentially curative resection. Patients received neoadjuvant CRT plus surgery (n = 55), or surgery alone (n = 51). To detect micrometastases, mononuclear cells were isolated from fresh marrow and immediately stained immunohistochemically with an anti-cytokeratin-18 antibody using the APAAP technique. Tumor cell viability was assessed by immunohistochemical staining of marrow cell cultures for cytokeratin-positive cells.

RESULTS

Micrometastases were detected in fresh marrow in 42% (23/55) of patients who received neoadjuvant CRT plus surgery, and in 67% (34/51) of patients treated with surgery alone. Viable tumor cells were demonstrated in 10 of 18 marrow cultures from CRT plus surgery cases. In this patient subset, combination of results of staining fresh and cultured marrow significantly increased micromet detection to 78%.

CONCLUSIONS

A significant proportion of patients with esophagogastric cancer have disseminated viable tumor cells at time of surgery, irrespective of pre-operative treatment. The use of marrow culture in parallel with fresh marrow staining may increase the detection of micrometastases. The persistence of tumor cells resistant to systemic therapy may explain why these regimens fail in a majority of patients.