1
|
Graf M, Gawlitza J, Makowski M, Meurer F, Huber T, Ziegelmayer S. Evaluating Treatment Response in GEJ Adenocarcinoma: The Role of Pretherapeutic and Posttherapeutic Iodine Mapping. Invest Radiol 2024; 59:583-588. [PMID: 38265075 DOI: 10.1097/rli.0000000000001064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND Neoadjuvant therapy regimens have significantly improved the prognosis of GEJ (gastroesophageal junction) cancer; however, there are a significant percentage of patients who benefit from earlier resection or adapted therapy regimens, and the true response rate can only be determined histopathologically. Methods that allow preoperative assessment of response are lacking. PURPOSE The purpose of this retrospective study is to assess the potential of pretherapeutic and posttherapeutic spectral CT iodine density (IoD) in predicting histopathological response to neoadjuvant chemotherapy in patients diagnosed with adenocarcinoma of the GEJ. METHODS In this retrospective cohort study, a total of 62 patients with GEJ carcinoma were studied. Patients received a multiphasic CT scan at diagnosis and preoperatively. Iodine-density maps were generated based on spectral CT data. All tumors were histopathologically analyzed, and the tumor regression grade (TRG) according to Becker et al ( Cancer . 2003;98:1521-1530) was determined. Two experienced radiologists blindly placed 5 defined ROIs in the tumor region of highest density, and the maximum value was used for further analysis. Iodine density was normalized to the aortic iodine uptake. In addition, tumor response was assessed according to standard RECIST measurement. After assessing interrater reliability, the correlation of IoD values with treatment response and with histopathologic TRG was evaluated. RESULTS The normalized ΔIoD (IoD at diagnosis - IoD after neoadjuvant treatment) and the normalized IoD after neoadjuvant treatment correlated significantly with the TRG. For the detection of responders and nonresponders, the receiver operating characteristic (ROC) curve for normalized ΔIoD yielded the highest area under the curve of 0.95 and achieved a sensitivity and specificity of 92.3% and 92.1%, respectively. Iodine density after neoadjuvant treatment achieved an area under the curve of 0.88 and a sensitivity and specificity of 86.8% and 84.6%, respectively (cutoff, 0.266). Iodine density at diagnosis and RECIST did not provide information to distinguish responders from nonresponders. Using the cutoff value for IoD after neoadjuvant treatment, a reliable classification of responders and nonresponders was achieved for both readers in a test set of 11 patients. Intraclass correlation coefficient revealed excellent interrater reliability (intraclass correlation coefficient, >0.9). Lastly, using the cutoff value for normalized ΔIoD as a definition for treatment response, a significantly longer survival of responders was shown. CONCLUSIONS Changes in IoD after neoadjuvant treatment of GEJ cancer may be a potential surrogate for therapy response.
Collapse
Affiliation(s)
- Markus Graf
- From the Department of Diagnostic and Interventional Radiology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | | | | | | | | |
Collapse
|
2
|
Gao X, Overtoom HCG, Eyck BM, Huang SH, Nieboer D, van der Sluis PC, Lagarde SM, Wijnhoven BPL, Chao YK, van Lanschot JJB. Pathological response to neoadjuvant chemoradiotherapy for oesophageal squamous cell carcinoma in Eastern versus Western countries: meta-analysis. Br J Surg 2024; 111:znae083. [PMID: 38721902 DOI: 10.1093/bjs/znae083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 02/23/2024] [Accepted: 03/05/2024] [Indexed: 05/15/2024]
Abstract
OBJECTIVE Locally advanced oesophageal squamous cell carcinoma can be treated with neoadjuvant chemoradiotherapy or chemotherapy followed by oesophagectomy. Discrepancies in pathological response rates have been reported between studies from Eastern versus Western countries. The aim of this study was to compare the pathological response to neoadjuvant chemoradiotherapy in Eastern versus Western countries. METHODS Databases were searched until November 2022 for studies reporting pCR rates after neoadjuvant chemoradiotherapy for oesophageal squamous cell carcinoma. Multi-level meta-analyses were performed to pool pCR rates separately for cohorts from studies performed in centres in the Sinosphere (East) or in Europe and the Anglosphere (West). RESULTS For neoadjuvant chemoradiotherapy, 51 Eastern cohorts (5636 patients) and 20 Western cohorts (3039 patients) were included. Studies from Eastern countries included more men, younger patients, more proximal tumours, and more cT4 and cN+ disease. Patients in the West were more often treated with high-dose radiotherapy, whereas patients in the East were more often treated with a platinum + fluoropyrimidine regimen. The pooled pCR rate after neoadjuvant chemoradiotherapy was 31.7% (95% c.i. 29.5% to 34.1%) in Eastern cohorts versus 40.4% (95% c.i. 35.0% to 45.9%) in Western cohorts (fixed-effect P = 0.003). For cohorts with similar cTNM stages, pooled pCR rates for the East and the West were 32.5% and 41.9% respectively (fixed-effect P = 0.003). CONCLUSION The pathological response to neoadjuvant chemoradiotherapy is less favourable in patients treated in Eastern countries compared with Western countries. Despite efforts to investigate accounting factors, the discrepancy in pCR rate cannot be entirely explained by differences in patient, tumour, or treatment characteristics.
Collapse
Affiliation(s)
- Xing Gao
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Hidde C G Overtoom
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Ben M Eyck
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Shi-Han Huang
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | - Daan Nieboer
- Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Sjoerd M Lagarde
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan, Taiwan
| | | |
Collapse
|
3
|
Lu S, Wang C, Liu Y, Chu F, Jia Z, Zhang H, Wang Z, Lu Y, Wang S, Yang G, Qu J. The MRI radiomics signature can predict the pathologic response to neoadjuvant chemotherapy in locally advanced esophageal squamous cell carcinoma. Eur Radiol 2024; 34:485-494. [PMID: 37540319 DOI: 10.1007/s00330-023-10040-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/26/2023] [Accepted: 06/19/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVES To investigate the MRI radiomics signatures in predicting pathologic response among patients with locally advanced esophageal squamous cell carcinoma (ESCC), who received neoadjuvant chemotherapy (NACT). METHODS Patients who underwent NACT from March 2015 to October 2019 were prospectively included. Each patient underwent esophageal MR scanning within one week before NACT and within 2-3 weeks after completion of NACT, prior to surgery. Radiomics features extracted from T2-TSE-BLADE were randomly split into the training and validation sets at a ratio of 7:3. According to the progressive tumor regression grade (TRG), patients were stratified into two groups: good responders (GR, TRG 0 + 1) and poor responders (non-GR, TRG 2 + 3). We constructed the Pre/Post-NACT model (Pre/Post-model) and the Delta-NACT model (Delta-model). Kruskal-Wallis was used to select features, logistic regression was used to develop the final model. RESULTS A total of 108 ESCC patients were included, and 3/2/4 out of 107 radiomics features were selected for constructing the Pre/Post/Delta-model, respectively. The selected radiomics features were statistically different between GR and non-GR groups. The highest area under the curve (AUC) was for the Delta-model, which reached 0.851 in the training set and 0.831 in the validation set. Among the three models, Pre-model showed the poorest performance in the training and validation sets (AUC, 0.466 and 0.596), and the Post-model showed better performance than the Pre-model in the training and validation sets (AUC, 0.753 and 0.781). CONCLUSIONS MRI-based radiomics models can predict the pathological response after NACT in ESCC patients, with the Delta-model exhibiting optimal predictive efficacy. CLINICAL RELEVANCE STATEMENT MRI radiomics features could be used as a useful tool for predicting the efficacy of neoadjuvant chemotherapy in esophageal carcinoma patients, especially in selecting responders among those patients who may be candidates to benefit from neoadjuvant chemotherapy. KEY POINTS • The MRI radiomics features based on T2WI-TSE-BLADE could potentially predict the pathologic response to NACT among ESCC patients. • The Delta-model exhibited the best predictive ability for pathologic response, followed by the Post-model, which similarly had better predictive ability, while the Pre-model performed less well in predicting TRG.
Collapse
Affiliation(s)
- Shuang Lu
- Department of Radiology, the Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, No. 127 Dongming Road, Zhengzhou, 450008, Henan, China
| | - Chenglong Wang
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, 200062, China
| | - Yun Liu
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, 200062, China
| | - Funing Chu
- Department of Radiology, the Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, No. 127 Dongming Road, Zhengzhou, 450008, Henan, China
| | - Zhengyan Jia
- Department of Radiology, the Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, No. 127 Dongming Road, Zhengzhou, 450008, Henan, China
| | - Hongkai Zhang
- Department of Radiology, the Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, No. 127 Dongming Road, Zhengzhou, 450008, Henan, China
| | - Zhaoqi Wang
- Department of Radiology, the Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, No. 127 Dongming Road, Zhengzhou, 450008, Henan, China
| | - Yanan Lu
- Department of Radiology, the Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, No. 127 Dongming Road, Zhengzhou, 450008, Henan, China
| | - Shuting Wang
- Department of Radiology, the Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, No. 127 Dongming Road, Zhengzhou, 450008, Henan, China
| | - Guang Yang
- Shanghai Key Laboratory of Magnetic Resonance, East China Normal University, Shanghai, 200062, China.
| | - Jinrong Qu
- Department of Radiology, the Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, No. 127 Dongming Road, Zhengzhou, 450008, Henan, China.
| |
Collapse
|
4
|
Tsang Y, Hsu C, Shueng P. Comments on "Comparison of different neoadjuvant treatments for resectable locoregional esophageal cancer: A systematic review and network meta-analysis". Thorac Cancer 2022; 13:3436. [PMID: 36254594 PMCID: PMC9715774 DOI: 10.1111/1759-7714.14698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 01/09/2023] Open
Affiliation(s)
- Yuk‐Ming Tsang
- Division of Medical Imaging, Department of RadiologyFar Eastern Memorial HospitalNew Taipei CityTaiwan
| | - Chen‐Xiong Hsu
- Division of Radiation Oncology, Department of RadiologyFar Eastern Memorial HospitalNew Taipei CityTaiwan
| | - Pei‐Wei Shueng
- Division of Radiation Oncology, Department of RadiologyFar Eastern Memorial HospitalNew Taipei CityTaiwan,School of Medicine, College of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| |
Collapse
|
5
|
Diffusion-weighted MRI and 18F-FDG PET/CT in assessing the response to neoadjuvant chemoradiotherapy in locally advanced esophageal squamous cell carcinoma. Radiat Oncol 2021; 16:132. [PMID: 34281566 PMCID: PMC8287821 DOI: 10.1186/s13014-021-01852-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 07/04/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (nCRT) followed by surgery is a currently widely used strategy for locally advanced esophageal cancer (EC). However, the conventional imaging methods have certain deficiencies in the evaluation and prediction of the efficacy of nCRT. This study aimed to explore the value of functional imaging in predicting the response to neoadjuvant chemoradiotherapy (nCRT) in locally advanced esophageal squamous cell carcinoma (ESCC). METHODS Fifty-four patients diagnosed with locally advanced ESCC from August 2017 to September 2019 and treated with nCRT were retrospectively analyzed. DW-MRI scanning was performed before nCRT, at 10-15 fractions of radiotherapy, and 4-6 weeks after the completion of nCRT. 18F-FDG PET/CT scans were performed before nCRT and 4-6 weeks after the completion of nCRT. These 18F-FDG PET/CT and DW-MRI parameters and relative changes were compared between patients with pathological complete response (pCR) and non-pCR. RESULTS A total of 8 of 54 patients (14.8%) were evaluated as disease progression in the preoperative assessment. The remaining forty-six patients underwent operations, and the pathological assessments of the surgical resection specimens demonstrated pathological complete response (pCR) in 10 patients (21.7%) and complete response of primary tumor (pCR-T) in 16 patients (34.8%). The change of metabolic tumor volume (∆MTV) and change of total lesion glycolysis (∆TLG) were significantly different between patients with pCR and non-pCR. The SUVmax-Tpost, MTV-Tpost, and TLG-Tpost of esophageal tumors in 18F-FDG PET/CT scans after neoadjuvant chemoradiotherapy and the ∆ SUVmax-T and ∆MTV-T were significantly different between pCR-T versus non-pCR-T patients. The esophageal tumor apparent diffusion coefficient (ADC) increased after nCRT; the ADCduring, ADCpost and ∆ADCduring were significantly different between pCR-T and non-pCR-T groups. ROC analyses showed that the model that combined ADCduring with TLG-Tpost had the highest AUC (0.914) for pCR-T prediction, with 90.0% and 86.4% sensitivity and specificity, respectively. CONCLUSION 18F-FDG PET/CT is useful for re-staging after nCRT and for surgical decision. Integrating parameters of 18F-FDG PET/CT and DW-MRI can identify pathological response of primary tumor to nCRT more accurately in ESCC.
Collapse
|
6
|
A FDG-PET radiomics signature detects esophageal squamous cell carcinoma patients who do not benefit from chemoradiation. Sci Rep 2020; 10:17671. [PMID: 33077841 PMCID: PMC7573602 DOI: 10.1038/s41598-020-74701-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 10/06/2020] [Indexed: 11/21/2022] Open
Abstract
Detection of patients with esophageal squamous cell carcinoma (ESCC) who do not benefit from standard chemoradiation (CRT) is an important medical need. Radiomics using 18-fluorodeoxyglucose (FDG) positron emission tomography (PET) is a promising approach. In this retrospective study of 184 patients with locally advanced ESCC. 152 patients from one center were grouped into a training cohort (n = 100) and an internal validation cohort (n = 52). External validation was performed with 32 patients treated at a second center. Primary endpoint was disease-free survival (DFS), secondary endpoints were overall survival (OS) and local control (LC). FDG-PET radiomics features were selected by Lasso-Cox regression analyses and a separate radiomics signature was calculated for each endpoint. In the training cohort radiomics signatures containing up to four PET derived features were able to identify non-responders in regard of all endpoints (DFS p < 0.001, LC p = 0.003, OS p = 0.001). After successful internal validation of the cutoff values generated by the training cohort for DFS (p = 0.025) and OS (p = 0.002), external validation using these cutoffs was successful for DFS (p = 0.002) but not for the other investigated endpoints. These results suggest that pre-treatment FDG-PET features may be useful to detect patients who do not respond to CRT and could benefit from alternative treatment.
Collapse
|
7
|
Zhang Y, Wang J, Dai N, Han P, Li J, Zhao J, Yuan W, Zhou J, Zhou F. Alteration of plasma metabolites associated with chemoradiosensitivity in esophageal squamous cell carcinoma via untargeted metabolomics approach. BMC Cancer 2020; 20:835. [PMID: 32878621 PMCID: PMC7466788 DOI: 10.1186/s12885-020-07336-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/24/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND To investigate the differences in plasma metabolomic characteristics between pathological complete response (pCR) and non-pCR patients and identify biomarker candidates for predicting the response to neoadjuvant chemoradiotherapy (nCRT) in esophageal squamous cell carcinoma (ESCC). METHODS A total of 46 ESCC patients were included in this study. Gas chromatography time-of- flight mass spectrometry (GC-TOF/MS) technology was applied to detect the plasma samples collected before nCRT via untargeted metabolomics analysis. RESULTS Five differentially expressed metabolites (out of 109) was found in plasma between pCR and non-pCR groups. Compared with non-pCR group, isocitric acid (p = 0.0129), linoleic acid (p = 0.0137), citric acid (p = 0.0473) were upregulated, while L-histidine (p = 0.0155), 3'4 dihydroxyhydrocinnamic acid (p = 0.0339) were downregulated in the pCR plasma samples. Pathway analyses unveiled that citrate cycle (TCA cycle), glyoxylate and dicarboxylate metabolic pathway were associated with ESCC chemoradiosensitivity. CONCLUSION The present study provided supporting evidence that GC-TOF/MS based metabolomics approach allowed identification of metabolite differences between pCR and non-pCR patients in plasma levels, and the systemic metabolic status of patients may reflect the response of ESCC patient to neoadjuvant chemoradiotherapy.
Collapse
Affiliation(s)
- Yaowen Zhang
- Anyang Cancer Hospital, The 4th Affiliated Hospital of Henan University of Science and Technology, No.1 Huanbin North Road, Anyang, 455000, Henan Province, China
| | - Jianpo Wang
- Anyang Cancer Hospital, The 4th Affiliated Hospital of Henan University of Science and Technology, No.1 Huanbin North Road, Anyang, 455000, Henan Province, China
| | - Ningtao Dai
- Anyang Cancer Hospital, The 4th Affiliated Hospital of Henan University of Science and Technology, No.1 Huanbin North Road, Anyang, 455000, Henan Province, China
| | - Peng Han
- Anyang Cancer Hospital, The 4th Affiliated Hospital of Henan University of Science and Technology, No.1 Huanbin North Road, Anyang, 455000, Henan Province, China
| | - Jian Li
- Anyang Cancer Hospital, The 4th Affiliated Hospital of Henan University of Science and Technology, No.1 Huanbin North Road, Anyang, 455000, Henan Province, China
| | - Jiangman Zhao
- Shanghai Zhangjiang Institue of Medical Innovation, Shanghai Biotecan Pharmaceuticals Co., Ltd., 180 Zhangheng Road, Shanghai, 201204, China
| | - Weilan Yuan
- Shanghai Zhangjiang Institue of Medical Innovation, Shanghai Biotecan Pharmaceuticals Co., Ltd., 180 Zhangheng Road, Shanghai, 201204, China
| | - Jiahuan Zhou
- Shanghai Zhangjiang Institue of Medical Innovation, Shanghai Biotecan Pharmaceuticals Co., Ltd., 180 Zhangheng Road, Shanghai, 201204, China.
| | - Fuyou Zhou
- Anyang Cancer Hospital, The 4th Affiliated Hospital of Henan University of Science and Technology, No.1 Huanbin North Road, Anyang, 455000, Henan Province, China.
| |
Collapse
|
8
|
Saeki H, Sohda M, Sakai M, Sano A, Shirabe K. Role of surgery in multidisciplinary treatment strategies for locally advanced esophageal squamous cell carcinoma. Ann Gastroenterol Surg 2020; 4:490-497. [PMID: 33005843 PMCID: PMC7511562 DOI: 10.1002/ags3.12364] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/07/2020] [Accepted: 05/17/2020] [Indexed: 12/13/2022] Open
Abstract
We reviewed the current status and future perspectives regarding the role of surgery in multidisciplinary treatment strategies for locally advanced esophageal squamous cell carcinoma (ESCC). The treatment and management of ESCC have been improved by dramatic advances in diagnostic techniques and the development of surgery, chemotherapy, radiotherapy, and immunotherapy. The current standard treatment for locally advanced ESCC is preoperative chemotherapy followed by surgery in Japan, whereas preoperative chemoradiotherapy is a globally recommended approach. Differences of recognition regarding the role for surgery between Japan and many Western countries may have created peculiar preferences for preoperative therapy. The clinical significance of conversion strategy and salvage surgery for patients with ESCC should be further evaluated in terms of curability and safety. Although strategies to identify patients who would benefit from preoperative therapy are strongly required to avoid performing unnecessary treatment, it remains difficult to predict the efficacy of preoperative therapy prior to treatment. Prospective clinical trials and basic research to identify predictive biomarkers for response to chemotherapy, radiotherapy, and immunotherapy are needed to promote the development of multidisciplinary treatment strategies for patients with ESCC.
Collapse
Affiliation(s)
- Hiroshi Saeki
- Department of General Surgical ScienceGunma University Graduate School of MedicineMaebashiJapan
| | - Makoto Sohda
- Department of General Surgical ScienceGunma University Graduate School of MedicineMaebashiJapan
| | - Makoto Sakai
- Department of General Surgical ScienceGunma University Graduate School of MedicineMaebashiJapan
| | - Akihiko Sano
- Department of General Surgical ScienceGunma University Graduate School of MedicineMaebashiJapan
| | - Ken Shirabe
- Department of General Surgical ScienceGunma University Graduate School of MedicineMaebashiJapan
| |
Collapse
|
9
|
The value of tumor-stroma ratio as predictor of pathologic response after neoadjuvant chemoradiotherapy in esophageal cancer. Clin Transl Radiat Oncol 2019; 20:39-44. [PMID: 31886418 PMCID: PMC6906651 DOI: 10.1016/j.ctro.2019.11.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/24/2019] [Indexed: 02/06/2023] Open
Abstract
Scoring the tumor-stroma ratio is a simple and reproducible method. Tumor-stroma ratio and response to neoadjuvant chemoradiotherapy are correlated. Stroma-low tumors are likely to respond better to neoadjuvant chemoradiotherapy.
Background and purpose With currently available techniques, the prediction of pathologic complete response after neoadjuvant chemoradiotherapy is insufficient. The tumor-stroma ratio (TSR) has proven to be a predictor of survival for several types of cancer, including esophageal. The aim of this study was to investigate the value of TSR in predicting pathologic response after neoadjuvant chemoradiotherapy in esophageal cancer patients. Materials and methods Patients with esophageal adenocarcinoma or squamous cell carcinoma who received neoadjuvant chemoradiotherapy followed by a resection were selected. Haematoxylin and eosin (H&E) stained sections of diagnostic biopsies were collected and TSR was independently assessed by two investigators. Patients were categorized in stroma-low (≤50% stroma) and stroma-high (>50% stroma) groups for further analyses. The tumor regression grade (TRG) was assessed on H&E stained sections of the resected primary tumor to determine pathologic response. Results A total of 94 patients were included in this study, of which 76 patients were categorized as stroma-low and 18 as stroma-high. Forty-two (45%) patients had a major pathologic response (TRG 1–2), whereas 52 (55%) were considered non-responders. After adjustment for gender, tumor type, cT-status and differentiation grade, patients with a stroma-high tumor showed a higher chance of no response compared to patients with a stroma-low tumor (OR 3.57, 95%CI 1.03–12.31, P = 0.04). Conclusion TSR showed to have the potential to aid in the prediction of pathologic response in esophageal cancer patients receiving neoadjuvant chemoradiotherapy. Larger validation studies are necessary before implementing this method in daily practice.
Collapse
|
10
|
Andreollo NA, Beraldo GDC, Alves IPF, Tercioti-Junior V, Ferrer JAP, Coelho-Neto JDS, Lopes LR. PATHOLOGIC COMPLETE RESPONSE (YPT0 YPN0) AFTER CHEMOTHERAPY AND RADIOTHERAPY NEOADJUVANT FOLLOWED BY ESOPHAGECTOMY IN THE SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS. ACTA ACUST UNITED AC 2018; 31:e1405. [PMID: 30539980 PMCID: PMC6284395 DOI: 10.1590/0102-672020180001e1405] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 08/24/2018] [Indexed: 12/29/2022]
Abstract
Background: Esophageal squamous cell carcinoma is an aggressive neoplasia that requires a multidisciplinary treatment in which survival and prognosis are still not satisfactory. The complete pathologic response to neoadjuvant chemotherapy and radiotherapy is considered a good prognosis factor, and esophagectomy is indicated. Aim: Survival analysis of cases with pathologic complete response (ypT0 ypN0) to neoadjuvant chemotherapy and/or radiotherapy, submmitted to esophagectomy. Methods: Between 1983-2014, 222 esophagectomies were performed, and 177 were conducted to neoadjuvant treatment. In 34 patients the pathologic response was considered complete. Medical records of the patients were retrospectively reviewed regarding type of chemotherapy applied, amount of radiotherapy, interval between the neoadjuvant therapy and the surgery, body mass index; postoperative complications; hospital admission time and survival. Results: The average age was 55.8 years. Twenty-five patients were subjected to chemotherapy and radiotherapy, and nine to neoadjuvant radiotherapy. The total radiation dose ranged from 4400 until 5400 cGy. The chemotherapy was performed with 5FU, cisplatin, and carbotaxol, concomitantly with the radiotherapy. The esophagectomy was transmediastinal, followed by the cervical esophagogastroplasty performed on a average of 49.4 days after the neoadjuvant therapy. The hospital admission time was an average of 14.8 days. During the follow-up period, 52% of the patients submitted to radiotherapy and chemotherapy were disease-free, with 23.6% of them presenting more than five years survival. Conclusions: The neoadjuvant treatment followed by esophagectomy in patients with pathologic complete response is beneficial for the survival of patients with esophageal squamous cell carcinoma.
Collapse
Affiliation(s)
- Nelson Adami Andreollo
- Digestive Diseases Surgical Unit and Gastrocenter, Department of Surgery, School of Medical Sciences, State University of Campinas - UNICAMP , Campinas, SP, Brazil
| | - Giovanni de Carvalho Beraldo
- Digestive Diseases Surgical Unit and Gastrocenter, Department of Surgery, School of Medical Sciences, State University of Campinas - UNICAMP , Campinas, SP, Brazil
| | - Iuri Pedreira Filardi Alves
- Digestive Diseases Surgical Unit and Gastrocenter, Department of Surgery, School of Medical Sciences, State University of Campinas - UNICAMP , Campinas, SP, Brazil
| | - Valdir Tercioti-Junior
- Digestive Diseases Surgical Unit and Gastrocenter, Department of Surgery, School of Medical Sciences, State University of Campinas - UNICAMP , Campinas, SP, Brazil
| | - José Antonio Possato Ferrer
- Digestive Diseases Surgical Unit and Gastrocenter, Department of Surgery, School of Medical Sciences, State University of Campinas - UNICAMP , Campinas, SP, Brazil
| | - João de Souza Coelho-Neto
- Digestive Diseases Surgical Unit and Gastrocenter, Department of Surgery, School of Medical Sciences, State University of Campinas - UNICAMP , Campinas, SP, Brazil
| | - Luiz Roberto Lopes
- Digestive Diseases Surgical Unit and Gastrocenter, Department of Surgery, School of Medical Sciences, State University of Campinas - UNICAMP , Campinas, SP, Brazil
| |
Collapse
|
11
|
Fujigaki S, Nishiumi S, Kobayashi T, Suzuki M, Iemoto T, Kojima T, Ito Y, Daiko H, Kato K, Shouji H, Honda K, Azuma T, Yoshida M. Identification of serum biomarkers of chemoradiosensitivity in esophageal cancer via the targeted metabolomics approach. Biomark Med 2018; 12:827-840. [PMID: 30043633 DOI: 10.2217/bmm-2017-0449] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIM To identify the serum metabolomics signature that is correlated with the chemoradiosensitivity of esophageal squamous cell carcinoma (ESCC). MATERIALS & METHODS Untargeted and targeted metabolomics analysis of serum samples from 26 ESCC patients, which were collected before the neoadjuvant chemoradiotherapy, was performed. RESULTS On receiving the results of untargeted metabolomics analysis, we performed the targeted metabolomics analysis of the six metabolites (arabitol, betaine, glycine, L-serine, L-arginine and L-aspartate). The serum levels of the four metabolites (arabitol, glycine, L-serine and L-arginine) were significantly lower in the patients who achieved pathological complete response with neoadjuvant chemoradiotherapy compared with the patients who did not achieve pathological complete response (p = 0.0086, 0.0345, 0.0106 and 0.0373, respectively). CONCLUSION The serum levels of metabolites might be useful for predicting the chemoradiosensitivity of ESCC patients.
Collapse
Affiliation(s)
- Seiji Fujigaki
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Shin Nishiumi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Takashi Kobayashi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Makoto Suzuki
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Takao Iemoto
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Takashi Kojima
- Department of Gastrointestinal Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Yoshinori Ito
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroyuki Daiko
- Department of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Ken Kato
- Department of Gastrointestinal Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hirokazu Shouji
- Department of Gastrointestinal Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kazufumi Honda
- Department of Biomarkers for Early Detection of Cancer, National Cancer Center Research Institute, Tokyo, Japan
| | - Takeshi Azuma
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Masaru Yoshida
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Hyogo, Japan.,Division of Metabolomics Research, Department of Internal Related, Kobe University Graduate School of Medicine, Kobe, Japan.,AMED-CREST, AMED, Kobe, Japan
| |
Collapse
|
12
|
Concurrent neoadjuvant chemoradiotherapy could improve survival outcomes for patients with esophageal cancer: a meta-analysis based on random clinical trials. Oncotarget 2017; 8:20410-20417. [PMID: 28099899 PMCID: PMC5386772 DOI: 10.18632/oncotarget.14669] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 01/09/2017] [Indexed: 01/03/2023] Open
Abstract
Background The long-term survival benefit of concurrent neoadjuvant chemoradiotherapy in patients with resectable esophageal cancer remains controversial. In the present study, we conducted a meta-analysis to assess these effectiveness. Methods We searched for most relevant studies published up to the end of August 2016, using Pubmed and web of knowledge. And additional articles were identified from previous meta-analysis. The hazard ratio (HR, for overall survival and progression free survival) or risk ratio (RR, for R0 resection) with its corresponding 95 % confidence interval (CI) were used to assess the pooled effect. Results Twelve articles including 1756 patients were included in the meta-analysis. Concurrent neoadjuvant chemoradiotherapy followed by surgery was associated with significantly improved overall survival (HR=0.76 , 95% CI= 0.68-0.86), progression survival (HR =0.69, 95% CI= 0.59-0.81), and R0 resection rate(RR =1.17, 95% CI= 1.03-1.33). Subgroup analysis suggested that concurrent neoadjuvant chemoradiotherapy could improve overall survival outcome for squamous cell carcinoma (HR=0.73, 95%CI=0.61-0.88) but not those for adenocarcinoma (HR=0.72, 95%CI=0.48-1.04). Conclusion Our findings suggested that concurrent neoadjuvant chemoradiotherapy was associated with a significant survival benefit in patients with esophageal cancer.
Collapse
|
13
|
Goel R, Subramaniam RM, Wachsmann JW. PET/Computed Tomography Scanning and Precision Medicine: Esophageal Cancer. PET Clin 2017; 12:373-391. [PMID: 28867110 DOI: 10.1016/j.cpet.2017.05.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Esophageal cancer commonly has a poor prognosis, which requires an accurate diagnosis and early treatment to improve outcome. Other modalities for staging, such as endoscopic ultrasound imaging and computed tomography (CT) scans, have a role in diagnosis and staging. However, PET with fluorine-18 fluoro-2-deoxy-d-glucose/CT (FDG PET/CT) scanning allows for improved detection of distant metastatic disease and can help to prevent unnecessary interventions that would increase morbidity. FDG PET/CT scanning is valuable in the neoadjuvant chemotherapy assessment and predicting survival outcomes subsequent to surgery. FDG PET/CT scanning detects recurrent disease and metastases in follow-up.
Collapse
Affiliation(s)
- Reema Goel
- Department of Radiology, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8896, USA
| | - Rathan M Subramaniam
- Department of Radiology, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8896, USA; Department of Clinical Sciences, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8896, USA; Department of Biomedical Engineering, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8896, USA; Advanced Imaging Research Center, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8896, USA; Harold C. Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8896, USA
| | - Jason W Wachsmann
- Department of Radiology, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8896, USA.
| |
Collapse
|
14
|
Hsu HY, Chao YK, Hsieh CH, Wen YW, Chang HK, Tseng CK, Liu YH. Postoperative Adjuvant Therapy Improves Survival in Pathologic Nonresponders After Neoadjuvant Chemoradiation for Esophageal Squamous Cell Carcinoma: A Propensity-Matched Analysis. Ann Thorac Surg 2016; 102:1687-1693. [DOI: 10.1016/j.athoracsur.2016.05.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 03/21/2016] [Accepted: 05/09/2016] [Indexed: 10/21/2022]
|
15
|
Saeki H, Nakashima Y, Zaitsu Y, Tsuda Y, Kasagi Y, Ando K, Imamura Y, Ohgaki K, Ito S, Kimura Y, Egashira A, Oki E, Morita M, Maehara Y. Current status of and perspectives regarding neoadjuvant chemoradiotherapy for locally advanced esophageal squamous cell carcinoma. Surg Today 2015; 46:261-7. [PMID: 25740123 DOI: 10.1007/s00595-015-1144-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 02/15/2015] [Indexed: 12/15/2022]
Abstract
The significance of neoadjuvant chemoradiotherapy (NACRT) for esophageal squamous cell carcinoma (ESCC) remains controversial with regard to the pathological response and long-term survival. We herein review the current status of and future perspectives regarding NACRT followed by esophagectomy for locally advanced ESCC. Some studies have suggested that a pathological complete response with NACRT is more common in patients with ESCC than in those with adenocarcinoma and that NACRT provided a survival benefit limited to patients with ESCC. However, NACRT may increase the risk of postoperative complications after esophagectomy. It is obvious that a favorable pathological response is the most important factor for obtaining a survival benefit, although no established parameters have been implemented clinically to predict the response to NACRT. Prospective clinical studies and basic research studies to identify predictive biomarkers for the response to NACRT are needed to aid in the development of NACRT treatment strategies for patients with ESCC.
Collapse
Affiliation(s)
- Hiroshi Saeki
- Deptartment of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Yuichiro Nakashima
- Deptartment of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yoko Zaitsu
- Deptartment of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yasuo Tsuda
- Deptartment of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yuta Kasagi
- Deptartment of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koji Ando
- Deptartment of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yu Imamura
- Deptartment of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kippei Ohgaki
- Deptartment of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Shuhei Ito
- Deptartment of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yasue Kimura
- Deptartment of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Akinori Egashira
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan
| | - Eiji Oki
- Deptartment of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Masaru Morita
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan
| | - Yoshihiko Maehara
- Deptartment of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| |
Collapse
|
16
|
Lin J, Kligerman S, Goel R, Sajedi P, Suntharalingam M, Chuong MD. State-of-the-art molecular imaging in esophageal cancer management: implications for diagnosis, prognosis, and treatment. J Gastrointest Oncol 2015; 6:3-19. [PMID: 25642333 DOI: 10.3978/j.issn.2078-6891.2014.062] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 07/02/2014] [Indexed: 11/14/2022] Open
Abstract
Molecular imaging techniques are increasingly being used in addition to standard imaging methods such as endoscopic ultrasound (EUS) and computed tomography (CT) for many cancers including those of the esophagus. In this review, we will discuss the utility of the most widely used molecular imaging technique, (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET). (18)F-FDG PET has a variety of potential applications ranging from improving staging accuracy at the time of initial diagnosis to assisting in radiation target volume delineation. Furthermore, (18)F-FDG PET can be used to evaluate treatment response after completion of neoadjuvant therapy or potentially during neoadjuvant therapy. Finally, we will also discuss other novel molecular imaging techniques that have potential to further improve cancer care.
Collapse
Affiliation(s)
- Jolinta Lin
- 1 Department of Radiation Oncology, 2 Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Systems, Baltimore, USA ; 3 Department of Diagnostic Imaging, Baltimore Veterans Affairs Medical Center, Baltimore, USA
| | - Seth Kligerman
- 1 Department of Radiation Oncology, 2 Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Systems, Baltimore, USA ; 3 Department of Diagnostic Imaging, Baltimore Veterans Affairs Medical Center, Baltimore, USA
| | - Rakhi Goel
- 1 Department of Radiation Oncology, 2 Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Systems, Baltimore, USA ; 3 Department of Diagnostic Imaging, Baltimore Veterans Affairs Medical Center, Baltimore, USA
| | - Payam Sajedi
- 1 Department of Radiation Oncology, 2 Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Systems, Baltimore, USA ; 3 Department of Diagnostic Imaging, Baltimore Veterans Affairs Medical Center, Baltimore, USA
| | - Mohan Suntharalingam
- 1 Department of Radiation Oncology, 2 Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Systems, Baltimore, USA ; 3 Department of Diagnostic Imaging, Baltimore Veterans Affairs Medical Center, Baltimore, USA
| | - Michael D Chuong
- 1 Department of Radiation Oncology, 2 Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Systems, Baltimore, USA ; 3 Department of Diagnostic Imaging, Baltimore Veterans Affairs Medical Center, Baltimore, USA
| |
Collapse
|
17
|
van Rossum P, van Lier A, Lips I, Meijer G, Reerink O, van Vulpen M, Lam M, van Hillegersberg R, Ruurda J. Imaging of oesophageal cancer with FDG-PET/CT and MRI. Clin Radiol 2015; 70:81-95. [DOI: 10.1016/j.crad.2014.07.017] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/14/2014] [Accepted: 07/25/2014] [Indexed: 12/13/2022]
|
18
|
Gwynne S, Wijnhoven B, Hulshof M, Bateman A. Role of Chemoradiotherapy in Oesophageal Cancer — Adjuvant and Neoadjuvant Therapy. Clin Oncol (R Coll Radiol) 2014; 26:522-32. [DOI: 10.1016/j.clon.2014.05.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 02/28/2014] [Accepted: 05/27/2014] [Indexed: 02/07/2023]
|
19
|
Uemura N, Kondo T. Current status of predictive biomarkers for neoadjuvant therapy in esophageal cancer. World J Gastrointest Pathophysiol 2014; 5:322-334. [PMID: 25133032 PMCID: PMC4133529 DOI: 10.4291/wjgp.v5.i3.322] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Revised: 01/27/2014] [Accepted: 04/29/2014] [Indexed: 02/06/2023] Open
Abstract
Neoadjuvant therapy has been proven to be extremely valuable and is widely used for advanced esophageal cancer. However, a significant proportion of treated patients (60%-70%) does not respond well to neoadjuvant treatments and develop severe adverse effects. Therefore, predictive markers for individualization of multimodality treatments are urgently needed in esophageal cancer. Recently, molecular biomarkers that predict the response to neoadjuvant therapy have been explored in multimodal approaches in esophageal cancer and successful examples of biomarker identification have been reported. In this review, promising candidates for predictive molecular biomarkers developed by using multiple molecular approaches are reviewed. Moreover, treatment strategies based on the status of predicted biomarkers are discussed, while considering the international differences in the clinical background. However, in the absence of adequate treatment options related to the results of the biomarker test, the usefulness of these diagnostic tools is limited and new effective therapies for biomarker-identified nonresponders to cancer treatment should be concurrent with the progress of predictive technologies. Further improvement in the prognosis of esophageal cancer patients can be achieved through the introduction of novel therapeutic approaches in clinical practice.
Collapse
|