Should preoperative, post-chemoradiotherapy endoscopy be routine for esophageal cancer patients?

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

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Residual carcinoma cells after chemoradiotherapy for esophageal squamous cell carcinoma patients: striving toward appropriate judgment of biopsy

In esophageal squamous cell carcinoma (ESCC) patients who are treated with chemoradiotherapy (CRT), identification of the presence or absence of residual or recurrent carcinoma is usually pivotal in their clinical management. In addition, the extent of carcinoma invasion into the esophageal wall could determine the clinical outcome of these patients following CRT. Therefore, in this study, we evaluated the response to CRT both macroscopically and histologically in a consecutive series of 42 ESCC patients receiving neoadjuvant chemoradiotherapy following curative esophageal resection at Tohoku University Hospital between August 2011 and December 2012. The histological grading of tumor regression was as follows: grade 3, markedly effective (no viable residual tumor cells); grade 2, moderately effective (residual tumor cells in less than one-third of the tumor); grade 1, slightly effective (1b, residual tumor cells in one-third to two-thirds of the tumor; 1a, residual tumor cells in more than two-thirds of the tumor); and grade 0, ineffective. In this study, we selected grade 2 and 1b cases because they might show a complete response with definitive CRT. We evaluated the presence of any residual in situ lesions and tumor depth in detail. The grading of tumor regression in primary sites was as follows: grade 3 (7 cases), grade 2 (16 cases), grade 1b (13 cases), and grade 1a (6 cases). The concordance rate between macroscopic and histopathological evaluation on the depth of the tumor was 40% (17/42). Among 29 cases (grade 2 and grade 1b), intraepithelial lesions were not detected in 17 cases, and tumor nests were not detected in the lamina propria mucosae in 9 cases. The results of this study highlight the difficulties of detecting residual carcinoma cells using conventional endoscopic biopsy in patients who have received CRT. Therefore, when residual cancer is clinically suspected in patients who have received CRT, the biopsy specimen should be obtained from the deep layer of the esophagus whenever possible. Additionally, close follow-up is required using positron emission tomography/computed tomography, endoscopy, and other radiological evaluations.

Endoscopic biopsy and EUS for the detection of pathologic complete response after neoadjuvant chemoradiotherapy in esophageal cancer: a systematic review and meta-analysis

BACKGROUND AND AIMS

Accurate determination of residual cancer status after neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer could assist in selecting the optimal treatment strategy. The aim of this study was to review the evidence on the diagnostic accuracy of endoscopic biopsy and EUS after nCRT for detecting residual cancer at the primary tumor site (ypT+) and regional lymph nodes (ypN+) as opposed to a pathologic complete response (ypT0 and ypN0).

METHODS

PubMed/Medline, Embase, and the Cochrane library were systematically searched. The analysis included diagnostic studies reporting on the accuracy of endoscopic biopsy or EUS in detecting residual cancer versus complete response after nCRT for esophageal cancer with histopathology as the reference standard. Bivariate random-effects models were used to estimate pooled sensitivities and specificities and examine sources of heterogeneity.

RESULTS

Twenty-three studies comprising 12 endoscopic biopsy studies (1281 patients), 11 EUS studies reporting on ypT status (593 patients), and 10 EUS studies reporting on ypN status (602 patients), were included. Pooled estimates for sensitivity of endoscopic biopsy after nCRT for predicting ypT+ were 34.5% (95% confidence interval [CI], 26.0%-44.1%) and for specificity 91.0% (95% CI, 85.6%-94.5%). Pooled estimates for sensitivity of EUS after nCRT were 96.4% (95% CI, 91.7%-98.5%) and for specificity were 10.9% (95% CI, 3.5%-29.0%) for detecting ypT+, and 62.0% (95% CI, 46.0%-75.7%) and 56.7% (95% CI, 41.8%-70.5%) for detecting ypN+, respectively.

CONCLUSIONS

Endoscopic biopsy after nCRT is a specific but not sensitive method for detecting residual esophageal cancer. Although EUS after nCRT yields a high sensitivity, only a limited number of patients will have negative findings at EUS with still a substantial false-negative rate. Furthermore, EUS provides only moderate accuracy for detecting residual lymph node involvement. Based on these findings, these endoscopic modalities cannot be used to withhold surgical treatment in test-negative patients after nCRT. (

CLINICAL TRIAL REGISTRATION NUMBER

CRD42015016527.).

Factors associated with false-negative endoscopic biopsy results after neoadjuvant chemoradiotherapy in patients with esophageal squamous cell carcinoma

The usefulness of endoscopic biopsy following neoadjuvant chemoradiotherapy (nCRT) is limited because of its high false-negative (FN) rates. However, data on the factors associated with FN biopsy results remain scarce. The purpose of this study was to investigate factors associated with FN results on endoscopic biopsies in patients with esophageal squamous cell carcinoma (ESCC) following nCRT. We retrospectively reviewed the records of ESCC patients who were treated at the Chang Gung Memorial Hospital, Taoyuan, Taiwan, between 1999 and 2013. Inclusion criteria were receiving nCRT as first-line treatment before esophagectomy and having been preoperatively submitted to an endoscopic biopsy. Endoscopic findings at the lesion site were classified into 6 distinct categories: stricture, tumor, ulcer, scar, other findings, or normal. Univariate and multivariate analyses were used to identify factors associated with FN biopsy findings. A total of 227 patients were selected, of which 92 (41.9%) had positive biopsy results. Among patients with negative biopsy findings (n = 135), 85 were found to have residual cancer on the resected esophagus. Multivariate analysis identified endoscopic findings as the only independent predictor of FN biopsy results. The negative predictive values were 77.8%, 61.9%, 52.6%, 30.3%, 23.1%, and 20.0% for the normal, scar, other findings, ulcer, stricture, and tumor categories, respectively (P < 0.001). In ESCC patients, the FN rate of endoscopic biopsy after nCRT is associated with the type of residual lesion.

Endoscopic management of esophageal cancer after definitive chemoradiotherapy

BACKGROUND

Concurrent chemoradiotherapy (CRT) is a potentially curative non-surgical option for locally advanced esophageal cancer, with pathological complete response (CR) ranging from 13 to 49 %. The rate of persistent and recurrent disease within the esophagus remains high at 40-60 %, and treatment of these tumors may improve disease-free survival. The aim of this review is to assess the efficacy of salvage endoscopic therapies for recurrent esophageal cancer.

METHODS

Medline and Embase were searched for relevant studies published in the English-language literature that reported use of endoscopic modalities, including photodynamic therapy (PDT), endoscopic mucosal resection (EMR), and spray cryotherapy, as salvage therapies for esophageal cancer.

RESULTS

A total of 12 studies were identified. In small case series of PDT, CR varied from 20 to 100 %, with 1-, 3-, and 5-year overall survival rates of 65-80, 34-47, and 36 %, respectively. Data from three studies of EMR in squamous cell cancer show CR in 50 % of cases, with 3- and 5-year overall survival of 56-81 and 49 %, respectively. Endoscopic spray cryotherapy has recently been used in this setting with an observed CR of 37.5 %.

CONCLUSIONS

Endoscopic salvage therapies are options for those patients with disease limited to the superficial esophageal wall and those who are unfit to undergo salvage esophagectomy. Widespread application of endoscopic salvage therapies is limited by the lack of awareness and guidelines for endoscopic surveillance post-CRT and limited data on the effectiveness of endoscopic therapies.

Clinical utility of postchemoradiation endoscopic brush cytology and biopsy in predicting residual esophageal adenocarcinoma

BACKGROUND

Esophageal adenocarcinoma generally carries a poor prognosis. Treatment with combination chemoradiation (CRT) followed by esophagectomy is becoming common. A pathologic complete response is uncommon but predicts improved survival. Identifying the subset of patients with residual carcinoma has potential management implications. Post-CRT endoscopic brush cytology and biopsy may detect residual tumor; however, the accuracy and clinical value of these methods remain unclear.

METHODS

Sixty-seven patients with esophageal adenocarcinoma who underwent preoperative CRT and post-CRT endoscopic brush cytology and biopsy followed by esophagectomy were identified. By using esophagectomy histology as the gold standard, the performance of cytology and biopsy was evaluated in diagnosing residual carcinoma. Two pathologists independently reviewed all false-negative and false-positive cases and resolved disagreements by consensus.

RESULTS

The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of cytology for diagnosing residual carcinoma were 26%, 95%, 92%, 35%, and 45%, respectively. For biopsy, these rates were 13%, 90%, 75%, 31%, and 36%, respectively. Sampling error accounted for false-negative diagnoses in approximately 66% of cytology analyses and 98% of biopsy analyses. Approximately 33% of false-negative cytology analyses and 1 false-negative biopsy analysis were caused by the under-recognition of tumor cells. Major diagnostic pitfalls included obscuring acute inflammation, necrosis, tumor cells that mimicked benign cells with radiation/reactive atypia, and the under recognition of mucin-containing adenocarcinoma cells.

CONCLUSIONS

Brush cytology and biopsy were specific but not sensitive methods for predicting residual cancer after CRT. However, cytology was superior. The current results indicated that brush cytology can be used alone to diagnose residual esophageal carcinoma, and awareness of specific diagnostic pitfalls will help pathologists improve its accuracy.

Optimal timing of endoscopic evaluation of the primary site of esophageal cancer after chemoradiotherapy or radiotherapy: a retrospective analysis

BACKGROUND

Although use of gastrointestinal endoscopy for response evaluation in patients with esophageal cancer undergoing chemoradiotherapy or radiotherapy (CRT/RT) treatment is widely accepted, optimal timing for evaluation has not been sufficiently investigated. Here, we investigated optimal timing of primary site response evaluation in esophageal cancer patients treated with CRT/RT.

PATIENTS AND METHODS

This study examined esophageal cancer patients who underwent CRT/RT between September 2002 and December 2004. Time to complete response (CR) at the primary site was assessed in patients designated as CR at the primary site, while progression-free survival at the primary site (PFSp) was assessed in patients designated as incomplete response at the primary site.

RESULTS

Eighty-three patients were enrolled in this study. Median total RT dose was 60 Gy (range, 50-60 Gy), and median RT duration was 53 days (range, 35-74 days). Mean time to CR at the primary site was 97 days (range, 52-201 days). In four patients, although initial examination of biopsy specimens found evidence of viable cancer cells within 75 days of treatment initiation, subsequent examination found no such evidence, and the patients were thus designated as CR. Median PFSp was 149 days (range, 67-399 days), and PFSp rate at 90 days was 97%. Median interval between the previous examination and initial primary progressive disease was 37 days.

CONCLUSION

Recommended time of first response evaluation for esophageal cancer following initiation of CRT/RT was found to be between 75 and 90 days. Subsequent evaluation should be carried out approximately one month following non-CR/non-progressive disease declassification.

Epidermal growth factor receptor-directed therapy in esophageal cancer

Esophageal adenocarcinoma (EAC) is one of the fastest growing malignancies in the US. The long-term survival of patients with this cancer remains poor; only 25% of patients undergoing surgical excision are alive after 5 years. Multimodal programs that incorporate radiotherapy, chemotherapy and surgery for localized tumors may result in a modest survival advantage. However, significant strides in this disease can result from the inclusion of targeted therapies. The epidermal growth factor receptor (EGFR) family represents one such target and is receiving increasing attention due to the advent of specific inhibitors. Studies conducted by us and others have shown that the overexpression of EGFR family signaling intermediates is common in Barrett's esophagus and EAC. In the latter case, EGFR expression may have prognostic significance. EGFR inhibitors, including oral tyrosine kinase inhibitors and monoclonal antibodies, result in a synergistic antitumor effect with chemotherapeutic agents or with radiotherapy. Therefore, several ongoing studies include EGFR-directed therapy either alone or in combination with chemoradiotherapy for this disease. Our study of gefitinib, oxaliplatin and radiotherapy suggested that gefitinib can be safely incorporated into an oxaliplatin-based chemoradiation program for esophageal cancer, although the clinical activity of this combination is modest. Herein, we review the current literature on this subject.

Oesophagectomy after definitive chemoradiation in patients with locally advanced oesophageal cancer

AIMS

The clinical benefit of salvage oesophagectomy in patients who recur after radical chemoradiotherapy (CRT) is not clearly defined. This study retrospectively evaluated the outcome in patients who underwent salvage oesophagectomy having failed primary CRT.

MATERIALS AND METHODS

Between March 1999 and October 2005, 181 patients with oesophageal cancer were treated at the Royal Marsden Hospital with definitive CRT. Ten patients underwent salvage oesophagectomy. All of them had locally advanced cancer of the oesophagus at presentation (adenocarcinoma in three patients and squamous cell carcinoma in seven patients) and received combined CRT, consisting of 12 weeks of cisplatin and 5-fluorouracil-based chemotherapy followed by CRT. Radiotherapy was delivered with a computed tomography-planned technique to a dose of 54 Gy with daily 5-fluorouracil.

RESULTS

An Ivor-Lewis procedure was carried out in all cases. The median time between the end of CRT and surgery was 5 months (range 1-67). Curative resection was achieved in three patients, seven had microscopic positive circumferential margins. One patient died postoperatively and complications occurred in four cases: anastomotic leak in two patients, pneumonia in one patient, empyema and sepsis in one patient. The median critical care unit stay was 7 days (range 4-26) and hospitalisation was 21 days (range 15-84). With a median follow-up period of 45.5 months (range 5-89) the 1-, 2- and 3-year survival calculated from the completion of CRT was 70, 50 and 30%, respectively. Median survival was 21.5 months (range 8-90).

CONCLUSIONS

Salvage oesophagectomy may prolong survival in carefully selected patients with local relapse. Patients fit for surgery at presentation benefit from a more intensive follow-up protocol to detect early recurrence.