Omitting surgery in esophageal cancer patients with complete response after neoadjuvant chemoradiotherapy: a systematic review and meta-analysis

Nomogram for predicting pathologic complete response following preoperative chemoradiotherapy in patients with esophageal squamous cell carcinoma

Background

In patients with esophageal squamous cell carcinoma (ESCC), accurately predicting a pathologic complete response (pCR) to preoperative chemoradiotherapy (PCRT) has the potential to enable an active surveillance strategy without esophagectomy. We aimed to establish a reliable multiparameter nomogram model that combines tumor characteristics, imaging modalities, and hematologic markers to predict pCR in patients with ESCC who underwent PCRT and esophagectomy.

Methods

We retrospectively reviewed the medical records of 457 patients with ESCC who received PCRT followed by esophagectomy between January 2005 and October 2020. The nomogram model was developed using logistic regression analysis with a training cohort and externally validated with a validation cohort.

Results

In the training and validation cohorts, 44.2% (126/285) and 48.3% (83/172) of patients, respectively, achieved pCR after PCRT. The 5-year rates of overall survival, progression-free survival, and freedom from local progression in the training cohort were 51.6%, 48.5%, and 77.6%, respectively. The parameters included in the nomogram were histologic grade, clinical N stage, maximum standardized uptake value on positron emission tomography, and post-PCRT biopsy. Hematologic markers were significantly associated with survival outcomes but not with pCR. The area under the receiver operating characteristic curve of the nomogram was 0.717, 0.704, and 0.707 for the training cohort, internal validation cohort, and external validation cohort, respectively.

Conclusion

Our nomogram model based on four parameters obtained from standard clinical practice demonstrated good performance in both the training and validation cohorts and could be useful to aid clinical decision-making to determine whether surgery or active surveillance strategy should be pursued.

Practice pattern and risk of not receiving planned surgery after neoadjuvant chemoradiotherapy for locally advanced oesophageal squamous cell carcinoma

OBJECTIVES

Unlike the initial plan, some patients with oesophageal squamous cell carcinoma cannot or do not receive surgery after neoadjuvant chemoradiotherapy (nCRT). This study aimed to report the epidemiology of patients not receiving surgery after nCRT and to evaluate the potential risk of refusing surgery.

METHODS

We analysed patients with clinical stage T3-T4aN0M0 or T1-T4aN1-N3M0 oesophageal squamous cell carcinoma who underwent nCRT as an initial treatment intent between January 2005 and March 2020. Patients not receiving surgery were categorized using predefined criteria. To evaluate the risk of refusing surgery, a propensity-matched comparison with those who received surgery was performed. Recurrence-free (RFS) and overall survival (OS) was compared between groups, according to clinical response to nCRT.

RESULTS

Among the study population (n = 715), 105 patients (14.7%) eventually failed to reach surgery. There were three major patterns of not receiving surgery: disease progression before surgery (n = 25), functional deterioration at reassessment (n = 47), and patient's refusal without contraindications (n = 33). After propensity-score matching, the RFS curves of the surgery group and the refusal group were significantly different (P < 0.001), while OS curves were not significantly different (P = 0.069). In patients who achieved clinical complete response on re-evaluation, no significant difference in the RFS curves (P = 0.382) and in the OS curves (P = 0.290) was observed between the surgery group and the refusal group. However, among patients who showed partial response or stable disease on re-evaluation, the RFS and OS curves of the refusal group were overall significantly inferior compared to those of the surgery group (both P < 0.001). The 5-year RFS rates were 10.3% for the refusal group and 48.2% for the surgery group, and the 5-year OS rates were 8.2% for the refusal group and 46.1% for the surgery group.

CONCLUSIONS

Patient's refusal remains one of the major obstacles in completing the trimodality therapy for oesophageal squamous cell carcinoma. Refusing surgery when offered may jeopardize oncological outcome, particularly in those with residual disease on re-evaluation after nCRT. These results provide significant implications for consulting patients who are reluctant to oesophagectomy after nCRT.

Maintenance chemotherapy for esophageal squamous cell carcinoma after standard concurrent chemoradiotherapy: a national propensity score matching cohort study

Esophageal squamous cell carcinoma (ESCC) is a common and aggressive cancer, and its standard treatment is concurrent chemoradiotherapy (CCRT). Maintenance chemotherapy is often used to help prevent cancer recurrence, but its efficacy for patients with ESCC receiving CCRT remains unclear. We conducted a large head-to-head propensity score matching cohort study to estimate the effects of maintenance chemotherapy on overall survival and cancer-specific survival in patients with ESCC receiving standard CCRT. After propensity score matching (PSM), we recruited 2724 patients with ESCC (2177 in the maintenance chemotherapy group and 547 in the non-maintenance chemotherapy group). The adjusted hazard ratios (95% confidence intervals) of all-cause mortality and cancer-specific mortality for the maintenance chemotherapy group were 1.15 (1.06-1.26, P = 0.0014) and 1.08 (0.88-1.29, P = 0.1320), respectively, compared with the non-maintenance chemotherapy group. We also found that older age, relatively lower body mass index (BMI), higher American Joint Committee on Cancer clinical stage, and poor response to CCRT as measured using the Response Evaluation Criteria in Solid Tumors were poor independent predictors of all-cause mortality and cancer-specific mortality. Our findings indicated that maintenance chemotherapy may not improve the survival of patients with ESCC who have received CCRT. Additionally, we identified several key prognostic factors for patients with ESCC receiving CCRT, including relatively low BMI and poor response to CCRT. Further research is needed to understand the benefits and risks of maintenance chemotherapy in similar patient populations in order to identify new therapies that could improve treatment responses.

Early regression index (ERI) on MR images as response predictor in esophageal cancer treated with neoadjuvant chemo-radiotherapy: Interim analysis of the prospective ESCAPE trial

PURPOSE

The early regression index (ERI) predicts treatment response in rectal cancer patients. Aim of current study was to prospectively assess tumor response to neoadjuvant chemo-radiotherapy (nCRT) of locally advanced esophageal cancer using ERI, based on MRI.

MATERIAL AND METHODS

From January 2020 to May 2023, 30 patients with esophageal cancer were enrolled in a prospective study (ESCAPE). PET-MRI was performed: i) before nCRT (tpre); ii) at mid-radiotherapy, tmid; iii) after nCRT, 2-6 weeks before surgery (tpost); nCRT delivered 41.4 Gy/23fr with concurrent carboplatin and paclitaxel. For patients that skipped surgery, complete clinical response (cCR) was assessed if patients showed no local relapse after 18 months; patients with pathological complete response (pCR) or with cCR were considered as complete responders (pCR + cCR). GTV volumes were delineated by two observers (Vpre, Vmid, Vpost) on T2w MRI: ERI and other volume regression parameters at tmid and tpost were tested as predictors of pCR + cCR.

RESULTS

Complete data of 25 patients were available at the time of the analysis: 3/25 with complete response at imaging refused surgery and 2/3 were cCR; in total, 10/25 patients showed pCR + cCR (pCR = 8/22). Both ERImid and ERIpost classified pCR + cCR patients, with ERImid showing better performance (AUC:0.78, p = 0.014): A two-variable logistic model combining ERImid and Vpre improved performances (AUC:0.93, p < 0.0001). Inter-observer variability in contouring GTV did not affect the results.

CONCLUSIONS

Despite the limited numbers, interim analysis of ESCAPE study suggests ERI as a potential predictor of complete response after nCRT for esophageal cancer. Further validation on larger populations is warranted.

Patients with complete clinical response after neoadjuvant chemoradiotherapy for locally advanced esophageal cancer: A Markov decision analysis of esophagectomy versus active surveillance

OBJECTIVE

Chemoradiation followed by esophagectomy is a standard treatment option for patients with locally advanced esophageal cancer (LAEC). Esophagectomy is a high-risk procedure, and recent evidence suggests select patients may benefit from omitting or delaying surgery. This study aims to compare surgery versus active surveillance for LAEC patients with complete clinical response (cCR) after neoadjuvant chemoradiotherapy (nCRT).

METHODS

Decision analysis with Markov modeling was used. The base case was a 60-year-old man with T3N0M0 esophageal cancer with cCR after nCRT. The decision was modeled for a 5-year time horizon. Primary outcomes were life-years and quality-adjusted life-years (QALY). Probabilities and utilities were derived through the literature. Deterministic sensitivity analyses were performed using ranges from the literature with consideration for clinical plausibility.

RESULTS

Surgery was favored for survival with an expected life-years of 2.89 versus 2.64. After incorporating quality of life, active surveillance was favored, with an expected QALY of 1.70 versus 1.56. The model was sensitive to probability of recurrence on active surveillance (threshold value 0.598), probability of recurrence being resectable (0.318), and disutility of previous esophagectomy (-0.091). The model was not sensitive to perioperative morbidity and mortality.

CONCLUSIONS

Our study finds that surgery increases life expectancy but decreases QALY. Although the incremental change in QALY for either modality is insufficient to make broad clinical recommendations, our study demonstrates that either approach is acceptable. As probabilities of key factors are further defined in the literature, treatment decisions for patients with LAEC and a cCR after nCRT should consider histology, patient values, and quality of life.

Pathologic tumor response to neoadjuvant therapy in resected pancreatic cancer: does it affect prognosis?

Neoadjuvant therapy (NAT) + surgical resection for pancreatic cancer (PC) has gained consensus in recent years. Pathological response (PR) is generally assessed according to the College of American Pathologists grading system, ranging from 0 (complete response) to 3 (no response). The aim of our study is to evaluate the PR in a series of resections for PC after NAT and its prognostic implication. 112 patients undergone NAT and resection for PC between 2011 and 2020 were retrospectively evaluated. PR was 0/1, 2 and 3 in 18 (15%), 79 (61%) and 29 (24%) cases, respectively. Chemotherapy regimens different from FOLFIRINOX and gemcitabine + nab-paclitaxel (OR 11.61 (2.53-53.36), p = 0.002) and lymphovascular invasion (OR 11.28 (1.89-67.23), p = 0.008) were associated to PR-3. Median follow-up was 25.8 (3.6-130.5) months. For PR-0/1, PR-2 and PR-3, median DFS was 45.8, 11.5, 4.6 months (p < 0.0001), respectively, while median OS was not reached, 27.1 and 17.5 months (p = 0.0006), respectively. At univariate analysis, PR-0/1 was significantly associated to better DFS and OS (HR 0.33 (0.17-0.67), p = 0.002; HR 0.20 (0.07-0.54), p = 0.002, respectively). At multivariate analysis, pancreaticoduodenectomy (HR 0.50 (0.30-0.84), p = 0.009), LNR (HR 27.14 (1.21-608.9), p = 0.038) and lymphovascular invasion (HR 1.99 (1.06-3.76), p = 0.033) were independently associated to DFS; pre-treatment CA 19.9 value (HR 1.00 (1.00-1.00), p = 0.025), post-treatment resectability status (HR 0.51 (0.28-0.95), p = 0.035), pancreaticoduodenectomy (HR 0.56 (0.32-0.99), p = 0.050), severe morbidity (2.99 (1.22-7.55), p = 0.017), LNR (HR 56.8 (2.08-1548.3), p = 0.017), lymphovascular invasion (HR 2.18 (1.08-4.37), p = 0.029) were independently associated to OS. PR did not reach statistical significance at multivariate analysis. A favorable PR is observed only in a limited number of cases. The prognostic role of PR, despite being promising, remains unclear and further multicentric studies are needed.

Comparison of clinical outcomes of conservative treatment and surgery for esophageal cancer patients who achieve a clinical complete response following neoadjuvant chemoradiotherapy: a systematic review and meta-analysis

Background

Although the clinical complete response (cCR) for esophageal cancer patients after neoadjuvant chemoradiotherapy (nCRT) may be related to the good survival prognosis, the choice of conservative and surgical treatments is still controversial. This study sought to compare the clinical outcomes of these two treatments.

Methods

A systematic search was conducted according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses of the PubMed, Embase, and Cochrane Library databases to retrieve articles published between January 1, 2010 and March 31, 2022 on the efficacy of conservative treatment or surgery in esophageal cancer patients who had achieved a cCR after nCRT The predominant endpoints were overall survival (OS), disease-free-survival (DFS), local recurrence, and distant metastasis. Odds ratios (ORs) were generated for the dichotomous variants by meta-analysis. The software implemented was Stata 16.0 MP. This research was prospectively registered under PROSPERO (registration number: CRD42022332143).

Results

Ultimately, eight retrospective cohort studies and one randomized controlled trial, comprising 749 patients (nCRT group: 333 and nCRT + surgery group: 416), were included in the meta-analysis after two researchers independently assessed the risk of bias for all included studies. The 2-year OS [OR =1.239, 95% confidence interval (CI): 0.891 to 1.723] and 5-year OS (OR =1.369, 95% CI: 0.963 to 1.947) were comparable between the nCRT group and nCRT plus surgery (nCRT + S) group. Patients in the nCRT + S group had significantly longer DFS (2 and 5 years, OR ranging from 0.303 to 0.357) and lower local recurrence rate (OR =0.179, 95% CI: 0.104 to 0.291) than those in the nCRT group. However, the distant metastasis rate was similar between the nCRT group and the nCRT + S group.

Conclusions

Esophageal cancer patients who achieved a cCR after nCRT and received an esophagectomy had better DFS and lower local recurrence than those who received conservative treatment; however, this DFS advantage did not lead to a significant difference in OS. Salvage surgery may be a feasible option for resectable patients who have local recurrence after achieving cCR.

Comparison of outcomes between neoadjuvant treatment followed by surgery and surgical treatment alone in patients with locally advanced esophageal cancer: Our single-center experience

Background

This study aims to investigate the effect of neoadjuvant therapy on overall survival and recurrence-free survival in locally advanced esophageal cancer patients.

Methods

Between January 2010 and December 2019, a total of 143 patients (84 males, 59 females; mean age: 58.8±11.5 years; range, 26 to 87 years) operated for esophageal cancer were retrospectively analyzed. A comparison was made between the groups of 42 patients who underwent direct surgery and 42 patients who underwent surgery after neoadjuvant therapy. The patients were selected by matching one to one with propensity score with a sensitivty of 0.054.

Results

Pathological complete response was observed in 21 (50%) of 42 patients who received neoadjuvant therapy. No progression was detected in any of the patients. While the five-year overall survival rate was 58.3% in patients with a pathologic complete response, this rate was 52.8% in patients without a complete response (p=0.709). The five-year overall survival rate was 8% (median 22.3 months) in patients who did not receive neoadjuvant therapy and it was 52.9% (median 62.5 months) in those who received neoadjuvant therapy (p<0.001). The five-year recurrence-free survival rate for patients who did not receive neoadjuvant therapy was 26.2% (median 14.5 months), whereas this rate was 41.3% (median 35 months) for patients who received neoadjuvant therapy (p=0.025).

Conclusion

In patients with locally advanced esophageal cancer, the overall survival and disease-free survival rates are significantly better with surgical treatment after neoadjuvant chemotherapy/ neoadjuvant chemoradiotherapy compared to surgery alone.

PD-1 and PD-L1 expression predict regression and prognosis following neoadjuvant radiochemotherapy of oesophageal adenocarcinoma

•

Focus on pretherapeutic biopsies of patients with oesophageal adenocarcinoma.

•

PD-1 and PDL-1 expression predict response to RCT and prognosis.

•

PD-1 expression seems to be a better prognostic marker than PDL-1 expression.

Background and purpose

PD-1 and PD-L1 are involved in anticancer immunosurveillance, and their expression may be predictive for therapeutic effectiveness of specific antibodies. Their influence on response to neoadjuvant radiochemotherapy (RCT) and prognosis in patients with oesophageal adenocarcinoma (OAC) remains to be defined.

Materials and methods

Between 10/2004 and 06/2018, complete pre-RCT biopsy-specimens were available from 76 patients with locally advanced, non-metastatic OAC scheduled for trimodality therapy. We evaluated intra- and peritumoural expression of CD8, PD-1 and PD-L1 in pre-treatment specimens to determine their influence on tumour regression grade and survival. PD-1 and PD-L1 expression were considered positive (+) if ≥1% of all cells were stained positive, otherwise negative (-); densities of CD8+ cells were categorized as being high (Hi) or low (Lo) according to the median.

Results

A negative PD-L1 expression in peritumoural cells predicted a poor tumour regression (RD 0.24 [95% CI 0.03–0.44], p = 0.023). A positive PD-1 expression in intra- as well as peritumoural cells was identified as an unfavourable prognostic factor (HR 0.52 [95% CI 0.29–0.93], p = 0.028; HR 0.50 [0.25–0.99], p = 0.047, respectively). With respect to CD8+ infiltration, positive PD-1 and PD-L1 expressions attenuated its favourable prognostic effect in intratumoural area (LoCD8/PD1 + vs. HiCD8/PD1-: HR 0.25 [0.09–0.69], p = 0.007; LoCD8/PDL1+ vs. HiCD8/PDL1-: HR 0.32 [0.12–0.89], p = 0.028) and were associated with negative outcome when seen in peritumoural area (HiCD8/PD1+ vs. LoCD8/PD1-: HR 0.29 [0.11–0.74], p = 0.010); HiCD8/PDL1+ vs. LoCD8/PDL1-: HR 0.33 [0.12–0.90], p = 0.031).

Conclusions

PD-1 and PD-L1 expression were identified to be of predictive and prognostic value in patients with OAC, particularly when considering CD8+ infiltration. Further validation by a large size dataset is required.