Clinical study on postoperative recurrence in patients with pN0 esophageal squamous cell carcinoma

Prognostic role of lymph node micrometastasis in pN0 esophageal cancer: A meta-analysis

BACKGROUND

To further identify the association between the lymph node micrometastasis (LNM) and long-term survival among pN0 esophageal cancer patients receiving the surgery.

METHODS

Several databases were searched for relevant studies up to June 22, 2023. The primary and secondary outcomes were separately overall survival (OS) and relapse-free survival (RFS) and hazard ratios (HRs) with 95% confidence intervals (CIs) were combined. Subgroup analysis based on pathological type and source of HR was further performed. All statistical analyses were conducted by STATA 15.0 software.

RESULTS

A total of 20 studies involving 1830 pN0 patients were included in this meta-analysis. The pooled results demonstrated that the presence of LNM indicated significantly worse OS (HR = 2.19, 95% CI = 1.77-2.70, P < .001) and RFS (HR = 2.15, 95% CI = 1.65-2.80, P < .001). Besides, subgroup analysis for the OS and RFS stratified by the pathological type (squamous cell carcinoma vs mixed esophageal cancer) and source of HR (reported vs estimated) further identified the significant relationship of LNM with prognosis in surgical esophageal cancer.

CONCLUSION

The presence of LNM indicated significantly poorer long-term survival among operated pN0 esophageal cancer patients. LNM could serve as a novel and reliable prognostic indicator in surgical esophageal cancer.

Risk factors for postoperative recurrence of pT2-3N0M0 esophageal squamous cell carcinoma and patterns of its recurrence

This study aimed to explore the patterns of postoperative recurrence in patients with pT2-3N0M0 esophageal squamous cell carcinoma (ESCC) and to identify the risk factors for the recurrence. Patients with pT2-3N0M0 ESCC who were treated at our hospital from January 2010 to August 2019 were divided into three categories: those with anastomotic recurrence, those with lymph node recurrence, and those with hematogenous metastasis. The sites of initial recurrence and metastasis were counted and potential risk factors were analyzed using univariate and multivariate Cox proportional hazard regression. Four hundred and eighty-five patients with pT2-3N0M0 ESCC were ultimately included, 176 (36.29%) of whom experienced tumor recurrence or metastasis. Cox multivariate analysis revealed that the postoperative T-stage, procedure, tumor location, and degree of differentiation were independent risk factors for postoperative recurrence (P < 0.05). The median time of recurrence was 38 months, and the most common site of recurrence was the lymph nodes in 126 patients (71.59%), followed by hematogenous metastasis in 73 patients (41.47%), and anastomotic recurrence in 21 patients (11.93%). 119 patients (67.61%) experienced recurrence within 36 months, with a probability of recurrence of 84.09% within 5 years, and recurrence remained relatively unchanged after 5 years. The proportion of postoperative lymph node recurrence and hematogenous metastasis in patients with pT3N0M0 ESCC was significantly higher than that in patients with pT2N0M0 ESCC (P < 0.05). At higher tumor locations in the body, the proportion of lymph node recurrence increased (P < 0.05). In conclusion, postoperative T-stage, procedure, tumor location, and degree of differentiation were independent risk factors for postoperative recurrence in pT2-3N0M0 ESCC, with regional lymph node recurrence being the most common pattern, emphasizing the importance of regional lymph nodes in this context.

Serum VEGF levels as a predictor of recurrence in patients with advanced‑stage esophageal squamous cell carcinoma following curative esophagectomy followed by chemotherapy or concurrent radiotherapy

The present study evaluated serum levels of vascular endothelial growth factor (VEGF) as a predictor of recurrence in patients with advanced-stage esophageal squamous cell carcinoma (ESCC) following curative esophagectomy followed by chemotherapy or concurrent radiotherapy. Patients with locally advanced resectable ESCC underwent R0 esophagectomy followed by chemotherapy or concurrent radiotherapy as an adjuvant. Serum VEGF levels in 173 patients, including 57 patients with recurrent disease, and 183 healthy controls were determined using a Luminex assay. The results demonstrated that the serum VEGF levels were significantly higher in 57 patients with locally advanced resectable ESCC at recurrence compared with the levels at pre-treatment (P<0.001). The patients with recurrence exhibited significantly higher serum VEGF levels during chemotherapy or concurrent radiotherapy than patients with no recurrence (P<0.05). Patients with low serum VEGF levels had a significantly longer survival time than those with high serum VEGF levels prior to treatment (P<0.01). The median survival times were 70 and 25 months in patients with locally advanced resectable ESCC with serum VEGF levels <161.75 and ≥161.75 pg/ml following treatment, respectively (P<0.01). Compared with patients with VEGF levels <147 pg/ml following treatment, patients with locally advanced resectable ESCC with VEGF levels ≥147 pg/ml had a significantly higher risk of recurrence (P<0.01). Patients with low serum VEGF levels (<147 pg/ml) had significantly higher recurrence-free survival rates than those with high serum VEGF levels (≥147 pg/ml) following treatment (P<0.01). The findings of the present study demonstrate that serum VEGF levels are a potential predictor of recurrence and of the treatment outcomes of chemotherapy or concurrent radiotherapy in patients with locally advanced resectable ESCC.

Histological prognosticators in neoadjuvant naive oesophageal cancer patients

PURPOSE

Prognosis of oesophageal cancer is primarily based upon the TNM stage of the disease. However, even in those with similar TNM staging, survival can be varied. Additional histopathological factors including venous invasion (VI), lymphatic invasion (LI) and perineural invasion (PNI) have been identified as prognostic markers yet are not part of TNM classification. The aim of this study is to determine the prognostic importance of these factors and overall survival in patients with oesophageal or junctional cancer who underwent transthoracic oesophagectomy as the unimodality treatment.

METHODS

Data from patients who underwent transthoracic oesophagectomy for adenocarcinoma without neoadjuvant treatment were reviewed. Patients were treated with radical resection, with a curative intent using a transthoracic Ivor Lewis or three staged McKeown approach.

RESULTS

A total of 172 patients were included. Survival was poorer when VI, LI and PNI were present (p<0.001), with the estimated survival being significantly worse (p<0.001) when patients were stratified according to the number of factors present. Univariable analysis of factors revealed VI, LI and PNI were all associated with survival. Presence of LI was independently predictive of incorrect staging/upstaging in multivariable logistic regression analysis (OR 12.9 95% CI 3.6-46.6, p<0.001).

CONCLUSION

Histological factors of VI, LI and PNI are markers of aggressive disease and may have a role in prognostication and decision-making prior to treatment. The presence of LI as an independent marker of upstaging could be a potential indication for the use of neoadjuvant treatment in patients with early clinical disease.

SAMD9 Promotes Postoperative Recurrence of Esophageal Squamous Cell Carcinoma by Stimulating MYH9-Mediated GSK3β/β-Catenin Signaling

Recurrence is a challenge to survival after the initial treatment of esophageal squamous cell carcinoma (ESCC). But, its mechanism remains elusive and there are currently no biomarkers to predict postoperative recurrence. Here, the possibility of sterile alpha motif domain-containing protein 9 (SAMD9) as a predictor of postoperative recurrence of ESCC is evaluated and the molecular mechanisms by which SAMD9 promotes ESCC recurrence are elucidated. The authors found that the high level of SAMD9 is correlated with postoperative recurrence and poor prognosis of ESCC. Overexpression of SAMD9 promotes tumor stemness, angiogenesis, and EMT, while downregulation of SAMD9 reduced these phenotypes. Mechanistically, it is found that SAMD9 stimulated ubiquitination-mediated glycogen synthase kinase-3 beta (GSK-3β) degradation by interaction with myosin-9 (MYH9) and TNF receptor-associated factor 6 (TRAF6), which in turn activated Wnt/β-catenin pathway. Further, the authors demonstrated that silencing SAMD9 inhibited lung metastasis and tumor formation in vivo. Finally, the authors found that silencing MYH9 or β-catenin, or overexpressing GSK-3β inhibited SAMD9-stimulated ESCC cell stemness, EMT, angiogenesis, metastasis, and tumorigenicity. Together, the findings indicate that the SAMD9/MYH9/GSK3β/β-catenin axis promotes ESCC postoperative recurrence and that SAMD9 is a crucial target for ESCC therapy. Additionally, SAMD9 has the potential as a predictor of postoperative recurrence in ESCC.

Prognostic analysis of radiotherapy for cervical lymph node recurrence after curative resection of thoracic esophageal squamous cell carcinoma

To identify efficacy and prognosis of radiotherapy (RT) for cervical lymph node recurrence (CLNR) in thoracic esophageal squamous cell carcinoma (TESCC) after curative resection. The clinical data from 65 patients were retrospectively analyzed. The Kaplan-Meier method was employed to analyze the survival of patients. The Cox proportional hazards model was then exploited for multivariate analysis. The median overall survival (OS) was 20 months; one-year, two-year, three-year and five-year survival rates were 68.3%, 47.3%, 33.4% and 10.6%. The median progression-free survival (PFS) was 14 months. Univariate analysis indicated that time from surgery to recurrence, number of recurrent lymph nodes and dose of RT were significant prognostic factors, whereas multivariate analysis showed that number of recurrent lymph nodes and radiation dose were independent factors. RT was an effective salvage treatment for patients with CLNR after surgery. Those patients who showed single lymph node recurrence and who were exposed to ≥60 Gy of RT experienced a favorable prognosis.

Genome-Wide DNA Methylation and Gene Expression Profiling Characterizes Molecular Subtypes of Esophagus Squamous Cell Carcinoma for Predicting Patient Survival and Immunotherapy Efficacy

Simple Summary

Esophageal squamous cell carcinoma (ESCC) represents roughly 85–90% of all esophageal carcinoma patients in China. Immunotherapy is used to treat an increasing number of ESCC patients in clinical practice. This study aims to understand the molecular heterogeneity and the tumor immune microenvironment of ESCC for designing novel immunotherapies to improve response and outcomes. We identified two molecular subtypes associated with prognosis, immune-related pathways, and tumor microenvironment. In an independent cohort of Chinese ESCC patients treated with immunotherapy, the response rate of the S1 subtype is significantly higher than the S2 subtype. These findings provide a new perspective on the molecular subtyping for ESCC and a biological rationale for novel therapeutic intervention in a specific subgroup of ESCC that could potentially be translated into clinical practice both diagnostically and therapeutically to benefit ESCC patients.

Abstract

Background: Immunotherapy is recently being used to treat esophageal squamous cell carcinoma (ESCC); however, response and survival benefits are limited to a subset of patients. A better understanding of the molecular heterogeneity and tumor immune microenvironment in ESCC is needed for improving disease management. Methods: Based on the DNA methylation and gene expression profiles of ESCC patients, we identify molecular subtypes of patients and construct a predictive model for subtype classification. The clinical value of molecular subtypes for the prediction of immunotherapy efficacy is assessed in an independent validation cohort of Chinese ESCC patients who receive immunotherapy. Results: We identify two molecular subtypes of ESCC (S1 and S2) that are associated with distinct immune-related pathways, tumor microenvironment and clinical outcomes. Accordingly, S2 subtype patients had a poorer prognosis. A 15-gene expression signature is developed to classify molecular subtypes with an overall accuracy of 94.7% (89/94, 95% CI: 0.880–0.983). The response rate of immunotherapy is significantly higher in the S1 subtype than in the S2 subtype patients (68.75% vs. 25%, p = 0.028). Finally, potential target drugs, including mitoxantrone, are identified for treating patients of the S2 subtype. Conclusions: Our findings demonstrated that the identified molecular subtypes constitute a promising prognostic and predictive biomarker to guide the clinical care of ESCC patients.

Role of Recurrent Laryngeal Nerve Lymph Node Dissection in Surgery of Early-Stage Esophageal Squamous Cell Carcinoma

BACKGROUND

In esophageal cancer surgery, it is difficult to perform thorough dissection of lymph nodes along the recurrent laryngeal nerve (RLN-LN). However, there are limited data regarding the necessity of RLN-LN dissection in surgery for superficial esophageal squamous carcinoma (focused on T1b tumor) and its role in locoregional control and accurate nodal staging.

METHODS

Between 2001 and 2016, 567 patients with pT1N0 and 927 patients with cT1N0 squamous cell carcinoma were identified in a prospectively maintained, single institution esophagectomy registry. Sufficient or insufficient RLN-LN assessment group was defined by receiver operating characteristic curve analysis of the number of RLN-LN harvested. To mitigate bias, inverse probability weighting adjustment and several sensitivity analyses were performed.

RESULTS

In the pT1N0 cohort, patients with sufficient (≥ 4) harvested RLN-LNs showed significantly superior 5-year recurrence-free survival (89.1% versus 74.8%, log-rank P < 0.001). Patients with insufficient RLN-LN dissection mainly developed locoregional failure at the upper mediastinal or cervical area (87% of total recurred cases). The survival impact of sufficient RLN-LN dissection was more prominent in subsets of upper-middle thoracic tumors or with deep submucosal invasion. In the analysis on cT1N0 cohort, sufficient RLN-LN assessment conferred a 1.5-fold increase in the discovery of positive-nodal disease (19.4% versus 27.8%, P = 0.008).

CONCLUSIONS

Adequate RLN-LN dissection during surgery may help reduce the risk of recurrence and enhance the accuracy of nodal staging in early-stage esophageal squamous cell carcinoma. Therefore, meticulous surgical evaluation for this region should not be underrated, particularly in the high-risk subset with lymph node metastasis. Visual Abstract Graphical summary of key study findings. T wo cohorts (pT1 and cT1 ; both mainly comprised T1b ) were analyzed for separate purposes; the former controlled for pathologic stage was primarily analyzed in terms of survival and recurrence hazard, whereas the latter (controlled for clinical was used for stage migration ( and intention to treat analysis. Th e results show the significance of adequate bilateral RLN LN in the surgery for early stage ESCC (particularly those with T1b)T1b), in terms of accurate nodal staging, effective nodal clearance, and reduced regional.

Survival risk prediction model for patients with pT1-3 N0M0 esophageal squamous cell carcinoma after R0 esophagectomy with two-field lymphadenectomy for therapeutic purposes

BACKGROUND

The overall survival (OS) remains unsatisfactory in patients with esophageal squamous cell carcinoma (ESCC) after extended esophagectomy with two-field lymphadenectomy. Therefore, this retrospective study aimed to identify the risk factors that contribute to the low survival of patients with pT_1-3N₀M₀ ESCC.

METHODS

Patients with pT_1-3N₀M₀ ESCC who only underwent R0 esophagectomy with two-field lymphadenectomy in our department from January 2008 to December 2012 were retrospectively enrolled in this study and medical records were reviewed. Postoperative OS, disease-free survival (DFS), recurrence-free survival (RFS), and locoregional recurrence-free survival (LRFS) were analyzed sequentially.

RESULTS

This study recruited a total of 488 patients, whose follow-up visits were completed at the end of December 2019. The five-year OS, DFS, RFS and LRFS rates were 62.1, 53.1, 58.3 and 65.6%, respectively. Multivariate Cox analysis identified patient age, site of the lesion, small mediastinal lymph nodes in CT imaging (SLNs in CT), dissected lymph nodes (LNs), and stage of esophageal malignancy as independent risk factors for OS of the patients. Of these factors, the site of the lesion, SLNs in CT and stage of the cancer were determined to be independent factors for DFS, RFS and LRFS. Based on all five factors, the recursive partitioning analysis (RPA) score system was developed to stratify the patients into low-, medium- and high-risk groups, which were found to possess significantly different rates of OS, DFS, RFS and LRFS (p < 0.001).

CONCLUSIONS

Several factors were associated with the survival of patients with pT_1-3 N₀M₀ ESCC who underwent extended esophagectomy with two-field lymphadenectomy. These factors contributed to the RPA scoring system, which could stratify the risk of postoperative survival and may expedite the initiation of postoperative adjuvant therapy.

CircRNA circ-OGDH (hsa_circ_0003340) Acts as a ceRNA to Regulate Glutamine Metabolism and Esophageal Squamous Cell Carcinoma Progression by the miR-615-5p/PDX1 Axis

Background

Circular RNA hsa_circ_0003340 (circ-OGDH) has been uncovered to be involved in esophageal squamous cell carcinoma (ESCC) progression. However, the mechanism by which circ-OGDH regulates ESCC progression is unclear.

Methods

Expression levels of circ-OGDH, microRNA (miR)-615-5p, and PDX1 (pancreatic and duodenal homeobox 1) mRNA were evaluated with quantitative real-time polymerase chain reaction (qRT-PCR). The proliferation, apoptosis, migration, invasion, and cell cycle progression of ESCC cells were analyzed by MTT (3-(4,5-Dimethylthiazol-2-yl)-2,5-Diphenyltetrazolium Bromide), colony formation, flow cytometry, and transwell assays. Measurement of glutamine consumption, α-KG (α-ketoglutarate) production, and ATP (Adenosine Triphosphate) content using corresponding kits. Protein levels were analyzed by Western blotting. The targeting relationship between circ-OGDH or PDX1 and miR-615-5p was verified by dual-luciferase reporter and RNA immunoprecipitation (RIP) assays. The function of circ-OGDH in ESCC was confirmed by animal experiments.

Results

Circ-OGDH was upregulated in ESCC. Circ-OGDH inhibition reduced ESCC growth in vivo and accelerated cell apoptosis, cell cycle arrest, repressed cell proliferation, migration, invasion, and reduced cell glutamine metabolism in ESCC cells in vitro. MiR-615-5p was downregulated in ESCC, while PDX1 had an opposite result. Circ-OGDH sponged miR-615-5p to regulate PDX1 expression. MiR-615-5p inhibitor neutralized the repressive effect of circ-OGDH knockdown on malignancy and glutamine metabolism of ESCC cells. PDX1 overexpression counteracted the inhibitory impact of miR-615-5p mimic on malignancy and glutamine metabolism of ESCC cells.

Conclusion

Circ-OGDH sponged miR-615-5p to elevate PDX1 expression, thus elevating glutamine metabolism and promoting tumor growth in ESCC. The study offered evidence to support circ-OGDH as a promising target for ESCC therapy.

Simultaneous integrated boost for mediastinal lymph node recurrence after radical surgery for esophageal cancer: Interim results from a phase I/II prospective study

Background

This was a single institute, phase I/II study of salvage chemoradiotherapy (CRT) with simultaneous integrated boost in patients with mediastinal lymph node (LN) recurrence after esophagectomy.

Methods

Patients who presented with a clinical diagnosis of ≤5 mediastinal LN recurrence received three consecutive levels of radiotherapy dose for the recurrences. Level 1: 58.8 Gy/2.1 Gy/28 fractions, Level 2: 64.4 Gy/2.3 Gy/28 fractions and Level 3: 70 Gy/2.5 Gy/28 fractions.

Results

A total of 17 patients (10 patients in phase I and 7 patients in phase II) were enrolled in the present study between June 2019 and July 2020. The median duration from surgery to initial recurrence was four months (range: 3–43 months). The most common site of recurrence according to JES was 106recR, accounting for 35%. Dose‐limiting toxicity was not observed during three‐month follow‐up after completion of irradiation. The most common hematological toxicities were leukocytopenia and anemia. The most common nonhematological toxicity was esophagitis. The ORR according to RECIST was 58.8% (CR: seven patients; PR: three patients). With a median follow‐up of 15 months (95% CI: 7–16 months), all patients were still alive. Among them, two patients who received a level 1 dose and one patient who received a level III dose developed multiple lung metastases after salvage CRT, and another patient who received a level 1 dose developed an out‐of‐field recurrence in the left cervical lymph node area. Another patient who received a level III dose developed chest wall recurrence after salvage CRT.

Conclusions

The regimen of salvage CRT using the simultaneous integrated boost (SIB) technique (70 Gy/2.5 Gy/28F) for mediastinal lymph node recurrence in ESCC patients after esophagectomy is feasible and well tolerated.

Risk factors for tumor recurrence in patients with pT3N0M0 thoracic esophageal squamous cell carcinoma after esophagectomy

OBJECTIVE

To analyze the factors contributing to recurrence in patients with pT3N0M0 thoracic esophageal squamous cell carcinoma (ESCC).

METHODS

Patients with pT3N0M0 thoracic ESCC who underwent esophagectomy from January 2008 to December 2012 were included retrospectively. The last date of follow-up was 1 December 2016. Multivariate proportional hazard Cox models were used to identify factors associated with total (i.e., any) recurrence (TR), locoregional recurrence (LR), and distant metastasis (DM).

RESULTS

A total of 692 patients were included. The median follow-up was 53 months (range: 3-107). The 3- and 5-year TR, LR, and DM rates were 35.8% and 41.0%, 28.7% and 32.1%, and 16.8% and 21.1%, respectively. The Cox analyses showed that the tumor location, number of dissected lymph nodes, and postoperative therapies were significantly associated with LR. The subgroup analysis showed that postoperative therapies could significantly decrease LR in the mediastinum but not in the neck and upper abdomen regions.

CONCLUSIONS

The recurrence rate of pT3N0M0 thoracic ESCC patients was high, especially for LR in the mediastinum. Postoperative therapies can significantly reduce the incidence of mediastinal recurrence.

Postoperative Radiotherapy in Pathological T2-3N0M0 Thoracic Esophageal Squamous Cell Carcinoma: Interim Report of a Prospective, Phase III, Randomized Controlled Study

BACKGROUND

The role of postoperative radiotherapy in pathological T2-3N0M0 esophageal squamous cell carcinoma is unknown. We aimed to evaluate the efficacy and safety of postoperative radiotherapy in patients with pathological T2-3N0M0 thoracic esophageal squamous cell carcinoma.

MATERIALS AND METHODS

Patients aged 18-72 years with pathological stage T2-3N0M0 esophageal squamous cell carcinoma after radical surgery and without neoadjuvant therapy were eligible. Patients were randomly assigned to surgery alone or to receive postoperative radiotherapy of 50.4 Gy in supraclavicular field and 56 Gy in mediastinal field in 28 fractions over 6 weeks. The primary endpoint was disease-free survival. The secondary endpoints were local-regional recurrence rate, overall survival, and radiation-related toxicities.

RESULTS

From October 2012 to February 2018, 167 patients were enrolled in this study. We analyzed 157 patients whose follow-up time was more than 1 year or who had died. The median follow-up time was 45.6 months. The 3-year disease-free survival rates were 75.1% (95% confidence interval [CI] 65.9-85.5) in the postoperative radiotherapy group and 58.7% (95% CI 48.2-71.5) in the surgery group (hazard ratio 0.53, 95% CI 0.30-0.94, p = .030). Local-regional recurrence rate decreased significantly in the radiotherapy group (10.0% vs. 32.5% in the surgery group, p = .001). The overall survival and distant metastasis rates were not significantly different between two groups. Grade 3 toxicity rate related to radiotherapy was 12.5%.

CONCLUSION

Postoperative radiotherapy significantly increased disease-free survival and decreased local regional recurrence rate in patients with pathological T2-3N0M0 thoracic esophageal squamous cell carcinoma with acceptable toxicities in this interim analysis. Further enrollment and follow-up are warranted to validate these findings in this ongoing trial.

IMPLICATIONS FOR PRACTICE

The value of adjuvant radiotherapy for patients with node-negative esophageal cancer is not clear. The interim results of this phase III study indicated that postoperative radiotherapy significantly improved disease-free survival and decreased local-regional recurrence rate in patients with pathological T2-3N0M0 thoracic esophageal squamous cell carcinoma compared with surgery alone with acceptable toxicities. The distant metastasis rates and overall survival rates were not different between the two groups. Adjuvant radiotherapy should be considered for pathologic T2-3N0M0 thoracic esophageal squamous cell carcinoma. Prospective trials to identify high-risk subgroups are needed.

Patterns of recurrence after surgery and efficacy of salvage therapy after recurrence in patients with thoracic esophageal squamous cell carcinoma

BACKGROUND

Information on the optimal salvage regimen for recurrent esophageal cancer is scarce. We aimed to assess the patterns of locoregional failure, and evaluate the therapeutic efficacy of salvage therapy along with the prognostic factors in recurrent thoracic esophageal squamous cell carcinoma (TESCC) after radical esophagectomy.

METHODS

A total of 193 TESCC patients who were diagnosed with recurrence after radical surgery and received salvage treatment at our hospital were retrospectively reviewed from 2004 to 2014. The patterns of the first failure were assessed. The post-recurrence survival rate was determined using the Kaplan-Meier method and analyzed using the log-rank test. Multivariate prognostic analysis was performed using the Cox proportional hazard model.

RESULTS

The median time of failure was 7.0 months. Among the 193 patients, 163 exhibited isolated locoregional lymph node (LN) recurrence and 30 experienced locoregional LN relapse with hematogenous metastasis. Among the 193 patients, LN recurrence was noted at 302 sites; the most common sites included the supraclavicular (25.8%; 78/302) and mediastinal LNs (44.4%; 134/302), particularly stations 1 to 6 for the mediastinal LNs (36.4%; 110/302). The median overall survival (OS) was 13.1 months after recurrence. In those treated with salvage chemoradiotherapy, with radiotherapy, and without radiotherapy, the 1-year OS rates were 68.5, 55.0, and 28.6%; the 3-year OS rates were 35.4, 23.8, and 2.9%; and the 5-year OS rates were 31.8, 17.2, 2.9%, respectively (P < 0.001). Furthermore, patient survival in those who received salvage chemoradiotherapy was significantly better than those treated with salvage radiotherapy alone (P = 0.044). Multivariate analysis showed that the pathological TNM stage and salvage treatment regimen were independent prognostic factors.

CONCLUSIONS

Supraclavicular and mediastinal LN failure were the most common types of recurrence after R0 surgery in TESCC patients. Salvage chemoradiotherapy or radiotherapy could significantly improve survival in esophageal cancer with locoregional LN recurrence.

A phase-II/III randomized controlled trial of adjuvant radiotherapy or concurrent chemoradiotherapy after surgery versus surgery alone in patients with stage-IIB/III esophageal squamous cell carcinoma

Background

Preoperative chemoradiotherapy (CRT) followed by surgery is the most common approach for patients with resectable esophageal cancer. Nevertheless, considerable numbers of esophageal-cancer patients undergo surgery as the first treatment. The benefit of neoadjuvant therapy might only be for patients with a pathologic complete response, so stratified research is necessary. Postoperative treatments have important roles because of the poor survival rates of patients with stage-IIB/III disease treated with resection alone. Five-year survival of patients with stage-IIB/III thoracic esophageal squamous cell carcinoma (TESCC) after surgery is 20.0–28.4%, and locoregional lymph-node metastases are the main cause of failure. Several retrospective studies have shown that postoperative radiotherapy (PORT) and postoperative chemoradiotherapy (POCRT) after radical esophagectomy for esophageal carcinoma with positive lymph-node metastases and stage-III disease can decrease locoregional recurrence and increase overall survival (OS). Using intensity-modulated RT, PORT reduces locoregional recurrence further. However, the rate of distant metastases increases to 30.7%. Hence, chemotherapy may be vital for these patients. Therefore, a prospective randomized controlled trial (RCT) is needed to evaluate the value of PORT and concurrent POCRT in comparison with surgery alone (SA) for esophageal cancer.

Method

This will be a phase-II/III RCT. The patients with pathologic stage-IIB/III esophageal squamous cell carcinoma will receive concurrent POCRT or PORT after radical esophagectomy compared with those who have SA. A total of 120 patients in each group will be recruited. POCRT patients will be 50.4 Gy concurrent with paclitaxel (135–150 mg/m²) plus cisplatin or nedaplatin (50–75 mg/m²) treatment every 28 days. Two cycles will be required for concurrent chemotherapy. The prescription dose will be 54 Gy for PORT. The primary endpoint will be disease-free survival (DFS). The secondary endpoint will be OS. Other pre-specified outcome measures will be the proportion of patients who complete treatment, toxicity, and out-of-field regional recurrence rate between PORT and POCRT.

Discussion

This prospective RCT will provide high-level evidence for postoperative adjuvant treatment of pathologic stage-IIB/III esophageal squamous cell carcinoma.

Trial registration

clinicaltrials.gov (NCT02279134). Registered on October 26, 2014.

Pattern of recurrence and prognostic factors in patients with pT1-3 N0 esophageal squamous cell carcinoma after surgery: analysis of a single center experience

Background

The aims of this study were to determine the recurrence rate and the prognostic factors for recurrence-free survival (RFS) in esophageal squamous cell carcinoma (ESCC) patients without lymph node metastasis (LNM).

Methods

Between January 2011 and June 2017, 101 patients with ESCC were treated and pathologically confirmed to be lymph node negative. The clinicopathological parameters were evaluated to identify the prognostic factors for RFS using Cox proportional hazards models.

Results

Nineteen out of 101 patients (18.8%) developed recurrence, and the median RFS was 41 months. The most common pattern of relapse was local recurrence (n = 11; 57.9%), followed by distant recurrence (n = 7; 36.8%); one patient developed local and distant recurrence simultaneously. The results of multivariate analysis showed that the independent prognostic factors for decreased RFS in node-negative patients were a tumor located in the upper chest (odds ratio [OR], 0.767; 95% confidence intervals (CI), 1.523–14.916, P = 0.007), the presence of lymphovascular invasion (OR, 3.534; 95% CI, 1.077–11.596, P = 0.037), and a preoperative serum carcinoembryonic antigen level ≥ 5 μg/ml (OR = 5.466; 95% CI, 1.590–18.787, P = 0.007).

Conclusions

The aforementioned parameters were the prognostic factors in node-negative ESCC patients, and they associated with a higher probability of recurrence after surgery. These patients should be followed closely, and adjuvant therapy should be considered.

Recommendation for the definition of postoperative radiotherapy target volume based on a pooled analysis of patterns of failure after radical surgery among patients with thoracic esophageal squamous cell carcinoma

Background

Elective use of radiation therapy to treat regionally involved lymph nodes (LNs) after radical surgery for esophageal squamous cell carcinoma (ESCC) is controversial. We studied metastasis patterns through a pooled analysis of published results to guide post-operative radiotherapy (PORT) target designation.

Methods

We searched the MEDLINE database for literature published from May 1977 to March 2018, and found 14 relevant original studies that included 2738 patients with thoracic ESCC. We calculated probabilities of recurrence and metastasis in local (including anastomoses and tumor bed), LNs and distal areas.

Results

Recurrence rates were 1.88% for local, 13.18% for distal, and 22.16% for LNs. Within LNs, recurrence rates were cervical/supraclavicular: 37.69%, upper mediastinal: 44.30%, middle mediastinal: 21.81%, lower mediastinal: 2.57%, abdominal paraaortic: 25% and upper abdominal: 9.56%. Whereas cervical/supraclavicular and upper mediastinal LNs had the highest recurrence rates, abdominal LNs also had high recurrence rates in patients with lower thoracic ESCC.

Conclusions

PORT volume should include the cervical/supraclavicular and upper mediastinal LNs for all thoracic ESCC, and abdominal paraaortic LNs for lower thoracic ESCC. Anastomoses and tumor beds should not be included in the PORT volume if they are not adjacent to the PORT-LN regions. Upper abdominal LNs might not necessarily be included in the PORT volume for thoracic ESCC.

Electronic supplementary material

The online version of this article (10.1186/s13014-018-1199-3) contains supplementary material, which is available to authorized users.

Adjuvant radiotherapy, chemotherapy or surgery alone for high-risk histological node negative esophageal squamous cell carcinoma: Protocol for a multicenter prospective randomized controlled trial

Histologically node negative esophageal squamous cell carcinoma (pN0 ESCC) after radical resection still carries a significant risk of recurrence, especially in high‐risk patients. Our previous study showed that the risk of recurrence was associated with tumor location and cell differentiation, as well as the presence of lymphovascular invasion. Most recurrence occurs within two years after surgery. There is still a lack of knowledge on the risks or potential benefits of postoperative adjuvant therapies for high‐risk pN0 ESCC patients. This study was designed to evaluate the efficacy and toxicity of adjuvant therapies after radical surgery in high‐risk patients with pN0 ESCC. This study is a multicenter, prospective, controlled randomized trial, which will compare the differences between either adjuvant chemotherapy or adjuvant radiotherapy and surgery alone for high‐risk pN0 ESCC. Patients in group A will receive three cycles of adjuvant chemotherapy with paclitaxel and cisplatin, patients in group B will receive adjuvant radiotherapy with intensity‐modulated radiation of 50 Gy, and patients in group C (the control) will receive surgery alone. The primary endpoint is three‐year disease‐free survival. Secondary endpoints include toxicity of adjuvant therapies and five‐year overall survival. One hundred and sixty‐two patients in each group are required and a total of 486 patients will finally be enrolled into the study. This will be the first randomized trial to investigate the necessity or potential benefit of postoperative adjuvant therapies for high‐risk pN0 ESCC patients.

Long-term outcomes of 530 esophageal squamous cell carcinoma patients with minimally invasive Ivor Lewis esophagectomy

BACKGROUND AND OBJECTIVES

The short-term benefits of minimally invasive esophagectomy (MIE) Ivor Lewis were proved, but 6-year outcomes in esophageal squamous cell carcinoma (ESCC) patients remain unclear. We sought to investigate perioperative outcomes, quality of life (QOL), survival and impact of adjuvant therapy in ESCC patients who underwent MIE Ivor Lewis.

METHODS

We conducted a retrospective review of 530 ESCC patients treated with MIE Ivor Lewis from 2011 to 2016. Relevant variables were collected and assessed. Overall survival (OS) and disease-free survival (DFS) was analyzed by Kaplan-Meier or Cox proportional hazards modeling.

RESULTS

Median operation duration was 266 min. The median number of lymph nodes was 28. The 30-day postoperative mortality was 1.7%. At a median follow-up of 41 months, the 6-year OS and DFS were 44.7% and 46.1%. Adjuvant chemoradiotherapy offered survival advantages in advanced stage patients. Pathological tumor-node-metastasis stage, postoperative complications, and recurrent laryngeal nerve lymphadenectomy were independent prognostic factors based on multivariate analysis. Generalized estimating equation analysis showed a rapid postoperative QOL improvement.

CONCLUSIONS

MIE Ivor Lewis is a safe and feasible procedure in ESCC patients. It offers satisfactory perioperative outcomes, rapid QOL improvement, and acceptable long-term oncologic survival. Adjuvant chemoradiotherapy may improve OS and DFS in advanced stage patients.

Analysis of the causes of failure after radical surgery in patients with PT3N0M0 thoracic esophageal squamous cell carcinoma and consideration of postoperative radiotherapy

BACKGROUND

Five-year overall survival rate of TESCC after surgery is low (approximately 30% to 60%), so it is meaningful to discuss the significance of PORT.

METHODS

We retrospectively collected the data of 227 patients with _PT₃N₀M₀ esophageal cancer (EC). The failure pattern after surgery was analyzed. Difference of adjuvant PORT in patients with _PT₃N₀M₀ TESCC and the appropriate population were explored based on the relevant studies.

RESULTS

There were 58 cases with intrathoracic locoregional recurrence (LRR) after radical surgery and 27 cases with distant metastasis, including 10 cases of recurrence. The recurrence rate of mediastinal lymph nodes in the thoracic cavity was 50.0%. Univariate analysis revealed that compared with patients with middle and lower thoracic EC, the 3/5-year survival rate of patients with upper thoracic EC was significantly lower, accompanied with remarkably higher thoracic LRR. Compared with those with moderately- and well-differentiated TESCC, the 3/5-year survival rate of patients with poorly differentiated TESCC was significantly lower, whereas the distant metastasis rate was notably higher. Multivariate analysis revealed that different lesion locations and different pathologic differentiation were the independent prognostic factors. The lesion location and degree of differentiation were the independent influencing factors for thoracic LRR and distant metastasis, respectively.

CONCLUSION

The intrathoracic LRR is the major failure pattern for patients with _PT₃N₀M₀ TESCC after conventional two-field lymphadenectomy. In addition, recurrence rate of _PT₃N₀M₀ TESCC was significantly higher in upper thoracic EC than in middle and lower thoracic EC. PORT is recommended to patients with _PT₃N₀M₀ upper TESCC.

Characteristics of Postoperative Recurrence in Lymph Node-Negative Superficial Esophageal Carcinoma

BACKGROUND

This study aimed to evaluate the recurrence rates, timings, locations, and risk factors, and survival in patients with lymph node-negative superficial esophageal squamous cell carcinomas (ESCCs).

METHODS

We investigated 167 patients with pathological T1 thoracic ESCC who underwent curative esophagectomy with lymphadenectomy between 1986 and 2013. They were classified into lymph node-negative and lymph node-positive groups, each of which included 15 relapsed patients. The recurrence rates, timings, locations, and risk factors, and survival were examined retrospectively.

RESULTS

Significantly better recurrence (12.4 %) and the 5-year overall survival (85.7 %) rates were seen in patients with node-negative superficial ESCC compared with those with node-positive superficial ESCC. Relapsed patients with node-negative superficial ESCC showed a 5-month delay in the time to recurrence compared with relapsed patients with node-positive superficial ESCC, but the recurrence locations were similar. Upper thoracic tumors and the presence of lymph node metastases were independent risk factors for recurrence in superficial ESCC patients, but we did not determine any risk factors in patients who were node negative only. The 5-year overall survival rates did not differ between relapsed node-negative and node-positive patients. Furthermore, the mean times to death and the survival rates from recurrence to death were similar in the node-negative (20.3 months and 9.3 %, respectively) and in the node-positive patients (19.1 months and 13.6 %, respectively) who had relapsed.

CONCLUSIONS

Node-negative and node-positive superficial ESCC patients should be followed up similarly, because when recurrences occur, the prognoses and the times to death are similar in node-negative and node-positive superficial ESCC patients.

Low expression of microRNA-202 is associated with the metastasis of esophageal squamous cell carcinoma

The present study aimed to determine the expression levels and biological functions of microRNA-202 (miR-202) in patients with esophageal squamous cell carcinoma (ESCC). A total of 60 patients with ESCC and 30 healthy individuals were enrolled and reverse transcription-quantitative polymerase chain reaction was performed to measure the expression levels of miR-202. In order to investigate the effects of miR-202 expression levels on the proliferative, migratory and invasive abilities of ESCC cells, methylthiazolyl-tetrazolium bromide proliferation, in vitro scratch and Transwell® chamber assays were performed. Expression levels of miR-202 were significantly decreased in the peripheral blood of patients with ESCC, which is associated with the degree of cell differentiation and lymph node metastasis (P<0.05). Following miR-202 transfection, cell proliferation was significantly inhibited (P<0.05). Cell migration and invasion was also significantly inhibited by miR-202 transfection (P<0.05). The results of the present study demonstrated that the expression of miR-202 inhibited the proliferation, migration and invasion of ESCC cells. Furthermore, low expression levels of miR-202 were detected in the peripheral blood of patients with ESCC, which is associated with the development, invasion and metastasis of ESCC.

The presence of lymphovascular and perineural infiltration after neoadjuvant therapy and oesophagectomy identifies patients at high risk for recurrence

Background:

In patients treated for oesophageal cancer the importance of lymphovascular and perineural invasion (PNI) after neoadjuvant therapy has yet to be established. The aim of this study was to assess the incidence and prognostic significance of these factors in a consecutive series of patients with cancer of the oesophagus or gastro-oesophageal junction (GOJ) who underwent neoadjuvant therapy followed by oesophagectomy.

Methods:

Clinical and pathology results from patients with potentially curable adenocarcinoma, or squamous cell carcinoma of the oesophagus or GOJ were reviewed. Patients were treated with neoadjuvant chemotherapy or chemoradiation followed by transthoracic oesophagectomy and two-field lymphadenectomy. The presence of venous invasion (VI), lymph vessel invasion (LI) and perineural invasion (PNI) were correlated with clinical outcomes.

Results:

A total of 396 patients underwent oesophagectomy after neoadjuvant therapy for oesophageal cancer. Venous invasion was identified in 150 (38%) of patients, LI in 203 (51%) patients and PNI in 204 (52%) patients. In all, 123 (31%) patients had no evidence of either VI, LI or PNI. A total of 96 (24%) had a combination of two factors and 94 (24%) had all three factors. The presence of VI, LI and PNI was significantly related to tumour stage (P=0.001). Median overall survival was 170.8 months when all three factors were absent, 44.0 months when one factor was present, 27.1 months when two factors were present and 16.0 months when all were present. Multivariate analyses revealed VI, LI and PNI or a combination of these factors were independent predictors of prognosis.

Conclusions:

In oesophageal cancer patients treated with neoadjuvant therapy followed by oesophagectomy the presence of VI, LI and PNI has an important prognostic impact and may identify patients at high risk of recurrence who would benefit from adjuvant therapies.