Histological regression of squamous esophageal carcinoma assessed by percentage of residual viable cells after neoadjuvant chemoradiation is an important prognostic factor

Sex differences in survival following surgery for esophageal cancer: A systematic review and meta-analysis

The impact of sex on the prognosis of patients with esophageal cancer remains unclear. Evidence supports that sex- based disparities in esophageal cancer survival could be attributed to sex- specific risk exposures, such as age at diagnosis, race, socioeconomic status, smoking, drinking, and histological type. The aim of our study is to investigate the role of sex disparities in survival of patients who underwent surgery for esophageal cancer. A systematic review and meta-analysis of the existing literature in PubMed, EMBASE, and CENTRAL from December 1966 to February 2023, was held. Studies that reported sex-related differences in survival outcomes of patients who underwent esophagectomy for esophageal cancer were identified. A total of 314 studies were included in the quantitative analysis. Statistically significant results derived from 1-year and 2-year overall survival pooled analysis with Relative Risk (RR) 0.93 (95% Confidence Interval (CI): 0.90-0.97, I2 = 52.00) and 0.90 (95% CI: 0.85-0.95, I2 = 0.00), respectively (RR < 1 = favorable for men). In the postoperative complications analysis, statistically significant results concerned anastomotic leak and heart complications, RR: 1.08 (95% CI: 1.01-1.16) and 0.62 (95% CI: 0.52-0.75), respectively. Subgroup analysis was performed among studies with <200 and > 200 patients, histology types, study continent and publication year. Overall, sex tends to be an independent prognostic factor for esophageal carcinoma. However, unanimous results seem rather obscure when multivariable analysis and subgroup analysis occurred. More prospective studies and gender-specific protocols should be conducted to better understand the modifying role of sex in esophageal cancer prognosis.

Pathological response to neoadjuvant chemoradiotherapy for oesophageal squamous cell carcinoma in Eastern versus Western countries: meta-analysis

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.

Prognosis of patients with residual pathological disease after neoadjuvant docetaxel, cisplatin, and 5-fluorouracil therapy and surgery for esophageal squamous cell carcinoma: a retrospective cohort study

Background

Docetaxel, cisplatin, and 5-fluorouracil (DCF) combination chemotherapy has been established as one of the standard neoadjuvant therapies for locally advanced esophageal squamous cell carcinoma (ESCC). However, little is known about prognostic factors in patients with residual pathological disease after neoadjuvant DCF followed by surgery for locally advanced ESCC who are candidates for adjuvant nivolumab.

Objectives

This study aimed to investigate prognostic factors in patients with residual pathological disease after neoadjuvant DCF chemotherapy followed by surgery for locally advanced ESCC.

Design

This was a retrospective cohort study.

Methods

This retrospective cohort study included patients who received neoadjuvant DCF followed by surgery for locally advanced ESCC between June 2014 and January 2020 at the National Cancer Center Hospital East.

Results

Among a total of 210 patients, 45 patients (21.4%) achieved a pathological complete response. The 3-year disease-free survival (DFS) rate was significantly lower in patients with residual pathological disease than in those with a pathological complete response [53.5% versus 74.5%; hazard ratio (HR): 2.09, 95% confidence interval (CI): 1.16-3.77, p = 0.01]. In patients with residual pathological disease (n = 165), multivariate analysis revealed that pathological node positivity (HR: 3.59, 95% CI: 1.92-6.71, p < 0.01), supraclavicular lymph node metastasis (HR: 2.15, 95% CI: 1.19-3.90, p = 0.01), and lymphovascular invasion (HR: 1.90, 95% CI: 1.14-3.17, p = 0.02) were significantly associated with poor DFS.

Conclusion

In this largest-to-date cohort study, patients with residual pathological disease after neoadjuvant DCF followed by surgery for locally advanced ESCC had a poor prognosis. In these patients, pathological node positivity, including supraclavicular lymph node metastasis, and lymphovascular invasion were considered significant prognostic factors.

Prognostic value of Mandard score and nodal status for recurrence patterns and survival after multimodal treatment of oesophageal adenocarcinoma

BACKGROUND

This study evaluated the association of pathological tumour response (tumour regression grade, TRG) and a novel scoring system, combining both TRG and nodal status (TRG-ypN score; TRG1-ypN0, TRG>1-ypN0, TRG1-ypN+ and TRG>1-ypN+), with recurrence patterns and survival after multimodal treatment of oesophageal adenocarcinoma.

METHODS

This Dutch nationwide cohort study included patients treated with neoadjuvant chemoradiotherapy followed by oesophagectomy for distal oesophageal or gastro-oesophageal junctional adenocarcinoma between 2007 and 2016. The primary endpoint was the association of Mandard score and TRG-ypN score with recurrence patterns (rate, location, and time to recurrence). The secondary endpoint was overall survival.

RESULTS

Among 2746 inclusions, recurrence rates increased with higher Mandard scores (TRG1 30.6%, TRG2 44.9%, TRG3 52.9%, TRG4 61.4%, TRG5 58.2%; P < 0.001). Among patients with recurrent disease, the distribution (locoregional versus distant) was the same for the different TRG groups. Patients with TRG1 developed more brain recurrences (17.7 versus 9.8%; P = 0.001) and had a longer mean overall survival (44 versus 35 months; P < 0.001) than those with TRG>1. The TRG>1-ypN+ group had the highest recurrence rate (64.9%) and worst overall survival (mean 27 months). Compared with the TRG>1-ypN0 group, patients with TRG1-ypN+ had a higher risk of recurrence (51.9 versus 39.6%; P < 0.001) and worse mean overall survival (33 versus 41 months; P < 0.001).

CONCLUSION

Improved tumour response to neoadjuvant therapy was associated with lower recurrence rates and higher overall survival rates. Among patients with recurrent disease, TRG1 was associated with a higher incidence of brain recurrence than TRG>1. Residual nodal disease influenced prognosis more negatively than residual disease at the primary tumour site.

Progress of magnetic resonance imaging radiomics in preoperative lymph node diagnosis of esophageal cancer

Esophageal cancer, also referred to as esophagus cancer, is a prevalent disease in the cardiothoracic field and is a leading cause of cancer-related mortality in China. Accurately determining the status of lymph nodes is crucial for developing treatment plans, defining the scope of intraoperative lymph node dissection, and ascertaining the prognosis of patients with esophageal cancer. Recent advances in diffusion-weighted imaging and dynamic contrast-enhanced magnetic resonance imaging (MRI) have improved the effectiveness of MRI for assessing lymph node involvement, making it a beneficial tool for guiding personalized treatment plans for patients with esophageal cancer in a clinical setting. Radiomics is a recently developed imaging technique that transforms radiological image data from regions of interest into high-dimensional feature data that can be analyzed. The features, such as shape, texture, and waveform, are associated with the cancer phenotype and tumor microenvironment. When these features correlate with the clinical disease outcomes, they form the basis for specific and reliable clinical evidence. This study aimed to review the potential clinical applications of MRI-based radiomics in studying the lymph nodes affected by esophageal cancer. The combination of MRI and radiomics is a powerful tool for diagnosing and treating esophageal cancer, enabling a more personalized and effectual approach.

Prognostic Impact of Postoperative Lymph Node Metastases After Neoadjuvant Chemoradiotherapy for Locally Advanced Squamous Cell Carcinoma of Esophagus: From the Results of NEOCRTEC5010, a Randomized Multicenter Study

OBJECTIVE

To determine the prognostic impact of pathologic lymph node (LN) status and investigate risk factors of recurrence in esophageal squamous cell carcinoma (ESCC) patients with pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (NCRT).

SUMMARY BACKGROUND DATA

There are no large-scale prospective study data regarding ypN status and recurrence after pCR in ESCC patients receiving NCRT.

METHODS

The NEOCRTEC5010 trial was a prospective multicenter trial that compared the survival and safety of NCRT plus surgery (S) with S in patients with locally advanced ESCC. The relationships between survival and cN, pN, and ypN status were assessed. Potential prognostic factors in patients with ypN+ and pCR were identified.

RESULTS

A total of 389 ESCC patients (NCRT: 182; S: 207) were included. Patients with pN+ in the S group and ypN+ in the NCRT group had decreased overall survival (OS) and disease-free survival (DFS) compared with pN0 and ypN0 patients, respectively. Partial response at the primary site [hazard ratio (HR), 2.09] and stable disease in the LNs (HR, 3.26) were independent risk factors for lower DFS, but not OS. For patients with pCR, the recurrence rate was 13.9%. Patients with distant LN metastasis had a median OS and DFS of 16.1 months and 14.4 months, respectively. Failure to achieve the median total dose of chemotherapy was a significant risk factor of recurrence and metastasis after pCR (HR, 44.27).

CONCLUSIONS

Persistent pathologic LN metastasis after NCRT is a strong poor prognostic factor in ESCC. Additionally, pCR does not guarantee a cure; patients with pCR should undergo an active strategy of surveillance and adjuvant therapy.

Diagnostic Performance of Artificial Intelligence-Centred Systems in the Diagnosis and Postoperative Surveillance of Upper Gastrointestinal Malignancies Using Computed Tomography Imaging: A Systematic Review and Meta-Analysis of Diagnostic Accuracy

Background

Upper gastrointestinal cancers are aggressive malignancies with poor prognosis, even following multimodality therapy. As such, they require timely and accurate diagnostic and surveillance strategies; however, such radiological workflows necessitate considerable expertise and resource to maintain. In order to lessen the workload upon already stretched health systems, there has been increasing focus on the development and use of artificial intelligence (AI)-centred diagnostic systems. This systematic review summarizes the clinical applicability and diagnostic performance of AI-centred systems in the diagnosis and surveillance of esophagogastric cancers.

Methods

A systematic review was performed using the MEDLINE, EMBASE, Cochrane Review, and Scopus databases. Articles on the use of AI and radiomics for the diagnosis and surveillance of patients with esophageal cancer were evaluated, and quality assessment of studies was performed using the QUADAS-2 tool. A meta-analysis was performed to assess the diagnostic accuracy of sequencing methodologies.

Results

Thirty-six studies that described the use of AI were included in the qualitative synthesis and six studies involving 1352 patients were included in the quantitative analysis. Of these six studies, four studies assessed the utility of AI in gastric cancer diagnosis, one study assessed its utility for diagnosing esophageal cancer, and one study assessed its utility for surveillance. The pooled sensitivity and specificity were 73.4% (64.6–80.7) and 89.7% (82.7–94.1), respectively.

Conclusions

AI systems have shown promise in diagnosing and monitoring esophageal and gastric cancer, particularly when combined with existing diagnostic methods. Further work is needed to further develop systems of greater accuracy and greater consideration of the clinical workflows that they aim to integrate within.

A Survival Prediction Nomogram for Esophageal Squamous Cell Carcinoma Treated with Neoadjuvant Chemoradiotherapy Followed by Surgery

Background

Neoadjuvant chemoradiotherapy (NCRT) followed by surgery is a component of the standard treatment for resectable locally advanced esophageal squamous cell carcinoma (ESCC), and the parameters for survival prediction are not clear yet. Our study aimed to construct a survival prediction nomogram for ESCC with NCRT followed by surgery.

Methods

We analyzed hematological parameters and related-derivative indexes from 122 ESCC patients treated with NCRT followed by surgery. Univariate and multivariate Cox survival analyses were performed to identify independent prognostic factors to establish a nomogram and predict overall survival (OS). The predictive value of the nomogram for OS was evaluated by the concordance index (C-index), decision curve analysis (DCA), the clinical impact curve (CIC), net reclassification improvement (NRI), and integrated discrimination improvement (IDI).

Results

The pretreatment nutritional candidate, prognostic nutrition index, inflammation-related absolute monocyte count and TNM staging were entered into the nomogram for ESCC with NCRT followed by surgery. The C-index of the nomogram for OS was 0.790 (95% CI = 0.688–0.893), which was higher than that of TNM staging (0.681; 95% CI = 0.565–0.798, P = 0.026). The DCA, CIC, NRI, and IDI of the nomogram showed moderate improvement in predicting survival. Based on the cut point calculated according to the constructed nomogram, the high-risk group had poorer OS than that of the low-risk group (P < 0.05).

Conclusion

A novel nomogram based on nutrition- and inflammation-related indicators might help predict the survival of ESCC treated with NCRT followed by surgery.

Prognostic relevance of lymph node regression on survival in esophageal cancer: a systematic review and meta-analysis

INTRODUCTION

The prognostic value of histomorphologic regression in primary esophageal cancer has been previously established, however the impact of lymph node (LN) response on survival still remains unclear. The aim of this review was to assess the prognostic significance of LN regression or downstaging following neoadjuvant therapy for esophageal cancer.

METHODS

An electronic search was performed to identify articles evaluating LN regression or downstaging after neoadjuvant therapy. Random effects meta-analyses were performed to assess the influence of regression in the LNs and nodal downstaging on overall survival. Histomorphologic tumor regression in LNs was defined by the absence of viable cells or degree of fibrosis on histopathologic examination. Downstaged LNs were defined as pN0 nodes by the tumor, node, and metastasis classification, which were positive prior to treatment neoadjuvant.

RESULTS

Eight articles were included, three of which assessed tumor regression (number of patients = 292) and five assessed downstaging (number of patients = 1368). Complete tumor regression (average rate of 29.1%) in the LNs was associated with improved survival, although not statistically significant (hazard ratio [HR] = 0.52, 95% confidence interval [CI] = 0.26-1.06; P = 0.17). LNs downstaging (average rate of 32.2%) was associated with improved survival compared to node positivity after neoadjuvant treatment (HR = 0.41, 95%CI = 0.22-0.77; P = 0.005).

DISCUSSION

The findings of this meta-analysis have shown a survival benefit in patients with LN downstaging and are suggestive for considering LN downstaging to ypN0 as an additional prognostic marker in staging and in the comparative evaluation of differing neoadjuvant regimens in clinical trials. No statistically significant effect of histopathologic regression in the LNs on long-term survival was seen.

Impact of pathological tumor response after CROSS neoadjuvant chemoradiotherapy followed by surgery on long-term outcome of esophageal cancer: a population-based study

BACKGROUND

With increasing interest in organ-preserving strategies for potentially curable esophageal cancer, real-world data is needed to understand the impact of pathological tumor response after neoadjuvant chemoradiotherapy (CRT) on patient outcome. The objective of this study is to assess the association between pathological tumor response following CROSS neoadjuvant CRT and long-term overall survival (OS) in a nationwide cohort.

MATERIAL AND METHODS

All patients diagnosed in the Netherlands with potentially curable esophageal cancer between 2009 and 2017, and treated with neoadjuvant CRT followed by esophagectomy were included. Through record linkage with the nationwide Dutch Pathology Registry (PALGA), pathological data were obtained. The primary outcome was pathological tumor response based on ypTNM, classified into pathological complete response (ypT0N0) and incomplete responders (ypT0N+, ypT+N0, and ypT+N+). Multivariable logistic and Cox regression models were used to identify predictors of pathological complete response (pCR) and survival.

RESULTS

A total of 4946 patients were included. Overall, 24% achieved pCR, with 19% in adenocarcinoma and 42% in squamous cell carcinoma. Patients with pCR had a better estimated 5-year OS compared to incomplete responders (62% vs. 38%, p< .001). Of the patients with incomplete response, ypT+N+ patients (32% of total population) had the lowest estimated 5-year OS rate, followed by ypT0N+ and ypT+ N0 (22%, 47%, and 49%, respectively, p< .001). Adenocarcinoma, well to moderate differentiation, cT3-4, cN+, signet ring cell differentiation and lymph node yield (≥15) were associated with lower likelihood of pCR.

CONCLUSION

In this population-based study, pathological tumor response based on the ypTNM-stage was associated with different prognostic subgroups. A quarter of patients achieved ypT0N0 with favorable long-term survival, while one-third had an ypT+N+ response with very poor survival. The association between pathological tumor response and long-term survival could help in more accurate assessments of individual prognosis and treatment decisions.

Prognostic value of visual residual tumour cells (VRTC) for patients with esophageal squamous cell carcinomas after neoadjuvant therapy followed by surgery

Background

We assessed visual residual tumour cells (VRTC) with both Becker’s tumour regression grading (TRG) system and Japanese TRG system in esophageal squamous cell carcinoma (ESCC) patients treated with neoadjuvant therapy followed by surgery.

Methods

We compared Becker system and Japanese system in 175 ESCC patients treated between 2009 and 2015.

Results

According to Becker system, the 5-year DFS/DSS rates were 70.0%/89.3, 53.8%/56.7, 43.0%/49.0, and 42.4%/39.1% for TRG 1a (VRTC 0), TRG 1b (1–10%), TRG 2 (11–50%), and TRG 3 (> 50%). According to Japanese system, the rates were 38.8%/34.1, 49.5%/58.7, 50.2%/49.0 and 70.0%/89.3% for Grade 0-1a (VRTC> 66.6%), Grade 1b (33.3–66.6%), Grade 2 (1–33.3%) and Grade 3 (0). TRG according to two systems significantly discriminate the patients’ prognosis. TRG according to Becker system (HR 2.662, 95% CI 1.151–6.157), and lymph node metastasis (HR 2.567, 95% CI 1.442–4.570) were independent parameters of DSS.

Conclusions

Both Becker and Japanese system had their advantage in risk stratification of these ESCC patients. It was speculated that dividing 1–10% VRTC into a group might contribute to independently prognostic significance of Becker’s TRG system. Therefore, in addition to TRG of different systems, the percentage of VRTC might be recommended in the pathologic report, which could make the results more comparable among different researches, and more understandable for oncologists in the clinical practice.

Clinicopathological Significance of Pathologic Complete Lymph Node Regression After Neoadjuvant Chemoradiotherapy in Esophageal Squamous Cell Carcinoma

BACKGROUND

Pathologic complete lymph node regression (LNR), where the lymph nodes show evidence of neoadjuvant treatment effect but have no viable residual tumor cells, is sometimes observed following neoadjuvant treatments and has been shown to be prognostic; conflicting results exist in the current literature.

METHODS

Patients who received neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy for squamous carcinoma (ESCC) were retrospectively reviewed and classified according to their LNR score; 0: N(-) with no evidence of tumor involvement or regression; 1: N(-) with evidence of complete regression; 2: N(+) with < 50% viable tumor; and 3: N(+) with > 50% viable tumor.

RESULTS

In total, 136 patients, comprising 73, 25, 16, and 22 patients with LNR scores of 0, 1, 2, or 3, respectively, were included. Pathologic complete LNR (LNR 1) was significantly associated with lower risks of lymphovascular invasion (0%, p < 0.001) and perineural invasion (4%, p = 0.038), and a higher rate of pathologic complete response in the primary tumor (76%, p < 0.001). The 5-year overall survival rates were 42.1%, 52.8%, and 8.0% in patients with an LNR score of 0, 1, and 2/3, respectively (p < 0.001). There was no significant difference between patients with LNR scores of 0 and 1 in overall survival (p = 0.454), disease-free survival (p = 0.501), and cumulative incidence of recurrences (hazard ratio 0.84, 95% confidence interval 0.432-1.623, p = 0.601).

CONCLUSIONS

Pathologic complete LNR could be an indicator of nCRT sensitivity and can be regarded as a good prognostic factor in patients with ESCC. In the survival curve analysis that included patients with lymph node regression (LNR) scores of 0 (blue), 1 (red), and 2/3 (green), we found that patients with pathologic complete LNR (LNR 1), which suggests prior positive nodal involvement, had similar outcomes as those without evidence of prior tumor involvement in lymph node (LNR0).

Linking Circulating Serum Proteins with Clinical Outcomes in Esophageal Adenocarcinoma-An Emerging Role for Chemokines

Simple Summary

Cancer of the esophagus (food pipe) is an aggressive type of cancer with poor prognosis and rates are increasing. Current treatments help to prolong survival but only for a minority of patients, therefore there is an urgent need to discover why some people do not respond and to develop new and improved treatments. Newer treatments targeting the immune system show promise but the anti-tumor immune response in esophageal cancer is not well understood. This study measured levels of 54 immune markers in serum of patients with esophageal cancer and evaluated a link with patient clinical outcomes, e.g., survival time, response to treatment, and adverse events. We found that certain chemokines, proteins which control immune cell trafficking, were particularly high in patients who survived longer (CCL22 and CCL26) and responded to treatment (CCL4), suggesting the importance of immune cell movement in orchestrating an effective immune response to esophageal cancer.

Abstract

Esophageal adenocarcinoma (EAC) is an aggressive cancer with poor prognosis and incidence is increasing rapidly in the Western world. Multi-modal treatment has improved survival outcomes but only for a minority of patients. Currently no markers have been identified to predict treatment response. This study investigated the association between clinical outcomes and pre-treatment levels of 54 serum proteins in n = 80 patients with EAC. Low tumor regression grade (TRG), corresponding to a favorable treatment response, was linked to prolonged overall survival (OS). CCL4 was higher in patients with a favorable treatment response, while Tie2 and CRP were higher in poor responders. Elevated CCL22 and CCL26 was associated with improved OS, while elevated IL-10 showed a negative association. CCL3, CCL4, IL-1α and IL-12/IL23p40 were highest in individuals with no adverse features of tumor biology, whereas levels of Tie2 and VEGF were lowest in this cohort. CCL4 was also elevated in patients with high tumor lymphocyte infiltration. Comparison of matched pre- and post-treatment serum (n = 28) showed a large reduction in VEGFC, and a concomitant increase in other cytokines, including CCL4. These data link several serum markers with clinical outcomes, highlighting an important role for immune cell trafficking in the EAC antitumor immune response.

Verification of the Optimal Interval Before Esophagectomy After Preoperative Neoadjuvant Chemoradiotherapy for Locally Advanced Thoracic Esophageal Cancer

BACKGROUND

The interval between preoperative chemoradiotherapy and surgery reportedly affects perioperative outcomes and survival; however, the optimal interval in esophageal cancer patients remains uncertain.

OBJECTIVE

Our aim was to determine whether a prolonged interval between preoperative neoadjuvant chemoradiotherapy (NACRT) and esophagectomy affects the outcomes of esophageal cancer patients.

METHODS

A total of 131 patients with esophageal cancer received curative surgery following NACRT at Akita University Hospital between 2009 and 2017. We divided these patients into two groups based on the median interval from NACRT to esophagectomy, and compared the rates of pathological complete response (pCR), surgical outcomes, and survival.

RESULTS

The median interval from NACRT to esophagectomy was 39 days (range 21-95). Of the 131 patients, 70 (53%) received esophagectomy after 39 days or more from completion of NACRT. There were no significant differences in the clinicopathological features, including pCR rates, between the two groups. Prolongation of the interval from NACRT to esophagectomy was significantly associated with an increased rate of anastomotic leakage and recurrent laryngeal nerve palsy (p = 0.0225 and p = 0.0022, respectively); however, no association with overall survival was detected.

CONCLUSIONS

A prolonged interval between NACRT and esophagectomy had no impact on pCR rates or survival. However, delaying esophagectomy may increase the likelihood of surgical complications such as anastomotic leakage and recurrent laryngeal nerve palsy.

A multicenter prospective phase III clinical randomized study of simultaneous integrated boost intensity-modulated radiotherapy with or without concurrent chemotherapy in patients with esophageal cancer: 3JECROG P-02 study protocol

BACKGROUND

Since the development of three-dimensional conformal radiotherapy and intensity-modulated radiotherapy (IMRT), no prospective study has investigated whether concurrent chemoradiotherapy (SIB-IMRT with 60 Gy) remains superior to radiotherapy (SIB-IMRT) alone for unresectable esophageal cancer (EC). Furthermore, the optimal therapeutic regimen for patients who cannot tolerate concurrent chemoradiotherapy is unclear. We recently completed a phase I/II radiation dose-escalation trial using simultaneous integrated boost (SIB), elective nodal irradiation, and concurrent chemotherapy for unresectable EC. We now intend to conduct a prospective, phase III, randomized study of SIB-IMRT with or without concurrent chemotherapy. We aim to find a safe, practical, and effective therapeutic regimen to replace the conventional segmentation (1.8-2.0 Gy) treatment mode (radiotherapy ± chemotherapy) for unresectable EC.

METHODS

This two-arm, open, randomized, multicenter, phase III trial will recruit esophageal squamous cell carcinoma patients (stage IIA-IVB [UICC 2002]; IVB only with metastasis to the supraclavicular or celiac lymph nodes). In all, 164 patients will be randomized using a 1:1 allocation ratio, and stratified by study site and disease stage, especially the extent of lymph node metastasis. Patients in the SIB arm will receive definitive SIB radiotherapy (95% planning target volume/planning gross tumor volume, 50.4 Gy/59.92 Gy/28 f, equivalent dose in 2-Gy fractions = 60.62 Gy). Patients in the SIB + concurrent chemotherapy arm will receive definitive SIB radiotherapy with weekly paclitaxel and a platinum-based drug (5-6 weeks). Four cycles of consolidated chemoradiotherapy will also be recommended. The primary objective is to compare the 1-year, 2-year, and 3-year overall survival of the SIB + chemotherapy group and SIB groups. Secondary objectives include progression-free survival, local recurrence-free rate, completion rate, and adverse events. Detailed radiotherapy protocol and quality-assurance procedures have been incorporated into this trial.

DISCUSSION

In unresectable, locally advanced EC, a safe and effective total radiotherapy dose and reasonable segmentation doses are required for the clinical application of SIB-IMRT + two-drug chemotherapy. Whether this protocol will replace the standard treatment regimen will be prospectively investigated. The effects of SIB-IMRT in patients with poor physical condition who cannot tolerate definitive chemoradiotherapy will also be investigated.

TRIAL REGISTRATION

clinicaltrials.gov ( NCT03308552 , November 1, 2017).

Real-world Scenario: CROSS Regimen as Preoperative Therapy for Oesophageal Squamous Cell Carcinoma

BACKGROUND

Preoperative chemoradiation (CROSS regimen) has been widely adopted worldwide. The survival advantage imparted is especially impressive for oesophageal squamous cell carcinoma (OSCC). This study aimed at investigating the efficacy of the CROSS regimen in real-world scenario.

METHODS

This is a retrospective study of all patients with OSCC intended for preoperative treatment using the CROSS regimen during 2012-2017. Patients were divided into two groups: those within the selection criteria in the CROSS trial and those beyond criteria, namely age > 75 years old, tumour length > 8 cm or clinical M1 stage of lymph node involvement (AJCC 6th edition). Clinical outcome and survival data were compared.

RESULTS

Eighty-eight patients were included. There were 46 patients in the "CROSS eligible" group and 42 in the "CROSS ineligible" group. By intention-to-treat, the estimated median survival was 24.2 months vs. 12.7 months, respectively (p = 0.047). The results were much inferior compared to that published in the original CROSS trial. Univariable and multivariable analyses showed tumour length and resectability as independent variables affecting survival.

DISCUSSION

In a real-world scenario, the clinical outcome remains suboptimal and the excellent results in the trial setting were not reproducible in this Asian cohort. Patient selection is one key element accountable for the difference. The efficacy of the CROSS regimen may not be adequate for patients with more advanced disease. The optimal multimodal therapy for this group of patients remains undefined.

The treatments and postoperative complications of esophageal cancer: a review

Abstract

Esophageal cancer is still one of the most common cancers in the world. We review the appropriate treatments at different stages of esophageal cancer and also analyze the advantages and disadvantages of these treatments. The prognosis and recovery of different treatment regimens are further discussed. In particular, post-operative complications are the major causes of high mortality derived from the esophageal cancer. Therefore, we particularly discuss the main complications resulting in high mortality after surgery of esophageal cancer, and summarize their risk factors and treatment options.

Background

As the common cancer, the complications of esophageal cancer after surgery have been not obtained systematic treatment strategy, focusing on treatment regimens based on the different stages of esophageal cancers.

Methods and overview

This paper systematically summarizes the appropriate treatment strategies for different stages of esophageal cancers, and their advantages and disadvantages. We particularly focus on the postoperative survival rate of patients and postoperative complications, and discuss the causes of high mortality risk factors after surgery. The risk factors of death and corresponding treatment methods are further summarized in this study.

Conclusion

Postoperative complications is the main cause responsible for the hard cure of esophageal cancers. The existing literatures indicate that postoperative anastomotic fistula is one of the most important complications leading to death, while it has not received much attention yet. We suggest that anastomotic fistula should be detected and dealt with early by summarizing these literatures. It is, therefore, necessary to develop a set of methods to predict or check anastomotic fistula in advance.

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.

Clinical outcomes according to the modified endoscopic criteria for neoadjuvant chemotherapy in resectable esophageal squamous cell carcinoma

OBJECTIVES

Neoadjuvant chemotherapy (nCT) followed by surgery is one of the standard treatments for resectable esophageal squamous cell carcinoma (ESCC). According to the Response Evaluation Criteria in Solid Tumors, endoscopic evaluation of a primary lesion is not recommended during nCT because of reduced objectivity. This study aimed to develop and validate endoscopic evaluation criteria for nCT.

METHODS

This study retrospectively investigated patients with T2/3 ESCC who underwent nCT followed by radical esophagectomy across two institutions (test and validation sets). We retrospectively estimated the therapeutic effect by classifying patients according to degree of tumor shrinkage (evaluated with endoscopy) as follows: marked reduction (MR), half reduction (HR), insufficient reduction (IR), and progressive disease (PD). Three endoscopists evaluated patients in the test set. Another three endoscopists evaluated patients in the validation set. We analyzed recurrence-free survival (RFS) 3 years after surgery.

RESULTS

Of 129 patients in the test set, 44 had MR, 35 had HR, 44 had IR, and six had PD. The 3-year RFS rates were 55% (overall), 79% (MR), 54% (HR), 35% (IR), and 33% (PD). Of 91 patients in the validation set, 22 had MR, 49 had HR, 18 had IR, and two had PD. The 3-year RFS rates were 54% (overall), 77% (MR), 55% (HR), 22% (IR), and 50% (PD).

CONCLUSIONS

Our endoscopic criteria for nCT predicted prognosis; however, future studies are needed to further investigate our criteria before general application in the clinical setting.

Histopathological Assessment for Esophageal Squamous Cell Carcinoma

Histological assessment of esophageal squamous malignancies is crucial for management of patients with the cancer as well as working in research on the cancer. The squamous malignancies in the esophagus comprise squamous dysplasia and squamous cell carcinoma. Current classification of squamous dysplasia in the esophagus is to divide it into low grade and high grade. Most of the esophageal squamous cell carcinomas are of conventional type and divided into well, moderately, and poorly differentiated. The variants of esophageal squamous cell carcinoma include basaloid squamous carcinoma, spindle cell carcinoma, and verrucous carcinoma. Preoperative chemoradiation is used commonly in the treatment of esophageal squamous cell carcinoma and induces changes in morphology. Tumor regression grading systems based on the percentage of the remaining carcinoma cells are used to assess the response to the neoadjuvant therapy in the cancer. Additional histological parameters including lymphovascular invasion, perineural invasion, clearance of resection margins, and carcinoma in the nodal and distant metastatic sites provide essential information for the management of the patient with the cancer.

MicroRNA-338-5p reverses chemoresistance and inhibits invasion of esophageal squamous cell carcinoma cells by targeting Id-1

5-Fluorouracil (5-FU) is a chemotherapeutic agent commonly used to treat esophageal squamous cell carcinoma (ESCC), but acquisition of chemoresistance frequently occurs and the underlying mechanisms are not fully understood. We found that microRNA (miR)-338-5p was underexpressed in ESCC cells with acquired 5-FU chemoresistance. Forced expression of miR-338-5p in these cells resulted in downregulation of Id-1, and restoration of both in vitro and in vivo sensitivity to 5-FU treatment. The effects were abolished by reexpression of Id-1. In contrast, miR-338-5p knockdown induced 5-FU resistance in chemosensitive esophageal cell lines, and knockdown of both miR-338-5p and Id-1 resensitized the cells to 5-FU. In addition, miR-338-5p had suppressive effects on migration and invasion of ESCC cells. Luciferase reporter assay confirmed a direct interaction between miR-338-5p and the 3'-UTR of Id-1. We also found that miR-338-5p was significantly downregulated in tumor tissue and serum samples of patients with ESCC. Notably, low serum miR-338-5p expression level was associated with poorer survival and poor response to 5-FU/cisplatin-based neoadjuvant chemoradiotherapy. In summary, we found that miR-338-5p can modulate 5-FU chemoresistance and inhibit invasion-related functions in ESCC by negatively regulating Id-1, and that serum miR-338-5p could be a novel noninvasive prognostic and predictive biomarker in ESCC.

Pathological Tumor Regression Grade Classifications in Gastrointestinal Cancers: Role on Patients' Prognosis

Preoperative chemotherapy or combined radiotherapy and chemotherapy (CRT), followed by surgery, represents the standard approach for locally advanced esophageal, gastric, and rectal carcinomas. To adequately evaluate the effects of neoadjuvant CRT in the resection specimens, several histopathologic tumor regression grade (TRG) scoring systems have been introduced into clinical practice. The primary goal of these TRG systems relies on a correct prognostic stratification of patients in the attempt to help clinical decision-making and influence surgical strategies, postoperative adjuvant therapies, and surveillance intensity. However, most TRG systems suffer from poor reproducibility and low interobserver concordance rates. Many efforts have been made in the identification of alternative, robust, simple, and universally accepted TRG scoring systems, which would help in the comparison of different treatment strategies and in the standardization of multimodal therapies. The aim of this review is to analyze the most commonly used TRG systems in gastrointestinal cancers highlighting their pitfalls and usefulness, depending on the tumor type.

Effect of modern high-dose versus standard-dose radiation in definitive concurrent chemo-radiotherapy on outcome of esophageal squamous cell cancer: a meta-analysis

Background and objectives

Radiation Therapy Oncology Group (RTOG) 94–05 has demonstrated that higher dose radiation didn’t improve outcome of patients with esophageal cancer (EC). However, several retrospective studies showed that a higher dose radiation based on modern radiotherapy techniques could improve overall survival (OS) and local control rate (LCR) of patients with EC, especially esophageal squamous cell cancer (ESCC). As trials have provided updated and controversial data, we performed this updated meta-analysis to investigate whether high-dose (> = 60 Gy) radiotherapy in definitive concurrent chemo-radiotherapy (CCRT) could yield benefit compared to standard dose radiotherapy.

Methods

A systematic literature search was carried out in the database of MEDLINE, PubMed and Embase. All studies published between 1 January 1990 and 31 December 2018 on the association between radiation dose and curative efficiency in EC were included in this meta-analysis. The hazard ratio (HR) was used to evaluate the time-to-event data employing RevMan version 5.3.

Results

Eight articles with a total of 3736 patients were finally included. Results indicated that there was a significant benefit in favor of high dose radiotherapy (HD-RT) regarding OS (HR = 0.78, 95%CI: 0.72–0.84, p < 0.001; 2-year OS risk ratio (RR) = 1.25, 95%CI: 1.14–1.37, p < 0.001), progression-free survival (PFS) (P = 0.001, HR = 0.7, 95%CI: 0.57–0.87) and LRFS (P < 0.001, HR = 0.52, 95%CI: 0.36–0.74) .

Conclusions

HD-RT (> = 60 Gy) based on modern radiotherapy techniques in definitive CCRT appears to improve OS, PFS amd LRFS compared to the SD-RT in patients with ESCC.

Prognostic significance of pathological tumor response and residual nodal metastasis in patients with esophageal squamous cell carcinoma after neoadjuvant chemotherapy followed by surgery

BACKGROUND

The present study investigated prognostic factors in patients with resectable locally advanced esophageal squamous cell carcinoma (ESCC) among various clinicopathological features related to neoadjuvant chemotherapy (NAC) and surgery, and the indications for additional treatment after surgery were considered.

METHODS

A total of 113 patients with clinical stage II or III ESCC, who had undergone NAC followed by a thoracic esophagectomy with a three-field lymphadenectomy were retrospectively reviewed. NAC consisted of either two courses of cisplatin and 5-fluorouracil or three courses of docetaxel, cisplatin and 5-fluorouracil, with a new course beginning every 3 weeks.

RESULTS

The overall survival (OS) rate was poorer in the pN-positive group than in the pN-negative group (P < 0.001). In terms of the histological therapeutic effect, the OS rate was poorer in the worse pathological responder group than in the better pathological responder group (P = 0.001). A multivariate analysis examining overall survival suggested that only pN (HR 3.204, P = 0.007) and worse pathological responder (HR 2.347, P = 0.041) were independent prognostic factors. The OS rate was compared among four groups classified according to the different combinations of pN and pathological response. A group of patients with pN-positive and worse pathological response had a significantly poorer outcome than the other groups.

CONCLUSIONS

The present study suggested that patients with resectable advanced ESCC undergoing NAC followed by surgery, who have both pN and worse pathological response, have a poor prognosis.

Neoadjuvant chemoradiation for patients with advanced oesophageal cancer - which response grading system best impacts prognostic discrimination?

AIMS

Neoadjuvant chemoradiation reduces tumour volume and improves the R0 resection rate, followed by extended survival for patients with advanced oesophageal cancer. The degree of tumour regression has high prognostic relevance. To date, there is still no generally accepted tumour regression grading system. The aim of this study was to compare the prognostic discrimination power of different histological regression grading systems: (i) the fibrosis/tumour ratio within the primary tumour (Mandard classification), (ii) the percentage of residual vital tumour cells (VTC) compared to the original primary tumour (Cologne Regression) and (iii) the ypT category, in patients with cT3 carcinoma of the oesophagus after neoadjuvant chemoradiation.

METHODS AND RESULTS

This study included 216 patients with oesophageal cancer clinically staged as cT3NxM0 and treated from 2009 to 2012 with standardised chemoradiation followed by oesophagectomy [median age 62 years, 176 (81%) male and 138 (64%) adenocarcinoma patients]. The subgroup frequencies of the three classification systems were ypT category: ypT0 = 18%, ypT1 = 14%, ypT2 = 23%, ypT3 = 44%, ypT4 = 1%; Mandard classification: TRG1 = 18%, TRG2 = 26%, TRG3 = 24%, TRG4 = 30%, TRG5 = 2%; and Cologne Regression Scale: no tumour = 18%, 1-10% VTC = 27%, 10-50% VTC = 26% and >50% VTC = 29%. The Mandard and Cologne Regression classifications showed better prognostic differentiation for the subgroups than the ypT category. The four-tiered Cologne Regression system had a good prognostic relevance. Comparing results of the re-evaluated Cologne Regression classification with the classification by routine pathological report showed very good inter-rater agreement, with kappa value 0.891.

CONCLUSION

Compared to the original primary tumour, the tumour regression grading system using the percentage of residual vital tumour has prognostic relevance.

Residual Cancer Volume Predicts Clinical Outcome in Patients With Esophageal Squamous Cell Carcinoma After Neoadjuvant Chemotherapy

Background. The aim of this study was to assess the prognostic significance of residual cancer volume (RCV) in patients with esophageal squamous cell carcinoma (ESCC) who received esophagectomy after neoadjuvant chemotherapy. Methods. We measured RCV by using complete stepwise sections at 6- to 8-mm intervals obtained from 81 ESCC patients with clinical stages IB to III. RCV was defined as the summation of all products of residual cancer area and thickness, and its cutoff value was set by receiver operator characteristic curve analysis on 3-year disease-specific survival (DSS). The multivariate analyses were performed in comparison with histopathological factors including tumor regression grades according to the Japanese Classification of Esophageal Cancer (TRG-JPN) or reported by Becker et al (TRG-Becker). Results. The range of RCV was 0 to 49.3 cm³ (median = 1.4 cm³), and the cutoff value was set at 1.0 cm³ (sensitivity = 78%; specificity = 68%). In the Kaplan-Meier curve analysis with the log-rank test, RCV > 1.0 cm³ predicted poorer prognosis for relapse-free survival (RFS; 5-year RFS rate, 12% vs 47%; P < .001) and DSS (5-year DSS rate, 27% vs 61%; P < .001). The multivariate analyses by the Cox hazards model revealed that RCV > 1.0 cm³ was a factor predicting poor prognosis for RFS (P = .013; hazard ratios [HR] = 2.62) and DSS (P = .028; HR = 2.56) compared with histopathological factors including TRG-JPN; RFS (P = .014; HR = 3.03) and DSS (P = .045; HR = 2.71) compared with histopathological factors including TRG-Becker. Conclusions. The study suggested that determining RCV is a new method of predicting prognosis in ESCC patients after neoadjuvant chemotherapy.

Prediction of response after chemoradiation for esophageal cancer using a combination of dosimetry and CT radiomics

PURPOSE

To investigate the treatment response prediction feasibility and accuracy of an integrated model combining computed tomography (CT) radiomic features and dosimetric parameters for patients with esophageal cancer (EC) who underwent concurrent chemoradiation (CRT) using machine learning.

METHODS

The radiomic features and dosimetric parameters of 94 EC patients were extracted and modeled using Support Vector Classification (SVM) and Extreme Gradient Boosting algorithm (XGBoost). The 94-sample dataset was randomly divided into a 70-sample training subset and a 24-sample independent test set while keeping the class proportions intact via stratification. A receiver operating characteristic (ROC) curve was used to assess the performance of models using radiomic features alone and using combined radiomic features and dosimetric parameters.

RESULTS

A total of 42 radiomic features and 18 dosimetric parameters plus the patients' characteristic parameters were extracted for these 94 cases (58 responders and 36 non-responders). XGBoost plus principal component analysis (PCA) achieved an accuracy and area under the curve of 0.708 and 0.541, respectively, for models with radiomic features combined with dosimetric parameters, and 0.689 and 0.479, respectively, for radiomic features alone. Image features of GlobalMean X.333.1, Coarseness, Skewness, and GlobalStd contributed most to the model. The dosimetric parameters of gross tumor volume (GTV) homogeneity index (HI), Cord Dmax, Prescription dose, Heart-Dmean, and Heart-V50 also had a strong contribution to the model.

CONCLUSIONS

The model with radiomic features combined with dosimetric parameters is promising and outperforms that with radiomic features alone in predicting the treatment response of patients with EC who underwent CRT.

KEY POINTS

• The model with radiomic features combined with dosimetric parameters is promising in predicting the treatment response of patients with EC who underwent CRT. • The model with radiomic features combined with dosimetric parameters (prediction accuracy of 0.708 and AUC of 0.689) outperforms that with radiomic features alone (best prediction accuracy of 0.625 and AUC of 0.412). • The image features of GlobalMean X.333.1, Coarseness, Skewness, and GlobalStd contributed most to the treatment response prediction model. The dosimetric parameters of GTV HI, Cord Dmax, Prescription dose, Heart-Dmean, and Heart-V50 also had a strong contribution to the model.

The Prognostic Value of a Pathologic Complete Response After Neoadjuvant Therapy for Digestive Cancer: Systematic Review and Meta-Analysis of 21 Studies

BACKGROUND

Neoadjuvant therapy (NAT) before radical excision has become the preferred initial option for locally advanced digestive cancers such as esophageal cancer (EC), esophagogastric junction adenocarcinoma (EGJAC), gastric adenocarcinoma (GAC), rectal cancer (RC), and pancreatic cancer (PC). Although some patients reportedly achieve a pathologic complete response (pCR) after neoadjuvant therapy, the published data are inconsistent regarding whether pCR yields a survival benefit. The current meta-analysis was performed to assess the potential prognostic value of pCR after preoperative therapy for patients with digestive cancers.

METHODS

An extensive electronic search in PubMed, Web of Science, and the Cochrane Library was performed for relevant articles, from which data relative to independent correlations of pCR with overall survival (OS) and disease-free survival (DFS) were extracted for analysis. A random-effects model was used to calculate the pooled hazard ratios (HRs) with their corresponding 95% confidence intervals (CIs).

RESULTS

The study identified 6780 patients who met the inclusion and exclusion criteria. The results showed that pCR was significantly correlated with better OS (HR, 0.50; 95% CI, 0.43-0.58; P < 0.001) and DFS (HR, 0.49; 95% CI, 0.40-0.60; P < 0.001) for the digestive cancer patients who achieved pCR than for those who did not achieve pCR. Subgroup analysis showed that the correlation of pCR with OS was significant in EC (HR, 0.57; 95% CI, 0.47-0.69; P < 0.001), EGJAC/GAC (HR, 0.38; 95% CI, 0.17-0.86; P = 0.02), RC (HR, 0.48; 95% CI, 0.28-0.81; P = 0.006), and PC (HR, 0.41; 95% CI, 0.17-0.97; P = 0.04). In addition, the survival benefit for pCR patients was of similar magnitude, irrespective of the type of study, type of NAT, or ethnicity.

CONCLUSIONS

A pCR is correlated with favorable survival outcomes compared with a non-pCR for digestive cancer patients after NAT.

Efficacy of 4'-[methyl-11C] thiothymidine PET/CT before and after neoadjuvant therapy for predicting therapeutic responses in patients with esophageal cancer: a pilot study

Background

4′-[Methyl-11C] thiothymidine (4DST) has been introduced as a new cell proliferation imaging PET tracer that incorporates into DNA directly. The aim of this prospective study was to evaluate the efficacy of 4DST PET/CT for predicting responses to neoadjuvant therapy in patients with esophageal cancer comparing with FDG PET/CT.

Methods

Twenty-six patients who had pre- and post-therapeutic 4DST and FDG PET/CT and underwent esophagectomy following neoadjuvant therapy were used for the analysis. Based on pathological findings, patients were divided into two groups: non-responders and responders. The maximum standardized uptake value (SUVmax), metabolic tumor volume, total lesion glycolysis, and total lesion proliferation of the primary lesion were measured for FDG and 4DST PET.

Results

The pathological diagnosis revealed 16 responders and 10 non-responders. Non-responders showed significantly higher 4DST post-therapeutic SUVmax (_postSUVmax) than responders, whereas FDG _postSUVmax showed no statistically significant difference (non-responders vs. responders: 4DST, 6.7 vs. 3.3, p = 0.001; FDG, 6.1 vs. 4.5, p = 0.11). Responders showed a greater reduction in percentage changes of 4DST and FDG SUVmax (ΔSUVmax) from baseline to post-therapeutic PET (non-responders vs. responders: 4DST, − 2.9% vs. − 56.7%, p < 0.001; FDG, − 36.3% vs. − 72.6%, p < 0.001). In ROC analysis, ΔSUVmax and _postSUVmax with 4DST provided great diagnostic performance for predicting responses (area under the curve: 4DST ΔSUVmax = 0.92, 4DST _postSUVmax = 0.88).

Conclusions

4DST PET/CT has a great potential for predicting pathologic response to neoadjuvant therapy in patients with esophageal cancer; it may be slightly superior to that with FDG PET/CT.

Evaluating the optimal radiation dose for definitive chemoradiotherapy for esophageal squamous cell carcinoma: A single institution experience

The optimal radiation dose for definitive chemoradiotherapy in inoperable esophageal squamous cell carcinoma (ESCC) has been long debated. In this study, we evaluated the effect of doses greater than the conventional radiation dose (50.4 Gy) on tumor control, tumor response, overall survival (OS), and disease-free survival (DFS).The database of patients diagnosed with inoperable ESCC from 2007 to 2015 was obtained from the cancer registry of Chi-Mei Medical Center. All categorical variables were compared using Chi-squared test. The risk of OS and DFS were estimated using Cox proportional hazards regression, and Kaplan-Meier plots presented the trend of OS and DFS with log-rank tests used to compare differences. All significance levels were set at P < .05.A total of 84 patients were retrospectively analyzed, with 42 (50%) receiving >50.4 Gy and 42 (50%) receiving ≤50.4 Gy (50%) concurrently with chemotherapy. Univariate and multivariate analysis revealed no significant differences between higher dose and conventional dose in OS (P = .21) and DFS (P = .26). Further dose analysis of <50, 50 to 50.4, 51 to 60, and >60 Gy showed no significant differences in OS or DFS. Higher doses conveyed no significant benefit on the failure pattern, either local regional failure or distant failure (P = .42). Major prognostic factors associated with better OS on multivariate analysis were stages I and II patients (P = .03) and radiation technique using arc therapy (P = .04). No acute toxicity of grade III or higher was recorded.The results of our study show that providing higher than conventional radiation doses concurrent with chemotherapy for inoperable ESCC does not impact OS or DSF, nor does it improve locoregional failure or distant failure. Although tumor response might be improved by radiation doses >50.4 Gy, the impact on OS and DFS remain to be studied.

Pathological tumor regression grade of metastatic tumors in lymph node predicts prognosis in esophageal cancer patients

Tumor regression grade of the primary tumor (TRG‐PT) and residual lymph node metastasis have been pathologically determined in esophageal squamous cell carcinoma (ESCC) patients who had received neoadjuvant chemotherapy (nCT) followed by surgery; however, TRG of the metastatic tumor involving lymph nodes (LN) has not yet been determined. The aim of the present study was to clarify the impact of TRG on the prognosis of ESCC patients. ESCC patients (n = 110) who had received nCT followed by surgery were enrolled. Dissected LN were classified into 2 categories: plausible positive metastatic LN (pp‐MLN) where viable and/or degenerated ESCC cells and/or tissue modifications were observed, and non‐metastatic LN (non‐MLN) where neither of them was observed. We defined nCT‐effective rate (CER) as the ratio of the number of pp‐MLN that showed tumor regression to the total number of pp‐MLN, and divided CER into low‐CER (LCER; ≥0% and <50%) and high‐CER (HCER; ≥50% and ≤100%). Relationships between CER and clinicopathological factors including prognosis were then examined. Multivariate analyses of 110 patients indicated that ypT3‐4 (P = .023, HR; 2.551), positive venous infiltration (P = .006, HR; 3.526), and LCER (P = .033, HR; 1.922) were independently associated with shorter recurrence‐free survival (RFS). Multivariate analyses of 43 patients with grade 0 TRG‐PT showed that ypT3‐4 (P = .033, HR; 3.397) and LCER (P = .008, HR; 3.543) were independently associated with shorter RFS. This study showed that CER was one of the prognostic factors for ESCC patients who had received nCT followed by surgery.

ypT0N+: the unusual patient with pathological complete tumor response but with residual lymph node disease after neoadjuvant chemoradiation for esophageal cancer, what's up?

Background

Little is known about the prognostic significance of residual nodal disease in otherwise complete pathologic responders (ypT0N+) after neoadjuvant chemoradiation (nCRT) for esophageal cancer (EC). The purpose is to analyze the long-term outcomes of EC patients with ypT0N+ following nCRT and esophagectomy.

Methods

From a single institution database, 466 consecutive EC patients undergoing esophagectomy after nCRT were collected (1996-2016). ypT0N+ responders were compared to pathological complete responders (ypT0N0) and to pathological non-complete responders (ypT+N0 and ypT+N+).

Results

There were 149 ypT0N0, 31 ypT0N+, 141 ypT+N0 and 145 ypT+N+. Median overall survival (OS) was worse in ypT0N+ (21.7 months) and ypT+N+ (16.8 months) compared to ypT0N0 (55.2 months) and ypT+N0 (42.0 months). Stratification by histology revealed a significant difference in prevalence of ypT0: 62.5% in 184 squamous cell carcinomas (SCC) compared to 23.0% in 282 adenocarcinomas (ADC) (P<0.0001) but not in ypT0N+ (15% vs. 22% respectively, P=0.25). In ADC, locoregional recurrence in ypT0N+ (43%) was comparable to ypT+N+ (31%) and more common compared to ypT0N0 (7%) and ypT+N0 (10%), reflected in median OS rates of 20.6, 17.5, 53.0 and 36.6 months respectively. Median OS in ADC is significantly determined by number of positive lymph nodes, being 21.7 months for pN1 and 2.7 months for pN2/3 (P=0.005) in ypT0N+ and 33.7 months for pN1 and 16.2 months for pN2/3 (P=0.031) in ypT+N+. In SCC, locoregional recurrences were found in 17% of ypT0N+, 33% of ypT+N+, 11% of ypT0N0 and 22% in ypT+N0 and median OS was 26.6, 15.6, 55.2 and 43.8 months respectively. In SCC ypN+ number of affected lymph nodes showed no difference on OS.

Conclusions

ypT0N+ in EC patients following nCRT has a poor prognosis and behaves similar to ypT+N+. However, stratification by histology shows that this is especially true in ADC but seems determined by the number of involved lymph nodes.

Pathologic assessment of gastrointestinal tract and pancreatic carcinoma after neoadjuvant therapy

Neoadjuvant therapy is increasingly used to treat patients with a wide variety of malignancies. Histologic evaluation of treated specimens provides important prognostic information and may guide subsequent chemotherapy. Neoadjuvant therapy is commonly employed in the treatment of locally advanced rectal adenocarcinoma, hepatic colorectal metastases, esophageal/esophagogastric junction carcinoma, and pancreatic ductal adenocarcinoma. Numerous tumor regression schemes have been used in these tumors and standardized approaches to evaluate these specimens are needed. In this review, the various tumor regression scoring systems that have been used in these organs are described and their associations with clinical outcomes are discussed. Recommendations regarding how to handle and report the histologic findings in these resections specimens are provided.

Radiotherapy for esophageal carcinoma: dose, response and survival

Esophageal cancer (EC) is an extremely aggressive, lethal malignancy that is increasing in incidence worldwide. At present, definitive chemoradiotherapy is accepted as the standard treatment for locally advanced EC. The EC guidelines recommend a radiation dose of 50.4 Gy for definitive treatment, yet the outcomes for patients who have received standard-dose radiotherapy remain unsatisfactory. However, some studies indicate that a higher radiation dose could improve local tumor control, and may also confer survival benefits. Some studies, however, suggest that high-dose radiotherapy does not bring survival benefit. The available data show that most failures occurred in the gross target volume (especially in the primary tumor) after definitive chemoradiation. Based on those studies, we hypothesize that at least for some patients, more intense local therapy may lead to better local control and survival. The aim of this review is to evaluate the radiation dose, fractionation strategies, and predictive factors of response to therapy in functional imaging for definitive chemoradiotherapy in esophageal carcinoma, with an emphasis on seeking the predictive model of response to CRT and trying to individualize the radiation dose for EC patients.

Serum microRNA-193b as a promising biomarker for prediction of chemoradiation sensitivity in esophageal squamous cell carcinoma patients

Esophageal squamous cell carcinoma (ESCC) is the most predominantly occurring type of esophageal cancer worldwide. Locally advanced ESCC patients are treated by neoadjuvant chemoradiation for tumor downstaging prior to tumor resection. Patients receiving this treatment have an increased expectation of cure via the following tumor resection and have better survival outcomes. However, not all patients respond well to chemoradiation and poor responders suffer from treatment-associated toxicity and complications without benefits. No method is currently available to predict patient chemoradiation response and to exclude poor responders from ineffective treatment. To address this clinical limitation, the present study aimed to identify non-invasive biomarkers for predicting patient chemoradiation response. Due to the features of microRNA (miRNA) in cancer diagnosis, prognosis and treatment response prediction, serum miRNA arrays were performed to identify potential miRNA(s) that may be used for chemoradiation response prediction in ESCC. Using an miRNA array to compare pre-treatment serum sample pools from 10 good responders and 10 poor responders, the present study identified miR-193b, miR-942 and miR-629* as candidate miRNAs for predicting chemoradiation response. Subsequent validation using reverse transcription-quantitative polymerase chain reaction confirmed that miR-193b, however not miR-942 and miR-629*, were significantly increased in sera from 24 good responders, compared with 23 poor responders. Further analyses using the receiver operating characteristic curve revealed a strong predictive power of serum miR-193b on discriminating good responders from poor responders to chemoradiation. In addition, a high serum level of miR-193b was significantly associated with better survival outcomes. Therefore, serum miR-193b may be considered a promising biomarker for predicting chemoradiation response and post-therapy survival of ESCC patients.

Clinical Significance of the Pre-therapeutic Nodal Size in Patients Undergoing Neo-Adjuvant Treatment Followed by Esophagectomy for Esophageal Squamous Cell Carcinoma

BACKGROUND

The clinical significance of pre-therapeutic nodal size in patients with esophageal squamous cell carcinoma (ESCC) is not clear. We investigated whether nodal size was correlated with survival in patients undergoing neo-adjuvant treatment followed by esophagectomy for ESCC.

METHODS

In 2009-2013, 222 patients who underwent neo-adjuvant treatment followed by esophagectomy for ESCC were enrolled in this retrospective study. Nodal size was measured along the short axis of the largest node using pre-therapeutic CT images. Patients were then stratified based on this short axis, and nodal size was correlated with clinicopathological factors and survival.

RESULTS

Patients with larger nodes were likely to have deeper cT, higher cN status, and poorer survival. Among the clinical factors cT, cN, cM, and nodal size, only cT and nodal size were independent prognostic factors in multivariate analysis [hazard ratio (HR) 2.0, 95 % confidence interval (CI) 1.1-3.5, p = 0.025 and HR 1.5, 95 % CI 1-2.3, p = 0.036, respectively]. In addition, nodal size was significantly associated with hematological recurrence (p = 0.007), but not lymphatic relapse (p = 0.272).

CONCLUSIONS

The short axis of the largest node before neo-adjuvant treatment in patients with ESCC is a prognostic factor.

MicroRNA-377 suppresses initiation and progression of esophageal cancer by inhibiting CD133 and VEGF

Esophageal cancer is one of the most lethal cancers worldwide with poor survival and limited therapeutic options. The discovery of microRNAs created a new milestone in cancer research. miR-377 is located in chromosome region 14q32, which is frequently deleted in esophageal squamous cell carcinoma (ESCC), but the biological functions, clinical significance and therapeutic implication of miR-377 in ESCC are largely unknown. In this study, we found that miR-377 expression was significantly downregulated in tumor tissue and serum of patients with ESCC. Both tumor tissue and serum miR-377 expression levels were positively correlated with patient survival. Higher serum miR-377 expression was inversely associated with pathologic tumor stage, distant metastasis, residual tumor status and chemoradiotherapy resistance. The roles of miR-377 in suppressing tumor initiation and progression, and the underlying molecular mechanisms were investigated. Results of in vitro and in vivo experiments showed that miR-377 overexpression inhibited the initiation, growth and angiogenesis of ESCC tumors as well as metastatic colonization of ESCC cells, whereas silencing of miR-377 had opposite effects. Mechanistically, miR-377 regulated CD133 and VEGF by directly binding to their 3' untranslated region. Moreover, systemic delivery of formulated miR-377 mimic not only suppressed tumor growth in nude mice but also blocked tumor angiogenesis and metastasis of ESCC cells to the lungs without overt toxicity to mice. Collectively, our study established that miR-377 plays a functional and significant role in suppressing tumor initiation and progression, and may represent a promising non-invasive diagnostic and prognostic biomarker and therapeutic strategy for patients with ESCC.

Predictive factors in the evaluation of treatment response to neoadjuvant chemoradiotherapy in patients with advanced esophageal squamous cell cancer

Neoadjuvant therapy before esophagectomy is evidence-based, and is a standard-of-care for locally advanced and operable esophageal cancer. However response to such treatment varies in individual patients, from no clinical response to pathological complete response. It has been consistently shown that a good pathological responses is of prognostic value, but perhaps in the expense of those who do not. It is important to identify suitable predictive factors for response, so that patients are not exposed to potentially harmful chemotherapy and/or radiotherapy without benefits. Alternative management strategies can be devised. Various clinical, radiological, serological and potential molecular markers have been studied. None has been shown to be sufficiently reliable to be used in daily practice. Certainly more understanding of the molecular basis for response to chemotherapy/radiotherapy is needed, so that patient treatment can be tailored and individualized.

Remnant lymph node metastases after neoadjuvant therapy and surgery in patients with pathologic T0 esophageal carcinoma impact on prognosis: A systematic review and meta-analysis

BACKGROUND

The aim of this study was to evaluate the outcomes of patients with pathologic T0 esophageal carcinoma after neoadjuvant therapy and surgery.

METHODS

We searched PubMed, Embase, Cochrane Library, and Medline databases from inception up to November 12, 2016. The meta-analysis was performed to compare odds ratios (OR) for overall survival (OS), disease-free survival (DFS), local control (LC), and distant control (DC).

RESULTS

Eight published studies of 837 patients were included in the meta-analysis. Data showed that the ypT0N1 group was associated with worse outcomes compared with the ypT0N0 group. The pooled OR and 95% confidence interval (CI) for 3-year and 5-year OS were 3.08 [2.07, 4.57] and 4.27 [2.76, 6.59], respectively. Whereas, the pooled OR and 95% CI for 3-year and 5-year DFS were 3.90 [2.08, 7.34] and 5.17 [1.93, 13.87], respectively. The pooled OR and 95% CI for LR and DR were 4.52 [1.72, 11.91] and 2.65 [1.38, 5.09], respectively.

CONCLUSIONS

Remnant lymph node metastases after neoadjuvant therapy and surgery in patients with pathologic T0 esophageal carcinoma portend poor survival, and it is an important prognostic factor.

Association between the thoroughness of the histopathological examination and survival in patients with esophageal squamous cell carcinoma who achieve pathological complete response after chemoradiotherapy

The College of American Pathologists guidelines recommend examining at least four representative tumor blocks for determining pathological T stage in patients with primarily resected esophageal cancer. Whether the same pathological requirements are adequate in patients undergoing esophagectomy following neoadjuvant chemoradiotherapy (nCRT) remains unclear. We hypothesized that current examination protocols may underestimate the presence of microscopical residual disease after nCRT, potentially leading to under-staging. We retrospectively reviewed the records of patients with esophageal squamous cancer (ESCC) who were diagnosed as having pathological complete response (pCR) following nCRT. The thoroughness of the pathological examination in pCR patients was examined using (i) the number of blocks examined in suspicious tumor area (≤4 vs. >4), and (ii) the block quotient (calculated as the pretreatment tumor length divided by the number of blocks examined in suspicious tumor area). A total of 91 patients were enrolled. The mean number of blocks used to confirm pCR was 4.8 (range: 2-14). The 5-year overall survival (OS) and disease-free survival (DFS) in the entire cohort were 55% and 65%, respectively. Multivariate analyses identified the block quotient as the only independent predictor of OS and DFS. Receiver operating characteristic curve analysis indicated an optimal cutoff value of 1.4 for the block quotient. Among the patients who achieved pCR, the 5-year DFS differed significantly between subjects with a low (≤1.4) or high (>1.4) block quotient (76% vs. 47%, respectively, P = 0.03). The block quotient (calculated by the pretreatment tumor length divided by the number of blocks) - which reflects the meticulousness of the histopathological examination for confirming pCR - is associated with survival in ESCC patients.

Individualized Radiation Dose Escalation Based on the Decrease in Tumor FDG Uptake and Normal Tissue Constraints Improve Survival in Patients With Esophageal Carcinoma

BACKGROUND

To determine whether individualized radiation dose escalation after planned chemoradiation based on the decrease in tumor and normal tissue constraints can improve survival in patients with esophageal carcinoma.

METHODS

From August 2005 to December 2010, 112 patients with squamous esophageal carcinoma were treated with radical concurrent chemoradiation. Patients received positron emission tomography-computer tomography scan twice, before radiation and after radiation dose of 50.4 Gy. All patients were noncomplete metabolic response groups according to the Response Evaluation Criteria in solid tumors. Only 52 patients with noncomplete metabolic response received individualized dose escalation based on tumor and normal tissue constraints. Survival and treatment failure were observed and analyzed using SPSS (13.0).

RESULTS

The rate of complete metabolic response for patients with noncomplete metabolic response after dose escalation reached 17.3% (9 of 52). The 2-year overall survival rates for patients with noncomplete metabolic response in the conventional and dose-escalation groups were 20.5% and 42.8%, respectively( P = .001). The 2-year local control rates for patients were 35.7% and 76.2%, respectively ( P = .002). When patients were classified into partial metabolic response and no metabolic response, 2-year overall survival rates for patients with partial metabolic response were significantly different in conventional and dose-escalation groups (33.8% vs 78.4%; P = .000). The 2-year overall survival rates for patients with no metabolic response in two groups (8.6% vs 15.1%) did not significantly differ ( P = .917).

CONCLUSION

Individualized radiation dose escalation has the potential to improve survival in patients with esophageal carcinoma according to increased rate of complete metabolic response. However, further trials are needed to confirm this and to identify patients who may benefit from dose escalation.

Impact of Neoadjuvant Chemoradiation on Short-Term Outcomes for Esophageal Squamous Cell Carcinoma Patients: A Meta-analysis

BACKGROUND

Neoadjuvant chemoradiation (NCRT) has emerged as a component of the standard treatment for esophageal squamous cell carcinoma (SCC). The primary benefit of NCRT is an improvement in long-term survival; however, the impact of NCRT on short-term outcomes is unclear.

METHODS

A comprehensive electronic literature search was performed via the MEDLINE (PubMed), Cochrane Library, and Google Scholar databases through November 2015 for the inclusion of randomized controlled trials (RCTs) that evaluated short-term outcomes of patients administered NCRT followed by surgery compared with surgery alone for resectable esophageal SCC. The main outcome measures were postoperative mortality and morbidity. A meta-analysis was performed using random-effects models to calculate odds ratios (ORs) with 95 % confidence intervals (CIs).

RESULTS

Eight RCTs were included, for a total of 1058 patients. Meta-analysis of the overall postoperative mortality and cardiopulmonary complication rates showed that there was a significant increase for patients administered NCRT followed by surgery compared with surgery alone (OR 1.87, 95 % CI 1.07-3.28, p = 0.03, number of patients needed to harm = 33.3; and OR 2.12, 95 % CI 1.03-4.35, p = 0.04, respectively). Dropout before surgery was higher for patients in the NCRT followed by surgery group compared with patients in the surgery-alone group. NCRT has no statistically impact on anastomosis and other complications compared with surgery alone.

CONCLUSIONS

NCRT for esophageal SCC significantly increases postoperative mortality and cardiopulmonary complications.

Which factors are associated with extremely short-term survival after surgery in patients with esophageal squamous cell carcinoma?

AIMS

Esophageal squamous cell carcinoma (ESCC) is associated with a short median survival and low cure rates. The postoperative survival time of some patients with ESCC is extremely short. It is important to understand risk factors in subsets of patients associated with extremely short-term survival. The standard factors such as T and N stage, which are predictive of actuarial survival, become less important as patients live for ≤1 year. However, the prevalence of these factors in these patient populations has not been well documented. We evaluated factors predictive of ≤1 year survival in this research.

METHODS

We analyzed 1596 patients underwent esophagectomy for ESCC retrospectively. The demographic and clinicopathologic characteristics were compared between patients who died within 1 year of esophagectomy and patients who survived more than 1 year after esophagectomy.

RESULTS

Univariate analysis showed significant differences between the two groups regarding gender, weight loss, comorbidity, neoadjuvant treatment, completeness of resection, pathological T stage, pathological N stage, histologic grade, the number of metastatic lymph nodes, postoperative complications, postoperative pulmonary infection and postoperative hospital stay. Based on logistic regression analysis, significant factors associated with extremely short-term survival were male gender, incomplete tumor resection, higher pathological T stage, higher pathological N stage and postoperative pulmonary infection.

CONCLUSION

The independent positive predictors for extremely short-term survival are male gender, incomplete tumor resection and postoperative pulmonary infection besides higher pathological T stage and higher pathological N stage.

Younger women have a better prognosis among patients with esophageal squamous cell carcinoma after esophagectomy

BACKGROUND

Epidemiological studies have suggested a potential role for sex hormones in esophageal squamous cell carcinoma (ESCC) etiology. However, the significance of gender as an independent prognostic factor remains uncertain. Our retrospective study was designed to investigate the prognostic role of gender for survival after esophagectomy.

METHODS

Data from 674 patients with ESCC who underwent surgical resection were retrospectively analysed. Age 55 years was selected as a surrogate for menopause. Patients were assigned to age-gender groups: A (female younger than age 55 years), B (female age 55 years and older), C (male younger than age 55 years) and D (male age 55 years and older). Univariate and multivariate analyses were performed to identify prognostic factors for survival.

RESULTS

There were 520 males and 154 females with median age was 58 years. The 1-, 3-, 5-year survival rates of group A, B, C and D were 93.6%, 70.2%, 61.7% vs. 86.9%, 47.7%, 40.2% vs. 77.8%, 43.9%, 37.0% and 80.3%, 47.9%, 36.6%, respectively (P=0.003). Multivariate analysis suggested that age-gender groups and pTNM staging were independent prognostic factors.

CONCLUSIONS

Among patients with ESCC after esophagectomy, women younger than age 55 years attained a favorable prognosis.

Prognostic significance of tumor regression grade for patients with esophageal squamous cell carcinoma after neoadjuvant chemotherapy followed by surgery

BACKGROUND AND OBJECTIVES

To clarify prognostic factors for the patients with esophageal squamous cell carcinoma (ESCC) through an assessment of surgically resected specimens modified by neoadjuvant chemotherapy (nCT).

METHODS

We retrospectively reviewed the clinicopathological data of 143 consecutive patients with ESCC who underwent nCT followed by surgery between 2008 and 2012 at our institution and conducted survival analysis. The tumor regression grade (TRG) was classified based on the proportion of residual tumor cells in the area where the tumor was thought to have existed before nCT as follows: Grade 0 (no therapeutic effect), Grade 1a (residual tumor cells ≥2/3), Grade 1b (1/3≤ residual tumor cells <2/3), Grade 2 (residual tumor cells <1/3), and Grade 3 (no residual tumor).

RESULTS

The 3-year OS and RFS of patients with tumor regression grade 0/1a/1b-3 were 53.6%/73.3%/88.6% and 37.7%/60.5%/83.8%, respectively. A multivariate analysis demonstrated that TRG was an independent predictor of OS (TRG 1a-3: HR, 0.46; 95%CI, 0.23-0.89), in addition to venous invasion, and of RFS (TRG 1a-3: HR, 0.49; 95%CI, 0.28-0.84), in addition to ypT factor, and venous invasion.

CONCLUSIONS

TRG is a critical prognostic factor in patients with ESCC who had undergone nCT followed by surgery. J. Surg. Oncol. 2016;113:390-396. © 2016 Wiley Periodicals, Inc.