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

Adjuvant treatment patterns for pT3N0M0 esophageal cancer undergoing surgery

To assess adjuvant treatment patterns on survival in patients with pT3N0M0 esophageal cancer who underwent esophagectomy without neoadjuvant chemoradiotherapy. Stage pT3N0M0 esophageal cancer patients were assessed between 2000 and 2020 from the Surveillance, Epidemiology, and End Results databases. Kaplan-Meier analysis was used to compare overall survival (OS) among various treatment patterns. We identified 445 patients: 252 (56.6%) received surgery alone, 85 (19.1%) received surgery+chemoradiotherapy, 80 (18.0%) underwent surgery+chemotherapy, and 28 (6.3%) received surgery+ radiotherapy. For squamous cell carcinoma, surgery+chemoradiotherapy ([hazard ratio] HR = 1.04, 95% confidence interval (CI): 0.65-1.66; P = 0.873), surgery+chemotherapy (HR = 0.72, 95% CI: 0.42-1.22; P = 0.221), and surgery+radiotherapy (HR = 1.33, 95% CI: 0.74-2.39; P = 0.341) had similar OS compared to surgery alone. For adenocarcinoma, surgery+chemoradiotherapy (HR = 0.51, 95% CI: 0.36-0.74; P < 0.001) and surgery+chemotherapy (HR = 0.61, 95% CI: 0.42-0.87; P = 0.006) had better OS compared to surgery alone. However, surgery+radiotherapy had a comparable OS (HR = 0.81, 95% CI: 0.44-1.49; P = 0.495).Adjuvant treatments did not improve survival in stage pT3N0M0 esophageal squamous cell carcinoma patients. In contrast, adjuvant chemoradiotherapy and chemotherapy were recommended for esophageal adenocarcinoma patients.

Immune checkpoint inhibitors in the treatment of oesophageal squamous cell carcinoma: where are we and where are we going?

Oesophageal squamous cell carcinoma (ESCC) is a kind of malignant tumour with high invasiveness and a poor prognosis. Immunotherapy, especially immune checkpoint inhibitors (ICIs), is a rapidly growing therapeutic method that activates and enhances anti-tumour immunity to treat patients with malignancy. Several clinical trials have confirmed the efficacy of ICIs in the treatment of ESCC. ICIs have been approved for the treatment of patients with ESCC. However, only a subset of patients can obtain excellent benefits from ICI therapy. In recent years, there has been a growing interest in exploring predictive biomarkers of immunotherapy response. In this review, we highlighted the predictive biomarkers for the prognosis of ESCC patients treated with ICIs and pointed out the existing problems and the direction of future research in this field.

Early versus delayed surgery following neoadjuvant chemoradiation for esophageal cancer: a systematic review and meta-analysis

BACKGROUND

Neoadjuvant chemoradiotherapy (nCRT) followed by surgery, is the mainstay of managing locally advanced esophageal cancer. However, the optimal timing of surgery after neoadjuvant therapy is not defined clearly.

METHODS

A systematic search of PubMed, Embase and Cochrane databases was conducted. 6-8 weeks were used as a cut-off to define early and delayed surgery groups. Overall Survival (OS) was the primary outcome, whereas pathological complete resolution (pCR), R0 resection, anastomotic leak, perioperative mortality, pulmonary complications, and major complication (> Clavien-Dindo grade 2) rates were secondary outcomes. Cohort studies and national registry bases studies were analysed separately. Survival data were pooled as Hazard Ratio (HR) and the rest as Odds Ratio (OR). According to heterogeneity, fixed-effect or random-effect models were used.

RESULTS

Twelve retrospective studies, one RCT, and six registry-based studies (13,600 participants) were included. Pooled analysis of cohort studies showed no difference in OS (HR 1.03, CI 0.91-1.16), pCR (OR 0.98, CI 0.80-1.20), R0 resection (OR 0.90, CI 0.55-I.45), mortality (OR 1.03, CI 0.59-1.77), pulmonary complications (OR 1.26, CI 0.97-1.64) or major complication rates (OR 1.29, CI 0.96-1.73). Delayed surgery led to increased leak (OR 1.48, CI 1.11-1.97). Analysis of registry studies showed that the delayed group had a better pCR rate (OR 1.12, CI 1.01-1.24), with no improvement in survival (HR 1.01, CI 0.92-1.10). Delayed surgery was associated with increased mortality (OR 1.35, CI 1.07-1.69) and major complication rate (OR 1.55, CI 1.20-2.01). Available RCT reported surgical outcomes only.

CONCLUSION

National registry-based studies' analysis shows that delay in surgery is riskier and leads to higher mortality and major complication rates. Further, well-designed RCTs are required.

The Key Clinical Questions of Neoadjuvant Chemoradiotherapy for Resectable Esophageal Cancer—A Review

Over 50% of individuals with esophageal cancer (EC) present with advanced stages of the disease; therefore, their outcome following surgery alone is poor, with only 25%–36% being alive 5 years post-surgery. Based on the evidence that the CROSS and NEOCRTEC5010 trials provided, neoadjuvant chemoradiotherapy (nCRT) is now the standard therapy for patients with locally advanced EC. However, there are still many concerning clinical questions that remain controversial such as radiation dose, appropriate patient selection, the design of the radiation field, the time interval between chemoradiotherapy (CRT) and surgery, and esophageal retention. With immune checkpoint inhibitors (ICIs) rapidly becoming a mainstay of cancer therapy, along with radiation, chemotherapy, and surgery, the combination mode of immunotherapy is also becoming a hot topic of discussion. Here, we try to provide constructive suggestions to answer the perplexing problems and clinical concerns for the progress of nCRT for EC in the future.

Association between ABCC2 polymorphism and hematological toxicity in patients with esophageal cancer receiving platinum plus 5-fluorouracil therapy

BACKGROUND

Platinum agents are taken up into cells by copper transporter (CTR) 1 (gene code: SLC31A1) and are excreted from cells by copper-transporting P-type adenosine triphosphatase (ATP7B) and multidrug resistance-associated protein (MRP) 2 (gene code: ABCC2). In addition, glutathione S transferase (GST) P1 is involved in the metabolism of platinum agents. The present study aimed to determine whether the rate of grade 3-4 hematological toxicity associated with platinum plus 5-fluorouracil (5-FU) therapy in 239 patients with esophageal cancer was affected by the SLC31A1 rs10981694A>C and rs12686377G>T, ATP7B rs9535828A>G, GSTP1 rs1695A>G, and ABCC2 -24C>T polymorphisms.

METHODS

Chemotherapy consisted of protracted infusion of 5-FU (800 mg/m²/day) on days 1-5 and cisplatin or nedaplatin (80 mg/m²/day) on day 1.

RESULTS

A total of 82 of 239 patients developed grade 3-4 hematological toxicity after chemotherapy. Univariate analysis showed that ABCC2 -24C/T + T/T genotypes (P = 0.038), radiation therapy (P = 0.013), baseline white blood cell count < 6000/μL (P = 0.003), and baseline neutrophil count < 3900/μL (P = 0.021) were statistically significant predictors of grade 3-4 hematological toxicity. Multivariate analysis revealed that ABCC2 -24C/T + T/T genotypes (P = 0.036), radiation therapy (P = 0.005), and baseline white blood cell count < 6000/μL (P < 0.001) were significant risk factors.

CONCLUSIONS

We determined that ABCC2 -24C>T is significantly associated with grade 3-4 hematological toxicity after platinum plus 5-FU therapy. These findings might contribute to improved treatment strategies for patients with esophageal cancer.

Prognostic factor for recurrence in esophagus cancer patients who underwent surgery for curative intent: A single-institution analysis

Objective

The purpose of this study is to analyze predisposing factors for a higher risk of recurrence in esophageal cancer patient who underwent surgery for curative intent and to do survival analysis of prognostic factors.

Materials and Methods

Between February 2018 and March 2020, we retrospectively identified 28 cases staged T1b to T4a managed electively at our institute as per multidisciplinary management plan. Demographic, clinical, radiological, operative, histopathological parameters, upfront surgery done or not, type of preoperative, and adjuvant treatment used and whether neoadjuvant or adjuvant therapy was planned along with waiting time for surgery, were assessed as potential risk factors. End point of study was to find potential risk factors for recurrence and to do their subgroup survival analysis.

Results

The recurrence rate in our study was 25% with a mean follow-up of 24 months. The median time of recurrence was 8.5 months, all recurrence occurred within 1 year. Overall DFS at 2 years was 72%. On univariate analysis, following prognostic factors were associated with high risk of recurrence, male sex X² (1) =4.42, p = 0.035; histology subtype of adenocarcinoma X² (1) = 7.07, p = 0.008; margin positive X² (1) =3.76, p = 0.05; presence of lymph vascular invasion (LVI) X² (1) =7.88, p = 0.005; presence of perineural invasion (PNI) X² (1) =5.97, p = 0.015; postoperative T size >4 cm X² (1) =3.86, p = 0.049; and nodal positivity X² (3) =13.47, p = 0.004.

Conclusions

Male sex, adenocarcinoma histological subtype, positive resected margin, presence of LVI and PNI, postoperative T size >4 cm, and high postoperative nodal positivity and whether neoadjuvant versus adjuvant therapy given (on K. M analysis) were the identified predictors of recurrence which compromised DFS.

Neoadjuvant Chemoradiotherapy Followed by Esophagectomy with Three-Field Lymph Node Dissection for Thoracic Esophageal Squamous Cell Carcinoma Patients with Clinical Stage III and with Supraclavicular Lymph Node Metastasis

Simple Summary

This study aimed to clarify the efficacy of neoadjuvant chemoradiotherapy (NACRT) followed by esophagectomy with three-field lymph node (LN) dissection for clinical Stage III patients and for clinical Stage IVB patients with supraclavicular LN metastasis as the only distant metastatic factor. We observed that NACRT followed by esophagectomy with three-field lymph node dissection is feasible and offers the potential for long-term survival of these patients. It is also suggested that supraclavicular LNs should be treated as regional LNs at least in patients with upper and middle thoracic esophageal squamous cell carcinoma (ESCC).

Abstract

Background: Neoadjuvant chemoradiotherapy (NACRT) followed by esophagectomy is now the standard treatment for patients with resectable advanced thoracic esophageal squamous cell carcinoma (ESCC) worldwide. However, the efficacy of NACRT followed by esophagectomy with three-field lymph node dissection for clinical Stage III patients and for clinical Stage IVB patients with supraclavicular LN metastasis has not yet been determined. Methods: Between 2008 and 2018, 94 ESCC patients diagnosed as clinical Stage III and 18 patients diagnosed as clinical Stage IVB with supraclavicular LN metastasis as the only distant metastatic factor were treated with NACRT followed by esophagectomy with extended lymph node dissection at Akita University Hospital. Long-term survival and the patterns of recurrence in these 112 patients were analyzed. Results: The median follow-up period of censored cases was 60 months. The five-year OS and DSS rates among the clinical Stage III patients were 57.6% and 66.6%, respectively. The five-year OS and DSS rates among the clinical Stage IVB patients were 41.3% and 51.6%, respectively. The most frequent recurrence pattern was distant metastasis (69.2%) in the Stage III patients and LN metastasis (75.0%) in the Stage IVB patients. Conclusion: NACRT followed by esophagectomy with three-field LN dissection is feasible and offers the potential for long-term survival of clinical Stage III ESCC patients and even clinical Stage IVB patients with supraclavicular LN metastasis as the only distant metastatic factor. At least in patients with upper and middle thoracic ESCC, treating supraclavicular LNs as regional LNs seems to be appropriate.