1
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Nilsson K, Klevebro F, Sunde B, Rouvelas I, Lindblad M, Szabo E, Halldestam I, Smedh U, Wallner B, Johansson J, Johnsen G, Aahlin EK, Johannessen HO, Alexandersson von Döbeln G, Hjortland GO, Wang N, Shang Y, Borg D, Quaas A, Bartella I, Bruns C, Schröder W, Nilsson M. Oncological outcomes of standard versus prolonged time to surgery after neoadjuvant chemoradiotherapy for oesophageal cancer in the multicentre, randomised, controlled NeoRes II trial. Ann Oncol 2023; 34:1015-1024. [PMID: 37657554 DOI: 10.1016/j.annonc.2023.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND The optimal time to surgery (TTS) after neoadjuvant chemoradiotherapy (nCRT) for oesophageal cancer is unknown and has traditionally been 4-6 weeks in clinical practice. Observational studies have suggested better outcomes, especially in terms of histological response, after prolonged delay of up to 3 months after nCRT. The NeoRes II trial is the first randomised trial to compare standard to prolonged TTS after nCRT for oesophageal cancer. PATIENTS AND METHODS Patients with resectable, locally advanced oesophageal cancer were randomly assigned to standard delay of surgery of 4-6 weeks or prolonged delay of 10-12 weeks after nCRT. The primary endpoint was complete histological response of the primary tumour in patients with adenocarcinoma (AC). Secondary endpoints included histological tumour response, resection margins, overall and progression-free survival in all patients and stratified by histologic type. RESULTS Between February 2015 and March 2019, 249 patients from 10 participating centres in Sweden, Norway and Germany were randomised: 125 to standard and 124 to prolonged TTS. There was no significant difference in complete histological response between AC patients allocated to standard (21%) compared to prolonged (26%) TTS (P = 0.429). Tumour regression, resection margins and number of resected lymph nodes, total and metastatic, did not differ between the allocated interventions. The first quartile overall survival in patients allocated to standard TTS was 26.5 months compared to 14.2 months after prolonged TTS (P = 0.003) and the overall risk of death during follow-up was 35% higher after prolonged delay (hazard ratio 1.35, 95% confidence interval 0.94-1.95, P = 0.107). CONCLUSION Prolonged TTS did not improve histological complete response or other pathological endpoints, while there was a strong trend towards worse survival, suggesting caution in routinely delaying surgery for >6 weeks after nCRT.
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Affiliation(s)
- K Nilsson
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm
| | - F Klevebro
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm
| | - B Sunde
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm
| | - I Rouvelas
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm
| | - M Lindblad
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm
| | - E Szabo
- Department of Surgery, Faculty of Medicine and Health, Örebro University Hospital, Örebro
| | | | - U Smedh
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg
| | - B Wallner
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå
| | - J Johansson
- Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - G Johnsen
- Department of Gastrointestinal Surgery, St. Olav's Hospital, Trondheim University Hospital, Trondheim
| | - E K Aahlin
- Department of GI and HPB Surgery, University Hospital of Northern Norway, Tromsø
| | - H-O Johannessen
- Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway
| | - G Alexandersson von Döbeln
- Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm; Medical Unit of Head, Neck, Lung and Skin Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - G O Hjortland
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - N Wang
- Department of Clinical Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm
| | - Y Shang
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm
| | - D Borg
- Department of Oncology, Skåne University Hospital, Lund, Sweden
| | - A Quaas
- Institute of Pathology, University of Cologne, Cologne
| | - I Bartella
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - C Bruns
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - W Schröder
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - M Nilsson
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm; Division of Surgery and Oncology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm.
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2
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Karthyarth MN, Mathew A, Ramachandra D, Goyal A, Yadav NK, Reddy KMR, Rakesh NR, Kaushal G, Dhar P. Early versus delayed surgery following neoadjuvant chemoradiation for esophageal cancer: a systematic review and meta-analysis. Esophagus 2023:10.1007/s10388-023-00989-y. [PMID: 36800076 DOI: 10.1007/s10388-023-00989-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/03/2023] [Indexed: 02/18/2023]
Abstract
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.
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Affiliation(s)
- Mithun Nariampalli Karthyarth
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Anvin Mathew
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India.
| | - Deepti Ramachandra
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Anuj Goyal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Neeraj Kumar Yadav
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | | | - Nirjhar Raj Rakesh
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Gourav Kaushal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bathinda, Punjab, 151001, India
| | - Puneet Dhar
- Department of Surgical Gastroenterology, Amrita Institute of Medical Sciences, Faridabad, Haryana, 121002, India
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3
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Lemini R, Díaz Vico T, Trumbull DA, Attwood K, Spaulding AC, Elli EF, Colibaseanu DT, Kukar M, Gabriel E. Prognostic models for stage I-III esophageal cancer: a comparison between existing calculators. J Gastrointest Oncol 2021; 12:1963-1972. [PMID: 34790364 DOI: 10.21037/jgo-20-337] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 02/15/2021] [Indexed: 12/16/2022] Open
Abstract
Background Determining the best approach for esophageal cancer and predicting accurate prognosis are critical. Multiple studies evaluated characteristics associated with overall survival, and several prediction models have been developed. This study aimed to evaluate existing models and perform external validation of selected models. Methods A retrospective investigation of a multi-site institutional enterprise for patients with a diagnosis of esophageal cancer between 2013-2014 was performed. Selected survival prediction models included the Roswell Park Comprehensive Cancer Center (RPCCC) calculator, Oregon Health & Science University (OHSU) calculator, and two nomograms published by Shapiro et al. and Sun et al. One-year overall survival, level of agreement, and performance for each model were evaluated. Results A total of 104 patients were included and used to assess the prediction models. One-year overall survival was 0.76. Different calculators tended to rank patients similarly; however, they did not agree on predicted overall survival. The least disparity in correlation was observed between OHSU and Shapiro calculators. Shapiro's model achieved the highest performance [area under the curve (AUC) =0.63]. Conclusions Selected models showed fair results in estimating individual overall survival, although none achieved a high performance. While these tools may support the decision-making process for esophageal cancer patients, their implementation in clinical practice requires improved refinement to optimize their clinical utility.
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Affiliation(s)
| | | | | | - Kristopher Attwood
- Department of Biostatistics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Aaron C Spaulding
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Enrique F Elli
- Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Moshim Kukar
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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4
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DE Rosa M, Pasculli A, Rondelli F, Mariani L, Avenia S, Ceccarelli G, Testini M, Avenia N, Bugiantella W. Could diagnostic and therapeutic delay affect the prognosis of gastrointestinal primary malignancies in the COVID-19 pandemic era? A literature review. Minerva Surg 2021; 76:467-476. [PMID: 33890444 DOI: 10.23736/s2724-5691.21.08736-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Emergency situations, as the Covid-19 pandemic that is striking the world nowadays, stress the national health systems which are forced to rapidly reorganizing their sources. Therefore, many elective diagnostic and surgical procedures are being suspended or significantly delayed. Moreover, patients might find it difficult to refer to physicians and delay the diagnostic and even the therapeutic procedures because of emotional or logistic problems. The effect of diagnostic and therapeutic delay on survival in patients affected by gastrointestinal malignancies is still unclear. METHODS We carried out a review of the available literature, in order to determine whether the delay in performing diagnosis and curative-intent surgical procedures affects the oncological outcomes in patients with oesophageal, gastric, colorectal cancers, and colorectal liver metastasis. RESULTS The findings indicate that for oesophageal, gastric and colon cancers delaying surgery up to 2 months after the end of the staging process does not worsen the oncological outcomes. Oesophageal cancer should undergo surgery within 7-8 weeks after the end of neoadjuvant chemoradiation. Rectal cancers should undergo surgery within 31 days after the diagnostic process and within 12 weeks after neoadjuvant therapy. Adjuvant therapy should start within 4 weeks after surgery, especially in gastric cancer; a delay up to 42 days may be allowed for oesophageal cancer undergoing adjuvant radiotherapy. CONCLUSIONS Gastrointestinal malignancies can be safely managed taking into account that reasonable delays of planned treatments appear a generally safe approach, not having a significant impact on long-term oncological outcome.
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Affiliation(s)
- Michele DE Rosa
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Perugia, Italy
| | - Alessandro Pasculli
- Department of Biomedical Sciences and Human Oncology - Unit Of Endocrine, Digestive And Emergency Surgery, University A. Moro of Bari, Polyclinic of Bari, Bari, Italy
| | - Fabio Rondelli
- General and Specialized Surgery, Santa Maria Hospital, Terni, Italy.,Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Lorenzo Mariani
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Perugia, Italy
| | - Stefano Avenia
- Postgraduate School of General Surgery, University of Perugia, Perugia, Italy
| | - Graziano Ceccarelli
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Perugia, Italy
| | - Mario Testini
- Department of Biomedical Sciences and Human Oncology - Unit Of Endocrine, Digestive And Emergency Surgery, University A. Moro of Bari, Polyclinic of Bari, Bari, Italy
| | - Nicola Avenia
- General and Specialized Surgery, Santa Maria Hospital, Terni, Italy.,Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Walter Bugiantella
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Perugia, Italy -
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5
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Zhang QZ, Li GL, Shang JB, Ren YM, Xie JL. Clinical study of a 125I particle-integrated esophageal covered stent and hyperbaric oxygen in the treatment of advanced esophageal cancer. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:576-579. [PMID: 33261505 DOI: 10.17235/reed.2020.7377/2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE this study aimed to investigate the clinical efficacy and feasibility of the treatment of advanced esophageal cancer with a combination of a 125I particle-integrated esophageal covered stent and hyperbaric oxygen. METHODS forty-five patients with advanced esophageal cancer were enrolled and were randomly divided into two groups: a treatment group and a control group. Patients in the treatment group were treated with a 125I particle-integrated esophageal covered stent and hyperbaric oxygen, while patients in the control group were treated with a 125I particle-integrated esophageal covered stent. The clinical effects and long-term survival time of the two groups were observed. RESULTS in the treatment group, the complete remission (CR) rate and partial remission (PR) rate of local lesions were 19.2 % and 61.5 %, respectively, and the total effective rate was 80.7 %. In the control group, the CR rate and PR rate of local lesions were 10.5 % and 52.6 %, respectively, and the total effective rate was 63.1 %. The total effective rate was higher in the treatment group than in the control group, which was statistically significant (p < 0.05). CONCLUSION the combination of a 125I particle-integrated esophageal covered stent and hyperbaric oxygen shows a good short- and long-term efficacy in the treatment of advanced esophageal cancer.
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Affiliation(s)
| | | | | | - Yi-Min Ren
- Intervention, The First Affiliated Hospital of Guangzhou Medical University
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6
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Fligor SC, Tsikis ST, Wang S, Ore AS, Allar BG, Whitlock AE, Calvillo-Ortiz R, Arndt K, Callery MP, Gangadharan SP. Time to surgery in thoracic cancers and prioritization during COVID-19: a systematic review. J Thorac Dis 2020; 12:6640-6654. [PMID: 33282365 PMCID: PMC7711379 DOI: 10.21037/jtd-20-2400] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Coronavirus disease 2019 (COVID-19) has overwhelmed hospital resources worldwide, requiring widespread cancellation of non-emergency operations, including lung and esophageal cancer operations. In the United States, while hospitals begin to increase surgical volume and tackle the backlog of cases, the specter of a “second wave,” with a potential vaccine months to years away, highlights the ongoing need to triage cases based upon the risk of surgical delay. We synthesize the available literature on time to surgery and its impact on outcomes along with a critical appraisal of the released triage guidelines in the United States. Methods We performed a systematic literature review using PubMed according to preferred reporting items for systematic reviews and meta-analyses guidelines evaluating relevant literature from the past 15 years. Results Out of 679 screened abstracts, 12 studies investigating time to surgery in lung cancer were included. In stage I–II lung cancer, delayed resection beyond 6 to 8 weeks is consistently associated with lower survival. No identified evidence justifies a 2 cm cutoff for immediate versus delayed surgery. For stage IIIa lung cancer, time to surgery greater than 6 weeks after neoadjuvant therapy is similarly associated with worse survival. For esophageal cancer, 254 abstracts were screened and 23 studies were included. Minimal literature addresses primary esophagectomy, but time to surgery over 8 weeks is associated with lower survival. In the neoadjuvant setting, longer time to surgery is associated with increased pathologic complete response, but also decreased survival. The optimal window for esophagectomy following neoadjuvant therapy is 6 to 8 weeks. Conclusions In the setting of the COVID-19 pandemic, timely resection of lung and esophageal cancer should be prioritized whenever possible based upon local resources and disease-burden.
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Affiliation(s)
- Scott C Fligor
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Savas T Tsikis
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sophie Wang
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ana Sofia Ore
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Benjamin G Allar
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ashlyn E Whitlock
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Rodrigo Calvillo-Ortiz
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kevin Arndt
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mark P Callery
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sidhu P Gangadharan
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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7
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Shang QX, Yang YS, Gu YM, Zeng XX, Zhang HL, Hu WP, Wang WP, Chen LQ, Yuan Y. Timing of surgery after neoadjuvant chemoradiotherapy affects oncologic outcomes in patients with esophageal cancer. World J Gastrointest Oncol 2020; 12:687-698. [PMID: 32699583 PMCID: PMC7340997 DOI: 10.4251/wjgo.v12.i6.687] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 04/09/2020] [Accepted: 04/28/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The optimal time interval between neoadjuvant chemoradiotherapy (nCRT) and esophagectomy in esophageal cancer has not been defined.
AIM To evaluate whether a prolonged time interval between the end of nCRT and surgery has an effect on survival outcome in esophageal cancer patients.
METHODS We searched PubMed, Embase, Web of Science, the Cochrane Library, Wanfang and China National Knowledge Infrastructure databases for relevant articles published before November 16, 2019, to identify potential studies that evaluated the prognostic role of different time intervals between nCRT and surgery in esophageal cancer. The hazard ratios and 95% confidence intervals (95%CI) were merged to estimate the correlation between the time intervals and survival outcomes in esophageal cancer, esophageal squamous cell carcinoma and adenocarcinoma using fixed- and random-effect models.
RESULTS This meta-analysis included 12621 patients from 16 studies. The results demonstrated that esophageal cancer patients with a prolonged time interval between the end of nCRT and surgery had significantly worse overall survival (OS) [hazard ratio (HR): 1.107, 95%CI: 1.014-1.208, P = 0.023] than those with a shorter time interval. Subgroup analysis showed that poor OS with a prolonged interval was observed based on both the sample size and HRs. There was also significant association between a prolonged time interval and decreased OS in Asian, but not Caucasian patients. In addition, a longer wait time indicated worse OS (HR: 1.385, 95%CI: 1.186-1.616, P < 0.001) in patients with adenocarcinoma.
CONCLUSION A prolonged time interval from the completion of nCRT to surgery is associated with a significant decrease in OS. Thus, esophagectomy should be performed within 7-8 wk after nCRT.
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Affiliation(s)
- Qi-Xin Shang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yu-Shang Yang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yi-Min Gu
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xiao-Xi Zeng
- West China Biomedical Big Data Center, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Han-Lu Zhang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Wei-Peng Hu
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Wen-Ping Wang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Long-Qi Chen
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yong Yuan
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
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8
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Klevebro F, Nilsson K, Lindblad M, Ekman S, Johansson J, Lundell L, Ndegwa N, Hedberg J, Nilsson M. Association between time interval from neoadjuvant chemoradiotherapy to surgery and complete histological tumor response in esophageal and gastroesophageal junction cancer: a national cohort study. Dis Esophagus 2019; 33:5610874. [PMID: 31676895 PMCID: PMC7203996 DOI: 10.1093/dote/doz078] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/24/2019] [Accepted: 08/04/2019] [Indexed: 12/11/2022]
Abstract
The optimal time interval from neoadjuvant therapy to surgery in the treatment of esophageal cancer is not known. The aim of this study was to investigate if a prolonged interval between completed neoadjuvant chemoradiotherapy and surgery was associated with improved histological response rates and survival in a population-based national register cohort. The population-based cohort study included patients treated with neoadjuvant chemoradiotherapy and esophagectomy due to cancer in the esophagus or gastroesophageal junction. Patients were divided into two groups based on the median time from completed neoadjuvant treatment to surgery. The primary outcome was complete histological response. Secondary outcomes were lymph node tumor response, postoperative complications, R0 resection rate, 90-day mortality, and overall survival. In total, 643 patients were included, 344 (54%) patients underwent surgery within 49 days, and 299 (47%) after 50 days or longer. The groups were similar concerning baseline characteristics except for a higher clinical tumor stage (P = 0.009) in the prolonged time to surgery group. There were no significant differences in complete histological response, R0 resection rate, postoperative complications, 90-day mortality, or overall survival. Adjusted odds ratio for ypT0 in the prolonged time to surgery group was 0.99 (95% confidence interval: 0.64-1.53). Complete histological response in the primary tumor (ypT0) was associated with significantly higher overall survival: adjusted hazard ratio: 0.55 (95% CI 0.41-0.76). If lymph node metastases were present in these patients, the survival was, however, significantly lower: adjusted hazard ratio for ypT0N1: 2.30 (95% CI 1.21-4.35). In this prospectively collected, nationwide cohort study of esophageal and junctional type 1 and 2 cancer patients, there were no associations between time to surgery and histological complete response, postoperative outcomes, or overall survival. The results suggest that it is safe for patients to postpone surgery at least 7 to 10 weeks after completed chemoradiotherapy, but no evidence was seen in favor of recommending a prolonged time to surgery after neoadjuvant chemoradiotherapy for esophageal cancer. A definitive answer to this question requires a randomized controlled trial of standard vs. prolonged time to surgery.
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Affiliation(s)
- F Klevebro
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institute, and Esophageal and Gastric Cancer Unit, Karolinska University Hospital, Stockholm, Sweden,Address correspondence to: Dr. Fredrik Klevebro, Karolinska University Hospital Huddinge, K42 14186 Stockholm, Sweden. E-mail:
| | - K Nilsson
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institute, and Esophageal and Gastric Cancer Unit, Karolinska University Hospital, Stockholm, Sweden
| | - M Lindblad
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institute, and Esophageal and Gastric Cancer Unit, Karolinska University Hospital, Stockholm, Sweden
| | - S Ekman
- Department of Oncology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - J Johansson
- Department of Surgery, Skåne University Hospital, Lund University, Sweden
| | - L Lundell
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institute, and Esophageal and Gastric Cancer Unit, Karolinska University Hospital, Stockholm, Sweden
| | - N Ndegwa
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institute, and Esophageal and Gastric Cancer Unit, Karolinska University Hospital, Stockholm, Sweden,Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - J Hedberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - M Nilsson
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institute, and Esophageal and Gastric Cancer Unit, Karolinska University Hospital, Stockholm, Sweden
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9
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Worrell SG, Towe CW, A Dorth J, Machtay M, Perry Y, Linden PA. Higher Doses of Neoadjuvant Radiation for Esophageal Cancer Do Not Affect the Pathologic Complete Response Rate or Survival: A Propensity-Matched Analysis. Ann Surg Oncol 2019; 27:500-508. [PMID: 31571054 DOI: 10.1245/s10434-019-07849-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Traditional neoadjuvant therapy for esophageal cancer has used chemoradiation doses greater than 45 Gy. This study aimed to examine the dose of preoperative radiation in relation to the pathologic complete response (pCR) rate and overall survival (OS) for patients with resectable esophageal cancer. METHODS The National Cancer Database was queried for all patients with esophageal or gastroesophageal junction cancer who received neoadjuvant chemoradiation (CRT) followed by esophagectomy between 2006 and 2015. The radiation doses were divided into four ranges based on Grays (Gy) received: less than 39.6 Gy, 39.60-44.99 Gy, 45-49.99 Gy, and 50 Gy or more. RESULTS The inclusion criteria were met by 10,293 patients. All patients received neoadjuvant CRT, with 689 patients (6.7%) receiving less than 39.6 Gy, 973 patients (9.5%) receiving 39.6-44.9 Gy, 3837 patients (37.3%) receiving 45-49.9 Gy, and 4794 patients (46.6%) receiving 50 Gy or more. The overall pCR rate was 17.2% (1769/10,293) and was significantly lower for those who received less than 39.6 Gy of radiation than for those who received 39.6 Gy or more (13.9% [96/689] vs. 17.4% [1673/9604]; p = 0.017). The median OS of 37.2 months was significantly better for those who received 39.6 Gy or more than for those who received less than 39.6 Gy (38 vs. 29.6 months (p < 0.0001). The pCR and OS did not differ between the three higher radiation doses (39.6-44.9 vs. 45-49.9 Gy vs. ≥ 50 Gy; pCR [p = 0.1] vs. OS [p = 0.097]). The patients who received 39.6-44.9 Gy were propensity matched with those who received 45 Gy or more of radiation. There remained no difference in pCR (p = 0.375) or OS (p = 0.957). CONCLUSIONS In the United States, the heterogeneity in neoadjuvant CRT dosing is significant, with 84% of patients receiving more than 45 Gy. The benefit of neoadjuvant CRT in terms of pCR and overall survival is seen with doses of 39.6 Gy or more, but not with doses higher than 45 Gy.
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Affiliation(s)
- Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jennifer A Dorth
- Division of Radiation Oncology, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Mitchell Machtay
- Division of Radiation Oncology, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Yaron Perry
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
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10
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Teng A, Nguyen T, Bilchik AJ, O'Connor V, Lee DY. Implications of Prolonged Time to Pancreaticoduodenectomy After Neoadjuvant Chemoradiation. J Surg Res 2019; 245:51-56. [PMID: 31401247 DOI: 10.1016/j.jss.2019.07.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/20/2019] [Accepted: 07/12/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND For patients with pancreatic adenocarcinoma (PA), the optimal time interval between neoadjuvant chemoradiation (CR) to surgical resection has not been well established. METHODS The National Cancer Database from 2006 to 2014 was queried for patients ≥18 y old diagnosed with PA who received neoadjuvant CR. Survival and short-term outcomes were compared between patients who had pancreaticoduodenectomy ≤12 wk and >12 wk after completion of CR. RESULTS 1610 patients met selection criteria. Average radiation to surgery (RS) interval was 58.2 ± 39.5 d. 1419 patients had RS interval ≤12 wk (mean 47.4 d) and 191 had RS interval >12 wk (mean 138.8 d). Demographics, CA 19-9 levels, types of chemotherapy and radiation dosage were similar between the two groups. There were more patients with clinical stage III cancers in the >12 wk group than in the ≤12 wk group (33.5% versus 14%). Short-term outcomes were similar between the two groups. However, a long-term survival benefit was observed in the >12 wk group (median 25.8 versus 30.2 mo P = 0.049). An interval >12 wk was associated with significantly prolonged survival on multivariate analysis (HR: 0.80, 95% CI: 0.65-0.99; P = 0.042). Higher clinical stage and positive surgical margins were independently associated with worse survival. CONCLUSIONS Surgical resection beyond 12 wk after CR for PA did not worsen short-term outcomes. Waiting may contribute to better patient selection, especially those with locally advanced tumors. In the absence of progressive disease, patients need to be continuously evaluated for surgical resection after CR.
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Affiliation(s)
- Annabelle Teng
- Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St. John's Health Center, Santa Monica, California
| | - Trang Nguyen
- Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St. John's Health Center, Santa Monica, California
| | - Anton J Bilchik
- Department of Surgical Oncology, The John Wayne Cancer Institute at Providence St. John's Health Center, Santa Monica, California
| | - Victoria O'Connor
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - David Y Lee
- Division of Surgical Oncology, Trihealth Cancer Institute, Cincinnati, Ohio.
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11
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Andreollo NA, Beraldo GDC, Alves IPF, Tercioti-Junior V, Ferrer JAP, Coelho-Neto JDS, Lopes LR. PATHOLOGIC COMPLETE RESPONSE (YPT0 YPN0) AFTER CHEMOTHERAPY AND RADIOTHERAPY NEOADJUVANT FOLLOWED BY ESOPHAGECTOMY IN THE SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS. ACTA ACUST UNITED AC 2018; 31:e1405. [PMID: 30539980 PMCID: PMC6284395 DOI: 10.1590/0102-672020180001e1405] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 08/24/2018] [Indexed: 12/29/2022]
Abstract
Background: Esophageal squamous cell carcinoma is an aggressive neoplasia that requires a multidisciplinary treatment in which survival and prognosis are still not satisfactory. The complete pathologic response to neoadjuvant chemotherapy and radiotherapy is considered a good prognosis factor, and esophagectomy is indicated. Aim: Survival analysis of cases with pathologic complete response (ypT0 ypN0) to neoadjuvant chemotherapy and/or radiotherapy, submmitted to esophagectomy. Methods: Between 1983-2014, 222 esophagectomies were performed, and 177 were conducted to neoadjuvant treatment. In 34 patients the pathologic response was considered complete. Medical records of the patients were retrospectively reviewed regarding type of chemotherapy applied, amount of radiotherapy, interval between the neoadjuvant therapy and the surgery, body mass index; postoperative complications; hospital admission time and survival. Results: The average age was 55.8 years. Twenty-five patients were subjected to chemotherapy and radiotherapy, and nine to neoadjuvant radiotherapy. The total radiation dose ranged from 4400 until 5400 cGy. The chemotherapy was performed with 5FU, cisplatin, and carbotaxol, concomitantly with the radiotherapy. The esophagectomy was transmediastinal, followed by the cervical esophagogastroplasty performed on a average of 49.4 days after the neoadjuvant therapy. The hospital admission time was an average of 14.8 days. During the follow-up period, 52% of the patients submitted to radiotherapy and chemotherapy were disease-free, with 23.6% of them presenting more than five years survival. Conclusions: The neoadjuvant treatment followed by esophagectomy in patients with pathologic complete response is beneficial for the survival of patients with esophageal squamous cell carcinoma.
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Affiliation(s)
- Nelson Adami Andreollo
- Digestive Diseases Surgical Unit and Gastrocenter, Department of Surgery, School of Medical Sciences, State University of Campinas - UNICAMP , Campinas, SP, Brazil
| | - Giovanni de Carvalho Beraldo
- Digestive Diseases Surgical Unit and Gastrocenter, Department of Surgery, School of Medical Sciences, State University of Campinas - UNICAMP , Campinas, SP, Brazil
| | - Iuri Pedreira Filardi Alves
- Digestive Diseases Surgical Unit and Gastrocenter, Department of Surgery, School of Medical Sciences, State University of Campinas - UNICAMP , Campinas, SP, Brazil
| | - Valdir Tercioti-Junior
- Digestive Diseases Surgical Unit and Gastrocenter, Department of Surgery, School of Medical Sciences, State University of Campinas - UNICAMP , Campinas, SP, Brazil
| | - José Antonio Possato Ferrer
- Digestive Diseases Surgical Unit and Gastrocenter, Department of Surgery, School of Medical Sciences, State University of Campinas - UNICAMP , Campinas, SP, Brazil
| | - João de Souza Coelho-Neto
- Digestive Diseases Surgical Unit and Gastrocenter, Department of Surgery, School of Medical Sciences, State University of Campinas - UNICAMP , Campinas, SP, Brazil
| | - Luiz Roberto Lopes
- Digestive Diseases Surgical Unit and Gastrocenter, Department of Surgery, School of Medical Sciences, State University of Campinas - UNICAMP , Campinas, SP, Brazil
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