Gross tumor volume is the prognostic factor for squamous cell esophageal cancer patients treated with definitive radiotherapy

A CT-based novel model to predict pathological complete response of locally advanced esophageal squamous cell carcinoma to neoadjuvant PD-1 blockade in combination with chemotherapy

PURPOSE

To develop a novel CT-based model to predict pathological complete response (pCR) of locally advanced esophageal squamous cell carcinoma (ESCC) to neoadjuvant PD-1 blockade in combination with chemotherapy.

METHODS

117 consecutive patients with locally advanced ESCC were stratified into training cohort (n = 82) and validation cohort (n = 35). All patients underwent non-contrast and contrast-enhanced thoracic and upper abdominal CT before neoadjuvant PD-1 blockade in combination with chemotherapy (CTpre), and after two cycles of the therapy before esophagectomy (CTpost), respectively. Univariate analyses and binary logistic regression analyses of ESCC quantitative and qualitative CT features were performed to determine independent predictors of pCR. Prediction performance of the model developed with independent predictors from training cohort was evaluated by receiver operating characteristic (ROC) analysis, and validated by Kappa test in validation cohort.

RESULTS

In training cohort, the difference in CT attenuation between tumor and background normal esophageal wall obtained from CTpre (ΔTNpre), tumoral increased CT attenuation after contrast-enhanced scan from CTpost images (ΔTpost) and gross tumor volume (GTV) from CTpre were independent predictors of pCR (odds ratio = 1.128 (95% confidence interval (CI): 0.997-1.277), 1.113 (95%CI: 0.965-1.239) and 1.133 (95%CI: 1.043-1.231), respectively, all P-values < 0.05). Logistic regression model equation (0.121 × ΔTNpre + 0.107 × ΔTpost + 0.125 × GTV - 9.856) to predict pCR showed the best performance with an area under the ROC of 0.876, compared with each independent predictor. The good performance was confirmed by the Kappa test (K-value = 0.796) in validation cohort.

CONCLUSIONS

This novel model can be reliable to predict pCR to neoadjuvant PD-1 blockade in combination with chemotherapy in locally advanced ESCC.

A preoperative prediction of lymph node metastasis in early cervical squamous cell cancer with hematologica - based model

Background: This study aimed to construct a preoperative model predicting lymph node metastasis (LNM) in IB1-IIA2 stage cervical squamous cell cancer (CSCC) based on hematological indexes. Merhods: Between February 2011 and February 2022, 463 patients with IB1-IIA2 stage CSCC underwent radical resection. Patients were allocated to either a model-development cohort (n=337) or a validation cohort (n=126). The final model was determined by comparing different methods of variable selection, and then its discrimination and calibration metrics were evaluated. A predicted probability of LNM < 5% was defined as low risk. ROC curves were used to define high risk. Results: Age, lactate dehydrogenase level, FIGO stage, squamous cell carcinoma antigen, cancer antigen 125, and cancer antigen 199 were identified as critical factors for the construction of the model. The model demonstrated good discrimination and calibration (concordance index, 0.761; 95% confidence interval, 0.666-0.884). In the validation cohort the discrimination accuracy was 0.821 (95% confidence interval, 0.714 - 0.927). In the model-development cohort, 11.9% were classified as low risk with a negative predictive value of 95.0%, and 24.9% were classified as high risk with a positive predictive value of 39.3%. Conclusion: A predictive model was developed and validated for LNM in IB1-IIA2 stage CSCC. The model will assist physicians in appraising the risk of LNM in preoperative patients and could aid in patient counseling and individualized clinical decision-making.

Complete response to definitive chemoradiotherapy in unresectable locally advanced esophageal squamous cell carcinoma

BACKGROUND

Although definitive chemoradiotherapy (CRT) is the standard therapy for patients with unresectable locally advanced esophageal squamous cell carcinoma (ESCC), poor survival has been reported. Although the complete response (CR) rate is strongly correlated with good prognosis, the predictive factors for CR have not been elucidated.

METHODS

This registry study aimed to identify predictors of CR to definitive CRT in patients with unresectable locally advanced ESCC. "Unresectable" was defined as the primary lesion invading unresectable adjacent structures such as the aorta, vertebral body, and trachea (T4b), or the regional and/or supraclavicular lymph nodes invading unresectable adjacent structures (LNT4b).

RESULTS

Overall, 175 patients who started definitive CRT between January 2013 and March 2020 were included. The confirmed CR (cCR) rate was 24% (42/175). The 2-year progression-free survival (PFS) and overall survival (OS) rates of cCR cases vs. non-cCR cases were 59% vs. 2% (log-rank p < 0.001) and 90% vs. 31% (log-rank p < 0.001), with a median follow-up period of 18.5 and 40.5 months, respectively. Multivariate analysis of clinicopathological factors revealed that tumor length ≥ 6 cm [odds ratio (OR) 0.446; 95% CI 0.220-0.905; p = 0.025] was a predictor of cCR.

CONCLUSIONS

Favorable PFS and OS rates were observed in patients with cCR. Tumor length was a predictive factor for cCR.

Esophageal stenosis as an independent factor of poor prognosis in patients with ESCC treated with definitive chemoradiotherapy

Aim: To evaluate the clinical outcome and elucidate the prognostic factors in patients with esophageal squamous cell carcinoma (ESCC) treated with definitive chemoradiotherapy (CRT). Patients: Data for patients newly diagnosed with ESCC receiving definitive CRT at our institution between 2012 and 2018 were retrospectively reviewed. Results: A total of 201 patients were included. Severe stenosis after radiotherapy was an independent factor relevant to prognosis. Maximal esophageal wall thickness, short-term responses, severe stenosis at diagnosis and a high neutrophil-to-lymphocyte ratio were independent risk factors for the occurrence of severe stenosis after radiotherapy. Conclusion: Severe stenosis after radiotherapy is a useful predictive indicator in patients with ESCC receiving definitive CRT. Further studies are needed to verify these findings.

Prognostic values of the gross volume of metastatic lymph nodes in patients with esophageal squamous cell carcinoma treated with definitive concurrent chemoradiotherapy

Purpose

We aim to explore whether the gross volume of metastatic lymph nodes (GTVnd) and the gross volume of primary tumor (GTVp) could be prognostic factors for esophageal squamous cell carcinoma (ESCC) patients treated with definitive concurrent chemoradiotherapy (dCCRT).

Methods

We retrospectively analyzed 252 ESCC patients treated with dCCRT in the era of intensity-modulated radiation therapy (IMRT) at our institution. The cut-off value for the GTVnd derived from the restricted cubic splines (RCS) was determined. Univariate and multivariate Cox proportional hazard models were performed to determine the association between GTVnd and prognosis. we performed recursive partitioning analysis (RPA) method using GTVnd to develop a new risk stratification (TGTVndM). Moreover, the linear trend χ2, likelihood ratio χ2, and akaike information criterion (AIC) were used to determine the prognostic value between the TNM and TGTVndM staging systems.

Results

The five-year overall survival (OS) rate was 30.6%, with a median follow-up of 38 months. The cut-off value of GTVnd determined by the RCS was 4.35 cm3. GTVnd≥4.35 cm3 was an independent and significant negative prognostic factor for OS (HR=1.949, P&lt;0.001), progression free survival (PFS) (HR=1.425, P=0.048), and distance metastasis free survival (DMFS) (HR=2.548, P=0.001). In multivariable analysis, gender, clinical T stage, and GTVnd were independently associated with OS. RPA segregated patients into 3 prognostic groups: high risk (T1-4 GTVnd≥4.35, n=126, III stage), intermediate risk (T4 GTVnd&lt;4.35,n=38,II stage), and low risk(T1-3GTVnd&lt;4.35, n=88, I stage). The 5-year OS(P&lt;0.001), PFS (P=0.002), and DMFS (P=0.001) were significantly worse in high-risk group in comparison with the intermediate and low risk groups. Compared with the TNM staging system, the clinical T stage combined with GTVnd (TGTVndM) had a higher linear trend χ2 (26.38 versus 25.77), higher likelihood ratio χ2 (24.39 versus 20.69), and lower AIC (1255.07 versus 1260.06).

Conclusions

GTVnd may serve as a good prognostic factor in predicting distant metastasis and death for ESCC patients treated with dCCRT. The TGTVndM staging system demonstrated superior accuracy for predicting OS and could serve as a more effective prognostic guidance for unresectable ESCC patients.

Dose escalation based on 18F-FDG PET/CT response in definitive chemoradiotherapy of locally advanced esophageal squamous cell carcinoma: a phase III, open-label, randomized, controlled trial (ESO-Shanghai 12)

INTRODUCTION

Definitive chemoradiotherapy has established the standard non-surgical treatment for locally advanced esophageal cancer. The standard dose of 50-50.4 Gy has been established decades ago and been confirmed in modern trials. The theorical advantage of better local control and technical advances for less toxicity have encouraged clinicians for dose escalation investigation. ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) have the potential to tailor therapy for esophageal patients not showing response to CRT and pioneers the PET-based dose escalation.

METHODS AND ANALYSIS

The ESO-Shanghai 12 trial is a prospective multicenter randomized phase 3 study in which patients are randomized to either 61.2 Gy or 50.4 Gy of radiation dose by PET response. Both groups undergo concurrent chemoradiotherapy with paclitaxel/cisplatin regimen for 2 cycles followed by consolidation chemotherapy for 2 cycles. Patients with histologically confirmed ESCC [T1N1-3M0, T2-4NxM0, TxNxM1 (Supraclavicular lymph node metastasis only), (AJCC Cancer Staging Manual, 8th Edition)] and without any prior treatment of chemotherapy, radiotherapy or surgery against esophageal cancer will be eligible. The primary endpoints included overall survival in PET/CT non-responders (SUV_max > 4.0) and overall survival in total population. Patients will be stratified by standardized uptake volume, gross tumor volume and tumor location. The enrollment could be ended, when the number of PET/CT non-responder reached 132 and the total population reached 646 for randomization.

ETHICS AND DISSEMINATION

This trial has been approved by the Fudan University Shanghai Cancer Center Institutional Review Board. Trial results will be disseminated via peer reviewed scientific journals and conference presentations. Trial registration The trial was initiated in 2018 and is currently recruiting patients. Trial registration number NCT03790553.

Impact of Blood Parameters and Normal Tissue Dose on Treatment Outcome in Esophageal Cancer Patients Undergoing Neoadjuvant Radiochemotherapy

Despite technological advances, normal tissue sparing in photon beam irradiation is still challenging. Since in esophageal cancer this may inflict damage on the lungs, heart and bone marrow, possibly impacting on outcome, the aim of this study was to investigate the association of normal tissue dose and blood parameters on the survival of patients having undergone neoadjuvant radiochemotherapy (RCTx) followed by surgery. This retrospective study included 125 patients irradiated to 40−41.4 Gy with photons or protons combined with concurrent chemotherapy. On initial and restaging 18F-FDG-PET/CT, the lungs and heart were contoured as organs at risk for which standardized uptake values (SUV) were evaluated. The mean radiation dose (Dmean) to the lungs and heart, the volume of the lungs receiving at least 20 Gy (V20Gy_lung) and various pre- and per-treatment blood parameters were included in the Cox regression analyses. Results: The median follow-up time was 19.8 months and median overall survival 37 months (95% confidence interval: 16−58.9 months). In multivariate analysis, higher radiation doses to the lungs and heart were statistically significantly associated with decreased overall survival (Dmean_lung: p < 0.001; V20Gy_lung: p < 0.002; Dmean_heart: p = 0.005). Neither the 18F-FDG-PET nor blood parameters were predictive for overall survival. In patients with locally advanced esophageal cancer treated with RCTx, the radiation dose to the heart and lungs was significantly associated with overall survival.

Significance of intratreatment tumor volume change during chemoradiotherapy for potentially resectable thoracic esophageal squamous cell carcinoma

OBJECTIVE

The purpose of this study was to investigate the clinical significance of tumor response assessment at a twentieth fraction of radiotherapy when predicting the survival of patients with potentially resectable esophageal squamous cell carcinoma (ESCC).

METHODS

A total of 123 ESCC patients with clinical stages II to IV_a were enrolled and analyzed. Gross tumor volume (GTV) of the esophagus (GTV_e) and GTV of the metastatic lymph node (GTV_nd) were manually contoured by at least 2 senior professional radiotherapists on the simulated computed tomography (CT) images in a process that followed the delineating rules for ESCC.

RESULTS

The GTV_e reduction ratio (RR) and GTV_nd RR were calculated based on the evaluation of the tumor volume at a twentieth fraction of radiotherapy. Univariate analysis showed that GTV_e and GTV_nd before treatment, and GTV_e RR and GTV_nd RR at the twentieth fraction of radiotherapy were all significantly associated with complete clinical response (cCR) and overall survival (OS). The Kaplan-Meier method was used to estimate OS and locoregional recurrence-free survival (LRRFS).

CONCLUSIONS

The GTV_e RR ≥27.92% and GTV_nd RR ≥21.49% at a twentieth fraction of radiotherapy are positive predictive factors of LRRFS, and according to multivariate analysis, only GTV_e RR at the twentieth fraction of radiotherapy ≥27.92% is prognostic for a favorable OS.

A Radiomics Nomogram for Non-Invasive Prediction of Progression-Free Survival in Esophageal Squamous Cell Carcinoma

To construct a prognostic model for preoperative prediction on computed tomography (CT) images of esophageal squamous cell carcinoma (ESCC), we created radiomics signature with high throughput radiomics features extracted from CT images of 272 patients (204 in training and 68 in validation cohort). Multivariable logistic regression was applied to build the radiomics signature and the predictive nomogram model, which was composed of radiomics signature, traditional TNM stage, and clinical features. A total of 21 radiomics features were selected from 954 to build a radiomics signature which was significantly associated with progression-free survival (p &lt; 0.001). The area under the curve of performance was 0.878 (95% CI: 0.831–0.924) for the training cohort and 0.857 (95% CI: 0.767–0.947) for the validation cohort. The radscore of signatures' combination showed significant discrimination for survival status. Radiomics nomogram combined radscore with TNM staging and showed considerable improvement over TNM staging alone in the training cohort (C-index, 0.770 vs. 0.603; p &lt; 0.05), and it is the same with clinical data (C-index, 0.792 vs. 0.680; p &lt; 0.05), which were confirmed in the validation cohort. Decision curve analysis showed that the model would receive a benefit when the threshold probability was between 0 and 0.9. Collectively, multiparametric CT-based radiomics nomograms provided improved prognostic ability in ESCC.

Gross Tumor Volume Definition and Comparative Assessment for Esophageal Squamous Cell Carcinoma From 3D 18F-FDG PET/CT by Deep Learning-Based Method

Background

The accurate definition of gross tumor volume (GTV) of esophageal squamous cell carcinoma (ESCC) can promote precise irradiation field determination, and further achieve the radiotherapy curative effect. This retrospective study is intended to assess the applicability of leveraging deep learning-based method to automatically define the GTV from 3D 18F-FDG PET/CT images of patients diagnosed with ESCC.

Methods

We perform experiments on a clinical cohort with 164 18F-FDG PET/CT scans. The state-of-the-art esophageal GTV segmentation deep neural net is first employed to delineate the lesion area on PET/CT images. Afterwards, we propose a novel equivalent truncated elliptical cone integral method (ETECIM) to estimate the GTV value. Indexes of Dice similarity coefficient (DSC), Hausdorff distance (HD), and mean surface distance (MSD) are used to evaluate the segmentation performance. Conformity index (CI), degree of inclusion (DI), and motion vector (MV) are used to assess the differences between predicted and ground truth tumors. Statistical differences in the GTV, DI, and position are also determined.

Results

We perform 4-fold cross-validation for evaluation, reporting the values of DSC, HD, and MSD as 0.72 ± 0.02, 11.87 ± 4.20 mm, and 2.43 ± 0.60 mm (mean ± standard deviation), respectively. Pearson correlations (R2) achieve 0.8434, 0.8004, 0.9239, and 0.7119 for each fold cross-validation, and there is no significant difference (t = 1.193, p = 0.235) between the predicted and ground truth GTVs. For DI, a significant difference is found (t = −2.263, p = 0.009). For position assessment, there is no significant difference (left-right in x direction: t = 0.102, p = 0.919, anterior–posterior in y direction: t = 0.221, p = 0.826, and cranial–caudal in z direction: t = 0.569, p = 0.570) between the predicted and ground truth GTVs. The median of CI is 0.63, and the gotten MV is small.

Conclusions

The predicted tumors correspond well with the manual ground truth. The proposed GTV estimation approach ETECIM is more precise than the most commonly used voxel volume summation method. The ground truth GTVs can be solved out due to the good linear correlation with the predicted results. Deep learning-based method shows its promising in GTV definition and clinical radiotherapy application.

Primary gross tumor volume is prognostic and suggests treatment in upper esophageal cancer

Background

To aid clinicians strategizing treatment for upper esophageal squamous cell carcinoma (ESCC), this retrospective study investigated associations between primary gross tumor volume (GTVp) and prognosis in patients given surgical resection, radiotherapy, or both resection and radiotherapy.

Methods

The population comprised 568 patients with upper ESCC given definitive treatment, including 238, 216, and 114 who underwent surgery, radiotherapy, or combined radiotherapy and surgery. GTVp as a continuous variable was entered into the multivariate Cox model using penalized splines (P-splines) to determine the optimal cutoff value. Propensity score matching (PSM) was used to adjust imbalanced characteristics among the treatment groups.

Results

P-spline regression revealed a dependence of patient outcomes on GTVp, with 30 cm³ being an optimal cut-off for differences in overall and progression-free survival (OS, PFS). GTVp ≥30 cm³ was a negative independent prognostic factor for OS and PFS. PSM analyses confirmed the prognostic value of GTVp. For GTVp < 30 cm³, no significant survival differences were observed among the 3 treatments. For GTVp ≥30 cm³, the worst 5-year OS rate was experienced by those given surgery. The 5-year PFS rate of patients given combined radiotherapy and surgery was significantly better than that of patients given radiotherapy. The surgical complications of patients given the combined treatment were comparable to those who received surgery, but radiation side effects were significantly lower.

Conclusion

GTVp is prognostic for OS and PFS in upper ESCC. For patients with GTVp ≥30 cm³, radiotherapy plus surgery was more effective than either treatment alone.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08838-w.

The Predictive Value of Tumor Volume and Its Change on Short-Term Outcome for Esophageal Squamous Cell Carcinoma Treated With Radiotherapy or Chemoradiotherapy

Objectives

To investigate the tumor volume and its change on short-term outcome in esophageal squamous cell carcinoma (ESCC) patients who underwent definitive radiotherapy or chemoradiotherapy.

Methods and Materials

All data were retrospectively collected from 418 ESCC patients who received radiotherapy or chemoradiotherapy at our institution between 2015 and 2019. Short-term outcome using the treatment response evaluation was assessed according to the RECIST 1.1. The tumor volume change rate (TVCR) was defined as follows: TVCR = {1 - [gross tumor volume (GTV) at shrinking irradiation field planning)]/(GTV at the initial treatment planning)} ×100%. Chi square test was used to compare the clinic characteristics in different TVCR groups, and the difference between initial GTV (GTVi) and shrinking GTV (GTVs) was compared using Wilcoxon's sign rank test. Logistic regression analysis and Spearman correlation was performed.

Results

There was a significant decrease in GTVi compared to GTVs (P < 0.001). In univariate analysis, age, cT-stage, TNM stage, treatment modality, GTVi, and TVCR were associated with short-term outcome (all P < 0.05). In multivariate analysis, gender and TVCR were statistically significant (P = 0.010, <0.001) with short-term outcome, and the combined predictive value of gender and TVCR exceeded that of TVCR (AUC, 0.876 vs 0.855).

Conclusions

TVCR could serve to forecast short-term outcome of radiotherapy or chemoradiotherapy in ESCC. It was of great significance to guide the individualized treatment of ESCC.

Prognostic Value of CT Imaging-Based Tumor Volume in Patients With Non-Surgical Esophageal Squamous Cell Carcinoma

BACKGROUND

The American Joint Committee on Cancer-Tumor (AJCC-T) staging system for esophageal carcinoma patients, which is based on the depth of tumor invasion, is not applicable in some cases. This study aims to assess the prognostic value of CT imaging-based tumor volume and its usefulness for T staging in patients with non-surgical esophageal squamous cell carcinoma (ESCC).

METHODS

We retrospectively reviewed the records of 158 ESCC patients undergoing definitive (chemo) radiotherapy from two hospitals. Tumor volume based on the CT imaging was calculated using the formula: V = πabc / 6. Three cutoff points for tumor volume were obtained with the X-tile software. Overall survival (OS) was analyzed using the Kaplan-Meier method. The -2 log-likelihood ratio and Akaike Information Criterion (AIC) value were evaluated to compare the AJCC-T staging system with the proposed T staging method.

RESULTS

The median tumor volume was 19.8 cm³ (range from 1.0 to 319.5 cm³). The three optimal cutoff points of tumor volume were 12.7, 22.8, and 51.9 cm³, and the patients were divided into four groups named as proposed T1-T4 stages. The 3-year OS rates in patients with proposed T1 to T4 stages were 67.9%, 30.6%, 21.3%, and 5.3%, respectively. The -2 log-likelihood ratios of the AJCC-T stage and proposed T stage were 1,068.060 and 1,047.418, respectively. The difference in the AIC value between the two T staging systems was 18.642.

CONCLUSION

CT imaging-based tumor volume was superior to the depth of tumor invasion for T staging in predicting the prognosis of non-surgical ESCC patient.

Stage III Esophageal Squamous Cell Carcinoma Patients With Three-Dimensional Conformal or Intensity-Modulated Radiotherapy: A Multicenter Retrospective Study

Aim: To evaluate long-term outcome and prognostic factors of stage III esophageal cancer after definitive radiotherapy using three dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT) techniques.

Methods: Patients with T3N1M0/T4N0-1M0 esophageal squamous cell carcinoma (ESCC) treated with definitive radiotherapy from 2002 to 2016 in 10 Chinese medical centers were retrospectively analyzed. Overall survival (OS) and progression-free survival (PFS) rates were calculated. Prognostic factors were analyzed by Log-rank test and multivariable Cox model.

Results: Survival data of 1,450 patients were retrospectively collected. With a median follow-up time of 65.9 months, 1-, 3-, and 5-year OS rates were 69.3, 36.7, and 27.7%, respectively, and PFS rates were 58.6, 32.7, and 27.4%, respectively. Univariable analyses showed that gender, age, lesion location, lesion length, largest tumor diameter, lymph node metastasis, gross tumor volume, EQD2, short-term response, and concurrent chemotherapy were prognostic factors for OS. Multivariable analyses showed that lesion location, T-classification, GTV size, EQD2, and short-term response to RT were independent prognostic factors for OS, and tumor diameter, GTV size, and short-term response were independent prognostic factors for PFS.

Conclusions: This study demonstrated that definitive radiotherapy using 3DCRT and IMRT provides promising outcomes for locally advanced ESCC.

Analysis of influencing factors of no/low response to preoperative concurrent chemoradiotherapy in locally advanced rectal cancer

The aim of this study is to investigate the influencing factors associated with no/low response to preoperative concurrent chemoradiotherapy (CCRT) for locally advanced rectal cancer (LARC) patients. A total of 79 patients were included in this prospective study. Fifteen factors that might affect the resistance to CCRT were included in this logistic regression analysis, these factors include the general clinical data of patients, the expression status of tumor stem cell marker CD44v6 and the volumetric imaging parameters of primary tumor lesions. We found that the no/low response status to preoperative CCRT was positively correlated with the real tumor volume (RTV), the total surface area of tumor (TSA), and CD44v6 expression, whereas negatively correlated with the tumor compactness (TC). According to the results of logistic regression analysis, two formulas that could predict whether or not no/low response to preoperative CCRT were established. The Area Under Curve (AUC) of the two formulas and those significant measurement data (RTV, TC, TSA) were 0.900, 0.858, 0.771, 0.754, 0.859, the sensitivity were 95.8%, 79.17%, 62.50%, 95.83%, 62.5%, the specificity were 70.9%, 74.55%, 83.64%,47.27%, 96.36%, the positive predictive values were 58.96%, 57.58%, 62.51%,44.23%, 88.23%, the negative predictive values were 97.48%, 89.13%, 83.64%, 96.29%, and 85.48%, respectively.

The Prognostic Significance of Metastatic Nodal Size in Non-surgical Patients With Esophageal Squamous Cell Carcinoma

Background: The present study aimed to determine the prognostic value of the size of metastatic lymph node (LN) in non-surgical patients with esophageal squamous cell carcinoma (ESCC).

Methods: Three hundred seventy-six ESCC patients treated with definitive (chemo-) radiotherapy from January 2013 to March 2016 were reviewed. We analyzed potential associations of metastatic nodal size with responses, patterns of failure, and survival. Log-rank testing and Cox proportional hazards regression models were used to assess the impact of the clinical factors on survival.

Results: The 3-years over survival (OS) rates following a median follow-up of 28.2 months were 53.2, 46.2, 35.5, and 22.7% for the N0 group, the >0.5 to ≤1 cm group, the >1 to ≤2 cm group, and the >2 cm group, respectively. The progression-free survival (PFS) rates for 2 years were 50.9, 44.2, 26.6, and 23.4% for the N0 group, the >0.5 to ≤1 cm group, the >1 to ≤2 cm group, and the >2 cm group, respectively. The objective response rates (ORR) for the 280 patients with metastatic LNs were 43.1% for the LN >0.5 to ≤1 cm group, 46.9% for the LN >1 to ≤2 cm group, and 25.5% for the LN ≥2 cm group. The LN >2 cm group had the worst ORR of the three groups with LNs. Gross tumor volume (GTV) failure was the most common failure pattern, followed by distant failure and out of GTV LN failure, with incidences of 47.9% (180 of 376), 42% (158 of 376), and 13.8% (52 of 376), respectively. Nodal size correlated statistically with GTV failure and distant failure but not with out-of-GTV nodal failure. After adjusting for age, sex, T category, Primary tumor location, and CRT, the size of metastatic LNs was an independent prognostic factor for OS and PFS in multivariate analyses.

Conclusions: Nodal size is one of prognostic factors for non-surgical patients with ESCC and correlated statistically with GTV failure and distant failure.

Sex-related differences in primary metastatic site in rectal cancer; associated with hemodynamic factors?

BACKGROUND AND PURPOSE

We investigated how features relating to pelvic cavity anatomy and tumor hemodynamic factors may influence systemic failure in rectal cancer.

MATERIALS AND METHODS

Rectal cancer patients (207 women, 343 men), who had been prospectively enrolled onto six cohorts and given curative-intent therapy, were analyzed for the first metastatic event. In one of the cohorts, the diameter of the inferior mesenteric vein (IMV) was assessed on diagnostic abdominal computed tomography images (n = 113). Tumor volume (n = 193) and histologic response to neoadjuvant therapy (n = 445) were recorded from diagnostic magnetic resonance images and surgical specimens, respectively.

RESULTS

More women than men developed lung metastasis (p = 0.037), while the opposite was the case for liver metastasis (p = 0.040). Wider IMV diameter correlated with larger tumor volume (r = 0.481, p < 0.001) and male sex (p < 0.001). Female sex was the only adverse prognostic factor for lung metastasis. When sex, tumor volume, and histologic response were taken into consideration, poor tumor response remained the only determinant for liver metastasis (p = 0.002).

CONCLUSIONS

In a diverse rectal cancer population given curative-intent treatment, women and men had different outcome with regard to the primary metastatic site. Tumor hemodynamic factors should be considered in rectal cancer risk stratification.

Intratreatment Tumor Volume Change During Definitive Chemoradiotherapy is Predictive for Treatment Outcome of Patients with Esophageal Carcinoma

BACKGROUND

This study aimed to assess the predictive value of tumor volume changes of esophagus evaluated by serial computed tomography (CT) scans before, during, and after radical chemoradiotherapy (CRT) for treatment outcomes in patients with esophageal cancer (EC).

METHODS

Fifty-three patients with histologically confirmed EC were included for analysis. Gross tumor volume of esophagus (GTVe) was manually contoured on the CT images before treatment, at a twentieth fraction of radiotherapy, at completion of CRT and three months after treatment. GTVe reduction ratio (RR) was calculated to reveal changes of tumor volume by time. The Kaplan-Meier method was used to estimate survival and for univariate analysis. The Cox regression model was performed for multivariate analysis.

RESULTS

Predominant reduction of GTVe was observed during the first 20 fractions of radiotherapy. Age, pretreatment GTVe, GTVe three months after treatment and GTVe RR at twentieth fraction of radiotherapy were all significantly associated with overall survival (OS) in a univariate analysis. Gender was correlated with locoregional recurrence-free survival (LRRFS) in univariate analysis. Multivariate analysis showed that GTVe ≤20 cc, GTVe RR at twentieth fraction of radiotherapy ≥35% were positive predictive factors of OS and pretreatment GTVe ≤20 cc was prognostic for a favorable LRRFS.

CONCLUSION

Pretreatment tumor volume and intratreatment volume reduction ratio are reliable prognostic factors for esophageal cancer treated with definitive CRT.

Volumetric imaging parameters are significant for predicting the pathological complete response of preoperative concurrent chemoradiotherapy in local advanced rectal cancer

Preoperative concurrent chemoradiotherapy (CCRT) as the standard treatment for locally advanced rectal cancer (LARC) has been widely used in clinic. Its efficiency influences the prognosis and the selection of subsequent treatment. The current criteria for evaluating the prognosis of patients with extremely sensitive preoperative CCRT include the clinical complete remission response (cCR) and pathological complete response (pCR), but those with cCR may not necessarily achieve pCR, and the pCR can be confirmed only after surgery. Some scholars believe that patients with pCR after CCRT can be categorized as 'watch and wait'. Therefore, it is extremely important to find a way to predict the pCR status of patients before therapy. In this study, we examined the expression of stem cell markers and obtained direct and derivative volumetric imaging parameters before treatment. Subsequently, these factors and the general clinical data were adopted into a regression model, and the correlation between them and the pCR was analyzed. We found that the pCR of LARC was positively correlated with tumor compactness (TC), whereas it was negatively correlated with approximate tumor volume (ATV), real tumor volume (RTV), total surface area of the tumor (TSA) and tumor maximum longitudinal length (TML). In these meaningful predictors, the positive predictive values and the negative predictive values of TC were 74.73% and 94.61%, respectively. Compared with other possible predictors, TC is the most encouraging predictor of pCR. Our findings provide a way for clinicians to predict the sensitivity of preoperative CCRT and will help to select individualized treatment options for LARC patients.

The long-term impact of tumor burden in pT3N0M0 esophageal squamous cell carcinoma: A propensity score-matched analysis

The purpose of this study was to assess the impact of tumor burden on the survival of patients with pathologic T3N0M0 (pT3N0M0) esophageal squamous cell carcinoma (ESCC).A total of 84 patients with pathologic T3N0M0 ESCC treated with radical esophagectomy and 3-field lymphadenectomy (3-FL) from January 2008 to December 2009 in our center were analyzed. Receiver-operating characteristic (ROC) curve analysis was performed to calculate the optimal cutoff value. The Kaplan-Meier method and log-rank test were used to assess the overall survival (OS) differences between groups. A regression model was applied to identify prognostic factors for OS. Propensity score matching (PSM) was performed to adjust for the imbalance and indication biases in the 2 groups.The median follow-up time was 62 months (range, 1-84 months), and the 5-year OS rate was 62% (95% confidence interval, 52.2-71.8%). According to the ROC curve analysis, the optimal cutoff values for the maximal esophageal wall thickness, tumor length, and tumor volume were 1.3 cm, 5.9 cm, and 18.6 cc, respectively. Univariate analysis revealed that maximal esophageal wall thickness >1.3 cm (P = .014), tumor volume >18.6 cc (P < .001), and vascular invasion (P < .001) were significantly associated with OS. The multivariate Cox regression model identified tumor volume and vascular invasion as factors affecting OS. After propensity matching, patients with a tumor volume ≤18.6 cc had a better OS than those with a tumor volume >18.6 cc (5-year OS, 85% vs 50%, P = .008).Tumor volume may serve as a good prognostic factor for patients with pT3N0M0 ESCC treated with radical esophagectomy and 3-FL. Larger-scale studies are warranted to validate these findings.

Tumor Compactness based on CT to predict prognosis after multimodal treatment for esophageal squamous cell carcinoma

We aimed to establish a risk model using computed tomography-based compactness to predict overall survival (OS) and progression-free survival (PFS) after multimodal treatment for esophageal squamous cell carcinoma (ESCC). We extracted pre-treatment computed tomography-based tumor data (volume, surface area, and compactness) for 512 cases of ESCC that were treated at 3 centers. A risk model based on compactness was trained using Cox regression analyses of data from 83 cases, and then the model was validated using two independent cohorts (98 patients and 283 patients). The largest cohort (283 patients) was then evaluated using the risk model to predict response to radiotherapy with or without chemotherapy. In the three datasets, the pre-treatment compactness risk model provided good accuracy for predicting OS (P = 0.012, P = 0.022, and P = 0.003) and PFS (P < 0.001, P = 0.003, and P = 0.005). Patients in the low-risk group did not experience a significant OS benefit from concurrent chemoradiotherapy (P = 0.099). Furthermore, after preoperative concurrent chemoradiotherapy, the OS outcomes were similar among patients in the low-risk group who did and did not achieve a pathological complete response (P = 0.127). Tumor compactness was correlated with clinical T stage but was more accurate for predicting prognosis after treatment for ESCC, based on higher C-index values in all three datasets. The compactness-based risk model was effective for predicting OS and PFS after multimodal treatment for ESCC. Therefore, it may be useful for guiding personalized treatment.

Prognostic significance of lung radiation dose in patients with esophageal cancer treated with neoadjuvant chemoradiotherapy

Background

The prognostic significance of radiation dose to the lung or heart is unknown in esophageal cancer patients receiving neoadjuvant chemoradiotherapy followed by surgery (trimodal therapy). This study aimed to determine the association between lung and heart radiation dose volumes and prognosis of esophageal cancer after trimodal therapy.

Methods

This study reviewed 123 esophageal cancer patients treated with trimodal therapy in two tertiary institutions between 2010 and 2015. The dose-volume histogram parameter of Vx was defined as the percentage of total organ volume receiving a radiation dose of x (Gy) or more. Predictors of overall survival (OS) were identified using Cox regression models. Receiver-operating characteristic curves were used to select cut-off values for dose-volume.

Results

Median follow-up was 28.3 months (range: 4.7–92.8 months). Median OS and progression-free survival were 34.0 months (95% confidence interval [CI]: 27.4–40.6 months) and 24.8 months (95% CI, 18.9–30.7 months), respectively. Multivariate analyses showed that lung V20 (hazard ratio, 1.09; 95% CI: 1.04–1.14; p < 0.001) and lung V5 (hazard ratio, 1.02; 95% CI: 1.00–1.05; p = 0.03) were associated with OS when adjusting for surgical margin and pathological treatment response. The 5-year OS for patients with lung V20 ≤ 23% vs. patients with lung V20 > 23% was 54.4% vs. 5% (p < 0.001) whereas that for patients with lung V5 ≤ 56% vs. patients with lung V5 > 56% was 81.5% vs. 23.4% (p < 0.001). Mean heart dose showed no association with survival outcomes.

Conclusions

Lung radiation dose was independently associated with survival outcomes in esophageal cancer patients treated with neoadjuvant chemoradiotherapy and surgery.

Electronic supplementary material

The online version of this article (10.1186/s13014-019-1283-3) contains supplementary material, which is available to authorized users.

Relative tumor volume is a better independent prognostic factor in esophageal squamous cell carcinoma: Results of a retrospective study

The present study is to evaluate the significance in prognosis of relative tumor volume (RTV) in patients with non-resectable esophageal squamous cell carcinoma (ESCC) treated by definitive radiotherapy alone or in combination with chemotherapy.Fifty-eight consecutive patients with ESCC in UICC stage I to IV were retrospectively analyzed. Relative primary gross volume (RGTVp) was defined as primary gross volume (GTVp) divided by body volume. Relative primary gross volume for lymph nodes (RGTVnd) was defined as primary gross volume for lymph nodes (GTVnd) divided by body volume. The relationships were analyzed between overall survival (OS), disease free survival (DFS), local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), and RGTVp (RGTVnd) in univariate and multivariate analyses.The cut-off values of 0.947 and 0.007 were determined for RGTVp and RGTVnd, respectively. The 3-year OS, DFS, and LRFS for patients with RGTVp ≤ 0.947 vs RGTVp > 0.947 was 65.4% vs 25.0% (P = .001), 46.2% vs 12.5% (P = .002), and 90.1% vs 42.0% (P < .001). RGTVp was an independent risk factor for OS (P = .046), DFS (P = .015) and LRFS (P = .032), but showed no association with DMFS in univariate and multivariate analyses. The 3-year DFS and DMFS for patients with RGTVnd ≤ 0.007 vs RGTVnd > 0.007 was 44.4% vs 20.0% (P = .023), and 62.9% vs 24.6% (P < .004). RGTVnd was associated with DMFS (P = .012) in multivariate, but showed no associated with DFS.The present study demonstrates that RTV was an independent factor relevant to prognosis for ESCC. It provides new clinical basis for personalized therapeutic regimens and might be included in the staging system.

Proposed revision of the 8th edition AJCC clinical staging system for esophageal squamous cell cancer treated with definitive chemo-IMRT based on CT imaging

Purpose

To validate and propose revision of the 8th edition American Joint Committee on Cancer (AJCC) clinical staging system for esophageal squamous cell cancer (ESCC) patients treated with definitive intensity-modulated radiation therapy combined with concurrent chemotherapy (Chemo-IMRT) based on computed tomography (CT) imaging.

Methods

The clinical data of patients with ESCC treated with Chemo-IMRT were collected and retrospectively reviewed. All CT images were independently reevaluated and restaged according to the 8th edition AJCC staging system. The overall survival (OS) rates were analyzed statistically. ROC curves of the various parameters of the primary tumor and metastatic lymph nodes were generated in order to identify the cutoff values correlated to patient survival using the area under curve.

Results

The gross tumor volume of the primary tumor (GTV-prT) and the clinical N stage (cN) were independent factors that influenced OS. The 5-year OS rate of patients with GTV-prT ≤28 cm³, GTV-prT > 28 and ≤ 56 cm³, and GTV-prT > 56 cm³ were 54.6, 31.1 and 18.6%, respectively. The 5-year OS rate of patients with cN0, cN1 SLNM (−), cN2 SLNM (−), cN3 SLNM (−) and SLNM (+) were 62.8 (P < 0.001), 34.0 (P = 0.16), 20.0 (P = 0.785), 0 (P < 0.001) and 26.9%, respectively. After restaging the SLNM as regional MLNs, the 5-year OS rates of the patients with cN0, 1, 2 and 3 were 62.8, 36.3, 23.7 and 7.8%, respectively. Various GTV-prT were combined with the cN to establish a new clinical TNM staging system: I, GTV-prT1 and cN0; II, GTV-prT2 or 3 and cN0, GTV-prT1 and cN1; III, GTV-prT1 and cN2, GTV-prT2 and cN1,2; Iva, GTV-prT3 and cN1,2; IVb, GTV-prT_any and cN3; IVc, T_anyN_anyM1. Subsequently, the OS differed significantly between the adjacent GTV-prT cN categories, except those of stage I vs. II.

Conclusion

The SLNM should be dealt with as a regional rather than a distant disease in patients with ESCC when treated with CRT. The proposed nonsurgical staging system based on the GTV-prT and N appears to be a simple and accurate prognosis predictor for patients with ESCC who have undergone definitive Chemo-IMRT.

Tumor Volume Index as a Prognostic Factor in Patients after Curative Esophageal Cancer Resection

BACKGROUND

The tumor, node, metastasis classification system for staging esophageal cancer does not include tumor volume although it may be an important prognostic factor. We evaluated the prognostic value of tumor volume in esophageal cancer.

METHODS

We performed a retrospective study in patients with histologically confirmed primary esophageal cancer who underwent curative esophagectomy at our facility between April 1992 and December 2013. The Tumor Depth Parameter (TDP) was defined as mucosa = 1, submucosa = 2, muscularis propria = 3, adventitia = 4, and invasion into adjacent organs = 5. The pathological Tumor Volume Index (TVI) was defined as the major axis × the minor axis × TDP. The appropriate tumor diameter and TVI cutoff values were determined by the Youden index obtained from the receiver operating characteristic curve. Prognostic factors for overall survival were evaluated by univariate analysis and Cox proportional hazards regression models.

RESULTS

We enrolled 302 patients. In the univariate analysis, patient age and sex, thoracoscopic surgery, tumor depth of invasion and diameter, lymph node metastasis, and the TVI were significantly associated with overall survival. In our multivariate analysis, patient age and sex, thoracoscopic surgery, lymph node metastasis, and the TVI were independently associated with overall survival.

CONCLUSIONS

The pathological TVI was an independent prognostic factor in patients with esophageal carcinoma and could be included in the staging system of esophageal cancer.

Prognostic influence of 3-dimensional tumor volume on breast cancer compared to conventional 1-dimensional tumor size

Purpose

The prognostic influence of 3-dimensional tumor volume (Tv) on breast cancer compared to conventional 1-dimensional tumor size (T) was investigated.

Methods

Analysis was performed on a cohort of 8,996 primary breast cancer patients who were initially diagnosed with TNM stage I–III. Tumor size was defined as the maximum tumor dimension, and Tv was calculated by the equation of (4π × r1 × r2 × r3)/3; r1, r2, and r3 were defined as half of the largest, intermediate, and shortest dimension of the tumor, respectively. Tv was classified into Tv1, Tv2, and Tv3 according to the cut off values of 2.056 cm³ and 20.733 cm³.

Results

The survival curves according to both the T and Tv categories were clearly differentiated (all P < 0.001), as were those for staging by T and Tv (all P < 0.001). In T1 and T2 tumors, the Tv1 group showed superior survival over the Tv2 group (T1, P < 0.001; T2, P = 0.001). Univariate and multivariate analysis both indicated that Tv was a significant prognostic factor (both P < 0.001). The receiver operating characteristic curve showed that the area under the curves were 0.712 (P < 0.001) for Tv and 0.699 (P < 0.001) for T. Positive correlations were observed between the number of positive nodes and T (coefficient = 0.325; P < 0.001), and between the number of positive nodes and Tv (coefficient = 0.321; P < 0.001).

Conclusion

Tv classification works well for predicting the prognosis of breast cancer, and it is a better predictor than conventional T classification in several aspects. Further studies are needed to validate the practical usefulness of Tv classification in clinical settings.

18F-fluorodeoxyglucose positron emission tomography predicts lymph node responses to definitive chemoradiotherapy in esophageal squamous cell carcinoma patients

Purpose

To evaluate the capability of ¹⁸F-fluorodeoxyglucose positron emission tomography/ computed tomography (¹⁸F-FDG-PET/CT) to predict the clinical response of metastatic lymph node (mLN) to definitive chemoradiotherapy (dCRT) and guide personalized radiation dose in esophageal squamous cell carcinoma (ESCC) patients.

Patients and methods

One hundred and forty-three mLNs from 59 patients with ESCC treated with dCRT and who had undergone a pretreatment ¹⁸F-FDG-PET/CT scan were included in the study. All defined mLNs were contoured by nuclear medicine radiologists. Response was evaluated by contrast-enhanced computed tomography and ¹⁸F-FDG-PET/CT.

Results

Sixty-nine mLNs showed complete response (CR), and 74 mLNs showed non-complete response. The 143 mLNs were divided into 4 groups (Groups 1–4) based on the quartiles of maximum standardized uptake value (SUVmax-G1, SUVmax-G2, SUVmax-G3, and SUVmax-G4) and metabolic tumor volume (MTV-G1, MTV-G2, MTV-G3, and MTV-G4). The CR rate of SUVmax-G2 was significantly higher than the other 3 groups. The escalated radiation dose improved the CR rate of lymph nodes in SUVmax-G3 (55 Gy) and SUVmax-G4 (61 Gy). The lowest CR rate was found in MTV-G4 (the group with the largest MTV). The escalated radiation dose (59.7 Gy) improved the CR rate of lymph node in MTV-Groups 3 and 4.

Conclusion

Pretreatment metabolic parameters can predict the response of mLNs to dCRT for patients with ESCC. The parameters could also be used to guide personalized dose to mLNs.

Influential factors on radiotherapy efficacy and prognosis in patients with secondary lymph node metastasis after esophagectomy of thoracic esophageal squamous cell carcinoma

Background

The purpose of this study was to clarify whether pretreatment tumor burden-related index, including the gross tumor volume (GTV) of metastatic lymph nodes (V_LN) and maximum diameter of metastatic lymph nodes (D_LN), and inflammatory markers, consisting of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), are useful for assessing the therapeutic effects and prognosis with secondary lymph node metastasis (LNM) receiving chemoradiotherapy (CRT) or radiotherapy (RT) alone after resection of esophageal squamous cell carcinoma (ESCC).

Patients and methods

A total of 119 patients with secondary LNM after resection of ESCC were recruited and received curative RT only or CRT. The enrolled patients were grouped according to the median values of NLR, PLR, V_LN, and D_LN. The relationship between the responsiveness to treatment and these markers was analyzed by logistic analysis. The Kaplan–Meier method and log-rank test were adopted to calculate and compare the overall survival (OS) rates with these markers. The Cox models were used to carry out multivariate analyses.

Results

Univariate logistic regression analysis showed that the responses to treatment were highly associated with treatment method (P=0.011), NLR (P=0.000), PLR (P=0.003), V_LN (P=0.000), and D_LN (P=0.000). Next, multivariate logistic regression analysis showed that therapeutic method (hazard ratio [HR]=1.225, P=0.032), NLR (HR=2.697, P=0.019), and V_LN (HR=4.607, P=0.034) were independent risk factors for tumor response. Additionally, Kaplan–Meier survival analysis of this cohort revealed that NLR (χ²=27.298, P=0.000), PLR (χ²=16.719, P=0.000), V_LN (χ²=48.823, P=0.000), D_LN (χ²=40.724, P=0.000), and treatment methods (χ²=18.454, P=0.018) were significantly associated with OS. Furthermore, multivariate analysis was performed, and the results showed that therapeutic method (HR=1.223, P=0.048), NLR (HR=2.000, P=0.018), V_LN (HR=2.379, P=0.020), and D_LN (HR=2.901, P=0.002) were considered independent prognostic factors for OS.

Conclusion

This study found that NLR and V_LN were promising as predictive markers for therapeutic effects, and NLR combined with V_LN and with D_LN might be useful biomarkers in predicting outcomes in patients with secondary LNM receiving CRT or single RT after esophagectomy.

Radiomics approach for preoperative identification of stages III and IIIIV of esophageal cancer

Objective

To predict preoperative staging using a radiomics approach based on computed tomography (CT) images of patients with esophageal squamous cell carcinoma (ESCC).

Methods

This retrospective study included 154 patients (primary cohort: n=114; validation cohort: n=40) with pathologically confirmed ESCC. All patients underwent a preoperative CT scan from the neck to abdomen. High throughput and quantitative radiomics features were extracted from the CT images for each patient. A radiomics signature was constructed using the least absolute shrinkage and selection operator (Lasso). Associations between radiomics signature, tumor volume and ESCC staging were explored. Diagnostic performance of radiomics approach and tumor volume for discriminating between stages I-II and III-IV was evaluated and compared using the receiver operating characteristics (ROC) curves and net reclassification improvement (NRI).

Results

A total of 9,790 radiomics features were extracted. Ten features were selected to build a radiomics signature after feature dimension reduction. The radiomics signature was significantly associated with ESCC staging (P<0.001), and yielded a better performance for discrimination of early and advanced stage ESCC compared to tumor volume in both the primary [area under the receiver operating characteristic curve (AUC): 0.795vs. 0.694, P=0.003; NRI=0.424)] and validation cohorts (AUC: 0.762 vs. 0.624, P=0.035; NRI=0.834).

Conclusions

The quantitative approach has the potential to identify stage I-II and III-IV ESCC before treatment.