The optimal neoadjuvant treatment of locally advanced esophageal cancer

Systemic Inflammatory Response and the Noble and Underwood (NUn) Score as Early Predictors of Anastomotic Leakage after Esophageal Reconstructive Surgery

Anastomotic leakage (AL) remains the main cause of post-esophagectomy morbidity and mortality. Early detection can avoid sepsis and reduce morbidity and mortality. This study evaluates the diagnostic accuracy of the Nun score and its components as early detectors of AL. This single-center observational cohort study included all esophagectomies from 2010 to 2020. C-reactive protein (CRP), albumin (Alb), and white cell count (WCC) were analyzed and NUn scores were calculated. The area under the curve statistic (AUC) was used to assess their predictive accuracy. A total of 74 of the 668 patients (11%) developed an AL. CRP and the NUn-score proved to be good diagnostic accuracy tests on postoperative day (POD) 2 (CRP AUC: 0.859; NUn score AUC: 0.869) and POD 4 (CRP AUC: 0.924; NUn score AUC: 0.948). A 182 mg/L CRP cut-off on POD 4 yielded a 87% sensitivity, 88% specificity, a negative predictive value (NPV) of 98%, and a positive predictive value (PPV) of 47.7%. A NUn score cut-off > 10 resulted in 92% sensitivity, 95% specificity, 99% NPV, and 68% PPV. Albumin and WCC have limited value in the detection of post-esophagectomy AL. Elevated CRP and a high NUn score on POD 4 provide high accuracy in predicting AL after esophageal cancer surgery. Their high negative predictive value allows to select patients who can safely proceed with enhanced recovery protocols.

Study on the efficacy and safety of neoadjuvant immunotherapy combined with chemotherapy regimen for III-IVA esophageal squamous cell carcinoma post-surgery

BACKGROUND AND AIMS

The treatment of esophageal squamous cell carcinoma is still controversial, and neoadjuvant chemotherapy combined with immunotherapy is a hot topic of current research. We investigated the recent efficacy and surgical safety of patients with III-IVA esophageal squamous cell carcinoma after neoadjuvant regimen of paclitaxel + cisplatin/nedaplatin/carboplatin + sindilizumab, to provide a theoretical basis for evaluating the feasibility of surgery after neoadjuvant therapy.

METHODS

The clinical data of patients with stage III-IVA esophageal squamous cell carcinoma admitted from January 2022 to April 2023 at our hospital were collected for retrospective analysis. The patients were divided into the neoadjuvant combination surgery group (34 patients with the regimen of paclitaxel + cisplatin/nedaplatin/carboplatin + sintilimab two/three cycles of preoperative neoadjuvant therapy) and surgery-only group (36 patients). Statistical analysis was performed to compare the differences between both groups particularly for intraoperative bleeding, operative time, incidence of postoperative pulmonary complications, laryngeal recurrent nerve injury, thoracic duct injury, anastomotic fistula, and postoperative hospital days. Additionally, the pCR/MPR rates of the neoadjuvant group were analysed.

RESULTS

Significant differences were present in the clinical and pathological staging before and after neoadjuvant treatment (P ≤ 0.001). The neoadjuvant group had a pCR rate of 26.47% and an ORR rate of 88.23%. No significant differences were discovered in R0 resection rate between both groups, as well as intraoperative bleeding, operative time, intraoperative laryngeal recurrent nerve injury rate, thoracic duct injury rate, postoperative anastomosis incidence, postoperative hospital days, and postoperative lung infection incidence (P > 0.05).

CONCLUSIONS

The neoadjuvant immune combination chemotherapy regimen had considerable tumor regression and pathological remission benefits, without reducing the safety of surgery, possibly presenting as a new treatment plan.

The Evolution of Neo-Adjuvant Therapy in the Treatment of Oesophageal and Gastro-Oesophageal Junction Adenocarcinomas

Historically, oesophageal and gastro-oesophageal junction adenocarcinomas were associated with a poor prognosis. The advent of neoadjuvant therapy has transformed the management of oesophageal and gastro-oesophageal junction adenocarcinomas further and offers the possibility to reverse disease progression, eliminate micrometastasis, and offer potentially better outcomes for these patients. This review provides an overview of landmark clinical trials in this area, with different treatment regimens considered over the years as well as potential therapeutic agents on the horizon that may transform the management of oesophageal and gastro-oesophageal junction adenocarcinomas further.

Oncological recurrence following pathological complete response after neoadjuvant treatment in patients with esophageal cancer - a retrospective cohort study

BACKGROUND

To evaluate recurrence in patients with post-neoadjuvant pathological complete response (pCR) and in patients with complete response of primary tumor but persisting lymphatic spread of disease (non-pCR, ypT0ypN +) of esophageal cancer.

METHODS

Seventy-five patients (63 pCR, 12 non-pCR) were analyzed retrospectively. Pattern and incidence of local and distant recurrence as well as the impact on overall (OS) and disease-free survival (DFS) were evaluated. The efficacy of neoadjuvant chemotherapy according to FLOT protocol was compared to neoadjuvant chemoradiation according to CROSS protocol.

RESULTS

In the pCR group, isolated local recurrence was diagnosed in 3%, while no isolated local recurrence was observed in the non-pCR group due to the high incidence of distant recurrence. Distant recurrence was most common in both cohorts (isolated distant recurrence: pCR group 10% to non-pCR group 55%; simultaneous distant and local recurrence: pCR group 3% to non-pCR group 18%). Median time to distant recurrence was 5.5 months, and median time to local recurrence was 8.0 months. Cumulative incidence of distant recurrence (with and without simultaneous local recurrence) was 16% (± 6%) in pCR patients and 79% (± 13%) in non-pCR patients (hazard ratio (HR) 0.123) estimated by Kaplan-Meier method. OS (HR 0.231) and DFS (HR 0.226) were significantly improved in patients with pCR compared to patients with non-pCR. Advantages for FLOT protocol compared to CROSS protocol, especially with regard to distant control of disease (HR 0.278), were observed (OS (HR 0.361), DFS (HR 0.226)).

CONCLUSION

Distant recurrence is the predominant site of treatment failure in patients with pCR and non-pCR grade 1a regression, whereby recurrence rates are much higher in patients with non-pCR.

Impact of Perineural Invasion and Preexisting Type 2 Diabetes on Patients with Esophageal Squamous Cell Carcinoma Receiving Neoadjuvant Chemoradiotherapy

Neoadjuvant chemoradiotherapy (neoCRT) followed by surgery is the cornerstone treatment strategy in locally advanced esophageal squamous cell carcinoma (ESCC). Despite this high- intensity multimodality therapy, most patients still experience recurrences and metastases, especially those who do not achieve a pathological complete response (pCR) after neoCRT. Here, we focused on identifying poor prognostic factors. In this retrospective cohort study; we enrolled 140 patients who completed neoCRT plus surgery treatment sequence with no interval metastasis. Overall, 45 of 140 patients (32.1%) achieved a pCR. The overall survival, disease-free survival (DFS), and metastasis-free survival was significantly better in patients with a pCR than in patients with a non-pCR. In the non-pCR subgroup, the presence of perineural invasion (PNI) and preexisting type 2 diabetes (T2DM) were two factors adversely affecting DFS. After adjusting for other factors, multivariate analysis showed that the hazard ratio (HR) was 2.354 (95% confidence interval [CI] 1.240-4.467, p = 0.009) for the presence of PNI and 2.368 (95% CI 1.351-4.150, p = 0.003) for preexisting T2DM. Patients with a combination of both factors had the worst survival. In conclusion, PNI and preexisting T2DM may adversely affect the prognosis of patients with ESCC receiving neoadjuvant chemoradiotherapy.

Neoadjuvant Anlotinib and chemotherapy followed by minimally invasive esophagectomy in patients with locally advanced esophageal squamous cell carcinoma: Short-term results of an open-label, randomized, phase II trial

Background

Clinical benefits of neoadjuvant Anlotinib for locally advanced esophageal squamous cell carcinoma (ESCC) remains unclear. This study evaluated the efficacy and safety of neoadjuvant Anlotinib plus chemotherapy followed by minimally invasive esophagectomy (MIE) for the treatment of patients with locally advanced ESCC.

Methods

Patients with locally advanced ESCC were randomly assigned to neoadjuvant Anlotinib combined with chemotherapy (Anlotinib group) or neoadjuvant chemoradiotherapy alone (nCRT group) with an allocation ratio of 1:1. The primary endpoint was the R0 surgical resection rate. Secondary endpoints included postoperative pathologic stage, complete response (CR) rate, and safety. Safety was assessed by adverse events (AEs) and postoperative complications.

Results

From August 2019 to August 2021, 93 patients were assigned to the nCRT or Anlotinib group. Of the 93 patients, 79 underwent MIE and were finally included in the per-protocol set (nCRT group: n=39; Anlotinib group: n=40). The R0 resection rate was 97.4% for nCRT versus 100.0% for Anlotinib group (p>0.05). Compared with the nCRT group, patients in the Anlotinib group had shorter total operation duration (262.2 ± 39.0 vs. 200.7 ± 25.5 min, p=0.010) and less blood loss (161.3 ± 126.7 vs. 52.4 ± 39.3 mL, p<0.001). No significant differences were found in the postoperative pathologic stage between the Anlotinib group and nCRT group (all p>0.05). Besides, the incidences of AEs (80.0% vs. 92.3%) and postoperative complications (22.5% vs. 30.8%) were similar between the two groups (all p>0.05).

Conclusions

Neoadjuvant Anlotinib plus chemotherapy had a similar safety profile and pathologic response, but better surgical outcomes than nCRT for locally advanced ESCC.

Trimodality treatment in gastric and gastroesophageal junction cancers: Current approach and future perspectives

Gastric and gastroesophageal junction (GEJ) cancers represent an aggressive group of malignancies with poor prognosis even when diagnosed in relatively early stage, with an increasing incidence both in Asia and in Western countries. These cancers are characterized by heterogeneity as a result of different pathogenetic mechanisms as shown in recent molecular analyses. Accordingly, the understanding of phenotypic and genotypic correlations/classifications has been improved. Current therapeutic strategies have also advanced and moved beyond surgical extirpation alone, with the incorporation of other treatment modalities, such as radiation and chemotherapy (including biologics). Chemoradiotherapy has been used as postoperative treatment after suboptimal gastrectomy to ensure local disease control but also improvement in survival. Preoperative chemoradiotherapy/chemotherapy has been employed to increase the chance of a successful R0 resection and pathologic complete response rate, which is associated with improved long-term outcomes. Several studies have defined various chemotherapy regimens to accompany radiation (before and after surgery). Recently, addition of immunotherapy after trimodality of gastroesophageal cancer has produced an advantage in disease-free interval. Targeted agents used in the metastatic setting are being investigated in the early setting with mixed results. The aim of this review is to summarize the existing data on trimodality approaches for gastric and GEJ cancers, highlight the remaining questions and present the current research effort addressing them.

Recent Progress in the Neoadjuvant Treatment Strategy for Locally Advanced Esophageal Cancer

Neoadjuvant therapies, primarily chemotherapy and chemoradiotherapy, are able to improve the overall survival (OS) in patients with locally advanced resectable esophageal cancer (EC) based on the results of several randomized clinical trials. The advantage of neoadjuvant therapy is chiefly attributed to the decreased risk of local-regional recurrence and distant metastasis. Thus, it has been recommended as standard treatment for patients with resectable EC. However, several fundamental problems remain. First, the combination of neoadjuvant chemotherapy (nCT), neoadjuvant chemoradiotherapy (nCRT), and surgery for EC patients with different histological types remain controversial. Furthermore, to reduce the toxicity of preoperative chemotherapy and the risk of complications caused by preoperative radiation therapy, the treatment protocols of nCT and nCRT still need to be investigated and optimized by prospective trials. Moreover, for patients with complete clinical response following neoadjuvant therapy, it is worth ascertaining whether a "watch and wait" surveillance plus surgery-as-needed policy is more favorable, as well as, in addition to preoperative chemoradiotherapy, whether immunotherapy, especially when combined with the traditional neoadjuvant therapy regimens, brings new prospects for EC treatment. In this review, we summarize the recent insights into the research progress and existing problems of neoadjuvant therapy for locally advanced resectable EC.

Three-field versus two-field lymphadenectomy for esophageal squamous cell carcinoma: A long-term survival meta-analysis

BACKGROUND

In the setting of esophageal squamous cell carcinoma, controversy exists regarding the optimal extent of lymphadenectomy, while conclusive evidence regarding the advantages of 3-field versus 2-field lymphadenectomy remains controversial. The purpose of the present meta-analysis was to investigate the effect of 3-field lymphadenectomy versus 2-field lymphadenectomy on overall survival.

METHODS

Systematic review and meta-analyses were computed to compare 3-field lymphadenectomy versus 2-field lymphadenectomy in the setting of esophageal squamous cell carcinoma. Risk ratio, weighted mean difference, hazard ratio, and restricted mean survival time difference were used as pooled effect size measures.

RESULTS

Fourteen studies (3,431 patients) were included. Overall, 1,664 (48.8%) patients underwent 3-field lymphadenectomy, and 1,767 (51.5%) underwent 2-field lymphadenectomy. Three-field lymphadenectomy was associated with a significantly improved 5-year overall survival (hazard ratio: 0.80; 95% confidence interval 0.71-0.90; P < .001). The restricted mean survival time difference showed a statistically significant difference between 3-field lymphadenectomy versus 2-field lymphadenectomy up to 48 months (1.6 months; P = .04), however, no significant differences were found at 60-month follow-up (1.2 months; P = .14). No significant differences were found in term of postoperative mortality, anastomotic leak, pulmonary complications, chylothorax, and recurrent nerve palsy.

CONCLUSION

For resectable esophageal squamous cell carcinoma, 3-field lymphadenectomy seems associated with a slight trend toward improved 5-year overall survival; however, its clinical benefit remains limited.

The Landmark Series: Multimodal Therapy for Esophageal Cancer

INTRODUCTION

Esophagectomy is the mainstay of treatment for patients with resectable esophageal cancer, and chemotherapy and chemoradiation have become essential adjuncts to improve survival. Controversy remains regarding the optimal perioperative therapy.

METHODS

This review focuses on three landmark, randomized, controlled trials that have greatly influenced esophageal cancer management and established chemotherapy and chemoradiotherapy as standard of care: Medical Research Council Adjuvant Gastric Infusional Chemotherapy Trial (MAGIC); The United Kingdom Medical Research Council Esophageal Cancer Trial (OEO2); and Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS).

RESULTS

The findings from these landmark studies are reviewed and summarized.

CONCLUSION

Chemotherapy regimens are heterogeneous but centered around platinum-based therapy and should be included in the management for all appropriate patients. Ongoing and future studies will further delineate the roles of various chemo- and chemoradiotherapy regimens and also will investigate the promising area of immunotherapy in the treatment of esophageal cancer.

Small nucleolar RNA host gene 22 (SNHG22) promotes the progression of esophageal squamous cell carcinoma by miR-429/SESN3 axis

Background

It has been observed that lncRNAs have been taking part in many cancer progressions, including non-small cell lung cancer and gastric cancer. Meanwhile, lncRNA small nucleolar RNA host gene 22 (SNHG22) has been studied, taking part in the progression of ovarian epithelial carcinoma. However, we know little about the function of SNHG22 in esophageal squamous cell carcinoma (ESCC).

Methods

In this study, we will explore the inner mechanism of SNHG22 in ESCC. Quantitative real-time PCR (qRT-PCR) assay was implemented in ESCC cells for detecting the expression of lncRNA, SNHG22, and miR-429. Also, functional experiments, including CCK8 and colony formation assay, were implemented to assess the growth of ESCC cells. Meanwhile, flow cytometry analysis was conducted to test the apoptosis of ESCC cells. The immunofluorescence (IF) assay and western blot were conducted to verify the autophagy of ESCC cells.

Results

Inhibition of SNHG22 was found that can inhibit the progression and promotes autophagy and apoptosis of ESCC cells. Meanwhile, as subcellular fraction assay and FISH assay found that SNHG22 mainly in the cytoplasm, miR-429 was found can bind to SNHG22 and SESN3 by RIP assay and luciferase reporter assay. SESN3 was found it can play the oncogene in ESCC cells.

Conclusions

SNHG22 promotes the progression of ESCC by the miR-429/SESN3 axis.

Quercetin as an anticancer agent: Focus on esophageal cancer

Esophageal cancer (EC) is regarded as the sixth highest contributor to all cancer-related mortality, worldwide. In spite of advances in the treatment of EC, currently used methods remain ineffective. Quercetin, as a dietary antioxidant, is a plant flavonol from the flavonoid group of polyphenols, and can be found in numerous vegetables, fruits, and herbs. Quercetin can affect the processes of cancer-related diseases via cell proliferation inhibitory effects, potential apoptosis effects, and antioxidant properties. Of the various types of cancer, the use of quercetin has now become prominent in the treatment of EC. In this review, we discuss how quercetin may be an important supplement for the prevention, treatment, and management of EC, owing to its natural origin, and low-cost relative to synthetic cancer drugs. However, most findings cited in the current study are based on in vitro and in vivo studies, and thus, further human-based research is necessitated. PRACTICAL APPLICATIONS: In spite of advances in the treatment of esophageal cancer, currently used methods remain ineffective, therefore, an alternative or complementary therapy is required. Quercetin, as a dietary antioxidant, can affect the processes of cancer-related diseases via cell proliferation inhibitory effects, potential proapoptotic functions, and antioxidant properties. Quercetin may be an important supplement for the prevention, treatment, and management of EC, owing to its natural origin. The low cost of quercetin as supplement or dietary intake, relative to synthetic cancer drugs, is an advantage of the compound which should be considered.

Multidisciplinary treatment of esophageal cancer: The role of active surveillance after neoadjuvant chemoradiation

The optimal treatment of esophageal cancer is still controversial. Neoadjuvant chemoradiotherapy followed by radical esophagectomy is a standard treatment. Morbidity after esophagectomy however is still considerable and has an impact on patients' quality of life. Given a pathologic complete response rate of approximately 30% in patients after neoadjuvant chemoradiation followed by surgery, active surveillance has been introduced as a new alternative approach. Active surveillance involves regular clinical response evaluations in patients after neoadjuvant therapy to detect residual or recurrent disease. As long as there is no suspicion of disease activity, surgery is withheld. Esophagectomy is reserved for patients presenting with an incomplete response or resectable recurrent disease. Active surveillance after neoadjuvant treatment has been previously applied in other types of malignancy with encouraging results. This paper discusses its role in esophageal cancer.

Harnessing the potential of multimodal radiotherapy in prostate cancer

Radiotherapy in combination with androgen deprivation therapy (ADT) is a standard treatment option for men with localized and locally advanced prostate cancer. However, emerging clinical evidence suggests that radiotherapy can be incorporated into multimodality therapy regimens beyond ADT, in combinations that include chemotherapy, radiosensitizing agents, immunotherapy and surgery for the treatment of men with localized and locally advanced prostate cancer, and those with oligometastatic disease, in whom the low metastatic burden in particular might be treatable with these combinations. This multimodal approach is increasingly recognized as offering considerable clinical benefit, such as increased antitumour effects and improved survival. Thus, radiotherapy is becoming a key component of multimodal therapy for many stages of prostate cancer, particularly oligometastatic disease.

Ubiquitination of NOTCH2 by DTX3 suppresses the proliferation and migration of human esophageal carcinoma

The NOTCH2 gene plays a role in the development of many tumors. Deltex E3 ubiquitin ligase 3 (DTX3) was identified as a novel E3 ligase for NOTCH2 and as a potential therapeutic target for esophageal cancer. However, whether DTX3 could regulate NOTCH2 to suppress the progression of esophageal carcinoma remains unknown. In our study, NOTCH2 had higher expression in human esophageal carcinoma cell lines compared to normal human esophageal epithelial cell line, and ablation of NOTCH2 suppressed the proliferation and migration of esophageal carcinoma cells. A novel E3 ligase for NOTCH2 was identified by yeast two-hybrid (Y2H) screening, and DTX3 promoted the ubiquitination and degradation of NOTCH2. Further study showed that DTX3 overexpression suppressed the proliferation and tumorigenicity of human oesophageal carcinoma cells. The analysis of tissue samples from patients revealed that the expression of NOTCH2 was high while the expression of DTX3 was low in esophageal cancer. Furthermore, the expression of DTX3 and NOTCH2 showed a significant negative correlation in human oesophageal cancer samples. Our study suggested that the DTX3-NOTCH2 axis plays an important role in the progression of esophageal cancer, and DTX3 acts as an anti-oncogene in esophageal carcinoma, potentially offering a therapeutic target for esophageal cancer.