Neoadjuvant chemoradiation versus perioperative chemotherapy followed by surgery in resectable adenocarcinomas of the esophagogastric junction: A retrospective single center analysis

Peri-operative chemotherapy versus preoperative chemoradiotherapy in treatment of gastro-oesophageal junctional adenocarcinomas: A 10-year cohort study

BACKGROUND

Gastro-oesophageal junctional (GOJ) cancers have been, more latterly, considered a distinct tumor entity with characteristic genetic profiles. The optimal multimodal therapy of advanced GOJ cancers remains debatable. In this comparative study, we analyzed the outcomes of peri-operative chemotherapy (CT) versus pre-operative chemoradiotherapy (CRT) in treatment of advanced GOJ adenocarcinomas.

METHODS

This study included patients with locally advanced but resectable GOJ adenocarcinomas who underwent surgical resection after oncological therapy between 2010 till 2019 at our institution. Follow up to May 2021 was completed. The outcomes between CT and CRT groups were retrospectively analyzed. The long-term follow up data was obtained via direct contact with the patients during oncological clinics, cross-checked with hospital/national patients' electronic databases.

RESULTS

107 patients had GOJ cancers; 90 (84%) patients met our inclusion criteria. Perioperative chemotherapy was administrated in 65 (72%) patients. Overall median survival rate was 2.2 years in CRT-group compared to 2.4 years in CT-group (p-value 0.29), with comparable recurrence rates (48% vs 36% respectively). R0-resections were higher in CRT-group (84%) compared to CT-group (71%), yet insignificant p-value 0.197. Preoperative chemoradiotherapy achieved higher complete pathological response (28% vs 6%, p-value 0.009) and negative lymph nodes rates (64% vs 37%, p-value 0.014) compared to CT-group. Short-term outcomes (postoperative complications, morbidity rates and length of hospital stay) were similar across both groups.

CONCLUSION

Preoperative chemoradiotherapy was associated with higher complete pathological response and negative lymph nodes rates for GOJ adenocarcinomas compared to peri-operative chemotherapy, without an increase in postoperative complications or morbidity rates. However, it wasn't associated with improved overall or disease-free survival rates.

Multimodal treatments for resectable esophagogastric junction cancer: A Bayesian network meta-analysis

PURPOSE

To comprehensively investigate the optimal multimodal treatment of resectable esophagogastric junction (EGJ) cancer.

METHODS

PubMed, Embase, Cochrane Library and Web of Science were searched until March 11, 2022. The outcomes were overall survival (OS), locoregional and distant recurrence, and R0 resection. Network plots, forest plots and league tables were drawn for each outcome. Rank probabilities for different treatments in each outcome were also depicted.

RESULTS

A total of 23 studies with 18,319 EGJ participants were included. No significant differences in OS between any two of the 6 treatments. Perioperative chemoradiotherapy (pCRT) had the highest probability (36.03%) to be the optimal treatment as regards OS. Patients undergoing pCRT had a significantly lower incidence of locoregional recurrence than those undergoing adjuvant chemotherapy (aCT), neoadjuvant chemotherapy (nCT), perioperative chemotherapy (pCT), or surgery alone (S). Patients with pCRT had the greatest likelihood (68.86%) to have the lowest incidence of locoregional recurrence. Comparable impacts of the 6 treatments on the incidence of distant recurrence, and pCRT was most likely (46.65%) to be the optimal treatment with respect to distant recurrence. Neoadjuvant CRT (nCRT) was associated with a significantly increased incidence of R0 resection compared with nCT or S, and nCRT had the highest probability (97.68%) to be the best therapy regarding R0 resection.

CONCLUSION

For patients with resectable EGJ cancer, pCRT may be the optimal multimodal treatment regarding survival and recurrence.

Targeted Molecular Therapies in the Treatment of Esophageal Adenocarcinoma, Are We There Yet?

Esophageal adenocarcinoma is one of the leading causes of cancer-related deaths worldwide. The incidence of esophageal adenocarcinoma has increased at an alarming rate in the Western world and long-term survival remains poor. Current treatment approaches involve a combination of surgery, chemotherapy, and radiotherapy. Unfortunately, standard first-line approaches are met with high rates of recurrence and metastasis. More recent investigations into the distinct molecular composition of these tumors have uncovered key genetic and epigenetic alterations involved in tumorigenesis and progression. These discoveries have driven the development of targeted therapeutic agents in esophageal adenocarcinoma. While many agents have been studied, therapeutics targeting the human epidermal growth factor receptor (HER2) and vascular endothelial growth factor (VEGF) pathways have demonstrated improved survival. More recent advances in immunotherapies have also demonstrated survival advantages with monoclonal antibodies targeting the programmed death ligand 1 (PD-L1). In this review we highlight recent advances of targeted therapies, specifically agents targeting receptor tyrosine kinases, small molecule kinase inhibitors, and immune checkpoint inhibitors. While targeted therapeutics and immunotherapies have significantly improved survival, the benefits are limited to patients whose tumors express biomarkers such as PD-L1 and HER2. Survival remains poor for the remainder of patients with esophageal adenocarcinoma, underscoring the critical need for development of novel treatment strategies.

Neoadjuvant chemoradiotherapy or chemotherapy for gastroesophageal junction adenocarcinoma: A systematic review and meta-analysis

OBJECTIVE

The preferred neoadjuvant treatment for gastroesophageal junction (GEJ) adenocarcinoma is still matter of debate. We conducted a meta-analysis to assess the different impact of neoadjuvant combined chemotherapy and radiotherapy (CTRT) versus chemotherapy (CT) alone.

METHODS

A comprehensive search was performed in EMBASE, PubMed, and Cochrane Library databases from inception to 30th June 2018. Studies comparing survival of patients who underwent CTRT or CT alone before surgery for GEJ adenocarcinoma were included. Hazard ratio (HR) for overall survival (OS) was extracted, and a random-effects model was used for pooled analysis. Median OS, 5-year OS, complete pathologic response (pCR), locoregional and distant failure rates were also calculated.

RESULTS

22 studies including 18,260 patients were considered for the final analysis. The pooled results demonstrated that combined CTRT do not significantly reduce the risk of death (HR 0.95, 95% CI 0.84-1.07; P = 0.41) but has a positive impact on the risk of relapse (HR 0.85, 95% CI 0.75-0.97; P = 0.01) compared to CT alone. Addition of RT to CT alone significantly increased the odds of pCR by 2.8 (95% CI 2.27-3.47; P < 0.001) and reduced the risk of locoregional failure (OR 0.6, 95% CI 0.39-0.91; P = 0.01) but not the risk of distant metastases (OR 0.81, 95% CI 0.59-1.11; P = 0.19).

CONCLUSIONS

In this systematic review and meta-analysis comparing neoadjuvant CTRT with CT for adenocarcinoma of GEJ, we found no difference in terms of median OS, despite a higher pCR rate and a reduced risk of locoregional recurrences for the combined approach. Further studies, preferably large randomized clinical trials, are needed to confirm these results.