A clinical trial of neoadjuvant concurrent chemoradiotherapy followed by resection for esophageal carcinoma

Pathologic complete response in patients with esophageal cancer receiving neoadjuvant chemotherapy or chemoradiation: A systematic review and meta-analysis

BACKGROUND

Neoadjuvant chemoradiation and chemotherapy are recommended for the treatment of nonmetastatic esophageal cancer. The benefit of neoadjuvant treatment is mostly limited to patients who exhibit pathologic complete response (pCR). Existing estimates of pCR rates among patients receiving neoadjuvant therapy have not been synthesized and lack precision.

METHODS

We conducted an independently funded systematic review and meta-analysis (PROSPERO CRD42023397402) of pCR rates among patients diagnosed with esophageal cancer treated with neoadjuvant chemo(radiation). Studies were identified from Medline, EMBASE, and CENTRAL database searches. Eligible studies included trials published from 1992 to 2022 that focused on nonmetastatic esophageal cancer, including the gastroesophageal junction. Histology-specific pooled pCR prevalence was determined using the Freeman-Tukey transformation and a random effects model.

RESULTS

After eligibility assessment, 84 studies with 6451 patients were included. The pooled prevalence of pCR after neoadjuvant chemotherapy in squamous cell carcinomas was 9% (95% CI: 6%-14%), ranging from 0% to 32%. The pooled prevalence of pCR after neoadjuvant chemoradiation in squamous cell carcinomas was 32% (95% CI: 26%-39%), ranging from 8% to 66%. For adenocarcinoma, the pooled prevalence of pCR was 6% (95% CI: 1%-12%) after neoadjuvant chemotherapy, and 22% (18%-26%) after neoadjuvant chemoradiation.

CONCLUSIONS

Under one-third of patients with esophageal cancer who receive neoadjuvant chemo(radiation) experience pCR. Patients diagnosed with squamous cell carcinomas had higher rates of pCR than those with adenocarcinomas. As pCR represents an increasingly utilized endpoint in neoadjuvant trials, these estimates of pooled pCR rates may serve as an important benchmark for future trial design.

Outcomes of Neoadjuvant Chemoradiation in Patients with Gastro-esophageal Junction Adenocarcinoma: a Retrospective Cohort Study in Iran

PURPOSE

The optimal treatment for locally advanced GEJ and cardia adenocarcinoma is controversial. Several studies have shown that treating these patients with neoadjuvant chemoradiotherapy followed by surgery leads to survival benefits, and there are also studies that have declared conflicting results. It seems that there is still room for discussion. We calculated the survival rates and pathologic responses in our patients with characteristics which we mentioned above.

METHODS

Patients with locally advanced, non-metastatic GEJ and cardia adenocarcinomas (only patients with Siewert's type I and II), who were referred to Imam Khomeini hospital (Institute of cancer) between 2005 and 2014 and received neoadjuvant chemoradiation and underwent surgery were enrolled in this retrospective cohort study. Evaluations were done every 3 months.

RESULTS

Thirty-two patients enrolled in this study. Median follow up time was 23 months (Reverse Kaplan-Meier method). The rates of 1-year survival, 2-year survival, 3-year survival, 4-year survival, and 5-year survival were 75%, 52%, 52%, 37%, and 37%, respectively. No local recurrences occurred among patients; however, four patients experienced distal recurrence in the following locations: two cases (6.3%) in the liver, one case (3.1%) in the lung, and one case (3.1%) in the peritoneum. The rate of complete pathologic response (T₀N₀) was 21.9%.

CONCLUSIONS

Neoadjuvant chemoradiation in patients with locally advanced GEJ and cardia adenocarcinoma will lead to a survival benefit.

The Comparison of the Advantages of Neoadjuvant Chemoradiotherapy versus Postoperative Chemoradiotherapy: Outcomes in Esophageal Cancer Patients

BACKGROUND AND OBJECTIVES

Esophageal cancer is the eighth most common type of cancer worldwide. For the treatment of which, surgical intervention alone or with neoadjuvant chemoradiotherapy or chemotherapy is recommended. In this study, we aimed to compare the benefits of neoadjuvant chemoradiotherapy versus postoperative chemoradiotherapy.

PATIENTS AND METHODS

We collected data regarding 325 patients admitted for esophageal cancer to Qaem Hospital, Mashhad, Iran, during 2006-2016. The participants were divided into two groups of neoadjuvant and postoperative adjuvant therapies. Chi-square, McNemar, Kaplan-Mayer, and multivariate regression tests were performed using SPSS.

RESULTS

Gender, age, stage of the disease, tumor grade and location, disease histopathology, and the recurrence showed no significant differences between the two groups (P ˃ 0.05), but there was a significant association between the two types of treatment in terms of postoperative complications (P = 0.03). We followed up 147 patients postoperatively and found no significant differences between the groups (P ˃ 0.05).

CONCLUSION

No conclusion can be drawn on whether there are any advantages in adjuvant chemoradiotherapy over neoadjuvant approaches. Further confirmatory trials, particularly randomized trials, are necessary before any recommendations can be made.

The cost-effectiveness of neoadjuvant chemotherapy in women with locally advanced breast cancer: Adriamycin and cyclophosphamide in comparison with paclitaxel and gemcitabine

Background:

A decision analysis model was developed to assess the cost-effectiveness of adriamycin and cyclophosphamide (AC) in comparison with paclitaxel and gemcitabine (PG) in women with advanced breast cancer in Iran.

Materials and Methods:

This is a cost-effectiveness analysis performed as a cross-sectional study in Namazi Hospital in Shiraz, Iran. Patients were divided into two groups by random numbers, 32 women in the AC group and 32 women in the PG group. The costs were measured using the societal perspective and effectiveness of 2 regimens were assessed using tumor response. By a decision tree, the incremental cost-effectiveness ratio was calculated. In addition, the robustness of results was examined by sensitivity analysis.

Results:

The estimated total cost of AC and PG per patient was 1565.23 ± 765.31 and 2099.08 ± 926.99, respectively. Response to treatment in AC and PG arm were 84% versus 75% respectively. The incremental cost-effectiveness ratio results showed AC is a dominate alternative.

Conclusion:

Overall, AC was a simple dominate strategy. In other words, AC was estimated to have a lower cost and greater effectiveness than PG.

Essential role of Na+/Ca2+ exchanger 1 in smoking-induced growth and migration of esophageal squamous cell carcinoma

Tobacco-derived carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) is a major environmental risk factor for the pathogenesis of human esophageal squamous cell carcinoma (ESCC). However, the molecular mechanisms by which tobacco induces ESCC are not well understood. Na+/Ca2+ exchanger 1 (NCX1) is a plasma membrane transporter protein that plays an essential role in maintaining cytosolic Ca²⁺ ([Ca²⁺]_cyt) homeostasis under physiological conditions and is implicated in tumorigenesis as well. In this study, we found that NCX1 expression was significantly higher in ESCC primary tissues compared to the noncancerous tissues and was overexpressed in tumor samples from the smoking patients. The expression of NCX1 proteins was also significantly higher in human ESCC cell lines compared to normal esophageal epithelial cell line. Moreover, NNK potentiated the [Ca²⁺]_cyt signaling induced by removal of extracellular Na⁺, which was abolished by KB-R7943 or SN-6. NNK dose-dependently promoted proliferation and migration of human ESCC cells induced by NCX1 activation. Therefore, NCX1 expression correlates with the smoking status of ESCC patients, and NNK activates the Ca²⁺ entry mode of NCX1 in ESCC cells, leading to cell proliferation and migration. Our findings suggest NCX1 protein is a novel potential target for ESCC therapy.

Gene expression profiling and pathway network analysis of anti-tumor activity by Jaridon 6 in esophageal cancer

Jaridon 6, a novel ent-kaurene diterpenoid derived from Rabdosia rubescens (Hemsl.) Hara, possesses strong anti-tumor activity in esophageal cancer cells. In this study, we explored the underlying molecular events of the anti-tumor activity of Jaridon 6. Cell viability and apoptosis results obtained by flow cytometry confirmed the tumor inhibitory effect of Jaridon 6 in esophageal cancer cells. A cDNA microarray was performed and the observations were validated using quantitative reverse transcription polymerase chain reaction. The microarray data showed that 151 genes were differentially expressed between the untreated group and the Jaridon 6-treated group, among these were 57 upregulated genes, and 94 downregulated genes (P < 0.01, fold change threshold: 2). These included genes such as Wnt, peroxisome, and genes involved in chemokine signaling pathways. In addition, Western blot analysis demonstrated that Jaridon 6 regulated the expression of Wnt pathway proteins, including reduced levels of Dvl 2, survivin and cyclin D1, and increased levels of p-β-catenin, and AXIN2 in EC109 and EC9706 esophageal cancer cells. In addition, recombinant murine Wnt3a could change the regulation of Jaridon 6 on Wnt pathway proteins. Immunohistochemical analysis indicated that the anti-tumor activity of Jaridon 6 was closely related to the Wnt signaling pathway in esophageal cancer cells.

High dose radiation with chemotherapy followed by salvage esophagectomy among patients with locally advanced esophageal squamous cell carcinoma

Background

Locoregional failure is a major problem associated with chemoradiation treatment for squamous cell esophageal carcinoma. The aim of this study was to assess the feasibility, efficacy, and toxicity of preoperative radiation (dose > 50 Gy) with platinum‐based chemotherapy followed by esophagectomy in locally advanced squamous cell carcinoma.

Methods

Data of patients with cT2‐cT4 or node positive squamous cell carcinoma of the esophagus who received trimodality treatment between February 2006 and June 2015 were reviewed.

Results

Forty‐four patients were treated with intensity‐modulated radiation therapy, volumetric‐modulated arc therapy or three‐dimensional radiation therapy. The median radiation dose was 60 Gy. The average volume of the lungs receiving 10 Gy was 48.1%, 20 Gy was 24.5%, and the average mean lung dose was 14 Gy. After chemoradiation, R0 resection was achieved in 31 patients (71%). Patients who received >60 Gy had a higher pathologic complete remission rate than those in the lower dose group (59.1% vs. 36.4%). R0 resection and radiation dose >60 Gy were associated with better overall survival in Cox proportional hazards regression analysis. The median follow‐up duration was 22.4 months and median survival was 25.6 months. Two‐year overall, progression‐free survival and locoregional control rates were 55.9%, 28.6%, and 56%, respectively. The most common grade 3–4 toxicities were esophagitis (63.6%) and neutropenia (25%). Grade 3–4 postoperative morbidities included surgical wound infection (2.3%), acute renal failure (2.3%), and anastomosis stricture (2.3%).

Conclusion

Trimodality treatment with a high preoperative radiation dose and chemotherapy yielded a good pathologic complete response rate, and long‐term survival with low toxicities.

The prevalence and expression pattern of melanoma-associated antigen 1 in esophageal squamous cell carcinoma: a historical cohort study

Introduction

Melanoma-associated antigen 1 (MAGE1) expression in normal tissues is restricted to the testes, whilst being over-expressed in a number of human cancers. This feature of MAGE1 makes it a promising cancer biomarker. This study aimed to determine the expression of MAGE1 in esophageal squamous cell carcinoma (SCC) and its relationship with clinicopathological factors.

Methods

This is a cross-sectional study conducted on pretreatment endoscopic tissue specimens of 43 patients with non-metastatic esophageal SCC, admitted to Omid Hospital, Mashhad, Iran, between 2011 and 2013. Out of 127 esophageal SCC patients who had already enrolled in a trial of trimodality therapy, we chose 43 patients whose paraffin blocks of endoscopic samples were accessible, which we then stained for MAGE1 expression by immunohistochemistry. Correlation of MAGE1expression and clinicopathological data (age, sex, stage, grade, and outcome) was assessed using SPSS 16 by T test, chi-square, and Pearson tests (p <0.05 was considered significant).

Results

MAGE1 was expressed in 46.5% (20 out of 43) of esophageal SCC specimens. The MAGE1 nuclear staining increased significantly by age; its expression for <40, 41–49, 50–59, 60–69, and ≥70 years old was 0%, 0%, 8.3%, 26.3%, and 100%, respectively (p=0.02; Person’s R value = 0.3 and p=0.04). There was no significant correlation between MAGE1 expression and other clinicopathological parameters.

Conclusion

MAGE1 antigen has considerable expression in the esophageal SCC among the Iranian population; it can be potentially applied as a cancer biomarker as well as a target for immunotherapy in patients with esophageal SCC.