Can Clinical Response Predict Pathologic Response Following Neoadjuvant Chemoradiation for Esophageal Cancer?

OBJECTIVES

Approximately 20-40% of patients with locally advanced esophageal cancer will achieve a pathologic complete response (ypCR) following neoadjuvant chemoradiotherapy (nCRT). Predicting ypCR based on a clinical complete response (ycCR) has been a challenge. This study assessed the correlation between ycCR and ypCR, as determined from esophagectomy specimens.

METHODS

Patients undergoing esophagectomy following nCRT at three major institutions between 2005 and 2018 were reviewed. Restaging, including PET/CT, endoscopy with biopsy, and esophageal ultrasound (EUS), was performed to determine ycCR.

RESULTS

Six hundred sixty patients were included, with 93.3% with esophageal adenocarcinoma histology. Six hundred fifty-eight of these patients underwent PET, 304 EUS, and 584 underwent a biopsy. Following nCRT, 148 (22.4%) were found to have a ypCR. Only 12/32 (37.5%) determined to have a ycCR were found to have a ypCR, while 136/628 (21.6%) with a non-ycCR were found to have a ypCR (p 0.075). Individual modality PPV was 28% for PET, 54% for EUS, and 26% for biopsy. When PET was combined with EUS, 168 reports were concordant and the PPV of ypCR was 50%, though the number of patients was low (1/2). With all 3 re-staging modalities combined, the PPV and NPV both rose to 100%.

CONCLUSIONS

Current restaging tools cannot reliably predict ypCR after nCRT. While multimodal restaging appears to be a more accurate predictor of ypCR than any testing modality alone, patients cannot reliably be advised to avoid an esophagectomy on the assumption that ycCR predicts ypCR at this time.

Age-based differences in the diagnosis and management of esophageal eosinophilia

BACKGROUND

Eosinophilic esophagitis (EoE) is hallmarked by esophageal eosinophilia, >15 eosinophils(eos)/high-powered field (hpf), unresponsive to acid inhibition, and varied symptomatology. EoE consensus guidelines do not discriminate based on age for initiating treatment.

OBJECTIVE

To evaluate if age-related differences exist in managing esophageal eosinophilia and EoE within a university population.

METHODS

In a retrospective cohort study from a referral center, the medical records of 426 pediatric and adult patients with at least 1 presenting symptom of esophagitis, reflux, or upper gastrointestinal dysfunction, who underwent esophageal biopsy between 2009 and 2011 were analyzed for age-based differences in care in diagnosing and managing esophageal eosinophilia.

RESULTS

For these patients, 79.6% (336/426) had ≥15 eos/hpf in biopsy specimens, which was not associated with age. Significantly fewer adults than children with ≥15 eos/hpf were diagnosed with EoE (P < .001), referred for allergy evaluation (P < .001), started on swallowed steroid therapy (P < .001), or underwent repeated biopsy (P < .001). Increasing age, atopy, and increasing biopsy peak eos count moderated these effects, but the adjusted predicted probabilities for these outcomes were significantly lower among adults. Restriction for an 8-week prebiopsy proton-pump inhibitor trial did not alter the age-based relationships for an allergy referral or repeated biopsy.

CONCLUSIONS

Numerous age-based differences in the management of symptomatic patients with esophageal eosinophilia existed in this cohort. Adults were significantly less likely than children to receive a clinical diagnosis of EoE, allergy referral, or steroid treatment, or to have a repeated biopsy. Even when stratified for an 8-week prebiopsy proton-pump inhibitor trial, advancing age was associated with lower odds of referral or repeated biopsy. Further study is necessary to better understand why discrepancies exist and their potential ramifications.

Incidence of gastroesophageal reflux disease and positive maxillary antral cultures in children with symptoms of chronic rhinosinusitis

OBJECTIVES

Studies have shown that gastroesophageal reflux disease occurs more frequently than expected in children with chronic rhinosinusitis. The objective of this study is to further understand the relationship of pediatric chronic rhinosinusitis and gastroesophageal reflux disease in children with symptoms of rhinorrhea, nasal congestion, and chronic cough.

METHODS

A retrospective chart review of 63 children, ages 6 months to 10 years old with rhinorrhea, nasal congestion, and chronic cough. The patients underwent maxillary cultures, adenoidectomy, and distal third esophageal biopsies. Children with esophageal biopsies showing esophagitis were classified as positive for gastroesophageal reflux disease, and maxillary antral swabs growing a high density of bacteria were classified as positive for chronic rhinosinusitis.

RESULTS

Six months to 5 years old children (n=43), 6 (14%) had simultaneous positive maxillary antral cultures and positive esophageal biopsies, 11 (26%) had positive esophageal biopsies alone, 23 (53%) had positive maxillary antral cultures alone, and 3 (7%) had neither. Six to 10 years old children (n=20), 9 (45%) had simultaneous positive maxillary antral cultures and positive esophageal biopsies, 1 (5%) patient had positive esophageal biopsies alone, 3 (15%) patients had positive maxillary antral cultures alone, and 7 (35%) patients had neither. Twenty-seven (42%) of the patients from the whole study had gastroesophageal reflux positive biopsies. The younger children were statistically likely to have chronic rhinosinusitis and gastroesophageal reflux disease independently of each other (p=0.0002). A direct group comparison found the younger group to have independent chronic rhinosinusitis and gastroesophageal reflux disease and the older group to have simultaneous chronic rhinosinusitis and gastroesophageal reflux disease (p=0.0006).

CONCLUSION

In children with the presenting symptoms of rhinorrhea, nasal congestion, and chronic cough, younger children tend to have either chronic rhinosinusitis or gastroesophageal reflux disease, whereas older children tend to have a more complicated etiology of chronic rhinosinusitis and gastroesophageal reflux disease or other. In all of these patients gastroesophageal reflux disease plays an important role, as over 40% of all patients had gastroesophageal positive biopsies.