Chemotherapy for carcinoma of the esophagus: a comparison of evidence from meta-analyses of randomized trials and of historical control studies

Combined Modality Therapy for Management of Esophageal Cancer: Current Approach Based on Experiences from East and West

Human evolutionary genetic divergence and distinctive environmental exposures have contributed to the development of clinicopathologic variations of esophageal cancer in Eastern and Western countries. Different treatment strategies have derived from the disparate regional experiences. Treatment strategy is more standardized in the West. Trimodality treatment with neoadjuvant chemoradiation followed by surgery is widely accepted as the standard treatment of locally advanced esophageal adenocarcinoma and esophageal squamous cell carcinoma. Trimodality treatment has not been adopted in many Eastern countries, and standard treatment is neoadjuvant chemotherapy. Several randomized trials are ongoing that may alter the standard management of esophageal cancer worldwide.

Western strategy for EGJ carcinoma

In this paper, the epidemiological and clinicobiological behavior of esophagogastric junction (EGJ) adenocarcinoma in the West is compared and contrasted to that in the East, and an overview is provided of current therapeutic strategies employed for this type of tumor in Western countries. It is well known that multimodal treatment is the therapeutic standard in locally advanced EGJ adenocarcinoma, but whether neoadjuvant/perioperative chemotherapy (CT) or neoadjuvant chemoradiotherapy (CRT) is the optimal approach is still debated. Neoadjuvant CRT improves local control in locally advanced Siewert type I and II tumors, so it should be considered the treatment of choice. In the subset of these patients with microscopic systemic disease at diagnosis, more intensive exclusive chemotherapy protocols could be of benefit. Therefore, there is an urgent need to identify these patients before planning the treatment. For Siewert type III tumors, perioperative chemotherapy is the standard. While there is general agreement on the optimal surgical approach for Siewert types I and III (a two-field Ivor Lewis operation and a total gastrectomy with distal esophagectomy, respectively), no standard surgical treatment has been defined for Siewert type II tumors. When data from Western series on proximal and circumferential resection margins and on nodal spread in Siewert type II tumors are taken into account, the optimal surgical approach appears to be Ivor Lewis esophagectomy. Whether the extent of esophageal invasion can correctly predict nodal involvement in middle-upper mediastinal stations as a means to restrict indications for transthoracic esophagectomy requires further investigation in the West.

A comparative study of cisplatin-based definitive chemo-radiation in non-metastatic squamous cell carcinoma of the esophagus

Introduction

Esophageal cancer is the seventh most frequent malignancy in Iranian men and the fourth most common cancer in Iranian women. It is also among the 10 most frequent cancers in the world. Definitive chemo-radiation using cisplatin with 5-fluorouracil (5-FU) is known as the standard of care among various chemotherapy regimens used with esophageal cancer patients who are not eligible for surgery. Cisplatin with paclitaxel and cisplatin with irinotecan also have been used often during the past five years. The aim of this research was to compare overall survival (OS) and hematological toxicity rates between these regimens.

Methods

This single-institutional study included 55 patients who were treated with definitive chemo-radiation in the radiation-oncology ward at Shohada-e-Tajrish Hospital in Tehran, Iran, between 2006 and 2013. They received one of four regimens, i.e., cisplatin, cisplatin with 5-FU (old chemotherapy regimens), cisplatin with paclitaxel, or cisplatin with irinotecan (new chemotherapy regimens) as part of their definitive chemo-radiation with curative intent. The Kaplan-Meier estimator was used to estimate the overall survival times, which were compared by using the Breslow test.

Results

The follow-up period was between 26–109 months, with a median of 72 months. OS was not different between the old and new chemotherapy regimen groups (p = 0.18). Hematological toxicity (leucopenia) in the old chemotherapy regimen groups (10%) was significantly lower than in the new chemotherapy regimen groups (43%, p = 0.012). But OS in cisplatin or cisplatin with 5-FU scheme was statistically better than with the cisplatin with paclitaxel scheme (p = 0.026, p = 0.028, respectively).

Conclusion

This study showed that OS are similar in both the old and new chemotherapy treatment regimens in esophageal cancer patients who were treated with definitive chemo-radiation. The new chemotherapy treatment regimens should be used with caution as an alternative treatment of cisplatin with 5-FU for further evaluation.

Preoperative chemotherapy for resectable thoracic esophageal cancer

BACKGROUND

Surgery has been the treatment of choice for patients with localized esophageal cancer. Several studies have investigated whether preoperative chemotherapy followed by surgery leads to improvement in cure rates, but individual reports have provided conflicting results. An explicit systematic update of the role of preoperative chemotherapy in the treatment of patients with resectable thoracic esophageal cancer is, therefore, warranted.

OBJECTIVES

The objective of this review is to determine the role of preoperative chemotherapy in the treatment of patients with resectable thoracic esophageal carcinoma.

SEARCH METHODS

We identified trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to 2013), EMBASE (1988 to 2013), and CANCERLIT (1993 to 2013). We did not confine our search to English language publications. We updated searches in CENTRAL, MEDLINE, and EMBASE in October 2013.

SELECTION CRITERIA

All trials of patients with potentially resectable carcinoma of the esophagus (of any histologic type) who were randomly assigned to chemotherapy or no chemotherapy before surgery.

DATA COLLECTION AND ANALYSIS

The primary outcome was survival, which was assessed with the use of hazard ratios. This is an amendment to the original review, which used risk ratios to assess survival at yearly intervals. Hazard ratios (HRs) have now been introduced to summarize the complete survival experience in a single analysis. Risk ratios (RRs) were used to compare rates of resection, tumor recurrences, and treatment morbidity and mortality.

MAIN RESULTS

We identified a total of 13 randomized trials involving 2362 participants. Ten trials (2122 participants) reported sufficient detail on survival to be included in a meta-analysis for the primary outcome. Preoperative chemotherapy improves overall survival (HR 0.88, 95% confidence interval (CI) 0.80 to 0.96) and is associated with a significantly higher rate of complete (R0) resection (RR 1.11, 95% CI 1.03 to 1.19).No evidence suggests that the overall rate of resection (RR 0.96, 95% CI 0.92 to 1.01), tumor recurrence (RR 0.81, 95% CI 0.54 to 1.22) or nonfatal complications (RR 0.90; 95% CI 0.76 to 1.06) was different for preoperative chemotherapy compared with surgery alone. Trials reported risks of toxicity with chemotherapy that ranged from 11% to 90%.

AUTHORS' CONCLUSIONS

In summary, preoperative chemotherapy plus surgery offers a survival advantage compared with surgery alone for patients with resectable thoracic esophageal cancer, but the evidence is of moderate quality. Some evidence of toxicity and preoperative mortality have been associated with chemotherapy.

Comparison of anticipated and actual control group outcomes in randomised trials in paediatric oncology provides evidence that historically controlled studies are biased in favour of the novel treatment

BACKGROUND

Historically controlled studies are commonly undertaken in paediatric oncology, despite their potential biases. Our aim was to compare the outcome of the control group in randomised controlled trials (RCTs) in paediatric oncology with those anticipated in the sample size calculations in the protocols. Our rationale was that, had these RCTs been performed as historical control studies instead, the available outcome data used to calculate the sample size in the RCT would have been used as the historical control outcome data.

METHODS

A systematic search was undertaken for published paediatric oncology RCTs using the Cochrane Central Register of Controlled Trials (CENTRAL) database from its inception up to July 2013. Data on sample size assumptions and observed outcomes (timetoevent and proportions) were extracted to calculate differences between randomised and historical control outcomes, and a one-sample t-test was employed to assess whether the difference between anticipated and observed control groups differed from zero.

RESULTS

Forty-eight randomised questions were included. The median year of publication was 2005, and the range was from 1976 to 2010. There were 31 superiority and 11 equivalence/noninferiority randomised questions with time-to-event outcomes. The median absolute difference between observed and anticipated control outcomes was 5.0% (range: -23 to +34), and the mean difference was 3.8% (95% CI: +0.57 to +7.0; P = 0.022).

CONCLUSIONS

Because the observed control group (that is, standard treatment arm) in RCTs performed better than anticipated, we found that historically controlled studies that used similar assumptions for the standard treatment were likely to overestimate the benefit of new treatments, potentially leading to children with cancer being given ineffective therapy that may have additional toxicity.

Multimodality management of esophageal cancer

Esophageal cancer is a morbid disease with a grim prognosis. The outcomes of treatment even in non-metastatic disease undergoing potentially curative surgery are poor with 5-year survival ranging from 20 to 35 %. Several multimodality treatment options have been investigated in well-conducted randomised trials and meta-analyses evaluating both neoadjuvant and adjuvant therapies. However, there is still lack of uniform practice in the management of operable esophageal cancer. We review the current evidence for multimodality treatment of esophageal cancer, critically analysing the evidence supporting the use of each strategy, the pros and cons of each approach and discuss our approach in management. Neoadjuvant chemotherapy or chemoradiotherapy are currently the standard of care in localised esophageal cancer.

Undervalued criteria in the evaluation of multimodal trials for upper GI cancers

Global economies and their health systems face a huge challenge from cancer: 1 in 3 women and 1 in 2 men will develop cancer in their lifetime. In the less developed countries, the volume of cancer patients will overwhelm the existing healthcare systems. Even in developed regions, patients with upper gastrointestinal (GI) cancer usually present with locally advanced tumors that their prognosis is poor. A detailed knowledge of anatomy, embryology, epidemiology, tumor classifications and tumor growth is key understanding and evaluating the relevant research. We review undervalued criteria necessary to evaluate the response to multimodal therapy for upper GI cancers.

Multimodality therapy for cancers of the esophagus and gastric cardia

The role of multimodal treatment in the management of esophageal cancer is controversial. There are conflicting results from studies on the effect of neoadjuvant and/or adjuvant treatment on long-term survival. Following a search of the Medline database, the authors examine the results of randomized studies on the various treatment protocols available and discuss future therapeutic improvements.

Is a nurse-led telephone intervention a viable alternative to nurse-led home care and standard care for patients receiving oral capecitabine? Results from a large prospective audit in patients with colorectal cancer

Home care nursing has been shown to be a valuable service for patients receiving oral chemotherapy; however, associated costs can be high and telephone-based services may be more cost-effective options. This prospective audit explored the usefulness of a nurse-led telephone intervention for supporting cancer patients treated with Capecitabine, comparing historical findings from a randomised trial evaluating a home-based intervention over standard care with a modified nurse-led telephone follow-up intervention. Self-reported toxicity and service use were assessed in 298 patients who received nurse-led telephone follow-up, compared with historical data from 164 patients (81 receiving standard care and 83 home care intervention). Findings suggested that nurse-led telephone follow-up can potentially lead to reduced toxicity (chest pain, vomiting, oral mucositis, nausea, insomnia) when compared with standard care, and that it has a similar impact on the management of some symptoms when compared with home care (i.e. vomiting, oral mucositis), although it was not as effective as the home care intervention for other toxicities (diarrhoea and insomnia). These encouraging findings need to be explored further using a randomised trial design before we reach any conclusions. Further research should also include a health economics study to assess the cost-effectiveness of the telephone-based services for patients receiving oral chemotherapy.

Multimodality management of esophageal cancer

Esophageal cancer is a highly lethal and aggressive disease and a major public health problem worldwide. The incidence of esophageal cancer in the western hemisphere has increased by 400 % in the past few decades (Posner et al. 2011). Surgery is the mainstay of definitive management of esophageal cancer; however, the results of surgery alone have been dismal, with survival rates of approximately 15 to 20 % at 5 years (Hingorani et al., Clin Oncol 23:696-705, 2011). The last three decades have seen growing interest in various adjuvant and neoadjuvant treatment strategies, with an aim to improve disease control and overall survival. However, due to conflicting and often contradictory results, there was controversy on the ideal treatment paradigm. Recent evidence suggests an improvement in overall survival with neoadjuvant therapy, both chemotherapy and chemoradiotherapy, over surgery. In this review we address various issues concerning multimodality management of locally advanced esophageal cancers: Does neoadjuvant therapy offer a definite benefit over surgery alone? If so, which neoadjuvant strategy? Does the survival benefit outweigh the increased treatment related toxicity/morbidity? Finally, is neoadjuvant treatment the standard of care for locally advanced resectable esophageal cancer?

Randomisation to protect against selection bias in healthcare trials

BACKGROUND

Randomised trials use the play of chance to assign participants to comparison groups. The unpredictability of the process, if not subverted, should prevent systematic differences between comparison groups (selection bias). Differences due to chance will still occur and these are minimised by randomising a sufficiently large number of people.

OBJECTIVES

To assess the effects of randomisation and concealment of allocation on the results of healthcare studies.

SEARCH STRATEGY

We searched the Cochrane Methodology Register, MEDLINE, SciSearch and reference lists up to September 2009. In addition, we screened articles citing included studies (ISI Science Citation Index) and papers related to included studies (PubMed).

SELECTION CRITERIA

Eligible study designs were cohorts of studies, systematic reviews or meta-analyses of healthcare interventions that compared random allocation versus non-random allocation or adequate versus inadequate/unclear concealment of allocation in randomised trials. Outcomes of interest were the magnitude and direction of estimates of effect and imbalances in prognostic factors.

DATA COLLECTION AND ANALYSIS

We retrieved and assessed studies that appeared to meet the inclusion criteria independently. At least two review authors independently appraised methodological quality and extracted information. We prepared tabular summaries of the results for each comparison and assessed the results across studies qualitatively to identify common trends or discrepancies.

MAIN RESULTS

A total of 18 studies (systematic reviews or meta-analyses) met our inclusion criteria. Ten compared random allocation versus non-random allocation and nine compared adequate versus inadequate or unclear concealment of allocation within controlled trials. All studies were at high risk of bias.For the comparison of randomised versus non-randomised studies, four comparisons yielded inconclusive results (differed between outcomes or different modes of analysis); three comparisons showed similar results for random and non-random allocation; two comparisons had larger estimates of effect in non-randomised studies than in randomised trials; and two comparisons had larger estimates of effect in randomised than in non-randomised studies.Five studies found larger estimates of effect in trials with inadequate concealment of allocation than in trials with adequate concealment. The four other studies did not find statistically significant differences.

AUTHORS' CONCLUSIONS

The results of randomised and non-randomised studies sometimes differed. In some instances non-randomised studies yielded larger estimates of effect and in other instances randomised trials yielded larger estimates of effect. The results of controlled trials with adequate and inadequate/unclear concealment of allocation sometimes differed. When differences occurred, most often trials with inadequate or unclear allocation concealment yielded larger estimates of effects relative to controlled trials with adequate allocation concealment. However, it is not generally possible to predict the magnitude, or even the direction, of possible selection biases and consequent distortions of treatment effects from studies with non-random allocation or controlled trials with inadequate or unclear allocation concealment.

Meta-analysis of neoadjuvant treatment modalities and definitive non-surgical therapy for oesophageal squamous cell cancer

BACKGROUND

The standard treatment for resectable oesophageal squamous cell carcinoma (OSCC) is surgical resection with adequate lymphadenectomy. Most Western patients receive neoadjuvant chemotherapy or chemoradiotherapy (CRT). In recent years some patients have received CRT alone (definitive CRT, dCRT). This meta-analysis sought to clarify the benefits of neoadjuvant and definitive treatment for OSCC.

METHODS

Eligible randomized controlled trials (RCTs) were identified using the Cochrane database, MEDLINE and Embase. Only RCTs with intention-to-treat analysis, and published hazard ratios (HRs) or estimates from survival data, were included.

RESULTS

Nine RCTs involving neoadjuvant CRT versus surgery, eight involving neoadjuvant chemotherapy versus surgery, and three involving neoadjuvant treatment followed by surgery or surgery alone versus dCRT were identified. The HR for overall survival was 0·81 (95 per cent confidence interval 0·70 to 0·95; P = 0·008) after neoadjuvant CRT and 0·93 (0·81 to 1·08; P = 0·368) after neoadjuvant chemotherapy. The likelihood of R0 resection was significantly higher after neoadjuvant treatment (CRT: HR 1·15, P = 0·043; chemotherapy: HR 1·16, P = 0·006). Morbidity rates were not increased after neoadjuvant CRT (HR 0·94, P = 0·363) but 30-day mortality was non-significantly higher with combined treatment. Morbidity (HR 1·03, P = 0·638) and mortality (HR 1·04, P = 0·810) rates after neoadjuvant chemotherapy and surgery did not differ from those after surgery alone. None of the RCTs reporting outcome after dCRT demonstrated a significant survival benefit, but treatment-related mortality rates were lower (HR 7·60, P = 0·007) than with neoadjuvant treatment followed by surgery or surgery alone.

CONCLUSION

For patients with resectable OSCC, a significant survival benefit for neoadjuvant CRT was evident, with no increase in morbidity rate. dCRT did not demonstrate any survival benefit over other curative strategies. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Impact of postoperative radiation after esophagectomy for esophageal cancer

INTRODUCTION

Though postoperative radiation for esophageal cancer is offered in selected cases, there is conflicting evidence as to whether it improves overall survival (OS). We performed a retrospective analysis using the Surveillance Epidemiology and End Results database to analyze the impact of adjuvant radiation in a large cohort of patients.

METHODS

From 1998 to 2005, patients diagnosed with stage T3-4N0M0 or T1-4N1M0 esophageal adenocarcinoma (AC) or squamous cell carcinoma (SCC) who were definitively treated with esophagectomy, with or without postoperative radiation, were selected. Kaplan-Meier and Cox regression analysis were used to compare OS and disease-specific survival (DSS).

RESULTS

A total of 1046 patients met the selection criteria: 683 (65.3%) received surgery alone and 363 (34.7%) received postoperative radiation. For American Joint Committee on Cancer stage III esophageal carcinoma (T3N1M0 or T4N0-1M0), there was significant improvement in median and 3-year OS (p < 0.001) and DSS (p < 0.001), respectively. This benefit was present for both SCC and AC. However, for American Joint Committee on Cancer stages IIA and IIB disease there was no significant differences in OS or DSS. Multivariate analysis revealed that postoperative radiation was the most significant predictor for improved OS (hazard ratio 0.70, 95% confidence interval 0.59-0.83, p < 0.001).

CONCLUSIONS

This large population-based review supports the use of postoperative radiation for stage III SCC and AC of the esophagus. Given the retrospective nature of this study, until appropriately powered randomized trials confirm these results, caution should be used before broadly applying these findings in clinical practice.

Surgery within multimodal therapy concepts for esophageal squamous cell carcinoma (ESCC): the MRI approach and review of the literature

BACKGROUND

Radical esophagectomy with lymphadenectomy remains the only curative therapy for patients with resectable esophageal squamous cell cancer (ESCC), however, combined treatment modalities may improve survival. Based upon more than 1300 consecutive esophageal resections, we present our current multidisciplinary ESCC approach with analysis in the context of recently published RCTs.

METHODS

Subject to tumor staging, patients with resectable ESCC receive either a neoadjuvant radiochemotherapy (uT3N+) or are referred to primary surgery (uT1/2N0). By Medline searches (1997-2009), all published RCTs containing multimodal ESCC therapy concepts were identified and a systematic review was generated.

RESULTS

From July 2007 to June 2009, 62 patients with ESCC were treated in our department (40 multimodal treatment concept, 21 primary surgery, 1 definite radiochemotherapy). The R0 resection rate was 78%, in hospital mortality 4.8%. 60% of patients showed a good response to neoadjuvant treatment. 18-month follow-up data revealed absence of tumor recurrence in 7 patients (18%). Our approach is aligned to the current published literature including 12 studies in this review. In line with our institutional experience, neodjuvant radiochemotherapy tends to improve overall survival and increases the likelihood of R0 resection. However, postoperative morbidity and mortality rates are increased. Adjuvant treatment failed to demonstrate any improvement in prognosis. For palliation, concurrent radiochemotherapy is the treatment of choice.

CONCLUSION

The MRI approach can be aligned to the most recent published data. Surgical resection remains the principle treatment for patients with resectable ESCC. Although multimodal therapy concepts tend to improve survival rates, postoperative morbidity and mortality rates are increased.

Who profits from neoadjuvant radiochemotherapy for locally advanced esophageal carcinoma?

BACKGROUND

Patients suffering from locally advanced esophageal carcinoma are generally treated using multimodal therapies. This prospective, non-randomized trial was performed to evaluate the survival benefit of neoadjuvant radiochemotherapy prior to surgery in comparison with surgery only.

PATIENTS & METHODS

Histopathological outcomes and survival were compared between 61 patients who underwent neoadjuvant radiochemotherapy and 64 comparable control patients who had been under-staged. After neoadjuvant therapy, tumor regression was assessed using the method described by Mandard in 1994. Survival curves for the two groups were estimated using the Kaplan-Meier method, and compared with the log-rank test.

RESULTS

Median and 3-year recurrence-free survival for the entire group were 26 months and 39.7%, respectively. The median and 3-year overall survival reached 34 months and 48.1%. Patients who showed complete response to neoadjuvant therapy had significantly improved survival (35 months) compared to patients with residual tumor cells (28 months), patients with tumors unresponsive to radiochemotherapy (22 months), or patients who received surgery only (control group, 29 months). Patients with nodal-negative carcinomas showed significantly longer survival after surgery only and after neoadjuvant therapy compared to patients with lymph node-positive cancers.

CONCLUSIONS

Complete response after neoadjuvant radiochemotherapy is associated with significantly improved survival. Negative nodal status is a major determinant of outcomes following primary operation or neoadjuvant treatment.

Therapeutic strategies in oesophageal carcinoma: role of surgery and other modalities

Traditionally, surgery is considered the best treatment for oesophageal cancer in terms of locoregional control and long-term survival. However, survival 5 years after surgery alone is about 25%, and, therefore, a multidisciplinary approach that includes surgery, radiotherapy, and chemotherapy, alone or in combination, could prove necessary. The role of each of these treatments in the management of oesophageal cancer is under intensive research to define optimum therapeutic strategies. In this report we provide an update on treatment strategies for resectable oesophageal cancers on the basis of recent published work. Results of the latest randomised trials allow us to propose the following guidelines: surgery is the standard treatment, to be used alone for stages I and IIa, or possibly with neoadjuvant chemotherapy or chemoradiotherapy for stage IIb disease. For locally advanced cancers (stage III), neoadjuvant chemotherapy or chemoradiotherapy followed by surgery is appropriate for adenocarcinomas. Chemoradiotherapy alone should only be considered in patients with squamous-cell carcinomas who show a morphological response to chemoradiotherapy, and produces a similar overall survival to chemoradiotherapy followed by surgery, but with less post-treatment morbidity. Although the addition of surgery to chemotherapy or chemoradiotherapy could result in improved local control and survival, surgery should be done in experienced hospitals where operative mortality and morbidity are low. Moreover, surgery should be kept in mind as salvage treatment in patients with no morphological response or persistent tumour after definitive chemoradiotherapy.

Randomisation to protect against selection bias in healthcare trials

BACKGROUND

Randomised trials use the play of chance to assign participants to comparison groups. The unpredictability of the process, if not subverted, should prevent systematic differences between comparison groups (selection bias), provided that a sufficient number of people are randomised.

OBJECTIVES

To assess the effects of randomisation and concealment of allocation on the results of healthcare trials.

SEARCH STRATEGY

We searched the Cochrane Methodology Register, MEDLINE, SciSearch, reference lists up to August 2000 and used personal communication.

SELECTION CRITERIA

Cohorts of trials, systematic reviews or meta-analyses of healthcare interventions that compared outcomes or prognostic factors for one of the following comparisons: randomised versus non-randomised trials, randomised trials with adequately versus inadequately concealed allocation, or high versus low quality trials where selection bias could not be separated from other sources of bias.

DATA COLLECTION AND ANALYSIS

One of us went through all of the citations in the Cochrane Methodology Register and accumulated reference lists. Studies that appeared to meet the inclusion criteria were retrieved and assessed independently by two of the reviewers. The methodological quality of included studies was appraised and information extracted by one of us and checked by a second. Tabular summaries of the results were prepared for each comparison and the results across studies were assessed qualitatively to identify common trends or discrepancies.

MAIN RESULTS

We identified 32 studies including over 3000 trials. Twenty-two studies compared randomised versus non-randomised trials, three compared adequately versus inadequately concealed allocation, and nine compared high versus low quality trials (some studies included more than one comparison). Five studies were of high methodological quality. In 15 of the 22 studies that compared randomised and non-randomised trials of the same intervention, important differences were found in the estimates of effect. Some of these differences were due to a poorer prognosis in the control groups in the non-randomised trials. The results of the other seven studies that compared randomised and non-randomised trials across different interventions are less clear. Comparisons of adequately and inadequately concealed allocation in randomised trials of the same intervention provided high quality evidence that concealment can be crucial in achieving similar treatment groups and, therefore, unbiased estimates of treatment effects. Studies with inadequate concealment tended to overestimate treatment effects. Comparisons of high and low quality trials of the same intervention have found important differences in estimates of effect, but it is not possible to determine the extent to which these differences can be attributed to randomisation or concealment of allocation. Omitting comparisons between randomised trials and non-randomised trials using historical controls did not substantially alter the results or conclusions of our review.

AUTHORS' CONCLUSIONS

On average, non-randomised trials and randomised trials with inadequate concealment of allocation tend to result in larger estimates of effect than randomised trials with adequately concealed allocation. However, it is not generally possible to predict the magnitude, or even the direction, of possible selection biases and consequent distortions of treatment effects.

Survival benefits from neoadjuvant chemoradiotherapy or chemotherapy in oesophageal carcinoma: a meta-analysis

BACKGROUND

Resectable oesophageal cancer is often treated with surgery alone or with preoperative (neoadjuvant) chemoradiotherapy or chemotherapy. We aimed to clarify the benefits of neoadjuvant chemoradiotherapy or chemotherapy versus surgery alone by a meta-analysis of randomised trial data.

METHODS

Eligible trials were identified first from earlier published meta-analyses and systematic reviews. We also used MEDLINE, Cancerlit, and EMBASE databases to identify additional studies and published abstracts from major scientific meetings since 1980. Only randomised studies with an analysis by an intention-to-treat principle were included, and searches were restricted to those databases citing articles in English. We used published hazard ratios if available or estimates from other survival data or survival curves. Treatment effects by type of tumour and treatment sequencing were also investigated.

FINDINGS

Ten randomised comparisons of neoadjuvant chemoradiotherapy versus surgery alone (n=1209) and eight of neoadjuvant chemotherapy versus surgery alone (n=1724) in patients with local operable oesophageal carcinoma were identified. The hazard ratio for all-cause mortality with neoadjuvant chemoradiotherapy versus surgery alone was 0.81 (95% CI 0.70-0.93; p=0.002), corresponding to a 13% absolute difference in survival at 2 years, with similar results for different histological tumour types: 0.84 (0.71-0.99; p=0.04) for squamous-cell carcinoma (SCC), and 0.75 (0.59-0.95; p=0.02) for adenocarcinoma. The hazard ratio for neoadjuvant chemotherapy was 0.90 (0.81-1.00; p=0.05), which indicates a 2-year absolute survival benefit of 7%. There was no significant effect on all-cause mortality of chemotherapy for patients with SCC (hazard ratio 0.88 [0.75-1.03]; p=0.12), although there was a significant benefit for those with adenocarcinoma (0.78 [0.64-0.95]; p=0.014).

INTERPRETATION

A significant survival benefit was evident for preoperative chemoradiotherapy and, to a lesser extent, for chemotherapy in patients with adenocarcinoma of the oesophagus. The findings provide an evidence-based framework for the use of neoadjuvant treatment in management decisions.

Epidermal growth factor receptor tyrosine kinase inhibitor, erlotinib, and concurrent 5-fluorouracil, cisplatin and radiotherapy for patients with esophageal cancer: a phase I study

This phase I trial investigates the safety of combining radiation, 5-fluorouracil (5-FU) and cisplatin with the epidermal growth factor receptor tyrosine kinase inhibitor, erlotinib, in patients with esophageal carcinoma. From April 2000 to January 2005, 11 patients with squamous or adenocarcinoma of the esophagus were enrolled. Patients received either 50, 100 or 150 mg oral erlotinib/day beginning on the first day of radiation (three patients in each dose cohort). Concurrent cisplatin (75 mg/m2 i.v., days 8 and 36) and 5-FU (1000 mg/m2 i.v., days 8-11 and 36-39) were also given with 50.4 Gy thoracic radiation, delivered at 180 cGy/day, 5 days/week. Toxicity was evaluated using the National Cancer Institute Common Toxicity Criteria (version 3.0). Erlotinib with concurrent 5-FU, cisplatin and thoracic radiation was well-tolerated at 50, 100 and 150 mg/day. The major toxicities were diarrhea (grade 1=18%, grade 2=18%), skin rash (grade 4=54.5%), nausea (grade 1=18%, grade 2=54%, grade 3=9%) and dehydration (grade 3=27%). All patients experienced esophagitis during treatment (grade 1=55%, grade 2=32%, grade 3=9%, grade 4=9%). Two patients were discontinued from the study secondary to non-erlotinib-related toxicities. We conclude that the phase I study demonstrates the safety and tolerability of erlotinib delivered at 150 mg/day with concurrent 5-FU, cisplatin and thoracic radiation. The major toxicities encountered were grade 1-2 diarrhea, grade 1 skin rash, grade 1-3 nausea and grade 3 dehydration. A phase II study is planned.

Adjuvant chemotherapy with 5-fluorouracil and cisplatin in lymph node-positive thoracic esophageal squamous cell carcinoma

BACKGROUND

In this study we explored the effectiveness of adjuvant chemotherapy in node-positive, resected thoracic esophageal squamous cell carcinoma patients.

METHODS

A prospective study of postoperative chemotherapy in N1 esophageal cancer patients who received curative resection was conducted and compared with the historical control group in regard to recurrence rate, patterns of failure, disease-free survival rate, and overall survival rate. The postoperative chemotherapy consisted of cisplatin (60 mg/m2 intravenously) and 5-fluorouracil (1,000 mg/m2 per day) in a continuous infusion for 4 days. Three cycles were administered at 3-week intervals.

RESULTS

Forty patients were accrued from January 1998 to January 2003 at Samsung Medical Center for adjuvant chemotherapy. The historical control group consisted of 52 patients who received curative resection but not adjuvant chemotherapy during the same period of time. The 3-year disease-free survival rate was 47.6% in the adjuvant group and 35.6% in the control group (p = 0.049). The estimated 5-year overall survival rates were 50.7% in the adjuvant group and 43.7% in the control group (p = 0.228). The significant predictive factors for tumor recurrence were the number of positive lymph nodes (p = 0.008) and the adjuvant chemotherapy (p = 0.030).

CONCLUSIONS

This study suggests that the postoperative chemotherapy may prolong disease-free survival in lymph node-positive, curatively resected esophageal cancer patients. The postoperative treatment modality for esophageal cancer patients should be determined according to the lymph node status and a randomized phase III clinical trial is warranted using adjuvant chemotherapy if the esophageal cancer is lymph node-positive.

Preoperative chemotherapy for resectable thoracic esophageal cancer

BACKGROUND

Surgery has been the treatment of choice for localized esophageal cancer. A number of studies have investigated whether preoperative chemotherapy followed by surgery leads to an improvement in cure rates but the individual reports have been conflicting. An explicit systematic update of the role of preoperative chemotherapy in the treatment of resectable thoracic esophageal cancer is, therefore, warranted.

OBJECTIVES

The objective of this review is to determine the role of preoperative chemotherapy on patients with resectable thoracic esophageal carcinomas.

SEARCH STRATEGY

Trials were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to 2006), EMBASE (1988 to 2006) and CANCERLIT (1993 to 2002). There were no language restrictions.

SELECTION CRITERIA

All trials of patients with potentially resectable carcinomas of the esophagus (of any histologic type) who were randomised to having either chemotherapy or no chemotherapy before surgery.

DATA COLLECTION AND ANALYSIS

The primary outcome was survival, which was assessed using hazard ratios. This is an amendment to the original review which used relative risks to assess survival at yearly intervals. Hazard ratios (HR) have now been introduced to summarise the complete survival experience in a single analysis. The risk ratio (relative risk; RR) was used to compare rates of resections, tumour recurrences and treatment morbidity and mortality.

MAIN RESULTS

There were eleven randomised trials involving 2019 patients. Eight trials (1729 patients) reported sufficient detail on survival to be included in a meta-analysis for the primary outcome. There was some evidence to suggest that preoperative chemotherapy improves survival, but this was inconclusive (HR 0.88; 95% CI 0.75 to 1.04). There was no evidence to suggest that the overall rate of resections (RR 0.96, 95% CI 0.92 to 1.01) or the rate of complete resections (R0) (RR 1.05; 95% CI 0.97 to 1.15) differ between the preoperative chemotherapy arm and surgery alone. There is no evidence that tumour recurrence (RR 0.81, 95% CI 0.54 to 1.22) or non-fatal complication rates (RR 0.90; 95% CI 0.76 to 1.06) differ for preoperative chemotherapy compared to surgery alone. Trials reported risks of toxicity with chemotherapy that ranged from 11% to 90%.

AUTHORS' CONCLUSIONS

In summary, preoperative chemotherapy plus surgery may offer a survival advantage compared to surgery alone for resectable thoracic esophageal cancer, but the evidence is inconclusive. There is some evidence of toxicity and preoperative mortality associated with chemotherapy.

Systemic treatment for oesophageal cancer

Oesophageal cancer, in particular adenocarcinomas, has shown a rapid and largely unexplained increase in incidence in the Western world. Despite advances in diagnostic and surgical techniques and improved pre- and postoperative care, the prognosis of most patients is poor. This Review will focus on the use of chemotherapy as part of multimodal treatment and for patients with metastatic disease. Randomised phase III trials have, for the most part, failed to demonstrate a survival advantage with the use of chemotherapy. It must be emphasised that many of these phase III trial were underpowered and do not meet today's standards. Recent phase II trials have suggested some progress when chemotherapy is incorporated into the management of patients with oesophageal cancer. However, confirmatory and adequately powered and designed phase III studies are urgently needed to improve patient outcomes and for better palliation of symptoms.

Surgery for Esophageal Cancer after Concomitant Radiochemotherapy: Oncologic and Functional Results

The aim of this study was to evaluate the results of surgery after preoperative radiochemotherapy (PRCT) for esophageal cancer. This retrospective study included 88 patients scan between 1992 and 2000. The median follow-up was 55.7 months (3.3-104.1 months). Surgical mortality was 15.9%. Multivariate analysis found that the following were risk factors for surgical mortality: gamma-glutamyltransferase level > 75 UI/ml (p = 0.007), weight loss = 10% (p = 0.05), and digestive toxicity World Health Organization grade III or IV during PRCT (p = 0.019). The median overall survival was 24.9 months. The 5-year overall survival (OS) and disease-free survival (DFS) were, respectively, 33.1% and 33.2%. Complete responder patients had a 71.8% 5-year OS (p = 0.01) and a 71.8% 5-year DFS (p = 0.009). The rate of recurrence was 37.5%. Multivariate analysis found that female gender (p = 0.03), weight loss = 10% (p = 0.03), preoperative computed tomography scan bronchial contact (p = 0.01), and N+ status (pN+) at pathology examination (p = 0.0001) were predictors of poor oncologic results. Patients with high preoperative risk of surgical mortality need to be selected for intensive perioperative management. In association with surgery, PRCT improves the local control, DFS, and OS of responder patients. Morphologic evaluation for staging esophageal cancer in predicting the pathologic response after PRCT is poor or controversial. Only surgical resection can provide accurate prognostic information for staging esophageal cancer and improving local control.

Esophageal Carcinoma: Current Controversial Topics

Worldwide, esophageal carcinoma is a common gastrointestinal cancer with a high mortality. The incidence of adenocarcinoma of the esophagus is increasing in the western world, but squamous cell carcinoma remains dominant in the underdeveloped parts of the world. Both types of esophageal carcinoma remain equally virulent. Currently, there are no optimal preventative screening programs available and most patients present with advanced or metastatic disease. Although many options are available for improving diagnostic accuracy, a single method has not displayed significant advantages over the others. In addition, selecting a superior treatment regimen has not surfaced. Preferred resection techniques exist, but one method has not illustrated improvements in survival over the others. A lack of improved survival rates with single modality therapies has led to a multi modality approach. However, developments in neoadjuvant and adjuvant therapies have led to mixed conclusions. Collectively, past studies have not shown an optimal neoadjuvant or adjuvant regimen in terms of survival benefit. This review highlights existing staging modalities and treatment regimens for esophageal carcinoma, in an effort to illustrate the controversial nature surrounding its management.

[Radiotherapy and chemotherapy in the treatment of oesophageal carcinoma]

Surgery, chemotherapy and radiotherapy are the three major arms of treatment for cancer of the oesophagus, and combined modality therapy is required to treat advanced disease. Exclusive chemoradiotherapy is a feasible option for locoregionally advanced disease in responder patients. Elective surgery as a palliative procedure should not be regarded as a standard option in patients with metastatic or non-resectable oesophageal cancer. Surgery appears more and more as an adjuvant therapy in the curative treatment of oesophageal cancer, especially for advanced tumours.

Neoadjuvant or adjuvant therapy for resectable esophageal cancer: a systematic review and meta-analysis

BACKGROUND

Carcinoma of the esophagus is an aggressive malignancy with an increasing incidence. Its virulence, in terms of symptoms and mortality, justifies a continued search for optimal therapy. The large and growing number of patients affected, the high mortality rates, the worldwide geographic variation in practice, and the large body of good quality research warrants a systematic review with meta-analysis.

METHODS

A systematic review and meta-analysis investigating the impact of neoadjuvant or adjuvant therapy on resectable thoracic esophageal cancer to inform evidence-based practice was produced.MEDLINE, CANCERLIT, Cochrane Library, EMBASE, and abstracts from the American Society of Clinical Oncology and the American Society for Therapeutic Radiology and Oncology were searched for trial reports. Included were randomized trials or meta-analyses of neoadjuvant or adjuvant treatments compared with surgery alone or other treatments in patients with resectable thoracic esophageal cancer. Outcomes of interest were survival, adverse effects, and quality of life. Either one- or three-year mortality data were pooled and reported as relative risk ratios.

RESULTS

Thirty-four randomized controlled trials and six meta-analyses were obtained and grouped into 13 basic treatment approaches. Single randomized controlled trials detected no differences in mortality between treatments for the following comparisons:- Preoperative radiotherapy versus postoperative radiotherapy.- Preoperative and postoperative radiotherapy versus postoperative radiotherapy. Preoperative and postoperative radiotherapy was associated with a significantly higher mortality rate.- Postoperative chemotherapy versus postoperative radiotherapy.- Postoperative radiotherapy versus postoperative radiotherapy plus protein-bound polysaccharide versus chemoradiation versus chemoradiation plus protein-bound polysaccharide. Pooling one-year mortality detected no statistically significant differences in mortality between treatments for the following comparisons:- Preoperative radiotherapy compared with surgery alone (five randomized trials).- Postoperative radiotherapy compared with surgery alone (five randomized trials).- Preoperative chemotherapy versus surgery alone (six randomized trials).- Preoperative and postoperative chemotherapy versus surgery alone (two randomized trials).- Preoperative chemoradiation therapy versus surgery alone (six randomized trials). Single randomized controlled trials detected differences in mortality between treatments for the following comparison:- Preoperative hyperthermia and chemoradiotherapy versus preoperative chemoradiotherapy in favour of hyperthermia. Pooling three-year mortality detected no statistically significant difference in mortality between treatments for the following comparison:- Postoperative chemotherapy compared with surgery alone (two randomized trials). Pooling three-year mortality detected statistically significant differences between treatments for the following comparisons:- Preoperative chemoradiation therapy versus surgery alone (six randomized trials) in favour of preoperative chemoradiation with surgery.- Preoperative chemotherapy compared with preoperative radiotherapy (one randomized trial) in favour of preoperative radiotherapy.

CONCLUSION

For adult patients with resectable thoracic esophageal cancer for whom surgery is considered appropriate, surgery alone (i.e., without neoadjuvant or adjuvant therapy) is recommended as the standard practice.

Preoperative chemotherapy for resectable thoracic esophageal cancer

BACKGROUND

Surgery has been the treatment of choice for localized esophageal cancer. A number of studies have investigated whether preoperative chemotherapy followed by surgery leads to an improvement in cure rates, but the individual reports have been conflicting. An explicit systematic update of the role of preoperative chemotherapy in the treatment of resectable thoracic esophageal cancer is therefore warranted.

OBJECTIVES

The objective of this review is to determine the role of preoperative chemotherapy on patients with resectable thoracic esophageal carcinomas.

SEARCH STRATEGY

Trials were identified by searching the Cochrane Controlled Trials Register, MEDLINE (1966 - 2003), EMBASE (1988 - 2003) and CancerLit (1993 - 2003). There were no language restrictions.

SELECTION CRITERIA

Types of studies. Studies that randomised patients with potentially resectable carcinomas of the esophagus (of any histologic type) to chemotherapy or no chemotherapy before surgeries were included in this review. Types of participants. The participants consisted of patients with localized potentially resectable thoracic esophageal carcinomas. Trials involving patients with carcinomas of the cervical esophagus were excluded. Types of interventions. Trials that compared chemotherapy before surgery (esophagectomy) with surgical resections alone (esophagectomy) were included. Types of outcome measures. The primary outcome was overall survival at yearly intervals after randomisation. Secondary outcomes of interest included rates of resections, response to chemotherapy, rates of local and distant recurrences, quality-of-life, and treatment morbidity and mortality.

DATA COLLECTION AND ANALYSIS

All analyses were carried out on intention-to-treat. Survival at 1, 2, 3, 4 and five years were used as endpoints of clinical relevance along with the median survival. The risk ratio (relative risk; RR) was the primary measure of effect for survival, rates of resections, and tumour recurrences. The risk difference (RD) was used to describe differences in response to chemotherapy, treatment morbidity and mortality.

MAIN RESULTS

There were 11 randomised trials involving 2051 patients. At 1- year and 2-year the risk ratios showed no difference in survival between preoperative chemotherapy and surgery alone. The 3-year risk ratios found a 21% increase in survival (RR = 1.21; 95% CI 0.88 to 1.68; p = 0.25) and a 24% increase in survival with preoperative chemotherapy at 4 years (RR = 1.24; 95% CI 0.92 to 1.68; p = 0.15) but they did not reach statistical significance. Only at 5 years did the results become significant (RR = 1.44; 95% CI 1.05 to 1.97; p = 0.02). The overall rate of resections and the rate of complete resections (R0) did not differ between the preoperative chemotherapy arm and surgery alone. The pooled clinical response to chemotherapy was about 36% (RD = 0.36; 95% CI 0.26 to 0.47) but the complete pathologic response was a disappointing 3% (RD = 0.03; 95% CI 0.01 to 0.04). No single agent or combination of chemotherapeutic agents was found to be superior to the others. There was a 19% reduction in local recurrence with preoperative chemotherapy, but this was not significant (RR = 0.81; 95% CI 0.54 to 1.22; p = 0.3). Preoperative chemotherapy was somewhat more harmful to patients than surgery alone.

REVIEWER'S CONCLUSIONS

In summary, preoperative chemotherapy plus surgery appears to offer a survival advantage at 3, 4, and 5 years, which reached significance only at 5 years compared to surgery alone for resectable thoracic esophageal cancer of any histologic type. The number needed to treat for one extra survivor at five years is eleven patients. The results are tempered by the increased toxicity and mortality associated with chemotherapy. The most beneficial chemotherapy combination appears to be cisplatin and 5-flurouracil based, however, the dosing is unclear.

Ten-year survival with chemotherapy and radiotherapy in patients with squamous cell carcinoma of the esophagus

BACKGROUND

The effects of multimodality treatment on the survival of patients with esophageal carcinoma are unclear. The authors performed a prospective, Phase II study to assess the long-term results of chemotherapy plus radiotherapy (RT) on patients with esophageal squamous cell carcinoma.

METHODS

Of 106 consecutive patients who were recruited between 1985 and 1992, 101 patients were evaluable. Cisplatin (100 mg/m2 per day) on Day 1 and fluorouracil (1000 mg/m2 per day) on Days 1-4 were given for two cycles, with concomitant RT (30 grays [Gy] in 15 fractions) over 19 days. Patients with potentially resectable tumors were then assessed for curative surgery; the other patients received two more courses of chemotherapy and further RT (20 Gy in 10 fractions).

RESULTS

Of 40 patients who were candidates for surgery, 32 patients underwent surgery, and 24 patients had complete resection; 8 patients (25%) had no residual tumor in the specimen, and 12 patients (37%) had microscopic foci only. Surgical mortality was high (22%). Of 61 nonsurgical patients, 37 patients (61%) achieved complete clinical remission, and 14 patients (23%) achieved partial remission. The median survival for the entire series was 15 months (range, 1-136 months). The overall survival rate was 22% at 5 years and 12% at 10 years. At 10 years, freedom from disease progression was similar in the two groups (24%), whereas the median survival (22 months vs. 12 months) and the overall survival rates (17% vs. 9%) were better in nonsurgical patients compared with surgical patients, respectively, probably in relation to high surgical mortality. The larynx was preserved in 28% of 32 patients with cervical disease sites, with a 10-year disease free survival rate of 31%. Three deaths were attributed to nonsurgical treatments.

CONCLUSIONS

Careful multidisciplinary pretreatment evaluation can identify patients who are ineligible for surgery without compromising long-term results. For patients with inoperable disease, chemoradiotherapy can produce relatively good long-term results. The combined approach without surgery can permit laryngeal preservation in a useful fraction of patients.

The use of chemoradiotherapy in oesophageal cancer

The results of treatment for oesophageal carcinoma remain poor and few patients are curable by surgery alone. The use of chemoradiotherapy (CRT) given as a definitive treatment or in combination with surgery may improve locoregional control and survival, when compared with radiotherapy or surgery alone. Using the keywords "chemoradiotherapy" and "radiochemotherapy", a Medline-based literature review (1980-2001) was performed. Additional literature was obtained from original papers and published meeting abstracts. Two-year survival rates of 28-72% in squamous cell carcinoma and 14-29% in adenocarcinoma from definitive CRT were reported. This is comparable to results achievable by surgery alone. The use of preoperative CRT followed by surgery may further improve survival, but current data are insufficient to justify this approach within routine clinical practice. Acute treatment-related toxicity is increased with CRT. In selected patients with localised unresectable oesophageal cancer, definitive CRT is recommended. There are uncertainties about the role of routine surgery following CRT in patients with resectable disease. For the future, the pretreatment staging of patients needs to be improved and standardised, the optimal CRT regimen needs to be defined and the role of predictive markers for CRT response needs to be developed.

Cancer of the esophagus and gastro-esophageal junction: potentially curative therapies

The definition of potential curative tumors of the esophagus and gastro-esophageal junction remains problematic. This is due to a lack of accuracy in clinical staging despite recent advances in CT, endoscopic ultrasonography (EUS), positron emission tomography scan and minimally invasive staging modalities. As a result much controversy persists regarding indications for surgery and extent of resection and lymphadenectomy. Today surgery with curative option results in five-year survival of over 30%. Multimodality regimens, especially neoadjuvant chemoradiotherapy, seem to be beneficial in patients with a complete response on pathologic staging. Other indications are investigational and should be studied within carefully monitored study protocols. In early carcinoma T(is)-T(1a) endoluminal ablation technique seem to open promising perspectives provided of discrimination between T(is)-T(1a) and T(1b) can be made by the use of 20mhz EUS probes.

Preoperative (neoadjuvant) chemoradiotherapy in oesophageal cancer

BACKGROUND

Oesophageal cancer carries a poor prognosis. The 5-year survival rate following resection ranges from 10 to 35 per cent. Recent evidence suggests that the addition of non-surgical treatments to surgery may improve resection rates, reduce the risk of recurrence and improve survival. This review examines the role of preoperative chemoradiotherapy (CRT) in oesophageal cancer.

METHODS

A Medline-based literature review (1980-2000) was performed using the key words 'neoadjuvant or preoperative' and 'chemoradiotherapy or radiochemotherapy'. Additional literature was obtained from original papers and published meeting abstracts.

RESULTS

Forty-six non-randomized and six randomized trials of preoperative CRT were found. Resection rates, pathological complete response (pCR), treatment-related mortality rates and relapse patterns are documented. Improved 5-year survival rates approaching 60 per cent may be achieved following pCR. Three of the six randomized trials show a benefit in either overall survival or disease-free survival compared with surgery alone. Treatment-related toxicity can be significant.

CONCLUSION

Preoperative CRT may improve survival. Emerging evidence suggests that CRT alone can achieve similar survival rates to surgery alone. New imaging modalities may help to select which patients require surgery. Larger randomized trials of preoperative CRT or chemotherapy are needed to define optimal regimens and produce higher pCR rates with acceptable toxicity.

Analysis of the role of adjuvant chemotherapy for invasive carcinoma of the esophagus

The purpose of this report is to analyze the role and optimum integration of chemotherapy for invasive carcinoma of the esophagus in the combined modality setting. The charts of 157 patients with primary invasive nonmetastatic carcinoma of the esophagus treated with curative intent between 1984 and 1998 were reviewed. Various combinations of chemotherapy (C), radiotherapy (R), and surgery (S) were used. Chemotherapy was multiagent (typically 5-fluorouracil [5-FU]/cisplatin/hydroxyurea, 5-FU/cisplatin/leucovorin, or docetaxel/cisplatin) for all but seven patients treated with single agents. The clinical endpoints examined were overall survival (OS) and cause-specific survival (CSS). Multivariate analyses and pairwise comparisons were made for determination of the benefit of chemotherapy. On the multivariate analyses, only American Joint Committee on Cancer stage and chemotherapy were statistically significant determinants of both OS and CSS. Following are the results of the pairwise analyses: 3-year OS: (no C) versus (any C): 16% versus 27% (p = 0.02); (S) versus (C+S): 19% versus 34% (p = 0.35); (R) versus (C+R): 0% versus 13% (p = 0.05); (R + S) versus (C + R + S): 18% versus 33% (p = 0.03). The administration of adjuvant chemotherapy can improve survival in patients with invasive nonmetastatic esophageal carcinoma. This benefit appears to be greater when chemotherapy is given with radiotherapy (with or without surgery) than in the absence of radiotherapy, perhaps because of a radiosensitizing effect not possible when using surgery is the only local control modality.

Histopathologic validation of lymph node staging with FDG-PET scan in cancer of the esophagus and gastroesophageal junction: A prospective study based on primary surgery with extensive lymphadenectomy

OBJECTIVE

To assess the value of positron emission tomography with 18fluorodeoxyglucose (FDG-PET) for preoperative lymph node staging of patients with primary cancer of the esophagus and gastroesophageal junction.

SUMMARY BACKGROUND DATA

FDG-PET appears to be a promising tool in the preoperative staging of cancer of the esophagus and gastroesophageal junction. Recent reports indicate a higher sensitivity and specificity for detection of stage IV disease and a higher specificity for diagnosis of lymph node involvement compared with the standard use of computed tomography and endoscopic ultrasound.

METHODS

Forty-two patients entered the prospective study. All underwent attenuation-corrected FDG-PET imaging of the neck, thorax, and upper abdomen, a spiral computed tomography scan, and an endoscopic ultrasound. The gold standard consisted exclusively of the histology of sampled nodes obtained by extensive two-field or three-field lymphadenectomies (n = 39) or from guided biopsies of suspicious distant nodes indicated by imaging (n = 3).

RESULTS

The FDG-PET scan had lower accuracy for the diagnosis of locoregional nodes (N1-2) than combined computed tomography and endoscopic ultrasound (48% vs. 69%) because of a significant lack of sensitivity (22% vs. 83%). The accuracy for distant nodal metastasis (M+Ly), however, was significantly higher for FDG-PET than the combined use of computed tomography and endoscopic ultrasound (86% vs. 62%). Sensitivity was not significantly different, but specificity was greater (90% vs. 69%). The FDG-PET scan correctly upstaged five patients (12%) from N1-2 stage to M+Ly stage. One patient was falsely downstaged by FDG-PET scanning.

CONCLUSIONS

FDG-PET scanning improves the clinical staging of lymph node involvement based on the increased detection of distant nodal metastases and on the superior specificity compared with conventional imaging modalities.

Esophageal cancer: a systematic review

Carcinoma of the esophagus has one of the lowest possibilities of cure, with 5-year survival rates estimated to be approximately 10% overall; these rates are second only to hepatobiliary and pancreatic cancers. This fact and the rapid increase in the incidence of adenocarcinomas of the esophagus in recent years challenges us to identify areas of improvement for all aspects of this disease. We discuss potential reasons for the increase in the incidence of adenocarcinomas, evidence that defines the similarity between tumors of the gastroesophageal junction and the tubular esophagus, and other prognostic factors that may influence future modifications of our staging classification of this disease. Surgical advances have translated into improvements in surgical morbidity and mortality rates. Current therapeutic options and the relative merits of the options are discussed. Improvements in patient outcome most likely hinge on earlier diagnosis, more accurate staging, and the optimal use of combined modalities, coupled with technical advances in the modalities. A systematic review approach was undertaken to evaluate the performance characteristics of newer staging tools and the value of different combined modality approaches with particular focus on the use of those approaches for patients with potentially curable disease. A similar methodologic approach was used to address the utility of the many strategies currently used in practice for the palliation of esophageal tumors, with particular focus on the relief of malignant dysphagia. Finally, a summary of published guidelines and population-based patterns of care are presented. This serves as an overview of how all of this evidence actually translates into the care we are providing. A coordinated international effort in population-based research and randomized controlled trials would be the cornerstone to future advances in this relatively uncommon but devastating disease.

Effect of neoadjuvant chemotherapy for lymph node micrometastasis and tumor cell microinvolvement in the patients with esophageal carcinoma

Micrometastasis (MM) and tumor cell microinvolvement (TCM) in the lymph node were immunohistochemically evaluated using the cytokeratin (CK) antibody between a surgery group (n=20; 929 lymph nodes) and a chemotherapy group (n=20; 1052 lymph nodes). The incidence of MM+/-TCM in the surgery and chemotherapy groups was 50.0 (10/20) and 55.0% (11/20), respectively. Limiting the analysis to TCM alone revealed that the incidence in the chemotherapy group (10.0%; 2/20) was significantly lower than that in the surgery group (40.0%; 8/20; P=0.032). Preoperative chemotherapy in this regime was not effective, except for some patients with TCM alone.

Important issues in planning and conducting multi-centre randomised trials in cancer and publishing their results

The principles and practical issues involved in planning and conducting multi-centre randomised trials in cancer and in publishing their results are reviewed for the benefit of those conducting trials or planning to do so. There is increasing public awareness of the importance of randomised trials and this needs to be nurtured. Questions addressed by trials must be clinically worthwhile, and trials must be planned and conducted to provide reliable results that will convince the clinical community and influence future clinical practice to patients' benefit. Trial protocols must justify the trial and give clear and unambiguous instructions to collaborating centres. Only data necessary for answering the trial questions should be collected, and the reliability of data should be checked. All trials should be published in peer-reviewed journals, and ways should be considered of communicating their results to patients, their families and the public. Wide consultation and independent review are needed to achieve these aims.