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Prognostic Value of Pretreatment Pathological Tumor Extent in Patients Treated With Neoadjuvant Chemoradiotherapy Plus Surgery for Esophageal or Junctional Cancer. Ann Surg 2017; 265:356-362. [PMID: 28059964 DOI: 10.1097/sla.0000000000001630] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE We aimed to determine pretreatment pathological tumor extent in the resection specimen after neoadjuvant chemoradiotherapy (nCRT) and to assess its prognostic value in patients with esophageal cancer. METHODS Patients with esophageal cancer, treated with nCRT plus surgery were included (2003-2011). Pretreatment pathological T-stage (prepT-stage) and N-stage (prepN-stage) were estimated based on the extent of regressional changes and residual tumor cells in the resection specimen. Interobserver agreement was determined between 3 pathologists. The prognostic performance of prepT-stage and prepN-stage was scored using the difference in Akaike information criterion (ΔAIC). PrepN-stage and posttreatment pathological N-stage (ypN-stage) were combined to determine the effect of nodal sterilization on prognosis. RESULTS Overall concordance for prepT-stage and prepN-stage was 0.69 and 0.84, respectively. Prognostic strength of prepT-stage was similar to clinical T-stage and worse compared with ypT-stage (ΔAIC 1.3 versus 2.0 and 8.9, respectively). In contrast, prognostic strength of prepN-stage was better than cN-stage and similar to ypN-stage (ΔAIC 17.9 versus 6.2 and 17.2, respectively). PrepN+ patients who become ypN0 after nCRT have a worse survival compared with prepN0 patients, with a five year overall survival of 51% versus 68%, P = 0.019, respectively. CONCLUSIONS PrepT-stage and prepN-stage can be estimated reproducibly. Prognostic strength of prepT-stage is comparable with clinical T-stage, whereas prepN-stage is better than cN-stage. PrepN+ patients who become ypN0 after nCRT have a worse survival compared with prepN0 patients. Pretreatment pathological staging should be considered useful as a new staging parameter for esophageal cancer and could also be of interest for other tumor types.
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Bollschweiler E, Plum P, Mönig SP, Hölscher AH. Current and future treatment options for esophageal cancer in the elderly. Expert Opin Pharmacother 2017; 18:1001-1010. [DOI: 10.1080/14656566.2017.1334764] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Elfriede Bollschweiler
- Department of General, Visceral and Cancer Surgery, University of Cologne, Köln, Germany
| | - Patrick Plum
- Department of General, Visceral and Cancer Surgery, University of Cologne, Köln, Germany
| | - Stefan P. Mönig
- Department of General, Visceral and Cancer Surgery, University of Cologne, Köln, Germany
- Service de Chirurgie viscéral, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Arnulf H. Hölscher
- Department of General, Visceral and Cancer Surgery, University of Cologne, Köln, Germany
- Department of Surgery, AGAPLESION Markus Krankenhaus, Frankfurt, Germany
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53
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P53 and SOX2 Protein Expression Predicts Esophageal Adenocarcinoma in Response to Neoadjuvant Chemoradiotherapy. Ann Surg 2017; 265:347-355. [DOI: 10.1097/sla.0000000000001625] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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54
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Chao YK, Chang HK, Tseng CK, Liu YH, Wen YW. Development of a nomogram for the prediction of pathological complete response after neoadjuvant chemoradiotherapy in patients with esophageal squamous cell carcinoma. Dis Esophagus 2017; 30:1-8. [PMID: 27868287 DOI: 10.1111/dote.12519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Nomograms incorporating multiple prognostic factors are useful for individualized estimation of survival in cancer patients. However, nomograms for the prediction of pathological complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) in patients with esophageal cancer are scarce. Here, we describe the development of a nomogram for predicting pCR after nCRT in patients with esophageal squamous cell carcinoma (ESCC). We retrospectively reviewed the records of 392 ESCC patients who underwent nCRT followed by esophagectomy. Seventy percent of the participants (n = 274) were randomly assigned to a training cohort, whereas the remaining 30% were included in a validation cohort (n = 118). Data from the training cohort were subjected to multivariate logistic regression analyses for selecting variables to be included in the nomogram. The performance of the resulting nomogram was internally and externally validated by calculating the bias-corrected concordance statistic (c-statistic) and the area under the receiver operating characteristics curve (AUROC) in the training and validation cohorts, respectively. After surgery, 25.77% of the study patients achieved pCR. The following variables were included in the nomogram: (i) age, (ii) pretreatment tumor length, (iii) history of head and neck cancer, (iv) post-nCRT albumin levels, and (v) post-nCRT endoscopic findings coupled with endoscopic biopsy results. The bias-corrected c-statistic and AUROC of the internal and external validation sets were 0.77 and 0.747, respectively. Our nomogram showed a good performance for predicting pCR after nCRT in ESCC patients.
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Affiliation(s)
- Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsien-Kun Chang
- Division of Hematology/Oncology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chen-Kan Tseng
- Department of Radiation Oncology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yun-Hen Liu
- Division of Thoracic Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Wen Wen
- Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan
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55
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Fang HY, Chao YK, Chang HK, Tseng CK, Liu YH. Survival outcomes of consolidation chemoradiotherapy in esophageal cancer patients who achieve clinical complete response but refuse surgery after neoadjuvant chemoradiotherapy. Dis Esophagus 2017; 30:1-8. [PMID: 27878893 DOI: 10.1111/dote.12515] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Some esophageal cancer patients may be reluctant to accept the scheduled resection after neoadjuvant chemoradiotherapy (nCRT) because of its potential negative impact on quality of life as a result of high morbidity. This study was performed to investigate the survival outcomes of these patients. Between 2000 and 2012, we identified 190 patients with resectable esophageal squamous cell carcinoma (ESCC) who did not proceed to surgery following nCRT. Subjects who had a clinical complete response (cCR) and were medically fit for surgery were deemed eligible. Survival rates, recurrence patterns, and risk factors for recurrence served as the main outcome measures. The study cohort consisted of 73 patients (67 males and 6 females; mean age: 61.3 years). The 5-year overall survival was 39.6% (median survival time: 46.77 months). Cancer recurrences were observed in 44 patients (60.2%), with locoregional recurrence (LR) being the most common failure pattern (n = 35). Endoscopic findings after nCRT were the most important independent predictor of LR identified in multivariate analysis. Compared with the 'normal findings' subgroup, the odds ratios for LR in cCR patients who refused surgery were 4.774 (P = 0.026) and 2.844 (P = 0.16) in the 'scar' and 'other findings' subgroups, respectively. Patients with 'normal findings' had the lowest rate of LR (22.2%), with no recurrences occurring within the first 6 months. Sixty percent of ESCC patients who achieve cCR following nCRT but refuse esophagectomy develop disease recurrence, with LR being the most common pattern. Post-nCRT endoscopic findings may serve as a predictor for LR.
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Affiliation(s)
- Hsin-Yueh Fang
- Division of Thoracic Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsien-Kun Chang
- Division of Hematology/Oncology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chen-Kan Tseng
- Department of Radiation Oncology, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yun-Hen Liu
- Division of Thoracic Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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18FDG-PET-CT improves specificity of preoperative lymph-node staging in patients with intestinal but not diffuse-type esophagogastric adenocarcinoma. Eur J Surg Oncol 2017; 43:196-202. [DOI: 10.1016/j.ejso.2016.08.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 08/12/2016] [Indexed: 01/01/2023] Open
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Hölscher AH, Babic B. New approaches in esophageal carcinomas. Innov Surg Sci 2016; 1:87-95. [PMID: 31579724 PMCID: PMC6753992 DOI: 10.1515/iss-2016-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 10/18/2016] [Indexed: 11/15/2022] Open
Abstract
New approaches in the treatment of esophageal cancer comprise endoscopy with refinements of esophagoscopic intraluminal resection by endoscopic submucosal dissection. Radical open surgery is more and more replaced by minimally invasive esophagectomy (MIO), especially in the hybrid technique with laparoscopic gastrolysis and transthoracic esophageal resection and gastric pull-up. Total MIO also in the robotic technique has not yet shown that it produces superior results than the hybrid technique. Fluorescent dye can improve the intraoperative visualization of the vascularization of the gastric conduit. The individualization of neoadjuvant therapy is the magic word in clinical research of multimodal treatment of esophageal cancer. This means response prediction based on molecular markers or clinical response evaluation. The documentation of the diversity of postoperative complications is now standardized by an international consensus. The value of enhanced recovery after surgery is not yet approved compared to conventional management.
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Affiliation(s)
- Arnulf H. Hölscher
- Center for Esophageal and Gastric Surgery, Agaplesion Markus Krankenhaus, Wilhelm-Epstein-Straße 4, 60431 Frankfurt am Main, Germany
| | - Benjamin Babic
- Center for Esophageal and Gastric Surgery, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
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Can CT-PET and Endoscopic Assessment Post-Neoadjuvant Chemoradiotherapy Predict Residual Disease in Esophageal Cancer? Ann Surg 2016; 264:831-838. [DOI: 10.1097/sla.0000000000001902] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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59
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Chao YK, Chang Y, Yeh CJ, Chang HK, Tseng CK, Chuang WY. Characterization of residual tumours at the primary site in patients with a near pathological complete response after neoadjuvant chemoradiotherapy for oesophageal cancer. Br J Surg 2016; 103:1874-1879. [PMID: 27620361 DOI: 10.1002/bjs.10293] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 03/21/2016] [Accepted: 07/11/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND A 'surgery as needed' strategy has been proposed for patients with oesophageal cancer who truly achieve a pathological complete response (pCR) following neoadjuvant chemoradiotherapy (nCRT). However, the ability to detect residual disease remains problematic. This study investigated the anatomical locations and pathological characteristics of residual cancer in patients with oesophageal squamous cell carcinoma (SCC) who achieved a near pCR following nCRT. METHODS Patients with oesophageal SCC who achieved a near pCR after nCRT were eligible. Near pCR was defined as residual cancer in the resection specimen representing less than 10 per cent of the apparent original tumour area. RESULTS Detailed histopathological reassessment of 76 consecutive patients (mean age 54·4 years) with a near pCR was undertaken. Some 32 patients (42 per cent) with a near pCR had no detectable mucosal lesions. Residual tumour was identified most frequently in the submucosal layer (54, 71 per cent), followed by the mucosa (44, 58 per cent), muscle layer (36, 47 per cent) and adventitia (22, 29 per cent) (P < 0·001). Among patients without ypT1a disease, increasing depth of tumour invasion correlated negatively with the likelihood of mucosal involvement. Of patients with ypT3 disease, 16 of 22 had no detectable cancer located in the mucosa, compared with six of 29 with ypT1b disease (P < 0·001). CONCLUSION Better tools for predicting pCR are required before considering a 'surgery as needed' approach in the management of oesophageal cancer.
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Affiliation(s)
- Y-K Chao
- Division of Thoracic Surgery, Chang Gung University, Taoyuan, Taiwan
| | - Y Chang
- Department of Surgery, Chang Gung University, Taoyuan, Taiwan
| | - C-J Yeh
- Department of Pathology, Chang Gung University, Taoyuan, Taiwan
| | - H-K Chang
- Division of Haematology/Oncology, Chang Gung University, Taoyuan, Taiwan
| | - C-K Tseng
- Department of Radiation Oncology, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
| | - W-Y Chuang
- Department of Pathology, Chang Gung University, Taoyuan, Taiwan
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60
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Arnett ALH, Merrell KW, Macintosh EM, James SE, Nathan MA, Shen KR, Ravi K, Neben Wittich MA, Haddock MG, Hallemeier CL. Utility of 18F-FDG PET for Predicting Histopathologic Response in Esophageal Carcinoma following Chemoradiation. J Thorac Oncol 2016; 12:121-128. [PMID: 27569732 DOI: 10.1016/j.jtho.2016.08.136] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 08/08/2016] [Accepted: 08/15/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION For patients with esophageal cancer undergoing neoadjuvant chemoradiation (CRT) followed by surgical resection, complete histopathologic response (pCR) is associated with favorable overall survival (OS). The aim of this study was to evaluate the correlation between 18F-fluorodeoxyglucose positron emission tomography (FDG PET) response to neoadjuvant CRT and pCR. METHODS Maximum standardized uptake values and standardized uptake ratios (SURs) were measured before and after CRT. SUR was normalized to liver uptake and mediastinal blood pool uptake. FDG PET complete response was defined as metabolic activity normalization to hepatic and blood pool activity. The correlation between FDG PET parameters and pCR was examined through logistic regression analyses. RESULTS In total, 193 patients were monitored for a median of 3.6 years after initiation of CRT. Most tumors were adenocarcinoma (85%) and stage T3 (75%). Complete FDG PET response and pCR occurred in 27% and 34% of patients, respectively. Histologic findings, chemotherapy type, tumor stage, and radiation dose were not significantly associated with complete radiographic response. The rates of pCR in patients with and without radiographic complete response were 42% and 31% (p = 0.17), respectively. No predictive correlation was found between pCR and change in maximum standardized uptake value (p = 0.25), in SUR normalized to blood pool uptake (p = 0.20), or in SUR normalized to liver uptake (p = 0.15). The 5-year OS rate was 46% for patients with a complete FDG PET response versus 44% without a complete response (p = 0.78). The 5-year OS rate of patients who achieved pCR was 49% versus 43% for patients with residual tumor (p = 0.04). CONCLUSION For patients with esophageal cancer who received neoadjuvant chemoradiation, pretreatment and posttreatment FDG PET parameters did not correlate with pCR or OS.
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Affiliation(s)
| | | | | | - Sarah E James
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Mark A Nathan
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - K Robert Shen
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Karthik Ravi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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61
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Heethuis SE, van Rossum PSN, Lips IM, Goense L, Voncken FE, Reerink O, van Hillegersberg R, Ruurda JP, Philippens ME, van Vulpen M, Meijer GJ, Lagendijk JJW, van Lier ALHMW. Dynamic contrast-enhanced MRI for treatment response assessment in patients with oesophageal cancer receiving neoadjuvant chemoradiotherapy. Radiother Oncol 2016; 120:128-35. [PMID: 27296409 DOI: 10.1016/j.radonc.2016.05.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 04/22/2016] [Accepted: 05/12/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE To explore and evaluate the potential value of dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) for the prediction of pathologic response to neoadjuvant chemoradiotherapy (nCRT) in oesophageal cancer. MATERIAL AND METHODS Twenty-six patients underwent DCE-MRI before, during (week 2-3) and after nCRT, but before surgery (pre/per/post, respectively). Histopathologic tumour regression grade (TRG) was assessed after oesophagectomy. Tumour area-under-the-concentration time curve (AUC), time-to-peak (TTP) and slope were calculated. The ability of these DCE-parameters to distinguish good responders (GR, TRG 1-2) from poor responders (noGR, TRG⩾3), and pathologic complete responders (pCR) from no-pCR was assessed. RESULTS Twelve patients (48%) showed GR of which 8 patients (32%) pCR. Analysis of AUC change throughout treatment, AUCper-pre, was most predictive for GR, at a threshold of 22.7% resulting in a sensitivity of 92%, specificity of 77%, PPV of 79%, and a NPV of 91%. AUCpost-pre was most predictive for pCR, at a threshold of -24.6% resulting in a sensitivity of 83%, specificity of 88%, PPV of 71%, and a NPV of 93%. TTP and slope were not associated with pathologic response. CONCLUSIONS This study demonstrates that changes in AUC throughout treatment are promising for prediction of histopathologic response to nCRT for oesophageal cancer.
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Affiliation(s)
- Sophie E Heethuis
- Department of Radiotherapy, University Medical Center Utrecht, Netherlands.
| | - Peter S N van Rossum
- Department of Radiotherapy, University Medical Center Utrecht, Netherlands; Department of Surgery, University Medical Center Utrecht, Netherlands
| | - Irene M Lips
- Department of Radiotherapy, University Medical Center Utrecht, Netherlands
| | - Lucas Goense
- Department of Radiotherapy, University Medical Center Utrecht, Netherlands; Department of Surgery, University Medical Center Utrecht, Netherlands
| | - Francine E Voncken
- Department of Radiotherapy, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands
| | - Onne Reerink
- Department of Radiotherapy, University Medical Center Utrecht, Netherlands
| | | | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Netherlands
| | | | - Marco van Vulpen
- Department of Radiotherapy, University Medical Center Utrecht, Netherlands
| | - Gert J Meijer
- Department of Radiotherapy, University Medical Center Utrecht, Netherlands
| | - Jan J W Lagendijk
- Department of Radiotherapy, University Medical Center Utrecht, Netherlands
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van Rossum PSN, Goense L, Meziani J, Reitsma JB, Siersema PD, Vleggaar FP, van Vulpen M, Meijer GJ, Ruurda JP, van Hillegersberg R. Endoscopic biopsy and EUS for the detection of pathologic complete response after neoadjuvant chemoradiotherapy in esophageal cancer: a systematic review and meta-analysis. Gastrointest Endosc 2016; 83:866-79. [PMID: 26632523 DOI: 10.1016/j.gie.2015.11.026] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 11/15/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Accurate determination of residual cancer status after neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer could assist in selecting the optimal treatment strategy. The aim of this study was to review the evidence on the diagnostic accuracy of endoscopic biopsy and EUS after nCRT for detecting residual cancer at the primary tumor site (ypT+) and regional lymph nodes (ypN+) as opposed to a pathologic complete response (ypT0 and ypN0). METHODS PubMed/Medline, Embase, and the Cochrane library were systematically searched. The analysis included diagnostic studies reporting on the accuracy of endoscopic biopsy or EUS in detecting residual cancer versus complete response after nCRT for esophageal cancer with histopathology as the reference standard. Bivariate random-effects models were used to estimate pooled sensitivities and specificities and examine sources of heterogeneity. RESULTS Twenty-three studies comprising 12 endoscopic biopsy studies (1281 patients), 11 EUS studies reporting on ypT status (593 patients), and 10 EUS studies reporting on ypN status (602 patients), were included. Pooled estimates for sensitivity of endoscopic biopsy after nCRT for predicting ypT+ were 34.5% (95% confidence interval [CI], 26.0%-44.1%) and for specificity 91.0% (95% CI, 85.6%-94.5%). Pooled estimates for sensitivity of EUS after nCRT were 96.4% (95% CI, 91.7%-98.5%) and for specificity were 10.9% (95% CI, 3.5%-29.0%) for detecting ypT+, and 62.0% (95% CI, 46.0%-75.7%) and 56.7% (95% CI, 41.8%-70.5%) for detecting ypN+, respectively. CONCLUSIONS Endoscopic biopsy after nCRT is a specific but not sensitive method for detecting residual esophageal cancer. Although EUS after nCRT yields a high sensitivity, only a limited number of patients will have negative findings at EUS with still a substantial false-negative rate. Furthermore, EUS provides only moderate accuracy for detecting residual lymph node involvement. Based on these findings, these endoscopic modalities cannot be used to withhold surgical treatment in test-negative patients after nCRT. ( CLINICAL TRIAL REGISTRATION NUMBER CRD42015016527.).
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Affiliation(s)
- Peter S N van Rossum
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jihane Meziani
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johannes B Reitsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marco van Vulpen
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert J Meijer
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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The Role of Surgery in Patients With a Complete Clinical Response After Chemoradiation for Esophageal Cancer. Ann Surg 2016; 262:e101. [PMID: 24743620 DOI: 10.1097/sla.0000000000000666] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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64
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van Rossum PSN, Fried DV, Zhang L, Hofstetter WL, van Vulpen M, Meijer GJ, Court LE, Lin SH. The Incremental Value of Subjective and Quantitative Assessment of 18F-FDG PET for the Prediction of Pathologic Complete Response to Preoperative Chemoradiotherapy in Esophageal Cancer. J Nucl Med 2016; 57:691-700. [PMID: 26795288 DOI: 10.2967/jnumed.115.163766] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 12/07/2015] [Indexed: 12/21/2022] Open
Abstract
UNLABELLED A reliable prediction of a pathologic complete response (pathCR) to chemoradiotherapy before surgery for esophageal cancer would enable investigators to study the feasibility and outcome of an organ-preserving strategy after chemoradiotherapy. So far no clinical parameters or diagnostic studies are able to accurately predict which patients will achieve a pathCR. The aim of this study was to determine whether subjective and quantitative assessment of baseline and postchemoradiation (18)F-FDG PET can improve the accuracy of predicting pathCR to preoperative chemoradiotherapy in esophageal cancer beyond clinical predictors. METHODS This retrospective study was approved by the institutional review board, and the need for written informed consent was waived. Clinical parameters along with subjective and quantitative parameters from baseline and postchemoradiation (18)F-FDG PET were derived from 217 esophageal adenocarcinoma patients who underwent chemoradiotherapy followed by surgery. The associations between these parameters and pathCR were studied in univariable and multivariable logistic regression analysis. Four prediction models were constructed and internally validated using bootstrapping to study the incremental predictive values of subjective assessment of (18)F-FDG PET, conventional quantitative metabolic features, and comprehensive (18)F-FDG PET texture/geometry features, respectively. The clinical benefit of (18)F-FDG PET was determined using decision-curve analysis. RESULTS A pathCR was found in 59 (27%) patients. A clinical prediction model (corrected c-index, 0.67) was improved by adding (18)F-FDG PET-based subjective assessment of response (corrected c-index, 0.72). This latter model was slightly improved by the addition of 1 conventional quantitative metabolic feature only (i.e., postchemoradiation total lesion glycolysis; corrected c-index, 0.73), and even more by subsequently adding 4 comprehensive (18)F-FDG PET texture/geometry features (corrected c-index, 0.77). However, at a decision threshold of 0.9 or higher, representing a clinically relevant predictive value for pathCR at which one may be willing to omit surgery, there was no clear incremental value. CONCLUSION Subjective and quantitative assessment of (18)F-FDG PET provides statistical incremental value for predicting pathCR after preoperative chemoradiotherapy in esophageal cancer. However, the discriminatory improvement beyond clinical predictors does not translate into a clinically relevant benefit that could change decision making.
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Affiliation(s)
- Peter S N van Rossum
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - David V Fried
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, Texas; and
| | - Lifei Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marco van Vulpen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert J Meijer
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Laurence E Court
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Hatogai K, Fujii S, Kojima T, Daiko H, Kadota T, Fujita T, Yoshino T, Doi T, Takiguchi Y, Ohtsu A. Prognostic significance of tumor regression grade for patients with esophageal squamous cell carcinoma after neoadjuvant chemotherapy followed by surgery. J Surg Oncol 2016; 113:390-6. [PMID: 27100024 DOI: 10.1002/jso.24151] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 12/15/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND OBJECTIVES To clarify prognostic factors for the patients with esophageal squamous cell carcinoma (ESCC) through an assessment of surgically resected specimens modified by neoadjuvant chemotherapy (nCT). METHODS We retrospectively reviewed the clinicopathological data of 143 consecutive patients with ESCC who underwent nCT followed by surgery between 2008 and 2012 at our institution and conducted survival analysis. The tumor regression grade (TRG) was classified based on the proportion of residual tumor cells in the area where the tumor was thought to have existed before nCT as follows: Grade 0 (no therapeutic effect), Grade 1a (residual tumor cells ≥2/3), Grade 1b (1/3≤ residual tumor cells <2/3), Grade 2 (residual tumor cells <1/3), and Grade 3 (no residual tumor). RESULTS The 3-year OS and RFS of patients with tumor regression grade 0/1a/1b-3 were 53.6%/73.3%/88.6% and 37.7%/60.5%/83.8%, respectively. A multivariate analysis demonstrated that TRG was an independent predictor of OS (TRG 1a-3: HR, 0.46; 95%CI, 0.23-0.89), in addition to venous invasion, and of RFS (TRG 1a-3: HR, 0.49; 95%CI, 0.28-0.84), in addition to ypT factor, and venous invasion. CONCLUSIONS TRG is a critical prognostic factor in patients with ESCC who had undergone nCT followed by surgery. J. Surg. Oncol. 2016;113:390-396. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ken Hatogai
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan.,Division of Pathology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Chiba, Japan.,Department of Medical Oncology, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
| | - Satoshi Fujii
- Division of Pathology, Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Chiba, Japan
| | - Takashi Kojima
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Hiroyuki Daiko
- Department of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Tomohiro Kadota
- Department of Digestive Endoscopy, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Takeo Fujita
- Department of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Takayuki Yoshino
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Toshihiko Doi
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Yuichi Takiguchi
- Department of Medical Oncology, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
| | - Atsushi Ohtsu
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan.,Exploratory Oncology Research and Clinical Trial Center, National Cancer Center, Kashiwa, Chiba, Japan
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Residual Esophageal Cancer After Neoadjuvant Chemoradiotherapy Frequently Involves the Mucosa and Submucosa. Ann Surg 2015; 262:e83-4. [PMID: 24743619 DOI: 10.1097/sla.0000000000000671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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67
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Bollschweiler E, Hölscher AH, Schmidt M, Warnecke-Eberz U. Neoadjuvant treatment for advanced esophageal cancer: response assessment before surgery and how to predict response to chemoradiation before starting treatment. Chin J Cancer Res 2015; 27:221-30. [PMID: 26157318 DOI: 10.3978/j.issn.1000-9604.2015.04.04] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 03/20/2015] [Indexed: 12/22/2022] Open
Abstract
Patients with advanced esophageal cancer (T3-4, N) have a poor prognosis. Chemoradiation or chemotherapy before esophagectomy with adequate lymphadenectomy is the standard treatment for patients with resectable advanced esophageal carcinoma. However, only patients with major histopathologic response (regression to less than 10% of the primary tumor) after preoperative treatment will have a prognostic benefit of preoperative chemoradiation. Using current therapy regimens about 40% to 50% of the patients show major histopathological response. The remaining cohort does not benefit from this neoadjuvant approach but might benefit from earlier surgical resection. Therefore, it is an aim to develop tools for response prediction before starting the treatment and for early response assessment identifying responders. The current review discusses the different imaging techniques and the most recent studies about molecular markers for early response prediction. The results show that [(18)F]-fluorodeoxyglucose-positron emission tomography (FDG-PET) has a good sensitivity but the specificity is not robust enough for routine clinical use. Newer positron emission tomography detector technology, the combination of FDG-PET with computed tomography, additional evaluation criteria and standardization of evaluation may improve the predictive value. There exist a great number of retrospective studies using molecular markers for prediction of response. Until now the clinical use is missing. But the results of first prospective studies are promising. A future perspective may be the combination of imaging technics and special molecular markers for individualized therapy. Another aspect is the response assessment after finishing neoadjuvant treatment protocol. The different clinical methods are discussed. The results show that until now no non-invasive method is valid enough to assess complete histopathological response.
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Affiliation(s)
- Elfriede Bollschweiler
- 1 Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany ; 2 Institute of Nuclear Medicine, University of Cologne, Cologne, Germany
| | - Arnulf H Hölscher
- 1 Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany ; 2 Institute of Nuclear Medicine, University of Cologne, Cologne, Germany
| | - Matthias Schmidt
- 1 Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany ; 2 Institute of Nuclear Medicine, University of Cologne, Cologne, Germany
| | - Ute Warnecke-Eberz
- 1 Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany ; 2 Institute of Nuclear Medicine, University of Cologne, Cologne, Germany
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Vincent J, Mariette C, Pezet D, Huet E, Bonnetain F, Bouché O, Conroy T, Roullet B, Seitz JF, Herr JP, Di Fiore F, Jouve JL, Bedenne L. Early surgery for failure after chemoradiation in operable thoracic oesophageal cancer. Analysis of the non-randomised patients in FFCD 9102 phase III trial: Chemoradiation followed by surgery versus chemoradiation alone. Eur J Cancer 2015; 51:1683-93. [PMID: 26163097 DOI: 10.1016/j.ejca.2015.05.027] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 05/27/2015] [Accepted: 05/31/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Two randomised trials concerning thoracic oesophageal cancer concluded that for squamous cell carcinoma, chemoradiation alone leads to the same overall survival (OS) as chemoradiation followed by surgery. One of these trials, FFCD 9102, randomised only fit, compliant and operable responders to induction chemoradiation between continuation of chemoradiation and surgery. In the present analysis, the outcome in the patients not eligible for randomisation was calculated to determine if attempt of surgery should be recommended. METHODS Eligible patients had operable T3-N0/N1-M0 thoracic oesophageal cancer. After initial chemoradiation, patients with no clinical response, or with contraindication to follow any attributed treatment, were not randomised. OS was studied first in the whole population of not randomised patients, and then specifically in clinical non-responders. The impact of surgery on OS was studied in these two populations. FINDINGS Of the 451 registered patients in the trial, 192 were not randomised. Among them, 111 were clinical non-responders. Median OS was significantly shorter for non-randomised patients (11.5 months) than for randomised patients (18.9 months; p=0.0024). However, for the 112 non-randomised patients who underwent surgery, median OS was not different from that in randomised patients: 17.3 versus 18.9 months (p=0.58). Concerning clinical non-responders, median OS was longer for those who underwent surgery compared to non-operated patients: 17.0 versus 5.5 months (hazard ratio (HR)=0.39 [0.25-0.61]; p<0.0001), and again was not different from that in responding, randomised patients (p=0.40). INTERPRETATION In patients with locally advanced thoracic oesophageal cancer, overall survival did not differ between responders to induction chemoradiation and patients having surgery after clinical failure of chemoradiation. Surgery should therefore be considered in those patients who are still operable.
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Affiliation(s)
| | | | - Denis Pezet
- Hôtel-Dieu University Hospital, Clermont-Ferrand, France
| | | | | | | | - Thierry Conroy
- Alexis Vautrin Anticancer Centre, Vandoeuvre-lès Nancy, France
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Diffusion-weighted magnetic resonance imaging for the prediction of pathologic response to neoadjuvant chemoradiotherapy in esophageal cancer. Radiother Oncol 2015; 115:163-70. [PMID: 26002307 DOI: 10.1016/j.radonc.2015.04.027] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 04/10/2015] [Accepted: 04/12/2015] [Indexed: 12/13/2022]
Abstract
PURPOSE To explore the value of diffusion-weighted magnetic resonance imaging (DW-MRI) for the prediction of pathologic response to neoadjuvant chemoradiotherapy (nCRT) in esophageal cancer. MATERIAL AND METHODS In 20 patients receiving nCRT for esophageal cancer DW-MRI scanning was performed before nCRT, after 8-13 fractions, and before surgery. The median tumor apparent diffusion coefficient (ADC) was determined at these three time points. The predictive potential of initial tumor ADC, and change in ADC (ΔADC) during and after treatment for pathologic complete response (pathCR) and good response were assessed. Good response was defined as pathCR or near-pathCR (tumor regression grade [TRG] 1 or 2). RESULTS A pathCR after nCRT was found in 4 of 20 patients (20%), and 8 patients (40%) showed a good response to nCRT. The ΔADCduring was significantly higher in pathCR vs. non-pathCR patients (34.6%±10.7% [mean±SD] vs. 14.0%±13.1%, p=0.016), as well as in good vs. poor responders (30.5%±8.3% vs. 9.5%±12.5%, p=0.002). The ΔADCduring was predictive of residual cancer at a threshold of 29% (sensitivity of 100%, specificity of 75%, PPV of 94%, and NPV of 100%), and for poor pathologic response at a threshold of 21% (sensitivity of 82%, specificity of 100%, PPV of 100%, and NPV of 80%). CONCLUSIONS In this exploratory study, the treatment-induced change in ADC during the first 2-3weeks of nCRT for esophageal cancer seemed highly predictive of histopathologic response. Larger series are warranted to verify these results.
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70
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Blom RLGM, Bogush T, Brücher BLDM, Chang AC, Davydov M, Dudko E, Leong T, Polotsky B, Swanson PE, van Rossum PSN, Ruurda JP, Sagaert X, Tjulandin S, Schraepen MC, Sosef MN, van Hillegersberg R. Therapeutic approaches to gastroesophageal junction adenocarcinomas. Ann N Y Acad Sci 2015; 1325:197-210. [PMID: 25266026 DOI: 10.1111/nyas.12532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the distinction between adenocarcinomas above, below, or within the gastroesophageal junction; combined modality therapy; tumor markers for use in personalized medicine; PET-CT and endoscopic biopsies in the evaluation of response to neoadjuvant chemoradiation therapy; a standardized grading system for tumor regression in squamous cell cancer and adenocarcinoma; the experimental basis for new approaches to medical treatment; the criteria measuring response in esophageal cancer; and the impact of novel imaging on staging and response assessment.
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Affiliation(s)
- Rachel L G M Blom
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
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71
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Blank S, Lordick F, Bader F, Burian M, Dobritz M, Grenacher L, Becker K, Weichert W, Langer R, Sisic L, Stange A, Jäger D, Büchler M, Bruckner T, Siewert J, Ott K. Post-therapeutic response evaluation by a combination of endoscopy and CT scan in esophagogastric adenocarcinoma after chemotherapy: better than its reputation. Gastric Cancer 2015; 18:314-25. [PMID: 24722800 DOI: 10.1007/s10120-014-0367-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 03/09/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy is an accepted standard of care for locally advanced esophagogastric cancer. As only a subgroup benefits, a response-based tailored treatment would be of interest. The aim of our study was the evaluation of the prognostic and predictive value of clinical response in esophagogastric adenocarcinomas. METHODS Clinical response based on a combination of endoscopy and computed tomography (CT) scan was evaluated retrospectively within a prospective database in center A and then transferred to center B. A total of 686/740 (A) and 184/210 (B) patients, staged cT3/4, cN0/1 underwent neoadjuvant chemotherapy and were then re-staged by endoscopy and CT before undergoing tumor resection. Of 184 patients, 118 (B) additionally had an interim response assessment 4-6 weeks after the start of chemotherapy. RESULTS In A, 479 patients (70%) were defined as clinical nonresponders, 207 (30%) as responders. Median survival was 38 months (nonresponders: 27 months, responders: 108 months, log-rank, p < 0.001). Clinical and histopathological response correlated significantly (p < 0.001). In multivariate analysis, clinical response was an independent prognostic factor (HR for death 1.4, 95% CI 1.0-1.8, p = 0.032). In B, 140 patients (76%) were nonresponders and 44 (24%) responded. Median survival was 33 months, (nonresponders: 27 months, responders: not reached, p = 0.003). Interim clinical response evaluation (118 patients) also had prognostic impact (p = 0.008). Interim, preoperative clinical response and histopathological response correlated strongly (p < 0.001). CONCLUSION Preoperative clinical response was an independent prognostic factor in center A, while in center B its prognostic value could only be confirmed in univariate analysis. The accordance with histopathological response was good in both centers, and interim clinical response evaluation showed comparable results to preoperative evaluation.
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Affiliation(s)
- Susanne Blank
- Department of Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany,
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72
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Prolonged time to surgery after neoadjuvant chemoradiotherapy increases histopathological response without affecting survival in patients with esophageal or junctional cancer. Ann Surg 2015; 260:807-13; discussion 813-4. [PMID: 25379852 DOI: 10.1097/sla.0000000000000966] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To determine the relation between time to surgery (TTS) after neoadjuvant chemoradiotherapy (nCRT) and pathologically complete response (pCR), surgical outcome, and survival in patients with esophageal cancer. BACKGROUND Standard treatment for potentially curable esophageal cancer is nCRT plus surgery after 4 to 6 weeks. In rectal cancer patients, evidence suggests that prolonged TTS is associated with a higher pCR rate and possibly with better survival. METHODS We identified patients treated with nCRT plus surgery for esophageal cancer between 2001 and 2011. TTS (last day of radiotherapy to day of surgery) varied mainly for logistical reasons. Minimal follow-up was 24 months. The effect of TTS on pCR rate, postoperative complications, and survival was determined with (ordinal) logistic, linear, and Cox regression, respectively. RESULTS In total, 325 patients were included. Median TTS was 48 days (p25-p75=40-60). After 45 days, TTS was associated with an increased probability of pCR [odds ratio (OR)=1.35 per additional week of TSS, P=0.0004] and a small increased risk of postoperative complications (OR=1.20, P<0.001). Prolonged TTS had no effect on disease-free and overall survivals (HR=1.00 and HR=1.06 per additional week of TSS, P=0.976 and P=0.139, respectively). CONCLUSIONS Prolonged TTS after nCRT increases the probability of pCR and is associated with a slightly increased probability of postoperative complications, without affecting disease-free and overall survivals. We conclude that TTS can be safely prolonged from the usual 4 to 6 weeks up to at least 12 weeks, which facilitates a more conservative wait-and-see strategy after neoadjuvant chemoradiotherapy to be tested.
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73
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Kim YH, Song SY, Shim HJ, Chung WK, Ahn SJ, Yoon MS, Jeong JU, Song JY, Nam TK. Treatment outcomes of neoadjuvant concurrent chemoradiotherapy followed by esophagectomy for patients with esophageal cancer. Radiat Oncol J 2015; 33:12-20. [PMID: 25874173 PMCID: PMC4394064 DOI: 10.3857/roj.2015.33.1.12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 12/22/2014] [Accepted: 01/21/2015] [Indexed: 01/05/2023] Open
Abstract
Purpose To evaluate treatment outcomes and determine prognostic factors in patients with esophageal cancer treated with esophagectomy after neoadjuvant chemoradiotherapy (NCRT). Materials and Methods We retrospectively evaluated 39 patients with esophageal cancer who underwent concurrent chemoradiotherapy followed by esophagectomy between 2002 and 2012. Initial clinical stages of patients were stage IB in 1 patient (2.6%), stage II in 5 patients (12.9%), and stage III in 33 patients (84.6%). Results The median age of all the patients was 62 years, and the median follow-up period was 17 months. The 3-year overall survival (OS) rate was 33.6% in all the patients. The 3-year locoregional recurrence-free survival (LRFS) rate was 33.7%. In multivariate analysis with covariates of age, the Eastern Cooperative Oncology Group performance status, hypertension, diabetes mellitus, tumor length, clinical response, clinical stage, pathological response, pathological stage, lymphovascular invasion, surgical type, and radiotherapy to surgery interval, only pathological stage was an independent significant prognostic factor affecting both OS and LRFS. The complications in postoperative day 90 were pneumonia in 9 patients, anastomotic site leakage in 3 patients, and anastomotic site stricture in 2 patients. Postoperative 30-day mortality rate was 10.3% (4/39); the cause of death among these 4 patients was respiratory failure in 3 patients and myocardial infarction in one patient. Conclusion Only pathological stage was an independent prognostic factor for both OS and LRFS in patients with esophageal cancer treated with esophagectomy after NCRT. We could confirm the significant role of NCRT in downstaging the initial tumor bulk and thus resulting in better survival of patients who gained earlier pathological stage after NCRT.
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Affiliation(s)
- Yong-Hyub Kim
- Department of Radiation Oncology, Chonnam National University Medical School, Gwangju, Korea
| | - Sang-Yun Song
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Hyun-Jeong Shim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Woong-Ki Chung
- Department of Radiation Oncology, Chonnam National University Medical School, Gwangju, Korea
| | - Sung-Ja Ahn
- Department of Radiation Oncology, Chonnam National University Medical School, Gwangju, Korea
| | - Mee Sun Yoon
- Department of Radiation Oncology, Chonnam National University Medical School, Gwangju, Korea
| | - Jae-Uk Jeong
- Department of Radiation Oncology, Chonnam National University Medical School, Gwangju, Korea
| | - Ju-Young Song
- Department of Radiation Oncology, Chonnam National University Medical School, Gwangju, Korea
| | - Taek-Keun Nam
- Department of Radiation Oncology, Chonnam National University Medical School, Gwangju, Korea
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Heger U, Bader F, Lordick F, Burian M, Langer R, Dobritz M, Blank S, Bruckner T, Becker K, Herrmann K, Siewert JR, Ott K. Interim endoscopy results during neoadjuvant therapy for gastric cancer correlate with histopathological response and prognosis. Gastric Cancer 2015; 17:478-88. [PMID: 23996162 DOI: 10.1007/s10120-013-0296-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 08/14/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy for locally advanced gastric cancer leads to major histopathological response in less than 30 % of patients. Data on interim endoscopic response assessment do not exist. This exploratory prospective study evaluates early endoscopy after 50 % of the chemotherapy as predictor for later response and prognosis. METHODS Forty-seven consecutive patients were included (45 resected; 33 R0 resections). All patients received baseline endoscopy and CT scans, after 50 % of their chemotherapy (EGD-1, CT-1) and after completion of chemotherapy (EGD-2, CT-2). Interim endoscopic response (EGD-1) was assessed after having received 50 % (6 weeks) of the planned 12 weeks of neoadjuvant chemotherapy. Post-chemotherapy response was clinically assessed by a combination of CT scan (CT-2) and endoscopy (EGD-2). Histopathological response was determined by a standardized scoring system (Becker criteria). Endoscopic response was defined as a reduction of >75 % of the tumor mass. RESULTS Twelve patients were responders at EGD-1 and 13 at EGD-2. Nine patients (19.1 %) were clinical responders and 7 patients (15.6 %) were histopathological responders after chemotherapy. Specificity, accuracy, and negative predictive value of the interim EGD-1 for subsequent histopathological response were 31/38 (82 %), 36/47 (76 %), and 31/33 (93 %); and for recurrence or death, 28/30 (93.3 %), 38/47 (80.9 %), and 28/35 (80.0 %). Response at EGD-1 was significantly associated with histopathological response (p = 0.010), survival (p < 0.001), and recurrence-free survival (p = 0.009). CONCLUSIONS Interim endoscopy after 6 weeks predicts response and prognosis. Therefore, tailoring treatment according to interim endoscopic assessment could be feasible, but the findings of this study should be validated in a larger patient cohort.
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Affiliation(s)
- Ulrike Heger
- Department of Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
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75
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Chao YK, Tsai CY, Chang HK, Tseng CK, Liu YH, Yeh CJ. A Pathological Study of Residual Cancer in the Esophageal Wall Following Neoadjuvant Chemoradiotherapy: Focus on Esophageal Squamous Cell Carcinoma Patients with False Negative Preoperative Endoscopic Biopsies. Ann Surg Oncol 2015; 22:3647-52. [DOI: 10.1245/s10434-015-4412-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Indexed: 12/24/2022]
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76
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Chao YK, Yeh CJ, Lee MH, Wen YW, Chang HK, Tseng CK, Liu YH. Factors associated with false-negative endoscopic biopsy results after neoadjuvant chemoradiotherapy in patients with esophageal squamous cell carcinoma. Medicine (Baltimore) 2015; 94:e588. [PMID: 25715265 PMCID: PMC4554138 DOI: 10.1097/md.0000000000000588] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The usefulness of endoscopic biopsy following neoadjuvant chemoradiotherapy (nCRT) is limited because of its high false-negative (FN) rates. However, data on the factors associated with FN biopsy results remain scarce. The purpose of this study was to investigate factors associated with FN results on endoscopic biopsies in patients with esophageal squamous cell carcinoma (ESCC) following nCRT. We retrospectively reviewed the records of ESCC patients who were treated at the Chang Gung Memorial Hospital, Taoyuan, Taiwan, between 1999 and 2013. Inclusion criteria were receiving nCRT as first-line treatment before esophagectomy and having been preoperatively submitted to an endoscopic biopsy. Endoscopic findings at the lesion site were classified into 6 distinct categories: stricture, tumor, ulcer, scar, other findings, or normal. Univariate and multivariate analyses were used to identify factors associated with FN biopsy findings. A total of 227 patients were selected, of which 92 (41.9%) had positive biopsy results. Among patients with negative biopsy findings (n = 135), 85 were found to have residual cancer on the resected esophagus. Multivariate analysis identified endoscopic findings as the only independent predictor of FN biopsy results. The negative predictive values were 77.8%, 61.9%, 52.6%, 30.3%, 23.1%, and 20.0% for the normal, scar, other findings, ulcer, stricture, and tumor categories, respectively (P < 0.001). In ESCC patients, the FN rate of endoscopic biopsy after nCRT is associated with the type of residual lesion.
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Affiliation(s)
- Yin-Kai Chao
- From the Division of Thoracic and Cardiovascular Surgery (Y-KC, Y-HL); Department of Pathology (C-JY); Division of Gastroenterology (M-HL); Clinical Informatics and Medical Statistics Research Center (Y-WW); Division of Hematology/Oncology (H-KC); and Department of Radiation Oncology (C-KT), Chang Gung Memorial Hospital, Linkou, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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77
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Role of rebiopsy in relapsed non-small cell lung cancer for directing oncology treatments. JOURNAL OF ONCOLOGY 2015; 2015:809835. [PMID: 25699082 PMCID: PMC4325200 DOI: 10.1155/2015/809835] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 01/05/2015] [Accepted: 01/05/2015] [Indexed: 12/29/2022]
Abstract
Background. Currently, few rebiopsies are performed in relapses of advanced non-small cell lung cancer. They are not customary in clinical practice of lung cancer. However, it is not possible to properly target treatments in cases of relapse without knowing the nature of new lesions. Design. This paper comprehensively summarizes the available literature about rebiopsy and broadly discusses the importance of rebiopsy in advanced non-small cell lung cancer. Results. Altogether 560 abstracts were used as material for further analysis. 19 articles were about clinical rebiopsy in lung cancer and were reviewed in detailed manner. Conclusions. This review shows that rebiopsy is feasible in non-small cell lung cancer, and success rates can be high if rebiopsy is accompanied by adequate evaluation before biopsy. Its use may resolve the difficulties in sampling bias and detecting changes in cancer characteristics. In cases where treatment was selected based on tissue characteristics that then change, the treatment selection process must be repeated while considering new characteristics of the tumor. Rebiopsy may be used to predict therapeutic resistance and consequently redirect targeted therapies. Such knowledge may resolve the difficulties in sampling bias and also in selecting preexisting clones or formulating drug-resistant ones. Rebiopsy should be performed more often in non-small cell lung cancer.
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78
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Yip C, Cook GJR, Landau DB, Davies A, Goh V. Performance of different imaging modalities in assessment of response to neoadjuvant therapy in primary esophageal cancer. Dis Esophagus 2015; 29:116-30. [PMID: 25604614 DOI: 10.1111/dote.12315] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- C Yip
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.,Department of Radiation Oncology, National Cancer Center, Singapore
| | - G J R Cook
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - D B Landau
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.,Department of Clinical Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Davies
- Department of General Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - V Goh
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.,Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Shim CN, Song MK, Lee HS, Chung H, Lee H, Shin SK, Lee SK, Lee YC, Park JC. Prediction of survival by tumor area on endosonography after definitive chemoradiotherapy for locally advanced squamous cell carcinoma of the esophagus. Digestion 2014; 90:98-107. [PMID: 25196528 DOI: 10.1159/000365073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 06/04/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND Definitive chemoradiotherapy (CRT) is a reasonable approach for patients with locally advanced esophageal cancer who are not surgical candidates. This study was performed to investigate whether endosonography (EUS) assessment of tumor area response is a useful prognostic marker in patients with squamous cell carcinoma (SCC) of the esophagus who receive definitive CRT. METHODS A total of 33 patients who received definitive CRT for locally advanced esophageal SCC were enrolled. The maximal transverse cross-sectional area of the tumor was measured before and after definitive therapy. EUS response was defined as a ≥50% reduction of the tumor area after definitive CRT. RESULTS Based on EUS evaluation, there were 20 nonresponders (60.6%) and 13 responders (39.4%). The median progression-free survival (PFS) was significantly longer in EUS responders than EUS nonresponders (p = 0.005). However, there was no statistical significance in overall survival according to EUS response (p = 0.120). During multivariate analysis, EUS response to definitive CRT was the only significant factor associated with PFS (p = 0.045), whereas EUS response to definitive CRT was not associated with overall survival (p = 0.221). CONCLUSIONS A reduction of the maximal cross-sectional tumor area measured by EUS correlates with a superior prognosis in patients with locally advanced SCC of the esophagus after definitive CRT.
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Affiliation(s)
- Choong Nam Shim
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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80
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Sun F, Chen T, Han J, Ye P, Hu J. Staging accuracy of endoscopic ultrasound for esophageal cancer after neoadjuvant chemotherapy: a meta-analysis and systematic review. Dis Esophagus 2014; 28:757-71. [PMID: 25168285 DOI: 10.1111/dote.12274] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This study aims to evaluate the accuracy of endoscopic ultrasound (EUS) in the staging of esophageal cancer after neoadjuvant chemotherapy (NAC). Articles were searched in Medline, Pubmed, Cochrane Database of Systemic Reviews, Google scholar, and EMBASE. Two reviewers independently searched and extracted data. Meta-analysis of the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios (LR), and diagnostic odds ratio (DOR). Pooling was conducted using either fixed-effects model or random-effects model depending on the heterogeneity across studies. Sixteen studies (n = 724) were included in this analysis. The pooled sensitivity and specificity of EUS to diagnose T1 stage tumor was 23% (95% confidence interval [CI] 16-32%) and 95% (95%CI 93-97%), respectively. For T2 stage, EUS had a pooled sensitivity and specificity of 29% (95%CI 19-41%) and 84% (95%CI 77-88%). The pooled sensitivity and specificity of EUS were 81% (95%CI 72-88%) and 42% (95%CI 33-52%) in determining T3 stage tumor. To diagnose T4 stage tumor, EUS had a pooled sensitivity of 43% (95%CI 31-56%) and specificity of 96% (95%CI 94-97%), respectively. In determining N stage, the pooled sensitivity and specificity of EUS were 69% (95%CI 58-79%) and 52% (95%CI 42-62%). EUS is a moderately accurate technique in staging esophageal cancer after NAC. Its sensitivity is relatively high in T3 while specificity is high in other T stages (T1, T2, and T4). Tumors restaged by EUS as T4 should not be assigned to surgery because it is very likely to be inoperable. EUS is not reliable for N staging with its poor sensitivity and specificity. Subgroup analysis shows that staging accuracy did not improve with time.
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Affiliation(s)
- F Sun
- Department of Thoracic Surgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - T Chen
- Department of Thoracic Surgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - J Han
- Department of Thoracic Surgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - P Ye
- Department of Thoracic Surgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - J Hu
- Department of Thoracic Surgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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81
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Molena D, Sun HH, Badr AS, Mungo B, Sarkaria IS, Adusumilli PS, Bains MS, Rusch VW, Ilson DH, Rizk NP. Clinical tools do not predict pathological complete response in patients with esophageal squamous cell cancer treated with definitive chemoradiotherapy. Dis Esophagus 2014; 27:355-9. [PMID: 24033404 DOI: 10.1111/dote.12126] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Chemoradiotherapy for locally advanced esophageal squamous cell carcinoma is associated with high rates of pathological complete response. A pathological complete response is recognized to be an important predictor of improved survival, to the extent that observation rather than surgery is advocated by some in patients with presumed pathological complete response based on their clinical response. The goal of this study was to look at the ability of clinical variables to predict pathological complete response after chemoradiotherapy for locally advanced esophageal squamous cell carcinoma. We reviewed retrospectively patients with locally advanced esophageal squamous cell carcinoma who underwent chemoradiotherapy followed by surgery and compared those with pathological complete response to patients with residual disease. Between January 1996 and December 2010, 116 patients met inclusion criteria. Fifty-six percent of patients had a pathological complete response and a median survival of 128.1 months versus 28.4 months in patients with residual disease. When compared with patients with residual disease, patients with a pathological complete response had a lower post-neoadjuvant positron emission tomography (PET) maximum standardized uptake value (SUVmax), a larger decrease in PET SUVmax, a less thick tumor on post-chemoradiotherapy computed tomography and a higher rate of normal appearing post-chemoradiotherapy endoscopy with benign biopsy of the tumor bed. However, none of these characteristics alone was able to correctly identify patients with a pathological complete response, and none has significant specificity. Although the rate of pathological complete response after chemoradiotherapy is high in patients with esophageal squamous cell carcinoma, the ability of identifying patients with pathological complete response is limited. A reduction of the PET SUVmax by >70%, a normal appearing endoscopic examination, and no residual disease on biopsy all were seen in >65% of the patients with a pathological complete response. Even if these findings were unable to confirm the absence of residual disease in the primary tumor, they can help guide expectant management in high-risk patients.
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Affiliation(s)
- D Molena
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Medicine, Baltimore, Maryland
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82
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Eil RL, Thomas CR. New methodology, tools, and protocolized analysis are needed to advance individualized treatment paradigms in esophageal cancer. Dis Esophagus 2014; 27:360-1. [PMID: 24592977 DOI: 10.1111/dote.12211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- R L Eil
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
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83
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Schmidt T, Sicic L, Blank S, Becker K, Weichert W, Bruckner T, Parakonthun T, Langer R, Büchler MW, Siewert JR, Lordick F, Ott K. Prognostic value of histopathological regression in 850 neoadjuvantly treated oesophagogastric adenocarcinomas. Br J Cancer 2014; 110:1712-20. [PMID: 24569472 PMCID: PMC3974097 DOI: 10.1038/bjc.2014.94] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Revised: 01/21/2014] [Accepted: 01/27/2014] [Indexed: 01/16/2023] Open
Abstract
Background: Recently, histopathological tumour regression, prevalence of signet ring cells, and localisation were reported as prognostic factors in neoadjuvantly treated oesophagogastric (junctional and gastric) cancer. This exploratory retrospective study analyses independent prognostic factors within a large patient cohort after preoperative chemotherapy including clinical and histopathological factors. Methods: In all, 850 patients presenting with oesophagogastric cancer staged cT3/4 Nany cM0/x were treated with neoadjuvant chemotherapy followed by resection in two academic centres. Patient data were documented in a prospective database and retrospectively analysed. Results: Of all factors prognostic on univariate analysis, only clinical response, complications, ypTNM stage, and R category were independently prognostic (P<0.01) on multivariate analysis. Tumour localisation and signet ring cells were independently prognostic only when investigator-dependent clinical response evaluation was excluded from the multivariate model. Histopathological tumour regression correlates with tumour grading, Laurén classification, clinical response, ypT, ypN, and R categories but was not identified as an independent prognostic factor. Within R0-resected patients only surgical complications and ypTNM stage were independent prognostic factors. Conclusions: Only established prognostic factors like ypTNM stage, R category, and complications were identified as independent prognostic factors in resected patients after neoadjuvant chemotherapy. In contrast, histopathological tumour regression was not found as an independent prognostic marker.
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Affiliation(s)
- T Schmidt
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - L Sicic
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - S Blank
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - K Becker
- Department of Pathology, Technische Universitaet Muenchen, 81675 Munich, Germany
| | - W Weichert
- Department of Pathology, University of Heidelberg, 69120 Heidelberg, Germany
| | - T Bruckner
- Institute of Medical Biometry and Informatics (IMBI), University of Heidelberg, 69120 Heidelberg, Germany
| | - T Parakonthun
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - R Langer
- Department of Pathology, University of Bern, 3010 Bern, Switzerland
| | - M W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - J-R Siewert
- Directorate, University of Freiburg, 79095 Freiburg, Germany
| | - F Lordick
- University Cancer Center Leipzig (UCCL), University of Leipzig, 04103 Leipzig, Germany
| | - K Ott
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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84
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Heger U, Blank S, Wiecha C, Langer R, Weichert W, Lordick F, Bruckner T, Dobritz M, Burian M, Springfeld C, Grenacher L, Siewert JR, Büchler M, Ott K. Is preoperative chemotherapy followed by surgery the appropriate treatment for signet ring cell containing adenocarcinomas of the esophagogastric junction and stomach? Ann Surg Oncol 2014; 21:1739-48. [PMID: 24419755 DOI: 10.1245/s10434-013-3462-z] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recent data suggest primary resection as the preferable approach in patients with signet ring cell gastric cancer (SRC). The aim of our retrospective exploratory study was to evaluate the influence of SRC on prognosis and response in esophagogastric adenocarcinoma treated with neoadjuvant chemotherapy. METHODS A total of 723 locally advanced esophagogastric adenocarcinomas (cT3/4 N any) documented in a prospective database from two academic centers were classified according to the WHO definition for SRC (more than 50 % SRC) and analyzed for their association with response and prognosis after neoadjuvant treatment. RESULTS A total of 235 tumors (32.5 %) contained SRC. Median survival of SRC was 26.3 compared with 46.6 months (p < 0.001) for non-SRC. SRC were significantly associated with female gender, gastric localization, advanced ypT and R1/2 categories, and lower risk of surgical complications and anastomotic leakage (each p < 0.001). Clinical (21.1 vs. 33.7 %, p = 0.001) and histopathological response (less than 10 % residual tumor: 16.3 vs. 28.9 %, p < 0.001) were significantly less frequent in SRC. Clinical response (p = 0.003) and complete histopathological response (pCR) (3.4 %) (p = 0.003) were associated with improved prognosis in SRC. Clinical response, surgical complications, ypTN categories, but not SRC were independent prognostic factors in forward Cox regression analysis in R0 resected patients. Risk of peritoneal carcinomatosis was increased (p < 0.001), while local (p = 0.015) and distant metastases (p = 0.02) were less frequent than in non-SRC. CONCLUSIONS Prognosis of SRC is unfavorable. Although response to neoadjuvant chemotherapy is rare in SRC, it is associated with improved outcome. Thus, chemotherapy might not generally be abandoned in SRC. A stratification based on SRC should be included in clinical trials.
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Affiliation(s)
- Ulrike Heger
- Department of Surgery, Heidelberg University Hospital, University of Heidelberg, Heidelberg, Germany,
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85
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Vallböhmer D, Brabender J, Grimminger P, Schröder W, Hölscher AH. Predicting response to neoadjuvant therapy in esophageal cancer. Expert Rev Anticancer Ther 2014; 11:1449-55. [DOI: 10.1586/era.11.126] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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86
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Jeong Y, Kim JH, Kim SB, Yoon DH, Park SI, Kim YH, Kim HR, Jung HY, Lee GH, Ryu JS. Role of surgical resection in complete responders on FDG-PET after chemoradiotherapy for locally advanced esophageal squamous cell carcinoma. J Surg Oncol 2013; 109:472-7. [PMID: 24301552 DOI: 10.1002/jso.23514] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 11/06/2013] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES To determine the role of surgery in complete responders on FDG-PET after CRT and the prognostic significance of metabolic response in locally advanced esophageal squamous cell carcinoma. METHODS We retrospectively reviewed 154 patients with locally advanced esophageal cancer with increased uptake on FDG-PET. Eighty-one patients received definitive CRT and 73 received trimodality therapy. We defined metabolic complete remission (PET-CR) when FDG uptake of the primary tumor and lymph nodes were decreased and was indistinguishable from surrounding normal tissue. Oncologic outcomes were compared between trimodality group, definitive CRT group, and PET-CR subgroup of definitive CRT. RESULTS Thirty-one (38.3%) of the definitive CRT patients and 39 (53.4%) of the trimodality therapy patients achieved PET-CR after CRT. The 2-year OS of the trimodality group was higher than that of the definitive CRT group, but equivalent to that of the PET-CR subgroup of definitive CRT. The 2-year LRFS and DFS of the trimodality group were higher than that of the PET-CR subgroup or the entire of definitive CRT group. CONCLUSION The addition of surgery showed higher DFS and LRFS rates than those of the PET-CR subgroup of definitive CRT. Despite achieving PET-CR, surgery still seems to improve local tumor control.
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Affiliation(s)
- Yuri Jeong
- Department of Radiation Oncology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
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87
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Reply to letter: "significance of lymphadenectomy in ypT0N0M0R0 esophageal cancer". Ann Surg 2013; 259:e68. [PMID: 24253158 DOI: 10.1097/sla.0000000000000365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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88
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Residual Esophageal Cancer after Neoadjuvant Chemoradiotherapy Frequently Involves the Mucosa and Submucosa. Ann Surg 2013; 258:678-88; discussion 688-9. [DOI: 10.1097/sla.0b013e3182a6191d] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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89
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Kim JY, Hofstetter WL. Esophagectomy after chemoradiation: who and when to operate. Semin Thorac Cardiovasc Surg 2013; 24:288-93. [PMID: 23465677 DOI: 10.1053/j.semtcvs.2012.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2012] [Indexed: 11/11/2022]
Abstract
Neoadjuvant chemoradiation is the standard of care for locally advanced esophageal cancer. After completion of chemoradiotherapy, deciding which patients benefit from surgery remains a challenge. For patients who decide on surgery, the optimal timing is unknown. The complexity of these questions requires an individualized approach, taking into account the expertise of the surgeon, the condition of the patient, and the biology of the tumor.
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Affiliation(s)
- Jae Y Kim
- Division of Thoracic Surgery, City of Hope Cancer Center, Duarte, California, USA
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90
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Adenis A, Tresch E, Dewas S, Romano O, Messager M, Amela E, Clisant S, Kramar A, Mariette C, Mirabel X. Clinical complete responders to definite chemoradiation or radiation therapy for oesophageal cancer: predictors of outcome. BMC Cancer 2013; 13:413. [PMID: 24010566 PMCID: PMC3844443 DOI: 10.1186/1471-2407-13-413] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 08/19/2013] [Indexed: 11/27/2022] Open
Abstract
Background To identify predictors of long-term outcome for patients with clinical complete response (cCR) after definite chemoradiotherapy (CRT) or radiation therapy (RT) for oesophageal cancer (EC). Methods In this retrospective study, we reviewed the files of all patients from our institution that underwent definitive RCT or RT for EC, from January 1998 to December 2003. Among 402 consecutive patients with EC, 110 cCR responses were observed, i.e. without evidence of tumour on morphological examination of the biopsy specimens, 8 to 10 weeks after radiation. Baseline patient and tumour characteristics were as follows: male = 98/110, median age = 60, squamous histology = 103/110, tumour site (upper/middle/lower third) = 41/50/19, weight loss none/<10%/≥10% = 36/45/29, dysphagia grade 1/2/≥3 = 30/14/66. Patients were staged according to endosonography and/or computed tomography. There were 9 stage I, 31 stage IIA, 15 stage IIB, 41 stage III, 6 stage IV. Post treatment nutritional characteristics were as follows: weight loss during treatment none/<10% ≥ 10% = 35/38/37, remaining dysphagia grade 1/2/≥3 = 54/24/32. Univariate and multivariate analyses were performed using log-rank and Cox proportional hazards models, and survival curves were estimated using the Kaplan-Meier method. Results During follow up (median: 6 [0.4–9.8] years), 16 patients had salvage surgery. Median OS was 2.5 years, and 5-year OS was 33.5%. Histological type, stage, age, gender, and treatment characteristics had no significant impact on outcome. The risk of death was increased two-fold for patients with grade ≥ 3 dysphagia after treament (HR = 1.9 [1.2–3.1], p = 0.007). Weight loss ≥10% during treatment also negatively affected outcome (HR = 1.8 [1.0–3.2], p = 0.040). Conclusion One EC patient among 3 with cCR after definite CRT/RT is still alive at 5 years. Variables related to reduced OS were: remaining significant dysphagia after treatment and weight loss ≥10% during treatment.
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Affiliation(s)
- Antoine Adenis
- Gastrointestinal Oncology Department, Centre Oscar Lambret, 3 rue Combemale, 59020 Lille Cedex, France.
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91
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Castoro C, Scarpa M, Cagol M, Alfieri R, Ruol A, Cavallin F, Michieletto S, Zanchettin G, Chiarion-Sileni V, Corti L, Ancona E. Complete clinical response after neoadjuvant chemoradiotherapy for squamous cell cancer of the thoracic oesophagus: is surgery always necessary? J Gastrointest Surg 2013; 17:1375-81. [PMID: 23797888 DOI: 10.1007/s11605-013-2269-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 06/14/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (CT-RT) before oesophagectomy is standard management for squamous cell carcinoma(SCC) of the thoracic oesophagus. The aim of this study was to compare the outcome of patients who had clinical complete response(CR) with neoadjuvant CT-RT + oesophagectomy with the survival of patients who had clinical CR and were not operated on. PATIENTS AND METHODS Seventy-seven consecutive patients with SCC of the thoracic oesophagus with CR with neoadjuvant CT-RT presenting at the Regional Center of Esophageal Diseases from 1992 to 2008 were included in this retrospective study on a prospectively collected database. Thirty-nine patients underwent oesophagectomy (CT-RT + oesophagectomy), while 38(CT-RT) were not operated on because they were considered unfit for surgery or refused the operation. Patients’ outcome and survival were compared. RESULTS In the CT-RT + oesophagectomy group, clinical CR was confirmed after histological examination of the surgical specimen in 27/39 (69.2 %) patients. Five-year overall survival rates were 50.0 % in the CT-RT + oesophagectomy group and 57.0 % in the CT-RT group (p=0.99); 5-year disease-free survival rates were 55.5%in the CT-RT + oesophagectomy group and 34.6%in the CTRT group (p=0.15). Even after adjusting for propensity score, age, ASA and clinical stage, the treatment regimen did not show a statistically significant effect on overall survival (adjusted p=0.65) nor on disease-free survival (adjusted p=0.15). CONCLUSION In our group of patients with clinical CR after neoadjuvant CT-RT for SCC of the thoracic oesophagus, waiting for recurrence and then using salvage surgery did not negatively impact their survival compared to patients treated with surgery. More accurate restaging protocols are warranted to improve decision making after CR with neoadjuvant CT-RT.
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Affiliation(s)
- Carlo Castoro
- Oncological Surgery Unit, Veneto Institute of Oncology(IOV-IRCCS), via Gattamelata 64, 35128 Padua, Italy
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92
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Odenthal M, Bollschweiler E, Grimminger P, Schröder W, Brabender J, Drebber U, Hölscher A, Metzger R, Vallböhmer D. MicroRNA profiling in locally advanced esophageal cancer indicates a high potential of miR-192 in prediction of multimodality therapy response. Int J Cancer 2013; 133:2454-63. [DOI: 10.1002/ijc.28253] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 04/03/2013] [Indexed: 01/16/2023]
Affiliation(s)
- M. Odenthal
- Institute of Pathology, University of Cologne; Cologne; Germany
| | - E. Bollschweiler
- Department of General; Visceral and Cancer Surgery, University of Cologne; Cologne; Germany
| | - P.P. Grimminger
- Department of General; Visceral and Cancer Surgery, University of Cologne; Cologne; Germany
| | - W. Schröder
- Department of General; Visceral and Cancer Surgery, University of Cologne; Cologne; Germany
| | - J. Brabender
- Department of General; Visceral and Cancer Surgery, University of Cologne; Cologne; Germany
| | - U. Drebber
- Institute of Pathology, University of Cologne; Cologne; Germany
| | - A.H. Hölscher
- Department of General; Visceral and Cancer Surgery, University of Cologne; Cologne; Germany
| | - R. Metzger
- Department of General; Visceral and Cancer Surgery, University of Cologne; Cologne; Germany
| | - D. Vallböhmer
- Department of General; Visceral and Cancer Surgery, University of Cologne; Cologne; Germany
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93
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Khangura SK, Greenwald BD. Endoscopic management of esophageal cancer after definitive chemoradiotherapy. Dig Dis Sci 2013; 58:1477-85. [PMID: 23325163 DOI: 10.1007/s10620-012-2554-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 12/24/2012] [Indexed: 01/29/2023]
Abstract
BACKGROUND Concurrent chemoradiotherapy (CRT) is a potentially curative non-surgical option for locally advanced esophageal cancer, with pathological complete response (CR) ranging from 13 to 49 %. The rate of persistent and recurrent disease within the esophagus remains high at 40-60 %, and treatment of these tumors may improve disease-free survival. The aim of this review is to assess the efficacy of salvage endoscopic therapies for recurrent esophageal cancer. METHODS Medline and Embase were searched for relevant studies published in the English-language literature that reported use of endoscopic modalities, including photodynamic therapy (PDT), endoscopic mucosal resection (EMR), and spray cryotherapy, as salvage therapies for esophageal cancer. RESULTS A total of 12 studies were identified. In small case series of PDT, CR varied from 20 to 100 %, with 1-, 3-, and 5-year overall survival rates of 65-80, 34-47, and 36 %, respectively. Data from three studies of EMR in squamous cell cancer show CR in 50 % of cases, with 3- and 5-year overall survival of 56-81 and 49 %, respectively. Endoscopic spray cryotherapy has recently been used in this setting with an observed CR of 37.5 %. CONCLUSIONS Endoscopic salvage therapies are options for those patients with disease limited to the superficial esophageal wall and those who are unfit to undergo salvage esophagectomy. Widespread application of endoscopic salvage therapies is limited by the lack of awareness and guidelines for endoscopic surveillance post-CRT and limited data on the effectiveness of endoscopic therapies.
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Affiliation(s)
- Sajneet K Khangura
- Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA.
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94
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Konieczny A, Meyer P, Schnider A, Komminoth P, Schmid M, Lombriser N, Weishaupt D. Accuracy of multidetector-row CT for restaging after neoadjuvant treatment in patients with oesophageal cancer. Eur Radiol 2013; 23:2492-502. [PMID: 23645329 DOI: 10.1007/s00330-013-2844-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 02/18/2013] [Accepted: 02/21/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To assess the diagnostic accuracy of 64-multidetector CT (MDCT) for restaging of patients with oesophageal cancer undergoing neoadjuvant therapy. METHODS Results of pathological staging were correlated with those from 64-MDCT before and after neoadjuvant treatment in 35 patients using the American Joint Committee on Cancer/TNM classification (7th edition). CT response was determined using the Response Evaluation Criteria in Solid Tumours (RECIST) method, modified for one-dimensional tumour diameter measurement. RESULTS 64-MDCT predicted T stage correctly in 34 % (12/35), overstaged in 49 % (17/35) and understaged in 17 % (6/35). Sensitivity/specificity values were as follows: T0, 20 %/92 %; T1-T2, 31 %/59 %; T3, 60 %/64 %; T4, 100 %/4 %. Negative predictive values for T3/T4 were 80 %/100 %. MDCT accurately predicted complete histopathological response in 20 % (accuracy 74 %) and overstaged in 80 %. Tumour regression grade was predicted correctly in only 8 % (2/25) and underestimated in 68 % (17/25). Accurate N stage was noted in 69 % (24/35). CONCLUSION Although MDCT tends to be able to exclude advanced tumour stages (T3, T4) with a higher likelihood, the diagnostic accuracy of high resolution MDCT for restaging oesophageal cancer and assessing the response to neoadjuvant therapy has not improved in comparison to older-generation CT. Therefore, the future assessment of oesophageal tumour response should focus on combined morphologic and metabolic imaging. KEY POINTS • Multidetector CT (MDCT) has been beneficial for the evaluation of many tumours. • However diagnostic accuracy for restaging oesophageal cancer has not improved with MDCT. • MDCT tends to be able to exclude advanced tumour stages (T3/T4). • MDCT has a low accuracy for determining lymph node metastasis. • Oesophageal tumour response should be assessed by combined morphological and metabolic imaging.
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Affiliation(s)
- Agnieszka Konieczny
- Institute of Radiology, Triemli Hospital, Birmensdorferstrasse 497, CH-8063, Zürich, Switzerland
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Chao YK, Tseng CK, Wen YW, Liu YH, Wan YL, Chiu CT, Chang WC, Chang HK. Using Pretreatment Tumor Depth and Length to Select Esophageal Squamous Cell Carcinoma Patients for Nonoperative Treatment After Neoadjuvant Chemoradiotherapy. Ann Surg Oncol 2013; 20:3000-8. [DOI: 10.1245/s10434-013-2962-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Indexed: 01/09/2023]
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96
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Bedenne L, Hamza S, Jouve JL. Radiochimiothérapie comme traitement médical du cancer de l’œsophage. La chirurgie est-elle toujours nécessaire ? ONCOLOGIE 2013. [DOI: 10.1007/s10269-013-2265-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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97
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Evaluation of early response to concomitant chemoradiotherapy by interim 18F-FDG PET/CT imaging in patients with locally advanced oesophageal carcinomas. Eur J Nucl Med Mol Imaging 2013; 40:477-85. [DOI: 10.1007/s00259-012-2325-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 12/12/2012] [Indexed: 10/27/2022]
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98
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Factors predicting prognosis and recurrence in patients with esophago-gastric adenocarcinoma and histopathological response with less than 10 % residual tumor. Langenbecks Arch Surg 2012; 398:239-49. [PMID: 23269519 DOI: 10.1007/s00423-012-1039-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 12/05/2012] [Indexed: 12/22/2022]
Abstract
PURPOSE Neoadjuvant treatment is an accepted standard approach for treating locally advanced esophago-gastric adenocarcinomas. Despite a response of the primary tumor, a significant percentage dies from tumor recurrence. The aim of this retrospective exploratory study from two academic centers was to identify predictors of survival and recurrence in histopathologically responding patients. METHODS Two hundred thirty one patients with adenocarcinomas (esophagus: n = 185, stomach: n = 46, cT3/4, cN0/+, cM0) treated with preoperative chemotherapy (n = 212) or chemoradiotherapy (n = 19) followed by resection achieved a histopathological response (regression 1a: no residual tumor (n = 58), and regression 1b < 10 % residual tumor (n = 173)). RESULTS The estimated median overall survival was 92.4 months (5-year survival, 56.6 %) for all patients. For patients with regression 1a, median survival is not reached (5-year survival, 71.6 %) compared to patients with regression 1b with 75.3 months median (5-year survival, 52.2 %) (p = 0.031). Patients with a regression 1a had lymph node metastases in 19.0 versus 33.7 % in regression 1b. The ypT-category (p < 0.001), the M-category (p = 0.005), and the type of treatment (p = 0.04) were found to be independent prognostic factors in R0-resected patients. The recurrence rate was 31.7 % (n = 66) (local, 39.4 %; peritoneal carcinomatosis, 25.7 %; distant metastases, 50 %). Recurrence was predicted by female gender (p = 0.013), ypT-category (p = 0.007), and M-category (p = 0.003) in multivariate analysis. CONCLUSION Response of the primary tumor does not guarantee recurrence-free long-term survival, but histopathological complete responders have better prognosis compared to partial responders. Established prognostic factors strongly influence the outcome, which could, in the future, be used for stratification of adjuvant treatment approaches. Increasing the rate of histopathological complete responders is a valid endpoint for future clinical trials investigating new drugs.
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99
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Li Z, Rice TW. Diagnosis and staging of cancer of the esophagus and esophagogastric junction. Surg Clin North Am 2012; 92:1105-26. [PMID: 23026272 DOI: 10.1016/j.suc.2012.07.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Esophageal/esophagogastric junction cancer staging in the 7th edition of the AJCC staging manual is data driven and harmonized with gastric staging. New definitions are Tis, T4, regional lymph node, N, and M. Nonanatomic characteristics (histopathologic cell type, histologic grade, cancer location) and TNM classifications determine stage groupings. Classifications before treatment define clinical stage (cTNM or ycTNM). Current best clinical staging modalities include endoscopic ultrasonography for T and N and CT/PET for M. Classifications at resection define pathologic stage (pTNM or ypTNM). Accurate pathologic stage requires communication/cooperation between surgeon and pathologist. Classifications are defined at retreatment (rTNM) and autopsy (aTNM).
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Affiliation(s)
- Zhigang Li
- Department of Thoracic and Cardiovascular Surgery, The Second Military Medical University, Changhai Hospital, Shanghai, People's Republic of China
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100
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Power DG, O'Sulleabhain C, Murphy TJ. Preoperative chemoradiotherapy for esophageal cancer. N Engl J Med 2012; 367:873; author reply 873-4. [PMID: 22931331 DOI: 10.1056/nejmc1207702] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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