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Teoh AYB, Chiu PWY, Yeung WK, Liu SYW, Wong SKH, Ng EKW. Long-term survival outcomes after definitive chemoradiation versus surgery in patients with resectable squamous carcinoma of the esophagus: results from a randomized controlled trial. Ann Oncol 2012; 24:165-71. [PMID: 22887465 DOI: 10.1093/annonc/mds206] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The aim of this study was to report on the 5-year survival outcomes of patients with resectable esophageal carcinoma who were treated by definitive chemoradiotherapy (CRT) or standard esophagectomy. PATIENTS AND METHODS Between July 2000 and December 2004, 81 patients with resectable squamous cell carcinoma of the mid- or lower thoracic esophagus were randomized to receive esophagectomy or definitive CRT. The primary outcome was the overall survival and secondary outcomes included disease-free survival, morbidities and mortalities. RESULTS Forty-five patients received esophagectomy and 36 patients were treated by definitive CRT. The overall 5-year survival favors CRT but the difference did not reach statistical significance (surgery 29.4% and CRT 50%, P=0.147). A trend to improved 5-year survival was observed for patients suffering from node-positive disease (P=0.061). The 5-year disease-free survival also showed a trend to significance favoring CRT (P=0.068), particularly for patients suffering from node-positive disease (P=0.017). Both the stage of the disease and albumin level were significant predictors to mortality and disease-free survival. CONCLUSIONS Definitive CRT for squamous esophageal carcinoma resulted in comparable long-term survival to surgery. Further large-scale studies would be required to further investigate the role of CRT in node-positive patients. Clinicaltrials.gov identifier: NCT01032967.
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Affiliation(s)
- A Y B Teoh
- Division of Upper Gastrointestinal Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, SAR, China
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102
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Klayton T, Li T, Yu JQ, Keller L, Cheng J, Cohen SJ, Meropol NJ, Scott W, Xu-Welliver M, Konski A. The Role of Qualitative and Quantitative Analysis of F18-FDG Positron Emission Tomography in Predicting Pathologic Response Following Chemoradiotherapy in Patients with Esophageal Carcinoma. J Gastrointest Cancer 2012; 43:612-8. [DOI: 10.1007/s12029-012-9412-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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103
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Disseminated Tumor Cells in Bone Marrow and the Natural Course of Resected Esophageal Cancer. Ann Surg 2012; 255:1105-12. [DOI: 10.1097/sla.0b013e3182565b0b] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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104
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Kauppi JT, Oksala N, Salo JA, Helin H, Karhumäki L, Kemppainen J, Sihvo EI, Räsänen JV. Locally advanced esophageal adenocarcinoma: response to neoadjuvant chemotherapy and survival predicted by ([18F])FDG-PET/CT. Acta Oncol 2012; 51:636-44. [PMID: 22208782 DOI: 10.3109/0284186x.2011.643822] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND ([18F])fluorodeoxyglycose-Positron Emission Tomography/Computer Tomography (([18F])FDG-PET/CT) is commonly used in staging of locally advanced esophageal cancer. Its predictive value for response to neoadjuvant therapy and survival after multimodality therapy is controversial. METHODS Sixty-six consecutive patients with locally advanced adenocarcinoma of the esophagus or esophagogastric junction underwent surgery after neoadjuvant chemotherapy. Staging was done prospectively with ([18F])FDG-PET/CT, before and after completion of neoadjuvant therapy. Pre- and post-therapy maximal standardized uptake values for the primary tumor (SUV1 and SUV2) were determined, and their relative change (SUV∆%) calculated. Percentage change in SUV1 was compared with histopathologic response (HPR, complete or subtotal histologic remission), disease-free- (DFS) and overall survival (OS). RESULTS Resection with negative margins was achieved in 60 patients. HPR rate was 14 of 66 (21.2%). Median follow-up was 16 months (range 4-72). For all patients, OS probability at three years was 59% and DFS 50%. In receiver operating characteristics (ROC) analysis, HPR was optimally predicted by a > 67% change in baseline maximal SUV (sensitivity 79% and specificity 75%). In univariate survival analysis (Cox regression proportional hazards), HPR associated with improved DFS (HR 0.208, p = 0.033) but not OS (HR 0.030, p = 0.101), SUV % > 67% associated with improved OS (HR 0.249, p = 0.027) and DFS (HR 0.383, p = 0.040). In a multivariate model (adjusted by age, sex, and ASA score), neither HPR nor SUV∆% > 67% was predictive of improved OS and DFS. However, SUV∆% as a continuous variable was an independent predictor of OS (HR 0.966, p < 0.0001) or DFS (HR 0.973, p < 0.0001). CONCLUSION Our results support previous results showing that ([18F])FDG-PET/CT can distinguish a group of patients with worse prognosis after neoadjuvant chemotherapy in adenocarcinoma of the esophagus or esophagogastric junction. This information could offer a new independent preoperative marker of prognosis.
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Affiliation(s)
- Juha T Kauppi
- Helsinki University Central Hospital, Division of General Thoracic and Esophageal Surgery, Department of Cardiothoracic Surgery, Helsinki University Central Hospital, Haartmaninkatu 4, Helsinki, Finland
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105
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Preoperative Work-up: EsophagoGastroDuodenoScopy, Tracheobronchoscopy, and Endoscopic Ultrasonography. Updates Surg 2012. [DOI: 10.1007/978-88-470-2330-7_4] [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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106
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Hölscher AH, Bollschweiler E. Choosing the best treatment for esophageal cancer : criteria for selecting the best multimodal therapy. Recent Results Cancer Res 2012; 196:169-77. [PMID: 23129373 DOI: 10.1007/978-3-642-31629-6_11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The best multimodal therapy in esophageal cancer comprises neoadjuvant radiochemotherapy in patients with adenocarcinoma or squamous cell carcinoma whereas neoadjuvant chemotherapy is only appropriate for patients with adenocarcinoma. However, the 2-year survival benefit by this induction therapy compared to surgery alone is only 5-9 %. Targeted drugs seem to be promising in order to improve the response rate. The choice of the best multimodal therapy by response prediction seems only to be possible in patients during chemotherapy for adenocarcinoma, whereas during neoadjuvant radiochemotherapy a response prediction by FDG-PET is not possible. The principle item of multimodal therapy is still transthoracic en bloc esophagectomy which should be performed in high volume centers in order to guarantee stable and good results.
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Affiliation(s)
- A H Hölscher
- Department of General, Visceral and Cancer Surgery, University of Cologne, Köln, Germany.
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107
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Yue J, Yang Y, Cabrera AR, Sun X, Zhao S, Xie P, Zheng J, Ma L, Fu Z, Yu J. Measuring tumor hypoxia with ¹⁸F-FETNIM PET in esophageal squamous cell carcinoma: a pilot clinical study. Dis Esophagus 2012; 25:54-61. [PMID: 21595781 DOI: 10.1111/j.1442-2050.2011.01209.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The purpose of this study was to evaluate hypoxia in esophageal squamous cell carcinoma (SCC) with (18)F-fluoroerythronitroimidazole positron emission tomography/computed tomography ((18)F-FETNIM PET/CT). We determined an imaging threshold for hypoxia, quantified the spatiotemporal variability of hypoxia in untreated tumor, and evaluated the ability of (18)F-FETNIM PET to predict clinical response following concurrent chemoradiotherapy (CCRT). Twenty-eight consecutive patients with inoperable SCC of the esophagus were consecutively accrued between April 2007 and June 2010. The first 10 patients received two pretreatment (18)F-FETNIM PET/CT scans on separate days. The remaining 18 patients only underwent (18)F-FETNIM PET/CT once before CCRT. The ratio of the maximum standardized uptake value (SUV(max) ) of 336 normal tissue regions (i.e. heart, lung, brain, or muscle) to the mean standardized uptake value (SUV(mean)) of the respective patient's spleen was calculated, and the imaging threshold for hypoxia defined as the level of uptake demonstrated by less than 5% of tissue regions. Among the patients with two pretreatment scans, each pair of scans was compared with respect to location and intensity of uptake to assess for baseline spatiotemporal variability. Logistic regression analysis was used to determine whether pretreatment imaging characteristics are predictive of clinical response. The mean and median ratios of the SUV(max) of tissue : SUV(mean) of spleen were nearly identical, and 95% of the ratios fell below 1.3. The mean Dice similarity coefficient for the hypoxic volumes on pretreatment PET scans acquired in the same patient on different days was 0.12 (range, 0.05-0.21). Individuals' tumor SUV(max) and SUV(mean) did not vary significantly, but on average, the geometric centers of hypoxic regions shifted 15 mm (range, 8-20 mm) from the first pretreatment scan to the second. SUV(max) was the imaging characteristic most predictive of treatment response (P= 0.041), with high SUVmax associated with poor clinical response. (18)F-FETNIM PET/CT can depict hypoxia in esophageal SCC. Prior to CCRT, tumor hypoxia demonstrates spatial variability on different days, although overall (18)F-FETNIM uptake remains similar. Baseline SUV(max) may be predictive of treatment response.
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Affiliation(s)
- J Yue
- Department of Oncology, Shandong University, Jinan, China
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108
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Dittrick GW, Weber JM, Shridhar R, Hoffe S, Melis M, Almhanna K, Barthel J, McLoughlin J, Karl RC, Meredith KL. Pathologic nonresponders after neoadjuvant chemoradiation for esophageal cancer demonstrate no survival benefit compared with patients treated with primary esophagectomy. Ann Surg Oncol 2011; 19:1678-84. [PMID: 22045465 DOI: 10.1245/s10434-011-2078-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Indexed: 01/12/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiation (NCRT) has become the preferred treatment for patients with locally advanced esophageal cancer. Survival often is correlated to degree of pathologic response; however, outcomes in patients who are found to be pathologic nonresponders (pNR) remain uninvestigated. This study was designed to evaluate survival in pNR to NCRT compared with patients treated with primary esophagectomy (PE). METHODS Using our comprehensive esophageal cancer database, we identified patients treated with NCRT and deemed pNR along with patients who proceeded to PE. Clinical and pathologic data were compared using Fisher's exact and χ(2), whereas Kaplan-Meier estimates were used for survival analysis. RESULTS We identified 63 patients treated with NCRT and were found to have a pNR, and 81 patients who underwent PE. Disease-free (DFS) and overall survival (OS) were significantly decreased in the pNR group compared with those treated with PE (10 vs. 50 months (0-152), P < 0.001 and 13 vs. 50 months (0-152), P < 0.001, respectively). For patients with stage II disease, DFS and OS were similarly decreased in pathologic nonresponders (13 vs. 62 months (0-120), P < 0.001 and 31 vs. 62 months (0-120), P = 0.024, respectively). There were no differences in DFS or OS for patients with stage III disease (10 vs. 14 months (0-152), P = 0.29 and 10 vs. 19 months (0-152), P = 0.16, respectively). CONCLUSIONS Pathologic nonresponders to NCRT for esophageal cancer receive no benefit in DFS or OS compared with patients treated with PE. For patients with stage II disease, DFS and OS are, in fact, significantly decreased in the pNR.
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Affiliation(s)
- George W Dittrick
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
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109
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[Squamous cell carcinoma of the esophagus]. Chirurg 2011; 82:974-80. [PMID: 22002703 DOI: 10.1007/s00104-011-2128-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The prognosis of locally advanced squamous cell carcinomas (SCC) of the esophagus after surgery only is poor. Therefore a definitive chemoradiotherapy (RCTx) was also discussed as the therapy of choice. Besides tumor biology, patient-related factors, such as alcohol and nicotine abuse increase the perioperative mortality and morbidity. Multimodal treatment can improve the outcome in comparison to surgery alone. A recently published meta-analysis confirmed that preoperative RCTx followed by surgery improves the prognosis compared to surgery alone in SCC of the esophagus. After chemotherapy this effect is less pronounced. Patients with a complete histopathological response (pCR) after preoperative RCTx have a 5-year survival rate of more than 55% and a low probability of local recurrence. However, a pCR cannot be predicted neither by negative biopsy nor by negative FDG-PET uptake after RCTx. Up to now FDG-PET has shown a low impact for response prediction or therapy modification in SCC of the esophagus in clinical studies. Responding patients should be transferred to surgery after preoperative treatment, because of a reduced perioperative morbidity and mortality and improved prognosis.
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110
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Misra S, Choi M, Livingstone AS, Franceschi D. The role of endoscopic ultrasound in assessing tumor response and staging after neoadjuvant chemotherapy for esophageal cancer. Surg Endosc 2011; 26:518-22. [PMID: 21938577 DOI: 10.1007/s00464-011-1911-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 08/06/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although the role of endoscopic ultrasound (EUS) in the initial staging of esophageal cancer is well established, its role in assessing tumor response and staging esophageal cancers after neoadjuvant chemotherapy (NAC) is controversial, and this study aimed to investigate this role. METHODS This study retrospectively analyzed 110 patients with esophageal cancer who underwent EUS by single surgeon before and after NAC. Tumor response was assessed before and after NAC. Patients with more than a 50% reduction in tumor size based on EUS evaluation were classified as having a significant response to chemotherapy, and those with less than a 50% reduction were categorized as having a partial response. Disease stage was established by tumor node metastasis (TNM) classification. Initial staging was performed using EUS and computed tomography (CT) scans of the chest and abdomen. The EUS-determined stage was compared with the postsurgical pathologic stage. χ(2) analysis and Fisher's exact testing were performed. RESULTS A response to NAC was shown by 96 patients (87.3%) and no response by 14 patients (12.7%). Of the 96 responding patients, 37 (38.5%) showed a significant response, whereas 43 (61.5%) of 69 patients showed a partial response. The EUS staging correlated well with the pathologic staging for 9 (64.3%) of the 14 nonresponders and for 34 (35.4%) of the 96 responders to NAC (P = 0.04). The EUS accurately predicted both the T and N status for 26 (23.6%) of the 110 patients. Prediction of N status was significantly more accurate than prediction of the T stage for the post-NAC patients. Of the 110 patients, 43 (39.1%) patients had an accurate T-stage prediction, and 64 (58.2%) had an accurate N stage match (P = 0.02). The T stage was overstaged for 60 (54.5%) of the patients and understaged for 7 of the patients (6.4%).The study found overstaging of the T stage to be more common among the patients who responded to chemotherapy. The N stage was overstaged for 25 (22.7%) and understaged for 21 (19.1%) of the 110 patients. CONCLUSION The findings showed EUS to be a useful tool for assessing response to chemotherapy and for evaluating the extent of disease, thus facilitating surgical decision making. However, EUS is an unreliable tool for staging esophageal cancer after NAC. Overstaging of the T stage is significantly more common and could be related to the inflammatory effect or fibrosis after NAC.
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Affiliation(s)
- Subhasis Misra
- DeWitt Daughtry Family Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, FL, USA.
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111
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Twaddell WS, Wu PC, Verhage RJJ, Feith M, Ilson DH, Schuhmacher CP, Luketich JD, Brücher B, Vallböhmer D, Hofstetter WL, Krasna MJ, Kandioler D, Schneider PM, Wijnhoven BPL, Sontag SJ. Barrett's esophagus: treatments of adenocarcinomas II. Ann N Y Acad Sci 2011; 1232:265-291. [PMID: 21950818 DOI: 10.1111/j.1749-6632.2011.06056.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The following topics are explored in this collection of commentaries on treatments of adenocarcinomas related to Barrett's esophagus: the importance of intraoperative frozen sections of the margins for the detection of high dysplasia; the preferable way for sentinel node dissection; the current role of robotic surgery and of video-endoscopic approach; the value of the Siewert's classification of adenocarcinomas; the indications of two-step esophagectomy; the evaluation of pathological complete response; the role of PET scan in staging and response assessment; the role of p53 in the selection of adenocarcinomas patients; chemotherapy regimens for adenocarcinomas; the use of monoclonal antibodies in the control of cell proliferation; he attempt to define a stage-specific strategy, and the possible indications of selective therapy; and changes in mortality rates from esophageal cancer.
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Affiliation(s)
- William S Twaddell
- Anatomic Pathology, University of Maryland Medical Center, Baltimore, Maryland, USA
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112
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Palmes D, Brüwer M, Bader FG, Betzler M, Becker H, Bruch HP, Büchler M, Buhr H, Ghadimi BM, Hopt UT, Konopke R, Ott K, Post S, Ritz JP, Ronellenfitsch U, Saeger HD, Senninger N. Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group. Langenbecks Arch Surg 2011; 396:857-66. [PMID: 21713594 DOI: 10.1007/s00423-011-0818-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 06/07/2011] [Indexed: 12/16/2022]
Abstract
PURPOSE Correct diagnosis, surgical treatment, and perioperative management of patients with esophageal carcinoma remain crucial for prognosis within multimodal treatment procedures. This study aims to achieve a consensus regarding current management strategies in esophageal cancer by questioning a panel of experts from the German Advanced Surgical Treatment Study (GAST) group, comprised of 9 centers specialized in esophageal surgery, with a combined total of >220 esophagectomies per year. MATERIALS AND METHODS The Delphi method, a systematic and interactive, evidence-based approach, was used to obtain consensus statements from the GAST group regarding ambiguities and disparities in diagnosis, patient selection, surgical technique, and perioperative management of patients with esophageal carcinoma. After four rounds of surveys, agreement was measured by Likert scales and defined as full (100% agreement), near (≥66.6% agreement), or no consensus (<66.6% agreement). RESULTS Full or near consensus was obtained for essential aspects of esophageal cancer staging, proper surgical technique, perioperative management and indication for primary surgery, and neoadjuvant treatment or palliative treatment. No consensus was achieved regarding acceptability of minimally invasive technique and postoperative nutrition after esophagectomy. CONCLUSION The GAST consensus statement represents a position paper for treatment of patients with esophageal carcinoma which both contributes to the development of clinical treatment guidelines and outlines topics in need of further clinical studies.
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Affiliation(s)
- Daniel Palmes
- Department of General and Visceral Surgery, University of Münster, Waldeyerstrasse 1, 48149 Münster, Germany.
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113
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Miyata H, Yamasaki M, Takiguchi S, Nakajima K, Fujiwara Y, Konishi K, Morii E, Mori M, Doki Y. Prognostic Value of Endoscopic Biopsy Findings After Induction Chemoradiotherapy With and Without Surgery for Esophageal Cancer. Ann Surg 2011; 253:279-84. [DOI: 10.1097/sla.0b013e318206824f] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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114
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Impact of PET-CT on Primary Staging and Response Control on Multimodal Treatment of Esophageal Cancer. World J Surg 2011; 35:608-16. [DOI: 10.1007/s00268-010-0946-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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115
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A multicenter study of survival after neoadjuvant radiotherapy/chemotherapy and esophagectomy for ypT0N0M0R0 esophageal cancer. Ann Surg 2010; 252:744-9. [PMID: 21037429 DOI: 10.1097/sla.0b013e3181fb8dde] [Citation(s) in RCA: 140] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To evaluate 5-year survival of patients with locally advanced esophageal cancer (LAEC) who have undergone multimodality treatment with complete histopathologic response. BACKGROUND Patients with LAEC may obtain excellent local-regional response to multimodality therapy. The overall benefit of a complete histopathologic response, when no viable tumor is present in the surgical specimen, is incompletely understood and existing data are limited to single-center studies with relatively few patients. The aim of this multicenter study was to define the outcome of patients with complete histopathologic response after multimodality therapy for LAEC. METHODS The study population included 299 patients (229 male, 70 female; median age: 60 years) with LAEC (cT2N1M0, T3-4N0-1M0; 181 adenocarcinomas, 118 squamous carcinomas) who underwent either neoadjuvant radiochemotherapy (n = 284) or chemotherapy (n = 15) followed by esophagectomy at 6 specialized centers: Europe (3) and United States (3). All patients in the study had stage ypT0N0M0R0 after resection. RESULTS Esophagectomy with thoracotomy (n = 255) was more frequent than with a transhiatal approach (n = 44). The median number of analyzed lymph nodes in the surgical specimens was 20 (minimum-maximum: 1-77). Thirty-day mortality rate was 2.4% and 90-day mortality rate was 5.7%. Overall 5-year survival rate was 55%. The disease-specific 5-year survival rate was 68%, with a recurrence rate of 23.4% (n = 70; local vs distant recurrence: 3.3% vs 20.1%). Cox regression analysis identified age as the only independent predictor of survival, whereas gender, histology, type of esophagectomy, type of neoadjuvant therapy, and the number of resected lymph nodes had no prognostic impact. CONCLUSION Patients with histopathologic complete response at the time of resection of LAEC achieve excellent survival.
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116
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Sendler A. Metabolic response evaluation by PET during neoadjuvant treatment for adenocarcinoma of the esophagus and esophagogastric junction. Recent Results Cancer Res 2010; 182:167-77. [PMID: 20676880 DOI: 10.1007/978-3-540-70579-6_14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Following several randomized trials, neoadjuvant therapy in adenocarcinoma of esophagus and the esophagogastric junction can be seen as an international standard. However, in a large proportion of patients the objective response achieved is unsatisfactory. These patients do not benefit from neoadjuvant therapy, but do suffer from toxic side effects; sometimes progressive and appropriate surgical therapy is delayed. For this reason, a diagnostic test that can accurately assess tumor response to neoadjuvant therapy might be of crucial importance. Response evaluation using CT scan, endoluminal ultrasound, or rebiopsy is not reliable. In recent times, response evaluation using 18FGD PET after and during neoadjuvant treatment is in the focus of clinical and scientific interest. Most studies have evaluated the diagnostic modalities for response to neoadjuvant treatment after completion of the treatment. Following the published data so far, FDG-PET seems to be less accurate after and during chemoradiation than after chemotherapy alone. The data of early response evaluation (14 days after the onset of chemotherapy) are very much encouraging; however, they have to be evaluated in an international randomized trial. Standardization of PET technology as well as defining the thresholds used for the estimation of early response is mandatory. So far, FDG-PET does not change treatment in esophageal and gastric cancer.
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Affiliation(s)
- A Sendler
- Allgemein-, Viszeral- und Tumorchirurgie, Isar Medizin Zentrum, Sonnenstr. 24 - 26, 80331, München, Germany.
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Phase II randomised trial of chemoradiotherapy with FOLFOX4 or cisplatin plus fluorouracil in oesophageal cancer. Br J Cancer 2010; 103:1349-55. [PMID: 20940718 PMCID: PMC2990616 DOI: 10.1038/sj.bjc.6605943] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: Concurrent chemoradiotherapy is a valuable treatment option for localised oesophageal cancer (EC), but improvement is still needed. A randomised phase II trial was initiated to assess the feasibility and efficacy in terms of the endoscopic complete response rate (ECRR) of radiotherapy with oxaliplatin, leucovorin and fluorouracil (FOLFOX4) or cisplatin/fluorouracil. Methods: Patients with unresectable EC (any T, any N, M0 or M1a), or medically unfit for surgery, were randomly assigned to receive either six cycles (three concomitant and three post-radiotherapy) of FOLFOX4 (arm A) or four cycles (two concomitant and two post-radiotherapy) of cisplatin/fluorouracil (arm B) along with radiotherapy 50 Gy in both arms. Responses were reviewed by independent experts. Results: A total of 97 patients were randomised (arm A/B, 53/44) and 95 were assessable. The majority had squamous cell carcinoma (82% arm A/B, 42/38). Chemoradiotherapy was completed in 74 and 66%. The ECRR was 45 and 29% in arms A and B, respectively. Median times to progression were 15.2 and 9.2 months and the median overall survival was 22.7 and 15.1 months in arms A and B, respectively. Conclusion: Chemoradiotherapy with FOLFOX4, a well-tolerated and convenient combination with promising efficacy, is now being tested in a phase III trial.
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118
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Orditura M, Galizia G, Napolitano V, Martinelli E, Pacelli R, Lieto E, Aurilio G, Vecchione L, Morgillo F, Catalano G, Ciardiello F, Del Genio A, Di Martino N, De Vita F. Weekly chemotherapy with cisplatin and paclitaxel and concurrent radiation therapy as preoperative treatment in locally advanced esophageal cancer: a phase II study. Cancer Invest 2010; 28:820-827. [PMID: 20482249 DOI: 10.3109/07357901003630926] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We evaluated the association of a weekly cisplatin (35 mg/mq) and paclitaxel (45 mg/mq) regimen with radiotherapy (46 Gy) as primary treatment in locally advanced esophageal cancer (LAEC). The main end point was the activity in terms of pathologic complete response (pathCR) rate. Thirty-three LAEC patients received chemoradiation therapy during weeks 1-6 followed by esophagectomy. A pathCR was observed in 10/33 patients; 20/33 and 3/33 patients showed PR and SD, respectively. The EUS maximal transverse cross sectional area reduction >50% significantly correlated with pathCR. Three-year survival rate was 35%. These results support the activity and mild toxicity of this regimen.
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Affiliation(s)
- Michele Orditura
- Division of Medical Oncology, Department of Clinical and Experimental Medicine and Surgery F. Magrassi e A. Lanzara, Second University of Naples, School of Medicine, Naples, Italy
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119
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Courrech Staal EFW, Aleman BMP, Boot H, van Velthuysen MLF, van Tinteren H, van Sandick JW. Systematic review of the benefits and risks of neoadjuvant chemoradiation for oesophageal cancer. Br J Surg 2010; 97:1482-96. [DOI: 10.1002/bjs.7175] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Abstract
Background
Surgery alone for locally advanced oesophageal cancer is associated with low cure rates. The benefits and risks of neoadjuvant chemoradiation for patients with oesophageal cancer were evaluated.
Methods
A systematic review of publications between 2000 and 2008 on neoadjuvant chemoradiation for oesophageal cancer was undertaken.
Results
Thirty-eight papers comprising 3640 patients met the inclusion criteria. Chemoradiation regimens varied widely with a predominance of 5-fluorouracil/cisplatin chemotherapy. Chemoradiation-related toxicity was reported in only ten studies and consisted mainly of neutropenia. The chemoradiation-related mortality rate was 2·3 per cent. The mean R0 resection rate and pathological complete response (pCR) rate were 88·4 and 25·8 per cent respectively. Postoperative morbidity was not uniformly reported. The in-hospital mortality rate after oesophagectomy following chemoradiation was 5·2 per cent. Five-year survival rates varied from 16 to 59 per cent in all patients and from 34 to 62 per cent in those with a pCR. Chemoradiation had a temporary negative effect on quality of life.
Conclusion
Neoadjuvant chemoradiation regimens for oesophageal cancer vary widely. Besides traditional outcome variables (such as survival), other parameters should be analysed (for example toxicity) to assess whether the risks of chemoradiation are sufficiently compensated for by the benefits.
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Affiliation(s)
- E F W Courrech Staal
- Department of Surgery, The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - B M P Aleman
- Department of Radiotherapy, The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - H Boot
- Department of Gastroenterology and Hepatology, The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - M-L F van Velthuysen
- Department of Pathology, The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - H van Tinteren
- Department of Biometrics, The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - J W van Sandick
- Department of Surgery, The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Bollschweiler E, Besch S, Drebber U, Schröder W, Mönig SP, Vallböhmer D, Baldus SE, Metzger R, Hölscher AH. Influence of neoadjuvant chemoradiation on the number and size of analyzed lymph nodes in esophageal cancer. Ann Surg Oncol 2010; 17:3187-94. [PMID: 20585867 DOI: 10.1245/s10434-010-1196-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Indexed: 01/14/2023]
Abstract
BACKGROUND Studies have shown that along with primary tumor response, lymph node status after RTx/CTx is one of the most important prognostic factors for advanced esophageal carcinoma. The goal of our study was to investigate the influence of neoadjuvant radiochemotherapy (RTx/CTx) on lymph nodes (LN). MATERIALS AND METHODS From 1997 until 2006, 297 patients underwent surgery for advanced esophageal carcinoma. Of these, 192 received preoperative chemoradiation (5-FU, cisplatin, 36 Gy). The following matched subgroups were chosen: Group I, 20 with surgery alone: 10 adenocarcinoma (AC), 10 squamous cell carcinoma (SCC); Group II, 20 with minor response (10 AC, 10 SCC); Group III, 20 with major response (10 AC, 10 SCC). Tumor response was graded as "minor" or "major" according to the Cologne Regression Scale, the LN size determined by the largest measured diameter. RESULTS A total of 1967 LNs from 60 patients were examined. Of these, 161 LNs showed metastasis. The median number of LNs examined per patient was not significantly higher in group I compared with the group with pretreatment (32 vs 31). Group I and group II showed LN metastasis (LNM) in 65% of cases, and group III in only 20% (p = 0.011). LNMs after pretreatment had significantly smaller median diameters (5.0 mm) than those without (7.0 mm) (p < 0.02). Nonmetastatic LN size did not vary between the three groups. LN size with and without metastasis did not differ between AC and SCC or between major and minor responders. CONCLUSION With good response to neoadjuvant radiochemotherapy, the size and the number of metastatic LNs is significantly reduced regardless of histologic cancer type.
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Affiliation(s)
- Elfriede Bollschweiler
- Department of General, Visceral, and Cancer Surgery, University of Cologne, Cologne, Germany.
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Hurmuzlu M, Monge OR, Smaaland R, Viste A. High-dose definitive concomitant chemoradiotherapy in non-metastatic locally advanced esophageal cancer: toxicity and outcome. Dis Esophagus 2010; 23:244-52. [PMID: 19664075 DOI: 10.1111/j.1442-2050.2009.00999.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This study is a retrospective analysis of high-dose definitive concomitant chemoradiotherapy in locally advanced esophageal cancer in a single institution. The aim of the study was to identify and quantify the toxicity associated with the high-dose treatment and to analyze the outcome of this treatment. Forty-six patients (41 men and 5 women, median age of 67.5 years) with disease stage IIA-III esophageal cancer were treated with high-dose definitive chemoradiotherapy. Thirty patients had squamous cell carcinomas and 16 had adenocarcinomas. The patients were treated with three courses of chemotherapy. Each chemotherapy course consisted of cisplatin 100 mg/m(2), day 1 and 5-Fluorouracil 1000 mg/m(2)/day, day 1-5. One course was given every 3 weeks. Concurrent radiotherapy (66 Gy/33 fractions) was administered during the last two courses of chemotherapy. Toxicity grades three and four were seen in 47.5% and 40% of the patients, respectively. Treatment related mortality occurred in one patient (2.5%) due to neutropenic septicemia. Follow-up time for surviving patients (2/46) was 45 and 112 months. For the entire study population, the median time to local recurrence in the radiotherapy field was 33 months and the median time to distant metastasis was 8.7 months, whereas median overall survival was 10.8 months and median disease-specific survival 11 months. For responders to chemoradiotherapy, the median time to local recurrence was 76 months, the median time to distant metastasis 16.8 months, the median overall survival and the median disease-specific survival for the responders were both 17 months. The 2, 3 and 5-year survival rates were 22%, 15% and 11% for the entire study population, and 31%, 24% and 17% for the responders to chemoradiotherapy, respectively. By multivariate analysis response to chemoradiotherapy and lower disease stage were positive prognostic factors for survival. The results of our study have shown that concurrent high-dose chemoradiotherapy provides long-term local tumor control in locally advanced esophageal cancer. However, toxicities following this high-dose treatment, while manageable, were significant. Survival rates were not improved by high-dose chemoradiotherapy compared with what is reported in previous studies applying lower doses of definitive chemoradiotherapy.
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Affiliation(s)
- M Hurmuzlu
- Department of Oncology and Medical Physics, Haukeland University Hospital, N-5021 Bergen, Norway.
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122
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[18F]-Fluorodeoxyglucose-positron emission tomography for the assessment of histopathologic response and prognosis after completion of neoadjuvant chemoradiation in esophageal cancer. Ann Surg 2010; 250:888-94. [PMID: 19953708 DOI: 10.1097/sla.0b013e3181bc9c0d] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the potential of [(18)F]-fluorodeoxyglucose-positron emission tomography (FDG-PET) after the completion of neoadjuvant chemoradiation for the assessment of histopathologic response and prognosis in the multimodality treatment of patients with esophageal cancer. BACKGROUND Combined chemoradiation with and without surgery are widely accepted treatment options for patients with locally advanced esophageal cancer. Evidence suggests that patients with response to chemoradiation have no additional benefit from surgery compared with definitive chemoradiation. However, there is still a great lack in noninvasive markers for response assessment in patients with esophageal cancer undergoing multimodality treatment. Interestingly, recent studies imply that FDG-PET significantly correlates with histopathologic response and survival in patients with esophageal cancer undergoing neoadjuvant chemotherapy followed by surgical resection. METHODS Study patients were recruited from a prospective clinical observation trial on neoadjuvant chemoradiation for esophageal cancer between 1997 and 2006. The study included 119 (98 men, 21 women; median age, 59.4 years; squamous cell cancer: 66; adenocarcinoma: 53) patients with locally advanced esophageal cancer (cT2- 4, N(x), M(0)). All patients received neoadjuvant chemoradiation (cisplatin, 5-FU, 36 Gy) and subsequently underwent transthoracic en bloc esophagectomy. Histomorphologic regression was defined as major histopathologic response when resected specimens contained less than 10% vital residual tumor cells (major response: 47 patients [39.5%]; minor response: 72 patients [60.5%]). FDG-PET was performed before and 2 to 3 weeks after the end of chemoradiation with assessment of the intratumoral FDG-uptake (pretreatment standardized uptake value; post-treatment standardized uptake value; percentage change). These variables were correlated with histopathologic response and survival. RESULTS Major histomorphologic response was confirmed as an important prognostic factor (P = 0.005; log-rank test). Neoadjuvant chemoradiation led to a significant reduction of intratumoral FDG-uptake (P = 0.0001). A nonsignificant association was seen between major responders and FDG-PET results (P = 0.056). However, the receiver operating characteristic analysis could not identify a standardized uptake value threshold with a relevant predictive value for histomorphologic response. No significant association between metabolic imaging and prognosis was found. CONCLUSION FDG-PET seems not to be an imaging system that effectively characterizes the groups of major and minor response as well as survival in patients with esophageal cancer after multimodality treatment.
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Bollschweiler E, Hölscher AH, Metzger R. Histologic tumor type and the rate of complete response after neoadjuvant therapy for esophageal cancer. Future Oncol 2010; 6:25-35. [DOI: 10.2217/fon.09.133] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A review of the literature demonstrated that clinical evaluation cannot be used to determine ‘complete response’. The different classification systems of the histopathologic response grading after neoadjuvant radiochemotherapy of esophageal carcinoma are summarized in this report. A systematic review of studies analyzing preoperative chemoradiation of squamous cell carcinoma (SCC) or adenocarcinoma (AC) of the esophagus demonstrated no significant difference in pathologic complete response (pCR) rates between the AC and SCC studies. Analyzing only the applied dose of radiation demonstrated that patients with AC required a higher dose than patients with SCC to achieve complete response. Incorporating chemotherapy administration does not markedly change the difference in required radiation dose. However, when the tumor does respond, the rate of pCR with increasing dosage of chemoradiotherapy increases more rapidly in AC patients than in SCC patients.
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Affiliation(s)
- Elfriede Bollschweiler
- Department of General, Visceral and Cancer Surgery, University of Cologne, Kerpener Str. 62, 50937 Köln, Germany
| | - Arnulf H Hölscher
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - Ralf Metzger
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany and, Center of Integrated Oncology (CIO), University Hospital of Cologne, Cologne, Germany
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Cordin J, Lehmann K, Schneider PM. Clinical staging of adenocarcinoma of the esophagogastric junction. Recent Results Cancer Res 2010; 182:73-83. [PMID: 20676872 DOI: 10.1007/978-3-540-70579-6_6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Tumors of the esophagogastric junction are among the most frequent and cause lethal cancers. Patients often do not present until late in the disease when the tumor is sufficiently large to cause obstruction or invasion of the adjacent structures, and thus becomes symptomatic. Preoperative staging is critical to select those patients whose disease is still locally confined for curative surgery. Ideally, clinical staging should accurately predict tumor invasion, lymph node involvement, and distant metastases. Upper endoscopy establishes the tumor diagnosis by multiple biopsies and defines the tumor type (Siewert I-III), based on tumor localization in relation to the endoscopic cardia. Preoperative TNM staging has a strong impact on treatment strategy. Endoscopic Ultrasound (EUS) determines the T category, and to a lesser extent, the presence of lymph node metastases. Multislice Computed Tomography (CT) and 18Fluorode-ocx-glucose Positron Emission Computed Tomography (18FDG-PET-CT) provide further information, especially about systemic metastases. Diagnostic laparascopy is suggested in advanced (CT3/4) Siewert type II-III tumors to exclude peritoneal carcinomatosis. This chapter summarizes current staging modalities and their accuracy in clinical practice.
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Peng HQ, Halsey K, Sun CCJ, Manucha V, Nugent S, Rodgers WH, Suntharalingam M, Greenwald BD. Clinical utility of postchemoradiation endoscopic brush cytology and biopsy in predicting residual esophageal adenocarcinoma. Cancer 2009; 117:463-72. [PMID: 19806643 DOI: 10.1002/cncy.20051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Esophageal adenocarcinoma generally carries a poor prognosis. Treatment with combination chemoradiation (CRT) followed by esophagectomy is becoming common. A pathologic complete response is uncommon but predicts improved survival. Identifying the subset of patients with residual carcinoma has potential management implications. Post-CRT endoscopic brush cytology and biopsy may detect residual tumor; however, the accuracy and clinical value of these methods remain unclear. METHODS Sixty-seven patients with esophageal adenocarcinoma who underwent preoperative CRT and post-CRT endoscopic brush cytology and biopsy followed by esophagectomy were identified. By using esophagectomy histology as the gold standard, the performance of cytology and biopsy was evaluated in diagnosing residual carcinoma. Two pathologists independently reviewed all false-negative and false-positive cases and resolved disagreements by consensus. RESULTS The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of cytology for diagnosing residual carcinoma were 26%, 95%, 92%, 35%, and 45%, respectively. For biopsy, these rates were 13%, 90%, 75%, 31%, and 36%, respectively. Sampling error accounted for false-negative diagnoses in approximately 66% of cytology analyses and 98% of biopsy analyses. Approximately 33% of false-negative cytology analyses and 1 false-negative biopsy analysis were caused by the under-recognition of tumor cells. Major diagnostic pitfalls included obscuring acute inflammation, necrosis, tumor cells that mimicked benign cells with radiation/reactive atypia, and the under recognition of mucin-containing adenocarcinoma cells. CONCLUSIONS Brush cytology and biopsy were specific but not sensitive methods for predicting residual cancer after CRT. However, cytology was superior. The current results indicated that brush cytology can be used alone to diagnose residual esophageal carcinoma, and awareness of specific diagnostic pitfalls will help pathologists improve its accuracy.
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Affiliation(s)
- Hong-Qi Peng
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland 21201-1595, USA
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Closing the loop around esophagectomy after neoadjuvant therapy. Ann Surg 2009; 250:500; author reply 500. [PMID: 19730188 DOI: 10.1097/sla.0b013e3181b4c745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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127
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Hölscher AH, Vallböhmer D, Bollschweiler E. Closing the Loop Around Esophagectomy After Neoadjuvant Therapy. Ann Surg 2009. [DOI: 10.1097/sla.0b013e3181b4ca13] [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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