Systematic review of the benefits and risks of neoadjuvant chemoradiation for oesophageal cancer

The Ratio of the Preoperative Fecal Short-Chain Fatty Acid to Lactic Acid Concentrations as a Predictor of Postoperative Infectious Complications After Esophagectomy

BACKGROUND

The ratio of the fecal short-chain fatty acid (SCFA) to lactic acid concentrations (APB-L ratio) is a useful indicator for the healthiness of the intestinal microenvironment. A recent study indicated that the low APB-L ratio can be a predictor of postoperative infectious complications (POICs) in patients undergoing pancreaticoduodenectomy. However, the predictive power of the APB-L ratio in other highly invasive surgeries, such as esophagectomy, is still unclear. This study investigated whether the APB-L ratio can be a sensitive predictor of POICs in patients undergoing esohpagectomy.

METHODS

A total of 129 patients undergoing esohpagectomy with gastric conduit reconstruction were included in this study. Preoperative fecal samples were analyzed for SCFA and lactic acid concentrations. The associations between clinical characteristics, POICs, and the APB-L ratio were analyzed. Preoperative and intraoperative risk factors for POICs were explored via multivariate logistic regression analysis.

RESULTS

Postoperative infectious complications were observed in 34 patients (26%), including surgical site infections in 18 patients (14%). A low APB-L ratio was significantly associated with higher POICs and surgical site infections risk (both p < 0.05). A low APB-L ratio was identified as an independent risk factor for POICs, with an odds ratio of 3.62 (95% confidence interval, 1.44-9.10, p = 0.006).

CONCLUSIONS

The APB-L ratio measured with preoperative fecal organic acid concentrations is useful to assess the risk of POICs for esohpagectomy. The results also imply the importance of maintaining a healthy intestinal metabolism (thus high APB-L ratio) to reduce POICs before highly invasive surgery.

Practice pattern and risk of not receiving planned surgery after neoadjuvant chemoradiotherapy for locally advanced oesophageal squamous cell carcinoma

OBJECTIVES

Unlike the initial plan, some patients with oesophageal squamous cell carcinoma cannot or do not receive surgery after neoadjuvant chemoradiotherapy (nCRT). This study aimed to report the epidemiology of patients not receiving surgery after nCRT and to evaluate the potential risk of refusing surgery.

METHODS

We analysed patients with clinical stage T3-T4aN0M0 or T1-T4aN1-N3M0 oesophageal squamous cell carcinoma who underwent nCRT as an initial treatment intent between January 2005 and March 2020. Patients not receiving surgery were categorized using predefined criteria. To evaluate the risk of refusing surgery, a propensity-matched comparison with those who received surgery was performed. Recurrence-free (RFS) and overall survival (OS) was compared between groups, according to clinical response to nCRT.

RESULTS

Among the study population (n = 715), 105 patients (14.7%) eventually failed to reach surgery. There were three major patterns of not receiving surgery: disease progression before surgery (n = 25), functional deterioration at reassessment (n = 47), and patient's refusal without contraindications (n = 33). After propensity-score matching, the RFS curves of the surgery group and the refusal group were significantly different (P < 0.001), while OS curves were not significantly different (P = 0.069). In patients who achieved clinical complete response on re-evaluation, no significant difference in the RFS curves (P = 0.382) and in the OS curves (P = 0.290) was observed between the surgery group and the refusal group. However, among patients who showed partial response or stable disease on re-evaluation, the RFS and OS curves of the refusal group were overall significantly inferior compared to those of the surgery group (both P < 0.001). The 5-year RFS rates were 10.3% for the refusal group and 48.2% for the surgery group, and the 5-year OS rates were 8.2% for the refusal group and 46.1% for the surgery group.

CONCLUSIONS

Patient's refusal remains one of the major obstacles in completing the trimodality therapy for oesophageal squamous cell carcinoma. Refusing surgery when offered may jeopardize oncological outcome, particularly in those with residual disease on re-evaluation after nCRT. These results provide significant implications for consulting patients who are reluctant to oesophagectomy after nCRT.

Risk Factor Analysis for Developing Major Complications Following Esophageal Surgery-A Two-Center Study

BACKGROUND

Esophagectomy carries a high risk of morbidity and mortality compared to other major surgeries. With the aim of creating an easy-to-use clinical preoperative risk assessment tool and to validate previously described risk factors for major complications following surgery, esophagectomies at two tertiary medical centers were analyzed.

METHODS

A total of 450 patients who underwent esophagectomy for esophageal carcinoma at the University Medical Centre, Hamburg, or at the Medical Center University Duisburg-Essen, Germany (January 2008 to January 2020) were retrospectively analyzed. Epidemiological and perioperative data were analyzed to identify the risk factors that impact major complication rates. The primary endpoint of this study was to determine the incidence of major complications.

RESULTS

The mean age of the patients was 63 years with a bimodal distribution. There was a male predominance across the cohort (81% vs. 19%, respectively). Alcohol abuse (p = 0.0341), chronic obstructive pulmonary disease (p = 0.0264), and cardiac comorbidity (p = 0.0367) were associated with a significantly higher risk of major complications in the multivariate analysis. Neoadjuvant chemotherapy significantly reduced the risk of major postoperative complications (p < 0.0001).

CONCLUSIONS

Various patient-related risk factors increased the rate of major complications following esophagectomy. Patient-tailored prehabilitation programs before esophagectomy that focus on minimizing these risk factors may lead to better surgical outcomes and should be analyzed in further studies.

Comparison of therapeutic outcomes in esophageal squamous cell carcinoma following neoadjuvant chemoradiotherapy: A prospective observational cohort study

BACKGROUND

Patients with locally advanced esophageal squamous cell carcinoma (ESCC) following neoadjuvant chemoradiotherapy (nCRT) may not always receive resection despite the possible achievement of a pathologic complete response (pCR) being associated with superior survival benefit. We aimed to compare outcomes among ESCC patients with or without pCR and those refusing surgery.

METHODS

In total, 111 medically operable, non-cervical ESCC patients after the same protocol of nCRT (platinum/5-fluorouracil plus radiation 50Gy) were prospectively enrolled between 2011 and 2021. Eighty-three of them underwent esophagectomy comprising pCR (n = 32) and non-pCR (n = 51), while 28 operable patients declined surgery (refusal-of-surgery group). Predictors and survival data were analyzed.

RESULTS

In terms of esophagectomy, 38.5% (32/83) patients achieved pCR. The pCR group exhibited better pretreatment performance status than the non-pCR group (adjusted odds ratio: 0.11, 95% confidence interval: 0.03-0.58; p = 0.01). Among pCR, non-pCR, and refusal-of-surgery groups, the 5-year overall survival (OS) rates were 56%, 29% and 50% (p = 0.08) and progression-free survival (PFS) rates were 52%, 28% and 36% (p = 0.07) respectively. The pCR group had significantly better OS and PFS than the non-PCR group (adjusted hazard ratio: 2.33 and 1.93, p = 0.02 and 0.049 respectively) but not the refusal-of-surgery group.

CONCLUSION

Better pretreatment performance status is associated with higher chance of pCR. Consistent with previous studies, we found attainment of pCR confers the best OS and PFS. Suboptimal OS in the refusal-of-surgery group reflects some of them would have residual disease in addition to complete remission. Further studies are needed to identify prognostic factors of pCR to select candidates who could validly decline esophagectomy.

Primary Surgery Not Inferior to Neoadjuvant Chemoradiotherapy for Esophageal Adenocarcinoma

BACKGROUND

The current gold standard for treatment of locally advanced esophageal adenocarcinoma is neoadjuvant chemotherapy or chemoradiotherapy followed by surgery. The shift toward neoadjuvant chemoradiotherapy (nCRT) was driven by the Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) trial. This study reassessed, in daily practice, the presumed advantage of nCRT followed by surgery on long-term survival compared with primary surgery, in a group of all adenocarcinomas treated through a transthoracic approach with extensive 2-field lymphadenectomy.

METHODS

This retrospective cohort study with propensity score-matched analysis included all surgically treated patients between 2000 and 2018 with locally advanced adenocarcinoma (cT1/2 N+ or cT3/4 N0/+). For appropriate comparison, exclusion criteria of the CROSS trial were applied. Patients were matched on age, Charlson comorbidity score, clinical tumor length, and lymph node status. The primary end point was 5-year overall survival.

RESULTS

There were 473 eligible patients who underwent primary surgery (225 patients) or nCRT + surgery (248 patients). After propensity score-matched analysis, 149 matched cases were defined in each group for analysis. There was no significant difference after 5 years between the matched groups in median overall survival (32.5 and 35.0 months, P = .41) and median disease-free survival (14.3 and 13.5 months, P = .16). nCRT was associated with significantly more postoperative complications (mean Comprehensive Complication Index score: 21.0 vs 30.5, P < .0001) and longer mean stay in the hospital (14.0 vs 18.2 days, P = .05) and intensive care unit (11.7 vs 37.7 days, P = .05).

CONCLUSIONS

Our propensity score-matched results indicate that primary surgery, performed through transthoracic approach with extensive 2-field lymphadenectomy, can offer a comparable overall and disease-free survival after 5 years, with potentially fewer postoperative complications and shorter hospital and intensive care unit stay compared with nCRT followed by surgery.

Preoperative Risk Stratification in Esophageal Cancer Surgery: Comparing Risk Models with the Clinical Judgment of the Surgeon

BACKGROUND

Numerous prediction models estimating the risk of complications after esophagectomy exist but are rarely used in practice. The aim of this study was to compare the clinical judgment of surgeons using these prediction models.

METHODS

Patients with resectable esophageal cancer who underwent an esophagectomy were included in this prospective study. Prediction models for postoperative complications after esophagectomy were selected by a systematic literature search. Clinical judgment was given by three surgeons, indicating their estimated risk for postoperative complications in percentage categories. The best performing prediction model was compared with the judgment of the surgeons, using the net reclassification improvement (NRI), category-free NRI (cfNRI), and integrated discrimination improvement (IDI) indexes.

RESULTS

Overall, 159 patients were included between March 2019 and July 2021, of whom 88 patients (55%) developed a complication. The best performing prediction model showed an area under the receiver operating characteristic curve (AUC) of 0.56. The three surgeons had an AUC of 0.53, 0.55, and 0.59, respectively, and all surgeons showed negative percentages of cfNRIevents and IDIevents, and positive percentages of cfNRInonevents and IDIevents. This indicates that in the group of patients with postoperative complications, the prediction model performed better, whereas in the group of patients without postoperative complications, the surgeons performed better. NRIoverall was 18% for one surgeon, while the remainder of the NRIoverall, cfNRIoverall and IDIoverall scores showed small differences between surgeons and the prediction models.

CONCLUSION

Prediction models tend to overestimate the risk of any complication, whereas surgeons tend to underestimate this risk. Overall, surgeons' estimations differ between surgeons and vary between similar to slightly better than the prediction models.

Endoscopic vacuum therapy for anastomotic leakage after esophagectomy: a retrospective analysis at a tertiary university center

Introduction

Anastomotic leakage after esophagectomy with gastric-pullup is the most feared postoperative complication associated with high morbidity and mortality rates. Management of anastomotic leakage underwent an evolution in the last decade from surgical and conservative to an endoscopic management. However, to date there is no clear consensus on management and if endoluminal vacuum therapy (EVT) is the most superior therapy.

Material and methods

Between 2012 and 2022 all patients that underwent Ivor-Lewis esophagectomy for an underlying malignancy were included in this study. Patients that developed an anastomotic leakage and received endoscopic vacuum therapy were further analysed.

Results

A total of 17 patients were treated with EVT following AL after esophagectomy. The median duration of EVT was 23 days with a median number of 5,5 vacuum sponge changes per patient. EVT-systems were placed 12 times intraluminal and 5 times extraluminal. Successful closure of the defect was achieved in 14 patients.

Conclusion

Endoscopic vacuum therapy can be successfully applied in the treatment of anastomotic leakage after esophagectomy even in septic patients with an extraluminal cavity. Event-related complications are present but rare.

Identification of Novel Molecular Subgroups in Esophageal Adenocarcinoma to Predict Response to Neo-Adjuvant Therapies

Simple Summary

Gene expression of esophageal adenocarcinoma is highly heterogeneous. In general, these cancers have poor prognosis and unpredictable responses to chemo- and radiotherapy. Investigating expression profiles from RNA from pre-treatment biopsies are highly attractive to investigate the existence of diverse biological groups and signatures associated with the clinical response to current treatment strategies. We identified and validated three distinct biological esophageal adenocarcinoma subgroups and identified immune signatures with association to therapy response using RNA sequencing. These findings aid in understanding biological mechanisms’ underlying response to neo-adjuvant treatment.

Abstract

Esophageal adenocarcinoma (EAC) is a highly aggressive cancer and its response to chemo- and radiotherapy is unpredictable. EACs are highly heterogeneous at the molecular level. The aim of this study was to perform gene expression analysis of EACs to identify distinct molecular subgroups and to investigate expression signatures in relation to treatment response. In this prospective observational study, RNA sequencing was performed on pre-treatment endoscopic EAC biopsies from a discovery cohort included between 2012 and 2017 in one Dutch Academic Center. Four additional cohorts were analyzed for validation purposes. Unsupervised clustering was performed on 107 patients to identify biological EAC subgroups. Specific cell signaling profiles were identified and evaluated with respect to predicting response to neo-adjuvant chemo(radio)therapy. We identified and validated three distinct biological EAC subgroups, characterized by (1) p38 MAPK/Toll-like receptor signaling; (2) activated immune system; and (3) impaired cell adhesion. Subgroup 1 was associated with poor response to chemo-radiotherapy. Moreover, an immune signature with activated T-cell signaling, and increased number of activated CD4 T memory cells, neutrophils and dendritic cells, and decreased M1 and M2 macrophages and plasma cells, was associated with complete histopathological response. This study provides a novel molecular classification for EACs. EAC subgroup 1 proved to be more therapy-resistant, while immune signaling was increased in patients with complete response to chemo-radiotherapy. Our findings give insight into the biology of EACs and in cellular signaling mechanisms underlying response to neo-adjuvant treatment. Future implementation of this classification will improve patient stratification and enhance the development of targeted therapies.

Short- (30-90 days) and mid-term (1-3 years) outcomes and prognostic factors of patients with esophageal cancer undergoing surgical treatments

BACKGROUND

The factors influencing the prognosis of patients with esophageal cancer vary among studies and are still poorly known.

AIM

To determine the factors associated with survival in patients with esophageal cancer.

METHODS

This retrospective study included patients with esophageal cancer admitted between January 2017 and March 2020 at Heping Hospital Affiliated to Changzhi Medical College. All patients were treated according to the available guidelines. Follow-up was censored in October 2020. Univariable and multivariable Cox regression analyses were used to determine the independent risk factors for overall survival (OS).

RESULTS

In total, 307 patients were included. Their median age was 64 (range, 44-79) years, 63.5% were male, and the median disease course was 2 (0.1-36) months. The median tumor size was 3 (0-10) cm. Most patients were T3 (29.6%), N0 (70.0%). Most tumors were grade 2 (48.2%), and 87.3% were squamous cell carcinoma. The in-hospital mortality was 16.9%, the 30-day mortality was 19.9%, and the 90-day mortality was 25.4%. The cumulative OS rates at the last follow-up were 82.1% (95%CI: 67.7%-96.5%) for stage 0/I/II and 47.4% (95%CI: 16.5-78.6%) for stage III/IVA (P < 0.001). The multivariable analysis showed that creatinine levels (HR = 1.02, 95%CI: 1.00-1.03, P = 0.050), pTNM III/IVA (HR = 4.19, 95%CI: 2.19-8.01, P < 0.001), adjuvant radiotherapy and/or chemotherapy (HR = 0.23, 95%CI: 0.11-0.49), and the Comprehensive Complication Index (CCI) (HR = 1.02, 95%CI: 1.004-1.03, P = 0.011) were independently associated with OS.

CONCLUSION

The survival of patients with esophageal cancer is poor, especially those with pTNM III/IVA. pTNM stage III/IVA, CCI, and adjuvant therapy (radiotherapy and/or chemotherapy) are independently associated with OS.

Indocyanine green (ICG) fluorescence imaging for prevention of anastomotic leak in totally minimally invasive Ivor Lewis esophagectomy: a systematic review and meta-analysis

BACKGROUND

Indocyanine green (ICG) fluorescence imaging is an emerging technology that might help decreasing anastomotic leakage (AL) rates. The aim of this study was to determine the usefulness of ICG fluorescence imaging for the prevention of AL after minimally invasive esophagectomy with intrathoracic anastomosis.

METHODS

A systematic literature review of the MEDLINE and Cochrane databases was performed to identify all articles on totally minimally invasive Ivor Lewis esophagectomy. Studies were then divided into two groups based on the use or not of ICG for perfusion assessment. Primary outcome was anastomotic leak. Secondary outcomes included operative time, ICG-related adverse reactions, and mortality rate. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for main outcomes.

RESULTS

A total of 3,171 patients were included for analysis: 381 (12%) with intraoperative ICG fluorescence imaging and 2,790 (88%) without ICG. Mean patients' age and proportion of males were similar between groups. Mean operative time was also similar between both groups (ICG: 354.8 vs. No-ICG: 354.1 minutes, P = 0.52). Mean ICG dose was 12 mg (5-21 mg). No ICG-related adverse reactions were reported. AL rate was 9% (95% CI, 5-17%) and 9% (95% CI, 7-12%) in the ICG and No-ICG groups, respectively. The risk of AL was similar between groups (odds ratio 0.85, 95% CI 0.53-1.28, P = 0.45). Mortality was 3% (95% CI, 1-9%) in patients with ICG and 2% (95% CI, 2-3%) in those without ICG. Median length of hospital stay was also similar between groups (ICG: 13.6 vs. No-ICG: 11.2 days, P = 0.29).

CONCLUSION

The use of ICG fluorescence imaging for perfusion assessment does not seem to reduce AL rates in patients undergoing minimally invasive esophagectomy with intrathoracic anastomosis.

Prospective study of surgical site infections post-open esophageal cancer surgery, and the impact of care bundles

SSIs represent common infection-related morbidity following major surgery. Modern care bundles have been established as prophylactic measures aimed at preventing SSI occurring postoperatively. SSI incidence and data on common culprit pathogens post-esophagectomy for cancer have not been previously reported. Patients (2013-2018) treated with curative intent were studied. SSI was defined as per the Center for Disease Control (CDC) definition. A care bundle pathway following the National Institute for Clinical Excellence (NICE) guidelines for prevention of SSIs was introduced in 2013 and was audited quarterly. Risk factors and associations of SSIs were analyzed, as was the prevalence of isolated pathogens. Multivariable logistic regression examined independently predictive factors of SSIs and oncologic outcomes. Of 343 patients, 34 (9.9%) developed a postoperative SSI, with a median (range) of 8 (6-17). Quarterly audit carried out over 6 years showed no significant annual variance or trend. The most prevalent pathogen cultured was Methicillin-sensitive Staphylococcus aureus (MSSA) in nine patients (32%) followed by Candida albicans (29%), Escherichia coli (14%), and Enterococcus faecium (11%). SSI was significantly associated with pneumonia (P = 0.001), respiratory failure (P = 0.014), atrial fibrillation (P = 0.004), anastomotic leak (P < 0.001), and in-hospital blood transfusions (P = 0.031). SSI did not impact the overall survival (P = 0.951). SSI rates can be maintained at less than 10% using strict care bundles and regular audit. The most common culprit pathogen is gram-positive MSSA representing 32% of cases. These data are novel and may represent a modern benchmark for SSI post-open esophagectomy for cancer. This study highlights the incidence and associations of SSI post-esophageal cancer surgery.

Surgical Therapy of Esophageal Adenocarcinoma-Current Standards and Future Perspectives

Transthoracic esophagectomy is currently the predominant curative treatment option for resectable esophageal adenocarcinoma. The majority of carcinomas present as locally advanced tumors requiring multimodal strategies with either neoadjuvant chemoradiotherapy or perioperative chemotherapy alone. Minimally invasive, including robotic, techniques are increasingly applied with a broad spectrum of technical variations existing for the oncological resection as well as gastric reconstruction. At the present, intrathoracic esophagogastrostomy is the preferred technique of reconstruction (Ivor Lewis esophagectomy). With standardized surgical procedures, a complete resection of the primary tumor can be achieved in almost 95% of patients. Even in expert centers, postoperative morbidity remains high, with an overall complication rate of 50-60%, whereas 30- and 90-day mortality are reported to be <2% and <6%, respectively. Due to the complexity of transthoracic esophagetomy and its associated morbidity, esophageal surgery is recommended to be performed in specialized centers with an appropriate caseload yet to be defined. In order to reduce postoperative morbidity, the selection of patients, preoperative rehabilitation and postoperative fast-track concepts are feasible strategies of perioperative management. Future directives aim to further centralize esophageal services, to individualize surgical treatment for high-risk patients and to implement intraoperative imaging modalities modifying the oncological extent of resection and facilitating surgical reconstruction.

Patterns and timing of recurrence in esophageal squamous cell carcinoma patients treated with neoadjuvant chemoradiotherapy plus esophagectomy

Background

Tumor regression grade (TRG) after neoadjuvant therapy is reportedly predictive of prognosis in esophageal cancer patients, as lack of a response to neoadjuvant therapy is associated with a poor prognosis. However, there is little information available on the timing and pattern of recurrence after esophagectomy for thoracic esophageal squamous cell carcinoma (TESCC) that takes into consideration TRG after neoadjuvant chemoradiotherapy (NACRT). Here, in an effort to gain insight into a treatment strategy that improves the prognosis of NACRT non-responders, we evaluated the patterns and timing of recurrence in TESCC patients, taking into consideration TRG after NACRT.

Methods

A total of 127 TESCC patients treated with NACRT and esophagectomy between 2009 and 2017 were enrolled in this observational cohort study. TRGs were assigned based on the proportion of residual tumor cells in the area (TRG1, ≥1/3 viable cancer cells; 2, < 1/3 viable cancer cells; 3, no viable cancer cells). We retrospectively investigated the timing and patterns of recurrence and the prognoses in TESCC patients, taking into consideration TRG after NACRT.

Results

The 127 participating TESCC patients were categorized as TRG1 (42 patients, 33%), TRG2 (56 patients, 44%) or TRG3 (29 patients, 23%). The locoregional recurrence rate was higher in TRG1 (36.4%) patients than combined TRG2–3 (7.4%) patients. Patients with TRG3 had better prognoses, though a few TRG3 patients experienced distant recurrence. There were no significant differences in median time to first recurrence or OS among patients with locoregional or distant recurrence. There was a trend toward better OS in TRG2–3 patients with recurrence than TRG1 patients with recurrence, but the difference was not significant.

Conclusions

NACRT non-responders (TRG1 patients) experienced higher locoregional recurrence rates and earlier recurrence with distant or locoregional metastasis. TRG appears to be useful for establishing a strategy for perioperative treatments to improve TESCC patient survival, especially among TRG1 patients. (303 words).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08918-x.

Towards Personalized Treatment Strategies for Esophageal Adenocarcinoma; A Review on the Molecular Characterization of Esophageal Adenocarcinoma and Current Research Efforts on Individualized Curative Treatment Regimens

Esophageal cancers confer a major health challenge and are highly aggressive malignancies with poor prognosis. Esophageal adenocarcinoma (EAC) is one of the two major histopathological subtypes of esophageal cancer. Despite advances in treatment modalities, the prognosis of patients with EAC remains poor, with a 5-year survival rate that rarely exceeds 30% in patients treated with curative intent. Chemoradiotherapy followed by resection is the treatment of choice for EAC patients, which are deemed to be curable. Current patient stratification and treatments are based on outcomes from clinical trials. Unfortunately, the molecular heterogeneity of EAC which determines the chemo- and radiosensitivity of these cancers are not taken into account. A more personalized approach in the treatment of EAC could improve patient outcomes. This review aims at summarizing literature on translational and clinical research in the field of EAC which could be of importance to develop personalized approaches. As suggested by the TCGA, expression data features molecular classifications by different platforms, including miRNA, genomic mutations and reverse-phase protein arrays. Here, we summarize literature on transcriptomic, data-driven approaches to identify distinct subtypes of EAC associated with molecular features. These novel classifications may determine the responsiveness to chemo(radio)therapy and help to identify novel molecular targets within cell signaling pathways. Moreover, we discuss the current clinical research efforts on tailored treatment regimens for patients with EAC taking into account the heterogeneous response to chemoradiotherapy. We summarize the evidence regarding active surveillance instead of immediate surgical resection after application of neoadjuvant chemo(radio)therapy in EAC. We consider that in future patients with complete response to chemo(radio)therapy, predicted by (transcriptomic) biomarkers, might benefit most from this approach. Finally, challenges to overcome for current findings to be implemented in clinical practice and move the field forward are being discussed.

Assessing failure patterns of radical intent radiation strategies in patients with locally advanced carcinoma of the esophagus

BACKGROUND

Patterns of failure following definitive CRT (dCRT) are different as compared to neoadjuvant chemoradiotherapy (NACRT) with increased locoregional failures documented with dCRT.

AIM

To document failure patterns in patients with esophageal carcinoma treated with neoadjuvant and definitive intent radiation strategies.

METHODS

Subjects were 123 patients treated with two chemoradiotherapy strategies. Group 1 (n = 99) underwent dose escalated definitive chemoradiotherapy (dCRT), Group 2 (n = 24) received neoadjuvant chemoradiotherapy (NACRT) followed by surgery. Cumulative incidence of locoregional failure (LRF), local failure (LF), regional lymph node failure (RLNF), and distant metastasis (DM) were computed; differences between the groups was evaluated using log rank test. Univariable and multivariable predictors of failure were identified using Cox regression analysis.

RESULTS

Cumulative LRF: 64% in Group 1 vs 35% in Group 2 (P = .050). Cumulative LF: 59% in Group 1 vs 12% in Group 2 (P = .000). Cumulative RLNF: 30% in Group 1 vs 24% in Group 2 (P = .592). Most common RLNF: mediastinum for both groups (6% vs 12.5%, respectively). Distant metastasis: 40.4% Group 1 vs 17% Group 2 (P = .129), predominantly lung (Group 1, 5%), and nonregional nodes (Group 2, 8.3%). Univariate analysis identified age ≤50, absence of concurrent chemotherapy, dose ≤50 Gy, and incomplete radiotherapy to predict higher odds of LRF and DM for Group 1; absence of comorbidities predicted for lower odds of LRF for Group 2. Age ≤50 predicted for higher odds of RNLR for Group 1, while absence of comorbidities predicted for lower odds of RNLR in Group 2. Multivariate analysis identified age ≤50, incomplete radiotherapy, and absence of concurrent chemotherapy to predict higher odds of LRF for Group 1. Age ≤50, absence of concurrent chemotherapy predicted higher odds of DM for Group 1. Absence of comorbidity predicted lower odds of LRF in Group 2.

CONCLUSION

LRF is common in both groups, with LF being predominant in dCRT as opposed to RNLF in NACRT. Age ≤50, absence of concurrent chemotherapy is a predictor of LRF and DM in dCRT.

Are muscle parameters obtained by computed tomography associated with outcome after esophagectomy for cancer?

BACKGROUND & AIMS

Esophageal cancer patients often suffer from cancer-related malnutrition and, as a result, sarcopenia. Whether sarcopenia worsens the outcome after esophagectomy is unclear. Inconsistent study results are partly caused by varying cut-off values used for defining sarcopenia. To overcome this challenge, a new statistical approach is proposed in this study: analyzing the linear association of computer tomography derived muscle parameters with important clinical short- and long-term outcomes post esophagectomy, regardless of cut-offs.

METHODS

Skeletal muscle index (SMI), quantifying muscle mass, was assessed with computed tomography (CT) in 98 patients undergoing esophagectomy. Muscle radiation attenuation (MRA) was measured to evaluate muscle quality. To evaluate the influence of the SMI and MRA on post-surgery complications, logistic regression models were used. To analyze the relationship of lengths of stay to muscle parameters, the competing risk approach introduced by Fine and Gray was applied. For survival analysis, log-rank test and Cox proportional hazards regression modeling were used.

RESULTS

Neither a relevant association of SMI nor MRA with pneumonia and esophagoenteric leak were observed. Furthermore, no relevant association to lengths of stay in intensive care or hospital were detected. If the SMI increased, the odds for pleural effusion and pleural empyema decreased, but the odds of a pulmonary embolism increased. Univariate, unadjusted long-term survival analysis revealed that lower MRA and lower SMI were associated with shorter survival (P = 0.03). However, if the analysis was adjusted for confounders, e.g., Charlson Comorbidity Index, no relevant association regarding long-term survival was detected.

CONCLUSION

Consequently, poor muscle status, determined by CT imaging, does not justify denying a patient an oncologic resection. The Charlson Comorbidity Index, however, was superior for preoperative risk stratification.

Association of Malnutrition, as Defined by the PG-SGA, ESPEN 2015, and GLIM Criteria, With Complications in Esophageal Cancer Patients After Esophagectomy

Background: There are several approaches that can be used for the pre-treatment identification of malnutrition in oncology populations including the Patient-Generated Subjective Global Assessment (PG-SGA), the 2015 consensus statement by the European Society for Clinical Nutrition and Metabolism (ESPEN 2015) and the Global Leadership Initiative on Malnutrition (GLIM). Aims: This study aimed to evaluate whether malnutrition, as defined by these three methods, can be used to predict complications in esophageal cancer (EC) patients after esophagectomy. Methods: We performed a single center, observational cohort study that included 360 EC patients undergoing esophagectomy from December 2014 to November 2019 at Daping Hospital in China. The prevalence of malnutrition in the study population was prospectively defined using the PG-SGA (≥9 defined malnutrition), and retrospectively defined using the ESPEN 2015 and the GLIM. The prevalence of malnutrition and association with postoperative complications were compared in parallel for the three methods. Results: The prevalence of malnutrition before surgery was 23.1% (83/360), 12.2% (44/360), and 33.3% (120/360) in the study population, as determined by the PG-SGA, the ESPEN 2015 and the GLIM, respectively. The PG-SGA and GLIM had higher diagnostic concordance (Kappa = 0.519, P < 0.001) compared to the ESPEN 2015 vs. GLIM (Kappa = 0.361, P < 0.001) and PG-SGA vs. ESPEN 2015 (Kappa = 0.297, P < 0.001). The overall incidence of postoperative complications for the study population was 58.1% (209/360). GLIM- and ESPEN 2015-defined malnutrition were both associated with the total number of postoperative complications in multivariable analyses. Moreover, GLIM-defined malnutrition exhibited the highest power to identify the incidence of complications among all independent predictors in a pooled analysis. Conclusion: Among the PG-SGA, the ESPEN 2015 and the GLIM, the GLIM framework defines the highest prevalence rate of malnutrition and appears to be the optimal method for predicting postoperative complications in EC patients undergoing esophagectomy. These results support the importance of preoperatively identifying malnutrition using appropriate assessment tools, because it can facilitate the selection of management strategies that will optimize the clinical outcomes of EC patients.

Novel 5-point 18-FDG-PET/CT visual scoring system for assessing treatment response in patients with oesophageal or gastro-oesophageal junction carcinoma

INTRODUCTION

The purpose of this study was to investigate the prognostic utility and reproducibility of a qualitative 5-point 18-fluorodeoxyglucose (FDG)-PET primary visual score (PVS) in patients with oesophageal and gastro-oesophageal junction (GOJ) cancer.

METHODS

This was a retrospective review of patients with histologically proven oesophageal or GOJ cancer who received curative intent therapy. Clinical, pathological and imaging data were extracted from electronic medical records. Patients were required to have pre-treatment and post-treatment FDG-PET scans, that were evaluated with a 5-point primary visual score (prePVS, postPVS). The changes in PVS (ΔPVS) were correlated with progression-free survival and overall survival. Interobserver variability was assessed using Cohen's Kappa intraclass correlation and agreement.

RESULTS

Sixty-seven patients were retrospectively identified. Two (3%), 36 (54%) and 29 (43%) of the patients had stage I, II and III disease respectively. Twenty-five (37%) patients had squamous cell carcinoma. Thirty-seven (55%) patients proceeded onto surgical resection. postPVS was associated with both PFS (P = 0.013) and OS (P = 0.0002). ΔPVS predicted for PFS (P = 0.002) and OS (P = 0.0003). When thresholds of response were considered, agreement was 80.6% (K = 0.78) and 74.6% (K = 0.69) for postPVS and ΔPVS respectively.

CONCLUSION

Qualitative assessment of oesophageal and GOJ cancers utilising FDG-PET is reproducible and may be able to prognosticate outcomes in patients undergoing treatment. Prospective validation is required.

Patterns of Failure After Trimodal Treatment in Esophageal Squamous Cell Carcinoma: Initial Experiences from a High-Risk Endemic Area

Recurrence is a significant problem faced in patients with esophageal cancer even after treatment with trimodal approach. We report patterns of failure in our patients of esophageal squamous cell cancer (ESCC) treated with trimodal approach. This is a single-institution retrospective analysis of 46 patients of locally advanced ESCC (treated between 2013 and 2017) managed by trimodal treatment approach. Variables were summarized using descriptive statistics. Survival statistics were estimated using Kaplan-Meier method. With a median follow-up of about 28 months, we noted an overall recurrence rate of 37% (17/46), with most of the failures being distant, with or without locoregional recurrence (4 isolated distant and 6 combined distant and locoregional). Median RFS was 34 months and median OS was yet to be reached at the last follow-up. To conclude, optimization of treatment approaches in ESCC is of utmost importance and need of the hour to further improve outcomes in these patients.

EphA5 Silencing Increases the Radiosensitivity of ESCC Cells Through ATM-Dependent Pathway

Background

Radiotherapy is one of the most important treatments for esophageal squamous cell carcinoma (ESCC). Previously, we found that EphA5 expression was increased in ESCC cells and tumor tissues. Studies from other groups reported that EphA5 is abnormally expressed in numerous malignant tumors and may be involved in the radiosensitivity of lung cancer. However, the role of EphA5 in radiotherapy for ESCC remains unclear.

Methods

The siRNA sequences against human EPHA5 were transfected to the ESCC cells (KYSE150 and KYSE450). After ionizing radiation (IR), cell viability and colony formation assays were used to test the changes of cell proliferation in EphA5-silenced cells. Flow cytometry analysis was performed to investigate the cell apoptosis and cycle in the irradiated cells interfered by siRNA. The key molecules involved in cell cycle checkpoints and DNA damage repair were evaluated by Western blot and immunofluorescence.

Results

CCK8 assay and clonogenic assay showed that the proliferation of EphA5-silenced ESCC cells was inhibited after IR. At 24 h post-IR treatment, we found that the G1/S checkpoint triggered by DNA damage in EphA5-silenced cells was defective. γ-H2AX foci in the irradiated EphA5-silenced cells were impaired at 0.5 h post-IR treatment as well as ATM activation. The defective activation of ATM resulted in a decrease of p-Chk2, p-p53 and p21 expression.

Conclusion

In conclusion, these results indicate that EphA5 silencing increases radiosensitivity in ESCC cells through ATM-dependent pathway, which provides a potential target for the radiotherapy in ESCC.

Analysis on plausible factors related to the prognosis of stage IV esophageal cancer

To investigate factors related to poor prognosis of patients with stage IV esophageal cancer and to provide some bases on which proper therapeutic schemes could be formulated for stage IV esophageal cancer patients with performance status (PS) score between 0 and 2.Clinical data of 60 patients with stage IV esophageal cancer were retrospectively analyzed, and the relationships of clinical characteristics and therapeutic methods with patients' prognosis were explored. Univariate analysis on factors possibly affecting the prognosis of patients with stage IV esophageal cancer was performed using Log-rank test, and independent risk factors for the prognosis were estimated in multivariate Cox regression analysis through embracing variables which showed statistical significance in univariate analyses.According to univariate analysis results, nutritional status, anemia, therapeutic method, esophageal stent, and visceral metastasis were main influencing factors for the prognosis of stage IV esophageal cancer (P < .05). While in multivariate Cox regression analysis, visceral metastasis was revealed to be an independent risk factor for poor prognosis in patients with stage IV esophageal cancer.Visceral metastasis is an independent risk factor for poor prognosis in patients with stage IV esophageal cancer. Optimizing therapeutic modes according to with or without combined visceral metastasis possesses certain clinical significance in prolonging survival time and in improving the quality of life among patients with stage IV esophageal cancer.

Benchmarking Complications Associated with Esophagectomy

OBJECTIVE

Utilizing a standardized dataset with specific definitions to prospectively collect international data to provide a benchmark for complications and outcomes associated with esophagectomy.

SUMMARY OF BACKGROUND DATA

Outcome reporting in oncologic surgery has suffered from the lack of a standardized system for reporting operative results particularly complications. This is particularly the case for esophagectomy affecting the accuracy and relevance of international outcome assessments, clinical trial results, and quality improvement projects.

METHODS

The Esophageal Complications Consensus Group (ECCG) involving 24 high-volume esophageal surgical centers in 14 countries developed a standardized platform for recording complications and quality measures associated with esophagectomy. Using a secure online database (ESODATA.org), ECCG centers prospectively recorded data on all resections according to the ECCG platform from these centers over a 2-year period.

RESULTS

Between January 2015 and December 2016, 2704 resections were entered into the database. All demographic and follow-up data fields were 100% complete. The majority of operations were for cancer (95.6%) and typically located in the distal esophagus (56.2%). Some 1192 patients received neoadjuvant chemoradiation (46.1%) and 763 neoadjuvant chemotherapy (29.5%). Surgical approach involved open procedures in 52.1% and minimally invasive operations in 47.9%. Chest anastomoses were done most commonly (60.7%) and R0 resections were accomplished in 93.4% of patients. The overall incidence of complications was 59% with the most common individual complications being pneumonia (14.6%) and atrial dysrhythmia (14.5%). Anastomotic leak, conduit necrosis, chyle leaks, recurrent nerve injury occurred in 11.4%, 1.3%, 4.7%, and 4.2% of cases, respectively. Clavien-Dindo complications ≥ IIIb occurred in 17.2% of patients. Readmissions occurred in 11.2% of cases and 30- and 90-day mortality was 2.4% and 4.5%, respectively.

CONCLUSION

Standardized methods provide contemporary international benchmarks for reporting outcomes after esophagectomy.

Analysis of patients scheduled for neoadjuvant therapy followed by surgery for esophageal cancer, who never made it to esophagectomy

BACKGROUND

Neoadjuvant treatment followed by esophagectomy is standard practice in locally advanced esophageal cancer. However, not all patients who started neoadjuvant treatment will undergo esophageal resection. The purpose of our study was to investigate the group of patients, scheduled for neoadjuvant treatment followed by esophagectomy, who never made it to esophageal resection.

METHODS

We retrospectively analyzed patients treated between 2002 and 2015 for locally advanced esophageal cancer, who did not undergo esophagectomy after neoadjuvant treatment. Subanalysis was performed according to time period (2002-2010 versus 2011-2015) and histology (adenocarcinoma versus squamous cell carcinoma).

RESULTS

In 114 of 679 patients (16.8%), surgery was not performed after neoadjuvant treatment. Reasons for cancelation were disease progression (50 patients, 43.9%), poor general condition (26 patients, 22.8%), irresectability (14 patients, 12.3%), patients' own decision (15 patients, 13.2%), and death during neoadjuvant treatment (9 patients, 7.9%). In the second time period, there were less irresectable tumors (17.7% versus 5.8%; p = 0.044). Median overall survival was not different over time (9.2 versus 12.5 months; p = 0.937). Irresectability (p = 0.032), patients' refusal (p = 0.012), and poor general condition (p = 0.002) were more frequent as reasons for cancelation in squamous cell carcinoma patients. Median overall survival was, respectively, 12.5 and 9.9 months for adenocarcinoma and squamous cell carcinoma patients (p = 0.441). The majority of patients refusing surgery had a clinical complete response (73.3%). They had a median overall survival of 33.2 months.

CONCLUSIONS

One in six patients starting neoadjuvant treatment for locally advanced esophageal cancer never made it to esophagectomy, more than half of them for oncological reasons, but also 1.3% because of death during treatment. Over time, irresectability as reason decreased. As a result, the relative weight of medical inoperability increased, indicating the importance of upfront testing of medical operability. Cancelation of surgery was significantly more common in patients with a squamous cell carcinoma, and this histology seems to represent a more complex oncological and functional entity. Refusal of esophagectomy based on clinical complete response showed a significant survival benefit compared to those who did not undergo esophagectomy because of other reasons.

Lymphopenia in Esophageal Squamous Cell Carcinoma: Relationship to Malnutrition, Various Disease Parameters, and Response to Concurrent Chemoradiotherapy

Management of esophageal squamous cell carcinoma remains challenging, because detection often occurs at advanced stages and because of the high incidence of lymph node metastasis. This article focuses on whether lymphopenia is associated with response and tumor progression in patients with advanced esophageal squamous cell carcinoma who received concurrent chemotherapy.

Background.

Lymphopenia occurs commonly in esophageal squamous cell carcinoma (ESCC) and may influence treatment outcomes. We aimed to examine its association with treatment response and tumor progression in patients with locally advanced ESCC treated with concurrent chemoradiotherapy (CCRT).

Materials and Methods.

A total of 286 patients with stage II–IVa ESCC treated with CCRT between 2015 and 2017 were analyzed. Total lymphocyte counts were assessed at baseline, weekly, and 4 weeks after CCRT. Pretreatment lymphopenia was defined as total lymphocyte count <1,000 cells per mm³ at diagnosis, and treatment‐related lymphopenia was defined as total lymphocyte count <200 cells per mm³ with 6 weeks after starting CCRT. Univariate and multivariate logistic regression methods were used to analyze factors associated treatment‐related lymphopenia and treatment response.

Results.

Lymphopenia was observed in 44 patients (15.4%) at initial diagnosis. Pretreatment lymphopenia was significantly associated with greater tumor length, worse T status, body mass index ≤18.5 kg/m², and weight loss ≥3 kg in the previous 3 months. Six weeks after starting CCRT, 89 patients (31%) developed treatment‐related lymphopenia. Tumor progression and cancer‐related death were more frequently observed in treatment‐related lymphopenia group than those without (76.4% vs. 52.8% and 58.4% vs. 39.6%). A complete response (CR) was achieved in 62 patients (21.7%). In multivariate analysis, treatment‐related lymphopenia was significantly associated with lack of clinical CR, and older age, lower tumor location, greater tumor length, and larger planning target volume were independent predictors of treatment‐related lymphopenia.

Conclusion.

Treatment‐related lymphopenia during CCRT is an independent predictor for poor treatment response in ESCC.

Implications for Practice.

A total of 286 patients with locally advanced esophageal squamous cell carcinoma were treated with concurrent chemoradiotherapy (CCRT), and treatment‐related lymphopenia occurred in 31% of patients within 6 weeks from the start of CCRT. Treatment‐related lymphopenia was significantly associated with lack of treatment response, and older age, lower tumor location, greater tumor length, and larger planning target volume were independent predictors of treatment‐related lymphopenia. Lymphocyte count is an inexpensive biomarker that may be easily used by clinicians to identify patients who are most likely to benefit from CCRT.

Delayed emptying of the gastric conduit after esophagectomy

With increasing survival after esophagectomy for cancer, a growing number of individuals living with the functional results of a surgically altered anatomy calls for attention to the effects of delayed gastric conduit emptying (DGCE) on health-related quality of life and nutritional impairment. We here give an overview of the currently available literature on DGCE, in terms of epidemiology, pathophysiology, diagnostics, prevention and treatment. Attention is given to controversies in the current literature and obstacles related to general applicability of study results, as well as knowledge gaps that may be the focus for future research initiatives. Finally, we propose that measures are taken to reach international expert agreement regarding diagnostic criteria and a symptom grading tool for DGCE, and that functional radiological methods are established for the diagnosis and severity grading of DGCE.

Radiotherapy improves the survival of patients with metastatic esophageal squamous cell carcinoma: a propensity score matched analysis of Surveillance, Epidemiology, and End Results database

The survival advantage of radiotherapy (RT) for patients with metastatic esophagus cancer has not been adequately evaluated. This study aims to find out the role of RT for metastatic esophagus cancer and to find the different effect for RT to esophageal adenocarcinoma (EAC) and esophageal squamous cell carcinoma (ESCC). This study included 5,970 metastatic esophagus cancer patients from the Surveillance, Epidemiology, and End Results (SEER) database, registered from January 2004 to December 2013. Propensity score (PS) analysis with 1:1 nearest neighbor matching method was used to ensure well-balanced characteristics of all comparison groups by histological types. The Kaplan-Meier and Cox proportional hazardous models were used to evaluate the overall survival (OS), cancer-specific survival (CSS), and corresponding 95% confidence interval (CI). Generally speaking, EAC did not get survival benefit from RT (median OS for RT group vs. no-RT group-8.0, 7.6-8.4 vs. 9.0, 8.5-9.5, P = 0.073), whereas RT for metastatic ESCC did significantly improve OS (median OS for RT group vs. no-RT group-8.0, 7.4-8.6 vs. 7.0, 6.4-7.6, P = 0.044). Therefore, compared with adenocarcinoma, ESCC could get more survival benefit from RT.

Long non-coding RNAs in esophageal cancer: molecular mechanisms, functions, and potential applications

Esophageal cancer (EC) is the sixth leading cause of cancer-related death worldwide. The lack of early diagnostic biomarkers and effective prognostic indicators for metastasis and recurrence has resulted in the poor prognosis of EC. In addition, the underlying molecular mechanisms of EC development have yet to be elucidated. Accumulating evidence has demonstrated that lncRNAs play a vital role in the pathological progression of EC. LncRNAs may regulate gene expression through the recruitment of histone-modifying complexes to the chromatin and through interactions with RNAs or proteins. Recent evidence has demonstrated that the dysregulation of lncRNAs plays important roles in the proliferation, metastasis, invasion, angiogenesis, apoptosis, chemoradiotherapy resistance, and stemness of EC, which suggests potential clinical implications. In this review, we highlight the emerging roles and regulatory mechanisms of lncRNAs in the context of EC and discuss their potential clinical applications as diagnostic and prognostic biomarkers.

Early experience with totally robotic esophagectomy for malignancy. Surgical and oncological outcomes

BACKGROUND

Over recent decades, minimally invasive esophagectomy has gained popularity and is increasingly performed worldwide. The aim of this work was to investigate the perioperative, clinicopathologic, and oncological outcomes of robot-assisted esophagectomy on a consecutive series of totally robotic procedures.

METHODS

All patients received either an Ivor Lewis or a McKeown procedure according to tumor location. Perioperative, clinicopathologic and oncological outcomes were examined.

RESULTS

A total of 38 patients underwent robot-assisted esophagectomy procedures. All underwent surgery for primary esophageal neoplasms. Neoadjuvant therapy was given to 22 patients. R0 resections were achieved in all patients and no conversion to open surgery occurred. Overall morbidity and mortality were 42% and 10%, respectively. The 1 year disease free survival was 78.9%, whereas the 1 year overall survival was 84.2%.

CONCLUSIONS

Robotic surgery can be employed to treat esophageal malignancy competently. Robotic esophagectomy satisfies all features of pathologic appropriateness and offers the expected oncological results.

Hypoxia imaging with 18F-FAZA PET/CT predicts radiotherapy response in esophageal adenocarcinoma xenografts

Background

Esophageal cancer is an aggressive disease with poor survival rates. A more patient-tailored approach based on predictive biomarkers could improve outcome. We aimed to predict radiotherapy (RT) response by imaging tumor hypoxia with ¹⁸F-FAZA PET/CT in an esophageal adenocarcinoma (EAC) mouse model. Additionally, we investigated the radiosensitizing effect of the hypoxia modifier nimorazole in vitro and in vivo.

Methods

In vitro MTS cell proliferation assays (OACM5 1.C SC1, human EAC cell line) were performed under normoxic and hypoxic (< 1%) conditions: control (100 μL PBS), nimorazole, irradiation (5, 10 or 20 Gy) with or without nimorazole. In vivo, subcutaneous xenografts were induced in nude mice (OACM5 1.C SC1). Treatment was given daily for 5 consecutive days: (A) control (600 μl NaCl 0.9% intraperitoneally (IP)) (N = 5, n = 7), (B) RT (5 Gy/d) (N = 11, n = 20), (C) combination (nimorazole (200 mg/kg/d IP) 30 min before RT) (N = 13, n = 21). N = number of mice, n = number of tumors. ¹⁸F-FAZA PET/CT was performed before treatment and tumor to background (T/B) ratios were calculated. Relative tumor growth was calculated and tumor sections were examined histologically (hypoxia, proliferation).

Results

A T/B ≥ 3.59 on pre-treatment ¹⁸F-FAZA PET/CT was predictive for worse RT response (sensitivity 92.3%, specificity 71.4%). Radiation was less effective in hypoxic tumors (T/B ≥ 3.59) compared to normoxic tumors (T/B < 3.59) (P = 0.0025). In vitro, pre-treatment with nimorazole significantly decreased hypoxic radioresistance (P < 0.01) while in vivo, nimorazole enhanced the efficacy of RT to suppress cancer cell proliferation in hypoxic tumor areas (Ki67, P = 0.064), but did not affect macroscopic tumor growth.

Conclusions

Tumor tissue hypoxia as measured with ¹⁸F-FAZA PET/CT is predictive for RT response in an EAC xenograft model. The radiosensitizing effect of nimorazole was questionable and requires further investigation.

Electronic supplementary material

The online version of this article (10.1186/s13014-018-0984-3) contains supplementary material, which is available to authorized users.

A structured training program for minimally invasive esophagectomy for esophageal cancer- a Delphi consensus study in Europe

Evidence suggests that structured training programs for laparoscopic procedures can ensure a safe standard of skill acquisition prior to independent practice. Although minimally invasive esophagectomy (MIO) is technically demanding, no consensus on requirements for training for the MIO procedure exists. The aim of this study is to determine essential steps required for a structured training program in MIO using the Delphi consensus methodology. Eighteen MIO experts from 13 European hospitals were asked to participate in this study. The consensus process consisted of two structured meetings with the expert panel, and two Delphi questionnaire rounds. A list of items required for training MIO were constructed for three key domains of MIO, including (1) requisite criteria for units wishing to be trained and (2) to proctor MIO, and (3) a framework of a MIO training program. Items were rated by the experts on a scale 1-5, where 1 signified 'not important' and 5 represented 'very important.' Consensus for each domain was defined as achieving Cronbach alpha ≥0.70. Items were considered as fundamental when ≥75% of experts rated it important (4) or very important (5). Both Delphi rounds were completed by 16 (89%) of the 18 invited experts, with a median experience of 18 years with minimally invasive surgery. Consensus was achieved for all three key domains. Following two rounds of a 107-item questionnaire, 50 items were rated as essential for training MIO. A consensus among European MIO experts on essential items required for training MIO is presented. The identified items can serve as directive principles and core standards for creating a comprehensive training program for MIO.

Surveillance or resection after chemoradiation in esophageal cancer

The treatment of locally advanced esophageal cancer continues to evolve. Previously, surgery was considered the foundation of treatment, but chemoradiation (CRT) has taken on a larger role both in the neoadjuvant setting and as definitive treatment. It has become clear that although some patients benefit from esophagectomy after CRT, a large subset of patients likely derive no benefit, and may be harmed by surgery. Some patients are cured from CRT alone and therefore do not need surgery. Another group of patients likely have metastatic disease at the time of local therapy that is just undetected on imaging and also do not benefit from surgery. A third group of patients will have persistent locoregional disease only after CRT. This last group is the subset who will actually benefit from surgery, but this likely comprises only a minority of patients with locally advanced disease. A strategy to maximize survival while minimizing unnecessary surgery is a reasonable goal, but present technology does not allow us to do this with certainty. Thus, the decision of whether to pursue resection or surveillance after CRT can be difficult as clinicians and patients try to balance the goal of maximizing the likelihood of cure against the risk of surgery and its impact on quality of life.

Neoadjuvant chemo-radiotherapy for locally advanced esophageal cancer: A monocentric study

Aims and background

Multimodal therapy is a keystone of care in advanced esophageal cancer. Although neoadjuvant chemoradiotherapy is known to provide a survival advantage in selected cases, reliable prognostic and response predictive factors remain elusive. We report the outcome in a series of esophageal cancer patients treated at our center and the results of a retrospective analysis of epidermal growth factor receptor (EGFR) expression and EGFR/HER2 gene copy numbers taken as possible prognostic and predictive factors.

Methods and study design

Between 2001 and 2009, a total of 40 consecutive patients (34 men and 6 women; median age, 59 years) were treated for esophageal cancer. Treatment: cisplatin, 80 mg/m2 day 1, and 5-fluorouracil, 800 mg/m2/24 h on days 1–5, every 21 days, concomitant with 3D-conformal radiotherapy (54–59.4 in 30–33 fractions) for three up to four cycles. Surgery was performed in eligible patients 6–8 weeks after chemoradiation. EGFR expression and EGFR/HER2 amplification and gene copy number were studied by immunohistochemical analysis and fluorescence in situ hybridization, respectively.

Results

Acceptable toxicity following chemoradiation was recorded, with G3–G4 hematological toxicity in 20% of patients and G3–G4 dysphagia in less than 10%; 14 (35%) patients achieved complete response and 19 (48%) partial response; 18 underwent surgery after chemoradiation, of which 8 (20%) achieved pathologic complete response. The median survival was 29 months (95% CI, 25.7–32.1): 42 months for the resected and 20 for the unresected patients. EGFR and HER2 analysis in 28 patients showed that 89% had immunohistochemical EGFR expression, with 5 cases of EGFR and 10 of HER2 gene gain without a significant difference in response rate and survival in these patient subgroups.

Conclusions

Our results suggest a better outcome in patients who underwent surgery after chemoradiation. A larger sample size is necessary to clarify the role of EGFR and HER2 gene gain in predict response and survival.

Emerging therapeutic targets in esophageal adenocarcinoma

The incidence of gastro-esophageal disease and associated rate of esophageal adenocarcinoma (EAC) is rising at an exponential rate in the United States. However, research targeting EAC is lagging behind, and much research is needed in the field to identify ways to diagnose EAC early as well as to improve the rate of pathologic complete response (pCR) to systemic therapies. Esophagectomy with subsequent reconstruction is known to be a morbid procedure that significantly impacts a patient's quality of life. If indeed the pCR rate of patients can be improved and those patients destined to be pCR can be identified ahead of time, they may be able to avoid this life-altering procedure. While cancer-specific biological pathways have been thoroughly investigated in other solid malignancies, much remains unexplored in EAC. In this review, we will highlight some of the latest research in the field in regards with EAC, along with new therapeutic targets that are currently being explored. After reviewing conventional treatment and current changes in medical therapy for EAC, we will focus on unchartered grounds such as cancer stem cells, genetics and epigenetics, immunotherapy, and chemoradio-resistant pathways as we simultaneously propose some investigational possibilities that could be applicable to EAC.

Treatment results of neoadjuvant chemoradiotherapy followed by radical esophagectomy in patients with initially inoperable thoracic esophageal cancer

PURPOSE

We evaluated the effectiveness of neoadjuvant chemoradiotherapy (CRT) followed by esophagectomy for cT4 esophageal cancer or lymph node metastases (LNM) invading adjacent structures.

MATERIALS AND METHODS

We retrospectively evaluated 42 consecutive patients with thoracic esophageal cancer who underwent CRT followed by esophagectomy between 2008 and 2013. All were initially considered to be unresectable because of cT4 (n = 32) disease or LN invasion (n = 10). Radiotherapy was administered at 41.4 Gy/23 fr with concurrent chemotherapy. At completion of CRT, restaging was performed using computed tomography (CT).

RESULTS

All cT4 tumors were downstaged, LNM invading to adjacent structures were considered to be released, and subtotal esophagectomy was performed. The median follow-up period was 42 months. The curative resection (R0) rate was 94% in cT4 group and 70% in LN invasion group. The 3-year overall survival (OS) and 3-year locoregional control (LRC) rates were 65-80% in the cT4 group and 50-67% in LN invasion group, respectively.

CONCLUSIONS

The cT4 group showed good rates of R0, OS, and LRC. Surgical resection should be an effective option when downstaging is achieved by CRT for patients with initially inoperable thoracic esophageal cancer.

Operative and survival outcomes in a series of 100 consecutive cases of robot-assisted transhiatal esophagectomies

Robotic-assisted transhiatal esophagectomy (RATE) is a technically complex procedure with potential for improved postoperative outcomes. In this report, we describe our experience with RATE in a large case series. A retrospective review was conducted to collect clinical, outcomes, and survival data for 100 consecutive patients with esophageal cancer (n = 98) and benign (n = 2) conditions undergoing RATE between March 2007 and December 2014. Progression-free (PFS) and overall (OS) survival were estimated using the Kaplan-Meier curves with comparisons by log-rank tests. Median operative time and estimated blood loss were 264 minutes and 75 mL, respectively. Median intensive care unit stay was 1 day and median length of hospital stay was 8 days. Postoperative complications commonly observed were nonmalignant pleural effusion (38%) and recurrent laryngeal nerve injury (33%); 30 day mortality rate was 2%. Median number of lymph nodes removed during RATE was 17 and R0 resection was achieved in 97.8% patients. At the end of the median follow-up period of 27.7 months, median PFS was 41 months and median OS was 54 months. 1-year and 3-year PFS rates were 82% (95% CI, 75%-89%) and 53% (95% CI, 42%-62%), respectively, and OS rates were 95% (95% CI, 91%-99%) and 57% (95% CI, 46%-67%). In our experience, RATE is an effective and safe oncologic surgical procedure in a carefully selected group of patients with acceptable operative time, minimal blood loss, standard postoperative morbidity and adequate PFS and OS profiles.

Squamous cell carcinoma antigen (SCCA) is up-regulated during Barrett's carcinogenesis and predicts esophageal adenocarcinoma resistance to neoadjuvant chemotherapy

Squamous Cell Carcinoma Antigen (SCCA) is consistently overexpressed in many different solid tumors, and has been associated with both tumor aggressiveness and chemoresistance. No data, however, is currently available on SCCA expression during esophageal Barrett's carcinogenesis, nor on SCCA expression's role on esophageal adenocarcinoma chemoresistance. The SCCA immunohistochemical expression was assessed in a series of 100 biopsy samples covering the whole histological spectrum of Barrett's oncogenesis. Squamous native mucosa was characterized by a moderate to strong cytoplasmic and nuclear SCCA expression in suprabasal, medium, and superficial layers. On the other hand, almost half of the considered lesions did not express SCCA; the other half featured weak to moderate SCCA expression. The relationship between SCCA protein expression and tumor response to neoadjuvant chemotherapy was assessed in 90 esophageal adenocarcinoma specimens (40 biopsy and 50 surgery specimens), stratified according to Mandard tumor regression grade. As observed in other settings, the presence of SCCA expression clustered in the group of tumors characterized by a lower responsiveness to neoadjuvant treatments. The present results suggest an involvement of SCCA in a subset of Barrett-related tumors, and prompt to consider the SCCA-protein expression as response-predictive marker of neoadjuvant therapy in esophageal adenocarcinomas.

Surgical treatment of a rare complication after endoscopic stent placement for anastomotic leakage after esophageal resection

The best approach to achieve cure in esophageal cancer is a combination of chemo-radiation and surgery. However, complications occur in half of patients. The current report, reports a rare but severe complication: Complete obstruction of the esophagus, induced by preoperative chemo-radiation therapy. Normally, strictures are treated by repeated dilatations, however, in case of complete obstruction, the perforation rate of standard blind anterograde wire access and dilation is severely increased. In order to minimize the risk of perforations, the rendezvous technique was introduced. This technique involves an anterograde approach in combination with a retrograde approach in order to open and dilatate the esophagus. While technical success rates between 83% and 100% have been reported in literature, data on clinical outcomes are scarcer. The limited amount of studies available claim that success was achieved in almost half of patients. The patient in our case currently has an oral diet without restrictions and rates his quality of life with a VAS-score ten out of ten.

Prospective comparison of MR with diffusion-weighted imaging, endoscopic ultrasound, MDCT and positron emission tomography-CT in the pre-operative staging of oesophageal cancer: results from a pilot study

OBJECTIVE

To compare the diagnostic performance of MR and diffusion-weighted imaging (DWI), multidetector CT, endoscopic ultrasonography (EUS) and 18F-FDG (fluorine-18 fludeoxyglucose) positron emission tomography CT (PET-CT) in the pre-operative locoregional staging of oesophageal cancer.

METHODS

18 patients with oesophageal or Siewert I tumour (9 directly treated with surgery and 9 addressed to chemo-/radiotherapy before) underwent 1.5-T MR and DWI, 64-channel multidetector CT, EUS and PET-CT before (n = 18) and also after neoadjuvant treatment (n = 9). All images were analysed and staged blindly by dedicated operators (seventh TNM edition). Two radiologists calculated independently the apparent diffusion coefficient from the first scan. Results were compared with histopathological findings. After the population had been divided according to local invasion (T1-T2 vs T3-T4) and nodal involvement (N0 vs N+), sensitivity, specificity, accuracy, positive- and negative-predictive values were calculated and compared. Quantitative measurements from DWI and PET-CT were also analysed.

RESULTS

For T staging, EUS showed the best sensitivity (100%), whereas MR showed the highest specificity (92%) and accuracy (83%). For N staging, MR and EUS showed the highest sensitivity (100%), but none of the techniques showed adequate results for specificity. Overall, MR showed the highest accuracy (66%) for N stage, although this was not significantly different to the other modalities. The apparent diffusion coefficient was different between surgery-only and chemo-/radiotherapy groups (1.90 vs 1.30 × 10-3 mm2 s-1, respectively; p = 0.005)-optimal cut off for local invasion: 1.33 × 10-3 mm2 s-1 (p = 0.05). Difference in standardized uptake value was also very close to conventional levels of statistical significance (8.81 vs 13.97 g cm-3, respectively; p = 0.05)-optimal cut off: 7.97 g cm-3 (p = 0.44).

CONCLUSION

In this pilot study, we have shown that MR with DWI could enrich the current pre-operative work-up for oesophageal cancer and could be used for T and N staging. However, larger studies will need to be carried out before introducing this technique in the standard diagnostic pathway, in order to understand if MR with DWI could change its management and replace more costly or invasive tests such as PET-CT or EUS. Advances in knowledge: This pilot study represents the first effort where the four techniques have been prospectively compared together for oesophageal cancer staging. The combination of MR and DWI could provide important, additional information for staging and initial treatment decision-making.

[Timing of esophagectomy in multimodal therapy of esophageal cancer: Impact of time interval between neoadjuvant therapy and surgery on outcome and response]

BACKGROUND

Neoadjuvant radiochemotherapy [n(R)CT] has become the standard of care in the multimodal therapy concept for patients with locally advanced esophageal cancer; however, optimal timing of surgery is not clearly defined.

OBJECTIVES

The study analyzed whether the length of the interval between completion of n(R)CT and surgery can affect the postoperative outcome, tumor response and long-term survival.

MATERIAL AND METHODS

A total of 106 patients with adenocarcinoma and squamous cell carcinoma of the esophagus, treated between 2006 and 2013, were included in this study. On the basis of the median time interval to surgery, patients were divided into two groups [group A ≤ 40 days (n = 54) and group B > 40 days (n = 52)] and compared concerning demographic data, preoperative risk scores, morbidity, outcome, tumor response and long-term survival.

RESULTS

The groups were comparable in terms of demographics, preoperative condition of the patients, complications and outcome; however, group A showed a trend towards a higher mortality risk as preoperatively assessed by the physiological and operative severity score for the enumeration of mortality and morbidity in esophagogastric surgery patients (O-POSSUM) (p = 0.064) and group B showed a trend towards a higher rate of complete responders (p = 0.097).

CONCLUSION

Concerning perioperative morbidity and mortality, delayed surgery after n(R)CT showed no benefit for the patient's outcome; however, the rate of complete tumor response was higher in patients with a time interval of more than 40 days, although this did not influence long-term survival or recurrence rates.

Chemoradiotherapy in tumours of the oesophagus and gastro-oesophageal junction

Oesophageal cancer remains a malignancy with a poor prognosis. However, in the recent 10-15 years relevant progress has been made by the introduction of chemoradiotherapy (CRT) for tumours of the oesophagus or gastro-oesophageal junction. The addition of neo-adjuvant CRT to surgery has significantly improved survival and locoregional control, for both adenocarcinoma and squamous cell carcinoma. For irresectable or medically inoperable patients, definitive CRT has changed the treatment intent from palliative to curative. Definitive CRT is a good alternative for radical surgery in responding patients with squamous cell carcinoma and those running a high risk of surgical morbidity and mortality. For patients with an out-of-field solitary locoregional recurrence after primary curative treatment, definitive CRT can lead to long term survival.

Utility of dysphagia grade in predicting endoscopic ultrasound T-stage of non-metastatic esophageal cancer

Patients with non-metastatic esophageal cancer routinely undergo endoscopic ultrasound (EUS) for loco-regional staging. Neoadjuvant therapy is recommended for ≥T3 tumors while upfront surgery can be considered for ≤T2 lesions. The aim of this study was to determine if the degree of dysphagia can predict the EUS T-stage of esophageal cancer. One hundred eleven consecutive patients with non-metastatic esophageal cancer were retrospectively reviewed from a database. Prior to EUS, patients' dysphagia grade was recorded. Correlation between dysphagia grade and EUS T-stage, especially in reference to predicting ≥T3 stage, was determined. The correlation of dysphagia grade with EUS T-stage (Kendall's tau coefficient) was 0.49 (P < 0.001) for the lower and 0.59 (P = 0.008) for the middle esophagus. The sensitivity and specificity of dysphagia grade ≥2 (can only swallow semi-solids/liquids) for T3 cancer were 56% (95% confidence interval [CI] 43-67%) and 93% (95% CI 79-98%), respectively. The sensitivity, specificity, and positive predictive value of dysphagia grade ≥3 (can only swallow liquids or total dysphagia) for T3 lesions were 36% (95% CI 25-48%), 100% (95% CI 89-100%), and 100% (95% CI 83-100%), respectively. Overall, there was a significant positive correlation between dysphagia grade and the EUS T-stage of esophageal cancer. All patients with dysphagia grade ≥3 had T3 lesions. This may have clinical implications for patients who can only swallow liquids or have complete dysphagia by allowing for prompt initiation of neoadjuvant therapy, especially in countries/centers where EUS service is difficult to access in a timely manner or not available.

Which factors are associated with extremely short-term survival after surgery in patients with esophageal squamous cell carcinoma?

AIMS

Esophageal squamous cell carcinoma (ESCC) is associated with a short median survival and low cure rates. The postoperative survival time of some patients with ESCC is extremely short. It is important to understand risk factors in subsets of patients associated with extremely short-term survival. The standard factors such as T and N stage, which are predictive of actuarial survival, become less important as patients live for ≤1 year. However, the prevalence of these factors in these patient populations has not been well documented. We evaluated factors predictive of ≤1 year survival in this research.

METHODS

We analyzed 1596 patients underwent esophagectomy for ESCC retrospectively. The demographic and clinicopathologic characteristics were compared between patients who died within 1 year of esophagectomy and patients who survived more than 1 year after esophagectomy.

RESULTS

Univariate analysis showed significant differences between the two groups regarding gender, weight loss, comorbidity, neoadjuvant treatment, completeness of resection, pathological T stage, pathological N stage, histologic grade, the number of metastatic lymph nodes, postoperative complications, postoperative pulmonary infection and postoperative hospital stay. Based on logistic regression analysis, significant factors associated with extremely short-term survival were male gender, incomplete tumor resection, higher pathological T stage, higher pathological N stage and postoperative pulmonary infection.

CONCLUSION

The independent positive predictors for extremely short-term survival are male gender, incomplete tumor resection and postoperative pulmonary infection besides higher pathological T stage and higher pathological N stage.

Patients' Preferences for Surgical Management of Esophageal Cancer: A Discrete Choice Experiment

BACKGROUND

Obtaining insight into patients' preferences is important to optimize cancer care. We investigated patients' preferences for surgical management of esophageal cancer.

METHODS

We conducted a discrete choice experiment among adult patients who had undergone esophagectomy for adenocarcinoma or squamous cell cancer of the esophagus. Patients' preferences were quantified with regression analysis using scenarios based on five aspects: risk of in-hospital mortality, risk of persistent symptoms, chance of 5-year survival, risk of surgical and non-surgical complications, and hospital volume of esophageal cancer surgery.

RESULTS

The response rate was 68 % (104/142). All aspects proved to influence patients' preferences (p < 0.05). Persisting gastrointestinal symptoms and 5-year survival were the most important attributes, but preferences varied between patients. On average, patients were willing to trade-off 9.5 % (CI 2.4-16.6 %) 5-year survival chance to obtain a surgical treatment with 30 % lower risk of gastrointestinal symptoms, or 8.1 % (CI 4.0-12.2 %) 5-year survival chance for being treated in a high instead of a low-volume hospital.

CONCLUSIONS

Patients are willing to trade-off some 5-year survival chance to achieve an improvement in early outcomes. Given the preference heterogeneity among participants, the present study underlines the importance of a patient-tailored approach when discussing prognosis and treatment.

Impact of Treatment Modalities on Survival of Patients With Locoregional Esophageal Squamous-Cell Carcinoma in Taiwan

The optimal treatment modality for locoregional esophageal squamous-cell carcinoma (ESCC) is still undetermined. This study investigated the treatment modalities affecting survival of patients with ESCC in Taiwan.Data on 6202 patients who underwent treatment for locoregional esophageal squamous-cell carcinoma during 2008 to 2012 in Taiwan were collected from the Taiwan Cancer Registry. Patients were stratified by clinical stage. The major treatment approaches included definitive chemoradiotherapy, preoperative chemoradiation followed by esophagectomy, esophagectomy followed by adjuvant therapy, and esophagectomy alone. The impact of different treatment modalities on overall survival was analyzed.The majority of patients had stage III disease (n = 4091; 65.96%), followed by stage II (n = 1582, 25.51%) and stage I cancer (n = 529, 8.53%). The 3-year overall survival rates were 60.65% for patients with stage I disease, 36.21% for those with stage II cancer, and 21.39% for patients with stage III carcinoma. Surgery alone was associated with significantly better overall survival than the other treatment modalities for patients with stage I disease (P = 0.029) and was associated with significantly worse overall survival for patients with stage III cancer (P < 0.001). There was no survival risk difference among the different treatment methods for patients with clinical stage II disease.Multimodality treatment is recommended for patients with stage II-III esophageal squamous-cell carcinoma. Patients with clinical stage I disease can be treated with esophagectomy without preoperative therapy.

Quality Management and Key Performance Indicators in Oncologic Esophageal Surgery

Ranking systems and comparisons of quality and performance indicators will be of increasing relevance for complex "high-risk" procedures such as esophageal cancer surgery. The identification of evidence-based standards relevant for key performance indicators in esophageal surgery is essential for establishing monitoring systems and furthermore a requirement to enhance treatment quality. In the course of this review, we analyze the key performance indicators case volume, radicality of resection, and postoperative morbidity and mortality, leading to continuous quality improvement. Ranking systems established on this basis will gain increased relevance in highly complex procedures within the national and international comparison and furthermore improve the treatment of patients with esophageal carcinoma.

Pre-therapy mRNA expression of TNF is associated with regimen-related gastrointestinal toxicity in patients with esophageal cancer: a pilot study

PURPOSE

Esophageal cancer has a high mortality rate, and its multimodality treatment is often associated with significant rates of severe toxicity. Effort is needed to uncover ways to maximize effectiveness of therapy through identification of predictive markers of response and toxicity. As such, the aim of this study was to identify genes predictive of chemoradiotherapy-induced gastrointestinal toxicity using an immune pathway-targeted approach.

METHODS

Adults with esophageal cancer treated with chemotherapy consisting of 5-fluorouracil and cisplatin and 45-50 Gy radiation were recruited to the study. Pre-therapy-collected whole blood was analyzed for relative expression of immune genes using real-time polymerase chain reaction (RT-PCR). Gene expression was compared between patients who experienced severe regimen-related gastrointestinal toxicity vs. those experiencing mild to moderate toxicity.

RESULTS

Blood from 31 patients were analyzed by RT-PCR. Out of 84 immune genes investigated, TNF was significantly elevated (2.05-fold, p = 0.025) in the toxic group (n = 12) compared to the non-toxic group (n = 19). Nausea and vomiting was the most commonly documented severe toxicity. No associations between toxicity and response, age, sex, histology, or treatment were evident.

CONCLUSIONS

This study supports evidence of TNF as a predictive biomarker in regimen-related gastrointestinal toxicity. Confirming these findings in a larger cohort is warranted.