Neoadjuvant strategies for the treatment of locally advanced esophageal cancer

Efficacy of upfront hepatectomy without neoadjuvant chemotherapy for resectable colorectal liver metastasis

Background

Hepatectomy for resectable colorectal liver metastasis (CRLM) is recommended. However, the efficacy of upfront hepatectomy without neoadjuvant chemotherapy (NAC) is unclear due to the uncertainty of perioperative systemic chemotherapy. Moreover, it is crucial to predict the prognosis when considering perioperative chemotherapy. This study evaluated the impact of neoadjuvant chemotherapy on the prognosis of patients with resectable CRLM and assessed the usefulness of Beppu’s nomogram for predicting prognosis.

Methods

This retrospective study identified 88 consecutive inpatients who underwent primary hepatic resection for CRLM; 58 received neoadjuvant chemotherapy and 30 underwent upfront surgery. Factors associated with recurrence-free survival were identified via univariate and multivariate analysis. Furthermore, propensity score analysis using inverse probability of treatment weighting (IPTW) was performed.

Results

On univariate analysis, poor recurrence-free survival was associated with multiple tumors, advanced primary tumor stage, vascular invasion by the primary tumor, a Beppu’s nomogram score ≥ 6, and neoadjuvant chemotherapy. On multivariate analysis, a Beppu’s nomogram score ≥ 6 and neoadjuvant chemotherapy were independent risk factors for recurrence. Neoadjuvant chemotherapy recipients had a higher incidence of lymph node metastasis and vascular invasion than non-recipients. Propensity score analysis revealed no significant difference in the recurrence-free survival rate between these groups.

Conclusions

Our results show that upfront hepatectomy without neoadjuvant chemotherapy can be considered for resectable CRLM treatment. Beppu’s nomogram score can be a tool for predicting the prognosis of patients with CRLM.

Neoadjuvant chemotherapy versus neoadjuvant chemoradiotherapy for cancer of the esophagus or the gastroesophageal junction: A meta-analysis based on clinical trials

Background

The benefit of neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy for treating cancer of the esophagus or the gastroesophageal junction remains controversial. In the present study, we conducted a comprehensive meta-analysis to examine the efficacy of these two management strategies.

Methods

The MEDLINE (PubMed), SinoMed, Embase, and Cochrane Library databases were searched for eligible studies. We searched for the most relevant studies published until the end of September 2017. Data were extracted independently and were analyzed using RevMan statistical software version 5.3 (Cochrane Collaboration, http://tech.cochrane.org/revman/download). Weighted mean differences, risk ratios (RRs), and 95% confidence intervals (CIs) were calculated. Cochrane Collaboration’s risk of bias tool was used to assess the risk of bias. In this comprehensive meta-analysis, we examined the efficiency of neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy for the treatment of cancer of the esophagus or the gastroesophageal junction as reported in qualified clinical trials.

Results

Six qualified articles that included a total of 866 patients were identified. The meta-analysis showed that for 3-year and 5-year survival rates in primary outcomes, the results favored neoadjuvant chemoradiotherapy strategies compared with neoadjuvant chemotherapy (RR = 0.78, 95% CI = 0.62–0.98, P = 0.03; RR = 0.69, 95% CI = 0.50–0.96, P = 0.03, respectively). In terms of secondary outcomes, neoadjuvant chemoradiotherapy significantly increased the rate of R0 resection and pathological complete response as well (RR = 0.87, 95% CI = 0.81–0.92, P < 0.0001; RR = 0.16, 95% CI = 0.09–0.28, P < 0.00001, respectively). However, there were no significant differences in postoperative mortality between the two groups (RR = 1.85, 95% CI = 0.93–3.65, P = 0.08). For the results of postoperative complications, revealed that there was a statistically significant difference between the two groups in the incidence of postoperative complications such as pulmonary, anastomotic leak and cardiovascular complications. The subgroup analysis of patients with esophageal adenocarcinoma or squamous cell carcinoma showed that both esophageal adenocarcinoma and squamous cell carcinoma patients achieved a high rate of R0 resection (RR = 0.85, 95% CI = 0.77–0.93, P = 0.0006; RR = 0.88, 95% CI = 0.81–0.96, P = 0.005, respectively) and pathological complete response benefit of neoadjuvant chemoradiotherapy (RR = 0.23, 95% CI = 0.09–0.57, P = 0.001; RR = 0.18, 95% CI = 0.03–0.96, P = 0.05, respectively).

Conclusion

Our findings suggested that compared with neoadjuvant chemotherapy, neoadjuvant chemoradiotherapy should be recommended with a significant long-term survival benefit in patients with cancer of the esophagus or the gastroesophageal junction. In view of the clinical heterogeneity, whether these conclusions are broadly applicable should be further determined.

Postoperative survival following perioperative MAGIC versus neoadjuvant OE02-type chemotherapy in oesophageal adenocarcinoma

The optimal management of resectable oesophageal adenocarcinoma is controversial, with many centres using neoadjuvant chemotherapy following the Medical Research Council (MRC) oesophageal working group (OE02) trial and the MRC Adjuvant Gastric Infusional Chemotherapy (MAGIC) trial. The more intensive MAGIC regimen is used primarily in gastric cancer but some also use it for oesophageal cancer. A database of cancer resections (2001-2013) provided information on survival of patients following either OE02 or MAGIC-type treatment. The data were compared using Kaplan-Meier analysis. Straight-to-surgery patients were also reviewed and divided into an 'early' cohort (2001-2006, OE02 era) and a 'late' cohort (2006-2013, MAGIC era) to estimate changes in survival over time. Subgroup analysis was performed for responders (tumour regression grade [TRG] 1-3) versus non-responders (TRG 4 and 5) and for anatomical site (gastro-oesophageal junction [GOJ] vs oesophagus). An OE02 regimen was used for 97 patients and 275 received a MAGIC regimen. Those in the MAGIC group were of a similar age to those undergoing OE02 chemotherapy but the proportion of oesophageal cancers was higher among MAGIC patients than among those receiving OE02 treatment. MAGIC patients had a significantly lower stage following chemotherapy than OE02 patients and a higher median overall survival although TRG was similar. On subgroup analysis, this survival benefit was maintained for GOJ and oesophageal cancer patients as well as non-responders. Analysis of responders showed no difference between regimens. 'Late' group straight-to-surgery patients were significantly older than those in the 'early' group. Survival, however, was not significantly different for these two cohorts. Although the original MAGIC trial comprised few oesophageal cancer cases, our patients had better survival with MAGIC than with OE02 chemotherapy in all anatomical subgroups, even though there was no significant change in operative survival over the time period in which these patients were treated. The use of the MAGIC regimen should therefore be encouraged in cases of operable oesophagogastric adenocarcinoma.

Esophageal stent fixation with endoscopic suturing device improves clinical outcomes and reduces complications in patients with locally advanced esophageal cancer prior to neoadjuvant therapy: a large multicenter experience

BACKGROUND

Endoscopic placement of fully covered self-expanding metal stents (FCSEMS) to treat malignant dysphagia in patients with esophageal cancer significantly improves dysphagia; however, these stents have a high migration rate.

AIM

To determine whether FCSEMS fixation using an endoscopic suturing device treated malignant dysphagia and prevented stent migration in patients with locally advanced esophageal cancer receiving neoadjuvant therapy when compared to patients with FCSEMS placement alone.

METHOD

A review of patients with locally advanced esophageal cancer who underwent FCSEMS placement at 3 centers was performed. Patients were divided into two groups: Group A (n = 26) was composed of patients who underwent FCSEMS placement with suture placement, and Group B (n = 67) was composed of patients with FCSEMS placement alone.

RESULTS

There were no significant differences between Groups A and B in demographics, and tumor characteristics. The technical success rate for stent placement was 100 %. There was no difference between Groups A and B in the median stent diameter and stent lengths. Mean dysphagia score obtained at 1 week after stent placement had improved significantly from baseline (2.4 and 1, respectively, p < 0.001). Patients had a median follow-up of 4 months. Immediate adverse events were mild chest discomfort in 4 patients in Group A and 2 patients in Group B (p = 0.05), and significant acid reflux in 3 patient in Group A compared to 2 patients in Group B (p = 0.1). The stent migration rate was significantly lower in Group A compared to compared to Group B (7.7 vs 26.9 %, respectively, p = 0.004). There was a delayed perforation in 1 patient and 1 death due to aspiration pneumonia in Group B.

CONCLUSION

Fixation of esophageal FCSEMSs by using an endoscopic suturing device in patients receiving neoadjuvant therapy was shown to be feasible, safe, and relatively effective at preventing stent migration compared to those who had stent placed alone.

Survival after neoadjuvant chemotherapy versus neoadjuvant chemoradiotherapy for resectable esophageal carcinoma: A meta-analysis

BACKGROUND

The efficacy of surgery alone for patients with locally advanced esophageal cancer (EC) is still unsatisfactory. Presently, induction therapy followed by surgery is the standard treatment. Preoperative chemotherapy (CT) and chemoradiation (CRT) are proven effective induction therapies; however, few sample studies have addressed these treatments, thus, their superiority remains uncertain. We performed a systemic review and meta analysis to test the hypothesis that induction CRT prior to surgery could improve survival compared with induction CT alone.

METHODS

A comprehensive search of PubMed and the Ovid database for relevant studies comparing EC patients undergoing resection after treatment with induction CT alone or induction CRT was conducted. Hazard ratios (HR) and 95% confidence intervals (95% CI) were extracted from these studies to provide pooled estimates of the effect of induction therapy on overall survival.

RESULTS

Five studies met the criteria for analysis. Statistical analysis demonstrated a survival benefit of induction CRT compared with induction CT alone (HR0.73, 95% CI 0.61-0.89; P = 0.002). Further analysis showed that induction CRT perioperative mortality and complication rates were higher than for induction CT alone (HR 2.96, 95% CI 1.38-6.37; HR1.6, 95% CI 1.30-1.98; P = 0.01, respectively).

CONCLUSIONS

Published evidence comparing the different efficacies of induction CT and induction CRT is sparse, with few samples of adenocarcinoma. This analysis supports the view that, compared with induction CT, induction CRT could achieve a long-term survival benefit in EC patients.

Preoperative psychological nursing intervention promotes recovery of patients with esophageal cancer

AIM: To investigate whether preoperative psychological nursing intervention promotes the recovery of patients with esophageal cancer.

METHODS: Ninety-six patients with esophageal cancer were randomly divided into either an experiment group or a control group. The control group received conventional comprehensive nursing care, while the experiment group received preoperative psychological nursing intervention on the basis of conventional comprehensive nursing care. Blood pressure and heart rate (HR) at different time points as well as anxiety and satisfaction degree were compared between the two groups.

RESULTS: The systolic blood pressure and HR 30 min before and after entering into the operating room were significantly lower in the experiment group than in the control group (116.67 mmHg ± 5.65 mmHg vs 124.82 mmHg ± 7.36 mmHg, 117.90 min ± 6.47 min vs 127.67 min ± 6.45 min, 71.95 mmHg ± 7.26 mmHg vs 79.95 mmHg ± 7.26 mmHg, 71.69 min ± 6.20 min vs 80.40 min ± 7.80 min, P < 0.05). The self-rating anxiety scale score and state anxiety inventory score in the experiment group were significantly lower than those in the control group (35.09 ± 3.29 vs 48.04 ± 5.01, 34.65 ± 3.36 vs 44.06 ± 4.18, P < 0.05). The total satisfaction in the experiment group was significantly higher than that in the control group (97.92% vs 85.42%, P < 0.05).

CONCLUSION: Preoperative psychological nursing intervention can improve blood pressure, HR and anxiety, and increase the satisfaction degree in patients with esophageal cancer.

Role of barium esophagography in patients with locally advanced esophageal cancer: evaluation of response to neoadjuvant chemoradiotherapy

Purpose. This retrospective study examined the usefulness of barium esophagography, focusing on the luminal stenosis, in the response evaluation of neoadjuvant chemoradiotherapy (NACRT) in patients with esophageal cancer. Materials and Methods. Thirty-four patients with primary advanced esophageal cancer (≥T2) who were treated with NACRT before surgical resection were analyzed. All patients underwent barium esophagography before and after NACRT. The tumor length, volume, and percent esophageal stenosis (PES) before and after NACRT were measured. These values and their changes were compared between histopathologic responders (n = 22) and nonresponders (n = 12). Results. Posttreatment tumor length and PES in responders (4.5 cm ± 1.1 and 33.0% ± 18.5) were significantly smaller than those in nonresponders (5.8 cm ± 1.9 and 48.0% ± 12.9) (P = 0.018). Regarding posttherapeutic changes, the decrease in PES in responders (31.5% ± 13.9) was significantly greater than that in nonresponders (14.4% ± 10.7) (P < 0.001). The best decrease in PES cutoff with which to differentiate between responders and nonresponders was 18.8%, which yielded a sensitivity of 91% and a specificity of 75%. Conclusions. Decrease in PES is a good parameter to differentiate responders from nonresponders for NACRT. Barium esophagography is useful in response evaluation to NACRT in patients with locally advanced esophageal cancer.

CXCR7 expression in esophageal cancer

Background

The chemokine CXCL12 and its receptor CXCR4 play a major role in tumor invasion, proliferation and metastasis in different malignant diseases, including esophageal carcinoma, amongst others. CXCR7 was recently identified as a novel alternate receptor for CXCL12. The aim of this study was to evaluate the prognostic impact of expression of chemokine receptor CXCR7 in patients with esophageal carcinoma (EC).

Methods

Expression of CXCR7 in primary tumors, lymph nodes and distant metastases of 299 patients with EC was evaluated by immunohistochemistry on a tissue microarray and compared with clinical and histopathological data.

Results

In esophageal cancer sections, CXCR7-specific reactivity was apparent in 45% of the squamous cell carcinomas (ESCC), but only occasionally in adenocarcinomas. No correlation between CXCR4 and CXCR7 expression was evident. We correlated expression with clinical and histopathological characteristics, but could not find any association.

Conclusions

Contrary to the other known CXCL12 receptor, CXCR4, CXCR7 is expressed in ESCC only, underlining the divergent mechanisms and backgrounds of EAC and ESCC. The results of the study do not indicate a significant functional role for CXCR7 in EAC or ESCC of the esophagus. However, its variable expression in the main two main types of EC needs to be further investigated.

Progress in surgery-based multimodality therapy for resectable esophageal cancer

The incidence of esophageal cancer is rather high in China. For patients with resectable esophageal cancer, surgery is the standard treatment. However, the overall survival of patients with locally advanced esophageal cancer remains low, which necessitates the development of multimodality therapies for this malignancy. Among currently available multimodality treatments, preoperative chemoradiotherapy followed by surgery is the most promising strategy in terms of improving the prognosis of advanced esophageal cancer. Postoperative chemotherapy or radiotherapy is also feasible for selected patients. The aim of this article is to provide a complete review of the current status of esophageal cancer treatment with the addition of chemotherapy and radiotherapy to the surgical management of resectable disease.

Progress in medication treatment of esophageal cancer

Esophageal cancer is one of the common malignant tumors. Multimodality treatment (including surgery, chemotherapy and radiotherapy) of esophageal cancer has become a consensus. Although there is currently no standard treatment, neoadjuvant chemoradiotherapy followed by surgery and postoperative adjuvant radiotherapy or chemotherapy based on risk factors, such as positive surgical margin and lymph node metastasis, and definitive chemoradiotherapy when inoperable, has been recommended by the NCCN Guidelines. In recent years, clinical trials show that targeted drugs can further improve the prognosis of esophageal cancer. How to choose chemotherapy drugs and develop reasonable treatment modality has become a hotspot of clinical research. This article aims to review recent progress in medication treatment of esophageal cancer.

MicroRNAs and esophageal cancer

Cancer of the esophagus is a highly aggressive disease associated with an overall poor prognosis. There is an insistent need for improving our understanding of the molecular basis of this disease. The recent emergence of observations on the role of microRNAs in cancer and their potential as biomarkers has prompted many investigations to examine their relevance to esophageal cancer. This article provides an introduction to microRNA biology and the techniques involved in studying them, and summates what is now known about their role and utility in regard to neoplastic esophageal diseases.

Is there a role of whole-body bone scan in patients with esophageal squamous cell carcinoma

Background

Correct detection of bone metastases in patients with esophageal squamous cell carcinoma is pivotal for prognosis and selection of an appropriate treatment regimen. Whole-body bone scan for staging is not routinely recommended in patients with esophageal squamous cell carcinoma. The aim of this study was to investigate the role of bone scan in detecting bone metastases in patients with esophageal squamous cell carcinoma.

Methods

We retrospectively evaluated the radiographic and scintigraphic images of 360 esophageal squamous cell carcinoma patients between 1999 and 2008. Of these 360 patients, 288 patients received bone scan during pretreatment staging, and sensitivity, specificity, positive predictive value, and negative predictive value of bone scan were determined. Of these 360 patients, surgery was performed in 161 patients including 119 patients with preoperative bone scan and 42 patients without preoperative bone scan. Among these 161 patients receiving surgery, 133 patients had stages II + III disease, including 99 patients with preoperative bone scan and 34 patients without preoperative bone scan. Bone recurrence-free survival and overall survival were compared in all 161 patients and 133 stages II + III patients, respectively.

Results

The diagnostic performance for bone metastasis was as follows: sensitivity, 80%; specificity, 90.1%; positive predictive value, 43.5%; and negative predictive value, 97.9%. In all 161 patients receiving surgery, absence of preoperative bone scan was significantly associated with inferior bone recurrence-free survival (P = 0.009, univariately). In multivariate comparison, absence of preoperative bone scan (P = 0.012, odds ratio: 5.053) represented the independent adverse prognosticator for bone recurrence-free survival. In 133 stages II + III patients receiving surgery, absence of preoperative bone scan was significantly associated with inferior bone recurrence-free survival (P = 0.003, univariately) and overall survival (P = 0.037, univariately). In multivariate comparison, absence of preoperative bone scan was independently associated with inferior bone recurrence-free survival (P = 0.009, odds ratio: 5.832) and overall survival (P = 0.029, odds ratio: 1.603).

Conclusions

Absence of preoperative bone scan was significantly associated with inferior bone recurrence-free survival, suggesting that whole-body bone scan should be performed before esophagectomy in patients with esophageal squamous cell carcinoma, especially in patients with advanced stages.

The predictive value of histological tumor regression grading (TRG) for therapeutic evaluation in locally advanced esophageal carcinoma treated with neoadjuvant chemotherapy

Response criteria remain controversial in therapeutic evaluation for locally advanced esophageal carcinoma treated with neoadjuvant chemotherapy. We aimed to identify the predictive value of tumor regression grading (TRG) in tumor response and prognosis. Fifty-two patients who underwent neoadjuvant chemotherapy followed by esophagectomy and radical 2-field lymphadenectomy between June 2007 and June 2011 were included in this study. All tissue specimens were reassessed according to the TRG scale. Potential prognostic factors, including clinicopathologic factors, were evaluated. Survival curves were generated by using the Kaplan-Meier method and compared with the log-rank test. Prognostic factors were determined with multivariate analysis by using the Cox regression model. Our results showed that of 52 cases, 43 (83%) were squamous cell carcinoma and 9 (17%) were adenocarcinoma. TRG was correlated with pathologic T(P = 0.006) and N (P < 0.001) categories. Median overall survival for the entire cohort was 33 months. The 1- and 2-year overall survival rates were 71% and 44%, respectively. Univariate survival analysis results showed that favorable prognostic factors were histological subtype (P = 0.003), pathologic T category (P = 0.026), pathologic N category (P < 0.001), and TRG G0 (P = 0.041). Multivariate analyses identified pathologic N category (P < 0.001) as a significant independent prognostic parameter. Our results indicate that histomorphologic TRG can be considered as an alternative option to predict the therapeutic efficacy and prognostic factor for patients with locally advanced esophageal carcinoma treated by neoadjuvant chemotherapy.

The number of pathologic lymph nodes involved is still a significant prognostic factor even after neoadjuvant chemoradiotherapy in esophageal squamous cell carcinoma

BACKGROUND

The correlation between the number of pathologic metastatic LNs in patients with esophageal squamous cell carcinoma (ESCC) after neoadjuvant chemoradiotherapy (NACRT) and surgical outcome has rarely been reported. We evaluated the correlation between the number of pathologic metastatic lymph nodes (LNs) and the surgical outcome in ESCC after NACRT.

METHODS

Eighty-eight patients with ESCC who underwent NACRT followed by surgery were evaluated. The clinical response of NACRT was evaluated and surgical specimens of the primary tumor and resected LNs were analyzed clinicopathologically.

RESULTS

Fewer pathologic metastatic LNs was associated with better survival. According to the number of metastatic LNs, the difference in the median survival was the largest between the groups when patients were divided into those with 2 and 3 metastatic LNs (χ(2) : 13.694, P < 0.001). With regard to clinical factors, the initial N status prior to treatment had the most significant impact on survival by a univariate analysis (P = 0.064), and the number of pathologic metastatic LNs was a risk factor for poor survival, with a hazard ratio of 5.128 (95% C.I.: 1.438-18.285, P = 0.012) by a multivariate analysis.

CONCLUSIONS

Of the various factors, the number of pathologic metastatic LNs was the strongest indicator to predict the patients' survival.

MAGIC in practice: experience of peri-operative ECF/X chemotherapy in gastro-esophageal adenocarcinomas

BACKGROUND

The MAGIC trial demonstrated the perioperative regimen of Epirubicin (E), Cisplatin (C) and 5-Fluorouracil (F) to have an overall survival benefit for patients with gastro-esophageal adenocarcinomas. We present our experience of the peri-operative regimen of ECF/ECX(X = Capecitabine) in operable gastro-esophageal adenocarcinoma.

METHODS

Analysis of retrospective data of patients treated with MAGIC style therapy between May 2006 and August 2008 with potentially operable gastro-esophageal adenocarcinoma.

RESULTS

One hundred patients underwent peri-operative chemotherapy according to the MAGIC protocol. Median age was 66 years, with 39% above the age of 70 years. The tumours were evenly distributed between the lower esophagus, gastro-esophageal junction and stomach. Seventy-nine percent completed all pre-operative cycles of chemotherapy and 81% proceeded to surgery, whilst 24% did not receive curative surgery. The median survival on an intention to treat analysis is 31.7 months from diagnosis. The median survival of patients who underwent resection has not yet been reached after a median follow-up of 41.4 months.

CONCLUSION

Our patient population is older than the patients in the MAGIC trial (age 66 years vs. 62 years) with a much higher proportion of esophageal and GEJ tumours. Overall, curative resection rate was comparable to the MAGIC trial. Overall survival is superior to that found in the MAGIC trial.

Stent placement for esophageal strictures: an update

The use of stents for esophageal strictures has evolved rapidly over the past 10 years, from rigid plastic tubes to flexible self-expanding metal (SEMS), plastic (SEPS) and biodegradable stents. For the palliative treatment of malignant dysphagia both SEMS and SEPS effectively provide a rapid relief of dysphagia. SEMS are preferred over SEPS, as randomized controlled trials have shown more technical difficulties and late migration with plastic stents. Despite specific characteristics of recently developed stents, recurrent dysphagia due to food impaction, tumoral and nontumoral tissue overgrowth, or stent migration, remain a major challenge. The efficacy of stents with an antireflux valve for patients with distal esophageal cancer varies between different stent designs. Concurrent treatment with chemotherapy and/or radiotherapy seems to be safe and effective. In the future, it can be expected that removable stents will be used as a bridge to surgery to maintain luminal patency during neoadjuvant treatment. For benign strictures, new stent designs, such as fully covered SEMS and biodegradable stents, may potentially reduce complications during stent removal.

ALCAM (CD166) expression and serum levels are markers for poor survival of esophageal cancer patients

The expression of the activated leukocyte cell adhesion molecule (ALCAM and CD166) is increased in various types of cancer. We aimed to evaluate its role as a prognostic marker for esophageal cancer (EC). We retrospectively analyzed ALCAM expression in 299 primary lesions, 147 lymph node and 46 distant metastases from EC patients, on a tissue microarray using immunohistochemistry. Bone marrow samples from representative cancer patients (n = 16), taken before primary surgery, were stained by double-immunofluorescence for ALCAM and cytokeratins (CK). Blood serum samples from 236 cancer patients and 127 controls were analyzed for serum ALCAM (s-ALCAM) by ELISA. The immunohistochemical analysis showed increased ALCAM expression in the majority of lesions (primary tumor 71%, lymph node 76% and distant metastases 80%). ALCAM expression was not associated with histopathological parameters except for tumor grading (p = 0.015). ALCAM-positive patients had significantly worse recurrence-free and overall survival (OS; p = 0.002). Disseminated tumor cells (DTC) in bone marrow showed two phenotypes, ALCAM+/CK+ (36%) and ALCAM-/CK+ (64%). Multivariate analysis revealed that ALCAM expression and elevated s-ALCAM serum values are powerful prognostic variables for OS in patients with EC (hazard ratio [HR] 3.987, 95% confidence interval [95%CI] 1.906-8.340, p < 0.001 and HR 1.915, 95%CI 1.021-3.592, p = 0.043). The results of our study provide preliminary evidence for the potential clinical utility of ALCAM as a prognostic biomarker for EC, which might be a basis for future clinical application. In addition, ALCAM expression in a subset of DTC of the bone marrow indicates a potential function in the metastatic cascade of EC.

Prognostic implications of lymphadenectomy in esophageal cancer after neo-adjuvant therapy: a single center experience

INTRODUCTION

The objective of this study is to explore the prognostic implications of lymphadenectomy in esophageal cancer patients after neo-adjuvant therapy.

METHODS

Retrospective review of a prospectively maintained database identified esophageal cancer patients with locoregional disease who received neo-adjuvant therapy and surgery. Patients were grouped based on the number of nodes resected, pathological lymph node status, and percentage of positive nodes. Kaplan-Meier curves were used to analyze overall survival (OS) and disease-free survival (DFS). Log-rank test was used to compare survival between groups.

RESULTS

Eighty-four patients formed the study group. Patients with ≥ 18 nodes resected had a significantly longer median OS than those with <18 nodes resected (68.6 vs. 29.6 months; p = 0.014). Lymph node-negative patients had significantly longer median OS (51.4 vs. 27.4 months; p = 0.025) and DFS (45.3 vs. 12.9 months; p = 0.03) when compared to lymph node-positive patients. Patients with a percentage of positive nodes <0.25 had a significantly longer median OS (31.1 vs. 17.8 months; p = 0.015) and DFS (21.7 vs. 8.9 months; p = 0.021) than patients with ≥ 0.25% positive.

CONCLUSION

Extent of lymphadenectomy, percentage of positive nodes, and pathological lymph node status are significant prognostic markers in patients who undergo esophagectomy after neo-adjuvant therapy.

Local effectiveness and complications of neoadjuvant therapy in esophageal squamous cell carcinoma: radiotherapy versus chemoradiotherapy

OBJECTIVE

To evaluate tumor responses to neoadjuvant therapy, according to the histopathological findings of surgical specimens of patients operated and treated for squamous cell carcinoma of the middle third and distal esophagus.

METHODS

We conducted a retrospective nonrandomized study including 97 patients distributed as follows: Group I - 81 (83.5%) underwent neoadjuvant radiation therapy, and group II - 16 (16.5%) underwent neoadjuvant radiotherapy and chemotherapy. A third group of 26 patients undergoing esophagectomy alone was used for comparison of postoperative complications. The characteristics of each patient (age, gender and race), tumor site, staging, and histological evaluation of treatment modalities were reviewed and analyzed. Tumor response to neoadjuvant therapy was evaluated by histopathology of the specimen.

RESULTS

There was no statistically significant differences regarding race, gender, age, staging and postoperative complications in patients in the three groups. Patients undergoing radiotherapy and neoadjuvant chemotherapy showed more satisfactory tumor reduction, with improved local efficacy when compared to the group only submitted to neoadjuvant radiotherapy.

CONCLUSION

The study suggests that radiotherapy combined with chemotherapy was more efficient in reducing tumor site when compared to the group treated with radiotherapy. In addition, neoadjuvant therapy did not increase the postoperative complications when compared to patients undergoing surgery alone.

Neoadjuvant chemoradiotherapy for resectable oesophageal and gastro-oesophageal junction cancer--do we need another randomised trial?

AIMS

The optimal neoadjuvant therapy option for locally advanced oesophageal cancer remains elusive. Neoadjuvant chemoradiotherapy (CRT) is the preferred modality of choice in the USA. In contrast, neoadjuvant chemotherapy is commonly used in the UK. We provide a comprehensive overview of the available evidence for defining the ideal neoadjuvant treatment algorithm.

MATERIALS AND METHODS

The PubMed database combined with American Society of Clinical Oncology and American Society for Therapeutic Radiology and Oncology websites were searched online to identify randomised studies and published meta-analyses that have compared these modalities compared with surgery alone. In particular, we searched for randomised trials that may have directly compared outcomes after neoadjuvant CRT or chemotherapy.

RESULTS

We identified 17 published randomised studies of neoadjuvant CRT (n = 9) and chemotherapy (n = 8) compared with surgery alone and one prospective series that compared the above modalities against each other. Studies evaluating CRT have reported pathological complete response rates of 15-40% and no increase in postoperative mortality was observed, except in one study that used a hypofractionated radiation schedule. Two randomised studies showed significant survival benefit and the remaining (n = 7) were negative, but showed a trend towards improved survival. Furthermore, at least four meta-analyses have shown improved survival in favour of CRT extending up to an absolute benefit of 13% at 2 years. In comparison, five studies of neoadjuvant chemotherapy showed no survival difference and two of the remaining studies that showed significant benefit included gastric adenocarcinomas and used peri-operative chemotherapy. All the above studies have shown uniformly poor pathological complete response rates of less than 10 percent. Moreover, three meta-analyses were negative, but two showed up to 7% absolute survival benefit at 2 years in favour of chemotherapy. The trial comparing the above modalities showed a trend towards improved survival in favour of CRT, but closed early due to poor recruitment.

CONCLUSION

Data from the above studies are potentially conflicting and inconclusive for defining the optimal neoadjuvant treatment schedule. In our opinion, the above question can only be answered within the context of a randomised control trial. We have included a proposal for a trial design for direct comparison of these modalities.

Interleukin-2 -330T>G genetic polymorphism associates with prognosis following surgery for thoracic esophageal squamous cell cancer

BACKGROUND

Key molecules in the T helper (Th)1 and Th2 pathways underlie differential responses to the progression and surgical treatment of cancer. We investigated the relationship between Th1/Th2 cytokine polymorphism and prognosis in patients with thoracic esophageal squamous cell cancer.

MATERIALS AND METHODS

The study participants were 159 Japanese patients treated for thoracic esophageal squamous cell cancer with curative esophagectomy at Akita University Hospital. We determined the associations between prognosis following esophagectomy and genetic polymorphisms in Th1 cytokines (interleukin [IL]-2, Interferon-γ, IL-12β), and Th2 cytokines (IL-4, IL-10).

RESULTS

IL-2 -330T>G genetic polymorphism was significantly associated with prognosis after esophagectomy. Univariate and multivariate analyses using a Cox proportional hazards model revealed that patients carrying the IL-2 -330G/G genotype had a significantly poorer prognosis than those carrying the T/G or T/T genotype. However, IL-2 -330T>G polymorphism was not associated with preoperative serum IL-2 levels. Moreover, interferon-γ, IL-12β, IL-4, and IL-10 genetic polymorphisms were not associated with prognosis after esophagectomy for thoracic esophageal squamous cell cancer.

CONCLUSIONS

It is suggested that IL-2 -330T>G genetic polymorphism may be a predictive factor for prognosis in patients receiving esophagectomy for thoracic esophageal squamous cell cancer.

The value of epigenetic markers in esophageal cancer

Developing esophageal cancer is a multi-step process that begins with the accumulation of genetic and epigenetic alterations, and leads to the activation of oncogenes and the inactivation or loss of tumor suppressor genes (TSG). In addition to genetic alteration, epigenetic modifications, and in particular DNA methylation, are recognized as a common molecular alteration in human tumors. In esophageal cancer, aberrant methylation of promoter regions occurs not only in advanced cancer, but also in premalignant lesions. DNA methylation is related to survival time and sensitivity of chemoradiotherapy. This review is mainly focused on epigenetic changes in esophageal cancer and the value of early detection for patient prognosis, treatment choices, and potential targeting therapy.