Postoperative Adjuvant Therapy Versus Surgery Alone for Stage IIB-III Esophageal Squamous Cell Carcinoma: A Phase III Randomized Controlled Trial

In-Depth Analysis of the Necessity and Optimization Strategies for Adjuvant Radiotherapy Following Neoadjuvant Immunotherapy in the New Era of Esophageal Cancer Treatment

As immunotherapy rises to prominence in cancer treatment, the therapeutic approach to esophageal cancer is undergoing significant transformations. This review emphasizes the necessity and optimization pathways for adjuvant postoperative radiotherapy after neoadjuvant therapy in patients with esophageal cancer in the immunotherapy era. Initially, we review the advancements in neoadjuvant treatment strategies. Subsequently, we evaluate the role of postoperative radiotherapy and the latest advancements in radiotherapy target volume definition and dose optimization following neoadjuvant therapy, as well as the implications of tumor immunotherapy on postoperative radiotherapy strategies. In conclusion, in the new era of immunotherapy, postoperative radiotherapy following neoadjuvant therapy for esophageal cancer holds significant value. Optimization strategies should follow individualized treatment principles and comprehensively consider tumor biology, patient status, and treatment resources to achieve optimal therapeutic outcomes and quality of life, thereby driving continuous innovation in esophageal cancer treatment.

A dynamic nomogram for predicting abdominal lymph node recurrence in patients with esophageal carcinoma

Patients with middle and lower thoracic esophageal carcinoma (TEC) after surgery are prone to develop abdominal lymph node recurrence (LNR). However, questions remain regarding the indications for postoperative abdominal radiotherapy. We aimed to identify the risk factors for abdominal LNR and to develop a dynamic nomogram for predicting abdominal LNR. We reviewed 1004 patients with middle and lower TEC treated with three-field lymph node dissection between January 2010 and December 2020 at two clinical centers. Risk factors for abdominal LNR were identified using least absolute shrinkage and selection operator (LASSO) logistic regression analysis. A dynamic nomogram was then developed. Performance was evaluated using receiver operating characteristic (ROC) curve , calibration curve and decision curve analysis. The rates of abdominal LNR in the training, internal test and external test cohorts were 25.91%, 23.40% and 23.98%, respectively. A dynamic nomogram was developed to predict the abdominal LNR in patients with middle and lower TEC. The main predictors included tumor location, pathologic N stage and number of preoperative abdominal LNM. The AUC of the training, internal test, and external test cohorts were 0.767 (95%CI 0.7263-0.8079), 0.763 (95%CI 0.7002-0.8258) and 0.802 (95%CI 0.7419-0.8629), respectively. Furthermore, The calibration curves and DCA analysis indicated a favorable fit and significant clinical applicability of the nomogram. The dynamic nomograms is available at https://prediction-of-abdiminal-lymph-node-metastasis-in-tec.shinyapps.io/DynNomapp/ . Tumor location, pathologic N stage and number of preoperative abdominal LNM were identified as risk factors for predicting abdominal LNR. The online dynamic nomograms showed good prediction performance and convenient clinical application, which may help clinicians identify patients who require adjuvant abdominal radiotherapy.

Executive Summary of the American Radium Society Appropriate Use Criteria for Management of Squamous Cell Carcinoma of the Cervical Esophagus: Systematic Review and Guidelines

OBJECTIVES

Cervical esophageal cancer (CEC) is an uncommon malignancy accounting for <5% of all esophageal carcinomas. Treatment of CEC varies and is adapted from established regimens used for squamous cell carcinoma (SCC) or the lower esophageal and head and neck. The present systematic review and guidelines are intended to assist treatment decision making for patients with CEC based on the available evidence.

METHODS

Using the Population, Intervention, Comparator, Outcome, Timing, and Study Design (PICOTS) framework, the evidence regarding treatment outcomes was assessed using Cochrane and PRISMA 2020 methodology. Eligible studies included prospective Phase II to III trials and retrospective analyses published between January 1, 2013 and February 23, 2024 in the Ovid Medline database. These references were assessed through the American Radium Society (ARS) Appropriate Use Criteria (AUC) methodology. A systematic review PRISMA 2020 checklist confirmed the completion of essential elements. RAND-UCLA consensus methodology was used by the expert panel to rate the appropriateness of the treatment options.

RESULTS

ARS AUC recommendations include (1) larynx preservation using endoscopic resection (EMR or ESD) alone for the typical case with pT1a cN0 cM0 CEC, (2) definitive CRT for the typical case with cT1bN0M0 in patients who cannot undergo endoscopic resection, (3) larynx-preserving using definitive CRT (with or without induction chemotherapy) for the typical case with nonmetastatic locally advanced CEC (advanced T-stage tumors or involved lymph nodes), with surgery reserved for those patients with incomplete response or locoregional recurrence.

CONCLUSIONS

This ARS AUC summary provides guidelines for the management of SCC of the cervical esophagus provides based on available evidence. Topics that warrant further investigation include optimization of (1) patient selection; (2) multimodality therapies including chemotherapy, immunotherapy, and targeted agents; (3) radiation dose, schedule, and treatment volume; and (4) supportive care for patients with CEC. Ongoing trials continue to improve outcomes for patients with CEC.

Predictive and prognostic value of ACSL4 and GPX4 in patients with esophageal squamous cell carcinoma receiving post-operative radiotherapy

Background

Although multimodality treatment, including chemoradiotherapy and surgery has significantly improved the prognosis of patients with esophageal squamous cell carcinoma (ESCC), a valid predictor is crucial for individualized treatment. As acyl-CoA synthetase long-chain family member 4 (ACSL4) and glutathione peroxidase 4 (GPX4) are key genes with radiation responses and constituents of the ferroptosis signaling pathway, the present study adopted ACSL4 and GPX4 protein expression to explore their predictive and prognostic value in patients with ESCC receiving adjuvant radiotherapy.

Methods

A total of 108 patients with thoracic ESCC who had undergone radical surgery and adjuvant radiotherapy were enrolled in the present retrospectively study. ACSL4 and GPX4 immunohistochemistry experiments were performed on paraffin-embedded tumor samples. The prognostic value of ACSL4 and GPX4 was examined using survival analysis, and the predictive value of ACSL4 and GPX4 for long-term survival was examined using univariate and multivariate Cox regression analyses, and verified by receiver operating characteristic (ROC) analysis.

Results

The survival analysis revealed that overall survival (OS) and disease-free survival (DFS) were significantly longer in the high ACSL4 expression group, and the DFS was significantly shorter in the high GPX4 expression group. The results of univariate and multivariate Cox regression analyses revealed that the ACSL4 expression level was an independent predictor for OS and DFS, and that the GPX4 expression level was an independent predictor for DFS. ROC analysis verified the predictive role of ACSL4 expression for DFS and OS, with an area under the curve (AUC) of 0.713 and 0.663.

Conclusions

The present study demonstrates that ACSL4 and GPX4 may serve as valuable prognostic biomarkers for long-term survival, and play a key translational role in individualized therapy for patients with ESCC.

Preoperative inflammatory burden index for prognostication in esophageal squamous cell carcinoma undergoing radical resection

BACKGROUND

The Inflammatory burden Index (IBI) is an effective predictor for a range of malignancies. However, the significance of IBI in esophageal squamous cell carcinoma (ESCC) needs to be further verified. The aim of this study was to verify the predictive power of IBI in ESCC undergoing radical resection.

METHODS

The current retrospective study, which comprised 408 ESCC patients randomized into either the primary or validation cohort, evaluated the relationships between IBI, clinical characteristics, and cancer-specific survival (CSS). Additionally, the nomogram model was also constructed and verified.

RESULTS

The IBI is significantly related to tumor length, vessel invasion, perineural invasion, and TNM stage. Compared to other hematological indices, the decision curve analyses (DCA) and receiver operating characteristic curve (ROC) confirmed the higher prognostic value of IBI, indicating the better clinical applicability. In patients with high IBI compared to the low IBI cohort, the 5-year CSS was considerably worse (total: 27.0% vs. 59.1%, P < 0.001; primary: 25.0% vs. 58.9%, P < 0.001; validation: 31.7% vs. 59.7%, P = 0.002). The IBI was shown to be an independent parameter by multivariate analyses (primary: HR = 2.352, P < 0.001; validation: HR = 1.683, P = 0.045). Finally, with the C-index of 0.675 (0.656-0.695) in the primary set and 0.662 (0.630-0.694) in the validation set for CSS in ESCC, an IBI-based nomogram was created and validated.

CONCLUSION

The predictive significance of IBI in ESCC patients undergoing radical resection was validated by this investigation. IBI may be utilized for preoperative evaluation of ESCC as it was found to be substantially correlated with prognosis.

DEAD-box helicase family proteins: emerging targets in digestive system cancers and advances in targeted drug development

Cancer has become one of the major diseases threatening human health in the twenty-first century due to its incurability. In 2022, new cases of esophageal and gastrointestinal cancers accounted for 17.1% of all newly diagnosed cancer cases worldwide. Despite significant improvements in early cancer screening, clinical diagnostics, and treatments in recent years, the overall prognosis of digestive system cancer patients remains poor. The DEAD-box helicase family, a crucial member of the RNA helicase family, participates in almost every aspect of RNA metabolism, including transcription, splicing, translation, and degradation, and plays a key role in the occurrence and progression of various cancers. This article aims to summarize and discuss the role and potential clinical applications of DEAD-box helicase family proteins in digestive system cancers. The discussion includes the latest progress in the occurrence, development, and treatment of esophageal and gastrointestinal tumors; the main functions of DEAD-box helicase family proteins; their roles in digestive system cancers, including their relationships with clinical factors; effects on cancer proliferation, migration, and invasion; and involved signaling pathways; as well as the existing inhibitory strategies targeting DDX family proteins, are discussed. Additionally, outlooks on future research directions are provided.

Evaluation of the robustness of randomized controlled trials for the treatment modalities of esophageal cancer using the fragility index - a systematic review

BACKGROUND

Esophageal cancer remains a significant global health challenge. Several treatment modalities were explored in randomized controlled trials (RCTs) in recent decades. This study evaluates the robustness of RCTs focusing on esophageal cancer treatment using the fragility index (FI) and reverse fragility index (RFI).

METHODS

A systematic review of RCTs studying different treatment modalities for esophageal cancer from 2000 to 2023 was conducted. The FI and RFI were utilized to gauge the robustness of statistically significant and non-significant outcomes, respectively. The FI represents the minimal number of patient outcomes that would need to alter to overturn a trial's statistical significance, while RFI indicates the minimal changes required to achieve significance in non-significant results.

RESULTS

Out of 4028 studies retrieved, 21 RCTs were included for final analysis. The studies spanned 2001 to 2023 with a mean followup of 66 months (range, 29-108 months) and median number of patients of 194 (range, 45-802). The most common treatment modalities examined in these studies were neoadjuvant chemoradiotherapy (n = 7, 33.3%), neoadjuvant chemotherapy (n = 4, 19.0%), and neoadjuvant immunotherapy (n = 2, 9.5%). Only 5 studies (23.8%) had a statistically significant primary outcome result with a median FI of 6 (IQR, 2.5-8.5). Non-significant primary outcomes were seen in 16 studies (76.2%) with a median RFI of 4 (IQR 1-11) and lost to followup of 0 (IQR 0-4). In the study with the highest FI (10), the FI was lower than the number of patients lost to followup (13).

CONCLUSION

Our findings demonstrate that most RCTs on esophageal cancer treatments did not report significant primary outcomes. The few studies that reported significant results had a low fragility index, suggesting a vulnerability in their findings.

Postoperative tumor bed radiation versus T-shaped field radiation in the treatment of locally advanced thoracic esophageal squamous cell carcinoma: a phase IIb multicenter randomized controlled trial

BACKGROUND

Postoperative radiotherapy (PORT) is crucial for patients with thoracic locally advanced esophageal squamous cell carcinoma (LA-ESCC, pT3-4aN0-3M0) following esophagectomy. However, the appropriate radiation volume has not been well established. This study aimed to determine the optimal PORT volume for LA-ESCC patients.

METHODS

LA-ESCC patients post-esophagectomy were randomly assigned to either the large-field irradiation (LFI, primary lesion and lymph node tumor bed plus elective nodal irradiation) group or the small-field irradiation (SFI, primary lesion and lymph node tumor bed alone) group. Stratification was based on T stage and the number of lymph node metastases. The primary endpoint was disease-free survival (DFS), while the secondary endpoints included overall survival (OS), adverse events, and patterns of initial failure.

RESULTS

A total of 401 patients were randomly assigned to the intention-to-treat analysis(LFI group, n = 210; SFI group, n = 191). The median DFS of patients in the LFI group was 47.9 months and 48.1 months in the SFI group (HR = 0.87, 95%CI, 0.65 to 1.16; p = 0.32). The estimated one-year and three-year OS rates were 89.2% and 63.2% for patients in the LFI group, compared to 86.6% and 60.7% for the SFI group, respectively. The difference of OS between the two groups was not significant (HR = 0.86, 95%CI, 0.63 to 1.16; p = 0.35). Fewer patients in the LFI group experienced locoregional recurrence compared to the SFI group (12.9% vs 20.4%, p = 0.013). Additionally, locoregional recurrence-free survival of the LFI group was significantly longer than that of SFI group (HR = 0.54, 95%CI, 0.34-0.87; p = 0.01). The most common toxicity was grade 2 esophagitis, observed in 22.9% of the LFI group and 16.8% of the SFI group. Grade 3 adverse events occurred in 6.7% of the LFI group and 2.6% of the SFI group. No grade 4 or 5 toxicities were observed. Adverse events did not significantly differ between the two groups.

CONCLUSIONS

Postoperative radiotherapy, with the specified radiation volume shows encouraging survival outcomes that are comparable to those of neoadjuvant chemoradiotherapy in patients with thoracic LA-ESCC. Both postoperative irradiation fields were found to be feasible and safe.

A propensity score-matched analysis to evaluate the benefit of adjuvant therapy on disease recurrence of esophageal squamous cell carcinoma after R0 esophagectomy

Background

Esophageal squamous cell carcinoma (ESCC) is common in China and has a poor prognosis despite radical surgery. Guidelines around the use of adjuvant therapy (AT) in ESCC are indecisive. We assessed the benefit of AT on recurrence-free survival (RFS) in Chinese patients with ESCC using propensity score (PS) matching.

Methods

This retrospective cohort study used hospital electronic medical records (EMRs) of 523 adults diagnosed between 2013 to 2019 with pathologically confirmed ESCC after R0 esophagectomy without neoadjuvant therapy. PSs were calculated using a generalized linear regression model based on demographic, clinical, and pathologic features. Patients with and without AT were matched using nearest neighbor method and caliper value 0.05. Subgroup analyses were stratified by PS.

Results

Younger patients with more advanced/poorly differentiated disease were more likely to receive AT (P<0.05). There were 137 matched pairs in the AT/No AT groups. After matching, the AT group tended to have longer median RFS [95% confidence interval (CI): 2.21 years (1.54-3.20)] than the No AT group [1.75 years (1.37-2.21)] (P=0.18). The benefit was significant in patients with PS ≥0.40 [hazard ratio 0.55, 95% CI: 0.32-0.87, median RFS (95% CI): 2.22 years (1.30-3.52) versus 1.23 years (0.90-1.64), P=0.03]. In other PS subgroups, median RFS was similar in AT and No AT groups.

Conclusions

After adjusting for baseline characteristics, AT tended to improve RFS after R0 esophagectomy in Chinese patients, with significant benefit associated with a higher PS score. The utility of PS to guide patient selection for AT in clinical practice needs further investigation.

Survival risk stratification based on prognosis nomogram to identify patients with esophageal squamous cell carcinoma who may benefit from postoperative adjuvant therapy

OBJECTIVE

The purpose of the study is to develop a prognosis nomogram for esophageal squamous cell carcinoma (ESCC) patients with radical resection and to identify patients who may benefit from postoperative adjuvant radiotherapy/chemoradiotherapy through survival risk stratification.

METHODS

We retrospectively enrolled patients who underwent esophagectomy in the First Affiliated Hospital of Nanjing Medical University from July 2015 to June 2017. Patients with stage I-III esophageal squamous cell carcinoma who received radical R0 resection with or without postoperative adjuvant radiotherapy/chemoradiotherapy were included. Further, patients were randomly allocated into two groups (training and validation cohorts) with a distribution ratio of 7:3. The prognosis nomogram was constructed based on independent factors determined by univariate and multivariate Cox analyses. The area under the receiver operating characteristic curve (AUC) and calibration curve were adopted to evaluate the discriminative ability and reliability of the nomogram. The accuracy and clinical practicability were respectively assessed by C-index values and decision curve analysis (DCA), and further contrasted the nomogram model and the eighth edition of the American Joint Committee on Cancer (AJCC) TNM staging system. In addition, survival risk stratification was further performed according to the nomogram, and the effect of postoperative adjuvant therapy on each risk group was appraised by the Kaplan-Meier survival analysis.

RESULTS

A total of 399 patients with esophageal squamous cell carcinoma were recruited in this study, including the training cohort (n = 280) and the validation cohort (n = 119). The nomogram-related AUC values ​​for 1, 3, and 5-year OS were 0.900, 0.795, and 0.802, respectively, and 0.800, 0.865, 0.829 in the validation cohort, respectively. The slope of the calibration curve for both cohorts was close to 1, indicating good consistency. The C-index value of the nomogram was 0.769, which was higher than that of the AJCC 8th TNM staging system by 0.061 (p < 0.001). Based on the prognosis nomogram, patients were stratified into three risk groups (low, medium, and high), and there were obvious differences in prognosis among the groups (p < 0.001). Furthermore, postoperative adjuvant therapy has been shown to enhance the 5-year survival rate by over 15% among patients classified as medium- and high-risk.

CONCLUSION

The constructed nomogram as developed resulted in accurate and effective prediction performance in survival outcomes for patients with stage I-III esophageal squamous cell carcinoma who underwent radical R0 resection, which is superior to the AJCC 8th TNM staging system. The survival risk stratification had potential clinical application to guide further personalized adjuvant therapy.

Propensity-matched study on locally advanced esophageal cancer: surgery versus post-operative radiotherapy

BACKGROUND

This study aims to delineate the long-term outcomes and recurrence patterns of locally advanced thoracic esophageal squamous cell carcinoma (TESCC) patients managed with or without postoperative radiotherapy (PORT).

METHODS

A retrospective cohort from two academic centers, encompassing patients who initially underwent esophagectomy and were pathologically staged T3-4, was analyzed. Survival outcomes were constructed using Kaplan-Meier method, with survival significance was evaluated using the log-rank test. Propensity score matching (PSM) was utilized to balance potential selection bias.

RESULTS

Among the 506 patients, 251 underwent surgery alone and 255 received radiotherapy following radical surgery. With a median follow-up of 49.1 months, PORT significantly improved 5-year overall survival (53.8% vs. 25.3%; p < 0.001) and 5-year disease-free survival rates (45.3% vs. 8.5%; p < 0.001) compared to surgery alone. These differences in survival outcomes persisted even after PSM (p < 0.001 for both). Treatment failure was significantly less frequent in the PORT group (46.7%) compared to the surgery-only group (90.0%; p < 0.001), with corresponding reductions in locoregional recurrence (9.4% vs. 54.1%; p < 0.001). This underscores the significant association between PORT and disease control.

CONCLUSION

The absence of neoadjuvant chemoradiotherapy highlights the importance of PORT in improving survival and reducing recurrence in advanced T3-4 TESCC patients. This study underscores the importance of PORT as a salvage treatment for locally advanced TESCC patients without neoadjuvant chemoradiotherapy.

Vasculogenic mimicry triggers early recidivation and resistance to adjuvant therapy in esophageal cancer

OBJECTIVE

To investigate the impact of vasculogenic mimicry (VM) and postoperative adjuvant therapy on the prognosis and survival of patients with esophageal squamous cell carcinoma (ESCC), as well as to assess whether VM affects the clinical benefit of postoperative adjuvant therapy.

METHODS

This single-center retrospective analysis included patients who underwent radical surgery for ESCC, which was documented in the medical record system. The presence or absence of VM in surgical specimens was determined using double staining with PAS/CD31. Stratification was applied based on adjuvant therapy and VM status. Survival curves and COX modeling were used to analyze the impact of the presence or absence of VM on the benefit of adjuvant therapy and the survival prognosis of patients.

RESULTS

VM-positive patients were more prone to postoperative recurrence and metastasis. VM was identified as an independent risk factor for progression-free survival (PFS) (p < 0.001, 95% CI:1.809-3.852) and overall survival (OS) (p < 0.001, 95% CI:1.603-2.786) in postoperative ESCC. Postoperative adjuvant therapy significantly prolonged PFS (p = 0.008) and OS time (p < 0.001) in patients with stage II and III ESCC, with concurrent chemoradiotherapy being the most effective. However, the presence of VM significantly reduced the benefits of postoperative adjuvant therapy (p < 0.001).

CONCLUSION

VM negatively impacts the prognosis of postoperative ESCC patients and reduces the efficacy of postoperative adjuvant therapy.

PET/CT deep learning prognosis for treatment decision support in esophageal squamous cell carcinoma

OBJECTIVES

The clinical decision-making regarding choosing surgery alone (SA) or surgery followed by postoperative adjuvant chemotherapy (SPOCT) in esophageal squamous cell carcinoma (ESCC) remains controversial. We aim to propose a pre-therapy PET/CT image-based deep learning approach to improve the survival benefit and clinical management of ESCC patients.

METHODS

This retrospective multicenter study included 837 ESCC patients from three institutions. Prognostic biomarkers integrating six networks were developed to build an ESCC prognosis (ESCCPro) model and predict the survival probability of ESCC patients treated with SA and SPOCT. Patients who did not undergo surgical resection were in a control group. Overall survival (OS) was the primary end-point event. The expected improvement in survival prognosis with the application of ESCCPro to assign treatment protocols was estimated by comparing the survival of patients in each subgroup. Seven clinicians with varying experience evaluated how ESCCPro performed in assisting clinical decision-making.

RESULTS

In this retrospective multicenter study, patients receiving SA had a median OS 9.2 months longer than controls. No significant differences in survival were found between SA patients with predicted poor outcomes and the controls (p > 0.05). It was estimated that if ESCCPro was used to determine SA and SPOCT eligibility, the median OS in the ESCCPro-recommended SA group and SPOCT group would have been 15.3 months and 24.9 months longer, respectively. In addition, ESCCPro also significantly improved prognosis accuracy, certainty, and the efficiency of clinical experts.

CONCLUSION

ESCCPro assistance improved the survival benefit of ESCC patients and the clinical decision-making among the two treatment approaches.

CRITICAL RELEVANCE STATEMENT

The ESCCPro model for treatment decision-making is promising to improve overall survival in ESCC patients undergoing surgical resection and patients undergoing surgery followed by postoperative adjuvant chemotherapy.

KEY POINTS

ESCC is associated with a poor prognosis and unclear ideal treatments. ESCCPro predicts the survival of patients with ESCC and the expected benefit from SA. ESCCPro improves clinicians' stratification of patients' prognoses.

Clinical significance of preoperative CALLY index for prognostication in patients with esophageal squamous cell carcinoma undergoing surgery

The C-reactive protein-albumin-lymphocyte (CALLY) index has been identified as a useful and sensitive predictive tool for stratification in cancers. This investigation aimed to validate the prognostic ability of CALLY in esophageal squamous cell carcinoma (ESCC). Clinical characteristics of 318 patients with ESCC who underwent radical excision were gathered and analyzed retrospectively. A restricted cubic spline (RCS) model was used to determine an ideal threshold of CALLY due to the non-linear relation. To investigate the predictors, Cox hazard regression analysis was used. The recursive partitioning analysis (RPA), a method of risk categorization, was also developed for prognostic prediction. The receiver operating characteristic (ROC) curves and decision curve analysis (DCA) curves were used to distinguish from the traditional TNM stage. Patients were compared by groups according to the optimal threshold of CALLY index, which was depicted by the non-linear relation between the cancer-specific survival (CSS) and CALLY index (P < 0.0001). Compared to those with high CALLY index, patients with low CALLY index experienced significantly worse 5-year CSS (21.8% vs. 62.6%, P < 0.001). At different TNM stages, patients with high CALLY index also had better 5-year CSS (I: P = 0.029; II: P < 0.001; III: P < 0.001) in subgroup analyses. The hazard ratio for CSS was 0.368 and CALLY index was an independent predictive factor (P < 0.001). Using TNM stage and CALLY-based RPA algorithms, a new staging was created. The RPA model considerably outperformed the TNM classification for prognostication using ROC (P < 0.001). The DCA also demonstrated that the new model outperformed the TNM stage with significantly improved accuracy for CSS. The prognostic value of CALLY in ESCC undergoing radical resection was initially determined in this study. CALLY was substantially related to prognosis and might be utilized in conjunction with TNM to evaluate ESCC prior to surgery.

Esophageal cancer - French intergroup clinical practice guidelines for diagnosis, treatments and follow-up (TNCD, SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, ACHBT, SFP, RENAPE, SNFCP, AFEF, SFR)

INTRODUCTION

This document is a summary of the French intergroup guidelines regarding the management of esophageal cancer (EC) published in July 2022, available on the website of the French Society of Gastroenterology (SNFGE) (www.tncd.org).

METHODS

This collaborative work was conducted under the auspices of several French medical and surgical societies involved in the management of EC. Recommendations were graded in three categories (A, B and C), according to the level of evidence found in the literature until April 2022.

RESULTS

EC diagnosis and staging evaluation are mainly based on patient's general condition assessment, endoscopy plus biopsies, TAP CT-scan and 18F FDG-PET. Surgery alone is recommended for early-stage EC, while locally advanced disease (N+ and/or T3-4) is treated with perioperative chemotherapy (FLOT) or preoperative chemoradiation (CROSS regimen) followed by immunotherapy for adenocarcinoma. Preoperative chemoradiation (CROSS regimen) followed by immunotherapy or definitive chemoradiation with the possibility of organ preservation are the two options for squamous cell carcinoma. Salvage surgery is recommended for incomplete response or recurrence after definitive chemoradiation and should be performed in an expert center. Treatment for metastatic disease is based on systemic therapy including chemotherapy, immunotherapy or combined targeted therapy according to biomarkers testing such as HER2 status, MMR status and PD-L1 expression.

CONCLUSION

These guidelines are intended to provide a personalised therapeutic strategy for daily clinical practice and are subject to ongoing optimization. Each individual case should be discussed by a multidisciplinary team.

Clinical utility of preoperative pan-immune-inflammation value (PIV) for prognostication in patients with esophageal squamous cell carcinoma

BACKGROUND

Several researches have shown that pan-immune-inflammation value (PIV) is related to cancer prognosis in recent years. In esophageal squamous cell carcinoma (ESCC), nevertheless, the prognostic impact of PIV remains unclear. The present study sought to investigate the prognostic impact of preoperative PIV in ESCC with radical resection.

METHODS

The data of 294 ESCC patients who received radical resection were retrospectively analyzed. Based on analyzing the non-linear relationship between PIV and cancer-specific survival (CSS), the optimal cutoff value for PIV was calculated by the restricted cubic spline (RCS) model. Cox proportional hazards regression was carried out to identify the prognostic factors. A risk stratification model was established by recursive partitioning analysis (RPA). The performance of the RPA-based model was assessed by the decision curve analysis (DCA) and receiver operating characteristic (ROC).

RESULTS

The RCS visualized the non-linear relationship between PIV and CSS (P < 0.0001). Then patients were then divided into high and low groups based on the optimal threshold of 308.2. The 5-year CSS (17.7 % vs. 48.3 %, P < 0.001) was significantly worse in patients with high PIV than those in the low group. Subgroup analyses confirmed that patients with low PIV also achieved better 5-year survival at different pathological tumor node metastasis (pTNM) stages (pTNM I: P = 0.022; pTNM II: P = 0.001; pTNM III: P = 0.011). PIV served as an independent prognostic factor of CSS (hazard ratio = 1.983, P < 0.001). A new staging involving three risk groups with significantly different CSS was developed using RPA algorithms based on pTNM and PIV. Compared with the pTNM classification, the RPA-based model exhibited significantly superior performance for prognostication.

CONCLUSION

The present study confirmed the prognostic impact of PIV in ESCC who treated with radical resection. PIV was associated with the tumor stage and prognosis, which might be useful in the preoperative assessment of ESCC.

Lymph node ratio precisely predicts the benefit of postoperative radiotherapy in esophageal cancer: A retrospective cohort study

BACKGROUND

The matter of postoperative radiotherapy (PORT) in esophageal cancer (ESCA) was far from conclusive. Some evidence indicated that lymph node status could affect treatment. We evaluated lymph node ratio (LNR) as an indicator that could be applied to predict PORT benefit.

METHODS

Retrospective cohort study collected the data of N1, N2, N3 stage ESCA patients from the Surveillance, Epidemiology, and End Results database (SEER) to analyze the association between LNR and prognosis from 2004 to 2015. Patients were categorized into two subsets based on the LNR cut-off value of 0.23 using receiver operating characteristic curve (ROC). Kaplan-Meier analysis was utilized to estimate the proportion of overall survival (OS) and esophagus cancer-specific survival (CSS) in two LNR groups. Cox regression analysis and competitive risk model was adopted to investigate the impacts of LNR on prognosis.

RESULTS

Of 2,165 ESCA patients identified, 1,165 (53.8%) had LNR>0.23. The LNR was an independent prognostic factor and associated with better OS and CSS of LNR≤0.23 (P < 0.001). In competitive risk model, a worse CSS was analyzed of LNR>0.23 (HR = 1.71; 95% CI 1.53-1.91). Subgroup analyses indicated that PORT was associated with favorable OS and CSS. Furthermore, when stratified by Node stage, PORT was associated with a survival benefit only in N1 stage with higher LNR (LNR>0.23) after adjusting for other covariates.

CONCLUSIONS

LNR exceeding 0.23 was negatively associated with prognosis in ESCA. The survival benefit from PORT in ESCA seems to be limited to LNR of 23% or more only in N1 stage. This study highlights the biomarker meaning of LNR on identifying PORT beneficiary in N1 stage.

Esophageal cancer in China: Practice and research in the new era

China, as the one of the largest developing countries in the world and with about one-fifth of the global population, is bearing an increasing burden on health from cancer. In the area of esophageal cancer (EC), China accounts for more than 50% of the global cases, with this disease being a particularly worse for those in disadvantaged populations. Along with China's socioeconomic condition, the epidemiology, diagnosis, therapeutics and research of EC have developed throughout the 21st century. In the current review, existing control measures for EC in China are outlined, including the incidence, mortality, screening, clinical diagnosis, multidisciplinary treatment and research landscape. EC in China are very different from those in some other parts of the world, especially in Western countries. Core measures that could contribute to the prevention of EC and improve clinical outcomes in patients of less developed countries and beyond are recommended. International cooperation among academia, government and industry is especially warranted in global EC control.

Prognostic significance and postoperative chemoradiotherapy guiding value of mean platelet volume for locally advanced esophageal squamous cell carcinoma patients

Objective

To investigate the predicting prognosis and guiding postoperative chemoradiotherapy (POCRT) value of preoperative mean platelet volume (MPV) in patients with locally advanced esophageal squamous cell carcinoma (LA-ESCC).

Methods

We proposed a blood biomarker, MPV, for predicting disease-free survival (DFS) and overall survival (OS) in LA-ESCC patients who underwent surgery (S) alone or S+POCRT. The median cut-off value of MPV was 11.4 fl. We further evaluated whether MPV could guide POCRT in the study and external validation groups. We used multivariable Cox proportional hazard regression analysis, Kaplan-Meier curves, and log-rank tests to ensure the robustness of our findings.

Results

In the developed group, a total of 879 patients were included. MVP was associated with OS and DFS defined by clinicopathological variables and remained an independent prognostic factor in the multivariate analysis (P = 0.001 and P = 0.002, respectively). For patients with high MVP, 5-year OS and 0DFS were significantly improved compared to those with low MPV (P = 0.0011 and P = 0.0018, respectively). Subgroup analysis revealed that POCRT was associated with improved 5-year OS and DFS compared with S alone in the low-MVP group (P < 0.0001 and P = 0.0002, respectively). External validation group analysis (n = 118) showed that POCRT significantly increased 5-year OS and DFS (P = 0.0035 and P = 0.0062, respectively) in patients with low MPV. For patients with high MPV, POCRT group showed similar survival rates compared with S alone in the developed and validation groups.

Conclusions

MPV as a novel biomarker may serve as an independent prognosis factor and contribute to identifying patients most likely to benefit from POCRT for LA-ESCC.

Esophageal Cancer: Whether and What Before or After Surgery?

Esophageal cancer is the eighth most common cancer and the sixth most common cause of cancer-related mortality worldwide. Surgery has been the mainstay of the treatment of esophageal cancer. However, given the dismal survival with surgery alone, other modalities, e.g., chemotherapy (CT) and radiotherapy (RT), have been used for the management of these cancers. This review aims to look at the evolution of multi-modality management of esophageal cancer and tries to answer certain questions pertaining to the management of these cancers.

Effect of Adjuvant Radiation Dose on Survival in Patients with Esophageal Squamous Cell Carcinoma

Background: For patients with esophageal squamous cell carcinoma (ESCC) treated with surgery alone, the incidence of local-regional recurrence remains unfavorable. Postoperative radiotherapy (PORT) has been associated with increased local-regional recurrence-free survival (LRFS), although its application is limited by concerns of PORT-related toxicities. Methods: Among 3591 patients with ESCC analyzed in this study, 2765 patients with T3-4N0 and T1-4N1-3 lesions and specific local-regional status information were analyzed in a subsequent analysis of adjuvant radiation dose (aRTD) effect. Application of the restricted cubic spline regression model revealed a non-linear relationship between aRTD and survival/radiotoxicity. Linear regression analysis (LRA) was performed to evaluate correlations between LRFS and overall survival (OS)/ disease-free survival (DFS). Results: For patients staged T1−2N0, T1−2N1−3, T3−4N0, and T3−4N1−3, 5-year OS in PORT and non-PORT groups were 77.38% vs. 72.91%, p = 0.919, 52.35% vs. 46.60%, p = 0.032, 73.41% vs. 61.19%, p = 0.005 and 38.30% vs. 25.97%, p < 0.001. With aRTD escalation, hazard ratios (HRs) of OS/DFS declined until aRTD exceeded 50Gy, then increased, whereas that of LRFS declined until aRTD exceeded 50 Gy, then remained steady. HR of treatment-related mortality was stable until aRTD exceeded 50 Gy, then increased. LRA revealed strong correlations between LRFS and OS/DFS (r = 0.984 and r = 0.952, respectively). An absolute 1% advancement in LRFS resulted in 0.32% and 0.34% improvements in OS and DFS. Conclusions: An aRTD of 50Gy was well-tolerated, with favorable survival resulting from PORT-related LRFS improvement in patients staged T3−4N0 or T1-4N1−3. Further stratification analyses based on tumor burden would help determine potential PORT-beneficiaries.

Nomogram-Based Survival Predictions and Treatment Recommendations for Locally Advanced Esophageal Squamous Cell Carcinoma Treated with Upfront Surgery

Background and purpose: The aim of this study is to develop a prognostic nomogram, quantify survival benefit, and guide risk-dependent adjuvant therapy for locally advanced esophageal squamous cell carcinoma (LA-ESCC) after esophagectomy. Materials and methods: This was a single-center, retrospective study of consecutive LA-ESCCs treated by curative-intent esophagectomy with internal validation and independent external validation in a randomized controlled trial. After factor selection by the least absolute shrinkage and selection operator regression, a nomogram was developed to estimate 5-year overall survival (OS) based on the Cox proportional hazards model. The area under the curve (AUC) and calibration plot were used to determine its discriminative and predictive capacities, respectively. Survival improvement from adjuvant therapy was quantified and plotted corresponding to nomogram score. Results: A total of 1077, 718, and 118 patients were included for model development, internal validation, and external validation, respectively. The nomogram identified eight significant prognostic factors: gender, pathological T and N stages, differentiation, surgical margin, lymphovascular invasion, number of lymph node resection, and adjuvant therapy. The nomogram showed superior discriminative capacity than TNM stage (AUC: 0.76 vs. 0.72, p < 0.01), with significant survival differences among different risk stratifications. The calibration plot illustrated a good agreement between nomogram-predicated and actual 5-year OS. Consistent results were concluded after external validation. At least 10% 5-year OS improvement from adjuvant chemoradiotherapy and chemotherapy was expected in almost all patients (nomogram score 110 to 260) and patients mainly with high-intermediate risk (nomogram score 159 to 207), respectively. Conclusions: The clinicopathological nomogram predicting 5-year OS for LA-ESCC after esophagectomy was developed with high accuracy. The proposed nomogram showed better performance than TNM stage and provided risk-dependent and individualized adjuvant treatment recommendations.

Genetic variant of ADH1C for predicting survival in esophageal squamous cell cancer patients who underwent postoperative radiotherapy

Background: Single nucleotide polymorphisms (SNPs) of essential enzymes for alcohol metabolism ADH1B, ADH1C, and ALDH2 are commonly regarded as genetic biomarkers for esophageal squamous cell carcinoma (ESCC) susceptibility. However, there have not been any reports on relations between SNPs of these genes and the prognosis of postoperative radiotherapy in ESCC. The current study aimed to understand the associations between gene variants of alcohol metabolism and adjuvant radiotherapy’s prognosis in ESCC.

Methods: This study retrospectively analyzed 110 ESCC patients from our institution who received adjuvant radiotherapy after surgery. The SNPs of ADH1B rs1229984, ADH1C rs1789924, and ALDH2 rs671 were detected by Sanger sequencing using formalin-fixed paraffin-embedded tumor samples. A nomogram was drawn based on prognostic factors associated with overall survival (OS).

Results: ADH1C rs1789924 (C&gt;T) was associated with poor DFS and OS in ESCC patients undergoing adjuvant radiotherapy. Multivariate analysis showed that ADH1C rs1789924 (C&gt;T) was one of the independent prognosis factors of DFS and OS. However, the genotypes of ADH1B SNP rs1229984 and ALDH2 rs671 were not associated with differences in the PFS and OS of these patients. Compared with the AJCC staging system, the nomogram containing the ADH1C genotype can more effectively and accurately predict the survival time of ESCC after surgery and adjuvant radiotherapy.

Conclusion: ADH1C rs1789924 might be a prognostic genetic biomarker for ESCC patients undergoing surgery and postoperative radiotherapy.

Severe radiation-induced lymphopenia during postoperative radiotherapy or chemoradiotherapy has poor prognosis in patients with stage IIB-III after radical esophagectomy: A post hoc analysis of a randomized controlled trial

Objective

To investigate whether radiation-induced lymphopenia (RIL) affects survival and identify the predictors of RIL in postoperative esophageal cancer.

Materials and methods

Post hoc analysis was conducted on data from 116 patients with esophageal cancer from a randomized controlled trial comparing adjuvant therapy with surgery alone. Doses of 54 Gy in 27 fractions was delivered in the postoperative radiotherapy (PORT) group and 50.4 Gy in 28 fractions combined with chemotherapy was delivered in postoperative concurrent chemoradiotherapy (POCRT) group. Blood counts were obtained before, during, and at first follow-up after treatment. Lymphopenia was graded per version 4.03 of the Common Terminology Criteria for Adverse Events. Disease-free survival (DFS) and overall survival (OS) were analyzed using the Kaplan-Meier method, and compared between groups using the log-rank test. Receiver operating characteristic curves identified thresholds for preventing grade 4 (G4) lymphopenia.

Results

Median follow-up duration was 56.0 months. During treatment, 16 patients (13.8%) had G4 lymphopenia. All cases of G4 lymphopenia occurred in group PORT (30.2% vs 0.0%, p<0.001). Baseline absolute lymphocyte count was comparable between G1-3 and G4 patients (2.0 ± 0.8 *10⁹/L vs 1.7 ± 0.5 *10⁹/L; p=0.101). The 3-year DFS was significantly lower in group G4 lymphopenia than that in group G1-3 (31.3% vs 57.6%, p=0.036). The 3-year OS was comparable between both groups (50.0% vs 66.5%, p=0.095). Logistic regression analysis revealed that exposed more thoracic marrow (TM V20 ≥75%; TVB V20 ≥71%), heart (V15 ≥40%) and PTV (volume ≥507 ml) were associated with G4 lymphopenia (p<0.05).

Conclusions

G4 RIL had poor disease-free survival, which may be related to more dose exposure of thoracic marrow and heart due to larger PTV. Reasonably reducing the radiation field combined with concurrent chemotherapy, or radiation dose constraints for these normal tissues may be sufficient to decrease the incidence of G4 lymphopenia, but further prospective trials are needed to verify the results.

Clinical Trial Registration

clinicaltrials.gov, identifier NCT02279134

Effectiveness evaluation of adjuvant concurrent chemoradiotherapy for patients with positron emission tomography-staged esophageal squamous cell carcinoma after complete resection: A population-based cohort study

Background

The role of adjuvant concurrent chemoradiotherapy (ACCRT) is unclear for patients with esophageal squamous cell carcinoma (ESCC) who receive esophagectomy with clean margins. We compared the survival of the ACCRT versus observation groups for these patients staged with positron emission tomography (PET) via a population‐based approach.

Methods

Eligible patients with locally advanced ESCC diagnosed between 2011 and 2017 were identified via the Taiwan Cancer Registry. We used propensity score (PS) weighting to balance observable potential confounders between groups. The hazard ratios (HR) of death and incidence of esophageal cancer mortality (IECM) were compared between the ACCRT and observation groups. We also evaluated overall survival (OS) in subgroups of either with or without lymph node metastases.

Results

Our primary analysis consisted of 105 patients in whom the covariates were well balanced after PS weighting. The HR for death when ACCRT was compared with observation was 0.58 (95% confidence interval 0.28–1.21, p = 0.15). The results were also not significantly different for IECM or in the subgroup analyses.

Conclusion

We found that for patients with PET‐staged ESCC who received esophagectomy with clean margins, the survival was not statistically different between ACCRT and observation. Further studies (randomized or larger sample size) are needed to clarify this issue.