Clinical staging of adenocarcinoma of the esophagogastric junction

Nomograms for Predicting Disease-Free Survival in Patients With Siewert Type II/III Adenocarcinoma of the Esophagogastric Junction Receiving Neoadjuvant Therapy and Radical Surgery

Objective

This study aimed to develop prognostic prediction models for patients with Siewert type II/III adenocarcinoma of the esophagogastric junction (AEG) who received neoadjuvant therapy (neoadjuvant chemoradiotherapy or neoadjuvant chemotherapy) and radical surgery. A baseline nomogram and a post-operative nomogram were constructed before neoadjuvant therapy and after surgery. The predictive performance of the constructed nomograms was internally validated and compared to the TNM staging system.

Materials and Methods

A total of 245 patients diagnosed with Siewert type II/III AEG and treated with neoadjuvant therapy followed by radical surgery at The Fourth Hospital of Hebei Medical University between January 2011 and December 2017 were enrolled. The variables before neoadjuvant therapy were defined as baseline factors, while the variables of baseline factors along with the variables of treatment and postoperative pathology were defined as post-operative factors. To construct the corresponding nomograms, independent predictors of baseline and post-operative factors were identified. The C-index and a time-dependent receiver operating characteristic curve were used to evaluate the model’s discrimination ability. The calibration ability of the model was determined by comparing the probability of predicted free-recurrence to the actual free-recurrence. Decision curve analysis (DCA) was used to determine the clinical usefulness of the nomogram.

Results

Among the baseline factors, age, cT stage, cN stage, Borrmann type, and staging laparoscopy were independent prognostic predictors. In contrast, among the post-operative factors, age, cN stage, staging laparoscopy, ypT stage, clinical response, number of positive lymph nodes, number of negative lymph nodes, laurén classification, and lymphatic, or perineural invasion (VELPI) were independent prognostic predictors. The two nomograms were constructed using the independent predictors of prognosis. The C-indexes for the baseline and post-operative nomograms were 0.690 (95% CI, 0.644-0.736) and 0.817 (95% CI, 0.782-0.853), respectively. The AUCs of the baseline nomogram at 3 and 5 years were both greater than cTNM (73.1 vs 58.8, 76.1 vs 55.7). Similarly, the AUCs of the post-operative nomogram were both greater than ypTNM (85.2 vs 69.1, 88.2 vs 71.3) at 3 and 5 years. The calibration curves indicated that both models had a high degree of calibration ability. By comparing the DCA at 3 and 5 years, we determined that the two nomograms constructed had better clinical utility than the TNM staging system.

Conclusions

The constructed nomograms have a more accurate predictive ability than the eighth edition TNM staging system, which can be useful for treatment selection and follow-up monitoring of patients.

Diagnostic tests for preoperative staging of esophagogastric junction tumors: performance and evidence-based recomendations

Preoperative clinical staging is critical to select those patients whose disease is localized and may benefit from surgery with curative intent. Ideally, such staging should predict tumor invasion, lymphatic involvement and distant metastases. With the cTNM, we are able to select patients who could benefit from endoscopic resection, radical surgery or less radical treatment in patients with distant metastasis. The initial diagnosis of adenocarcinomas of the esophagogastric junction requires endoscopy with biopsies. For clinical staging, thoracoabdominal-pelvic CT scan, endoscopic ultrasound and PET or PET/CT are used. Other useful explorations are: barium swallow, endoscopic mucosal resection or endoscopic submucosal dissection (for assessment in initial stages) and staging laparoscopy. Once the resectability of the tumor has been established, the operability of the tumor should be assessed according to the patient's condition.

CT findings in diagnosis of gastric bare area invasion: potential prognostic factors for proximal gastric carcinoma

PURPOSE

To investigate the correlation between the preoperative CT findings in diagnosis of gastric bare area (GBA) invasion and the 3-year-overall survival (OS) of patients with proximal gastric carcinoma (PGC).

METHODS

108 consecutive patients with PGC confirmed by biopsy underwent MDCT scan prior to gastrectomy were enrolled retrospectively from Dec 2009 to Dec 2014. GBA invasion in PGC were evaluated by measuring the direct CT signs including transmural involvement and lymph nodes in the GBA. The indirect signs were also evaluated including the infiltration of the diaphragm, gastrophrenic ligament and perigastric fat. Kaplan-Meier estimates with log-rank test and Cox proportional hazard model were used for analysis.

RESULTS

The two raters achieved excellent agreement. Univariate Kaplan-Meier estimates indicated that postoperative chemotherapy (p = 0.003), transmural involvement (p < 0.001), lymph nodes in the GBA (p = 0.015) and cT staging (p = 0.002) were associated with OS. Cox proportional hazard model indicated that the transmural involvement (HR = 8.194, 95% CI 2.15-31.266), diaphragm involvement (HR = 0.21, 95% CI 0.042-0.986), perigastric fat infiltration (HR = 0.125, 95% CI 0.018-0.885; HR = 0.02, 95% CI 0.001-0.264), and cT staging were independent prognostic factors for OS.

CONCLUSION

CT findings of GBA invasion in patients with PGC, not only the transmural involvement but also the indirect signs are independent prognostic factors potentially, which should be given more emphasis in future clinical practice.

CT/MRI accuracy in detecting and determining preoperative stage of gastric adenocarcinoma in Albania

AIM OF THE STUDY

Gastric adenocarcinoma is among most frequent among cancers in Albania. Early detection and staging is helped by imaging methods, including CT and MRI. This study provides evidence on the CT and MRI accuracy in detecting and pre-operative staging of gastric adenocarcinoma in 62 patients in a diagnostic clinic in Albania. The correct staging of the gastric adenocarcinoma helps decide on the next treatment options.

MATERIAL AND METHODS

Sixty-two patients with gastric adenocarcinoma, confirmed with biopsy, underwent both CT and MRI examination at a clinic in Tirana during same week. Images were reviewed to determine the TNM classifications and staging using the current AJCC guidelines. Data on age, sex, cancer location and differentiation were also collected and analyzed. The accuracy, sensitivity, specificity, positive predictive value and negative predictive value was estimated for both CT and MRI.

RESULTS AND CONCLUSIONS

CT has a higher accuracy than MRI (83% vs. 67%) for T1. Accuracy for T2 was the same (74%). Starting with T3 and upwards, MRI has a slightly more accurate ability to detect and stage the gastric adenocarcinoma (T3: 81 vs. 75; T4: 83 vs. 64). Both the CT and MRI abilities to accurately detect the N classification were the same. Regarding the M classification, the MRI has a slightly more accurate ability to detect metastases (M: 83 vs. 64). Clinicians might benefit from using CT whenever suspect gastric adenocarcinoma patients present first. Decision on surgery requires a MRI to rule out metastases.

FDG-PET/CT lymph node staging after neoadjuvant chemotherapy in patients with adenocarcinoma of the esophageal-gastric junction

Objectives

The aim of the analysis was to assess the accuracy of various FDG-PET/CT parameters in staging lymph nodes after neoadjuvant chemotherapy.

Methods

In this prospective study, 74 patients with adenocarcinoma of the esophageal–gastric junction were examined by FDG-PET/CT in the course of their neoadjuvant chemotherapy given before surgical treatment. Data from the final FDG-PET/CT examinations were compared with the histology from the surgical specimens (gold standard). The accuracy was calculated for four FDG-PET/CT parameters: (1) hypermetabolic nodes, (2) large nodes, (3) large-and-medium large nodes, and (4) hypermetabolic or large nodes.

Results

In 74 patients, a total of 1540 lymph nodes were obtained by surgery, and these were grouped into 287 regions according to topographic origin. Five hundred and two nodes were imaged by FDG-PET/CT and were grouped into these same regions for comparison. In the analysis, (1) hypermetabolic nodes, (2) large nodes, (3) large-and-medium large nodes, and (4) hypermetabolic or large nodes identified metastases in particular regions with sensitivities of 11.6%, 2.9%, 21.7%, and 13.0%, respectively; specificity was 98.6%, 94.5%, 74.8%, and 93.6%, respectively. The best accuracy of 77.7% reached the parameter of hypermetabolic nodes. Accuracy decreased to 62.0% when also smaller nodes (medium-large) were taken for the parameter of metastases.

Conclusions

FDG-PET/CT proved low sensitivity and high specificity. Low sensitivity was based on low detection rate (32.6%) when compared nodes imaged by FDG-PET/CT to nodes found by surgery, and in inability to detect micrometastases. Sensitivity increased when also medium-large LNs were taken for positive, but specificity and accuracy decreased.

Management of Locally Advanced Adenocarcinoma of the Esophagus and Gastroesophageal Junction: Finally a Consensus

Opinion statement: Adenocarcinoma of the esophagus is increasing in incidence in Western nations leading to increased interest in and opportunity to study optimal management. Randomized trials have now robustly demonstrated the preoperative therapy with chemoradiotherapy and chemotherapy alone improves survival outcome for the bulk of curable patients, those with locally advanced T1N1M0 and T2-3 N0-1 M0 disease. Evidence suggests but does not confirm that radiation-containing regimens are more beneficial. Clinical staging is designed to exclude patients with T1N0M0 disease who may be treated with surgery alone and those with metastatic disease who may not benefit from intensive local therapy. The approach to clinical staging includes endoscopy with ultrasound and fine needle aspirate to assess local and regional disease, supplemented by CT and PET scanning primarily to exclude metastatic disease. Minimally invasive approaches to esophagectomy may be used with the goal of reducing complications, but there is no evidence that mortality or ultimate outcome is improved.

Effect of sherbet timing on distension and evaluation of the esophagus with multidetector-row computed tomography

PURPOSE

The goal of this study was to analyze the effect of oral sherbet application on esophageal distension and esophageal evaluation with thoracic multidetector-row computed tomography (MDCT) regarding sherbet timing.

MATERIALS AND METHODS

A total 120 patients (65 men, 55 women) with a mean age of 59.7 years who were given 4g sherbet powder to be swallowed 60, 30 or 10seconds before thoracic MDCT were included. Inner esophageal diameter was measured in three planes at three anatomic levels. Area of esophageal lumen and assessable length of the esophagus were calculated and statistically analyzed using repeated-measures-ANOVA and post-hoc-t-tests. Results were compared groupwise and intra-individually with previous examinations without sherbet.

RESULTS

Intra-individual comparison and subgroup-analysis showed that esophageal distension was significantly better when sherbet was used (mean inner area: 1.98±0.66cm(2) vs. 0.49±0.14cm(2)) (P<0.001). After preparation, in average 80.2% of the esophageal length were assessable compared to 39.2% without sherbet (P<0.001). Timing of sherbet administration within one minute before scan-start revealed no significant differences (P=0.9), yet a shorter delay to scan-start led to the best results.

CONCLUSION

Oral sherbet administration within one minute before scan-start improves esophageal distension and evaluation using thoracic MDCT. This method of esophageal preparation is simple, can easily be applied in clinical routine and may improve the diagnosis of esophageal pathologies.

AKT expression is associated with degree of pathologic response in adenocarcinoma of the esophagus treated with neoadjuvant therapy

BACKGROUND

Neoadjuvant chemoradiation (NCRT) has become standard in the treatment of locally advanced esophageal adenocarcinoma (EAC) with survival correlated to degree of pathologic response. The phosphatidyl inositol 3 kinase (PI3K)/protein kinase B (AKT)/mTOR pathway plays an important role in tumorgenesis and resistance. We sought to elucidate the role of this pathway in patients with EAC who received NCRT.

METHODS

After IRB approval, a prospective trial was initiated in which patients with EAC underwent endoscopic biopsies of normal and tumor tissue prior to instituting NCRT. Patients then proceeded to esophagectomy. The pre-treatment tissues underwent gene expression profiling. SAM method was used to analyze expression of AKT within normal and tumor tissue. Expression was then correlated to degree of pathologic response.

RESULTS

One-hundred patients were consented for the study, of which 67 met final eligibility. Nineteen patient's tumors ultimately underwent gene expression profiling via microarray. The differential expression of all AKT isoforms in tumor tissue was markedly overexpressed compared to normal tissue (P=6×10(-5)). There were 3 patients designated as pNR, 6 as pPR, and 10 as pCR. Partial and non-responders had higher expressions of AKT compared to pCR with the non-responders consistently illustrated the highest expression of AKT (P=0.02). There was a significant correlation between individual isoforms of AKT-1, AKT-2, and AKT-3 and degree of pathologic response (P=0.002, 0.04, and 0.04 respectively).

CONCLUSIONS

AKT is overexpressed in patients with AC of the esophagus. Moreover, pathologic response to NCRT may be correlated with degree of AKT expression. Additional data is needed to clarify this relationship to potentially add targeted therapies to the neoadjuvant regimen.

Eastern Cooperative Oncology Group and American College of Radiology Imaging Network Randomized Phase 2 Trial of Neoadjuvant Preoperative Paclitaxel/Cisplatin/Radiation Therapy (RT) or Irinotecan/Cisplatin/RT in Esophageal Adenocarcinoma: Long-Term Outcome and Implications for Trial Design

PURPOSE

Toxicity, pathologic complete response, and long-term outcomes are reported for the neoadjuvant therapies assessed in a randomized phase 2 Eastern Cooperative Oncology Group and American College of Radiology Imaging Network trial for operable esophageal adenocarcinoma, staged as II-IVa by endoscopy/ultrasonography (EUS).

METHODS AND MATERIALS

A total of 86 eligible patients began treatment. For arm A, preoperative chemotherapy was cisplatin, 30 mg/m(2), and irinotecan, 50 mg/m(2), on day 1, 8, 22, 29 during 45 Gy radiation therapy (RT), 1.8 Gy per day over 5 weeks. Adjuvant therapy was cisplatin, 30 mg/m(2), and irinotecan, 65 mg/m(2) day 1, 8 every 21 days for 3 cycles. Arm B therapy was cisplatin, 30 mg/m(2), and paclitaxel, 50 mg/m(2), day 1, 8, 15, 22, 29 with RT, followed by adjuvant cisplatin, 75 mg/m(2), and paclitaxel, 175 mg/m(2), day 1 every 21 days for 3 cycles. Stratification included EUS stage and performance status.

RESULTS

In arm A, median overall survival was 35 months, and 5-, 6-, and 7-year survival rates were 46%, 39%, and 35%, respectively, whereas for arm B, they were 21 months and 27%, 27%, and 23%, respectively. Median progression- or recurrence-free survival (PFS) was 39.8 months with a 3-year PFS of 50% for arm A and 12.4 months (P=.046) with 3-year PFS of 28% for arm B. Eighty percent of the observed incidents of progression occurred within 19 months. Survival did not differ significantly by EUS and performance status strata.

CONCLUSIONS

Long-term survival was similar for both arms and did not appear superior to results achieved with other standard regimens.

Staging of adenocarcinoma of the gastroesophageal junction

BACKGROUND

Clinical staging of adenocarcinoma of the gastroesophageal junction (GEJ) determines the curative treatment regimen containing either neoadjuvant chemotherapy or chemoradiotherapy followed by either gastrectomy or esophagectomy. The value of current diagnostic tools is a matter of debate.

METHODS

A prospective database (2003-2013) was used to identify 266 consecutive patients with adenocarcinoma of the GEJ in order to evaluate the accuracy of endoscopic ultrasound (EUS) and computed tomography (CT) regarding tumor localization according to Siewert, nodal status and its consequences on treatment strategy.

RESULTS

Overall accuracy in determining tumor localization was 73% for endoscopy/EUS and 61% for CT (p = 0.018). With endoscopy/EUS, the accuracy was 97%, 66% and 75% respectively for type I, II and III. With CT this was respectively 69%, 57% and 80%. The overall accuracy for determining N-status (N0/N+) per patient was 75% for EUS and 71% for CT. Accuracy for determining a positive nodal station in patients without neoadjuvant therapy was 77% for EUS and 71% for CT (p = 0.001). Accuracy for detecting positive upper mediastinal nodes was 80-92%, whereas for peritumoral and abdominal nodes this was 50-80% in both EUS and CT. In 8/266 patients (3%) the type of surgery changed due to intraoperative findings. A radical resection was performed in 233 patients (88%).

CONCLUSIONS

Despite the suboptimal accuracy of determining tumor localization with EUS and CT, in only a small number of patients an intraoperative change of surgical treatment was needed. EUS is superior to CT in determining nodal status and tumor localization in GEJ tumors.

Outcomes associated with surgery for T4 esophageal cancer

BACKGROUND

T4 esophageal cancer often portends a dismal prognosis even after surgical resection. Historical incomplete resections and poor survival rates often make surgery palliative rather than curative.

METHODS

Using a comprehensive esophageal cancer database, we identified patients who underwent an esophagectomy for T4 tumors between 1994 and 2011. Neoadjuvant treatment (NT) and pathologic response variables were recorded, and response was denoted as complete response (pCR), partial response (pPR), and nonresponse (NR). Clinical and pathologic data were compared. Survival was calculated using Kaplan-Meier curves with log-rank tests for significance.

RESULTS

We identified 45 patients with T4 tumors all who underwent NT. The median age was 60 years (range, 31-79 years) with a median follow-up of 27 months (range, 0-122 months). There were 19 pCR (42 %), 22 pPR (49 %), and 4 NR (9 %). R0 resections were accomplished in 43 (96 %). There were 18 recurrences (40 %) with a median time to recurrence of 13.5 months (2.2-71 months). In this group pCR represented 7 (38.9 %), whereas pPR and NR represented 10 (55.5 %), and 1 (5.5 %) respectively. The overall and disease-free survival for all patients with T4 tumors were 35 and 36 %, respectively. Patients achieving a pCR had a 5 year overall and disease-free survival of 53 and 54 %, compared with pPR 23 and 28 %, while there were no 5 year survivors in the NR cohort.

CONCLUSION

We have demonstrated that neoadjuvant therapy and downstaging of T4 tumors leads to increased R0 resections and improvements in overall and disease-free survival.