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Huang S, Tang Y, Wu H, Shi Q, Tang J, Ben X, Zhang D, Xie L, Zhou H, Chen G, Wang S, Gao Z, Xie Z, Chen R, Qiao G. Early and Persistent Dysphagia Relief Predicts Tumor Response in Esophageal Squamous Cell Carcinoma Patients Treated with Immunochemotherapy. Ann Surg Oncol 2023; 30:5171-5181. [PMID: 37093412 DOI: 10.1245/s10434-023-13467-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/20/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND In this prospective study, we aimed to investigate the role of patient-reported dysphagia relief in predicting pathological tumor responses to neoadjuvant immunochemotherapy (NAIC) in locally advanced esophageal squamous cell carcinoma (ESCC) patients. METHODS This study was designed as a multi-center, prospective study including ESCC patients who received NAIC in the discovery and validation cohorts. The patients' responses to the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-OES 18 and QLQ-C30 were collected at multiple time points. Subsequent time point-intensive esophageal cancer-specific dysphagia trajectories were depicted using growth mixture modeling (GMM) analysis. Furthermore, univariate and multivariate binary logistic regression was used to assess the independent predictors for pathological tumor responses. RESULTS A total of 120 patients from the discovery cohort and 42 patients from the validation cohort were included in the analysis. In the discovery cohort, 19 (22.9%) of the 83 patients achieved pCR status. In the independent validation cohort, 24 patients underwent surgery, and 9 (37.5%) patients achieved pCR status. Trajectory analysis showed that, in the pCR group, the beginning of rapid declines in the slope occurred on days 3, 6, and 9. Further multivariate analysis showed that the degree of dysphagia relief (△dysphagia%) was the only significant independent predictor for pCR status (OR = 3.267, 95% CI 1.66-6.428, P < 0.001). The AUC value for △dysphagia% was 0.961 (95% CI: 0.922-0.999, P < 0.001). CONCLUSION The current study demonstrated that a longitudinal patient-reported outcome (PRO) was an easily obtained, cost-effective, and noninvasive tool for predicting tumor responses to neoadjuvant immunochemotherapy.
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Affiliation(s)
- Shujie Huang
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China
- Shantou University Medical College, Shantou, People's Republic of China
| | - Yong Tang
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China
| | - Hansheng Wu
- Department of Thoracic Surgery, The First Affiliated Hospital of Shantou University Medical College, Shantou, People's Republic of China
| | - Qiuling Shi
- School of Public Health and Management, Chongqing Medical University, Chongqing, People's Republic of China
| | - Jiming Tang
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China
| | - Xiaosong Ben
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China
| | - Dongkun Zhang
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China
| | - Liang Xie
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China
| | - Haiyu Zhou
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China
| | - Gang Chen
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China
| | - Sichao Wang
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China
| | - Zhen Gao
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China
| | - Zefeng Xie
- Department of Thoracic Surgery, The First Affiliated Hospital of Shantou University Medical College, Shantou, People's Republic of China
| | - Rixin Chen
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China.
- Research Center of Medical Sciences, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China.
| | - Guibin Qiao
- Department of Thoracic Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, People's Republic of China.
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2
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Sunde B, Johnsen G, Jacobsen AB, Glenjen NI, Friesland S, Lindblad M, Rouvelas I, Wang N, Lundell L, Lagergren P, Nilsson M. Effects of neoadjuvant chemoradiotherapy vs chemotherapy alone on the relief of dysphagia in esophageal cancer patients: secondary endpoint analysis in a randomized trial. Dis Esophagus 2019; 32:5063601. [PMID: 30084992 DOI: 10.1093/dote/doy069] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 07/10/2018] [Indexed: 12/11/2022]
Abstract
Dysphagia is the most significant symptom in patients with esophageal cancer. There are different therapeutic interventions designed to relieve dysphagia, but few studies have addressed the effects of neoadjuvant therapy. The aim of this study is to compare the effects on dysphagia of neoadjuvant chemotherapy (nCT) versus neoadjuvant chemoradiotherapy (nCRT) and further to study the association between dysphagia response and histological response. Patient reported swallowing function was a secondary endpoint in the NeoRes trial, in which patients were randomized between neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy. Patients completed dysphagia questionnaires before the start and after neoadjuvant therapy, using the European Organization for Research and Treatment of Cancer (EORTC) esophageal cancer modules QLQ-OES24/OG25. Chirieac tumor regression grade (TRG) was used to assess the histological response. Out of 181 patients were randomized, of whom 87% completed the dysphagia questionnaires before and 73% after neoadjuvant treatment. Patient characteristics were similar between the treatment arms. Among patients reporting dysphagia at baseline, neoadjuvant therapy improved dysphagia in both arms. The mean dysphagia score after neoadjuvant treatment was significantly lower after nCT compared to after nCRT (P = 0.022). The reported dysphagia did not differ between those with a complete histological response (TRG 1) and those without any response at all (TRG 4) (P = 0. 583).
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Affiliation(s)
- B Sunde
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Department of Upper Abdominal Diseases
| | - G Johnsen
- Department of Gastrointestinal Surgery, St. Olavs Hospital, Trondheim University Hospital, Trondheim
| | - A-B Jacobsen
- Department of Oncology, Oslo University Hospital, Oslo
| | - N I Glenjen
- Department of Oncology, Haukeland University Hospital, Bergen, Norway
| | - S Friesland
- Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - M Lindblad
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Department of Upper Abdominal Diseases
| | - I Rouvelas
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Department of Upper Abdominal Diseases
| | - N Wang
- Department of Pathology, Karolinska University Hospital, Stockholm, Sweden
| | - L Lundell
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Department of Upper Abdominal Diseases
| | - P Lagergren
- Surgical Care Science, Department of Molecular medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - M Nilsson
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Department of Upper Abdominal Diseases
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3
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Abstract
Definitive chemoradiotherapy (dCRT) is reflecting a treatment standard in oesophageal cancer. For irresectable localised tumours and for inoperable patients, dCRT can change the treatment intent from palliative to curative. In patients with squamous cell carcinoma (SCC), in particular in those of cervical location, dCRT is a proper alternative for treatment that may include radical surgery. Patients with localised locoregional recurrence after primary surgery can survive for long-term after salvage CRT.
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Affiliation(s)
- Michael Stahl
- Klinik für Internistische Onkologie und Hämatologie mit integrierter Palliativmedizin, Kliniken Essen-Mitte, Essen, Germany
| | - Wilfried Budach
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
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4
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van Rossum PSN, Fried DV, Zhang L, Hofstetter WL, Ho L, Meijer GJ, Carter BW, Court LE, Lin SH. The value of 18F-FDG PET before and after induction chemotherapy for the early prediction of a poor pathologic response to subsequent preoperative chemoradiotherapy in oesophageal adenocarcinoma. Eur J Nucl Med Mol Imaging 2017; 44:71-80. [PMID: 27511188 PMCID: PMC5121174 DOI: 10.1007/s00259-016-3478-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 07/26/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE The purpose of our study was to determine the value of 18F-FDG PET before and after induction chemotherapy in patients with oesophageal adenocarcinoma for the early prediction of a poor pathologic response to subsequent preoperative chemoradiotherapy (CRT). METHODS In 70 consecutive patients receiving a three-step treatment strategy of induction chemotherapy and preoperative chemoradiotherapy for oesophageal adenocarcinoma, 18F-FDG PET scans were performed before and after induction chemotherapy (before preoperative CRT). SUVmax, SUVmean, metabolic tumour volume (MTV), and total lesion glycolysis (TLG) were determined at these two time points. The predictive potential of (the change in) these parameters for a poor pathologic response, progression-free survival (PFS) and overall survival (OS) was assessed. RESULTS A poor pathologic response after induction chemotherapy and preoperative CRT was found in 27 patients (39 %). Patients with a poor pathologic response experienced less of a reduction in TLG after induction chemotherapy (p < 0.01). The change in TLG was predictive for a poor pathologic response at a threshold of -26 % (sensitivity 67 %, specificity 84 %, accuracy 77 %, PPV 72 %, NPV 80 %), yielding an area-under-the-curve of 0.74 in ROC analysis. Also, patients with a decrease in TLG lower than 26 % had a significantly worse PFS (p = 0.02), but not OS (p = 0.18). CONCLUSIONS 18F-FDG PET appears useful to predict a poor pathologic response as well as PFS early after induction chemotherapy in patients with oesophageal adenocarcinoma undergoing a three-step treatment strategy. As such, the early 18F-FDG PET response after induction chemotherapy could aid in individualizing treatment by modification or withdrawal of subsequent preoperative CRT in poor responders.
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Affiliation(s)
- Peter S N van Rossum
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
- Department of Radiation Oncology, University Medical Center Utrecht, PO Box 85500, Q00.3.11, 3508GA, Utrecht, The Netherlands.
| | - David V Fried
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lifei Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Linus Ho
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gert J Meijer
- Department of Radiation Oncology, University Medical Center Utrecht, PO Box 85500, Q00.3.11, 3508GA, Utrecht, The Netherlands
| | - Brett W Carter
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laurence E Court
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven H Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.
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5
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Enteral Access is not Required for Esophageal Cancer Patients Undergoing Neoadjuvant Therapy. Ann Thorac Surg 2016; 102:948-954. [DOI: 10.1016/j.athoracsur.2016.03.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 03/01/2016] [Accepted: 03/07/2016] [Indexed: 01/24/2023]
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6
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Sunde B, Ericson J, Kumagai K, Lundell L, Tsai JA, Lindblad M, Rouvelas I, Friesland S, Wang N, Nilsson M. Relief of dysphagia during neoadjuvant treatment for cancer of the esophagus or gastroesophageal junction. Dis Esophagus 2016; 29:442-7. [PMID: 25809837 DOI: 10.1111/dote.12352] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Dysphagia is the main symptom of cancer of the esophagus and gastroesophageal junction and causing nutritional problems and weight loss, often counteracted by insertion of self-expandable metal stents or nutrition via an enteral route. Clinical observations indicate that neoadjuvant therapy may effectively and promptly alleviate dysphagia, making such nutrition supportive interventions redundant before surgical resection. The objective of the current study was to carefully study the effects of induction neoadjuvant therapy on dysphagia and its subsequent course and thereby investigate the actual need for alimentary gateways for nutritional support. Thirty-five consecutive patients scheduled for neoadjuvant therapy were recruited and assessed regarding dysphagia and appetite at baseline, after the first cycle of preoperative treatment with either chemotherapy alone or with chemoradiotherapy and before surgery. Platinum-based therapy in combination with 5-fluorouracil was administered intravenously days 1-5 every 3 weeks and consisted of three treatments. Patients receiving combined chemoradiotherapy started radiotherapy on day one of second chemotherapy cycle. They received fractions of 2 Gy/day each up to a total dose of 40 Gy. Watson and Ogilvie dysphagia scores were used to assess dysphagia, while appetite was assessed by the Edmonton Assessment System Visual analogue scale-appetite questionnaire. Patients were evaluated at regular outpatient clinic visits or by telephone. The histological tumor response in the surgical specimen was assessed using the Chirieac scale. Ten patients scheduled for neoadjuvant chemotherapy and 25 patients scheduled for chemoradiotherapy were included in the analysis. There was a significant improvement in dysphagia in both treatment groups, according to both scales, already from baseline to the completion of the first chemotherapy cycle which remained to the end of the neoadjuvant treatment (P < 0.001). Appetite also improved after the first chemotherapy cycle (P = 0.03). Body weight did not change during any type of neoadjuvant therapy. We were unable to demonstrate any association between relief of dysphagia and the degree of histological response to neoadjuvant therapy in the surgical specimen. The present study shows that a platin - 5FU-based neoadjuvant chemotherapy, with or without concomitant radiotherapy, effectively and promptly relieves dysphagia in patients presenting with cancers of the esophagus or gastroesophageal junction already after the first cycle.
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Affiliation(s)
- B Sunde
- Division of Surgery, Department of Clinical Science, Technology and Intervention (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - J Ericson
- Division of Surgery, Department of Clinical Science, Technology and Intervention (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Nutrition and Dietetics, Karolinska University Hospital, Stockholm, Sweden
| | - K Kumagai
- Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - L Lundell
- Division of Surgery, Department of Clinical Science, Technology and Intervention (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - J A Tsai
- Division of Surgery, Department of Clinical Science, Technology and Intervention (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - M Lindblad
- Division of Surgery, Department of Clinical Science, Technology and Intervention (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - I Rouvelas
- Division of Surgery, Department of Clinical Science, Technology and Intervention (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - S Friesland
- Department of Oncology and Pathology, Karolinska Institutet, Stockholm, Sweden.,Department of Oncology, Karolinska University Hospital, Stockholm, Sweden
| | - N Wang
- Department of Pathology, Karolinska University Hospital, Stockholm, Sweden
| | - M Nilsson
- Division of Surgery, Department of Clinical Science, Technology and Intervention (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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7
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Abstract
Oesophageal cancer is a debilitating disease with a poor prognosis, and weight loss owing to malnutrition prevails in the majority of patients. Cachexia, a multifactorial syndrome characterized by the loss of fat and skeletal muscle mass and systemic inflammation arising from complex host-tumour interactions is a major contributor to malnutrition, which is a determinant of tolerance to treatment and survival. In patients with oesophageal cancer, cachexia is further compounded by eating difficulties owing to the stage and location of the tumour, and the effects of neoadjuvant therapy. Treatment with curative intent involves exceptionally extensive and invasive surgery, and the subsequent anatomical changes often lead to eating difficulties and severe postoperative malnutrition. Thus, screening for cachexia by means of percentage weight loss and BMI during the cancer trajectory and survivorship periods is imperative. Additionally, markers of inflammation (such as C-reactive protein), dysphagia and appetite loss should be assessed at diagnosis. Routine assessments of body composition are also necessary in patients with oesophageal cancer to enable assessment of skeletal muscle loss, which might be masked by sarcopenic obesity in these patients. A need exists for clinical trials examining the effectiveness of therapeutic and physical-activity-based interventions in mitigating muscle loss and counteracting cachexia in these patients.
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8
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Strandby RB, Svendsen LB, Bæksgaard L, Egeland C, Achiam MP. Dysphagia is not a Valuable Indicator of Tumor Response after Preoperative Chemotherapy for R0 Resected Patients with Adenocarcinoma of the Gastroesophageal Junction. Scand J Surg 2015; 105:97-103. [DOI: 10.1177/1457496915594716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 06/11/2015] [Indexed: 01/06/2023]
Abstract
Background: Monitoring treatment response to preoperative chemotherapy is of utmost importance to avoid treatment toxicity, especially in non-responding patients. Currently, no reliable methods exist for tumor response assessment after preoperative chemotherapy. Therefore, the aim of this study was to evaluate dysphagia as a predictor of tumor response after preoperative chemotherapy and as a predictor of recurrence and survival. Methods: Patients with adenocarcinoma of the gastroesophageal junction, treated between 2010 and 2012, were retrospectively reviewed. Dysphagia scores (Mellow-Pinkas) were obtained before and after three cycles of perioperative chemotherapy together with clinicopathological patient characteristics. A clinical response was defined as improvement of dysphagia by at least 1 score from the baseline. The tumor response was defined as down staging of T-stage from initial computer tomography (CT) scan (cT-stage) to pathologic staging of surgical specimen (pT-stage). Patients were followed until death or censored on June 27th, 2014. Results: Of the 110 included patients, 59.1% had improvement of dysphagia after three cycles of perioperative chemotherapy, and 31.8% had a chemotherapy-induced tumor response after radical resection of tumor. Improvement of dysphagia was not correlated with the tumor response in the multivariate analysis (p = 0.23). Moreover, the presence of dysphagia was not correlated with recurrence (p = 0.92) or survival (p = 0.94) in the multivariate analysis. Conclusion: In our study, improvement of dysphagia was not valid for tumor response evaluation after preoperative chemotherapy and was not correlated with the tumor response. The presence of dysphagia does not seem to be a predictor of recurrence or survival.
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Affiliation(s)
- R. B. Strandby
- Department of Surgical Gastroenterology, Rigshospitalet, University of Copenhagen, Denmark
| | - L. B. Svendsen
- Department of Surgical Gastroenterology, Rigshospitalet, University of Copenhagen, Denmark
| | - L. Bæksgaard
- Department of Oncology, Rigshospitalet, University of Copenhagen, Denmark
| | - C. Egeland
- Department of Surgical Gastroenterology, Rigshospitalet, University of Copenhagen, Denmark
| | - M. P. Achiam
- Department of Surgical Gastroenterology, Rigshospitalet, University of Copenhagen, Denmark
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9
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Won E, Ilson DH. Management of localized esophageal cancer in the older patient. Oncologist 2014; 19:367-74. [PMID: 24664485 PMCID: PMC3983810 DOI: 10.1634/theoncologist.2013-0178] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 01/06/2014] [Indexed: 12/21/2022] Open
Abstract
Most patients with gastroesophageal cancers are older than 65 years of age. The management of older patients poses challenges because they have multiple comorbidities and physiological changes associated with aging. Furthermore, data are limited on tolerance of cancer therapy and the use of combined-modality treatments in this patient population to guide their treatment. In this article, we focus on the management of older patients with localized esophageal cancer, highlighting the role of comprehensive geriatric assessment to identify and better tailor treatment approaches in this patient population. We review the literature and discuss the role of surgical resection and potential complications specific to an older patient. We review the rationale of combined-modality treatment and the potential benefits of a chemoradiotherapy-based approach in this patient population.
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Affiliation(s)
- Elizabeth Won
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
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10
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Lordick F, Ott K, Sendler A. [Gastric cancer and adenocarcinoma of the esophagogastric junction: principles of neoadjuvant therapy]. Chirurg 2012; 82:968-73. [PMID: 22002702 DOI: 10.1007/s00104-011-2127-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
According to the current European and German S3 guidelines, neoadjuvant chemotherapy is now an integral part of the treatment of locally advanced gastric cancer and adenocarcinoma of the esophagogastric junction. Neoadjuvant therapy seeks to achieve downsizing of the primary tumor, lowering of the T and N categories and eradication of micrometastases. As the indications for neoadjuvant treatment are based on pretherapeutic information alone, a sophisticated clinical staging plays a central role. Despite all progress made in the field of diagnostic work-up, clinical staging often fails. Despite this fact, controlled randomized trials showed that neoadjuvant chemotherapy enhances the rate of curative (R0) resections and reduces the likelihood of systemic relapse. Overall, survival can be improved by neoadjuvant chemotherapy. The current research is focused on the molecular prediction of response and early response monitoring with functional imaging. New targeted drugs are being integrated into the peri-operative treatment.
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Affiliation(s)
- F Lordick
- Medizinische Klinik III, Innere Medizin, Hämatologie und Onkologie, Klinikum Braunschweig, Celler Str. 38, 38114, Braunschweig, Deutschland.
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11
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Lordick F. Optimizing neoadjuvant chemotherapy through the use of early response evaluation by positron emission tomography. Recent Results Cancer Res 2012; 196:201-211. [PMID: 23129376 DOI: 10.1007/978-3-642-31629-6_14] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Metabolic imaging and early response assessment by positron emission tomography (PET) may guide treatment of localized esophageal cancers. The most consistent and validated results have been obtained during neoadjuvant treatment of adenocarcinoma of the esophago-gastric junction (AEG). It was demonstrated that 18F-Fluorodeoxyglucoe (FDG)-PET is highly accurate for identifying non-responding tumors within 2 weeks after the initiation of neoadjuvant chemotherapy when a quantitative threshold for metabolic response is used. In consecutive phase II studies the metabolic activity, defined by the standardized uptake (SUV) of 18-FDG before and during chemotherapy, was measured. Significant decreases of the SUV after only two weeks of induction chemotherapy were observed. A drop of >35 % 2 weeks after the start of chemotherapy revealed as an accurate cut-off value to predict response after a 12-week course of preoperative chemotherapy. This cut-off was recently confirmed in a US study, where investigators did follow-up PET not 14 days but 6 weeks after initiation of chemotherapy. It was further noticed that the metabolic response to induction chemotherapy revealed as an independent prognostic factor in locally advanced AEG. Therefore, PET could be used to tailor treatment according to the sensitivity of an individual tumor. This concept was realized in the MUNICON-1 and -2 trials. These trials prospectively confirmed that responders to induction chemotherapy can be identified by early metabolic imaging using FDG-PET. Continuing neoadjuvant chemotherapy in the responding population resulted in a favorable outcome. Moreover, MUNICON-1 showed that chemotherapy can be discontinued at an early stage in metabolic non-responders without compromising the patients' prognosis, but saving time and reducing side effects and costs. MUNICON-2 showed that the addition of neoadjuvant radiation therapy in metabolic nonresponders did not lead to an improvement of their poor prognosis, thus showing that early metabolic nonresponse indicates dismal tumor biology. Future studies need to validate the prognostic and predictive value of PET in multicenter settings and in conjunction with different neoadjuvant chemotherapy and chemo-immunotherapy regimens.
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12
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Scarpa M, Valente S, Alfieri R, Cagol M, Diamantis G, Ancona E, Castoro C. Systematic review of health-related quality of life after esophagectomy for esophageal cancer. World J Gastroenterol 2011; 17:4660-74. [PMID: 22180708 PMCID: PMC3233672 DOI: 10.3748/wjg.v17.i42.4660] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 05/21/2011] [Accepted: 05/28/2011] [Indexed: 02/06/2023] Open
Abstract
This study is aimed to assess the long-term health-related quality of life (HRQL) of patients after esophagectomy for esophageal cancer in comparison with es-tablished norms, and to evaluate changes in HRQL during the different stages of follow-up after esophageal resection. A systematic review was performed by searching medical databases (Medline, Embase and the Cochrane Library) for potentially relevant studies that appeared between January 1975 and March 2011. Studies were included if they addressed the question of HRQL after esophageal resection for esophageal cancer. Two researchers independently performed the study selection, data extraction and analysis processes. Twenty-one observational studies were included with a total of 1282 (12-355) patients. Five studies were performed with short form-36 (SF-36) and 16 with European Organization for Research and Treatment of Cancer (EORTC) QLQ C30 (14 of them also utilized the disease-specific OES18 or its previous version OES24). The analysis of long-term generic HRQL with SF-36 showed pooled scores for physical, role and social function after esophagectomy similar to United States norms, but lower pooled scores for physical function, vitality and general health perception. The analysis of HRQL conducted using the Global EORTC C30 global scale during a 6-mo follow-up showed that global scale and physical function were better at the baseline. The symptom scales indicated worsened fatigue, dyspnea and diarrhea 6 mo after esophagectomy. In contrast, however, emotional function had significantly improved after 6 mo. In conclusion, short- and long-term HRQL is deeply affected after esophagectomy for cancer. The impairment of physical function may be a long-term consequence of esophagectomy involving either the respiratory system or the alimentary tract. The short- and long-term improvement in the emotional function of patients who have undergone successful operations may be attributed to the impression that they have survived a near-death experience.
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13
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Lordick F, Ott K, Krause BJ. New trends for staging and therapy for localized gastroesophageal cancer: the role of PET. Ann Oncol 2011; 21 Suppl 7:vii294-9. [PMID: 20943631 DOI: 10.1093/annonc/mdq289] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Treatment options for localized gastroesophageal cancers reach from limited resection to multimodality treatment. Accurate clinical assessment, prognostic and predictive information are needed to select the most appropriate treatment approach. Positron emission tomography (PET) in combination with computed tomography (CT) in a hybrid imaging modality PET-CT may refine the staging accuracy and add prognostic information. Moreover, experiences from diverse centers indicate that PET also might improve significantly the assessment of response to preoperative chemotherapy and chemoradiotherapy. This article outlines the current value of PET in the staging and multidisciplinary care of gastroesophageal cancer. At this stage, it remains unclear whether the prognosis of patients can be improved by implementing PET in the management of localized disease. Prospective multicenter studies have to be carried out to validate metabolic cut-off values and to prove the benefit of PET-guided treatment decisions.
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Affiliation(s)
- F Lordick
- Department of Medicine, Klinikum Braunschweig, Hannover Medical School, Hannover, Germany.
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Ruhstaller T, Pless M, Dietrich D, Kranzbuehler H, von Moos R, Moosmann P, Montemurro M, Schneider PM, Rauch D, Gautschi O, Mingrone W, Widmer L, Inauen R, Brauchli P, Hess V. Cetuximab in combination with chemoradiotherapy before surgery in patients with resectable, locally advanced esophageal carcinoma: a prospective, multicenter phase IB/II Trial (SAKK 75/06). J Clin Oncol 2011; 29:626-31. [PMID: 21205757 DOI: 10.1200/jco.2010.31.9715] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE This multicenter phase IB/II trial investigated cetuximab added to preoperative chemoradiotherapy for esophageal cancer. PATIENTS AND METHODS Patients with resectable, locally advanced esophageal cancer received two 3-week cycles of induction chemoimmunotherapy (cisplatin 75 mg/m(2) day 1, docetaxel 75 mg/m(2) day 1, cetuximab 250 mg/m(2) days 1, 8,15 [400 mg/m(2) loading dose]) followed by chemoimmunoradiation therapy (CIRT) and surgery. CIRT consisted of 45 Gy radiotherapy (RT) plus concurrent cisplatin 25 mg/m(2) and cetuximab 250 mg/m(2) weekly for 5 weeks in cohort 1. If fewer than three of seven patients experienced limiting toxicity (LT), the next seven patients also received docetaxel (20 mg/m(2) weekly × 5). If fewer than three patients experienced LTs, 13 additional patients were treated at this dose. RESULTS In total, 28 patients (median age, 64 years) with predominantly node-positive (82%) esophageal adenocarcinoma (15 patients) or squamous cell carcinoma (13 patients) were enrolled and 24 (86%) completed the entire trimodal therapy. During CIRT, no LT occurred, rash was not exacerbated within the RT field, and the main grade 3 toxicities were esophagitis (seven patients), anorexia (three), fatigue (three), and thrombosis (two). Surgery (R0 resection) was performed in 25 patients. Anastomotic leakage occurred in three patients: two recovered spontaneously and one successfully underwent re-operation. There were no deaths at 30 days and no treatment-related mortality after 12 months. Nineteen patients (68%) showed complete or near complete pathologic regression. CONCLUSION Adding cetuximab to preoperative chemoradiotherapy is feasible without increasing postoperative mortality. Phase III investigation has begun based on the high histopathologic response and R0 resection rate.
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Affiliation(s)
- Thomas Ruhstaller
- Fachbereich Onkologie/Hämatologie, Kantonsspital St Gallen, CH-9007 St Gallen, Switzerland.
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15
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[Principles of neoadjuvant therapy]. Chirurg 2009; 80:1000-5. [PMID: 19812908 DOI: 10.1007/s00104-009-1731-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Neoadjuvant therapy is now an integral part in the treatment of locally advanced cancer of the esophagus and stomach. The mechanisms of action comprise downsizing of the primary tumor, improvement of the T and N categories and the earliest possible eradication of micrometastases. Several controlled clinical studies could show that these principles can indeed augment the rate of curative (R0) resections and can reduce the likelihood of systemic recurrences. As a consequence overall survival is improved by neoadjuvant therapy. This article summarizes how the basic principles of neoadjuvant therapy translate into clinical practice and gives a review of current developmental perspectives in this field.
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