Case involving long-term survival after esophageal cancer with liver and lung metastases treated by multidisciplinary therapy: report of a case

The Japanese nationwide cohort data of proton beam therapy for liver oligometastasis in esophagogastric cancer patients

A nationwide multicenter cohort study on particle therapy was launched by the Japanese Society for Radiation Oncology in Japan in May 2016. We analyzed the outcome of proton beam therapy (PBT) for liver oligometastasis of esophagogastric cancers. Cases in which PBT was performed at all PBT facilities in Japan between May 2016 and February 2019 were enrolled. The patients were selected based on the following criteria: controlled primary cancer, liver recurrence without extrahepatic tumors and no more than three liver lesions. Twenty-two males and two females with a median age of 69 (range, 52-80) years and 35 lesions were included. This study included 6 patients with esophageal and 18 patients with gastric cancer. The median lesion size, fraction size and biological effective dose (BED)10 were 32 (7-104) mm, 3.8 gray (relative biological effect)/fractions (Gy (RBE)/fr) (2-8 Gy (RBE)/fr) and 96.9 (88.8-115.2) Gy, respectively. The median follow-up period was 18 (4-47) months. The 1-, 2- and 3-year overall survival (OS) rates were 75, 51.8 and 45.3%, respectively, and the median OS was 25.3 months. The 1-, 2- and 3-year cumulative local recurrence (LR) rates were 3, 6 and 6%, respectively. Patients' age (P < 0.01), performance status (P = 0.017) and tumor size (P = 0.024) were significant OS-related factors. No Grade 3 or higher adverse events (AEs) were observed. Owing to the low incidence of AEs and the low LR cumulative incidence, PBT is a feasible option for liver oligometastasis of esophagogastric cancers.

Development and validation of a prognostic model for esophageal cancer patients with liver metastasis: a cohort study based on surveillance, epidemiology, and end results database

PURPOSE

Our objective is to examine the independent prognostic risk factors for patients with Esophageal Cancer with Liver Metastasis (ECLM) and to develop a predictive model.

METHODS

In this study, clinical data were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Cox regression analysis was employed to identify independent prognostic factors and construct nomograms based on the results of multivariate regression. The predictive performance of the nomograms was assessed using several methods, including the consistency index (C-index), calibration curve, time-dependent receiver-operating characteristic curve (ROC), and decision curve analysis (DCA). Additionally, Kaplan-Meier survival curves were generated to demonstrate the variation in overall survival between groups.

RESULTS

A total of 1163 ECLM patients were included in the study. Multivariate Cox analysis revealed that age, tumor differentiation grade, bone metastasis, therapy, and income were independently associated with overall survival (OS) in the training set. Subsequently, a prognostic nomogram was constructed based on these independent predictors. The C-index values were 0.739 and 0.715 in the training and validation sets, respectively. The area under the curve (AUC) values at 0.5, 1, and 2 years were all higher than 0.700. Calibration curves indicated that the nomogram accurately predicted OS. Decision curve analysis (DCA) showed moderately positive net benefits. Kaplan-Meier survival curves demonstrated significant differences in survival between high- and low-risk groups, which were divided based on the nomogram risk score.

CONCLUSIONS

The nomogram we developed for ECLM patients has demonstrated good predictive capability, allowing clinicians to accurately evaluate patient prognosis and identify those at high risk, thereby facilitating the development of personalized treatment plans.

Effectiveness of proton beam therapy for liver oligometastatic recurrence in patients with postoperative esophagus cancer

There are several reports of hepatic resection for postoperative hepatic metastatic recurrence of esophageal cancer. However, it is unclear whether surgery is the best local treatment for liver metastases. Thus, this study aimed to retrospectively analyze proton beam therapy (PBT) for postoperative liver metastatic recurrence of esophageal cancer without extrahepatic lesions and examine outcomes and adverse events. This single-center historical cohort study selected patients who underwent PBT at our proton therapy center between 2012 and 2018. The patients were selected based on the following criteria: primary esophagus carcinoma was resection and metachronous liver oligometastasis recurrence without extrahepatic tumors and no more than three liver metastases. This study included seven males with a median age of 66 (range, 58-78) years, and 15 lesions were included in the study. The median tumor size was 22.6 (7-55.3) mm. The most frequent dose was 72.6 Gy relative biological effect (RBE)/22 fractions (fr) for four lesions and 64 Gy (RBE)/8 fr for four lesions. The median survival time was 35.5 (13.2-119.4) months. The 1-, 2- and 3-year overall survival (OS) rates were 100%, 57.1% and 42.9%, respectively. The median progression-free survival (PFS) time was 8.7 (1.2-44.1) months. The 1-, 2- and 3-year PFS rates were 28.6%. The 1-, 2- and 3-year local control (LC) rates were 100%. No grade ≥4 radiation-induced adverse events (AEs) were observed. We conclude that PBT can be considered an alternative to hepatic resection for recurrent liver metastases postoperative esophageal cancer.

Treatment paradigms and survival outcomes in esophageal adenocarcinoma with liver metastasis: a retrospective cohort study using the SEER database

Background

Esophageal adenocarcinoma with liver metastasis (EACLM) at the time of diagnosis has a poor prognosis and few therapeutic options. The best treatment options and prognostic factors for EACLM patients are unclear. The present study sought to explore the optimal treatment modalities for and the prognosis of these patients.

Methods

Patients diagnosed with EACLM at the time of diagnosis were identified from the Surveillance, Epidemiology and End Results (SEER) database between 2010 and 2015. The last follow-up date was December 31, 2018. Treatment patterns were divided into four groups: local therapy (surgery/radiation), systemic therapy [chemotherapy (CT)], combination therapy (surgery/radiation + CT), and no treatment. The Kaplan-Meier (K-M) method and log-rank test were used for overall survival (OS) and disease-specific survival (DSS). Univariable and multivariable Cox regression were performed to identify the prognostic factors. Propensity score-matching (PSM) analyses were performed for sensitive analyses.

Results

A total of 925 patients diagnosed with EACLM were included in the study. The median OS was 12, 10, 3, and 2 months for combination therapy, systemic therapy, local therapy, and no treatment, respectively (P<0.001). After PSM, the patients who received systemic treatment had a better OS (median 9 vs. 2 months; P<0.001) and DSS (median 9 vs. 3 months; P<0.001) than those who received no treatment. Compared to systemic therapy, combination therapy did not increase patients' OS (median 13 vs. 12 months, P=0.069) but did improve their DSS (median 19 vs. 13 months, P=0.048).

Conclusions

EACLM patients might benefit the most from systemic therapy and combination therapy. For patients who are well-tolerated, combination therapy should be considered as a preferable option.

Hepatic Metastasis in Newly Diagnosed Esophageal Cancer: A Population-Based Study

Background

The hepatic metastasis pattern of esophageal cancer (EC) has not been fully explored. The primary objective of this study was to explore the predictors of esophageal cancer with hepatic metastasis (ECHM) at the time of diagnosis. In addition, we also analyzed the factors affecting ECHM prognosis.

Methods

We used the Surveillance, Epidemiology and End Result (SEER) database to identify ECHM patients at the time of initial diagnosis. The ECHM predictors were identified using multivariate logistic regression. Multivariate Cox regression and competing survival risk analyses were performed to identify factors associated with all-cause mortality and EC-specific mortality of ECHM, respectively.

Results

A total of 10,965 eligible EC patients were identified in the SEER database between 2010 and 2016, of which 1,197 were ECHM patients, accounting for 10.9% of the entire cohort. In the whole cohort, eight ECHM predictors (age, primary site, grade, histology type, T staging, N staging, insurance status, and number of extrahepatic metastatic sites) were determined using multivariate logistic regression analysis. Multivariate Cox regression and multivariate competing survival risks models confirmed that the male sex, advanced age, squamous cancer, and multiple extrahepatic metastasis increased the risk of both all-cause and EC-specific mortality, whereas chemotherapy and chemotherapy plus radiotherapy significantly reduced the risk of both.

Conclusions

This study explored population-level predictors of hepatic metastasis at the time of EC diagnosis and analyzed the clinical characteristics affecting the prognosis in ECHM patients. These findings may provide clinicians with a reference for the screening and treatment of hepatic metastasis in EC.

Association Between Multiple Lines of Active Therapy and Prognosis in Esophageal Squamous Cell Carcinoma

Purpose

Esophageal squamous cell carcinoma (ESCC) is a critical threat to health and life. More than half of ESCC patients have recurrent or metastatic disease. Most late-stage patients undergo first-line treatment but experience further progression. Many of these patients have good performance status and are able to receive second-line therapy and even further treatments rather than best supportive care. Our analysis aimed to explore whether multiple lines of active treatment are beneficial in ESCC patients.

Methods

We conducted a retrospective cohort study. Univariate and multivariate survival analyses were used to identify whether the number of active treatment lines was related to prognosis. All analyses and the corresponding survival curves were based on the Cox proportional hazard regression model and the Kaplan–Meier method. Comparisons between groups were conducted using the t-test, chi-square test, and Fisher’s exact test, as applicable.

Results

Of a total of 138 patients with recurrent or metastatic disease, 66 (61.1%) received one line of active treatment, and 42 (38.9%) patients received two and more lines. Multiple lines of active therapy were statistically significantly associated with better prognosis (crude hazard ratio (HR) (95% confidence interval (CI))=0.21 (0.06–0.73)), even after adjusting for relevant confounders (adjusted HR (95% CI)=0.19 (0.04–0.86)). More grade 3–4 hepatotoxicity patients were observed in the multiple-line treatment group (p=0.033). A small number of patients were cured by palliative management; these patients were more likely to have received both systematic and local treatment than other patients with repeated progression (9/15 versus 40/117, p=0.051).

Conclusion

Multiple lines of active treatment are related to prolonged survival in recurrent and metastatic ESCC patients, and adverse effects are acceptable. Comprehensive therapy modalities are recommended.

Management of Liver Oligometastatic Esophageal Cancer: Overview and Critical Analysis of the Different Loco-Regional Treatments

Esophageal cancer (EC) is an aggressive disease that is associated with a poor prognosis. Since metastastic EC is usually considered suitable only for palliative therapy with an estimated 5-year overall survival (OS) less than 5%, the optimal management of patients with liver oligometastatic EC (LOEC) is still undefined. The aim of this review is to provide an overview of the different treatment options for LOEC. A literature search was conducted using PubMed, Embase, and Cochrane to identify articles evaluating different treatment strategies for LOEC. Among 828 records that were identified, 20 articles met the inclusion criteria. These studies included patients who have undergone any type of surgical procedure and/or loco-regional therapy. Liver resection resulted in the best survival for patients with low tumor burden (3 lesions): 5-year OS 30–50% versus 8–12% after only chemotherapy (CHT). The 5-year OS of loco-regional therapies was 23% with a local recurrence risk ranging 0–8% for small lesions (2 to 3 cm). An aggressive multidisciplinary approach for LOEC patients may improve survival. Surgery seems to be the treatment of choice for resectable LOEC. If unfeasible, loco-regional therapies may be considered. In order to better select these patients and offer a chance of cure, prospective trials and a definition of treatment protocols are needed.

Palliative resection or radiation of primary tumor prolonged survival for metastatic esophageal cancer

PURPOSE

We aimed to explore the value of palliative resection or radiation of primary tumor for metastatic esophageal cancer (EC) patients.

METHODS

Surveillance, Epidemiology, and End Results database was used for identifying metastatic EC patients. The patients were divided into resection and nonresection groups. And patients without resection were divided into radiation and nonradiation groups. Propensity score matching (PSM) analyses were adopted to reduce the baseline differences between the groups. Cancer specific survivals (CSSs) and overall survivals (OSs) were compared by Kaplan-Meier (K-M) curves. Multivariable analyses by COX proportion hazards model were performed to identify risk factors for CSS and OS. Predictive nomograms were conducted according to both postoperative factors and preoperative factors.

RESULTS

A total of 7982 metastatic EC patients were selected for our analyses. After PSM, 978 patients were included in the survival analyses comparing palliative resection and nonresection. The CSS and OS for patients underwent palliative resection were significantly longer than those without resection (median CSS: 21 months vs 7 months, P < .001; median OS: 20 months vs 7 months, P < .001). In the overall population without resection, 654 patients were matched for radiation and nonradiation groups. And K-M curves showed that patients with radiation had longer CSS and OS than those without radiation (median CSS: 11 months vs 6 months, P < .001; median OS: 10 months vs 6 months, P < .001). Nomograms were generated for prediction of 1-, 2-, and 3-year CSS and OS. All C-indexes implied moderate discrimination and accuracy. And all nomograms had good calibration.

CONCLUSION

Palliative resection or radiation of primary tumor could prolong CSS and OS of metastatic EC patients.

The effect of tumor locations of esophageal cancer on the metastasis to liver or lung

Background

Liver and lung are the most common metastatic sites for esophageal cancer. Tumor location of esophageal cancer has been a prognostic factor of tumor, node and metastasis (TNM) staging system since 2009. However, the relationship between tumor location and metastatic sites remains unclear.

Methods

Patients with esophageal cancer were derived from surveillance, epidemiology and end results (SEER) database from 2010 to 2013. Age, sex, histologic type and grade were included in the model for propensity score matching between patients with or without liver and lung metastasis. After propensity score matching, the relationship between tumor location and the probability of liver or lung metastasis was analyzed using chi-square analysis. Overall survival was analyzed between different locations within liver or lung metastasis patients.

Results

A total of 6,812 patients were eligible. After matching, primary site was still an independent risk factor for both liver and lung metastasis. For patients with liver metastasis, lower esophagus was more likely to be the primary site than upper segment (P=0.014). In contrast, lung metastasis was more likely to be found in patients with upper esophageal cancer than lower segment (P=0.033). In liver metastasis group, those with upper esophageal cancer had the worst survival, followed by middle and lower segment and the results are opposite in lung metastasis group.

Conclusions

These findings are useful in the evaluation when diagnose and follow up. Targeted examinations in accordance with tumor location will assist to find early metastasis and deliver treatment timely and properly.

Successful multidisciplinary treatment including repeated metastasectomy for recurrent squamous cell esophageal carcinoma: a case report

Background

Recurrences after radical esophagectomy are common. The prognosis for recurrent esophageal cancer is generally poor. Recurrences usually occur between 1 and 3 years of surgery, with the duration of median survival after recurrence ranging from 5 to 10 months. The number of sites and involved organs vary among patients. Consequently, a standard therapeutic strategy has not been established, and the role of surgery in the management of recurrence is unclear.

Case presentation

A 67-year-old man presented with dysphagia 6 months previously and was diagnosed with esophageal squamous cell carcinoma (ESCC) in the upper thoracic region (T2M0M0, stage IB), for which he underwent thoracoscopy-assisted esophagectomy and lymphadenectomy. Adjuvant chemotherapy was not prescribed. Three years after the operation, he developed a solitary metastasis in the left lung, requiring segmentectomy followed by chemotherapy with combined cisplatin (CDDP) and 5-fluorouracil (5-FU). The following year, a metastatic lesion was recognized in the right lung, invading the chest wall, for which he underwent partial lobectomy with local chest wall resection. Multiple mediastinal and abdominal lymph node (LN) metastases were detected in the right lung a year later, which necessitated chemoradiation to a dose of 50.4 Gy with concomitant CDDP and 5-FU. Post-treatment computed tomography (CT) showed a good response. Positron emission tomography (PET)-CT revealed a reduction in the metastatic LNs with no fluoro-deoxy-glucose (FDG) uptake. The following year, metastases were detected in the left cervical LNs. Owing to the limited extent of metastases, resection was followed by chemoradiation to a dose of 50 Gy with CDDP and 5-FU. The following year, metastases were detected in the mediastinal LNs; chemotherapy was administered with nedaplatin and docetaxel. The follow-up CT and PET-CT demonstrated complete disappearance of the tumor, and the patient is currently surviving without recurrence for 11 years from the first curative operation.

Conclusions

This case demonstrates that aggressive multidisciplinary treatment including surgery and radiation to achieve local control could be a meaningful treatment strategy in cases with limited and slowly occurring recurrences.

Long-term survival after multimodality therapy including surgery for metastatic esophageal cancer

BACKGROUND AND OBJECTIVES

Esophageal cancer (EC) remains an aggressive disease with a poor survival. Management of metastatic EC is limited to palliative chemotherapy (CT). Scientific contributions regarding the role of surgery are scarce and controversial. We analysed outcome of surgically treated metastatic EC patients.

METHODS

We retrospectively identified surgically treated metastatic EC patients from our esophagectomy database. The aim of this study was to evaluate surgical complications, pathological response, oncological outcome and mean survival of these aggressively treated stage IV cancer patients.

RESULTS

Twelve stage IV patients with disease presentation limited to outfield lymph node (LN) and/or liver metastasis were treated with an aggressive multimodality treatment including surgery. Mean age was 58 years (75% male, 75% Adenocarcinomas). Median postoperative hospital stay was 15 d. Radiological anastomotic leakage occurred in one patient. In hospital, mortality was nil. Complete resection was achieved in all but one. Metastatic recurrence occurred in 64% of R0 resected patients. At date of censoring, after a median follow-up of 22 months, 50% of the surgical resected patients are still alive and 33% are free of disease recurrence. Kaplan-Meier curves show a possibility to long-term survival after aggressive multimodality therapy including surgery.

CONCLUSIONS

In selected metastatic EC patients, multimodality treatment including surgery has an acceptable surgical outcome with a potentially long-term survival.

Successful Endoscopic Treatment of Post-esophagectomy Refractory Reflux Using OverStitch: The First Clinical Case

Aims:

The reflux of duodeno-gastric contents into the remnant esophagus (gastric tube-esophageal reflux: GTER) is a significant issues in long-term esophageal cancer survivors after radical esophagectomy. We attempted endoscopic valve (funnel) creation for prevention for GTER using OverStitch endoscopic suturing system.

Methods:

The OverStitch was mounted onto a standard double-channel endoscope. Under general anesthesia, the funnel creation was attempted by placing semi-full thickness sutures on the gastric wall, at 3 cm distal to the primary esophago-gastric anastomosis. The postoperative outcomes were also evaluated.

Results:

In total, 4 sutures were needed and the operating time was 62 minutes without complication. The endoscopic and swallowing studies, as well as pH profile, were all improved postoperatively. The patient’s quality of life was dramatically improved with complete disappearance of night-time reflux in spine position.

Conclusions:

Endoscopic antireflux funnel creation was feasible and safe. This procedure may become a useful treatment for patients with severe GTER after esophagectomy.

The role of surgical treatment in isolated organ recurrence of esophageal cancer-a systematic review of the literature

BACKGROUND

Despite the improvements in the early detection and treatment of non-metastatic esophageal cancer, more than half of patients undergoing a curative treatment for esophageal cancer will develop recurrence within three years. The prognosis of these patients is poor. However, a wide range in overall survival has been reported, depending on the pattern of recurrence, and no optimal treatment strategy following recurrence has yet been uniformly accepted.

AIM

In this article, we aimed to systematically review the literature for the role of surgical resection of metachronous distant metastasis following primary treatment of esophageal cancer. Furthermore, we discuss possible factors that could possibly predict which patients may benefit from a surgical approach. A comprehensive literature search was conducted in PubMed using combinations of keywords.

RESULTS

Patients with recurrence may benefit of a multimodality treatment. Regarding the isolated recurrence of esophageal cancer in solid visceral organs, operative intervention has been proposed as a treatment that may offer a survival benefit in an individual basis. No definitive conclusions regarding the potential survival advantage offered by the surgical treatment of solitary recurrent lesions can be drawn. However, recent improvements in surgical treatment and optimization of perioperative management guarantee an acceptable operative risk, making surgical resection of solitary recurrence lesions a considerable therapeutic option.

CONCLUSIONS

It can be conferred from the available studies that the surgical treatment of isolated recurrence from esophageal cancer may offer a survival benefit for properly selected patients. Prospective, multicenter studies might be useful to gain a better insight into those factors that affect selection of patients to take benefit from an operative intervention.

Stereotactic body radiotherapy for oligo-recurrence in the liver in a patient with esophageal carcinoma: A case report

Stereotactic body radiation therapy (SBRT) is a safe and effective treatment for solitary cancerous lesions. The present study reported a rare case of sustained remission after SBRT for oligorecurrence in the liver in a patient with esophageal carcinoma. A 60-year-old Japanese man presented with a chief complaint of dysphagia. On medical examination, the patient was diagnosed as having squamous cell carcinoma of the esophagus that was clinically staged as T4bN1M0. The patient received definitive concurrent chemoradiotherapy, consisting of four 28-day cycles of chemotherapy comprising nedaplatin 80 mg/m² on day 1 and S-1 120 mg/body orally on days 1-14, with radiotherapy comprising a total of 50 Gy in daily fractions of 2 Gy. After a 9-month disease-free interval following the primary treatment, a solitary liver metastasis was identified. The patient underwent SBRT using a radiation dose of 48 Gy in 4 fractions and two 28-day cycles of adjuvant chemotherapy comprising nedaplatin 80 mg/m² on day 1, and S-1 100 mg/body orally on days 1-14. The patient exhibited no signs of recurrence for 3 years with sustained local control. SBRT may be considered a treatment option for patients with relapsed esophageal cancer with oligo-recurrence in the liver.

Prognosis and Treatment After Diagnosis of Recurrent Esophageal Carcinoma Following Esophagectomy with Curative Intent

Background

Strategies for the treatment of recurrence after initial curative esophagectomy are increasingly being recognized. The aim of this study was to identify prognostic factors that affect survival in patients with recurrence and to evaluate treatment strategies.

Methods

A prospective database (2003–2013) was used to collect consecutive patients with esophageal carcinoma treated with initial curative esophagectomy. Locations, symptoms, and treatment of recurrence were registered. Post-recurrence survival was defined as the time between the first recurrence and death or last follow-up.

Results

Of the 335 selected patients, 171 (51 %) developed recurrence. Multivariable analysis identified distant recurrence as opposed to locoregional recurrence [hazard ratio (HR) 2.15, 95 % confidence interval (CI) 1.27–3.65; p = 0.005], more than three recurrent locations (HR 2.42, 95 % CI 1.34–4.34; p = 0.003), and treatment (HR 0.29, 95 % CI 0.20–0.44; p < 0.001) as independent prognostic factors associated with post-recurrence survival. Primary tumor characteristics, including neoadjuvant therapy, histological type, pTN stage, and radicality, did not independently influence post-recurrence survival. Treatment was initiated in 62 patients (37 %) and included chemotherapy, radiotherapy, and/or surgery. Median post-recurrence survival of all patients was 3.0 months (range 0–112). In total, six patients (4 %) were still disease-free following treatment, indicating cure.

Conclusions

In patients treated for esophageal cancer at curative intent, distant recurrence and more than three recurrent locations were independent prognostic factors associated with worse post-recurrence survival, irrespective of primary tumor characteristics. Although survival after recurrence was poor, treatment can prolong survival and can even lead to cure in selected patients.

Liver metastases from esophageal carcinoma: is there a role for surgical resection?

Esophageal cancer recurrence rates after esophagectomy are high, and locally recurrent or distant metastatic disease has poor prognosis. Management is limited to palliative chemotherapy and symptomatic interventions. We report our experience of four patients who have undergone successful liver resection for metastases from esophageal cancer. All underwent esophagectomy and were referred to our unit with metastatic recurrent liver disease, two with solitary metastases and two with multi-focal disease. The patients underwent multidisciplinary assessment and proceeded to a course of neoadjuvant chemotherapy followed by open or laparoscopic liver resection. Three patients were male, and the mean age was 57.5 (range 44-71) years. Response to chemotherapy ranged from partial to complete response. Following liver resection, two patients developed recurrent disease at 5 and 15 months, and both had disease-specific mortality at 10 and 21 months, respectively. The other two patients remain disease free at 22 and 92 months. Recurrent metastatic esophageal cancer continues to have a poor prognosis, and the majority of patients with liver involvement will not be candidates for hepatic resection. However, this series suggests that in selected patients, liver resection of metastases from esophageal cancer combined with neoadjuvant and adjuvant chemotherapy is feasible, but further research is required to determine whether this can offer a survival advantage.