Esophageal stenosis and the Glasgow Prognostic Score as independent factors of poor prognosis for patients with locally advanced unresectable esophageal cancer treated with chemoradiotherapy (exploratory analysis of JCOG0303)

Nutritional management during chemotherapy and chemoradiotherapy for advanced esophageal cancer

Advanced esophageal cancer is treated by chemotherapy, radiation therapy, chemoradiotherapy, and immunotherapy. However, the stenosis caused by the tumor and cancer-related chronic inflammation leads to inadequate food intake, weight loss, and nutrition problems. Given that poor pre-treatment nutritional status increases the risks of treatment-related adverse events and a poor prognosis, the nutrition guidelines recommend a pre-treatment nutritional assessment. When malnutrition is present, nutritional interventions, such as dietary guidance and enteral nutrition supplements, provided by the medical team may reduce treatment-related adverse events. However, whether nutritional intervention improves the prognosis is a topic for future research, including randomized controlled trials. This review discusses the literature on nutritional management in patients undergoing chemotherapy and chemoradiotherapy for advanced esophageal cancer.

Palliative use of self-expanding metal stents in initially anticancer treatment-intolerant patients with esophageal cancer

BACKGROUND

The post-insertion clinical course of esophageal self-expandable metal stents (SEMS) in initially frail patients with esophageal carcinoma (EC) with dysphagia remains unclear. This study aimed to assess dysphagia improvement and evaluate prognosis in initially frail patients with advanced EC following SEMS insertion.

METHODS

We retrospectively reviewed EC patients with EC who underwent esophageal SEMS insertion at our institution between January 2014 and March 2023. Inclusion criteria comprised Eastern Cooperative Oncology Group Performance Status (ECOG PS) ≥ 3 or ECOG PS 2 for individuals aged ≥ 75 years and recommendation for best supportive care by a multidisciplinary team.

RESULTS

Forty-six patients met the inclusion criteria. Among them, 37 patients (80.4%) were ≥ 75 years old, and 21 patients (45.7%) exhibited ECOG PS 3 or 4. Dysphagia score (DS) ≥ 3 was observed in 27 patients (58.7%). All esophageal SEMS insertions were successfully completed. Post-procedure, there were two fatal cases of aspiration pneumonia and one perforation incident. DS improved to ≤ 1 in 25 patients (54.3%), with multivariate analysis indicating DS 3-4 and Glasgow Prognostic Score (GPS) 1-2 as negative predictive factors. The median overall survival was 4.1 months (95% confidence interval 1.8-6.5).

CONCLUSIONS

Esophageal SEMS insertion effectively alleviated dysphagia in initially frail EC patients, yet prognosis remained poor, with occurrences of some fatal adverse events. Careful selection of candidates for esophageal SEMS insertions is crucial in this demographic, particularly considering the challenges in improving dysphagia for patients with DS 3-4 and GPS 1-2.

Efficacy and survival of nivolumab treatment for recurrent/unresectable esophageal squamous-cell carcinoma: real-world clinical data from a large multi-institutional cohort

BACKGROUND

Real-world clinical outcomes of and prognostic factors for nivolumab treatment for esophageal squamous-cell carcinoma (ESCC) remain unclear. This study aimed to evaluate real-world outcomes of nivolumab monotherapy in association with relevant clinical parameters in recurrent/unresectable advanced ESCC patients.

METHODS

This population-based multicenter cohort study included a total of 282 patients from 15 institutions with recurrent/unresectable advanced ESCC who received nivolumab as a second-line or later therapy between 2014 and 2022. Data, including the best overall response, progression-free survival (PFS), and overall survival (OS), were retrospectively collected from these patients.

RESULTS

Objective response and disease control rates were 17.0% and 47.9%, respectively. The clinical response to nivolumab treatment significantly correlated with development of overall immune-related adverse events (P < .0001), including rash (P < .0001), hypothyroidism (P = .03), and interstitial pneumonia (P = .004). Organ-specific best response rates were 20.6% in lymph nodes, 17.4% in lungs, 15.4% in pleural dissemination, and 13.6% in primary lesions. In terms of patient survival, the median OS and PFS was 10.9 and 2.4 months, respectively. Univariate analysis of OS revealed that performance status (PS; P < .0001), number of metastatic organs (P = .019), C-reactive protein-to-albumin ratio (CAR; P < .0001), neutrophil-lymphocyte ratio (P = .001), and PMI (P = .024) were significant. Multivariate analysis further identified CAR [hazard ratio (HR) = 1.61, 95% confidence interval (CI) 1.15-2.25, P = .0053)] in addition to PS (HR = 1.65, 95% CI 1.23-2.22, P = .0008) as independent prognostic parameters.

CONCLUSIONS

CAR and PS before nivolumab treatment are useful in predicting long-term survival in recurrent/unresectable advanced ESCC patients with second-line or later nivolumab treatment.

TRIAL REGISTRATION

UMIN000040462.

Nutritional status as prognostic factor of advanced oesophageal cancer patients treated with immune checkpoint inhibitors

BACKGROUND & AIMS

Malnutrition is reported in 60%-85% of oesophageal cancer (EC) patients. Indicators commonly used in the clinic to evaluate the nutritional status of patients include haemoglobin (Hb), body mass index (BMI), albumin (ALB), prognostic nutritional index (PNI), prealbumin (PAB), transferrin (TRF), and NRS2002 scores. In this study, we explored the associations between pretreatment nutrition-related indicators and clinical outcomes in patients with advanced EC who were treated with immune checkpoint inhibitors (ICIs).

METHODS

The general clinical data of patients, NRS2002 scores, PNI, and levels of BMI, ALB, Hb, PAB, and TRF at baseline were collected. Categorical variables were compared using the chi-squared test. The chi-squared test was used to compare the differences in the objective response rate (ORR) and the disease control rate (DCR) between groups. The Kaplan-Meier method was used to compute the survival curves. Cox proportional hazard regression was performed to evaluate factors independently associated with OS and PFS.

RESULT

Of the 1340 patients diagnosed with EC at Zhejiang Cancer Hospital between June 2018 and September 2022, 354 patients with advanced EC who underwent ICI therapy were enrolled. In total, the ORR and DCR were 38.1% and 82.2%, respectively. A significantly worse response to ICI therapy was observed in the Hb-L group and the BMI-L group. The median PFS and OS among all enrolled patients were 6.0 months and 13.3 months, respectively. PFS was significantly associated with pretreatment levels of Hb, ALB, and PAB. OS was significantly associated with pretreatment levels of Hb, ALB, BMI, PNI, TRF, and PAB. The multivariate analysis further demonstrated that Hb was an independent prognostic factor of both OS (P = 0.004) and PFS (P = 0.047), and ALB was an independent prognostic factor of OS (P = 0.045). No independent relevance for OS or PFS was found in the BMI, PNI, TRF, or PAB groups. In this study, the NRS2002 scores was not significantly correlated with the therapeutic response or prognosis of ICI therapy.

CONCLUSION

Our study indicated the relevance of nutritional status to the efficacy and prognosis of advanced EC patients treated with ICIs. The pretreatment levels of Hb and BMI were significantly related to therapeutic response. The pretreatment levels of Hb, BMI, ALB, PAB, TRF, and PNI were partially associated with survival. Notably, Hb is not only related to therapeutic response but is also an independent prognostic indicator of survival outcomes.

Immune checkpoint inhibitors in the treatment of oesophageal squamous cell carcinoma: where are we and where are we going?

Oesophageal squamous cell carcinoma (ESCC) is a kind of malignant tumour with high invasiveness and a poor prognosis. Immunotherapy, especially immune checkpoint inhibitors (ICIs), is a rapidly growing therapeutic method that activates and enhances anti-tumour immunity to treat patients with malignancy. Several clinical trials have confirmed the efficacy of ICIs in the treatment of ESCC. ICIs have been approved for the treatment of patients with ESCC. However, only a subset of patients can obtain excellent benefits from ICI therapy. In recent years, there has been a growing interest in exploring predictive biomarkers of immunotherapy response. In this review, we highlighted the predictive biomarkers for the prognosis of ESCC patients treated with ICIs and pointed out the existing problems and the direction of future research in this field.

Effect of systemic inflammatory response on induction chemotherapy followed by chemoradiotherapy for locally advanced pancreatic cancer: an exploratory subgroup analysis on systemic inflammatory response in JCOG1106

OBJECTIVE

JCOG1106, a randomized phase II trial conducted to compare chemoradiotherapy (S-1 concurrent radiotherapy) with (Arm B) or without (Arm A) induction chemotherapy using gemcitabine in patients with locally advanced pancreatic cancer, showed a more favorable long-term survival in Arm A. This study was aimed at exploring whether some subgroups classified by the systemic inflammatory response might derive greater benefit from either treatment.

METHODS

All subjects eligible for JCOG1106 were included in this analysis (n = 51/49 in Arm A/B). This exploratory subgroup analysis was performed by Cox regression analysis to investigate the impact of the systemic inflammatory response, as assessed based on the serum C-reactive protein, serum albumin (albumin), Glasgow Prognostic Score and derived neutrophil-lymphocyte ratio, at the baseline on overall survival. P values <0.1 for the interaction were regarded as denoting significant association.

RESULTS

Glasgow prognostic score showed significant treatment interactions for overall survival. Hazard ratios of Arm B to Arm A were 1.35 (95% confidence interval, 0.82-2.23) in the Glasgow Prognostic Score 0 (C-reactive protein ≤10 mg/L and albumin ≥35 g/L) (n = 44/34 in Arm A/B) and 0.59 (95% confidence interval, 0.24-1.50) in the Glasgow Prognostic Score 1/2 (C-reactive protein >10 mg/L and/or albumin <35 g/L) (n = 7/15) (P-interaction = 0.06). C-reactive protein alone and albumin alone also showed significant treatment interactions for overall survival.

CONCLUSIONS

Survival benefits of induction chemotherapy in chemoradiotherapy for locally advanced pancreatic cancer were observed in patients with elevated Glasgow Prognostic Score, high C-reactive protein and low albumin. These results suggest that systemic inflammatory response might be considered to apply induction chemotherapy preceding chemoradiotherapy.

The Impact of Pretreatment Esophageal Stenosis on Survival of Esophageal Cancer Patients

BACKGROUND

Little is known about the survival impacts of pretreatment cancerous stenosis on patients with esophageal carcinoma (EC).

METHODS

The clinicopathologic characteristics of patients who underwent surgery for EC between January 2010 and December 2018 were retrospectively reviewed. Esophageal stenosis was defined as present when a thin endoscope could not be passed through the tumor site. The impacts of stenosis on overall survival (OS) and cancer-specific survival (CSS) were evaluated using Cox hazards analysis.

RESULTS

Of the 496 EC patients in this study, 51 (10.3 %) had pretreatment esophageal stenosis. Stenosis was associated with lower body mass index (P < 0.001) and higher pStage (P < 0.001). The 3-year OS rate for the patients with stenosis was significantly poorer than for the patients without stenosis (40.2 % vs 69.6 %; hazard ratio [HR], 2.19; P < 0.001). The survival outcomes, especially CSS, for the patients with stenosis were significantly poorer than for the patients without stenosis for both pStage II-III (P = 0.009) and pStage IV (P = 0.006) disease. The OS and CSS curves were well stratified by the presence of stenosis even in early-stage (pStage II) patients (P = 0.04 and P < 0.01, respectively). Multivariable analysis showed esophageal stenosis, pStage III-IV disease, and non-curative resection to be independently associated with poor OS (HR, 1.61; P = 0.02) and poor CSS (HR,1.67; P = 0.02). Higher pStage was an independent predictor of poor CSS for patients without stenosis, but not for those with stenosis.

CONCLUSIONS

Esophageal carcinoma patients with pretreatment stenosis had significantly poorer survival outcomes, especially poorer CSS, than those without stenosis in both early- and advanced-stage diseases.

Development and validation of an [18F]FDG-PET/CT radiomic model for predicting progression-free survival for patients with stage II - III thoracic esophageal squamous cell carcinoma who are treated with definitive chemoradiotherapy

BACKGROUND

Radiomics is a method for extracting a large amount of information from images and used to predict treatment outcomes, side effects and diagnosis. In this study, we developed and validated a radiomic model of [¹⁸F]FDG-PET/CT for predicting progression-free survival (PFS) of definitive chemoradiotherapy (dCRT) for patients with esophageal cancer.

MATERIAL AND METHODS

Patients with stage II - III esophageal cancer who underwent [¹⁸F]FDG-PET/CT within 45 days before dCRT between 2005 and 2017 were included. Patients were randomly assigned to a training set (85 patients) and a validation set (45 patients). Radiomic parameters inside the area of standard uptake value ≥ 3 were calculated. The open-source software 3D slicer and Pyradiomics were used for segmentation and calculating radiomic parameters, respectively. Eight hundred sixty radiomic parameters and general information were investigated.In the training set, a radiomic model for PFS was made from the LASSO Cox regression model and Rad-score was calculated. In the validation set, the model was applied to Kaplan-Meier curves. The median value of Rad-score in the training set was used as a cutoff value in the validation set. JMP was used for statistical analysis. RStudio was used for the LASSO Cox regression model. p < 0.05 was defined as significant.

RESULTS

The median follow-up periods were 21.9 months for all patients and 63.4 months for survivors. The 5-year PFS rate was 24.0%. In the training set, the LASSO Cox regression model selects 6 parameters and made a model. The low Rad-score group had significantly better PFS than that the high Rad-score group (p = 0.019). In the validation set, the low Rad-score group had significantly better PFS than that the high Rad-score group (p = 0.040).

CONCLUSIONS

The [¹⁸F]FDG-PET/CT radiomic model could predict PFS for patients with esophageal cancer who received dCRT.

Usefulness of Nutrition and Inflammation Assessment Tools in Esophageal Cancer Treatment

Multidisciplinary treatment for esophageal cancer leads to nutritional and inflammatory changes. Recent studies showed that nutritional and inflammatory changes during multidisciplinary treatment affect both short and long-term oncological outcomes in esophageal cancer treatment. Therefore, evaluation of the nutritional and inflammatory status during treatment is necessary in order to optimize and utilize multidisciplinary therapy for esophageal cancer. If patients with esophageal cancer are able to determine their nutritional and inflammatory status, they will be able to select the optimal esophageal cancer, anti-inflammation, and nutritional treatments. Various types of nutrition and inflammation assessment tools have been developed and reported for esophageal cancer, with each tool having its own clinical characteristics, which must be understood before being applied in clinical practice. This review summarizes the background, current status, and future perspectives on the application of nutrition and inflammation assessment tools in esophageal cancer treatment.

Esophageal stenosis as an independent factor of poor prognosis in patients with ESCC treated with definitive chemoradiotherapy

Aim: To evaluate the clinical outcome and elucidate the prognostic factors in patients with esophageal squamous cell carcinoma (ESCC) treated with definitive chemoradiotherapy (CRT). Patients: Data for patients newly diagnosed with ESCC receiving definitive CRT at our institution between 2012 and 2018 were retrospectively reviewed. Results: A total of 201 patients were included. Severe stenosis after radiotherapy was an independent factor relevant to prognosis. Maximal esophageal wall thickness, short-term responses, severe stenosis at diagnosis and a high neutrophil-to-lymphocyte ratio were independent risk factors for the occurrence of severe stenosis after radiotherapy. Conclusion: Severe stenosis after radiotherapy is a useful predictive indicator in patients with ESCC receiving definitive CRT. Further studies are needed to verify these findings.

Real-World Efficacy Data and Predictive Clinical Parameters for Treatment Outcomes in Advanced Esophageal Squamous Cell Carcinoma Treated with Immune Checkpoint Inhibitors

PURPOSE

This study aimed to evaluate the real-world efficacy of immune checkpoint inhibitors (ICIs), and to identify clinicolaboratory factors to predict treatment outcomes in patients with advanced esophageal squamous cell carcinoma (ESCC) receiving ICIs.

MATERIALS AND METHODS

Sixty patients with metastatic or unresectable ESCC treated with nivolumab (n=48) or pembrolizumab (n=12) as ≥ second-line treatment between 2016 and 2019 at Asan Medical Center were included.

RESULTS

The median age of the patients was 68 years (range, 52 to 76 years), and 93.3% were male. Most patients had metastatic disease (81.7%) and had been previously treated with fluoropyrimidines, platinum, and taxane. In 53 patients with measurable disease, the overall response rate and disease control rate were 15.1% and 35.8%, respectively. With a median follow-up duration of 16.0 months, the median progression-free survival (PFS) and overall survival (OS) were 1.9 months (95% confidence interval [CI], 1.54 to 2.19) and 6.4 months (95% CI, 4.77 to 8.11), respectively. After multivariate analysis, recent use of antibiotics, low prognostic nutrition index (< 35.93), high Glasgow Prognosis Score (≥ 1) at baseline, and ≥ 1.4-fold increase in neutrophil-to-lymphocyte ratio after one cycle from baseline were significantly unfavorable factors for both PFS and OS. Younger age (< 65 years) was a significant factor for unfavorable PFS and hyponatremia (< 135 mmol/L) for unfavorable OS.

CONCLUSION

The use of ICIs after the failure of chemotherapy showed comparable efficacy in patients with advanced ESCC in real practice; this may be associated with host immune-nutritional status, which could be predicted by clinical and routine laboratory factors.

Chemoradiotherapy for Locally Advanced Esophageal Squamous Cell Carcinoma

PURPOSE

Few studies have reported the impact of chemoradiotherapy (CRT) on the objective response of patients with locally advanced unresectable esophageal squamous cell carcinoma (ESCC). We evaluated the factors predicting therapeutic effectiveness and the short- and long-term outcomes in patients with T4b ESCC treated with CRT.

METHODS

We included 155 patients with T4b ESCC who underwent CRT at the Department of Surgery, Gastroenterological Center, Yokohama City University, between January 2000 and December 2018. Responders were defined as patients who demonstrated a complete response (CR) or partial response (PR). Multivariate analysis for objective response was performed using a logistic regression model, and prognostic factors were evaluated by univariate and multivariate analyses.

RESULTS

Among the 155 patients included, 20 and 84 patients demonstrated a CR and PR, respectively, resulting in a response rate of 67.1%. The median overall survival (OS) was 15.2 months, and the 3-year survival rate was 32.1%. High Glasgow prognostic score (GPS) and advanced N-category independently predicted the objective response to CRT. GPS and objective response were independent prognostic factors for OS. There was no significant difference in the long-term survival of responders who received subsequent chemotherapy or salvage surgery.

CONCLUSIONS

High GPS and advanced N-category predicted a poor objective response to CRT in patients with T4b ESCC. Therefore, chemotherapeutic regimens with a higher efficacy are required. The indications for salvage surgery for responders should be carefully considered, with care taken to avoid complications. To confirm this, prospective randomized controlled studies are necessary.

Clinical outcomes and prognostic factors for esophageal cancer in patients aged 80 years or older who were treated with definitive radiotherapy and chemoradiotherapy

OBJECTIVE

Aging of populations has been rapidly increasing worldwide. The aim of this study was to identify prognostic factors of overall survival (OS) and progression-free survival (PFS) in patients aged 80 years or older who had esophageal cancer and received radiotherapy.

METHODS

Patients aged 80 years or older who received radiotherapy between 2004 and 2015 were retrospectively reviewed. Pretreatment age, gender, performance status, Charlson comorbidity index score, tumor location, histology, clinical stage, results of blood tests and treatment methods were obtained to determine prognostic factors of OS and PFS. Survival curves were drawn using the Kaplan-Meier method and prognostic factors were analyzed using Cox's hazards model.

RESULTS

Ninety-two patients were included. Thirty-five patients were treated with chemo-radiotherapy. The median follow-up period was 19.0 months. The 3-year OS and PFS rates were 44.7% and 28.4%, respectively. In multivariate analysis, clinical stage (hazard ratio [HR] 2.28, 95% confidence interval [CI] 1.40-3.73, p = 0.001) and the geriatric nutritional risk index (GNRI, HR 0.95, 95% CI 0.92-0.97, p < 0.001) were significant prognostic factors of OS. Clinical stage (HR 2.06, 95% CI 1.34-3.18, p = 0.001), tumor location (HR 2.04, 95% CI 1.39-3.01, p < 0.001) and GNRI (HR 0.96, 95% CI 0.94-0.99, p = 0.003) were significant prognostic factors of PFS.

CONCLUSION

Clinical stage and GNRI were significant prognostic factors of OS and PFS. Tumor location was a significant prognostic factor of PFS. These prognostic factors might be useful for decision-making for elderly patients with esophageal cancer.

Analysis of expression profiles and prognostic value of COP9 signalosome subunits for patients with head and neck squamous cell carcinoma

Head and neck squamous cell carcinoma (HNSCC) has been associated with poor prognosis, due to its strong invasive ability and resistance to chemotherapy. Thus, there is an urgent requirement to identify effective biomarkers for the early diagnosis and prognostic evaluation of HNSCC. COP9 signalosome (COPS) regulates numerous cancer-associated biological processes in various malignancies. The aim of the present study was to investigate the association between COPS and HNSCC. The mRNA expression profiles of COPS in HNSCC were analyzed using UALCAN, Oncomine and UCSC Xena databases. The association between overall survival time in patients with HNSCC and the COPS genes was investigated using the Kaplan-Meier plotter database. The CERES score was obtained and evaluated to determine the importance of the COPS genes for survival of the HNSCC cell lines. Functional analysis for Gene Ontology and Gene Set Enrichment Analysis (GSEA) was performed using The Database for Annotation, Visualization and Integrated Discovery and GSEA software, respectively. After knocking down COPS5 and COPS6, cell Counting Kit-8 and wound healing assays were used to detect cell growth and migration of the CAL27 and SCC25 cell lines, respectively. Among the 10 COPS genes examined, most COPS subunits were upregulated in HNSCC samples compared with that in normal tissues, except for COPS9. Increased mRNA expression level of COPS5, COPS6, COPS7B, COPS8 and COPS9 was associated with TNM stage in patients with HNSCC. High mRNA expression level of COPS2, COPS5, COPS6, COPS7A, COPS7B, COPS8 and COPS9 had prognostic significance of patients with HNSCC. Knockdown of COPS5 and COPS6 inhibited cell growth and migration of the CAL27 and SCC25 cell lines. The results from the present study suggested that COPS subunits could be potential biomarkers in patients with HNSCC. COPS5 and COPS6 were important for cell survival and migration of the HNSCC cells.

Influences of the Charlson Comorbidity Index and Nutrition Status on Prognosis After Esophageal Cancer Surgery

BACKGROUND

The Charlson Comorbidity Index (CCI), an indicator that objectively quantifies comorbidities, reduces nutritional status; however, the impact of the CCI on the postoperative nutrition indexes of patients with esophageal cancer remains unclear.

METHODS

In total, 336 patients with esophageal cancer who underwent surgery between January 2011 and April 2017 were included in this study. We investigated the relationship between the CCI and postoperative nutrition indexes.

RESULTS

Patients were divided into two groups: CCI ≤1 (low CCI group) and CCI ≥2 (high CCI group). A high CCI was significantly associated with shortened overall survival (OS; 3-year OS rate of 77.9% in the low CCI group versus 59.7% in the high CCI group; p = 0.008). Nutritional indexes, such as the Prognostic Nutritional Index (PNI), at 1 month after esophagectomy were significantly lower in the high CCI group than in the low CCI group (p = 0.031); however, the PNI at 6 months after surgery was similar between the high and low CCI groups. Multivariate analysis identified high CCI as an independent risk factor associated with PNI <45 in esophageal cancer patients at 1 month after esophagectomy (p = 0.047).

CONCLUSION

This study showed that CCI ≥2 was significantly associated with poor PNI at 1 month after surgery for esophageal cancer, indicating that it is necessary to administer effective nutritional interventions for patients with postoperative malnutrition, especially those with multiple comorbidities.

Survival and prognostic factors of patients with esophageal fistula in advanced esophageal squamous cell carcinoma

The aim of the present study was to investigate the survival and prognostic factors of patients who were with advanced esophageal squamous cell carcinoma (ESCC) and developed an esophageal fistula. The data from 221 patients with advanced ESCC developed esophageal fistula from January 2008 to December 2017 at the Harbin Medical University Cancer Hospital was retrospectively analyzed. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated by the Cox proportional hazard models. The median survival time after a diagnosis of the esophageal fistula was calculated using the Kaplan–Meier method. We found that the pathogens infected by patients are common bacteria in nosocomial infection. Besides, the incidence rate of esophagomediastinal fistula was the highest (54.2%) in the lower third of the esophagus. Kaplan–Meier analysis revealed a median survival time of 11.00 months and a median post-fistula survival time of 3.63 months in patients who developed esophageal fistula in advanced esophageal cancer. In the univariate analysis, gender, therapies for ESCC before the development of fistula, type of esophageal fistula, treatment of esophageal fistula and hemoglobin (Hb) level were the factors with significant prognostic value. Gender, type of esophageal fistula and Hb level were identified as independent prognostic factors in further multivariate analysis. In summary, our study demonstrated that several factors are significantly related to patients with esophageal fistula and should be concerned about in clinical practice.

The association of primary tumor site with acute adverse event and efficacy of definitive chemoradiotherapy for cStage II/III esophageal cancer: an exploratory analysis of JCOG0909

BACKGROUND

JCOG0909 is a phase II trial of definitive chemoradiotherapy including salvage treatment for cStage II-III thoracic esophageal cancer; the radiation field for elective regional lymph node irradiation, which can affect patient outcome and adverse event, varied based on the primary tumor site, i.e., upper (Ut), middle (Mt), and lower thoracic (Lt) esophagus. The impact of different primary sites on the safety and efficacy of definitive chemoradiotherapy in JCOG0909 is not well characterized.

METHODS

Patients were categorized into three groups (Ut, Mt, and Lt) according to the primary tumor location. We compared acute adverse events during definitive chemoradiotherapy, complete response (CR) rate, 3-year progression-free survival (PFS), and overall survival (OS) among the 3 groups.

RESULTS

Out of the 96 patients enrolled in JCOG0909 between April 2010 and August 2014, 94 patients (16, 59, and 19 patients in the Ut, Mt, and Lt groups, respectively) were included in this exploratory analysis. The proportion of patients with cStage III was 25% in the Ut, 37% in the Mt, and 47% in the Lt group. Grade 3-4 leukopenia, neutropenia, and thrombocytopenia were more frequently observed in the Mt (66%, 54%, and 15%) and Lt groups (84%, 68%, and 16%) than in the Ut group (38%, 44%, and 0%). There was no significant between-group difference with respect to 3-year OS (73.3%, 77.9%, and 57.9%), 3-year PFS (60.0%, 59.3%, and 47.4%), or CR rate (62.5%, 62.7%, and 42.1%).

CONCLUSIONS

In JCOG0909, the incidence of severe hematological toxicity had a trend toward higher in the Mt and Lt than the Ut esophageal cancer; however, no remarkable difference by primary sites was observed with respect to efficacy endpoints.

The prevalence of cancer associated systemic inflammation: Implications of prognostic studies using the Glasgow Prognostic Score

The prognostic importance of SIR in patients with cancer is widely recognised. More recently it has become clear that the systemic inflammatory response is an important etiologic factor in the development of cancer cachexia. Two recent meta-analysis carried out in 2017 and 2018 were interrogated and the number of patients with specific cancer types were identified. The percentage of patients with operable cancer (n>28,000) who were systemically inflamed varied from 21% to 38%. The percentage of patients with inoperable cancer (n>12,000) who were systemically inflamed varied from 29% to 79%. Overall, the percentage of patients (n>40,000) who were systemically inflamed varied from 28% to 63% according to tumour type. The most commonly studied cancer was colorectal cancer (n∼10,000 patients) and 40% were systemically inflamed.

Prognostic Value of Inflammation Biomarkers for Survival of Patients with Neuroblastoma

PURPOSE

The prognostic significance of inflammation-based biomarkers for neuroblastoma (NB) has not been investigated before. The aim of this study was to evaluate the prognostic value of pre-treatment inflammation biomarkers in children patients with NB.

PATIENTS AND METHODS

Patients diagnosed with NB from 2008 to 2016 in our institution were enrolled in this study. The clinical data and survival outcomes were retrospectively reviewed. Inflammation biomarkers or scores including C-reactive protein (CRP), albumin (ALB), Glasgow Prognostic Score (GPS), modified Glasgow Prognostic Score (mGPS), high-sensitivity modified Glasgow Prognostic Score (Hs-mGPS), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), lymphocyte to monocyte ratio (LMR) and system inflammation index (SII) were tested in this study. Univariate and multivariate survival analyses were performed to assess the prognostic value of these inflammation indicators for overall survival (OS) of children with NB. Kaplan-Meier survival curves were also conducted.

RESULTS

A total of 70 children diagnosed with neuroblastoma were enrolled in this study. NLR, PLR, LMR and SII were found to be not predictive of OS for NB patients. However, CRP, ALB, GPS and CAR were significantly associated with OS of NB patients. Multivariate analysis adjusting for age, sex, histology, tumor size, tumor stage and metastasis revealed that ALB, CAR, GPS and Hs-mGPS were significantly associated with OS of NB patients. Receiver operating characteristic (ROC) curves and Akaike Information Criterion (AIC) analyses revealed that Hs-mGPS is superior to other inflammation biomarkers in predicting OS of NB patients. Subgroup survival analysis for immature NB patients revealed similar results.

CONCLUSION

Hs-mGPS is an effective prognostic factor for OS of patients with NB and is promising to be used as a factor for risk stratification and an indicator for more aggressive therapy.

Phase III study of tri-modality combination therapy with induction docetaxel plus cisplatin and 5-fluorouracil versus definitive chemoradiotherapy for locally advanced unresectable squamous-cell carcinoma of the thoracic esophagus (JCOG1510: TRIANgLE)

A randomized phase III trial commenced in Japan in February 2018. Definitive chemoradiotherapy (CRT) with cisplatin plus 5-fluorouracil is the current standard treatment for locally advanced unresectable esophageal carcinoma. The purpose of this study is to confirm the superiority of induction chemotherapy with docetaxel plus cisplatin and 5-fluorouracil (DCF) followed by conversion surgery or definitive CRT over definitive CRT alone for overall survival (OS) in patients with locally advanced unresectable squamous-cell carcinoma of thoracic esophagus. A total of 230 patients will be accrued from 47 Japanese institutions over 4.5 years. The primary endpoint is OS, and the secondary endpoints are progression-free survival, complete response rate of CRT, response rate of DCF, adverse events of DCF and CRT, late adverse events and surgical complications. This trial has been registered at the Japan Registry of Clinical Trials as jRCTs031180181.

Clinical significance of evaluating endoscopic response to neoadjuvant chemotherapy in esophageal squamous cell carcinoma

BACKGROUND AND AIM

Clinical significance of endoscopic response (ER) after neoadjuvant chemotherapy (NAC) for esophageal cancer has not been fully understood. Thus, the present study aimed to investigate the association between ER to NAC and its clinicopathological outcomes in patients with esophageal squamous cell carcinoma (ESCC).

METHODS

In total, 141 patients who underwent NAC and subsequent esophagectomy for ESCC were included. ER to NAC was retrospectively evaluated based on macroscopic findings of the primary tumor, which was classified into three categories: endoscopic no response (eNR), endoscopic partial response (ePR), and endoscopic good response (eGR). An endoscopic responder was defined as patients with eGR/ePR.

RESULTS

Approximately 89.4% of patients had cStage II-III disease, and 7.1% had pathological complete response. Upon ER evaluation, eNR, ePR, and eGR were observed in 46 (32.6%), 54 (38.3%), and 41 (29.1%) patients, respectively. Pathological responders significantly increased as the ER grade became better. Among preoperative clinical factors, only ER significantly correlated with pathological response in univariate and multivariate analysis. Endoscopic responders showed a significantly better prognosis than did eNR patients (P < 0.001), although the overall survival (OS) of the patients with eGR and ePR was equivalent. Endoscopic responder, ypT, ypN, and pathological responder were significant predictors of OS in the univariate analysis, and endoscopic responder, ypN, and pathological responder were independent predictors in the multivariate analysis.

CONCLUSION

This study suggests that ER can be a simple and important tool to predict the pathological response and survival of patients who undergo NAC for ESCC.

Long-term outcomes of multimodal therapy combining definitive chemoradiotherapy and salvage surgery for T4 esophageal squamous cell carcinoma

BACKGROUND

Survival outcomes of patients with cT4 esophageal squamous cell carcinoma (ESCC) remain extremely poor. We aimed to investigate long-term outcomes and identify prognostic factors in patients treated by definitive chemoradiotherapy (dCRT) alone or with dCRT plus salvage surgery (SALV) for cT4 ESCC.

PATIENTS AND METHODS

In total, 73 patients completing dCRT were analyzed. Patients achieving clinical complete response (CR) received follow-up evaluations thereafter. For patients diagnosed with clinical partial response (PR), potentially curative SALV was generally performed. Possible prognostic factors included demographic data, tumor staging, blood chemistry profiles, and esophageal stenosis.

RESULTS

The 1- and 3-year overall survival (OS) rates of the 73 patients were 67.1% and 40.8%, respectively. Twenty-one patients (29%) achieved clinical CR with dCRT alone. Among 35 patients (48%) with clinical PR, 31 underwent SALV and 4 opted for non-surgical treatments. In the dCRT-alone group (n = 42), patients with clinical CR-PR (n = 25) showed significantly better 3-year OS than those who responded poorly to dCRT (stable or progressive) (n = 17) (67.5% vs. 0%, P < 0.001). In the SALV group (n = 31), curative SALV (n = 22, 73%) provided significantly better 3-year OS than non-curative SALV (58.7% vs. 0%, P < 0.001). Multivariable analysis revealed stenosis before dCRT (P = 0.02) and pretreatment elevated CRP (P = 0.02) to be independently associated with poor outcomes.

CONCLUSIONS

The multimodal treatment strategy combining dCRT and SALV is rational for treating cT4 ESCC patients. When curative resection is feasible, SALV can provide good long-term survival outcome for patients who responded to dCRT but did not achieve clinical CR with dCRT alone.

The prognostic value of pretreatment Glasgow Prognostic Score in patients with esophageal cancer: a meta-analysis

Objectives

To examine the predictive role of Glasgow Prognostic Score (GPS) on long-term survival in esophageal cancer.

Method

Comprehensive searches of electronic databases were performed to identify potential studies that evaluated the prognostic value of pretreatment GPS in esophageal cancer patients. We combined the hazard ratios (HRs) with 95% confidence intervals (CIs) to assess the association of GPS with overall survival (OS), disease-free survival (DFS) and cancer-specific survival (CSS).

Results

A total of 21 studies including 6115 patients were analyzed. Compared with patients with GPS 0, patients with elevated GPS had poorer OS (HR =2.12, 95% CI: 1.83–2.45, P<0.001) and CSS (HR =2.16, 95% CI: 1.56–2.98, P<0.001); but no significant relationship was observed between the elevated GPS and DFS (HR=2.14, 95% CI:1.00–4.61, P=0.051). Subgroup analysis outcomes were similar to overall analyses.

Conclusion

Pretreatment GPS could serve as a valuable factor in predicting the prognosis of patients with esophageal cancer. More well-designed prospective studies are warranted to confirm our findings.

The Benefits of Docetaxel Plus Cisplatin and 5-Fluorouracil Induction Therapy in Conversion to Curative Treatment for Locally Advanced Esophageal Squamous Cell Carcinoma

BACKGROUND

Definitive chemoradiotherapy (CRT), used for treatment of patients with an initial diagnosis of unresectable locally advanced esophageal cancer, has led to unsatisfactory long-term prognosis. Moreover, CRT can lead to esophageal fistula, perforation, and strictures. Therefore, strong induction chemotherapeutic treatments are necessary to reduce the tumor volume for subsequent radical esophagectomy. This study aimed to determine the oncological utility of docetaxel plus cisplatin and 5-fluorouracil (DCF) and the technical feasibility of subsequent esophagectomy for locally advanced esophageal cancer.

METHODS

Eighty-seven patients with clinical borderline unresectable T3 and T4 esophageal squamous cell carcinoma without distant metastases were included in this study. There were 44 patients in primary DCF group and 43 patients in definitive CRT group, and perioperative and long-term oncological outcomes were compared between the two groups.

RESULTS

Twenty-two patients (50%) achieved R0 resection in the DCF group. Albeit not significant, the rate of curative treatment was higher in the DCF group than the definitive CRT group (p = 0.099). The overall survival (OS) and progression-free survival (PFS) were better with DCF than with definitive CRT (median OS, 29 vs. 17 months, p = 0.206; median PFS, 10 vs. 6 months, p = 0.020). Specifically, the OS of patients with a Charlson score of less than 3 among the DCF-treated patients tended to be better than those among the definitive CRT-treated patients.

CONCLUSION

DCF and subsequent esophagectomy achieved R0 resection in 50% of the patients and was associated with better long-term oncological outcomes in patients with initially unresectable esophageal cancer if their systemic status is acceptable.

Does oesophageal stenosis have any impact on survival of oesophageal cancer patients?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was 'Does oesophageal stenosis have any impact on survival of oesophageal cancer patients?'. A total of 542 papers were found using the reported search, of which 8 cohort studies represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Most of these studies defined stenosis as failure to cross the tumour at endoscopic ultrasonography. Seven studies demonstrated that oesophageal cancer patients with stenosis had significantly poorer survival than those without, while 2 studies found that oesophageal stenosis was also a predictor of poor recurrence-free survival. We conclude that oesophageal stenosis is a predictor of poor prognosis in patients with oesophageal cancer.

Cancerous esophageal stenosis before treatment was significantly correlated to poor prognosis of patients with esophageal cancer: a meta-analysis

Background

Cancerous esophageal stenosis encountered during endoscopic ultrasonography before treatment was observed in about 30% of esophageal cancer patients. Since the pT stage in TNM classification measures only the depth of infiltration but not the growth to esophagus, it is interesting to know whether tumor growth into the esophagus (and eventual stenosis) is of added value in prognostic assessment. However, the impact of esophageal stenosis on survival of esophageal cancer patient remains unclear. Therefore, we conducted a meta-analysis focusing on current topic for the first time.

Methods

A systematic literature search in PubMed and EMBASE was conducted to identify relevant studies up to 14 March 2018. Data of 5-year overall survival (OS) was extracted and analysed.

Results

A total of five cohort studies consisting of 1,282 patients (278 patients with cancerous esophageal stenosis before treatment and 1,004 patients without) with esophageal cancer treated with surgery, chemoradiotherapy, or palliative therapy were included for analysis. Meta-analysis showed that patients with esophageal stenosis had significantly lower 5-year OS [22.3% and 33.0%, respectively; risk ratio (RR) =1.21; 95% CI, 1.11-1.32; P<0.001; I²=27.1%] than those without. No heterogeneity or publication bias was observed during analysis.

Conclusions

Patients with cancerous esophageal stenosis identified by endoscopy before treatment had significantly poorer survival than those without. High-quality studies with appropriate adjustments for confounding factor are needed to confirm the findings.

The value of preoperative Glasgow Prognostic Score and the C-Reactive Protein to Albumin Ratio as prognostic factors for long-term survival in pathological T1N0 esophageal squamous cell carcinoma

Plenty of studies have confirmed the prognostic values of inflammation-based prognostic scores in many malignant tumors. In present study, we aim to explore whether these indexes has same prognostic values in patients with stage T1N0 esophageal squamous cell carcinoma (ESCC). The clinicopathological data of 160 consecutive patients with pathological stage T1N0 ESCC from January 2005 to December 2012 were collected retrospectively. As prognostic factors, the inflammation-based prognostic scores, including C-reactive protein (CRP), Glasgow prognostic score (GPS), prognostic index (PI), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR) and CRP to albumin ratio (CAR), were evaluated. The best cut-off values were determined by the receiver operating characteristic (ROC) curves. The median follow-up time was 71.8 months. During the follow-up period, 34 (21.3%) patients occurred postoperative recurrence and 30 (18.8%) tumor-related deaths were recorded. The best cut-off values of CRP, NLR, PLR and CAR were 1.090, 1.976, 103.200 and 0.023, respectively. After multivariate analysis, the GPS and CAR were identified as independently prognostic factors for overall survival (OS) (p=0.017 and 0.040, respectively). Of all 160 individuals, there were 86 (53.8%) and 85 (53.1%) patients classified into high GPS group (1-2) and elevated CAR group (>0.023), respectively. In addition, the GPS were positively associated with PI (p<0.000) and the levels of serum CRP (p<0.000), NLR (p=0.004), PLR (p=0.029) and CAR (p<0.000) and the above correlations were also observed between the CAR and other inflammation-based prognostic scores (all p<0.050, except for p=0.054 for PLR levels). The preoperative GPS and CAR were simple, inexpensive, readily available predictor for long-term survival in stage T1N0 ESCC patients who underwent esophagectomy.