Neoadjuvant chemoradiotherapy could improve survival outcomes for esophageal carcinoma: a meta-analysis

Tumor-Resident Microbiota-Based Risk Model Predicts Neoadjuvant Therapy Response of Locally Advanced Esophageal Squamous Cell Carcinoma Patients

Few predictive biomarkers exist for identifying patients who may benefit from neoadjuvant therapy (NAT). The intratumoral microbial composition is comprehensively profiled to predict the efficacy and prognosis of patients with esophageal squamous cell carcinoma (ESCC) who underwent NAT and curative esophagectomy. Least Absolute Shrinkage and Selection Operator (LASSO) regression analysis is conducted to screen for the most closely related microbiota and develop a microbiota-based risk prediction (MRP) model on the genera of TM7x, Sphingobacterium, and Prevotella. The predictive accuracy and prognostic value of the MRP model across multiple centers are validated. The MRP model demonstrates good predictive accuracy for therapeutic responses in the training, validation, and independent validation sets. The MRP model also predicts disease-free survival (p = 0.00074 in the internal validation set and p = 0.0017 in the independent validation set) and overall survival (p = 0.00023 in the internal validation set and p = 0.11 in the independent validation set) of patients. The MRP-plus model basing on MRP, tumor stage, and tumor size can also predict the patients who can benefit from NAT. In conclusion, the developed MRP and MRP-plus models may function as promising biomarkers and prognostic indicators accessible at the time of diagnosis.

Multidisciplinary treatment of advanced cervical esophageal adenocarcinoma derived from a gastric inlet patch: A case report

A gastric inlet patch (GIP) is an ectopic gastric mucosal lesion usually arising at the cervical esophagus that may rarely cause esophageal adenocarcinoma (EAC). To the best of our knowledge, this is the first case of a GIP-derived EAC that was successfully treated using a multidisciplinary treatment approach. A 64-year-old man was referred to the Department of Gastrointestinal Surgery, Kanazawa University Hospital (Kanazawa, Japan) for surgical treatment of refractory recurrent cervical EAC derived from GIP who had previously been treated with induction chemotherapy, definitive chemoradiotherapy and photodynamic therapy (PDT). Esophagogastroduodenoscopy revealed a stenotic tumor at the GIP site in the cervical esophagus and submucosal tumors with suspected multiple intramural metastases in the anal side of the thoracic esophagus. The patient underwent robot-assisted thoracoscopic esophagectomy with laryngopharyngectomy and cervical lymphadenectomy as radical salvage surgery 4 months after the last PDT procedure. After postoperative adjuvant chemotherapy using oral administration of tegafur/gimeracil/oteracil (oral 5-fluorouracil prodrug) for 1 year; at present, the patient is alive without recurrence 3 years after the operation.

Neoadjuvant radiochemotherapy with cisplatin/5-flourouracil or carboplatin/paclitaxel in patients with resectable cancer of the esophagus and the gastroesophageal junction - comparison of postoperative mortality and complications, toxicity, and pathological tumor response

PURPOSE

In 2012, the CROSS trial implemented a new neoadjuvant radiochemotherapy protocol for patients with locally advanced, resectable cancer of the esophagus prior to scheduled surgery. There are only limited studies comparing the CROSS protocol with a PF-based (cisplatin/5-fluorouracil) nRCT protocol.

METHODS

In this retrospective, monocentric analysis, 134 patients suffering from esophageal cancer were included. Those patients received either PF-based nRCT (PF group) or nRCT according to the CROSS protocol (CROSS group) prior to elective en bloc esophagectomy. Perioperative mortality and morbidity, nRCT-related toxicity, and complete pathological regression were compared between both groups. Logistic regression analysis was performed in order to identify independent factors for pathological complete response (pCR).

RESULTS

Thirty-day/hospital mortality showed no significant differences between both groups. Postoperative complications ≥ grade 3 according to Clavien-Dindo classification were experienced in 58.8% (PF group) and 47.6% (CROSS group) (p = 0.2) respectively. nRCT-associated toxicity ≥ grade 3 was 30.8% (PF group) and 37.2% (CROSS group) (p = 0.6). There was no significant difference regarding the pCR rate between both groups (23.5% vs. 30.5%; p = 0.6). In multivariate analysis, SCC (OR 7.7; p < 0.01) and an initial grading of G1/G2 (OR 2.8; p = 0.03) were shown to be independent risk factors for higher rates of pCR.

CONCLUSION

We conclude that both nRCT protocols are effective and safe. There were no significant differences regarding toxicity, pathological tumor response, and postoperative morbidity and mortality between both groups. Squamous cell carcinoma (SCC) and favorable preoperative tumor grading (G1 and G2) are independent predictors for higher pCR rate in multivariate analysis.

Does Loosening the Inclusion Criteria of the CROSS Trial Impact Outcomes in the Curative-Intent Trimodality Treatment of Oesophageal and Gastroesophageal Cancer Patients?

AIM

To determine the efficacy of preoperative chemoradiotherapy as per the CROSS protocol for oesophageal/gastroesophageal junction cancer (OEGEJC), when expanded to patients outside of the inclusion/exclusion criteria defined in the original clinical trial.

MATERIALS AND METHODS

Data were collected retrospectively on 229 OEGEJC patients referred for curative-intent preoperative chemoradiotherapy. Outcomes including pathological complete response (pCR), overall survival (OS), cancer-specific survival and recurrence-free survival (RFS) of patients who met CROSS inclusion criteria (MIC) versus those who failed to meet criteria (FMIC) were determined.

RESULTS

In total, 42.8% of patients MIC, whereas 57.2% FMIC; 16.6% of patients did not complete definitive surgery. The MIC cohort had higher rates of pCR, when compared with the FMIC cohort (33.3% versus 20.6%, P = 0.039). The MIC cohort had a better RFS, cancer-specific survival and OS compared with the FMIC cohort (P = 0.006, P = 0.004 and P = 0.009, respectively). Age >75 years and pretreatment weight loss >10% were not associated with a poorer RFS (P = 0.541 and 0.458, respectively). Compared with stage I-III patients, stage IVa was associated with a poorer RFS (hazard ratio (HR) = 2.158; 95% confidence interval (CI) = 1.339-3.480, P = 0.001). Tumours >8 cm in length or >5 cm in width had a trend towards worse RFS (HR = 2.060; 95% CI = 0.993-4.274, P = 0.052).

CONCLUSION

Our study showed that the robust requirements of the CROSS trial may limit treatment for patients with potentially curable OEGEJC and can be adapted to include patients with a good performance status who are older than 75 years or have >10% pretreatment weight loss. However, the inclusion of patients with celiac nodal metastases or tumours >8 cm in length or >5 cm in width may be associated with poor outcomes.

Modern Management of Esophageal Cancer: Radio-Oncology in Neoadjuvancy, Adjuvancy and Palliation

The modern management of esophageal cancer is crucially based on a multidisciplinary and multimodal approach. Radiotherapy is involved in neoadjuvant and adjuvant settings; moreover, it includes radical and palliative treatment intention (with a focus on the use of a stent and its potential integration with radiotherapy). In this review, the above-mentioned settings and approaches will be described. Referring to available international guidelines, the background evidence bases will be reviewed, and the ongoing, more relevant trials will be outlined. Target definitions and radiotherapy doses to administer will be mentioned. Peculiar applications such as brachytherapy (interventional radiation oncology), and data regarding innovative approaches including MRI-guided-RT and radiomic analysis will be reported. A focus on the avoidance of surgery for major clinical responses (particularly for SCC) is detailed.

Modern Management of Esophageal Cancer: Radio-Oncology in Neoadjuvancy, Adjuvancy and Palliation

The modern management of esophageal cancer is crucially based on a multidisciplinary and multimodal approach. Radiotherapy is involved in neoadjuvant and adjuvant settings; moreover, it includes radical and palliative treatment intention (with a focus on the use of a stent and its potential integration with radiotherapy). In this review, the above-mentioned settings and approaches will be described. Referring to available international guidelines, the background evidence bases will be reviewed, and the ongoing, more relevant trials will be outlined. Target definitions and radiotherapy doses to administer will be mentioned. Peculiar applications such as brachytherapy (interventional radiation oncology), and data regarding innovative approaches including MRI-guided-RT and radiomic analysis will be reported. A focus on the avoidance of surgery for major clinical responses (particularly for SCC) is detailed.

Modern Management of Esophageal Cancer: Radio-Oncology in Neoadjuvancy, Adjuvancy and Palliation

The modern management of esophageal cancer is crucially based on a multidisciplinary and multimodal approach. Radiotherapy is involved in neoadjuvant and adjuvant settings; moreover, it includes radical and palliative treatment intention (with a focus on the use of a stent and its potential integration with radiotherapy). In this review, the above-mentioned settings and approaches will be described. Referring to available international guidelines, the background evidence bases will be reviewed, and the ongoing, more relevant trials will be outlined. Target definitions and radiotherapy doses to administer will be mentioned. Peculiar applications such as brachytherapy (interventional radiation oncology), and data regarding innovative approaches including MRI-guided-RT and radiomic analysis will be reported. A focus on the avoidance of surgery for major clinical responses (particularly for SCC) is detailed.

The Optimal Treatment for Resectable Esophageal Cancer: A Network Meta-Analysis of 6168 Patients

The optimal treatment for resectable esophageal cancer remains unclear. This network meta-analysis compares the efficacy of different treatments. PubMed, Embase, and the Cochrane library were systematically screened. Randomized controlled trials comparing the efficacy of different treatments for resectable esophageal cancer were included. Hazard ratios (HR) for overall survival (OS), progression-free survival, or disease-free survival, and odds ratios for locoregional recurrence and distant metastasis rates were identified as the measurements of efficacy. A Bayesian network meta-analysis was performed. In this study, 26 studies were included. Patients received either surgery alone; neoadjuvant chemotherapy (CT), neoadjuvant radiotherapy (RT), or neoadjuvant chemoradiotherapy (CRT) followed by surgery; or surgery followed by adjuvant CT, adjuvant RT, or adjuvant CRT. Neoadjuvant CRT followed by surgery (pooled HR = 0.76, 95% credible interval: 0.67–0.85) and neoadjuvant CT followed by surgery compared with surgery alone were the only two showing statistically confident improvement on OS. Ranking analysis showed that neoadjuvant CRT with surgery was likely to be the best option in terms of efficacy. Therefore, for patients with resectable esophageal cancer, neoadjuvant CRT with surgery is the optimal treatment. Future studies should focus on the optimization of neoadjuvant CRT regimens.

Brazilian Group of Gastrointestinal Tumours' consensus guidelines for the management of oesophageal cancer

Oesophageal cancer is among the ten most common types of cancer worldwide. More than 80% of the cases and deaths related to the disease occur in developing countries. Local socio-economic, epidemiologic and healthcare particularities led us to create a Brazilian guideline for the management of oesophageal and oesophagogastric junction (OGJ) carcinomas. The Brazilian Group of Gastrointestinal Tumours invited 50 physicians with different backgrounds, including radiology, pathology, endoscopy, nuclear medicine, genetics, oncological surgery, radiotherapy and clinical oncology, to collaborate. This document was prepared based on an extensive review of topics related to heredity, diagnosis, staging, pathology, endoscopy, surgery, radiation, systemic therapy (including checkpoint inhibitors) and follow-up, which was followed by presentation, discussion and voting by the panel members. It provides updated evidence-based recommendations to guide clinical management of oesophageal and OGJ carcinomas in several scenarios and clinical settings.

Neoadjuvant cryotherapy improves dysphagia and may impact remission rates in advanced esophageal cancer

Background and study aims  Liquid nitrogen spray cryotherapy (LNSC) can provide rapid dysphagia relief, and is postulated to stimulate a local antitumor immune response. The aim of this prospective pilot clinical trial was to evaluate the safety and efficacy of LNSC when administered prior to chemoradiotherapy. Patients and methods  Treatment-naïve adult patients with dysphagia at the time of biopsy-proven squamous carcinoma or adenocarcinoma of the esophagus were prospectively enrolled at two tertiary medical centers. Patients underwent a single session of LNSC. The primary outcome measure was change in dysphagia at 1 and 2 weeks post-cryotherapy. A secondary outcome measure was clinical complete response rate (CR) following chemoradiotherapy. Results  Twenty-five patients were screened, of whom 21 patients were eligible and enrolled. There were seven with metastatic and 14 with locally advanced cancer. The primary outcome of dysphagia improvement of ≥ 1 point occurred in 15/21 patients (71 %) at 1 week, and 10/20 patients (50 %) at 2 weeks. The median dysphagia score improved by 1 at 1 week ( P  = 0.0003), and 0.5 at 2 weeks ( P  = 0.02). Six of nine patients (67 %) with locally advanced cancer who completed chemoradiation did not have residual tumor cells on mucosal biopsy, and five of nine patients (56 %) had a clinical CR. There were no serious cryotherapy-related complications. Conclusions  LNSC provided safe and effective palliation for esophageal cancer patients who presented with dysphagia at index diagnosis. Its combination with chemoradiotherapy did not lead to any serious toxicity. Our study provides a scientific rationale for pursuing larger clinical trials addressing synergistic effects of combining LNSC with chemoradiation.

Neoadjuvant chemoradiation for locally advanced resectable carcinoma of the esophagus: A single-center experience from India with a brief review of the literature

BACKGROUND

The management of locally advanced carcinomas of the esophagus and esophagogastric junction has undergone a major evolution over the past two decades with the widespread use of combined modality therapy. Although many Indian centers practice the combined modality therapy with neoadjuvant chemoradiation (nCRT), published data are sparse.

OBJECTIVES

The objective of this study was to study the safety and efficacy of nCRT in patients with locally advanced resectable carcinoma of the esophagus.

MATERIALS AND METHODS

Prospective single-arm study of the first fifty patients enrolled over 3 years (2014-2016).

RESULTS

The median age was 51 years (M:F = 3:2), 90% of the patients had squamous cell carcinomas, and 69% had lower-third lesions. All accrued patients completed the intended dose of radiation; however, approximately 20% had a treatment delay, which was duly gap corrected. Importantly, there were no treatment-related toxic deaths. Eleven patients could not undergo surgery following nCRT (two patients defaulted, two were deemed medically unfit, and seven (14%) patients had disease progression on imaging). Thirty-nine (78%) patients were planned for definitive surgery; however, a further 7 (14%) were found to be inoperable intraoperatively. Thirty-two patients successfully completed their definitive surgical procedures with R0 resections, of which 19 patients (38%) had a pathological complete response (pCR). There was no postoperative 90-day mortality in our study cohort. Analysis of prognostic factors that predicted a response showed that patients who had adenocarcinoma and with circumferential lesions responded poorly.

CONCLUSION

nCRT appears to be a safe and a reasonably well-tolerated option in carefully selected patients with resectable locally advanced esophageal cancers. Although our data are not mature to analyze the survival outcomes with a pCR rate of 38%, it suggests nCRT to be a promising option in the management of locally advanced resectable esophageal cancers.

A rationale multidisciplinary approach for treatment of esophageal and gastroesophageal junction cancer: Accurate review of management and perspectives

Cancer of the esophagus and of gastroesophageal junction can be cured, even if with lacking cure rate. Different approaches have been developed, mostly when carcinoma has loco-regional pattern. Multimodality therapy showed a survival rate superior than 10% if compared to a single approach. This is a systematic review, carried to assess the following matters: Which therapeutic opportunities are available? Who could benefit of them? Which adverse reactions could possibly verify? How can physicians definitely choose the proper strategy? Which is the role of surgery? We mean to give either General Practitioner or specialists clear and efficient updates about current treatment of this tumour, starting from physical examination. Four eminent guidelines were consulted for our study: Cancer Care Ontario's Program in Evidence-Based Care, NCCN, Belgian Health Care Knowledge Centre and Esmo.

Neoadjuvant chemotherapy versus neoadjuvant chemoradiotherapy for cancer of the esophagus or the gastroesophageal junction: A meta-analysis based on clinical trials

Background

The benefit of neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy for treating cancer of the esophagus or the gastroesophageal junction remains controversial. In the present study, we conducted a comprehensive meta-analysis to examine the efficacy of these two management strategies.

Methods

The MEDLINE (PubMed), SinoMed, Embase, and Cochrane Library databases were searched for eligible studies. We searched for the most relevant studies published until the end of September 2017. Data were extracted independently and were analyzed using RevMan statistical software version 5.3 (Cochrane Collaboration, http://tech.cochrane.org/revman/download). Weighted mean differences, risk ratios (RRs), and 95% confidence intervals (CIs) were calculated. Cochrane Collaboration’s risk of bias tool was used to assess the risk of bias. In this comprehensive meta-analysis, we examined the efficiency of neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy for the treatment of cancer of the esophagus or the gastroesophageal junction as reported in qualified clinical trials.

Results

Six qualified articles that included a total of 866 patients were identified. The meta-analysis showed that for 3-year and 5-year survival rates in primary outcomes, the results favored neoadjuvant chemoradiotherapy strategies compared with neoadjuvant chemotherapy (RR = 0.78, 95% CI = 0.62–0.98, P = 0.03; RR = 0.69, 95% CI = 0.50–0.96, P = 0.03, respectively). In terms of secondary outcomes, neoadjuvant chemoradiotherapy significantly increased the rate of R0 resection and pathological complete response as well (RR = 0.87, 95% CI = 0.81–0.92, P < 0.0001; RR = 0.16, 95% CI = 0.09–0.28, P < 0.00001, respectively). However, there were no significant differences in postoperative mortality between the two groups (RR = 1.85, 95% CI = 0.93–3.65, P = 0.08). For the results of postoperative complications, revealed that there was a statistically significant difference between the two groups in the incidence of postoperative complications such as pulmonary, anastomotic leak and cardiovascular complications. The subgroup analysis of patients with esophageal adenocarcinoma or squamous cell carcinoma showed that both esophageal adenocarcinoma and squamous cell carcinoma patients achieved a high rate of R0 resection (RR = 0.85, 95% CI = 0.77–0.93, P = 0.0006; RR = 0.88, 95% CI = 0.81–0.96, P = 0.005, respectively) and pathological complete response benefit of neoadjuvant chemoradiotherapy (RR = 0.23, 95% CI = 0.09–0.57, P = 0.001; RR = 0.18, 95% CI = 0.03–0.96, P = 0.05, respectively).

Conclusion

Our findings suggested that compared with neoadjuvant chemotherapy, neoadjuvant chemoradiotherapy should be recommended with a significant long-term survival benefit in patients with cancer of the esophagus or the gastroesophageal junction. In view of the clinical heterogeneity, whether these conclusions are broadly applicable should be further determined.

Neoadjuvant therapy or upfront surgery? A systematic review and meta-analysis of T2N0 esophageal cancer treatment options

BACKGROUND

Esophageal carcinoma usually shows poor long-term survival rates, even when esophagectomy, the standard curative treatment is performed. As a result, there has been increasing interest in the neoadjuvant therapy, which could potentially downstage cancer, eliminate micrometastasis and ergo increase resectability and curative (R0) resection. Currently, for the earliest stage esophageal cancers, most guidelines point out to the role of endoscopic treatment, and for T1bN0 upfront surgery. For locally advanced cases, several studies have demonstrated the benefits of neoadjuvant therapy to increase resectability. For clinical stage T2N0 esophageal cancer, there is no consensus as to the optimal treatment strategy.

METHODS

A systematic review and meta-analysis was performed to compare neoadjuvant therapy with surgery alone on clinical stage T2N0 esophageal cancer patients, concerning overall survival, recurrence, post-operative mortality, anastomotic leak, and R0 resection rate.

RESULTS

For overall survival at the mean follow-up point, the neoadjuvant therapy was not associated to a higher probability of survival than upfront surgery in cT2N0 patients (risk difference: 0.00; 95% CI: -0.09, 0.09). There was no difference between neoadjuvant therapy and primary surgery concerning recurrence (risk difference: 0.21; 95% CI: -0.03, 0.45); perioperative mortality (risk difference: 0.00; 95% CI: -0.02, 0.01); and risk for anastomotic leak (risk difference: -0.08; 95% CI: -0.21, 0.05). Pooled data showed that neoadjuvant therapy was associated to a higher risk for positive margins after resection (risk difference: 0.04; 95% CI: 0.02, 0.06).

CONCLUSIONS

This review showed that neoadjuvant therapy is not associated to better results than surgery alone, for the management of clinical stage T2N0 esophageal cancer patients, concerning overall survival, recurrence rate, perioperative mortality, anastomotic leak, and seems to be associated to a higher risk for resection with positive margins.

Multidisciplinary Approach to the Management of Esophageal Malignancies

INTRODUCTION

A multidisciplinary approach in the management of complex malignancies is becoming more common, and likewise, adopting such an approach to the care of patients with locally advanced esophageal is recommended in order to optimize clinical outcomes.

METHODS

In this review, we discuss both the surgical and medical oncology perspectives in the management of patients with locally advanced esophageal cancer. We review the data supporting the current standard-of-care approach, namely trimodality therapy with neoadjuvant chemo-radiotherapy followed by surgery. Other aspects of managing these patients including the control of dysphagia and pain as well as nutritional support are discussed. Finally, we review data that support the importance of incorporating a multidisciplinary streamlined approach in the management of these patients.

RESULTS

Rather than having patients see each provider separately, a multidisciplinary approach to esophageal cancer allows for the seamless flow of communication and proactive management of the patient's symptoms. These benefits include increasing the likelihood of evidence-based decision making, shorter time to treatment, and increased patient quality of life, all of which can result in improved patient outcomes.

CONCLUSION

The use of a multidisciplinary team can lead to a more accurate staging paradigm and thereby, better management decisions that translate to improved clinical outcomes. Therefore, optimizing the multidisciplinary approach for the care of patients with locally advanced esophageal cancer is essential for successful and individualized patient care.

The frontline of esophageal cancer treatment: questions to be asked and answered

Achieving a good treatment for esophageal cancer is a great challenge. For early stage cancer, endoscopic treatment is considered the first line and a possible curative therapy. Chemotherapy, radiotherapy, and surgery are all used for the treatment of locally advanced esophageal cancer, administered either alone or combined. Some combinations have proven to be feasible, effective, and superior, such as neoadjuvant chemoradiation (CRT) plus surgery in the Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) trial. However, other strategies such as perioperative chemotherapy or definitive chemoradiation also have demonstrated substantial effectiveness. The current article addresses the following questions: (I) how can a choice between different multi-modality treatments be made; (II) is there enough evidence to compare the merits of the different strategies; and (III) is there any new evidence to improve the current practice. Moreover, in this article, existing evidence for treatment strategies for locally advanced esophageal cancer have been reviewed.

A phase II Study Evaluating Combined Neoadjuvant Cetuximab and Chemotherapy Followed by Chemoradiotherapy and Concomitant Cetuximab in Locoregional Oesophageal Cancer Patients

BACKGROUND

Pre-operative chemoradiotherapy using a 5-fluorouracil (5-FU)/cisplatin backbone is widely used to improve surgical outcomes in locoregional oesophageal cancer patients, despite a non-negligible failure rate.

OBJECTIVE

We evaluated intensification of this approach to improve patient outcomes by adding cetuximab to induction 5-FU/cisplatin/docetaxel (TPF) and to chemoradiotherapy in a phase II study.

PATIENTS AND METHODS

Between November 2006 and April 2009, 50 patients with stage II-IVa squamous cell carcinoma (SCC) or adenocarcinoma of the oesophagus or gastro-oesophageal junction initiated three TPF/cetuximab cycles. Six weeks later, patients with response or stabilisation initiated 6 weeks of cisplatin/cetuximab/radiotherapy, followed by surgery. The primary objective was the clinical complete response (cCR) rate after induction therapy plus chemoradiotherapy in intent-to-treat patients.

RESULTS

Thirty-eight patients were evaluable after chemoradiotherapy, 84% of whom showed disease control. Six patients (12%) achieved a cCR, with a 54% overall response rate. Twenty-seven patients underwent surgery, 11 of whom (22%; nine SCC, two adenocarcinoma) had a pathological CR (41%). Fifteen patients were alive after a median follow-up of 23.2 months. Median progression-free survival was 12.2 months (95% confidence interval [CI] 1.7-22.8). Median overall survival was 23.4 months (95% CI 12.2-36.6) and was significantly longer among the 22 patients with complete resection than in the five patients without (42.1 vs. 24.9 months; p = 0.02, hazard ratio: 3.6, 95% CI 1.1-11.6). The toxicity profile was acceptable.

CONCLUSIONS

Neoadjuvant cetuximab/TPF followed by chemoradiotherapy in locoregional oesophageal carcinoma patients is feasible and offers a modest response rate in this trial. The results of combining trimodality neoadjuvant treatment with cetuximab are consistent with the literature. Registration: The study is registered at ClinicalTrials.gov (NCT00733889).

Concurrent neoadjuvant chemoradiotherapy could improve survival outcomes for patients with esophageal cancer: a meta-analysis based on random clinical trials

Background

The long-term survival benefit of concurrent neoadjuvant chemoradiotherapy in patients with resectable esophageal cancer remains controversial. In the present study, we conducted a meta-analysis to assess these effectiveness.

Methods

We searched for most relevant studies published up to the end of August 2016, using Pubmed and web of knowledge. And additional articles were identified from previous meta-analysis. The hazard ratio (HR, for overall survival and progression free survival) or risk ratio (RR, for R0 resection) with its corresponding 95 % confidence interval (CI) were used to assess the pooled effect.

Results

Twelve articles including 1756 patients were included in the meta-analysis. Concurrent neoadjuvant chemoradiotherapy followed by surgery was associated with significantly improved overall survival (HR=0.76 , 95% CI= 0.68-0.86), progression survival (HR =0.69, 95% CI= 0.59-0.81), and R0 resection rate(RR =1.17, 95% CI= 1.03-1.33). Subgroup analysis suggested that concurrent neoadjuvant chemoradiotherapy could improve overall survival outcome for squamous cell carcinoma (HR=0.73, 95%CI=0.61-0.88) but not those for adenocarcinoma (HR=0.72, 95%CI=0.48-1.04).

Conclusion

Our findings suggested that concurrent neoadjuvant chemoradiotherapy was associated with a significant survival benefit in patients with esophageal cancer.

Self-Expanding Metal Stents Improve Swallowing and Maintain Nutrition During Neoadjuvant Therapy for Esophageal Cancer

BACKGROUND

Patients with locally advanced esophageal cancer can have significant dysphagia. Nutritional support during neoadjuvant therapy is often delivered via nasoenteric or percutaneous feeding tubes. These approaches do not allow for per-oral feeding.

AIMS

Evaluate the safety and efficacy of fully covered self-expanding metal esophageal stents for nutritional support during neoadjuvant therapy.

METHODS

This was a pilot, prospective study at a single tertiary center. From March 2012 to May 2013, consecutive patients with esophageal cancer eligible for neoadjuvant therapy were enrolled. Metal stents were placed prior to starting neoadjuvant therapy. Data were collected at baseline and predetermined intervals until an endpoint (surgery or disease progression). Outcomes included dysphagia grade, satisfaction of swallowing score, nutritional status (weight, serum albumin), impact on surgery, and adverse events.

RESULTS

Fourteen stents were placed in 12 patients (59.1 ± 9.5 years, 11 men, 1 woman). Dysphagia grade (pre 3.4 ± 0.5 vs post 0.2 ± 0.4, p < 0.0001) and swallowing scores (20.2 ± 5.9 vs 6.3 ± 4.7, p < 0.0001) significantly improved after stent placement. Improvements were sustained throughout neoadjuvant therapy. Body weight and serum albumin levels remained stable. Adverse events included severe chest pain (2), food impaction (1), and delayed stent migration (2). Five patients underwent surgical resection. No significant chemoradiation or operative adverse events occurred due to the presence of a stent.

CONCLUSIONS

During neoadjuvant therapy for esophageal cancer, self-expanding metal stents are safe and effective in relieving dysphagia and maintaining nutrition. They allow patients to eat orally, thereby improving patient satisfaction. The presence of an in situ stent did not interfere with surgery.

Neoadjuvant Chemoradiotherapy Improving Survival Outcomes for Esophageal Carcinoma: An Updated Meta-analysis

BACKGROUND

The effectiveness of neoadjuvant chemoradiotherapy (NCRT) treatment for patients with esophageal carcinoma (EC) remains controversial. The aim of this study was to compare the effect of NCRT followed by surgery (NCRTS) with surgery alone (SA) for EC.

METHODS

The PubMed, EMBASE, and the Cochrane Library databases were electronically searched up to August 2015 for all the published studies that investigated EC patients receiving either NCRTS or SA, and the reference lists were also manually examined for the eligible studies. The risk ratio (RR) with 95% confidence intervals (CI s) as effective size was determined to assess the 1-, 3-, 5-year survival rates (SRs), postoperative morbidity, and postoperative mortality. Heterogeneity was determined using the Q-test. The Begg's test and Egger's test were used for assessing any potential publication bias.

RESULTS

Of 1120 identified studies, 16 eligible studies were included in this analysis (involving 2549 patients). Overall, the pooled results suggested that NCRTS was associated with significantly improved 1-year (RR: 1.07, 95% CI: 1.02-1.13), 3-year (RR: 1.26, 95% CI: 1.14-1.39), and 5-year (RR: 1.36, 95% CI: 1.18-1.56) SRs. However, the results also indicated that NCRTS had no or little effect on postoperative morbidity (RR: 0.93, 95% CI: 0.82-1.05) and postoperative mortality (RR: 1.17, 95% CI: 0.56-2.44).

CONCLUSIONS

Compared with SA, NCRTS can increase 1-, 3-, and 5-year SRs in patients with EC.

Chemoradiotherapy in tumours of the oesophagus and gastro-oesophageal junction

Oesophageal cancer remains a malignancy with a poor prognosis. However, in the recent 10-15 years relevant progress has been made by the introduction of chemoradiotherapy (CRT) for tumours of the oesophagus or gastro-oesophageal junction. The addition of neo-adjuvant CRT to surgery has significantly improved survival and locoregional control, for both adenocarcinoma and squamous cell carcinoma. For irresectable or medically inoperable patients, definitive CRT has changed the treatment intent from palliative to curative. Definitive CRT is a good alternative for radical surgery in responding patients with squamous cell carcinoma and those running a high risk of surgical morbidity and mortality. For patients with an out-of-field solitary locoregional recurrence after primary curative treatment, definitive CRT can lead to long term survival.

Prognostic Significance of 2-Deoxy-2-[18F]-Fluoro-D-Glucose PET/CT in Patients With Locally Advanced Esophageal Cancer Undergoing Neoadjuvant Chemoradiotherapy Before Surgery: A Nonparametric Approach

To investigate the prognostic value of tumor metabolism measurements on serial 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography and computed tomography scans in patients with locally advanced esophageal cancer undergoing neoadjuvant chemoradiotherapy. Forty-five patients (63 ± 7 years, 6 female) treated with concomitant chemoradiotherapy before surgery were followed up for 24 ± 18 months (range 4-71). Positron emission tomography and computed tomography scans were obtained within 1 week before the start (PET1) and 1 month after the completion of the treatment (PET2). Total body tumor metabolic activity was measured as the sum of the parameters: SUVmax, SUV corrected for lean body mass, and total lesion glycolysis (TLG40/50/70%). Then, delta values for the parameters between PET1 and PET2 were calculated and expressed as percentage of PET1 results. At the time of the analysis, 27 patients were dead and 18 were alive. There was no difference between the 2 groups in terms of age, sex, site of the disease, histology, and the presence/absence of linfonodal metastases (P = NS). Survival random forest analysis (20,000 trees) resulted in an estimate of error rate of 36%. The nonparametric approach identified ΔTLG40 as the most predictive factor of survival (relative importance 100%). Moreover, T (17%), N (5%), and M (5%) stage of the disease, cancer histology (11%), TLG70 (5%) at the end of chemioradioterapy, and ΔTLG(50-70) (17%-5%) were positively associated with patient outcome. The nonparametric analysis confirmed the prognostic importance of some clinical parameters, such as TNM stage and cancer histology. Moreover, ΔTLG resulted to be the most important factor in predicting outcome and should be considered in risk stratification of patients treated with neoadjuvant chemoradiotherapy.

Impact of Treatment Modalities on Survival of Patients With Locoregional Esophageal Squamous-Cell Carcinoma in Taiwan

The optimal treatment modality for locoregional esophageal squamous-cell carcinoma (ESCC) is still undetermined. This study investigated the treatment modalities affecting survival of patients with ESCC in Taiwan.Data on 6202 patients who underwent treatment for locoregional esophageal squamous-cell carcinoma during 2008 to 2012 in Taiwan were collected from the Taiwan Cancer Registry. Patients were stratified by clinical stage. The major treatment approaches included definitive chemoradiotherapy, preoperative chemoradiation followed by esophagectomy, esophagectomy followed by adjuvant therapy, and esophagectomy alone. The impact of different treatment modalities on overall survival was analyzed.The majority of patients had stage III disease (n = 4091; 65.96%), followed by stage II (n = 1582, 25.51%) and stage I cancer (n = 529, 8.53%). The 3-year overall survival rates were 60.65% for patients with stage I disease, 36.21% for those with stage II cancer, and 21.39% for patients with stage III carcinoma. Surgery alone was associated with significantly better overall survival than the other treatment modalities for patients with stage I disease (P = 0.029) and was associated with significantly worse overall survival for patients with stage III cancer (P < 0.001). There was no survival risk difference among the different treatment methods for patients with clinical stage II disease.Multimodality treatment is recommended for patients with stage II-III esophageal squamous-cell carcinoma. Patients with clinical stage I disease can be treated with esophagectomy without preoperative therapy.

Combined Modality Therapy for Thoracic and head and Neck Cancers: A Review of Updated Literature Based on a Consensus Meeting

Purpose

Combined modality therapy is a mainstay option for thoracic malignancies and head and neck cancers. The integration of different strategies is based on the multidisciplinary approach of modern clinical oncology. Radiation oncologists have to be educated, trained, and updated to provide state-of-the-art care to cancer patients and thus educational meetings are crucial.

Methods

The Italian Association of Radiation Oncology Young Members Working Group (AIRO Giovani) organized its 8th national meeting, focused on combination therapy in lung, esophageal, and head and neck cancer (with a specific focus on larynx-preservation strategies for larynx/hypopharynx tumors), involving young professionals working in Italy. The meeting was addressed to young radiation oncologists, presenting state-of-the-art knowledge, based on the latest evidence in this field. We performed a review of the current literature based on the highlights of the Congress.

Results

The multimodality approach of head and neck and thoracic malignancies includes surgery, chemotherapy, and radiotherapy, but also has to take into account new information and data coming from basic and translational research and including molecular biology, genetics, and immunology. All these aspects are crucial for the treatment of non-small-cell lung cancer and esophageal, esophagogastric junction, and larynx/hypopharynx malignancies. The integration of different treatments in the clinical decision-making process to combine therapies is crucial.

Conclusions

Combination therapy has proved to be a consolidated approach in these specific oncologic settings, highlighting the importance of multimodality management in modern clinical oncology. Dedicated meetings on specific topics are helpful to improve knowledge and skills of young professionals in radiation oncology.

Cost-effectiveness of neoadjuvant concurrent chemoradiotherapy versus esophagectomy for locally advanced esophageal squamous cell carcinoma: A population-based matched case-control study

Background

Neoadjuvant concurrent chemoradiotherapy (NCCRT) is often considered for locally‐advanced esophageal squamous cell carcinoma (LA‐ESCC) patients; however, no data regarding the cost‐effectiveness of this treatment is available. Our study aimed to evaluate the cost‐effectiveness of NCCRT versus esophagectomy for LA‐ESCC at population level.

Methods

We identified LA‐ESCC patients diagnosed within 2008–2009 and treated with either NCCRT or esophagectomy through the Taiwan Cancer Registry. We included potential confounding covariables (age, gender, residency, comorbidity, social‐economic status, disease stage, treating hospital level and surgeon's experience, and the use of endoscopic ultrasound before treatment) and used propensity score (PS) to construct a 1:1 population. The duration of interest was three years within the date of diagnosis. Effectiveness was measured as overall survival. We took the payer's perspective and converted the cost to 2014 United States dollars (USD). In sensitivity analysis, we evaluated the potential impact of an unmeasured confounder on the statistical significance of incremental net benefit at suggested willingness‐to‐pay.

Results

Our study population constituted 150 PS matched subjects. The mean cost (2014 USD) and survival (year) were higher for NCCRT compared with esophagectomy (US$91,460 vs. $75,836 for cost; 2.2 vs. 1.8 for survival) with an estimated incremental cost‐effectiveness ratio of US$39,060/life‐year.

Conclusions

When compared to esophagectomy, NCCRT is likely to improve survival and is probably more cost‐effective. Cost‐effectiveness results should be interpreted with caution given our results were sensitive to potential unmeasured confounder(s) in sensitivity analysis.

Absolute CT perfusion parameter values after the neoadjuvant chemoradiotherapy of the squamous cell esophageal carcinoma correlate with the histopathologic tumor regression grade

PURPOSE

To analyze value of the computed tomography (CT) perfusion imaging in response evaluation of the esophageal carcinoma to neoadjuvant chemoradiotherapy (nCRT) using the histopathology as reference standard.

METHODS

Forty patients with the squamous cell esophageal carcinoma were re-evaluated after the nCRT by CT examination, which included low-dose CT perfusion study that was analyzed using the deconvolution-based CT perfusion software (Perfusion 3.0, GE). Histopathologic assessment of tumor regression grade (TRG) according to Mandard's criteria served as reference standard of response evaluation. Statistical analysis was performed using Spearman's rank correlation coefficient (r(S)) and Kruskal-Wallis's test.

RESULTS

The perfusion CT parameter values, measured after the nCRT in the segment of the esophagus that had been affected by neoplasm prior to therapy, significantly correlated with the TRG: blood flow (BF) (r(S)=0.851; p<0.001), blood volume (BV) (r(S)=0.732; p<0.001) and mean transit time (MTT) (r(S)=-0.386; p=0.014). Median values of BF and BV significantly differed among TRG 1-4 groups (p<0.001), while maximal esophageal wall thickness did not (p=0.102). Median BF and BV were gradually rose and MTT decreased as TRG increased, from 21.4 ml/min/100 g (BF), 1.6 ml/100 g (BV) and 8.6 s (MTT) in TRG 1 group, to 37.3 ml/min/100 g, 3.5 ml/100 g and 7.5 s in TRG 2 group, 81.4 ml/min/100 g, 4.1 ml/100 g and 3.8 s in TRG 3 group, and 121.1 ml/min/100 g, 4.9 ml/100 g and 3.7 s in TRG 4 group. In all 15 patients who achieved complete histopathologic regression (TRG 1), BF was <30.0 ml/min/100 g.

CONCLUSIONS

CT perfusion could improve the accuracy in response evaluation of the esophageal carcinoma to nCRT.

Epidemiology, Diagnosis, and Management of Esophageal Adenocarcinoma

Esophageal adenocarcinoma (EAC) is rapidly increasing in incidence in Western cultures. Barrett's esophagus is the presumed precursor lesion for this cancer. Several other risk factors for this cancer have been described, including chronic heartburn, tobacco use, white race, and obesity. Despite these known associations, most patients with EAC present with symptoms of dysphagia from late-stage tumors; only a small number of patients are identified by screening and surveillance programs. Diagnostic analysis of EAC usually commences with upper endoscopy followed by cross-sectional imaging. Endoscopic ultrasonography is useful to assess the local extent of disease as well as the involvement of regional lymph nodes. T1a EAC may be treated endoscopically, and some patients with T1b disease may also benefit from endoscopic therapy. Locally advanced disease is generally managed with esophagectomy, often accompanied by neoadjuvant chemoradiotherapy or chemotherapy. The prognosis is based on tumor stage; patients with T1a tumors have an excellent prognosis, whereas few patients with advanced disease have long-term survival.

[Mini-invasive technologies in complex treatment of esophagus cancer]

It was evaluated mini-invasive endovideosurgical technologies using in complex treatment of esophagus cancer. The investigation included 28 patients with thoracic esophagus cancer. Age of patients operated in terms from April 2012 to December 2013 was from 42 to 74 years (mean 61.7 ± 8.7 years). Only surgical treatment was used in 10 patients. Neoadjuvant chemotherapy and radiotherapy were performed in 18 patients. Hybrid mini-invasive esophagectomy (laparoscopic stomach mobilization and right-side thoracotomy) were used in 14 cases. The frequency of postoperative complications was 35.5%. Mini-invasive endovideosurgical esophagectomy was done in 14 patients. The frequency of postoperative complications was 57.1%. There were not deaths. Our experience demonstrates good results of mini-invasive technologies using in treatment of patients with esophagus cancer. Endovideosurgical methods permit to perform adequate volume of surgery in case of oncological diseases.

Concurrent versus sequential chemoradiotherapy for esophageal cancer among Chinese population: a meta-analysis

AIMS AND BACKGROUND

Esophageal cancer can cause substantial mortality and there is controversy about the effectiveness of concurrent and sequential chemoradiotherapy (CRT) for this disease.

METHODS AND STUDY DESIGN

Based on established criteria, we searched electronic databases including PubMed, Excerpta Medica Database (Embase), China National Knowledge Infrastruction (CNKI), Wanfang, and Weipu databases up to March 2014 to collect eligible studies. Relative risks (RRs) and their 95% confidence intervals (CIs) were calculated. Q and I2 test were applied to test statistical heterogeneities among studies. Publication bias of total effective rate was evaluated through a funnel plot and sensitive analysis was conducted.

RESULTS

We identified 10 Chinese studies including 1024 esophageal cancer patients. The RRs of total effective rate and 1-, 2-, and 3-year survival rate for concurrent versus sequential CRT were 1.15 (95% CI 1.07 to 1.24), 1.15 (95% CI 1.05 to 1.26), 1.44 (95% CI 1.21 to 1.73), and 1.66 (95% CI 1.37 to 2.01), respectively, all with statistically significant differences (p&lt;0.05). With regards to incidence of leukocytopenia, the RR for concurrent versus sequential CRT was 1.14 (95% CI 1.03 to 1.26) with significant difference (p&lt;0.05). However, the RR of incidence of radiation esophagitis was 1.09 (95% CI 0.96 to 1.22) for concurrent versus sequential CRT without significant differences (p = 0.17).

CONCLUSIONS

Concurrent CRT was superior to sequential CRT for esophageal cancer management among Chinese people. Though higher toxic effects were revealed in concurrent CRT, it was tolerable. Therefore, concurrent CRT could be applied into esophageal cancer treatments for Chinese patients.

Neoadjuvant chemoradiotherapy for resectable esophageal cancer: an in-depth study of randomized controlled trials and literature review

Surgery following neoadjuvant chemoradiotherapy (NCRT) is a common multidisciplinary treatment for resectable esophageal cancer (EC). After analyzing 12 randomized controlled trials (RCTs), we discuss the key issues of surgery in the management of resectable EC. Along with chemoradiotherapy, NCRT is recommended for patients with squamous cell carcinoma (SCC) and adenocarcinoma (AC), and most chemotherapy regimens are based on cisplatin, fluorouracil (FU), or both (CF). However, taxane-based schedules or additional studies, together with newer chemotherapies, are warranted. In nine clinical trials, post-operative complications were similar without significant differences between two treatment groups. In-hospital mortality was significantly different in only 1 out of 10 trials. Half of the randomized trials that compare NCRT with surgery in EC demonstrate an increase in overall survival or disease-free survival. NCRT offers a great opportunity for margin negative resection, decreased disease stage, and improved loco-regional control. However, NCRT does not affect the quality of life when combined with esophagectomy. Future trials should focus on the identification of optimum regimens and selection of patients who are most likely to benefit from specific treatment options.

Surveillance of Barrett's esophagus and mortality from esophageal adenocarcinoma: a population-based cohort study

OBJECTIVES

Barrett's esophagus (BE) is associated with an increased risk of developing esophageal adenocarcinoma (EAC). Patients with a known diagnosis of BE are usually advised to participate in an endoscopic surveillance program, but its clinical value is unproven. Our objective was to compare patients participating in a surveillance program for BE before EAC diagnosis with those not participating in such a program, and to determine predictive factors for mortality from EAC.

METHODS

All patients diagnosed with EAC between 1999 and 2009 were identified in the nationwide Netherlands Cancer Registry. These data were linked to Pathologisch-Anatomisch Landelijk Geautomatiseerd Archief, the Dutch Pathology Registry. Prior surveillance was evaluated, and multivariable Cox proportional hazards regression analysis was performed to identify predictors for all-cause mortality at 2-year and 5-year follow-up.

RESULTS

In total, 9,780 EAC patients were included. Of these, 791 (8%) patients were known with a prior diagnosis of BE, of which 452 (57%) patients participated in an adequate endoscopic surveillance program, 120 (15%) patients in an inadequate program, and 219 (28%) patients had a prior BE diagnosis without participating. Two-year (and five-year) mortality rates were lower in patients undergoing adequate surveillance (adjusted hazard ratio (HR)=0.79, 95% confidence interval (CI)=0.64-0.92) when compared with patients with a prior BE diagnosis who were not participating. Other factors associated with lower mortality from EAC were lower tumor stage (stage I vs. IV, HR=0.19, 95% CI=0.16-0.23) and combining surgery with neoadjuvant chemo/radiotherapy (HR=0.66, 95% CI=0.58-0.76).

CONCLUSIONS

Participation in a surveillance program for BE, but only if adequately performed, reduces mortality from EAC. Nevertheless, it remains to be determined whether such a program is cost-effective, as more than 90% of all EAC patients were not known to have BE before diagnosis.

Gefitinib in definitive management of esophageal or gastroesophageal junction cancer: a retrospective analysis of two clinical trials

The role of epidermal growth factor receptor inhibition in resectable esophageal/gastroesophageal junction (E/GEJ) cancer is uncertain. Results from two Cleveland Clinic trials of concurrent chemoradiotherapy (CCRT) and surgery are updated and retrospectively compared, the second study differing only by the addition of gefitinib (G) to the treatment regimen. Eligibility required a diagnosis of E/GEJ squamous cell or adenocarcinoma, with an endoscopic ultrasound stage of at least T3, N1, or M1a (American Joint Committee on Cancer 6th). Patients in both trials received 5-fluorouracil (1000 mg/m(2) /day) and cisplatin (20 mg/m(2) /day) as continuous infusions over days 1-4 along with 30 Gy radiation at 1.5 Gy bid. Surgery followed in 4-6 weeks; identical CCRT was given 6-10 weeks later. The second trial added G, 250 mg/day, on day 1 for 4 weeks, and again with postoperative CCRT for 2 years. Preliminary results and comparisons have been previously published. Clinical characteristics were similar between the 80 patients on the G trial (2003-2006) and the 93 patients on the no-G trial (1999-2003). Minimum follow-up for all patients was 5 years. Multivariable analyses comparing the G versus no-G patients and adjusting for statistically significant covariates demonstrated improved overall survival (hazard ratio [HR] 0.64, 95% confidence interval [CI] = 0.45-0.91, P = 0.012), recurrence-free survival (HR 0.61, 95% CI = 0.43-0.86, P = 0.006), and distant recurrence (HR 0.68, 95% CI = 0.45-1.00, P = 0.05), but not locoregional recurrence. Although this retrospective comparison can only be considered exploratory, it suggests that G may improve clinical outcomes when combined with CCRT and surgery in the definitive treatment of E/GEJ cancer.

Primary adenosquamous carcinoma of the esophagus

AIM: To investigate the clinical characteristics, diagnosis, treatment, and prognosis of primary adenosquamous carcinoma (ASC) of the esophagus.

METHODS: A total of 4015 patients with esophageal carcinoma underwent surgical resection between January 1995 and June 2012 at the Cancer Hospital of Shantou University Medical College. In 37 cases, the histological diagnosis was primary ASC. Clinical data were retrospectively analyzed from these 37 patients, who underwent transthoracic esophagectomy with lymphadenectomy. The χ² or Fisher’s exact test was used to compare the clinicopathological features between patients with ASC and those with squamous cell carcinoma (SCC). The Kaplan-Meier and Log-Rank methods were used to estimate and compare survival rates. A Cox proportional hazard regression model was used to identify independent prognostic factors.

RESULTS: Primary esophageal ASC accounted for 0.92% of all primary esophageal carcinoma cases (37/4015). The clinical manifestations were identical to those of other types of esophageal cancer. All of the 24 patients who underwent preoperative endoscopic biopsy were misdiagnosed with SCC. The median survival time (MST) was 21.0 mo (95%CI: 12.6-29.4), and the 1-, 3-, and 5-year overall survival rates were 67.5%, 29.4%, and 22.9%, respectively. In multivariate analysis, only adjuvant radiotherapy (HR = 0.317, 95%CI: 0.114-0.885, P = 0.028) was found to be an independent prognostic factor. The MST for ASC patients was significantly lower than that for SCC patients [21.0 mo (95%CI: 12.6-29.4) vs 46.0 mo (95%CI: 40.8-51.2), P = 0.001]. In subgroup analyses, the MST for ASC patients was similar to that for poorly differentiated SCC patients.

CONCLUSION: Primary esophageal ASC is a rare disease that is prone to be misdiagnosed by endoscopic biopsy. The prognosis is poorer than esophageal SCC but similar to that for poorly differentiated SCC patients.

Present status and progress of neoadjuvant chemoradiotherapy for esophageal cancer

Trimodality based on neoadjuvant chemoradiotherapy (nCRT) followed by surgery is gaining popularity as a treatment strategy for locally advanced esophageal cancer. In this review, we summarize the role of nCRT and the recommended nCRT regimens based on clinical trials and meta-analyses. We analyze the relationship of nCRT with pathologic complete response (pCR) and then identify potential predictive markers of response. Compared with surgery alone and neoadjuvant chemotherapy followed by surgery, trimodality provides longer survival and has the advantage of local control compared with definitive chemoradiotherapy. The standard regimen is a platinum-based regimen with a radiation dose range of 41.4-50.4 Gy by conventional fractionation. Evidence shows that patients with pCR tend to live longer than non-responders, indicating that pCR is a significant prognostic factor for patients with esophageal cancer. Individualized medicine requires predictive markers of individual patients based on their own genes. Currently, no definite marker is proved to be sufficiently sensitive and specific for use in clinical practice, although 18-fluorodeoxyglucose positron emission tomography shows promise in predicting response to nCRT.