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Rodriguez-Quintero JH, Kamel MK, Jindani R, Elbahrawy M, Vimolratana M, Chudgar NP, Stiles BM. The Effect of Neoadjuvant Therapy on Esophagectomy for cT2N0M0 Esophageal Adenocarcinoma. Ann Surg Oncol 2024; 31:228-238. [PMID: 37884701 PMCID: PMC11088818 DOI: 10.1245/s10434-023-14441-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 09/27/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND For cT2N0M0 esophageal adenocarcinomas, the effects of neoadjuvant chemoradiotherapy (NT) on surgical outcomes and the oncological benefits to the patients are debatable. In this study, we investigated the optimal management for cT2N0M0 adenocarcinoma (1) assessing the perioperative impact of NT on esophagectomy and (2) evaluating the oncologic effect of NT in a homogeneous group of patients with clinical stage IIA. We hypothesized that NT does not negatively affect perioperative outcomes and provides an oncologic benefit to selected patients with cT2N0M0 disease. METHODS The National Cancer Database was queried (2010-2019) for patients with cT2N0M0 esophageal adenocarcinoma undergoing esophagectomy. After propensity-matching to adjust for differences in patient and tumor characteristics, we compared postoperative outcomes (logistic regression) and survival (Kaplan-Meier and Cox regression) among those who underwent NT vs upfront surgery (S). RESULTS This study included 3413 patients, of whom 2359 (69%) received NT, and 1054 (31%) S. In contrast to those who underwent S, in the matched cohort, patients treated with NT had comparable conversion rates (8% vs11.1%, p = 0.06), length of stay (9 vs 10 days, p = 0.078), unplanned readmission (5.4% vs 8.8%, p = 0.109), and 30- (3.9% vs 3.7%, p = 0.90) and 90-day mortality (5.7% vs 4.7%, p = 0.599). In addition, NT associated with improved survival in patients with cT2N0M0 tumors > 5 cm (HR 0.30, 95% CI 0.17-0.36). CONCLUSIONS NT does not appear to increase technical complexity or to adversely affect postoperative outcomes after esophagectomy. Furthermore, minimally invasive esophagectomy is feasible following NT, with comparable conversion rates to those who had upfront surgery. Lastly, NT was selectively associated with improved survival in patients with cT2N0M0 esophageal cancer.
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Affiliation(s)
- Jorge Humberto Rodriguez-Quintero
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Mohamed K Kamel
- Department of Cardiothoracic Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Rajika Jindani
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Mostafa Elbahrawy
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Marc Vimolratana
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Neel P Chudgar
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Brendon M Stiles
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY, USA.
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Zhao B, Yan S, Jia ZY, Zhu HT, Shi YJ, Li XT, Qu JR, Sun YS. CT radiomics in the identification of preoperative understaging in patients with clinical stage T1-2N0 esophageal squamous cell carcinoma. Quant Imaging Med Surg 2023; 13:7996-8008. [PMID: 38106287 PMCID: PMC10722054 DOI: 10.21037/qims-23-275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 10/11/2023] [Indexed: 12/19/2023]
Abstract
Background Predicting preoperative understaging in patients with clinical stage T1-2N0 (cT1-2N0) esophageal squamous cell carcinoma (ESCC) is critical to customizing patient treatment. Radiomics analysis can provide additional information that reflects potential biological heterogeneity based on computed tomography (CT) images. However, to the best of our knowledge, no studies have focused on identifying CT radiomics features to predict preoperative understaging in patients with cT1-2N0 ESCC. Thus, we sought to develop a CT-based radiomics model to predict preoperative understaging in patients with cT1-2N0 esophageal cancer, and to explore the value of the model in disease-free survival (DFS) prediction. Methods A total of 196 patients who underwent radical surgery for cT1-2N0 ESCC were retrospectively recruited from two hospitals. Among the 196 patients, 134 from Peking University Cancer Hospital were included in the training cohort, and 62 from Henan Cancer Hospital were included in the external validation cohort. Radiomics features were extracted from patients' CT images. Least absolute shrinkage and selection operator (LASSO) regression was used for feature selection and model construction. A clinical model was also built based on clinical characteristics, and the tumor size [the length, thickness and the thickness-to-length ratio (TLR)] was evaluated on the CT images. A radiomics nomogram was established based on multivariate logistic regression. The diagnostic performance of the models in predicting preoperative understaging was assessed by the area under the receiver operating characteristic curve (AUC). Kaplan-Meier curves with the log-rank test were employed to analyze the correlation between the nomogram and DFS. Results Of the patients, 50.0% (67/134) and 51.6% (32/62) were understaged in the training and validation groups, respectively. The radiomics scores and the TLRs of the tumors were included in the nomogram. The AUCs of the nomogram for predicting preoperative understaging were 0.874 [95% confidence interval (CI): 0.815-0.933] in the training cohort and 0.812 (95% CI: 0.703-0.912) in the external validation cohort. The diagnostic performance of the nomogram was superior to that of the clinical model (P<0.05). The nomogram was an independent predictor of DFS in patients with cT1-2N0 ESCC. Conclusions The proposed CT-based radiomics model could be used to predict preoperative understaging in patients with cT1-2N0 ESCC who have undergone radical surgery.
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Affiliation(s)
- Bo Zhao
- Department of Radiology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing, China
| | - Shuo Yan
- Department of Radiology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing, China
| | - Zheng-Yan Jia
- Department of Radiology, the Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Hai-Tao Zhu
- Department of Radiology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing, China
| | - Yan-Jie Shi
- Department of Radiology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing, China
| | - Xiao-Ting Li
- Department of Radiology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing, China
| | - Jin-Rong Qu
- Department of Radiology, the Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Ying-Shi Sun
- Department of Radiology, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing, China
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Ma W, Nuckles B, Frank K, Young KA, Hoffman RL, Blansfield JA. Clinical T2N0M0 Esophageal Cancer-Is Treatment Pathway Associated With Overall Survival? J Surg Res 2023; 283:205-216. [PMID: 36410237 DOI: 10.1016/j.jss.2022.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/26/2022] [Accepted: 10/15/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Esophageal cancer therapy is commonly multimodal. The CROSS trial demonstrated a survival benefit of neoadjuvant chemoradiation versus surgery alone in T1N1 or T2-3N0-1 patients. Theoretically, chemoradiation should be most beneficial to patients with advanced disease. Treating the intermediary stage, T2N0M0, is challenging as national guidelines offer multiple options. This study aims to compare survival outcomes and associated factors in clinical T2N0M0 esophageal cancer via treatment modality and compare clinical to pathological stage. The authors conclude that neoadjuvant therapy use has increased; however, there is no associated survival benefit, which may be due to over- or under-staging. METHODS A retrospective study was performed using the National Cancer Database (2006-2016). Patients who underwent neoadjuvant chemoradiation followed by surgery (NCRT + ESOPH) were compared to patients who underwent esophagectomy first (ESOPH). Multivariable logistic regression was used to determine factors associated with treatment pathway. Overall survival was compared using Kaplan-Meier estimates and log-rank tests at 1-, 3-, and 5-y post-treatment. Additionally, a multiple logistic regression analysis was conducted to identify factors associated with adjuvant therapy in ESOPH patients. RESULTS There were 1662 patients (NCRT + ESOPH: 904 [54.4%], ESOPH: 758 [45.6%]). There was no difference in 5-y survival between NCRT + ESOPH and ESOPH patients. Despite this, NCRT + ESOPH treatment rates rose from 33% to 74% between 2006 and 2016. Patients who received NCRT + ESOPH were younger and more commonly had no Charlson-Deyo comorbidities. Notably, 41% of patients were over-staged (T1 or lower), and 32.8% were under-staged (N ≥ 1). CONCLUSIONS T2N0M0 remains difficult to characterize, and pathological staging corresponds poorly to clinical staging. Neoadjuvant therapy use has increased; however, the lack of a significant survival benefit to correlate with such may be secondary to over- or under-staging.
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Affiliation(s)
- Wanyan Ma
- Geisinger Department of General Surgery, Danville, Pennsylvania.
| | - Brandon Nuckles
- Geisinger Department of General Surgery, Danville, Pennsylvania
| | - Katie Frank
- Geisinger Department of General Surgery, Danville, Pennsylvania
| | - Katelyn A Young
- Geisinger Department of General Surgery, Danville, Pennsylvania
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Cao X, Wu B, Li H, Xiong J. Influence of adverse effects of neoadjuvant chemoradiotherapy on the prognosis of patients with early-stage esophageal cancer (cT1b-cT2N0M0) based on the SEER database. Front Surg 2023; 10:1131385. [PMID: 37143768 PMCID: PMC10153569 DOI: 10.3389/fsurg.2023.1131385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 03/28/2023] [Indexed: 05/06/2023] Open
Abstract
Objective To analyze the prognostic impact of neoadjuvant chemoradiotherapy (NCRT) on early-stage (cT1b-cT2N0M0) esophageal cancer (ESCA) and construct a prognostic nomogram for these patients. Methods We extracted the clinical data about patients diagnosed with early-stage esophageal cancer from the 2004-2015 period of the Surveillance, Epidemiology, and End Results (SEER) database. We applied the independent risk factors affecting the prognosis of patients with early-stage esophageal cancer obtained after screening by univariate and multifactorial COX regression analyses to establish the nomogram and performed model calibration using bootstrapping resamples. The optimal cut-off point for continuous variables is determined by applying X-tile software. After balancing the confounding factors by propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) method, Kaplan-Meier(K-M) curve, and log-rank test were applied to evaluate the prognostic impact of NCRT on early-stage ESCA patients. Results Among patients who met the inclusion criteria, patients in the NCRT plus esophagectomy (ES) group had a poorer prognosis for overall survival (OS) and esophageal cancer-specific survival (ECSS) than patients in the ES alone group (p < 0.05), especially in patients who survived longer than 1 year. After PSM, patients in the NCRT + ES group had poorer ECSS than patients in the ES alone group, especially after 6 months, while OS was not significantly different between the two groups. IPTW analysis showed that, prior to 6 months patients in the NCRT + ES group had a better prognosis than patients in the ES group, regardless of OS or ECSS, whereas after 6 months, patients in the NCRT + ES group had a poorer prognosis. Based on multivariate COX analysis, we established a prognostic nomogram which showed areas under the ROC curve (AUC) for 3-, 5-, and 10-year OS 0.707, 0.712, and 0.706, respectively, with the calibration curves showing that the nomogram was well calibrated. Conclusions Patients with early-stage ESCA (cT1b-cT2) did not benefit from NCRT, and we established a prognostic nomogram to provide clinical decision aid for the treatment of patients with early-stage ESCA.
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Affiliation(s)
- Xiying Cao
- Department of Thoracic Surgery, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Bingqun Wu
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Department of Thoracic Surgery, Huaxin Hospital, First Hospital of Tsinghua University Beijing, Beijing, China
| | - Hui Li
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Correspondence: Hui Li Jianxian Xiong
| | - Jianxian Xiong
- Department of Thoracic Surgery, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Correspondence: Hui Li Jianxian Xiong
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da Costa WL, Gu X, Farjah F, Groth SS, Burt BM, Ripley RT, Massarweh NN. Clinical Understaging, Treatment Response, and Survival Among Esophageal Adenocarcinoma Patients. J Surg Res 2022; 279:256-264. [PMID: 35797753 DOI: 10.1016/j.jss.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/09/2022] [Accepted: 06/04/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Selecting appropriate management for patients with esophageal adenocarcinoma (EA) is predicated on accurate clinical staging information. Inaccurate information could lead to inappropriate treatment and suboptimal survival. We investigated the relationship between staging accuracy, treatment, and survival. METHODS This was a national cohort study of EA patients in the National Cancer Data Base (2006-2015) treated with upfront resection or neoadjuvant therapy (NAT). Clinical and pathological staging information was used to ascertain staging concordance for each patient. For NAT patients, Bayesian analysis was used to account for potential downstaging. We evaluated the association between staging concordance, receipt of NAT, and survival through hierarchical logistic regression and multivariable Cox regression. RESULTS Among 7635 EA patients treated at 877 hospitals, 3038 had upfront resection and 4597 NAT followed by surgery. Relative to accurately staged patients, understaging was associated with a lower likelihood (odds ratio [OR] 0.04 95% confidence interval [CI] 0.02-0.05) while overstaging was associated with a greater likelihood of receiving NAT (OR 1.98 [1.53-2.56]). Relative to upfront surgery, treatment of cT1N0 patients with NAT was associated with a higher risk of death (HR 3.08 [2.36-4.02]). For accurately or overstaged cT3-T4 patients, NAT was associated with a lower risk of death whether downstaging occurred (ypN0 disease-HR 0.67 [0.49-0.92]; N+ disease-HR 0.55 [0.45-0.66]) or not (ypN + disease-HR 0.78 [95% CI 0.65-0.93]). CONCLUSIONS Clinical understaging is associated with receipt of NAT which in turn may have a stage-specific impact on patients' survival regardless of treatment response. Guidelines should account for the possibility of inaccurate clinical staging.
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Wolfson P, Ho KMA, Bassett P, Haidry R, Olivo A, Lovat L, Sami SS. Accuracy of clinical staging for T2N0 oesophageal cancer: systematic review and meta-analysis. Dis Esophagus 2021; 34:6146603. [PMID: 33618359 DOI: 10.1093/dote/doab002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/24/2020] [Accepted: 01/03/2021] [Indexed: 12/24/2022]
Abstract
Oesophageal cancer is the sixth commonest cause of overall cancer mortality. Clinical staging utilizes multiple imaging modalities to guide treatment and prognostication. T2N0 oesophageal cancer is a treatment threshold for neoadjuvant therapy. Data on accuracy of current clinical staging tests for this disease subgroup are conflicting. We performed a meta-analysis of all primary studies comparing clinical staging accuracy using multiple imaging modalities (index test) to histopathological staging following oesophagectomy (reference standard) in T2N0 oesophageal cancer. Patients that underwent neoadjuvant therapy were excluded. Electronic databases (MEDLINE, Embase, Cochrane Library) were searched up to September 2019. The primary outcome was diagnostic accuracy of combined T&N clinical staging. Publication date, first recruitment date, number of centers, sample size and geographical location main histological subtype were evaluated as potential sources of heterogeneity. The search strategy identified 1,199 studies. Twenty studies containing 5,213 patients met the inclusion criteria. Combined T&N staging accuracy was 19% (95% CI, 15-24); T staging accuracy was 29% (95% CI, 24-35); percentage of patients with T downstaging was 41% (95% CI, 33-50); percentage of patients with T upstaging was 28% (95% CI, 24-32) and percentage of patients with N upstaging was 34% (95% CI, 30-39). Significant sources of heterogeneity included the number of centers, sample size and study region. T2N0 oesophageal cancer staging remains inaccurate. A significant proportion of patients were downstaged (could have received endotherapy) or upstaged (should have received neoadjuvant chemotherapy). These findings were largely unchanged over the past two decades highlighting an urgent need for more accurate staging tests for this subgroup of patients.
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Affiliation(s)
- Paul Wolfson
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | - Kai Man Alexander Ho
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | | | - Rehan Haidry
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | - Alessandro Olivo
- Department of Medical Physics and Bioengineering, University College London, London, UK
| | - Laurence Lovat
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | - Sarmed S Sami
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
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Capovilla G, Moletta L, Pierobon ES, Salvador R, Provenzano L, Zanchettin G, Costantini M, Merigliano S, Valmasoni M. Optimal Treatment of cT2N0 Esophageal Carcinoma: Is Upfront Surgery Really the Way? Ann Surg Oncol 2021; 28:8387-8397. [PMID: 34142286 DOI: 10.1245/s10434-021-10194-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/19/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Staging is inaccurate for cT2N0 esophageal cancer, and patients often are clinically mis-staged. This study aimed to evaluate the outcome after upfront surgery or neoadjuvant therapy, considering the impact of clinical "mis-staging." METHODS This study reviewed patients with squamous cell carcinoma (SCC) or adenocarcinoma (ADK) of the esophagus who underwent upfront surgery (S group) or neoadjuvant treatment (chemoradiotherapy [CRT] group) for cT2N0 cancer. Overall survival (OS), disease-free survival (DFS), morbidity, and mortality were evaluated. Correctly staged (cTNM = pTNM), understaged (cTNM < pTNM), and overstaged (cTNM > pTNM) patients in the S group and the CRT group were analyzed. Risk factors for unexpected lymph-node involvement were identified in the S group and for cancer-related death in the whole study cohort. RESULTS The study enrolled 229 patients with cT2N0 esophageal cancer. The 5-year OS rate was 34.2% in the S group versus 55.7% in the CRT group (p = 0.0088). The DFS also was significantly higher (p = 0.01). The morbidity and mortality rates were similar. In the S group, the cTNM was correctly staged for 21.4% and understaged for 63.4% of the patients, with 48.7% of the patients showing unexpected nodal involvement. A tumor length of 3 cm or more was an independent predictor of nodal metastases in SCC (p = 0.03), as was lymphovascular invasion (LVI) in ADK (p < 0.01). Cancer-related mortality was independently associated with lymph-node metastases (p = 0.03) and treatment by upfront surgery (p = 0.01). CONCLUSION Given the high rate of understaged patients in this study (63.4%), the authors advocate for combining the induction therapy with surgery in cT2N0, achieving better survival with similar morbidity and mortality.
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Affiliation(s)
- Giovanni Capovilla
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
| | - Lucia Moletta
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
| | - Elisa Sefora Pierobon
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy.
| | - Renato Salvador
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
| | - Luca Provenzano
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
| | - Gianpietro Zanchettin
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
| | - Mario Costantini
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
| | - Stefano Merigliano
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
| | - Michele Valmasoni
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
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Interobserver variability in target volume delineation in definitive radiotherapy for thoracic esophageal cancer: a multi-center study from China. Radiat Oncol 2021; 16:102. [PMID: 34107984 PMCID: PMC8188796 DOI: 10.1186/s13014-020-01691-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/20/2020] [Indexed: 12/02/2022] Open
Abstract
Purpose To investigate the interobserver variability (IOV) in target volume delineation of definitive radiotherapy for thoracic esophageal cancer (TEC) among cancer centers in China, and ultimately improve contouring consistency as much as possible to lay the foundation for multi-center prospective studies. Methods Sixteen cancer centers throughout China participated in this study. In Phase 1, three suitable cases with upper, middle, and lower TEC were chosen, and participants were asked to contour a group of gross tumor volume (GTV-T), nodal gross tumor volume (GTV-N) and clinical target volume (CTV) for each case based on their routine experience. In Phase 2, the same clinicians were instructed to follow a contouring protocol to re-contour another group of target volume. The variation of the target volume was analyzed and quantified using dice similarity coefficient (DSC). Results Sixteen clinicians provided routine volumes, whereas ten provided both routine and protocol volumes for each case. The IOV of routine GTV-N was the most striking in all cases, with the smallest DSC of 0.37 (95% CI 0.32–0.42), followed by CTV, whereas GTV-T showed high consistency. After following the protocol, the smallest DSC of GTV-N was improved to 0.64 (95% CI 0.45–0.83, P = 0.005) but the DSC of GTV-T and CTV remained constant in most cases. Conclusion Variability in target volume delineation was observed, but it could be significantly reduced and controlled using mandatory interventions. Supplementary information Supplementary information accompanies this paper at 10.1186/s13014-020-01691-4.
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Wang W, Sang Y, Chen Y. Should Neoadjuvant Therapy Be a Standard Modality for Patients With Clinical T2N0 Esophageal Cancer? Ann Thorac Surg 2021; 111:2085. [DOI: 10.1016/j.athoracsur.2020.08.090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 08/20/2020] [Indexed: 10/23/2022]
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Shao Y, Chen D, Ye L, Wang XM, Wu QC, Zhang C. Survival benefit of perioperative chemotherapy for T1-3N0M0 stage esophageal cancer: a SEER database analysis. J Thorac Dis 2021; 13:995-1004. [PMID: 33717572 PMCID: PMC7947537 DOI: 10.21037/jtd-20-2877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background The effect of perioperative chemotherapy on patients with lymph node-negative esophageal cancer (EC) is controversial. This study explored which EC patients, staged under the T1-3N0M0, would benefit from perioperative chemotherapy. Methods Data on patients with diagnosed primary EC were retrieved from Surveillance, Epidemiology and End Results (SEER) database. Propensity score-matched (PSM) method was performed to balance baseline covariates. Multivariate Cox regression analysis and Kaplan-Meier curve were used to assess potential survival difference between patients undergoing surgery plus perioperative chemotherapy (SA + CT) and those undergoing surgery alone (SA). Results In a total of 2,711 EC patients (T1–3N0M0), 166 patients underwent SA + CT and 2,545 patients received SA. In the multivariable analysis, T stage was significantly related to prognosis of EC patients before and after matching. Subgroup analysis showed that perioperative chemotherapy was associated with poor cancer-specific survival (CSS) for stage T1 patients. There was no effect of perioperative chemotherapy on overall survival (OS) or CSS for T2 patients, whereas a remarkable improvement in OS and CSS was observed for T3 patients. Survival analysis showed that T3 stage EC patients obtained survival benefit from SA + CT. Prognosis in the SA group was significantly better than in the SA + CT group for T1 patients. However, T2 patients showed no significant increase in survival after undergoing SA + CT compared with SA. Conclusions T3 patients benefit more from SA + CT. However, perioperative chemotherapy does not present survival benefit to T1–2 patients, and it is an adverse prognostic factor for T1 patients.
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Affiliation(s)
- Yue Shao
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dan Chen
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Liu Ye
- The First Branch, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xin-Mei Wang
- Department of Pathology, Chongqing Medical University, Chongqing, China
| | - Qing-Chen Wu
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Cheng Zhang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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da Costa WL, Gu X, Farjah F, Groth SS, Burt BM, Ripley RT, Carrott PW, Massarweh NN. Staging Concordance and Guideline-Concordant Treatment for Esophageal Adenocarcinoma. Ann Thorac Surg 2021; 113:279-285. [PMID: 33484675 DOI: 10.1016/j.athoracsur.2020.12.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/08/2020] [Accepted: 12/30/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Treatment selection for patients with esophageal adenocarcinoma is predicated on clinical staging information, which is inaccurate in 20% to 30% of cases and could impact the delivery of guideline-concordant treatment. We aimed to evaluate the association between staging concordance at the patient and hospital levels with the delivery of guideline-concordant treatment among esophageal adenocarcinoma patients. METHODS This was a national cohort study of resected esophageal adenocarcinoma patients in the National Cancer Data Base (2006 to 2015) treated either with upfront resection or neoadjuvant therapy followed by surgery. Patient- and hospital-level clinical and pathologic staging concordance and deviations from treatment guidelines were ascertained. For neoadjuvant therapy patients, staging concordance was predicted through Bayesian analysis. Reliability adjustment was used when evaluating hospital-level concordance. RESULTS Among 9393 esophageal adenocarcinoma patients treated at 927 hospitals, 41% had upfront surgery. Among upfront surgery patients, staging concordance was 85.1% for T1N0 and 86.9% for T3-T4N+ disease, but less than 50% for all others. Among patients treated with neoadjuvant therapy, treatment downstaging was observed in 33.9%. Deviations from treatment guidelines were identified in 38.5% of upfront surgery patients and 3.3% of neoadjuvant therapy patients. The proportion of concordantly staged patients ranged from 60.1% to 87.9%, and deviations from treatment guidelines were observed among 14.9% to 22.7% of the patients. Patient staging concordance increased, and deviations from guidelines decreased, as hospital-level concordance increased (trend test, P values less than .001 for all). CONCLUSIONS Deviations from treatment guidelines in esophageal adenocarcinoma patients appear to be a function of inaccurate clinical staging information, which should be a new focus for quality improvement efforts.
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Affiliation(s)
- Wilson Luiz da Costa
- Department of Medicine, Epidemiology, and Population Sciences, Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas.
| | - Xiangjun Gu
- Department of Medicine, Epidemiology, and Population Sciences, Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Farhood Farjah
- Department of Thoracic Surgery, University of Washington, Seattle, Washington
| | - Shawn S Groth
- Division of Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Bryan M Burt
- Division of Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Robert T Ripley
- Division of Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Phillip W Carrott
- Division of Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Nader N Massarweh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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12
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Liu XL, Shao CY, Sun L, Liu YY, Hu LW, Cong ZZ, Xu Y, Wang RC, Yi J, Wang W. An artificial neural network model predicting pathologic nodal metastases in clinical stage I-II esophageal squamous cell carcinoma patients. J Thorac Dis 2020; 12:5580-5592. [PMID: 33209391 PMCID: PMC7656440 DOI: 10.21037/jtd-20-1956] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Background Current preoperative staging for lymph nodal status remains inaccurate. The purpose of this study was to build an artificial neural network (ANN) model to predict pathologic nodal involvement in clinical stage I–II esophageal squamous cell carcinoma (ESCC) patients and then validated the performance of the model. Methods A total of 523 patients (training set: 350; test set: 173) with clinical staging I–II ESCC who underwent esophagectomy and reconstruction were enrolled in this study. Their post-surgical pathological results were assessed and analysed. An ANN model was established for predicting pathologic nodal positive patients in the training set, which was validated in the test set. A receiver operating characteristic (ROC) curve was also created to illustrate the performance of the predictive model. Results Of the enrolled 523 patients with ESCC, 41.3% of the patients were confirmed pathologic nodal positive (216/523). The ANN staging system identified the tumour invasion depth, tumour length, dysphagia, tumour differentiation and lymphovascular invasion (LVI) as predictors for pathologic lymph node metastases. The C-index for the ANN model verified in the test set was 0.852, which demonstrated that the ANN model had a good predictive performance. Conclusions The ANN model presented good performance for predicting pathologic lymph node metastasis and added indicators not included in current staging criteria and might help improve the staging strategies.
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Affiliation(s)
- Xiao-Long Liu
- Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Chen-Ye Shao
- Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Lei Sun
- Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Yi-Yang Liu
- Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Li-Wen Hu
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhuang-Zhuang Cong
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yang Xu
- Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Rong-Chun Wang
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jun Yi
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wei Wang
- Department of Thoracic Surgery, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Comparative Analysis of Blood and Bone Marrow for the Detection of Circulating and Disseminated Tumor Cells and Their Prognostic and Predictive Value in Esophageal Cancer Patients. J Clin Med 2020; 9:jcm9082674. [PMID: 32824841 PMCID: PMC7464950 DOI: 10.3390/jcm9082674] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/10/2020] [Accepted: 08/14/2020] [Indexed: 01/21/2023] Open
Abstract
Hematogenic tumor cell spread is a key event in metastasis. However, the clinical significance of circulating tumor cells (CTC) in the blood and disseminated tumor cells (DTC) in bone marrow is still not fully understood. Here, the presence of DTC and CTC in esophageal cancer (EC) patients and its correlation with clinical parameters was investigated to evaluate the CTC/DTC prognostic value in EC. This study included 77 EC patients with complete surgical tumor resection. CTC and DTC were analyzed in blood and bone marrow using nested CK20 reverse transcription-nested polymerase chain reaction (RT-PCR) and findings were correlated with clinical data. Twenty-seven of 76 patients (36.5%) showed CK20 positivity in the blood, 19 of 61 patients (31.1%) in bone marrow, and 40 (51.9%) of 77 patients were positive in either blood or bone marrow or both. In multivariate analyses, only the DTC status emerged as independent predictor of overall and tumor specific survival. Our study revealed that, while the presence of CTC in blood is not associated with a worse prognosis, DTC detection in the bone marrow is a highly specific and independent prognostic marker in EC patients. Larger cohort studies could unravel how this finding can be translated into improved therapy management in EC.
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Gao HJ, Wei YC, Gong L, Ge N, Han B, Shi GD, Yu ZT. Role of radiation therapy in node-negative esophageal cancer: A propensity-matched analysis. Thorac Cancer 2020; 11:2820-2829. [PMID: 32790041 PMCID: PMC7529582 DOI: 10.1111/1759-7714.13607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 07/18/2020] [Accepted: 07/18/2020] [Indexed: 01/03/2023] Open
Abstract
Background This study investigated the prognostic impact of (neo‐)adjuvant radiation therapies in early stage esophageal cancer. Methods A retrospective analysis using the Surveillance, Epidemiology, and End Results (SEER) database was conducted from 2004 to 2016. Patients with pathologically staged T1‐4N0M0 esophageal cancer were divided into two treatment groups: (i) neoadjuvant radiotherapy followed by surgery; and (ii) upfront esophagectomy followed by adjuvant radiotherapy. Propensity scored match and Cox proportional hazards model were used to identify covariates associated with overall survival and cancer‐specific survival. Results There were 821 patients selected, of whom 588 (71.6%) received neoadjuvant radiotherapy and 233 (28.4%) received adjuvant radiotherapy. For the entire cohort, neoadjuvant radiotherapy was associated with a significantly benefit in five‐year survival outcomes compared with adjuvant radiotherapy (P < 0.01). After matching, the survival outcomes were still better for neoadjuvant radiotherapy than that of adjuvant treatment. Stratifying based on pathologic tumor status, neoadjuvant radiation was associated with improved CSS (five‐year survival 73.7% vs. 42.1%; P = 0.014) for localized (pT3‐4N0) disease. The Cox multivariate regression analysis revealed that the addition of neoadjuvant radiation for pT3‐4N0 diseases with tumor length ≥ 5 cm and squamous cell carcinoma, was a powerful prognostic factor for improved cancer‐specific survival (P < 0.01). Conclusions Compared with adjuvant radiotherapy, the addition of neoadjuvant radiation for pT3‐4N0 diseases has been associated with improved cancer‐specific survival in high‐risk patients. Studies on preoperative neoadjuvant therapies would be plausible in high‐risk esophageal cancer patients.
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Affiliation(s)
- Hui-Jiang Gao
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yu-Cheng Wei
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lei Gong
- Department of Esophageal Cancer, Tianjin's Clinical Research Center for Cancer and Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Nan Ge
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Bin Han
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Guo-Dong Shi
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhen-Tao Yu
- Department of Esophageal Cancer, Tianjin's Clinical Research Center for Cancer and Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
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Gao HJ, Wei YC, Gong L, Ge N, Han B, Shi GD, Yu ZT. Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for clinical node-negative esophageal carcinoma. Thorac Cancer 2020; 11:2618-2629. [PMID: 32755068 PMCID: PMC7471040 DOI: 10.1111/1759-7714.13586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 01/03/2023] Open
Abstract
Background The impact of neoadjuvant chemoradiotherapy (nCRT) on early stage esophageal cancer is unknown. Here, we compared the outcomes after esophagectomy alone or nCRT plus surgery for clinically staged node‐negative esophageal cancer. Methods We searched the Surveillance, Epidemiology, and End Results database for patients with clinically node‐negative (cN0) esophageal cancer from 2004 to 2016 who underwent surgery alone or nCRT plus surgery. Propensity score matching and Cox regression analysis were used to identify covariates associated with overall survival and cancer‐specific survival. Results A total of 1587 patients were retrospectively identified, of whom 49.8% (n = 791) received nCRT and 80.2% (n = 1273) were truly node‐negative diseases. For the entire cohort, surgery alone was associated with a statistically significant but modest absolute increase in survival outcomes (P < 0.01). After matching, nCRT was associated with improved five‐year overall survival for pT3‐4N0 (localized) disease (59.6% vs. 37.7%; P < 0.001) and pathological node‐positive disease (60.5% vs. 40.7%; P = 0.002). Cox multivariate regression analysis revealed that the addition of nCRT for truly node‐negative patients with tumor length ≥ 3 cm, pT1‐2N0 (early‐staged) and localized disease were independent risk factors for survival than surgery alone (P < 0.01). Conclusions Compared with surgery alone, patients with cN0 esophageal cancer with pathological node‐positive or localized true node‐negative disease gain a significant survival benefit from nCRT. However, nCRT plus surgery was associated with decreased survival for early‐staged true node‐negative patients. This finding may have significant implications on the use of neoadjuvant chemoradiation in patients with cN0 disease.
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Affiliation(s)
- Hui-Jiang Gao
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yu-Cheng Wei
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lei Gong
- Department of Esophageal Cancer, Tianjin's Clinical Research Center for Cancer and Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Nan Ge
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Bin Han
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Guo-Dong Shi
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhen-Tao Yu
- Department of Esophageal Cancer, Tianjin's Clinical Research Center for Cancer and Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
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Rhodin KE, Raman V, Jawitz OK, Voigt SL, Farrow NE, Harpole DH, Tong BC, D'Amico TA. Patterns of Use of Induction Therapy for T2N0 Esophageal Cancer. Ann Thorac Surg 2020; 111:440-447. [PMID: 32681837 DOI: 10.1016/j.athoracsur.2020.05.089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/21/2020] [Accepted: 05/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Induction therapy for patients with cT2N0M0 esophageal cancer is controversial. We performed a retrospective cohort analysis of the National Cancer Database to examine the patterns of use of induction therapy for this population. METHODS The National Cancer Database was queried for patients with cT2N0M0 esophageal cancer who underwent esophagectomy (2004-2015). Patients were stratified by upfront surgery or induction therapy. Overall survival was analyzed and a multivariable logistic regression performed to identify factors associated with receipt of induction therapy. RESULTS Overall 2540 patients met study criteria: 1177 (46%) received upfront esophagectomy and 1363 (53%) received induction therapy. Patients receiving induction therapy were more likely to be younger, male, without comorbidities, privately insured, and treated at a nonacademic center. These patients were also less likely to be treated in highest volume surgery centers. In multivariable regression, factors independently associated with receipt of induction therapy included later year of diagnosis, increasing tumor size, and increasing tumor grade. Factors associated with upfront esophagectomy included advancing age, comorbidities, lack of insurance, geographic location, and highest volume centers. The receipt of induction chemotherapy was not associated with a survival benefit compared with no induction therapy. CONCLUSIONS Several patient-, treatment center-, and tumor-related factors are associated with receipt of induction therapy for cT2N0M0 esophageal cancer, although induction therapy is not associated with a survival benefit. Further inquiry into these differences and the potential benefit or lack thereof of induction therapy should be conducted to provide more equitable and appropriate care for patients with esophageal cancer.
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Affiliation(s)
- Kristen E Rhodin
- Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Vignesh Raman
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Oliver K Jawitz
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Soraya L Voigt
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Norma E Farrow
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - David H Harpole
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Betty C Tong
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Thomas A D'Amico
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Tian D, Huang H, Yang YS, Jiang KY, He X, Guo XG, Chen LQ. Depth of Invasion into the Circular and Longitudinal Muscle Layers in T2 Esophageal Squamous Cell Carcinoma Does Not Affect Prognosis or Lymph Node Metastasis: A Multicenter Retrospective Study. World J Surg 2019; 44:171-178. [PMID: 31552458 DOI: 10.1007/s00268-019-05194-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although a greater depth of tumor invasion is correlated with a poorer prognosis in esophageal squamous cell carcinoma (ESCC), it remains controversial whether T2 ESCC should be subclassified by circular and longitudinal muscle invasion. We conducted a multicenter retrospective study to evaluate the relationship between the depth of invasion and long-term outcome and to identify the clinical significance of subclassifying T2 ESCC. METHODS Patients with T2 ESCC who underwent esophagectomy at two different institutes between January 2009 and December 2017 were analyzed retrospectively. ESCC with circular and longitudinal muscle invasion was defined as T2 circular and T2 longitudinal ESCC, respectively. Survival outcomes and risk factors for lymph node metastasis (LNM) were evaluated by univariate and multivariate analyses. In addition, data from stage T1b ESCC cases during the same period were retrieved for use as a comparison cohort to evaluate the prognostic significance of the T2 substage. RESULTS A total of 536 T2 ESCC patients were eligible, and 192 (36%) patients developed LNM. No significant difference was found in general characteristics between the T2 circular and T2 longitudinal ESCC groups (n = 219 and n = 317, P > 0.05), except for tumor location (P = 0.02). The T2 substage was not significantly correlated with survival on univariate or multivariate analysis (P = 0.30 and P = 0.34, respectively). Multivariate analysis also indicated that the T2 substage was not an independent risk factor for LNM (P = 0.15). When patients with stage T1b ESCC were considered, their survival time was significantly different from that of patients with T2 circular and T2 longitudinal disease (P = 0.01). CONCLUSIONS The depth of tumor invasion into the circular and longitudinal muscle layers in T2 ESCC does not affect the prognosis or risk of LNM.
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Affiliation(s)
- Dong Tian
- Department of Thoracic Surgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, China
- Department of Thoracic Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, China
| | - Heng Huang
- College of Clinical Medicine, North Sichuan Medical College, Nanchong, 637000, China
| | - Yu-Shang Yang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Kai-Yuan Jiang
- College of Clinical Medicine, North Sichuan Medical College, Nanchong, 637000, China
| | - Xi He
- Institute of Imaging Medicine, North Sichuan Medical College, Nanchong, 637000, China
| | - Xiao-Guang Guo
- Department of Pathology, Nanchong Central Hospital, Nanchong, 637000, China
| | - Long-Qi Chen
- Department of Thoracic Surgery, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, China.
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Kidane B, Korst RJ, Weksler B, Farrell A, Darling GE, Martin LW, Reddy R, Sarkaria IS. Neoadjuvant Therapy Vs Upfront Surgery for Clinical T2N0 Esophageal Cancer: A Systematic Review. Ann Thorac Surg 2019; 108:935-944. [DOI: 10.1016/j.athoracsur.2019.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 03/30/2019] [Accepted: 04/02/2019] [Indexed: 12/20/2022]
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Li C, Ni W, Wang X, Zhou Z, Deng W, Chang X, Chen D, Feng Q, Liang J, Wang X, Deng L, Wang W, Bi N, Zhang T, Xiao Z. A phase I/II radiation dose escalation trial using simultaneous integrated boost technique with elective nodal irradiation and concurrent chemotherapy for unresectable esophageal Cancer. Radiat Oncol 2019; 14:48. [PMID: 30876442 PMCID: PMC6420772 DOI: 10.1186/s13014-019-1249-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 03/04/2019] [Indexed: 12/22/2022] Open
Abstract
Background To investigate the safety and tolerability of simultaneous integrated boost (SIB) technique concurrent with elective nodal irradiation (ENI) and dual-drug chemotherapy for patients with unresectable esophageal cancer. Methods In phase I, the prophylactic PTV received a stable dose of 50.40Gy/1.80Gy/28f while the boost area was planned with 3 consecutive dose levels: the first dose level was 60.76Gy/2.17Gy/28f, and then escalated approximately every 2 Gy. ENI was incorporated in Clinical Target Volume (CTV), and paclitaxel and nedaplatin were given concurrently for at least 5 weeks. In phase II, enrolled patients were treated with Maximum Tolerated Dose (MTD) obtained in phase I and the compliance rate, survival results and toxicities were evaluated. Results From December 2014 to April 2017, 53 patients were enrolled. In phase I, 2 out of 6 patients developed Dose-Limiting Toxicity (DLT) at dose level 1. Due to excessive treatment-related toxicities, the escalation process was suspended and de-escalated to 59.92Gy /2.14Gy /28 f. Three patients were treated at this dose level, all of whom completed at least 5 weeks of chemotherapy and none of whom reached a DLT, determining the newly added dose level to be the MTD. In phase II, 44 patients were treated with MTD, 31 of them (70.0%) completed at least 5 weeks of chemotherapy. The most common Grade 3 or 4 toxicities in phase II included leukopenia (21%) and esophagitis (15%). With a median follow-up time of 16.9 months, 1-y OS, DFS and local failure-free survival were 76.9, 63.6 and 78.8% respectively. Conclusion The SIB technique was feasible and safe at the MTD (95% PGTV/PTV 59.92/50.40Gy/28f) concurrent with ENI and dual-drug chemotherapy for patients with unresectable esophageal cancer. Trial registration clinicaltrials.govNCT02429622. Retrospectively registered on April 24, 2015. Electronic supplementary material The online version of this article (10.1186/s13014-019-1249-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chen Li
- Department of Radiation Oncology, National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Panjiayuan Nanli, Beijing, 100021, China
| | - Wenjie Ni
- Department of Radiation Oncology, National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Panjiayuan Nanli, Beijing, 100021, China
| | - Xin Wang
- Department of Radiation Oncology, National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Panjiayuan Nanli, Beijing, 100021, China
| | - Zongmei Zhou
- Department of Radiation Oncology, National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Panjiayuan Nanli, Beijing, 100021, China
| | - Wei Deng
- Department of Radiation Oncology, National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Panjiayuan Nanli, Beijing, 100021, China
| | - Xiao Chang
- Department of Radiation Oncology, National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Panjiayuan Nanli, Beijing, 100021, China
| | - Dongfu Chen
- Department of Radiation Oncology, National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Panjiayuan Nanli, Beijing, 100021, China
| | - Qinfu Feng
- Department of Radiation Oncology, National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Panjiayuan Nanli, Beijing, 100021, China
| | - Jun Liang
- Department of Radiation Oncology, National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Panjiayuan Nanli, Beijing, 100021, China
| | - Xiaozhen Wang
- Department of Radiation Oncology, National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Panjiayuan Nanli, Beijing, 100021, China
| | - Lei Deng
- Department of Radiation Oncology, National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Panjiayuan Nanli, Beijing, 100021, China
| | - Wenqing Wang
- Department of Radiation Oncology, National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Panjiayuan Nanli, Beijing, 100021, China
| | - Nan Bi
- Department of Radiation Oncology, National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Panjiayuan Nanli, Beijing, 100021, China
| | - Tao Zhang
- Department of Radiation Oncology, National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Panjiayuan Nanli, Beijing, 100021, China
| | - Zefen Xiao
- Department of Radiation Oncology, National Cancer Center/ National Clinical Research Center for Cancer/ Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.17 Panjiayuan Nanli, Beijing, 100021, China.
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Fox M. T2N0 esophageal cancer—We can't know where to go unless we know where we've been. J Thorac Cardiovasc Surg 2019; 157:1273-1274. [DOI: 10.1016/j.jtcvs.2018.11.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 01/25/2023]
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Atay SM, Correa A, Hofstetter WL, Swisher SG, Ajani J, Altorki NK, Blackmon SH, Blackstone EH, Rice TW, Crabtree TD, D'Amico TA, Darling GE, DeMeester SR, DeMeester TR, Worrell SG, Ferri LE, Gaissert HA, Krasna MJ, Lerut A, Nafteux P, Moons J, Little AG, Low DE, Carrott PW, Schmidt HM, Miller D, Nason KS, Luketich JD, Orringer MB, Chang AC, Rizk NP, Salo JA, Schneider PM, Smithers BM, Vallböhmer D, van Lanschot J, Varghese TK, Watson TJ, Peters JH, Yang SC. Predictors of staging accuracy, pathologic nodal involvement, and overall survival for cT2N0 carcinoma of the esophagus. J Thorac Cardiovasc Surg 2019; 157:1264-1272.e6. [DOI: 10.1016/j.jtcvs.2018.10.057] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 10/01/2018] [Accepted: 10/10/2018] [Indexed: 11/28/2022]
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Accuracy of Clinical Staging and Outcome With Primary Resection for Local-Regionally Limited Esophageal Adenocarcinoma. Ann Surg 2019; 267:484-488. [PMID: 28151801 DOI: 10.1097/sla.0000000000002139] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The aim of this study was to determine the accuracy of clinical staging, to assess survival with surgical resection alone, and to determine factors associated with understaging in patients with esophageal adenocarcinoma thought to have limited local-regional disease. BACKGROUND Primary surgical resection is the preferred treatment in patients with esophageal adenocarcinoma clinically staged to have limited nodal disease. This approach requires reliable clinical staging. METHODS A retrospective chart review was performed of all patients who had primary esophagectomy for clinical stage T1-3 N0-1 adenocarcinoma (seventh edition AJCC) from January 2002 to May 2013. Clinical and pathologic stages were compared and overall survival was analyzed. RESULTS There were 88 patients who met inclusion criteria. Final pathology confirmed appropriate clinical staging (≤T3N1) in 76% of patients (67/88). There were 21 patients who were understaged (>T3N1), and in all cases, understaging was based on the presence of advanced nodal (N2 or N3) disease. Factors independently associated with understaging were the presence of dysphagia, tumor length >3 cm, and poor differentiation. At a median follow-up of 35 months, 63% of all patients (55/88) remain alive. The 5-year survival in correctly staged patients was 67%, compared with 33% for those who were understaged (P < 0.0001). CONCLUSIONS Modern clinical staging will accurately identify the majority of patients with esophageal adenocarcinoma and limited local-regional disease (≤pT3N1). Survival with surgery alone in correctly staged patients was excellent and unlikely to be improved with neoadjuvant therapy. A combination of dysphagia, poor differentiation, and tumor length >3 cm was associated with understaging in 92% of patients. Patients with these factors are likely to have more advanced disease than clinically suspected and may benefit from neoadjuvant therapy before resection.
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Lv HW, Xing WQ, Shen SN, Cheng JW. Induction therapy for clinical stage T2N0M0 esophageal cancer: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e12651. [PMID: 30290643 PMCID: PMC6200548 DOI: 10.1097/md.0000000000012651] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE It is still controversial whether patients with clinical T2N0M0 (cT2N0M0) esophageal cancer are treated with induction therapy. The aim of this study was to determine the effect of induction therapy on cT2N0M0 esophageal cancer. METHODS AND MATERIALS We searched PubMed, Embase, the Cochrane Library, and Medline databases from inception up to May 1, 2017. This meta-analysis was performed to compare odds ratios (OR) for 5-year overall survival (OS), pathologically understaged and overstaged after esophagectomy. RESULTS Eight retrospective studies of 2646 patients were included in the meta-analysis. Data showed that no statistically significant difference in 5-year over survival was observed between induction therapy group and direct operation group. The pooled OR and 95% confidence interval (CI) for 5-year OS were 0.92 (95% CI = 0.72-1.18; P = .52). Whereas, compared with induction therapy group, direct operation group had more pathologically understaged and less overstaged after esophagectomy. CONCLUSIONS Currentclinical staging for T2N0M0 esophageal carcinoma remains inaccurate. In this study, we found that direct operation group had more pathologically understaged and less overstaged after esophagectomy compared with induction therapy group. Induction therapy could degrade the tumor staging but not improve the patient's survival.
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Affiliation(s)
- Hong-Wei Lv
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital Zhengzhou, Henan, P. R. China
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Shridhar R, Huston J, Meredith KL. Accuracy of endoscopic ultrasound staging for T2N0 esophageal cancer: a National Cancer Database analysis. J Gastrointest Oncol 2018; 9:887-893. [PMID: 30505591 DOI: 10.21037/jgo.2018.01.16] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background To determine accuracy of clinical staging of T2N0 esophageal cancer from the National Cancer Database (NCDB). Methods The NCDB was accessed to identify patients with T2N0M0 esophageal cancer (adenocarcinoma or squamous cell carcinoma) treated between 2004-2013 that underwent esophagectomy. Pathologic staging was compared to clinical stage. Univariate (UVA) and multivariate analysis (MVA) was performed to identify factors related to pathologic upstaging using Cox proportional hazard ratio. Results We identified 1,840 patients with T2N0 esophageal cancer who underwent esophagectomy as first line therapy. The median age was 67 years. The vast majority of patients were male and had distal adenocarcinomas. Clinical staging in was accurate pathologically in 30.7% of patients. While there was a trend for worse accuracy with increasing year of diagnosis, there rate of pT0-2N0 was stable. Tumor length >3 cm was significantly associated with tumor upstaging, while poor differentiation was significantly associated with nodal upstaging. UVA and MVA identified younger age, tumor length >3 cm, and poor differentiation were significantly associated with overall upstaging. Gender, tumor location, and tumor histology were not prognostic. Conclusions Clinical staging for T2N0M0 esophageal cancer continues to remain highly inaccurate, however, rates of pT0-2N0 have steadily remained over 50%. Tumor length >3 cm and poor differentiation are strongly associated with pathologic upstaging.
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Affiliation(s)
- Ravi Shridhar
- Department of Radiation Oncology, Florida Hospital Orlando, Orlando, FL, USA
| | - Jamie Huston
- Division of Surgical Oncology, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Kenneth L Meredith
- Division of Surgical Oncology, Sarasota Memorial Hospital, Sarasota, FL, USA
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Haque W, Verma V, Bernicker E, Butler EB, Teh BS. Management of pathologic node-positive disease following initial surgery for clinical T1-2 N0 esophageal cancer: patterns of care and outcomes from the national cancer data base. Acta Oncol 2018; 57:782-789. [PMID: 29188742 DOI: 10.1080/0284186x.2017.1409435] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Although clinical T1-2N0 esophageal cancer (EC) is often initially surgically resected (without neoadjuvant therapy), several studies have illustrated substantial rates of discovering pathologically node-positive disease. This study evaluated national practice patterns of adjuvant therapy for this population. METHODS The National Cancer Database (NCDB) was queried (2004-2013) for patients with cT1-2N0M0 EC that received up-front surgery (esophagectomy/local techniques) with subsequent discovery of nodal metastasis. Patients receiving any neoadjuvant therapy were excluded. Multivariable logistic regression determined factors predictive of receiving adjuvant therapy. Kaplan-Meier analysis evaluated overall survival (OS), and Cox proportional hazards modeling determined variables associated with OS. Propensity score matching assessed groups in a balanced manner while reducing indication biases. RESULTS Altogether, 715 patients met inclusion criteria; 114 (16%) underwent adjuvant chemotherapy, 183 (26%) chemoradiation, 16 (2%) radiotherapy alone, and 402 (56%) observation. Observation was more likely performed with advanced age (p = .002) and at nonacademic centers (p = .001). Median OS in the respective cohorts were 42.6, 35.1, 22.2, and 27.0 months. Both chemotherapy and chemoradiation were statistically similar (p = .462) but superior to observation (p < .05 for both). There was a survival benefit to any adjuvant treatment (median OS 38.5 vs. 27.0 months, p < .001), which persisted after propensity matching (median OS 35.1 vs. 24.3 months, p < .001). On multivariable analysis, any adjuvant treatment was independently associated with improved OS, along with treatment at an academic center (p < .05 for all). CONCLUSIONS In the largest study to date evaluating patterns of care for pN + disease following resection of cT1-2N0 EC, a strikingly high proportion of patients were observed. Adjuvant treatment, ideally chemotherapy or chemoradiation, independently correlated with higher survival, and should be considered in able patients. Treatment at academic facilities also associated with higher survival, which has implications for patient counseling.
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Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Eric Bernicker
- Department of Medical Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - E. Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Bin S. Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
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26
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Mota FC, Cecconello I, Takeda FR, Tustumi F, Sallum RAA, Bernardo WM. Neoadjuvant therapy or upfront surgery? A systematic review and meta-analysis of T2N0 esophageal cancer treatment options. Int J Surg 2018; 54:176-181. [PMID: 29730075 DOI: 10.1016/j.ijsu.2018.04.053] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/24/2018] [Accepted: 04/28/2018] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- F C Mota
- Digestive Surgery Division, Department of Gastroenterology, Sao Paulo School of Medicine, Brazil
| | - I Cecconello
- Esophageal Surgery Group, Digestive Surgery Division, Department of Gastroenterology, Sao Paulo School of Medicine, Brazil
| | - F R Takeda
- Medical Assistant of São Paulo Institute of Cancer, Esophageal Surgery Group, Digestive Surgery Division, Department of Gastroenterology, São Paulo School of Medicine, Brazil
| | - F Tustumi
- Digestive Surgery Division, Department of Gastroenterology, Sao Paulo School of Medicine, Brazil.
| | - R A A Sallum
- Director of Esophageal Surgery Group, Digestive Surgery Division, Department of Gastroenterology, Sao Paulo School of Medicine, Brazil
| | - W M Bernardo
- Department of Gastroenterology, Digestive Surgery Division, São Paulo School of Medicine, Brazil
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Yang J, Luo GY, Liang RB, Zeng TS, Long H, Fu JH, Xu GL, Yang MZ, Li S, Zhang LJ, Lin P, Wang X, Hou X, Yang HX. Efficacy of Endoscopic Ultrasonography for Determining Clinical T Category for Esophageal Squamous Cell Carcinoma: Data From 1434 Surgical Cases. Ann Surg Oncol 2018; 25:2075-2082. [PMID: 29667114 DOI: 10.1245/s10434-018-6406-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND The efficacy of endoscopic ultrasonography (EUS) for determining T category is variable for esophageal squamous cell carcinoma (ESCC). We aimed to assess the efficacy of EUS in accurately identifying T category for ESCC based on the 8th AJCC Cancer Staging Manual. METHODS A retrospective analysis was conducted using a prospectively collected ESCC database from January 2003 to December 2015, in which all patients underwent EUS examination followed by esophagectomy. The efficacy of EUS was evaluated by sensitivity, specificity, and accuracy compared with pathological T category as gold standard. Overall survival of different EUS-T (uT) categories was assessed. RESULTS In total, 1434 patients were included, of whom 58.2% were correctly classified by EUS, with 17.9% being overstaged and 23.9% being understaged. The sensitivity and accuracy of EUS for Tis, T1a, T1b, T2, T3, and T4a categories were 15.8 and 98.8%, 16.3 and 95.7%, 33.1 and 89.3%, 56.8 and 65.0%, 65.8 and 70.0%, and 27.3 and 97.5%, respectively. The survival difference between uT1a and uT1b was not statistically significant (p = 0.90), nor was that between uT4a and uT4b (p = 0.34). However, when uT category was integrated as uTis, uT1, uT2, uT3, and uT4, overall survival was clearly distinguished between the categories (p < 0.01). CONCLUSIONS EUS is in general feasible for classifying clinical T category for ESCC. However, EUS should be used with caution for discriminating between Tis, T1a, and T1b disease, as well as T4 disease.
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Affiliation(s)
- Jie Yang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Guang-Yu Luo
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.,Department of Endoscopy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Run-Bin Liang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Tai-Shan Zeng
- School of Mathematical Sciences, South China Normal University, Guangzhou, Guangdong, China
| | - Hao Long
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Jian-Hua Fu
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Guo-Liang Xu
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.,Department of Endoscopy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Mu-Zi Yang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Shuo Li
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Lan-Jun Zhang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Peng Lin
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Xin Wang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Xue Hou
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China. .,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China. .,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.
| | - Hao-Xian Yang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China. .,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China. .,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.
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Barbetta A, Schlottmann F, Nobel T, Sewell DB, Hsu M, Tan KS, Gerdes H, Shah P, Bains MS, Bott M, Isbell JM, Jones DR, Molena D. Predictors of Nodal Metastases for Clinical T2N0 Esophageal Adenocarcinoma. Ann Thorac Surg 2018; 106:172-177. [PMID: 29627387 DOI: 10.1016/j.athoracsur.2018.02.087] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 02/02/2018] [Accepted: 02/28/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Induction therapy has not been proven to be beneficial for patients with clinical T2N0 esophageal adenocarcinoma. Surgery alone is associated with disappointing survival for patients found to have nodal disease on final pathologic examination. The aim of this study was to identify factors that predict pathologic nodal involvement in patients with endoscopic ultrasound (EUS)-proven T2N0 esophageal adenocarcinoma. METHODS We retrospectively reviewed patients with EUS-staged T2N0 (uT2N0) esophageal adenocarcinoma treated with surgery alone. Final pathologic staging was compared with clinical staging. Demographic and clinicopathologic variables were evaluated as putative risk factors for nodal metastases. Logistic regression models were used to identify factors associated with nodal involvement. Kaplan-Meier analysis was performed to compare overall and recurrence-free survival between patients with (N+) and without (N-) nodal disease. RESULTS We identified 80 patients with uT2N0 esophageal adenocarcinoma treated with surgery alone. Clinical staging with EUS was inaccurate for 73 patients (91%). Twenty-eight patients (35%) had pathologic N+ disease at resection. Five-year overall survival was 67% for N- patients and 41% for N+ patients (p = 0.006). Recurrence-free survival was 65% for N- patients and 32% for N+ patients (p = 0.0043). Univariable analysis identified vascular invasion and neural invasion as risk factors for nodal metastasis. Multivariable analysis identified vascular invasion as an independent predictor of pathologic nodal involvement. CONCLUSIONS EUS is inaccurate for staging of T2N0 esophageal adenocarcinoma and often fails to identify nodal involvement. Identification of vascular invasion on preoperative biopsy should be explored as a prognostic marker to select patients for induction therapy.
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Affiliation(s)
- Arianna Barbetta
- Department of Surgery, Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Francisco Schlottmann
- Department of Surgery, Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Surgery, Division of GI Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Tamar Nobel
- Department of Surgery, Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David B Sewell
- Department of Surgery, Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Meier Hsu
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hans Gerdes
- Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Pari Shah
- Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Manjit S Bains
- Department of Surgery, Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Matthew Bott
- Department of Surgery, Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James M Isbell
- Department of Surgery, Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David R Jones
- Department of Surgery, Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniela Molena
- Department of Surgery, Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
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Semenkovich TR, Panni RZ, Hudson JL, Thomas T, Elmore LC, Chang SH, Meyers BF, Kozower BD, Puri V. Comparative effectiveness of upfront esophagectomy versus induction chemoradiation in clinical stage T2N0 esophageal cancer: A decision analysis. J Thorac Cardiovasc Surg 2018; 155:2221-2230.e1. [PMID: 29428700 DOI: 10.1016/j.jtcvs.2018.01.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 12/13/2017] [Accepted: 01/02/2018] [Indexed: 01/02/2023]
Abstract
OBJECTIVES We compared the effectiveness of upfront esophagectomy versus induction chemoradiation followed by esophagectomy for overall survival in patients with clinical T2N0 (cT2N0) esophageal cancer. We also assessed the influence of the diagnostic uncertainty of endoscopic ultrasound on the expected benefit of chemoradiation. METHODS We created a decision analysis model representing 2 treatment strategies for cT2N0 esophageal cancer: upfront esophagectomy that may be followed by adjuvant therapy for upstaged patients and induction chemoradiation for all patients with cT2N0 esophageal cancer followed by esophagectomy. Parameter values within the model were obtained from published data, and median survival for pathologic subgroups was derived from the National Cancer Database. In sensitivity analyses, staging uncertainty of endoscopic ultrasound was introduced by varying the probability of pathologic upstaging. RESULTS The baseline model showed comparable median survival for both strategies: 48.3 months for upfront esophagectomy versus 45.9 months for induction chemoradiation and surgery. The sensitivity analysis demonstrated induction chemoradiation was beneficial, with probability of upstaging > 48.1%, which is within the published range of 32% to 65% probability of pathologic upstaging after cT2N0 diagnosis. The presence of any of 3 key variables (size larger than 3 cm, high grade, or lymphovascular invasion) was associated with > 48.1% risk of upstaging, thus conferring a survival advantage to induction chemoradiation. CONCLUSIONS The optimal treatment strategy for cT2N0 esophageal cancer depends on the accuracy of endoscopic ultrasound staging. High-risk features that confer increased probability of upstaging can inform clinical decision making to recommend induction chemoradiation for select cT2N0 patients.
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Affiliation(s)
| | - Roheena Z Panni
- Division of Surgical Oncology, Department of Surgery, Washington University, St Louis, Mo
| | - Jessica L Hudson
- Division of Cardiothoracic Surgery, Washington University, St Louis, Mo
| | - Theodore Thomas
- Division of Oncology, Department of Medicine, Washington University, St Louis, Mo
| | - Leisha C Elmore
- Division of Surgical Oncology, Department of Surgery, Washington University, St Louis, Mo
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University, St Louis, Mo
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University, St Louis, Mo
| | | | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University, St Louis, Mo.
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Ilson DH, van Hillegersberg R. Management of Patients With Adenocarcinoma or Squamous Cancer of the Esophagus. Gastroenterology 2018; 154:437-451. [PMID: 29037469 DOI: 10.1053/j.gastro.2017.09.048] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 09/09/2017] [Accepted: 09/12/2017] [Indexed: 02/07/2023]
Abstract
Esophageal cancer is characterized by early and frequent metastasis. Surgery is the primary treatment for early-stage disease, whereas patients with patients with locally advanced disease receive perioperative chemotherapy or chemoradiotherapy. Squamous cancers can be treated with primary chemoradiotherapy without surgery, depending on their response to therapy and patient tolerance for subsequent surgery. Chemotherapy with a fluorinated pyrimidine and a platinum agent, followed by later treatment with taxanes and irinotecan, provides some benefit. Agents that inhibit the erb-b2 receptor tyrosine kinase 2 (ERBB2 or HER2), or vascular endothelial growth factor, including trastuzumab, ramucirumab, and apatinib, increase response and survival times. Esophageal adenocarcinomas have mutations in tumor protein p53 and mutations that activate receptor-associated tyrosine kinase, vascular endothelial growth factor, and cell cycle pathways, whereas esophageal squamous tumors have a distinct set of mutations. Esophageal cancers develop systems to evade anti-tumor immune responses, but studies are needed to determine how immune checkpoint modification contributes to esophageal tumor development.
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Affiliation(s)
- David H Ilson
- Memorial Sloan Kettering Cancer Center, New York, New York.
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31
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Song Y, Tao G, Guo Q, Yang X, Zhu H, Wang W, Sun X. Survival benefit of surgery with radiotherapy vs surgery alone to patients with T2-3N0M0 stage esophageal adenocarcinoma. Oncotarget 2017; 7:21347-52. [PMID: 26870996 PMCID: PMC5008289 DOI: 10.18632/oncotarget.7256] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 01/14/2016] [Indexed: 01/08/2023] Open
Abstract
Background & Aims This study is designed to analyze survival benefit of (neo-) adjuvant radiotherapy to patients with T2-3N0M0 stage esophageal adenocarcinoma (EAC). Methods T2-3N0M0 stage EAC patients from 2004 to 2012 were searched from the Surveillance Epidemiology and End Results (SEER) data. Clinical factors including age, sex, race were summarized. Univariate, multivariate analysis, and stratified cox analysis based on different T stages were performed to explore the survival effect of (neo-)adjuvant radiotherapy to T2-3N0M0 stage EAC. Results T2-3N0M0 stage EAC patients with surgery were more likely to be white race, T3 stage. Univariate analysis showed sex, age, and T stage were the prognostic factors of survival (P<0.05). Multivariate analysis proved (neo-)adjuvant radiotherapy can prolong survival time of T2-3N0M0 stage EAC (P<0.05). Further analysis based on different T stages showed that both neoadjuvant radiotherapy (HR 0.615; 95% CI 0.475-0.797) and adjuvant radiotherapy (HR 0.597; 95% 0.387-0.921) significantly reduced the risk of death of T3N0M0 stage EAC, but neither of which significantly reduced death risk of T2N0M0 stage EAC (P>0.05). Conclusions sex, age are the independent prognostic factors of T2-3N0M0 EAC. Significant survival benefit of (neo-)adjuvant radiotherapy is only observed in patients with T3N0M0 stage EAC, but not in those with T2N0M0 stage.
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Affiliation(s)
- Yaqi Song
- Department of Radiation Oncology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an 223300, China
| | - Guangzhou Tao
- Department of Radiation Oncology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an 223300, China
| | - Qing Guo
- Department of Oncology, Taizhou people's hospital, Taizhou 225300, China
| | - Xi Yang
- Department of Radiation Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Hongcheng Zhu
- Department of Radiation Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Wanwei Wang
- Department of Radiation Oncology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an 223300, China
| | - Xinchen Sun
- Department of Radiation Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
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32
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Chao YK, Ku HY, Chen CY, Liu TW. Induction therapy before surgery improves survival in patients with clinical T3N0 esophageal cancer: a nationwide study in Taiwan. Dis Esophagus 2017; 30:1-7. [PMID: 28881891 DOI: 10.1093/dote/dox103] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Indexed: 12/11/2022]
Abstract
The utility of induction therapy (IT) in patients with resectable esophageal cancer remains controversial, especially when clinical evidence of nodal metastases is lacking. We sought to compare the survival impact of IT versus upfront surgery (US) in patients with cT3N0 esophageal cancer. We searched the Taiwan Cancer Registry for patients with cT3N0 esophageal cancer who underwent US or IT between 2008 and 2013. Multivariate Cox regression analysis was used to analyze the potential benefits of IT in terms of overall survival (OS) and disease-free survival (DFS). Of the 11752 patients with esophageal cancer included in the nationwide database, 762 (6.5%) had cT3N0 disease. Most cases (720 [94.5%]) had a histological diagnosis of squamous cell carcinoma. Of them, 135 received IT (the IT group) and 237 received surgery first (the US group). In the US group, pretreatment clinical staging was accurate in 47.9% of patients. Twenty-one (8.97%) were clinically overstaged (pT1-2N0), whereas 101 (43.17%) were clinically understaged (pT4N0 or pTanyN1-3). The presence of unexpected nodal metastases was identified in 92.1% of clinically understaged patients. In the IT group, 28 (20.74%) patients did not proceed to surgery after IT. The use of IT was associated with higher R0 resection rates and fewer pathological nodal metastases, despite unexpected M1 disease being more common (all P< 0.05). The 5-year OS rate was significantly higher (42%) in the IT group than in the US group (33%, P= 0.032). Similar findings were observed in terms of 5-year DFS (37% in the IT group versus 29% in the US group, P= 0.009). Multivariate analysis identified US (hazard ratio: 1.42, P= 0.03) and non-R0 resection (hazard ratio: 1.58, P= 0.03) as independent adverse prognostic factors. We found that 43.17% of patients with cT3N0 disease undergoing primary surgery had their disease understaged. The use of IT before esophagectomy significantly improves OS and DFS in patients with clinical T3N0 esophageal squamous cell carcinoma.
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Affiliation(s)
- Y-K Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan
| | - H-Y Ku
- National Institute of Cancer Research, National Health Research Institute, Miaoli
| | - C-Y Chen
- Institute of Medicine, Chung Shan Medical University, Division of Thoracic Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - T-W Liu
- National Institute of Cancer Research, National Health Research Institute, Miaoli
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Le Bras GF, Farooq MH, Falk GW, Andl CD. Esophageal cancer: The latest on chemoprevention and state of the art therapies. Pharmacol Res 2016; 113:236-244. [PMID: 27565381 DOI: 10.1016/j.phrs.2016.08.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 08/11/2016] [Accepted: 08/16/2016] [Indexed: 02/07/2023]
Abstract
Esophageal cancer is currently the 8th most common cancer worldwide and the 6th leading cause of cancer-related mortality. Despite remarkable advances, the mortality for those suffering from esophageal cancer remains high, with 5-year survival rates of less than 20%. In part, because most patients present with late-stage disease, long-term survival even after resection and therapy is disappointingly low. As we will discuss in this review, multiple characteristics specific to the disease stage and patient must be considered when choosing a treatment plan. This article will summarize current standard therapies, potential application of chemoprevention drugs and the promise and partial failure of personalized medicine, as well as novel treatments addressing this disease.
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Affiliation(s)
- Gregoire F Le Bras
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL, United States
| | - Muhammad H Farooq
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL, United States
| | - Gary W Falk
- Division of Gastroenterology, Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Claudia D Andl
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, Orlando, FL, United States.
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Gabriel E, Attwood K, Du W, Tuttle R, Alnaji RM, Nurkin S, Malhotra U, Hochwald SN, Kukar M. Association Between Clinically Staged Node-Negative Esophageal Adenocarcinoma and Overall Survival Benefit From Neoadjuvant Chemoradiation. JAMA Surg 2016; 151:234-45. [PMID: 26559488 DOI: 10.1001/jamasurg.2015.4068] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE While neoadjuvant chemoradiation for esophageal cancer improves oncologic outcomes for a broad group of patients with locally advanced and/or node-positive tumors, it is less clear which specific subset of patients derives most benefit in terms of overall survival (OS). OBJECTIVE To determine whether neoadjuvant chemoradiation based on esophageal adenocarcinoma histology has similar oncologic outcomes for patients treated with surgery alone when stratified by clinical nodal status. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis using the American College of Surgeons National Cancer Database from 1998 to 2006. Patients with esophageal adenocarcinoma histology and clinical stage T1bN1-N3 or T2-T4aN-/+M0 were divided into 2 treatment groups: (1) neoadjuvant chemoradiation followed by surgery and (2) surgery alone. Subset analysis within each treatment group was performed for clinically node-negative patients (cN-) vs node-positive patients (cN+) in conjunction with pathological nodal status. A propensity score-adjusted analysis, which included patient demographics, comorbidity status, and clinical T stage, was also performed. MAIN OUTCOME AND MEASURES The primary outcome was 3-year OS. Secondary outcomes included margin status, postoperative length of stay, unplanned readmission rate, and 30-day mortality. RESULTS A total of 1309 patients were identified, of whom 539 received neoadjuvant chemoradiation followed by surgery and 770 received surgery alone. Of the 1309 patients, 41.2% (n = 539) received neoadjuvant chemoradiation and 47.2% (n = 618) were cN+. Median follow-up for the entire cohort was 73.3 months (interquartile range, 64.1-93.5 months). The 3-year OS was better for neoadjuvant chemoradiation followed by surgery compared with surgery alone (49% vs 38%, respectively; P < .001). Stratifying based on clinical nodal status, the propensity score-adjusted OS was significantly better for cN+ patients who received neoadjuvant chemoradiation (hazard ratio, 0.52; 95% CI, 0.42-0.66; P < .001). In contrast, there was no difference in OS for cN- patients based on treatment (hazard ratio, 0.84; 95% CI, 0.65-1.10; P = .22). CONCLUSIONS AND RELEVANCE Patients with cN+ esophageal adenocarcinoma benefit significantly from neoadjuvant chemoradiation. However, patients with cN- tumors treated with neoadjuvant chemoradiation plus surgery do not derive a significant OS benefit compared with surgery alone. This finding may have significant implications on the use of neoadjuvant chemoradiation in patients with cN- disease.
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Affiliation(s)
- Emmanuel Gabriel
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Kristopher Attwood
- Department of Biostatistics, New Center for Excellence, Buffalo, New York
| | - William Du
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Rebecca Tuttle
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Raed M Alnaji
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Steven Nurkin
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Usha Malhotra
- Department of Medical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Steven N Hochwald
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
| | - Moshim Kukar
- Department of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, New York
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Berry MF. The Role of Induction Therapy for Esophageal Cancer. Thorac Surg Clin 2016; 26:295-304. [PMID: 27427524 DOI: 10.1016/j.thorsurg.2016.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Survival of esophageal cancer generally is poor but has been improving. Induction chemoradiation is recommended before esophagectomy for locally advanced squamous cell carcinoma. Both induction chemotherapy and induction chemoradiation are found to be beneficial for locally advanced adenocarcinoma. Although a clear advantage of either strategy has not yet been demonstrated, consensus-based guidelines recommend induction chemoradiation for locally advanced adenocarcinoma.
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Affiliation(s)
- Mark F Berry
- Department of Cardiothoracic Surgery, Stanford University, 870 Quarry Road, Falk Cardiovascular Research Building, 2nd Floor, Stanford, CA 94305, USA.
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36
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Goense L, van Rossum PSN, Kandioler D, Ruurda JP, Goh KL, Luyer MD, Krasna MJ, van Hillegersberg R. Stage-directed individualized therapy in esophageal cancer. Ann N Y Acad Sci 2016; 1381:50-65. [PMID: 27384385 DOI: 10.1111/nyas.13113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 05/05/2016] [Indexed: 12/16/2022]
Abstract
Esophageal cancer is the eighth most common cancer worldwide, and the incidence of esophageal carcinoma is rapidly increasing. With the advent of new staging and treatment techniques, esophageal cancer can now be managed through various strategies. A good understanding of the advances and limitations of new staging techniques and how these can guide in individualizing treatment is important to improve outcomes for esophageal cancer patients. This paper outlines the recent progress in staging and treatment of esophageal cancer, with particularly attention to endoscopic techniques for early-stage esophageal cancer, multimodality treatment for locally advanced esophageal cancer, assessment of response to neoadjuvant treatment, and the role of cervical lymph node dissection. Furthermore, advances in robot-assisted surgical techniques and postoperative recovery protocols that may further improve outcomes after esophagectomy are discussed.
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Affiliation(s)
- Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter S N van Rossum
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Daniela Kandioler
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Khean-Lee Goh
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Mark J Krasna
- Meridian Cancer Care, Jersey Shore University Medical Center, Neptune, New Jersey
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Dolan JP, Kaur T, Diggs BS, Luna RA, Sheppard BC, Schipper PH, Tieu BH, Bakis G, Vaccaro GM, Holland JM, Gatter KM, Conroy MA, Thomas CA, Hunter JG. Significant understaging is seen in clinically staged T2N0 esophageal cancer patients undergoing esophagectomy. Dis Esophagus 2016; 29:320-5. [PMID: 25707341 DOI: 10.1111/dote.12334] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This study aimed to determine the impact of preoperative staging on the treatment of clinical T2N0 (cT2N0) esophageal cancer patients undergoing esophagectomy. We reviewed a retrospective cohort of 27 patients treated at a single institution between 1999 and 2011. Clinical staging was performed with computed tomography, positron emission tomography, and endoscopic ultrasound. Patients were separated into two groups: neoadjuvant therapy followed by surgery (NEOSURG) and surgery alone (SURG). There were 11 patients (41%) in the NEOSURG group and 16 patients (59%) in the SURG group. In the NEOSURG group, three of 11 patients (27%) had a pathological complete response and eight (73%) were partial or nonresponders after neoadjuvant therapy. In the SURG group, nine of 16 patients (56%) were understaged, 6 (38%) were overstaged, and 1 (6%) was correctly staged. In the entire cohort, despite being clinically node negative, 14 of 27 patients (52%) had node-positive disease (5/11 [45%] in the NEOSURG group, and 9/16 [56%] in the SURG group). Overall survival rate was not statistically significant between the two groups (P = 0.96). Many cT2N0 patients are clinically understaged and show no preoperative evidence of node-positive disease. Consequently, neoadjuvant therapy may have a beneficial role in treatment.
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Affiliation(s)
- J P Dolan
- Department of Surgery, Digestive Health Center & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - T Kaur
- Department of Surgery, Digestive Health Center & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - B S Diggs
- Department of Surgery, Digestive Health Center & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - R A Luna
- Department of Surgery, Digestive Health Center & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - B C Sheppard
- Department of Surgery, Digestive Health Center & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - P H Schipper
- Department of Surgery, Division of Cardiothoracic Surgery & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - B H Tieu
- Department of Surgery, Division of Cardiothoracic Surgery & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - G Bakis
- Department of Medicine, Division of Gastroenterology & the Digestive Health Center, Oregon Health and Science University, Portland, Oregon, USA
| | - G M Vaccaro
- Department of Medicine, Division of Hematology & Medical Oncology, Oregon Health and Science University, Portland, Oregon, USA
| | - J M Holland
- Department of Radiation Medicine & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - K M Gatter
- Department of Pathology, Oregon Health and Science University, Portland, Oregon, USA
| | - M A Conroy
- Department of Surgery, Digestive Health Center & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - C A Thomas
- Department of Radiation Medicine & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - J G Hunter
- Department of Surgery, Digestive Health Center & the Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon, USA
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Samson P, Puri V, Robinson C, Lockhart C, Carpenter D, Broderick S, Kreisel D, Krupnick AS, Patterson GA, Meyers B, Crabtree T. Clinical T2N0 Esophageal Cancer: Identifying Pretreatment Characteristics Associated With Pathologic Upstaging and the Potential Role for Induction Therapy. Ann Thorac Surg 2016; 101:2102-11. [PMID: 27083246 DOI: 10.1016/j.athoracsur.2016.01.033] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 12/30/2015] [Accepted: 01/06/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although studies have suggested standard therapy for clinical T2N0 esophageal cancer should be primary surgery, we hypothesize there is a subgroup for whom induction therapy may result in improved overall survival. METHODS Patients with cT2N0 esophageal cancer receiving induction therapy or upfront esophagectomy (UE) were identified in the National Cancer Data Base. The UE patients were dichotomized as (1) pathologically upstaged, or (2) same-staged or downstaged. Logistic regression models identified variables associated with upstaging, and Kaplan-Meier analysis compared median overall survival. RESULTS From 2006 to 2012, 932 cT2N0 patients (52.2%) received UE, and 853 (47.8%) received induction therapy first. In all, 326 of 713 UE patients (45.7%) were upstaged: 87 of 326 (26.7%) had T upstaging; 98 of 326 (30.1%) had N upstaging; and 141 of 326 (43.3%) had both. Patients upstaged after UE had a higher tumor grade (35.1% versus 57.1% grade 3), and a higher rate of lymphovascular invasion (57.1% versus 17.7%; both p < 0.001). Variables associated with upstaging included lymphovascular invasion (odds ratio 6.0, 95% confidence interval: 2.9 to 12.5, p < 0.001) and tumor grade 3 (odds ratio 9.4, 95% confidence interval: 1.8 to 48.4, p = 0.007). Of upstaged UE patients, only 144 (44.2%) received adjuvant therapy. The median overall survival for cT2N0 patients upstaged after UE was 27.5 ± 2.5 months versus 43.9 ± 2.9 months for induction therapy patients (any resultant pathologic stage, p < 0.001). CONCLUSIONS Half of all cT2N0 patients were pathologically upstaged after UE, with worse survival compared with patients receiving induction therapy. Refining an upstaging model would help select patients for induction therapy and increase the rate of chemotherapy in patients at risk for systemic disease.
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Affiliation(s)
- Pamela Samson
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri
| | - Craig Lockhart
- Division of Medical Oncology, Washington University in St. Louis, St. Louis, Missouri
| | - Danielle Carpenter
- Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, Missouri
| | - Stephen Broderick
- Division of Cardiothoracic Surgery, St. Luke's Hospital, Chesterfield, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - A Sasha Krupnick
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Bryan Meyers
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Traves Crabtree
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri.
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Role of neoadjuvant treatment in clinical T2N0M0 oesophageal cancer: results from a retrospective multi-center European study. Eur J Cancer 2016; 56:59-68. [PMID: 26808298 DOI: 10.1016/j.ejca.2015.11.024] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 11/08/2015] [Accepted: 11/29/2015] [Indexed: 11/23/2022]
Abstract
AIMS The aims of this study were to compare short- and long-term outcomes for clinical T2N0 oesophageal cancer with analysis of (i) primary surgery (S) versus neoadjuvant therapy plus surgery (NS), (ii) squamous cell carcinoma and adenocarcinoma subsets; and (iii) neoadjuvant chemoradiotherapy versus neoadjuvant chemotherapy. METHODS Data were collected from 30 European centres from 2000 to 2010. Among 2944 included patients, 355 patients (12.1%) had cT2N0 disease; 285 (S) and 70 (NS), were compared in terms of short- and long-term outcomes. Propensity score matching analyses were used to compensate for differences in baseline characteristics. RESULTS No significant differences between the groups were shown in terms of in hospital morbidity and mortality. Nodal disease was observed in 50% of S-group at the time of surgery, with 20% pN2/N3. Utilisation of neoadjuvant therapy was associated with significant tumour downstaging as reflected by increases in pT0, pN0 and pTNM stage 0 disease, this effect was further enhanced with neoadjuvant chemoradiotherapy. After adjustment on propensity score and confounding factors, for all patients and subset analysis of squamous cell and adenocarcinoma, neoadjuvant therapy had no significant effect upon survival or recurrence (overall, loco-regional, distant or mixed) compared to surgery alone. There were no significant differences between neoadjuvant chemotherapy and chemoradiotherapy in short- or long-term outcomes. CONCLUSION The results of this study suggest that a surgery alone treatment approach should be recommended as the primary treatment approach for cT2N0 oesophageal cancer despite 50% of patients having nodal disease at the time of surgery.
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Speicher PJ, Wang X, Englum BR, Ganapathi AM, Yerokun B, Hartwig MG, D'Amico TA, Berry MF. Induction chemoradiation therapy prior to esophagectomy is associated with superior long-term survival for esophageal cancer. Dis Esophagus 2015; 28:788-96. [PMID: 25212528 PMCID: PMC4362812 DOI: 10.1111/dote.12285] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The purpose of this study was to examine the role of induction chemoradiation in the treatment of potentially resectable locally advanced (T2-3N0 and T1-3N+) esophageal cancer utilizing a large national database. The National Cancer Data Base (NCDB) was queried for all patients undergoing esophagectomy for clinical T2-3N0 and T1-3N+ esophageal cancer of the mid- or lower esophagus. Patients were stratified by the use of induction chemoradiation therapy versus surgery-first. Trends were assessed with the Cochran-Armitage test. Predictors of receiving induction therapy were evaluated with multivariable logistic regression. A propensity-matched analysis was conducted to compare outcomes between groups, and the Kaplan-Meier method was used to estimate long-term survival. Within the NCDB, 7921 patients were identified, of which 6103 (77.0%) were treated with chemoradiation prior to esophagectomy, while the remaining 1818 (23.0%) were managed with surgery-first. Use of induction therapy increased over time, with an absolute increase of 11.8% from 2003-2011 (P < 0.001). As revealed by the propensity model, induction therapy was associated with higher rates of negative margins and shorter hospital length of stay, but no differences in unplanned readmission and 30-day mortality rates. In unadjusted survival analysis, induction therapy was associated with better long-term survival compared to a strategy of surgery-first, with 5-year survival rates of 37.2% versus 28.6%, P < 0.001. Following propensity score matching analysis, the use of induction therapy maintained a significant survival advantage over surgery-first (5-year survival: 37.9% vs. 28.7%, P < 0.001). Treatment with induction chemoradiation therapy prior to surgical resection is associated with significant improvement in long-term survival, even after adjusting for confounders with a propensity model. Induction therapy should be considered in all medically appropriate patients with resectable cT2-3N0 and cT1-3N+ esophageal cancer, prior to esophagectomy.
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Affiliation(s)
- Paul J Speicher
- Department of Surgery, Duke University Medical Center, Durham NC
| | - Xiaofei Wang
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham NC
| | - Brian R Englum
- Department of Surgery, Duke University Medical Center, Durham NC
| | | | | | | | - Thomas A D'Amico
- Department of Surgery, Duke University Medical Center, Durham NC
| | - Mark F Berry
- Department of Surgery, Duke University Medical Center, Durham NC,Department of Cardiothoracic Surgery, Stanford University, Stanford, CA
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Macrophage subtype predicts lymph node metastasis in oesophageal adenocarcinoma and promotes cancer cell invasion in vitro. Br J Cancer 2015; 113:738-46. [PMID: 26263481 PMCID: PMC4559839 DOI: 10.1038/bjc.2015.292] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 07/02/2015] [Accepted: 07/21/2015] [Indexed: 01/28/2023] Open
Abstract
Background: Currently, there is a lack of ideal biomarkers for predicting nodal status in preoperative stage of oesophageal adenocarcinoma (EAC) to aid optimising therapeutic options. We studied the potential of applying subtype macrophages to predict lymph node metastasis and prognosis in EAC. Material and Methods: Fifty-three EAC resection specimens were immunostained with CD68, CD40 (M1), and CD163 (M2). Lymphatic vessel density (LVD) was estimated with the staining of D2-40. Subsequently, we tested if M2d macrophage could promote EAC cell migration and invasion. Results: In EAC without neoadjuvant treatment, an increase in M2-like macrophage was associated with poor patient survival, independent of the locations of macrophages in tumour. The M2/M1 ratio that represented the balance between M2- and M1-like macrophages was significantly higher in nodal-positive EACs than that in nodal-negative EACs, and inversely correlated with patient overall survival. The M2/M1 ratio was not related to LVD. EAC cell polarised THP1 cell into M2d-like macrophage, which promoted EAC cell migration and invasion. Neoadjuvant therapy appeared to diminish the correlation between the M2/M1 ratio and survival. Conclusions: The ratio of M2/M1 macrophage may serve as a sensitive marker to predict lymph node metastasis and poor prognosis in EAC without neoadjuvant therapy. M2d macrophage may have important roles in EAC metastasis.
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FDG-PET nodal staging does not correlate with histopathological nodal stage for oesophageal cancers. Int J Surg 2015; 20:113-7. [PMID: 26118612 DOI: 10.1016/j.ijsu.2015.06.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 05/22/2015] [Accepted: 06/02/2015] [Indexed: 12/21/2022]
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Wang S, Wang Z, Yang Z, Liu Y, Liu X, Shang B, Jiang WP. Postoperative Radiotherapy Improves Survival in Stage pT2N0M0 Esophageal Squamous Cell Carcinoma with High Risk of Poor Prognosis. Ann Surg Oncol 2015; 23:265-72. [PMID: 26014154 DOI: 10.1245/s10434-015-4622-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Indexed: 12/22/2022]
Abstract
PURPOSE Clinically, some patients with stage pT2N0M0 esophageal squamous cell carcinoma (ESCC) might have poor survival outcomes after Ivor-Lewis esophagectomy. We explored whether adjuvant radiotherapy could improve the prognosis for the patients with high risk of poor clinical outcomes. METHODS We screened 326 pT2N0M0 ESCC patients who had complete resection with Ivor-Lewis esophagectomy. The expression profile of Ku80 was examined by immunohistochemistry and validated by Western blotting. Patients with high expression of Ku80 were divided randomly into the adjuvant radiotherapy group and control group. Patients with low expression of Ku80 were enrolled into the negative group. The overall survival (OS) and disease-free survival (DFS) was determined by Kaplan-Meier and log-rank analysis. RESULTS According to receiver operating characteristics curve analysis of Ku80 expression, 124 patients were enrolled into the negative group, 106 patients into the radiotherapy group, and 106 patients into the control group. Log-rank analysis showed that patients in the control group had worse OS and DFS than those in the negative group (P < 0.001, P < 0.001). There is no difference in OS and DFS of patients between radiotherapy group and negative group (P = 0.166, P = 0.648). Patients in the radiotherapy group had significantly better OS and DFS than those in the control group (P = 0.007, P < 0.001). Multivariate analysis further suggested that adjuvant radiotherapy was an independent prognostic indicator for patients with Ku80 overexpression. CONCLUSIONS In stage pT2N0M0 ESCC, Ku80 can be exploited as a predictor to identify patients with high risk of poor prognosis. Adjuvant radiotherapy could significantly improve survival for the patients with Ku80 overexpression.
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Affiliation(s)
- Shuai Wang
- Department of Thoracic Surgery, Provincial Hospital Affiliated to Shandong University, Shandong, People's Republic of China
| | - Zhou Wang
- Department of Thoracic Surgery, Provincial Hospital Affiliated to Shandong University, Shandong, People's Republic of China.
| | - Zhe Yang
- Cancer Center, Provincial Hospital Affiliated to Shandong University, Shandong, People's Republic of China
| | - Yu Liu
- Department of Pathology, Provincial Hospital Affiliated to Shandong University, Shandong, People's Republic of China
| | - Xiangyan Liu
- Department of Thoracic Surgery, Provincial Hospital Affiliated to Shandong University, Shandong, People's Republic of China
| | - Bin Shang
- Department of Thoracic Surgery, Provincial Hospital Affiliated to Shandong University, Shandong, People's Republic of China
| | - Wen Peng Jiang
- Department of Thoracic Surgery, Provincial Hospital Affiliated to Shandong University, Shandong, People's Republic of China
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44
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Induction therapy does not improve survival for clinical stage T2N0 esophageal cancer. J Thorac Oncol 2015; 9:1195-201. [PMID: 25157773 DOI: 10.1097/jto.0000000000000228] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION This study compared survival after initial treatment with esophagectomy as primary therapy to induction therapy followed by esophagectomy for patients with clinical T2N0 (cT2N0) esophageal cancer in the National Cancer Database (NCDB). METHODS Predictors of therapy selection for patients with cT2N0 esophageal cancer in the NCDB from 1998 to 2011 were identified with multivariable logistic regression. Survival was evaluated using Kaplan-Meier and Cox proportional hazards methods. RESULTS Surgery was used in 42.9% (2057 of 4799) of cT2N0 patients. Of 1599 esophagectomy patients for whom treatment timing was recorded, induction therapy was used in 44.1% (688). Pretreatment staging was proven accurate in only 26.7% of patients (210 of 786) who underwent initial surgery without induction treatment and had complete pathologic data available: 41.6% (n = 327) were upstaged and 31.7% (n = 249) were downstaged. Adjuvant therapy (chemotherapy or radiation therapy) was given to 50.2% of patients treated initially with surgery who were found after resection to have nodal disease. There was no significant difference in long-term survival between strategies of primary surgery and induction therapy followed by surgery (median 41.1 versus 41.9 months, p = 0.51). In multivariable analysis, induction therapy was not independently associated with risk of death (hazard ratio [HR], 1.16, p = 0.32). CONCLUSIONS Current clinical staging for early-stage esophageal cancer is highly inaccurate, with only a quarter of surgically resected cT2N0 patients found to have had accurate pretreatment staging. Induction therapy for patients with cT2N0 esophageal cancer in the NCDB is not associated with improved survival.
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Little AG, Lerut AE, Harpole DH, Hofstetter WL, Mitchell JD, Altorki NK, Krasna MJ. The Society of Thoracic Surgeons Practice Guidelines on the Role of Multimodality Treatment for Cancer of the Esophagus and Gastroesophageal Junction. Ann Thorac Surg 2014; 98:1880-5. [DOI: 10.1016/j.athoracsur.2014.07.069] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 07/02/2014] [Accepted: 07/14/2014] [Indexed: 02/04/2023]
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Tai P, Yu E. Esophageal cancer management controversies: Radiation oncology point of view. World J Gastrointest Oncol 2014; 6:263-274. [PMID: 25132924 PMCID: PMC4133794 DOI: 10.4251/wjgo.v6.i8.263] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 03/21/2014] [Accepted: 06/03/2014] [Indexed: 02/05/2023] Open
Abstract
Esophageal cancer treatment has evolved from single modality to trimodality therapy. There are some controversies of the role, target volumes and dose of radiotherapy (RT) in the literature over decades. The present review focuses primarily on RT as part of the treatment modalities, and highlight on the RT volume and its dose in the management of esophageal cancer. The randomized adjuvant chemoradiation (CRT) trial, intergroup trial (INT 0116) enrolled 559 patients with resected adenocarcinoma of the stomach or gastroesophageal junction. They were randomly assigned to surgery plus postoperative CRT or surgery alone. Analyses show robust treatment benefit of adjuvant CRT in most subsets for postoperative CRT. The Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) used a lower RT dose of 41.4 Gray in 23 fractions with newer chemotherapeutic agents carboplatin and paclitaxel to achieve an excellent result. Target volume of external beam radiation therapy and its coverage have been in debate for years among radiation oncologists. Pre-operative and post-operative target volumes are designed to optimize for disease control. Esophageal brachytherapy is effective in the palliation of dysphagia, but should not be given concomitantly with chemotherapy or external beam RT. The role of brachytherapy in multimodality management requires further investigation. On-going studies of multidisciplinary treatment in locally advanced cancer include: ZTOG1201 trial (a phase II trial of neoadjuvant and adjuvant CRT) and QUINTETT (a phase III trial of neoadjuvant vs adjuvant therapy with quality of life analysis). These trials hopefully will shed more light on the future management of esophageal cancer.
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Hardacker TJ, Ceppa D, Okereke I, Rieger KM, Jalal SI, LeBlanc JK, DeWitt JM, Kesler KA, Birdas TJ. Treatment of clinical T2N0M0 esophageal cancer. Ann Surg Oncol 2014; 21:3739-43. [PMID: 25047477 DOI: 10.1245/s10434-014-3929-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Management of clinical T2N0M0 (cT2N0M0) esophageal cancer remains controversial. We reviewed our institutional experience over 21 years (1990-2011) to determine clinical staging accuracy, optimal treatment approaches, and factors predictive of survival in this patient population. METHODS Patients with cT2N0M0 esophageal cancer determined by endoscopic ultrasound (EUS) were identified through a prospectively collected database. Demographics, perioperative data, and outcomes were examined. Cox regression model and Kaplan-Meier plots were used for statistical survival analysis. RESULTS A total of 731 patients underwent esophagectomy, of whom 68 cT2N0M0 patients (9 %) were identified. Fifty-seven patients (84 %) had adenocarcinoma. Thirty-three patients (48.5 %) were treated with neoadjuvant chemoradiation followed by surgery, and 35 underwent surgical resection alone. All resections except one included a transthoracic approach with two-field lymph node dissection. Thirty-day operative mortality was 2.9 %. Only 3 patients (8.5 %) who underwent surgery alone had T2N0M0 disease identified by pathology: the disease of 15 (42.8 %) was found to be overstaged and 17 (48.5 %) understaged after surgery. Understaging was more common in poorly differentiated tumors (p = 0.03). Nine patients (27.2 %) had complete pathologic response after chemoradiotherapy. Absence of lymph node metastases (pN0) was significantly more frequent in the neoadjuvant group (29 of 33 vs. 21 of 35, p = 0.01). Median follow-up was 44.2 months. Overall 5-year survival was 50.8 %. On multivariate analysis, adenocarcinoma (p = 0.001) and pN0 after resection (p = 0.01) were significant predictors of survival. CONCLUSIONS EUS was inaccurate in staging cT2N0M0 esophageal cancer in this study. Poorly differentiated tumors were more frequently understaged. Adenocarcinoma and absence of lymph node metastases (pN0) were independently predictive of long-term survival. pN0 status was significantly more common in patients undergoing neoadjuvant therapy, but long-term survival was not affected by neoadjuvant therapy. A strategy of neoadjuvant therapy followed by resection may be optimal in this group, especially in patients with disease likely to be understaged.
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Affiliation(s)
- Thomas J Hardacker
- Section of Thoracic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA,
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Berry MF. Esophageal cancer: staging system and guidelines for staging and treatment. J Thorac Dis 2014; 6 Suppl 3:S289-97. [PMID: 24876933 DOI: 10.3978/j.issn.2072-1439.2014.03.11] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 03/05/2014] [Indexed: 12/25/2022]
Abstract
Survival of esophageal cancer is improving but remains poor. Esophageal cancer stage is based on depth of tumor invasion, involvement of regional lymph nodes, and the presence or absence of metastatic disease. Appropriate work-up is critical to identify accurate pre-treatment staging so that both under-treatment and unnecessary treatment is avoided. Treatment strategy should follow guideline recommendations, and generally should be developed after multidisciplinary evaluation.
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Affiliation(s)
- Mark F Berry
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Shin S, Kim HK, Choi YS, Kim K, Shim YM. Clinical stage T1–T2N0M0 oesophageal cancer: accuracy of clinical staging and predictive factors for lymph node metastasis†. Eur J Cardiothorac Surg 2014; 46:274-9; discussion 279. [DOI: 10.1093/ejcts/ezt607] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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Vallböhmer D, Sisic L, Blank S, Kraus S, Stoecklein NH, Knoefel WT, Büchler MW, Ott K. Clinically Staged cT2 Adenocarcinomas of the Gastroesophageal Junction: Accuracy of Staging and Therapeutic Consequences. Oncol Res Treat 2014; 37:97-104. [DOI: 10.1159/000360177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 01/14/2014] [Indexed: 11/19/2022]
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