Clinical T2N0 Esophageal Cancer: Identifying Pretreatment Characteristics Associated With Pathologic Upstaging and the Potential Role for Induction Therapy

Predictors of Understaging with EUS and PET-CECT in Early Esophageal Carcinoma

BACKGROUND

The clinicoradiological staging for esophageal cancer is fraught with variable accuracy, potentially depriving patients who have been understaged of the benefit of neoadjuvant therapy, which has been shown to improve long-term survival in locally advanced malignancies. It is imperative to identify these high-risk tumors for tailored treatment.

METHODS

Retrospective analysis of a prospective database of patients undergoing esophagectomy for carcinoma esophagus between 2011 and 2019. Patients with clinicoradiological early-stage esophageal carcinoma (T1/2 and N0), staged with EUS and fluoro-deoxy-glucose positron emission tomography with contrast-enhanced computed tomography (FDG PET-CECT), and undergoing upfront surgery were included. Demographic profile, staging, perioperative outcomes, and follow-up data were extracted from electronic records and analyzed using SPSS 26.0.

RESULTS

During this period, we performed 1496 esophagectomies, of which 68 patients (4.5%) underwent upfront surgery for early-stage tumors. The overall concordance between clinical and surgical staging was 55.8%. The positive predictive value (PPV) of EUS for T1, T2, and N0 was 81.6%, 46.7%, and 82.4%, respectively, with 10.2% and 17% upstaging to T3 and N + , respectively. On multivariate analysis, T2 on EUS and tumors longer than 3.5 cm and having standardized uptake value (SUVmax) > 3.05 on FDG PET were strong predictors of stage migration. The 3-year overall survival (OS) of the entire cohort was 74.2%, while those who were understaged had a worse outcome, with a 3-year survival of 48.2%.

CONCLUSION

Endoscopic T2 stage, length more than 3.5 cm, and SUVmax more than 3.05 are associated with significant understaging and hence should be considered for neoadjuvant therapy.

Complete pathologic response in esophageal adenocarcinoma: does it make a difference?

Advancements in neoadjuvant regimens for esophageal adenocarcinoma have enabled some patients to achieve complete pathologic response at time of esophagectomy. There are currently limited data detailing this trend or the implications of complete pathologic response on survival. The National Cancer Database was used to identify 16,169 patients with esophageal adenocarcinoma that received trimodal therapy including esophagectomy between 2006 and 2020. Of these, 11.4% had complete pathologic response at esophagectomy. Patient factors, staging characteristics, and survival trends were evaluated. In patients diagnosed between 2016 and 2020, the rate of complete pathologic response was 17.5%. Female sex (OR 1.295, 95% CI 1.134-1.481, p = 0.0001), Black race (OR 1.729, 95% CI 1.362-2.196, p = 0.0002), Hispanic ethnicity (OR 1.418, 95% CI 1.073-1.875, p = 0.0141), and later era of diagnosis (2016-2020 OR 2.898, 95% CI 2.508-3.349, p < 0.0001) were independent predictors of complete pathologic response. Clinical stage II disease was associated with an increased probability of complete pathologic response (OR 1.492, 95% CI 1.19-1.871) while clinical stage III disease had a decreased probability of complete pathologic response (OR 0.762, 95% CI 0.621-0.936, p < 0.0001). Complete pathologic response conveyed a strong survival benefit, with a median survival of 86.4 months (95% CI 73.9-102.1) versus 30.7 months (95% CI 29.8-31.7, p < 0.0001) in those without complete pathologic response. Four-year median survival was also higher in those with complete pathologic response (63.3%, 95% CI 60.8-66.0% vs. 39.2%, 95% CI 38.4-40.1%, p < 0.0001). In summary, complete pathologic response is associated with a profound survival advantage in patients with esophageal adenocarcinoma. Such knowledge carries implications for patient counseling, prognostication, and surveillance and demonstrates a need for improved identification of complete clinical response prior to esophagectomy.

Surgery alone versus neoadjuvant chemoradiotherapy followed by surgery in patients with stage T2N0M0 esophageal cancer

To compare the survival outcomes of patients with stage T2N0M0 esophageal cancer treated with surgery alone versus those treated with neoadjuvant chemoradiotherapy followed by surgery. Patients with stage T2N0M0 esophageal cancer, who either underwent surgery alone or received neoadjuvant chemoradiotherapy followed by surgery, were extracted from the Surveillance, Epidemiology, and End Results database covering the period from 2000 to 2020. Cancer-specific survival (CSS) and overall survival (OS) between the two treatment groups were compared. A total of 583 patients were included: 267 (45.8%) received surgery alone, while 316 (54.2%) underwent neoadjuvant chemoradiotherapy followed by surgery. Prior to propensity score matching, no significant differences were observed between the surgery alone and neoadjuvant chemoradiotherapy groups in terms of 5-year CSS (60.86% vs. 59.02%; hazard ratio [HR] = 1.01, 95% confidence interval [CI]: 0.79-1.29; P = 0.916) and OS (50.64% vs. 49.81%; HR = 0.91, 95% CI: 0.75-1.12; P = 0.375). After propensity score matching, the 5-year CSS (66.43% vs. 56.67%; HR = 1.21, 95% CI: 0.89-1.64; P = 0.225) and OS (56.49% vs. 47.37%; HR = 1.09, 95% CI: 0.85-1.40; P = 0.481) remained statistically similar between the two groups. Subgroup analyses of patients with squamous cell carcinoma and adenocarcinoma revealed no significant differences in survival outcomes between the treatment modalities for either histological subtype. Neoadjuvant chemoradiotherapy followed by surgery does not confer a survival advantage over surgery alone in patients with stage T2N0M0 esophageal cancer, irrespective of histological subtype.

Optimal Treatment Strategies for cT2 Staged Adenocarcinoma of the Esophagus and the Gastroesophageal Junction: A Multinational, High-volume Center Retrospective Cohort Analysis

OBJECTIVE

To evaluate outcomes after primary surgery (PS) or neoadjuvant treatment followed by surgery (NAT/S) in cT2 staged adenocarcinomas of the esophagus (EAC) and gastroesophageal junction (GEJ), a multinational high-volume center study was undertaken.

BACKGROUND

The optimal treatment approach with either NAT/S or PS for clinically staged cT2cN any or cT2N0 EAC and GEJ remains unknown due to the lack of randomized controlled trials.

METHODS

A retrospective analysis of prospectively maintained databases from 10 centers was performed. Between January 2012 and August 2023, 645 patients who fulfilled inclusion criteria of GEJ Siewert type I, II, or EAC with cT2 status at diagnosis underwent PS or NAT/S with curative intent. The primary endpoint was overall survival (OS).

RESULTS

In the cT2cN any cohort, 192 patients (29.8%) underwent PS and 453 (70.2%) underwent NAT/S. In all cT2cN0 patients (n = 333), NAT/s remained the more frequent treatment (56.2%). Patients undergoing PS were in both cT2 cohorts older ( P < 0.001) and had a higher American Society of Anesthesiologists classification ( P < 0.05). R0 resection showed no differences between NAT/S and PS in both cT2 cohorts ( P > 0.4).Median OS was 51.0 months in the PS group (95% CI: 31.6-70.4) versus 114.0 months (95% CI: 53.9-174.1) in the NAT/S group ( P = 0.003) of cT2cN any patients. For cT2cN0 patients, NAT/S was associated with longer OS ( P = 0.002) and disease-free survival ( P = 0.001). After propensity score matching of the cT2N0 patients, survival benefit for NAT/S remained ( P = 0.004). Histopathology showed that 38.1% of cT2cN any and 34.2% of cT2cN0 patients were understaged.

CONCLUSIONS

Due to the unreliable identification of cT2N0 disease, all patients should be offered a multimodal therapeutic approach.

Clinical T2 N0 M0 Esophageal Cancer: Identifying Predictive Factors of Upstaging

BACKGROUND

Inaccuracy of clinical staging renders management of clinical T2 N0 M0 (cT2 N0 M0) esophageal cancer difficult. When an underlying advanced-stage disease is understaged to cT2 N0 M0, patients miss the opportunity to gain the potential benefits of neoadjuvant therapy. This study aimed to identify preoperative factors that predict underlying advanced-stage esophageal cancer.

METHODS

From 2000 to 2020, 1579 patients with esophageal cancer underwent esophagectomy. Sixty patients who underwent upfront surgery for cT2 N0 M0 esophageal cancer were included in this study. The median age was 62.5 years, and 78% (n = 47) of these patients were male. Radiologic, clinical, and endoscopic factors were evaluated as preoperative markers. The Fisher exact and the Wilcoxon rank sum tests were used for categoric and continuous variables, respectively. Random forest classification was used to identify preoperative factors for predicting upstaging and downstaging.

RESULTS

Of the 60 patients, 8 (13%) were found to have pathologic T2 N0 M0 esophageal cancer. Sixteen (27%) patients had cancer that was pathologically downstaged, and 36 (60%) had upstaged disease. Seven (19%) patients had upstaged cancer on the basis of the pathologic T stage, 14 (39%) had upstaging on the basis of the pathologic N stage, and 15 (42%) had upstaging on the basis of both T and N stages. Dysphagia (P = .003) and tumor maximum standardized uptake value (P = .048) were predictors of upstaging, with a combined predictive value of up to 75%.

CONCLUSIONS

The presence of dysphagia and of high maximum standardized uptake value (≥5) of the tumor is predictive of more advanced underlying disease for patients with cT2 N0 M0 esophageal cancer, and these patients should be considered for neoadjuvant therapy.

CT radiomics in the identification of preoperative understaging in patients with clinical stage T1-2N0 esophageal squamous cell carcinoma

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.

Implementation of Staging Guidelines in Early Esophageal Cancer: A Study of the Society of Thoracic Surgeons General Thoracic Surgery Database

OBJECTIVE

To evaluate the adoption and clinical impact of endoscopic resection (ER) in early esophageal cancer.

BACKGROUND

Staging for early esophageal cancer is largely inaccurate. Assessment of the impact of ER on staging accuracy is unknown, as is the implementation of ER.

METHODS

We retrospectively reviewed 2608 patients captured in the Society of Thoracic Surgeons General Thoracic Surgery Database between 2015 and 2020. Patients with clinical T1 and T2 esophageal cancer without nodal involvement (N0) who were treated with upfront esophagectomy were included. Staging accuracy was assessed by clinical-pathologic concordance among patients staged with and without ER. We also sought to measure adherence to National Comprehensive Cancer Network staging guidelines for esophageal cancer staging, specifically the implementation of ER.

RESULTS

For early esophageal cancer, computed tomography/positron emission tomography/endoscopic ultrasound (CT/PET/EUS) accurately predicts the pathologic tumor (T) stage 58.5% of the time. The addition of ER to staging was related to a decrease in upstaging from 17.6% to 10.8% ( P =0.01). Adherence to staging guidelines with CT/PET/EUS improved from 58.2% between 2012 and 2014 to 77.9% between 2015 and 2020. However, when ER was added as a staging criterion, adherence decreased to 23.3%. Increased volume of esophagectomies within an institution was associated with increased staging adherence with ER ( P =0.008).

CONCLUSIONS

The use of CT/PET/EUS for the staging of early esophageal cancer is accurate in only 56.3% of patients. ER may increase staging accuracy as it is related to a decrease in upstaging. ER is poorly utilized in staging of early esophageal cancer. Barriers to the implementation of ER as a staging modality should be identified and corrected.

Change in stage after neoadjuvant chemoradiation is associated with survival in patients with esophageal cancer

BACKGROUND

The aim of this study was to determine if change in stage after neoadjuvant chemoradiation (CRT) was associated with improved survival in esophageal cancer using a national database.

METHODS

Using the National Cancer Database, patients with non-metastatic, resectable esophageal cancer who received neoadjuvant CRT and surgery were identified. Comparing clinical to the pathologic stage, change in stage was classified as pathologic complete response (pCR), downstaged, same-staged, or upstaged. Univariable and multivariable Cox regression models were used to identify factors associated with survival.

RESULTS

A total of 7745 patients were identified. The median overall survival (OS) was 34.9 months. Median OS was 60.3 months if pCR, 39.1 months if downstaged, 28.3 months if same-staged, and 23.4 months if upstaged (p < 0.0001). On multivariable analysis, pCR was associated with improved OS compared to the other groups (downstaged: hazard ratio [HR]: 1.32 [95% confidence interval [CI]: 1.18-1.46]; same-staged: HR: 1.89 [95% CI: 1.68-2.13]; upstaged: HR: 2.54 [95% CI: 2.25-2.86]; all p < 0.0001).

CONCLUSIONS

In this large database study, change in stage after neoadjuvant CRT was strongly associated with survival for patients with non-metastatic, resectable esophageal cancer. There was a significant stepwise decline in survival, in descending order of pCR, downstaged tumor, same-staged tumor, and upstaged tumor.

Histological prognosticators in neoadjuvant naive oesophageal cancer patients

PURPOSE

Prognosis of oesophageal cancer is primarily based upon the TNM stage of the disease. However, even in those with similar TNM staging, survival can be varied. Additional histopathological factors including venous invasion (VI), lymphatic invasion (LI) and perineural invasion (PNI) have been identified as prognostic markers yet are not part of TNM classification. The aim of this study is to determine the prognostic importance of these factors and overall survival in patients with oesophageal or junctional cancer who underwent transthoracic oesophagectomy as the unimodality treatment.

METHODS

Data from patients who underwent transthoracic oesophagectomy for adenocarcinoma without neoadjuvant treatment were reviewed. Patients were treated with radical resection, with a curative intent using a transthoracic Ivor Lewis or three staged McKeown approach.

RESULTS

A total of 172 patients were included. Survival was poorer when VI, LI and PNI were present (p<0.001), with the estimated survival being significantly worse (p<0.001) when patients were stratified according to the number of factors present. Univariable analysis of factors revealed VI, LI and PNI were all associated with survival. Presence of LI was independently predictive of incorrect staging/upstaging in multivariable logistic regression analysis (OR 12.9 95% CI 3.6-46.6, p<0.001).

CONCLUSION

Histological factors of VI, LI and PNI are markers of aggressive disease and may have a role in prognostication and decision-making prior to treatment. The presence of LI as an independent marker of upstaging could be a potential indication for the use of neoadjuvant treatment in patients with early clinical disease.

Impacts of neoadjuvant therapy on the number of dissected lymph nodes in esophagogastric junction cancer patients

BACKGROUND

Neoadjuvant therapy favors the prognosis of various cancers, including esophagogastric junction cancer (EGC). However, the impacts of neoadjuvant therapy on the number of dissected lymph nodes (LNs) have not yet been evaluated in EGC.

METHODS

We selected EGC patients from the Surveillance, Epidemiology, and End Results (SEER) database (2006-2017). The optimal number of resected LNs was determined using X-tile software. Overall survival (OS) curves were plotted with the Kaplan-Meier method. Prognostic factors were evaluated using univariate and multivariate COX regression analyses.

RESULTS

Neoadjuvant radiotherapy significantly decreased the mean number of LN examination compared to the mean number of patients without neoadjuvant therapy (12.2 vs. 17.5, P = 0.003). The mean LN number of patients with neoadjuvant chemoradiotherapy was 16.3, which was also statistically lower than 17.5 (P = 0.001). In contrast, neoadjuvant chemotherapy caused a significant increase in the number of dissected LNs (21.0, P < 0.001). For patients with neoadjuvant chemotherapy, the optimal cutoff value was 19. Patients with > 19 LNs had a better prognosis than those with 1-19 LNs (P < 0.05). For patients with neoadjuvant chemoradiotherapy, the optimal cutoff value was 9. Patients with  > 9 LNs had a better prognosis than those with 1-9 LNs (P < 0.05).

CONCLUSIONS

Neoadjuvant radiotherapy and chemoradiotherapy decreased the number of dissected LNs, while neoadjuvant chemotherapy increased it in EGC patients. Hence, at least 10 LNs should be dissected for neoadjuvant chemoradiotherapy and 20 for neoadjuvant chemotherapy, which could be applied in clinical practice.

Management of Clinical T2N0 Esophageal and Gastroesophageal Junction Adenocarcinoma: What Is the Optimal Treatment?

BACKGROUND

The current standard of care for locally advanced esophageal and gastroesophageal junction (GEJ) adenocarcinoma includes neoadjuvant chemoradiation and surgery. The optimal treatment for clinical T2N0M0 (cT2N0) disease is debated. This study aims to determine the optimal treatment in these patients.

METHODS

The National Cancer Database was used to identify patients who underwent surgery for cT2N0 esophageal and GEJ adenocarcinoma from 2004 to 2017. Patients were grouped into surgery-alone, neoadjuvant therapy (NAT), and adjuvant therapy (AT) groups. Subgroups of high-risk patients (tumor ≥ 3 cm, poor differentiation, or lymphovascular invasion) and patients upstaged after upfront surgery were identified. Kaplan-Meier method and Cox proportional hazard ratios were used to compare overall survival.

RESULTS

Of 2160 patients included, 957 (44.3%) underwent surgery-alone, 821 (38.0%) underwent NAT and surgery, and 382 (17.7%) underwent surgery and AT. One thousand six hundred nineteen (75.0%) patients had high-risk features. Six hundred fourteen (45.9%) patients were upstaged after upfront surgery. In the overall cohort, AT was associated with improved survival compared to NAT (HR 0.618, p < 0.001) and surgery-alone (HR 0.699, p < 0.001). There was no difference in survival between NAT and surgery-alone (HR 1.132, p = 0.112). Similar results were observed in high-risk patients. Patients upstaged after upfront surgery who received AT had improved survival compared to those initially treated with NAT (HR 0.613, p < 0.001).

CONCLUSION

This analysis suggests that cT2N0 esophageal and GEJ adenocarcinomas may not benefit from the intensive multimodality therapy utilized in locally advanced disease. Selective use of AT for patients who are upstaged pathologically, or have high-risk features, is associated with improved outcomes.

Detecting Interval Distant Metastases With 18F-FDG PET/CT After Neoadjuvant Chemoradiotherapy for Locally Advanced Esophageal Cancer

PURPOSE

Patients with esophageal cancer can develop distant metastases between the start of neoadjuvant chemoradiotherapy (nCRT) and planned surgery (ie, interval distant metastases). 18F-FDG PET/CT restaging after nCRT detects interval distant metastases in ~8% of patients. This study aimed to identify patients for whom 18F-FDG PET/CT restaging after nCRT could be omitted using an existing prediction model predicting for interval distant metastases or by using clinical stage groups.

PATIENTS AND METHODS

Patients with locally advanced esophageal cancer who underwent baseline and restaging 18F-FDG PET/CT, nCRT, and were planned for esophagectomy between 2017 and 2021 were eligible for inclusion in this retrospective study. The primary outcome was the existing model's external performance (ie, discrimination and calibration) for predicting interval distant metastases. The existing model predictors included tumor length, cN status, squamous cell carcinoma histology, and baseline SUVmax. The secondary outcome determined the clinical stage groups (AJCC/UICC eighth edition) for adenocarcinoma and squamous cell carcinoma for which the incidence of interval distant metastases was <10%.

RESULTS

In total, 127 patients were included, of whom 17 patients developed interval distant metastases (13%; 95% confidence interval [CI], 8%-21%) and 9 patients were deemed to have false-positive lesions on 18F-FDG PET/CT (7%; 95% CI, 2%-11%). Applying the existing model to this cohort yielded a discriminatory c-statistic of 0.56 (95% CI, 0.40-0.72). The calibration of the existing model was poor (ie, mostly underestimating the actual risk). The incidence of true-positive versus false-positive interval distant metastases for patients with clinical stage II disease was 5% versus 0%; clinical stage III, 14% versus 8%; and clinical stage IVa, 22% versus 9%.

CONCLUSIONS

The existing prediction model cannot reliably identify patients at risk for developing interval distant metastases after nCRT for esophageal cancer. Omission of 18F-FDG PET/CT restaging after nCRT could be considered in patients with clinical stage II esophageal cancer.

The Least Nodal Disease Burden Defines the Minimum Number of Nodes Retrieved for Esophageal Squamous Cell Carcinoma

Background

Clinically, a single positive lymph node (SPLN) should indicate the least nodal disease burden in node-positive patients with esophageal squamous cell carcinoma (ESCC) and may also be used to define the minimum number of examined lymph nodes (NELNs) in ESCC patients.

Methods

Data from three Chinese cohorts of 2448 ESCC patients who underwent esophagectomy between 2008 and 2012 were retrospectively analyzed. Based on lymph node status, patients were divided into two groups: N0 ESCC and SPLN ESCC. A Cox proportional hazards regression model was used to determine the minimum NELNs retrieved to maximize survival for ESCC patients with localized lymph node involvement. The results were then validated externally in the SEER database.

Results

A total of 1866 patients were pathologically diagnosed with N0 ESCC, and 582 patients were diagnosed with SPLN ESCC. The overall survival rate of patients with N0 ESCC was significantly better than that of patients with SPLN ESCC (HR 1.88, 95% CI 1.64-2.13, P<0.001), but no significant difference was found between SPLN ESCC patients with ≥ 20 lymph nodes harvested and N0 ESCC patients (HR 1.20, 95% CI 0.95-1.52, P=0.13). Analysis of patients selected from the SEER database showed the same trend, and no significant difference was observed between N0 ESCC patients and SPLN ESCC patients with ≥ 20 lymph nodes retrieved (HR: 1.02, 95% CI 0.72-1.43, P=0.92).

Conclusions

A minimum of 20 lymph nodes retrieved should be introduced as a quality indicator for ESCC patients with localized lymph node involvement.

Comparison of standard and penalized logistic regression in risk model development

Objective

Regression models are ubiquitous in thoracic surgical research. We aimed to compare the value of standard logistic regression with the more complex but increasingly used penalized regression models using a recently published risk model as an example.

Methods

Using a standardized data set of clinical T1-3N0 esophageal cancer patients, we created models to predict the likelihood of unexpected pathologic nodal disease after surgical resection. Models were fitted using standard logistic regression or penalized regression (ridge, lasso, elastic net, and adaptive lasso). We compared the model performance (Brier score, calibration slope, C statistic, and overfitting) of standard regression with penalized regression models.

Results

Among 3206 patients with clinical T1-3N0 esophageal cancer, 668 (22%) had unexpected pathologic nodal disease. Of the 15 candidate variables considered in the models, the key predictors of nodal disease included clinical tumor stage, tumor size, grade, and presence of lymphovascular invasion. The standard regression model and all 4 penalized logistic regression models had virtually identical performance with Brier score ranging from 0.138 to 0.141, concordance index ranging from 0.775 to 0.788, and calibration slope from 0.965 to 1.05.

Conclusions

For predictive modeling in surgical outcomes research, when the data set is large and the outcome of interest is relatively frequent, standard regression models and the more complicated penalized models are very likely to have similar predictive performance. The choice of statistical methods for risk model development should be on the basis of the nature of the data at hand and good statistical practice, rather than the novelty or complexity of statistical models.

The ideal approach for treatment of cT1N+ and cT2Nany esophageal cancer.: a NCDB analysis

BACKGROUND

Neoadjuvant therapy followed by surgery is recommended for locally advanced esophageal cancer. With the inaccuracies of clinical staging particularly for cT1N+ and cT2Nany tumors, some have proposed consideration of surgery followed by adjuvant treatment. Our objective is to evaluate the efficacy of neoadjuvant therapy vs surgery followed by adjuvant therapy, and to identify the ideal sequence of treatment in patients with cT1N+ and cT2Nany tumors.

METHODS

We performed an analysis utilizing the National Cancer Database (2006-2015) identifying all patients with cT1N+ and cT2Nany esophageal cancer undergoing esophagectomy. The treatment was stratified as: neoadjuvant therapy (NT), adjuvant therapy (AT) and combination therapy of neoadjuvant and adjuvant (CT) groups and outcomes were analyzed.

RESULTS

We identified 2795 patients with 81.9% (n=2289) receiving NT, 10.2% (n=285) AT, and 7.9% (n=221) CT. There were no significant differences noted in survival among AT, NT, and CT group in cT1N+(P=0.376), cT2N-(P=0.436), cT2N+(P=0.261) esophageal cancer by multivariate analysis using Cox regression model. This relationship held true in both squamous cell carcinoma and adenocarcinoma.

CONCLUSION

In clinical T1N+, T2Nany patients, there was no evident superiority of NT over AT. Surgery followed by adjuvant therapy can be considered to be an alternative option in these patients. Further prospective studies are needed to validate these findings.

Development and Validation of a Clinical Prognostic Nomogram for Esophageal Adenocarcinoma Patients

Background

Clinical staging is essential for clinical decisions but remains imprecise. We purposed to construct a novel survival prediction model for improving clinical staging system (cTNM) for patients with esophageal adenocarcioma (EAC).

Methods

A total of 4180 patients diagnosed with EAC were extracted from the Surveillance, Epidemiology, and End Results (SEER) database and included as the training cohort. Significant prognostic variables were identified for nomogram model development using multivariable Cox regression. The model was validated internally by bootstrap resampling, and then subjected to external validation with a separate cohort of 886 patients from 2 institutions in China. The prognostic performance was measured by concordance index (C-index), Akaike information criterion (AIC) and calibration plots. Different risk groups were stratified by the nomogram scores.

Results

A total of six variables were determined related with survival and entered into the nomogram construction. The calibration curves showed satisfied agreement between nomogram-predicted survival and actual observed survival for 1-, 3-, and 5-year overall survival. By calculating the AIC and C-index values, our nomogram presented superior discriminative and risk-stratifying ability than current TNM staging system. Significant distinctions in survival curves were observed between different risk subgroups stratified by nomogram scores.

Conclusion

The established and validated nomogram presented better risk-stratifying ability than current clinical staging system, and could provide a convenient and reliable tool for individual survival prediction and treatment strategy making.

Accuracy of clinical staging for T2N0 oesophageal cancer: systematic review and meta-analysis

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.

Optimal Treatment of cT2N0 Esophageal Carcinoma: Is Upfront Surgery Really the Way?

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.

Interobserver variability in target volume delineation in definitive radiotherapy for thoracic esophageal cancer: a multi-center study from China

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.

A Clinical Nomogram for Predicting Node-positive Disease in Esophageal Cancer

OBJECTIVE

We developed and validated a nomogram predicting the likelihood of occult lymph node metastases in surgically resectable esophageal cancers.

BACKGROUND

Patients with esophageal cancer with positive lymph nodes benefit from neoadjuvant therapy, but limitations in current clinical staging techniques mean nodal metastases often go undetected preoperatively.

METHODS

The National Cancer Database was queried for patients with clinical T1-3N0M0 cancer undergoing upfront esophagectomy from 2004 to 2014. Multivariable logistic regression was used to develop the risk model using both statistical significance and clinical importance criteria for variable selection. Predictive accuracy was assessed and bootstrapping was used for validation. A nomogram was constructed for presentation of the final model.

RESULTS

Of 3186 patients, 688 (22%) had pathologic lymph node involvement (pN+) and 2498 (78%) had pN0 status. Variables associated with pN+ status included histology [adenocarcinoma vs squamous: odds ratio (OR) 1.75], tumor stage (T1: reference, T2: OR 1.90, T3: OR 2.17), tumor size (<1 cm: reference, 1-2 cm: OR 2.25, 2-3 cm: OR 3.82, 3-4 cm: OR 5.40, 4-5 cm: OR 5.66, ≥5 cm: OR 6.02), grade (1: reference, 2: OR 2.62, 3: OR 4.39, 4: OR 4.15, X: OR 1.87), and presence of lymphovascular invasion (absent: reference, present: OR 4.70, missing: OR 1.87), all P < 0.001. A nomogram with these variables had good predictive accuracy (Brier score: 0.14, calibration slope: 0.97, c-index: 0.77).

CONCLUSIONS

We created a nomogram predicting the likelihood of pathologic lymph node involvement in patients with esophageal cancer who are clinically node negative using a generalizable dataset. Risk stratification with this nomogram could improve delivery of appropriate perioperative care.

Development and validation of a new clinical staging system to predict survival for esophageal squamous cell carcinoma patients: Application of the nomogram

INTRODUCTION

Survival of patients with the same clinical stage varies widely and effective tools to evaluate the prognosis utilizing clinical staging information is lacking. This study aimed to develop a clinical nomogram for predicting survival of patients with Esophageal Squamous Cell Carcinoma (ESCC).

MATERIALS AND METHODS

On the basis of data extracted from the SEER database (training cohort, n = 3375), we identified and integrated significant prognostic factors for nomogram development and internal validation. The model was then subjected to external validation with a separate dataset obtained from Jinling Hospital of Nanjing Medical University (validation cohort, n = 1187). The predictive accuracy and discriminative ability of the nomogram were determined by concordance index (C-index), Akaike information criterion (AIC) and calibration curves. And risk group stratification was performed basing on the nomogram scores.

RESULTS

On multivariable analysis of the training cohort, seven independent prognostic factors were identified and included into the nomogram. Calibration curves presented good consistency between the nomogram prediction and actual observation for 1-, 3-, and 5-year OS. The AIC value of the nomogram was lower than that of the 8th edition American Joint Committee on Cancer TNM (AJCC) staging system, whereas the C-index of the nomogram was significantly higher than that of the AJCC staging system. The risk groups stratified by CART allowed significant distinction between survival curves within respective clinical TNM categories.

CONCLUSIONS

The risk stratification system presented better discriminative ability for survival prediction than current clinical staging system and might help clinicians in decision making.

The role of primary tumor SUVmax in the diagnosis of invasion depth: a step toward clinical T2N0 esophageal cancer

Background

The controversy regarding optimal clinical T2N0 esophageal cancer treatment ultimately stems from the clinical staging modalities’ inaccuracy. Because most inaccuracies lie in clinical T2 to pathological T1, it is vital to discriminate whether the muscularis propria is invaded.

Methods

We investigated the association between the primary tumor maximal standard uptake value (SUVmax), and the pathological features and overall survival. We attempted to construct a discriminative model through logistic regression analysis.

Results

A total of 140 cN0 esophageal squamous cell carcinoma (ESCC) patients were enrolled. Primary tumor SUVmax differed significantly in paired pathological T categories (P<0.05), but not pT2 vs. pT3 (P=0.648). Age (≤65 vs. >65), biopsy differentiation grades (well or moderately vs. poorly vs. unknown), and primary tumor SUVmax (continuous) were independent risk factors for invasion depth. Subsequently, the age categories, the biopsy differentiation grade categories, and the primary tumor SUVmax categories (≤7.4 vs. >7.4) were included in the logistic regression analysis to construct a discriminative model, showing a good performance in discriminating pT2–3 vs. pT1 in terms of accuracy 87.1%, sensitivity 93.6%, specificity 73.9%, and area under the curve (AUC) 0.887 [95% confidence interval (CI): 0.822 to 0.951]. Of these factors, biopsy differentiation grades and primary tumor SUVmax showed significant differences in overall survival (P<0.05), while the age categories did not.

Conclusions

The novel baseline model comprised of age, biopsy differentiation grades, and primary tumor SUVmax provide much discriminative performance in determining whether the muscularis propria is invaded. Further studies are necessary to validate the findings and guide clinical practice for cT2N0 esophageal cancer.

The modern management of Barrett's oesophagus and related neoplasia: role of pathology

Modern management of Barrett's oesophagus and related neoplasia essentially focuses upon surveillance to detect early low-risk neoplastic lesions and offering organ-preserving advanced endoscopic therapies, while traditional surgical treatments of oesophagectomy and lymph node clearance with or without chemoradiation are preserved only for high-risk and advanced carcinomas. With this evolution towards figless invasive therapy, the choice of therapy hinges upon the pathological assessment for risk stratifying patients into those with low risk for nodal metastasis who can continue with less invasive endoscopic therapies and others with high risk for nodal metastasis for which surgery or other forms of treatment are indicated. Detection and confirmation of neoplasia in the first instance depends upon endoscopic and pathological assessment. Endoscopic examination and biopsy sampling should be performed according to the recommended protocols, and endoscopic biopsy interpretation should be performed applying standard criteria using appropriate ancillary studies by histopathologists experienced in the pathology of Barrett's disease. Endoscopic resections (ERs) are both diagnostic and curative and should be performed by clinicians who are skilled with advanced endoscopic techniques. Proper preparation and handling of ERs are essential to assess histological parameters that dictate the curative nature of the procedure. Those parameters are adequacy of resection and risk of lymph node metastasis. The risk of lymph node metastasis is determined by depth invasion and presence of poor differentiation and lymphovascular invasion. Those adenocarcinomas with invasion up to muscularis mucosae (pT1a) and those with superficial submucosal invasion (pT1b) up to 500 µ with no poor differentiation and lymphovascular invasion and negative margins may be considered cured by endoscopic resections.

An artificial neural network model predicting pathologic nodal metastases in clinical stage I-II esophageal squamous cell carcinoma patients

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.

Should endoscopic mucosal resection be attempted for cT2N0 esophageal cancer?

Endoscopic mucosal resection (EMR) can be an effective therapy for superficial esophageal cancer. Many patients with cT2 invasion by endoscopic ultrasound (EUS) receive surgery but are subsequently found to have superficial disease. The purpose of this study was to investigate the safety profile and the added value of attempting EMR for EUS-staged cT2N0 esophageal cancer. A retrospective review was performed at a single institution from 2008 to 2017. Patients who were staged cT2N0 by EUS were identified from a prospectively maintained surgical database. Among 75 patients identified for analysis, 30 underwent an attempt at EMR. No perforations or other immediate complications occurred. EMR was more likely to be attempted among older patients (P = 0.001) with smaller tumor size (P < 0.001) and diminished SUVmax (P = 0.001). At the time of treatment, EMR was successful in clearing all known disease among 17/30 patients, with 12 representing pT1a or less and 5 representing pT1b with negative margins. Among the 17 patients for whom EMR was able to clear all known disease, there were no recurrences or cancer-related deaths. Although all the patients were staged as cT2N0 by EUS, many patients were identified by EMR to have superficial disease. There were no perforations or other adverse events related to EMR. Furthermore, EMR cleared all known disease among 17 patients with no known recurrences or cancer-related deaths. The results indicate that EMR for cT2N0 esophageal cancer is a safe diagnostic option that is therapeutic for some.

Reliability of clinical nodal status regarding response to neoadjuvant chemoradiotherapy compared with surgery alone and prognosis in esophageal cancer patients

Background: Clinical nodal (cN) staging is a key element in treatment decisions in patients with esophageal cancer (EC). The reliability of cN status regarding the effect on response and survival after neoadjuvant chemoradiotherapy (nCRT) with esophagectomy was evaluated in determining the up- and downstaged pathological nodal (pN) status after surgery alone. Material and methods: From a prospective database, we included all 395 EC patients who had surgery with curative intent with or without nCRT between 2000 and 2015. All patients were staged by a standard pretreatment protocol: 16-64 mdCT, 18 F-FDG-PET or 18 F-FDG-PET/CT and EUS ± FNA. After propensity score matching on baseline clinical tumor and nodal (cT/N) stage and histopathology, a surgery-alone and nCRT group (each N = 135) were formed. Clinical and pathological N stage was scored as equal (cN = pN), downstaged (cN > pN) or upstaged (cN < pN). Prognostic impact on disease free survival (DFS) was assessed with multivariable Cox regression analysis (factors with p value <.1 on univariable analysis). Results: The surgery-alone and nCRT group did not differ in cT/N status. Pathologic examination revealed equal staging (32 vs. 27%), nodal up (43 vs. 16%) and downstaging (25 vs. 56%), respectively (p < .001). Nodal up-staging was common in cT3-4a tumors and adenocarcinomas in the surgery-alone group, while nodal downstaging was found in half of cT1-2 and cT3-4 regardless of tumortype after nCRT. Prognostic factors for DFS were pN (p = .002) and lymph-angioinvasion (p = .016) in surgery-alone, and upper abdominal cN metastases (p = .012) and lymph node ratio (p = .034) in the nCRT group. Conclusions: Despite modern staging methods, correct cN staging remains difficult in EC. Nodal overstaging (cN > pN) occurred more often than understaging impeding an adequate assessment of pathologic complete response and prognosis after nCRT.

How Many Nodes Need to be Removed to Make Esophagectomy an Adequate Cancer Operation, and Does the Number Change When a Patient has Chemoradiotherapy Before Surgery?

INTRODUCTION AND DESIGN

Node dissection during esophagectomy is an important aspect of esophageal cancer staging. Controversy remains as to how many nodes need to be resected in order to properly stage a patient and whether the removal of more nodes carries a stage-independent survival benefit. A review of the literature performed by a group of experts in the subject may help define a minimum accepted number of lymph nodes to be resected in both primary surgery and post-induction therapy scenarios.

RESULTS AND CONCLUSIONS

The existing evidence generally supports the goal of obtaining a minimum of 15 lymph nodes for pathological examination in both primary surgery and post-induction therapy scenarios.

Predicting lymph node metastases with endoscopic resection in cT2N0M0 oesophageal cancer: A systematic review and meta-analysis

Background

Despite modern imaging modalities, staging of clinically staged T2N0M0 (cT2N0M0) oesophageal cancer is suboptimal, often leading to overtreatment. Endoscopic resection – the first-line therapy for early localised tumours – could be used to improve staging and to attain predictors of nodal upstaging enabling more stage-guided treatment decisions.

Objective

A systematic literature review and a meta-analysis were conducted to assess the prevalence and the pathological risk factors of lymph node metastases in cT2N0M0 oesophageal cancer.

Methods

Databases of PUBMED, EMBASE and Cochrane were searched for literature. The primary outcome was lymph node metastases determined after primary surgical resection.

Results

Nine studies with a total of 1650 cT2N0M0 patients were included. The prevalence of lymph node metastases was 43% (95% confidence interval: 35–50%) with heterogeneity being high across studies (I² = 0.86, p < 0.001). Factors potentially attainable by endoscopic resection and having a significant association with lymph node metastases were invasion depth, differentiation grade, tumour size, depth of invasion in the muscularis propria and lymphovascular invasion.

Conclusions

Clinical lymph node staging is inaccurate in almost half of cT2N0M0 oesophageal cancer. Endoscopic resection is a promising diagnostic modality that might even be a valid alternative to surgery in selected patients without high-risk features, but further evidence is warranted.

Management of clinical T2N0 esophageal cancer: a review

While management of locally advanced esophageal cancer has mostly involved multimodality therapy, management of clinical T2N0 patients has been more controversial, primarily as a result of inaccurate clinical staging with existing modalities. This review article examines current literature on this topic and provides recommendations for management of individual patients.

Predictors of staging accuracy, pathologic nodal involvement, and overall survival for cT2N0 carcinoma of the esophagus

OBJECTIVE

Clinical T2N0 esophageal carcinoma is a heterogenous disease frequently complicated by inaccurate staging. Incorrect staging may lead to suboptimal treatment for patients with unidentified local-regionally advanced disease. Therapeutic options for these patients remain controversial. We sought to evaluate the outcomes of patients with cT2N0 who underwent esophagectomy as either primary therapy or after neoadjuvant treatment.

METHODS

This was a multi-institutional collaboration of 26 high-volume esophageal centers. Patients with complete staging who underwent elective resection from 2002 to 2012 were included. Three treatment groups were identified; primary esophagectomy, preoperative chemotherapy, and preoperative chemoradiation (CXRT). Pretreatment variables were explored for independent predictors of long-term outcomes. The primary esophagectomy subgroup was evaluated for stage migration.

RESULTS

In total, 767 patients were evaluated; 35% (268) had preoperative therapy (195 CXRT, 73 chemotherapy). Staging accuracy was 14% (70/499), with pT < 2 identified in 45% (222) and pN > 0 in 39% (195). Preoperative treatment modality (none, CXRT, chemotherapy) was not identified as a predictor of outcome (median survival 63, 70, 71 months, respectively, P = .956). Longitudinal tumor length >3.25 cm was predictive of pN+ for the primary esophagectomy cohort as well as adenocarcinoma histology only (odds ratio 2.2 and 2.4, respectively, P < .001).

CONCLUSIONS

Current treatment options for patients with cT2N0M0 do not reveal a comparative survival advantage to preoperative therapy. Pretreatment tumor length can identify a subgroup of patients at risk for understaging (pN+). The incidence of overstaging suggests that organ-sparing approaches (endoscopic resection) may play a future role in appropriately selected patients.

Induction therapy for clinical stage T2N0M0 esophageal cancer: A systematic review and meta-analysis

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.

Accuracy of endoscopic ultrasound staging for T2N0 esophageal cancer: a National Cancer Database analysis

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Predictors of Nodal Metastases for Clinical T2N0 Esophageal Adenocarcinoma

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.

Role of neoadjuvant chemoradiotherapy in clinical T2N0M0 esophageal cancer: A population-based cohort study

BACKGROUND

The aim of this population-based cohort study was to determine whether the addition of neoadjuvant chemoradiotherapy (nCRT) to surgery is associated with improved pathologic outcomes and survival in patients with cT2N0M0 esophageal cancer.

METHODS

Patients who underwent nCRT followed by surgery or surgery alone for cT2N0M0 esophageal cancer were identified from The Netherlands Cancer Registry database (2005-2014). Accuracy of clinical staging was assessed using the resection specimen as gold standard. After propensity score matching, influences of both treatment strategies on radical resection (R0) rates and overall survival were compared.

RESULTS

In total 533 patients were included; 353 underwent nCRT followed by surgery and 180 underwent surgery alone. In the nCRT group 32% of patients achieved a pathologic complete response. Clinical understaging was observed in 62% of the patients in the surgery alone group based on pT-stage (n = 30, 27%), pN-stage (n = 26, 23%), or both (n = 55, 50%). Propensity score matching resulted in 78 patients who underwent nCRT plus surgery versus 78 who underwent surgery alone. In the nCRT group radical resections were more frequently observed (99% vs. 89% p = 0.031) and resulted in improved 5-year overall survival (46% vs. 33%, p = 0.017).

CONCLUSION

In this population-based study, clinical staging of cT2N0M0 esophageal cancer was highly inaccurate. Compared to surgery alone, neoadjuvant chemoradiotherapy was associated with higher radical resection rates and improved overall survival.

Comparative effectiveness of upfront esophagectomy versus induction chemoradiation in clinical stage T2N0 esophageal cancer: A decision analysis

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.

Management of Patients With Adenocarcinoma or Squamous Cancer of the Esophagus

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.

Neoadjuvant treatment of locally advanced esophageal and junctional cancer: the evidence-base, current key questions and clinical trials

Recent trials, including CROSS, MAGIC, ACCORD, and OEO2, have established neoadjuvant therapy as standard of care for locally advanced (cT_2-3N_anyM₀) esophageal and junctional cancer compared with surgery alone. The CROSS trial in particular defines a new benchmark for outcomes from multimodal therapy, with a 5 year survival rate of 47%, a median survival of 47 months, a pathologic complete response rate (pCR) of 29% and an R0 resection rate of 92%. Several key questions remain, in particular whether CROSS-regimen chemoradiotherapy is superior to neoadjuvant chemotherapy alone for esophageal cancer, in particular adenocarcinoma. Second, with respect to neoadjuvant chemoradiation, whether an apparent complete clinical response can justify a "watch and wait" surveillance policy, with salvage surgery reserved for where relapse occurs. Third, whether with modern staging, predicted node negative cT2 tumors merit neoadjuvant therapy as standard. Finally, with the enormous interest in the application of targeted and immune-based therapies, and positive leads from other cancers, whether such approaches can improve outcomes in patients undergoing treatment with curative intent. We review herein a brief overview of the existing evidence-base and current active trials addressing these key questions.

Neoadjuvant treatment of locally advanced esophageal and junctional cancer: the evidence-base, current key questions and clinical trials

Recent trials, including CROSS, MAGIC, ACCORD, and OEO2, have established neoadjuvant therapy as standard of care for locally advanced (cT_2-3N_anyM₀) esophageal and junctional cancer compared with surgery alone. The CROSS trial in particular defines a new benchmark for outcomes from multimodal therapy, with a 5 year survival rate of 47%, a median survival of 47 months, a pathologic complete response rate (pCR) of 29% and an R0 resection rate of 92%. Several key questions remain, in particular whether CROSS-regimen chemoradiotherapy is superior to neoadjuvant chemotherapy alone for esophageal cancer, in particular adenocarcinoma. Second, with respect to neoadjuvant chemoradiation, whether an apparent complete clinical response can justify a "watch and wait" surveillance policy, with salvage surgery reserved for where relapse occurs. Third, whether with modern staging, predicted node negative cT2 tumors merit neoadjuvant therapy as standard. Finally, with the enormous interest in the application of targeted and immune-based therapies, and positive leads from other cancers, whether such approaches can improve outcomes in patients undergoing treatment with curative intent. We review herein a brief overview of the existing evidence-base and current active trials addressing these key questions.

Western strategy for EGJ carcinoma

In this paper, the epidemiological and clinicobiological behavior of esophagogastric junction (EGJ) adenocarcinoma in the West is compared and contrasted to that in the East, and an overview is provided of current therapeutic strategies employed for this type of tumor in Western countries. It is well known that multimodal treatment is the therapeutic standard in locally advanced EGJ adenocarcinoma, but whether neoadjuvant/perioperative chemotherapy (CT) or neoadjuvant chemoradiotherapy (CRT) is the optimal approach is still debated. Neoadjuvant CRT improves local control in locally advanced Siewert type I and II tumors, so it should be considered the treatment of choice. In the subset of these patients with microscopic systemic disease at diagnosis, more intensive exclusive chemotherapy protocols could be of benefit. Therefore, there is an urgent need to identify these patients before planning the treatment. For Siewert type III tumors, perioperative chemotherapy is the standard. While there is general agreement on the optimal surgical approach for Siewert types I and III (a two-field Ivor Lewis operation and a total gastrectomy with distal esophagectomy, respectively), no standard surgical treatment has been defined for Siewert type II tumors. When data from Western series on proximal and circumferential resection margins and on nodal spread in Siewert type II tumors are taken into account, the optimal surgical approach appears to be Ivor Lewis esophagectomy. Whether the extent of esophageal invasion can correctly predict nodal involvement in middle-upper mediastinal stations as a means to restrict indications for transthoracic esophagectomy requires further investigation in the West.