Neoadjuvant chemoradiotherapy followed by surgery for esophageal adenocarcinoma: significance of microscopically positive circumferential radial margins

Time-dependent prognostic impact of circumferential resection margin in T3 thoracic esophageal squamous cell carcinoma

Esophageal cancer presents a clinical challenge due to its high incidence and unfavorable prognosis. The prognostic role of the circumferential resection margin (CRM) remains highly controversial, potentially due to its temporal dynamics coupled with variability in follow-up durations across studies. We aimed to explore the time-dependent prognostic significance of CRM in T3 esophageal squamous cell carcinomas (ESCCs). We systematically reviewed literature from 1990 to 2023 to determine how follow-up duration influences the prognostic role of CRM in esophageal cancer. Concurrently, we performed a retrospective examination of 354 patients who underwent treatment at the National Cancer Center between 2015 and 2018. Integrating a time interaction term in the Cox regression analyses enabled us to not only identify independent risk factors affecting overall survival (OS) but also to specifically scrutinize the potential temporal variations in CRM's prognostic impact. Our literature review suggested that CRM's influence on prognosis diminishes with longer follow-up durations for both classifications, namely the Royal College of Pathologists (RCP) (β = -0.003, P < 0.001) and the College of American Pathologists (CAP) (β = -0.007, P < 0.001). Time-dependent multivariate Cox regression analysis emphasized the evolving nature of CRM's prognostic effect, and the inclusion of the time interaction term enhanced model accuracy. In conclusion, CRM is an independent prognostic factor for T3 thoracic ESCC patients. Its influence appears to decrease over extended follow-up periods, shedding light on the heterogeneity seen in previous studies. With the time interaction term, CRM becomes a more precise post-operative prognostic indicator for esophageal cancer.

Positive circumferential resection margin in locally advanced esophageal cancer: an updated systematic review and meta-analysis

BACKGROUND

The impact of positive circumferential resection margin on prognosis in esophageal cancer is under controversy. Previous systematic reviews and meta-analyses had limitations. This updated systematic review and meta-analysis aimed to assess the prognostic impact of positive circumferential resection margin in esophageal cancer.PubMed and Web of Science were searched for studies investigating the association between circumferential resection margin status and prognosis in esophageal cancer. Study population were focused on T3 and/or T4a patients. Study selection was based on availability of survival information (Kaplan-Meier curves and adjusted analysis). Random-effects models were used to summarize hazard ratios for overall survival and disease-free survival.According to College of American Pathologists criteria, circumferential resection margin-positive patients had shorter median overall survival (P < 0.0001) and shorter median disease-free survival (P < 0.0001) compared with circumferential resection margin-negative patients. The pooled hazard ratios for overall survival and disease-free survival were 2.06 (95% confidence interval, 1.68-2.53; P < 0.0001) and 2.00 (95% confidence interval, 1.41-2.84; P < 0.0001), respectively. According to the Royal College of Pathologists criteria, circumferential resection margin-positive patients had shorter median overall survival (P < 0.0001) and shorter median disease-free survival (P < 0.0001) compared with circumferential resection margin-negative patients. The pooled hazard ratios for overall survival and disease-free survival were 1.31 (95% confidence interval, 1.16-1.48; P < 0.0001) and 1.31 (95% confidence interval, 1.09-1.57; P < 0.0001), respectively.ompared with negative circumferential resection margin, positive circumferential resection margin is associated with worse survival outcomes in esophageal cancer.

Is There an Optimal Definition for a Positive Circumferential Resection Margin in Locally Advanced Esophageal Cancer?

BACKGROUND

Two definitions of a positive circumferential resection margin (CRM) in esophageal cancer coexist: one by the College of American Pathologists (CAP) (CRM = 0 mm) and another by the Royal College of Pathologists (RCP) (CRM ≤ 1 mm). This study aimed to evaluate the prognostic value of both definitions in esophageal cancer and to identify a new cutoff value for the CRM to predict survival.

METHODS

Patients who underwent curative esophageal resection for locally advanced (≥ pT3) adenocarcinoma or squamous cell carcinoma were selected from 2007 to 2016. The CRM was reassessed using an ocular micrometer. Overall survival (OS) and disease-free survival were estimated with uni- and multivariate analyses.

RESULTS

The study enrolled 283 patients: 48 with a positive CRM according to the CAP definition and 171 with a positive CRM according to the RCP definition. In the multivariate analysis, a positive CRM according to both definitions was significantly associated with a poor OS (CAP: hazard ratio [HR], 2.26, p < 0.001; RCP: HR, 1.42, p = 0.035). A CRM of 0 mm was predictive of a worse OS and DFS than a CRM of 1 mm or less (p < 0.0001), whereas no significant difference was found between a CRM greater than 1 mm and a CRM of 1 mm or less, indicating that the CAP definition was more accurate for predicting prognosis and recurrence. New cutoff CRM values of 100 µm in squamous cell carcinoma and 200 µm in adenocarcinoma were optimal for predicting OS.

CONCLUSION

The CAP definition was more accurate for predicting prognosis and recurrence. The study identified a new cutoff value of CRM according to histologic type.

Impact of radial margins after esophagectomy for esophageal cancer

INTRODUCTION

The prognostic significance of radial margin (RM) involvement in esophagectomy cancer specimens is unclear. Our study investigated survival and recurrence rates between different depths of RM involvement.

MATERIALS AND METHODS

We retrospectively analyzed 1103 esophagectomies at our institution from 2005 to 2019. Patients were grouped by three-tier stratification: negative RM > 1 mm away, direct RM involvement at 0 mm, and close RM between 0 mm and 1 mm. Survival, loco-regional and distant recurrences were analyzed.

RESULTS

1103 esophageal cancer patients were analyzed. 389 patients had recurrence (35.3%). Median survival (13.2 months) and recurrence rates (71%) were worst with direct RM (p < 0.001) as compared to negative RM (median survival not achieved within 5-years from surgery and 30%). Without nodal involvement, RM involvement of <1 mm was associated with decreased overall survival, and overall, loco-regional and distant recurrence-free survival compared to negative RM (log rank p-value <0.05). In those with persistent nodal disease, only direct RM was associated with decreased overall and loco-regional recurrence-free survival as compared to negative margins (p < 0.05). Direct RM tended to do worse compared to close RM in terms of median survival and trended worse for recurrence. Direct RM (baseline negative RM), but not close RM, was an independent RF in a multivariable Cox model for worse overall survival (HR 2.74; p < 0.001), recurrence-free survival (HR 1.96; p = 0.019), and loco-regional recurrence-free survival (HR 3.19; p = 0.011).

CONCLUSION

RM involvement affects survival and recurrence. Tumor at 0 mm remained an independent RF for worse survival and overall and loco-regional recurrence.

Analysis of Esophagectomy Margin Practice and Survival Implications

BACKGROUND

The objective of this study was to determine how thoracic surgeons manage intraoperative esophagectomy positive margins and how these decisions may relate to overall survival and progression-free survival in esophageal cancer.

METHODS

A survey was sent to thoracic surgeons to understand the management of intraoperative positive esophagectomy margins. Primary data at two high-volume esophageal cancer institutions from 1994 to 2017 were retrospectively reviewed to identify patients who had intraoperative positive frozen section margins during esophagectomy. Patient characteristics and survival data were collected and analyzed. Overall survival and progression-free survival were assessed using a Cox model.

RESULTS

Eighty-five percent of thoracic surgeons responding to a survey reported the utilization of frozen pathologic evaluation during esophagectomy with attempts at re-resection to achieve negative margin. Our esophagectomy database identified 94 patients with intraoperative positive margins. Of those re-resected (n = 67, 63%), 44 patients (46.8%) were converted to R0 resections. overall survival was improved for patients in the R0 group (13 months) vs R+ group (3.4 months, P = .04). Progression-free survival was also improved between the R0 group (8.6 months) and the R+ group (2.2 months, P = .03). In a multivariable analysis for progression-free survival, margin status was an independent predictor of survival (hazard ratio 3.13, P = .03).

CONCLUSIONS

From a thoracic surgery survey, 85% of surgeons use intraoperative frozen section margin analysis to guide surgical decision making during an esophagectomy. Analyzing patients with a positive margin discovered during esophagectomy suggests that esophageal cancer patients who can undergo re-resection to a negative margin have increased progression-free survival. The final margin appears to be related to progression-free survival.

Prognostic impact of circumferential resection margin in esophageal cancer with or without neoadjuvant chemoradiotherapy

The prognostic impact of circumferential resection margin (CRM) in surgically resected esophageal squamous cell carcinoma (ESCC) has been controversial. This investigation assessed the prognostic impact of CRM in surgically resected pathologic T3 ESCC patients with or without neoadjuvant chemoradiotherapy (nCRT). We reviewed consecutive p/yp T3 ESCC patients undergoing esophagectomy from two medical centers between January 2009 and December 2016. The cohort was divided into two groups: upfront esophagectomy (upfront surgery) and nCRT followed by esophagectomy (nCRT + surgery). CRM status was assessed and divided into CRM > 1 mm, 0 < CRM < 1 mm, and tumor at CRM. A total of 217 p/yp T3 ESCC patients undergoing esophagectomy (138 patients in the upfront surgery group and 79 in the nCRT + surgery group) were enrolled. In the upfront surgery group, patients with 0 < CRM < 1 mm showed equivalent overall survival to those with CRM > 1 mm (log-rank P = 0.817) and significantly outlived those with tumor at CRM (log-rank P < 0.001). However, in the nCRT + surgery group, CRM > 1 mm failed to show survival superiority to CRM between 0 and 1 mm or involved by cancer (log-rank P = 0.390). In conclusion, a negative CRM, even though being <1 mm, is adequate for pT3 ESCC patients undergoing upfront esophagectomy. In contrast, the CRM status is less prognostic in ypT3 ESCC patients undergoing nCRT followed by esophagectomy.

Impact of Radial Margin Status After Esophagectomy for Adenocarcinoma

INTRODUCTION

The clinical impact of a positive radial margin after esophagectomy for cancer has not been clearly  identified. The goal of this study was to identify risk factors for a positive radial margin and determine the impact on recurrence and survival.

METHODS

Retrospective review of 196 patients with pathological T3 N0-3 esophageal adenocarcinoma undergoing esophagectomy between 2002 and 2017. Mortality data was extracted from Electronic Medical Records and Social Security Death Index.

RESULTS

Mean age was 63.7 ± 11.4 years, and there were 166 (84.7%) men. Neoadjuvant therapy was given in 141(71.9%) patients. We identified 29(14.8%) patients with a positive radial margin. Factors significantly associated with a positive radial margin include not receiving neoadjuvant therapy and presence of lymphatic, vascular, or perineural invasion. Overall, there were 94(48%) recurrences during a mean follow-up of 24.7 months. Involvement of the radial margin was not significantly associated with recurrence-free survival (HR 1.24, CI 95% 0.73-2.12, p = 0.425). Overall survival for the entire cohort was 41.6% and 28.9% at 3 and 5 years, respectively. Involvement of the radial margin did not have a significant impact on overall survival (HR 1.23, CI 95% 0.68-2.22, p = 0.493).

CONCLUSIONS

The likelihood of encountering a positive margin is associated with lack of neoadjuvant treatment and the presence of lymphatic, vascular, or perineural invasion in the esophagectomy specimen. An involved radial margin after esophagectomy for locally advanced cancer was not associated with tumor recurrence or overall survival in our cohort, and other factors such as lymph node involvement are stronger in determining outcome.

Prediction of a positive circumferential resection margin at surgery following neoadjuvant chemotherapy for adenocarcinoma of the oesophagus

Background

A positive circumferential resection margin (CRM) has been associated with higher rates of locoregional recurrence and worse survival in oesophageal cancer. The aim of this study was to establish if clinicopathological and radiological variables might predict CRM positivity in patients who received neoadjuvant chemotherapy before surgery for oesophageal adenocarcinoma.

Methods

Multivariable analysis of clinicopathological and CT imaging characteristics considered potentially predictive of CRM was performed at initial staging and following neoadjuvant chemotherapy. Prediction models were constructed. The area under the curve (AUC) with 95% confidence intervals (c.i.) from 1000 bootstrapping was assessed.

Results

A total of 223 patients were included in the study. Poor differentiation (odds ratio (OR) 2·84, 95 per cent c.i. 1·39 to 6·01) and advanced clinical tumour status (T3-4) (OR 2·93, 1·03 to 9·48) were independently associated with an increased CRM risk at diagnosis. CT-assessed lack of response (stable or progressive disease) following chemotherapy independently corresponded with an increased risk of CRM positivity (OR 3·38, 1·43 to 8·50). Additional CT evidence of local invasion and higher CT tumour volume (14 cm3) improved the performance of a prediction model, including all the above parameters, with an AUC (c-index) of 0·76 (0·67 to 0·83). Variables associated with significantly higher rates of locoregional recurrence were pN status (P = 0·020), lymphovascular invasion (P = 0·007) and poor response to chemotherapy (Mandard score 4-5) (P = 0·006). CRM positivity was associated with a higher locoregional recurrence rate, but this was not statistically significant (P = 0·092).

Conclusion

The presence of advanced cT status, poor tumour differentiation, and CT-assessed lack of response to chemotherapy, higher tumour volume and local invasion can be used to identify patients at risk of a positive CRM following neoadjuvant chemotherapy.

Meta-analysis of the influence of a positive circumferential resection margin in oesophageal cancer

Background

The evidence regarding the prognostic impact of a positive circumferential resection margin (CRM) in oesophageal cancer is conflicting, and there is global variability in the definition of a positive CRM. The aim of this study was to determine the impact of a positive CRM on survival in patients undergoing oesophagectomy for oesophageal cancer.

Methods

A systematic review and meta‐analysis was performed. PubMed and Embase databases were searched for articles to May 2018 examining the effect of a positive CRM on survival. Cohort studies written in English were included. Meta‐analyses of univariable and multivariable hazard ratios (HRs) were performed using both Royal College of Pathologists (RCP) and College of American Pathologists (CAP) criteria. Risk of bias was assessed using the Newcastle–Ottawa Scale. Egger regression, and Duval and Tweedie trim‐and‐fill statistics were used to assess publication bias.

Results

Of 133 studies screened, 29 incorporating 6142 patients were finally included for analysis. Pooled univariable HRs for overall survival in patients with a positive CRM were 1·68 (95 per cent c.i. 1·48 to 1·91; P < 0·001) and 2·18 (1·84 to 2·60; P < 0·001) using RCP and CAP criteria respectively. Subgroup analyses demonstrated similar results for patients by T category, neoadjuvant therapy and tumour type. Pooled HRs from multivariable analyses suggested that a positive CRM was independently predictive of a worse overall survival (RCP: 1·41, 1·21 to 1·64, P < 0·001; CAP: 2·37, 1·60 to 3·51, P < 0·001).

Conclusion

A positive CRM is associated with a worse prognosis regardless of classification system, T category, tumour type or neoadjuvant therapy.

Radiological prediction of positive circumferential resection margin in oesophageal cancer

PURPOSE

A positive circumferential resection margin (CRM) is regarded as a poor prognostic indicator in oesophageal cancer (OC) but its prediction can be challenging. MRI is used to predict a threatened CRM in rectal cancer but is not commonly performed in OC unlike PET/CT, which is now routinely used. Therefore, this study assessed the additional predictive value of PET-defined tumour variables compared with EUS and CT T-stage. The prognostic significance of CRM status was also assessed.

MATERIALS AND METHODS

This retrospective study included 117 consecutive patients [median age 64.0 (range 24-78), 102 males, 110 adenocarcinomas, 6 squamous cell carcinoma (SCC), 1 neuro-endocrine] treated between 1st March 2012 and 31st July 2015. A binary logistic regression model tested 5 staging variables; EUS T-stage (≤T2 vs ≥ T3), CT T-stage (≤T2 vs ≥ T3), PET metabolic tumour length (MTL), PET metabolic tumour width (MTW) and the maximum standardised uptake value (SUV_max).

RESULTS

The CRM was positive in 43.6%. Sixty-seven (57.3%) patients received neo-adjuvant chemotherapy (NACT), 31 patients (26.5%) underwent surgery alone and 19 patients (16.2%) had neo-adjuvant chemo-radiotherapy (NACRT). Median overall survival (OS) was 36.0 months (95% confidence interval (CI) 24.1-47.9) and the 2-year OS was 55.4%. A binary logistic regression model showed EUS ≥ T3 tumours were independently and significantly more likely to have a positive CRM than EUS ≤ T2 tumours (HR 5.188, 95% CI 1.265-21.273, p = 0.022). CT T-stage, PET MTL, PET MTW and SUV_max were not significantly associated with CRM status (p = 0.783, 0.852, 0.605 and 0.413, respectively). There was a significant difference in OS between CRM positive and negative groups (X² 4.920, df 1, p = 0.027).

CONCLUSION

Advanced EUS T-stage is associated with a positive CRM, but PET-defined tumour variables are unlikely to provide additional predictive information. This study demonstrates the continued benefit of EUS as part of a multi-modality OC staging pathway.

Prognostic significance of circumferential resection margin involvement in patients receiving potentially curative treatment for oesophageal cancer

INTRODUCTION

The utility of Circumferential Resection Margin (CRM) status in predicting prognosis in oesophageal cancer is controversial, with different definitions used by the College of American Pathologists and the Royal College of Pathologists. We aimed to determine prognostic significance of CRM involvement and evaluate which system is the best predictor of prognosis.

METHODS

A cohort of 390 patients who had potentially curative oesophagectomy (- + neoadjuvant chemotherapy) were analysed. Associations between CRM involvement and patient outcome were assessed for the whole cohort, and for pre-specified subgroups of T3 tumours and those who received neo-adjuvant chemotherapy.

RESULTS

CRM-involvement was associated with higher T and N stage, tumour differentiation, increased tumour length and both lymphovascular and perineural invasion. Overall Survival (OS) and Recurrence Free Survival (RFS) significantly worsened with CRM-involvement (p = 0.001, p < 0.001). R1a (<1 mm but no macroscopic involvement) resulted in significantly improved OS (p = 0.037) and RFS (P = 0.026) compared to R1b (macroscopic involvement), but did not differ significantly from R0 (≥1 mm). The association between CRM-involvement and both OS and RFS remained significant regardless of whether neoadjuvant chemotherapy was given. However, CRM-involvement was not a significant prognostic marker in T3 patients (p = 0.148). Multivariable analysis found N stage, lymphovascular invasion, patient age and neoadjuvant chemotherapy to be significantly predictive of patient outcome. CRM-involvement was not a significant independent prognostic marker.

CONCLUSIONS

CRM-involvement was not found to be independently predictive of prognosis, after accounting for other prognostic markers. As such, CRM should not be considered a major prognostic factor in patients with oesophageal cancer.

Impact of incremental circumferential resection margin distance on overall survival and recurrence in oesophageal adenocarcinoma

Background

Previous analyses of the oesophageal circumferential resection margin (CRM) have focused on the prognostic validity of two different definitions of a positive CRM, that of the College of American Pathologists (tumour at margin) and that of the Royal College of Pathologists (tumour within 1 mm). This study aimed to analyse the validity of these definitions and explore the risk of recurrence and survival with incremental tumour distances from the CRM.

Methods

This cohort study included patients who underwent resection for adenocarcinoma of the oesophagus between 2000 and 2014. Kaplan-Meier and Cox regression analyses were performed to determine the hazard ratio (HR) with 95 per cent confidence intervals for recurrence and mortality in CRM increments: tumour at the cut margin, extending to within 0·1-0·9, 1·0-1·9, 2·0-4·9 mm, and 5·0 mm or more from the margin.

Results

A total of 444 patients were included in the study. Kaplan-Meier and unadjusted analyses showed a significant incremental improvement in overall survival (P < 0·001) and recurrence (P for trend < 0·001) rates with increasing distance from the CRM. Tumour distance of 2·0 mm or more remained a significant predictor of survival on multivariable analysis (HR for risk of death 0·66, 95 per cent c.i. 0·44 to 1·00). Multivariable analysis of overall survival demonstrated a significant difference between a positive and negative CRM with the Royal College of Pathologists' definition (HR 1·37, 1·01 to 1·85), but not with the College of American Pathologists' definition (HR 1·22, 0·90 to 1·65).

Conclusion

This study demonstrated an incremental improvement in survival and recurrence rates with increasing tumour distance from the CRM.

Prognostic value of the circumferential resection margin and its definitions in esophageal cancer patients after neoadjuvant chemoradiotherapy

The accepted importance of a positive circumferential resection margin (CRM) (defined as R1 in the TNM classification) is based on histopathology of the resection specimen obtained after primary surgery in esophageal cancer patients. The aim of this study is to look for the prognostic value of CRM after neoadjuvant chemoradiotherapy and to compare the clinical significance of a histologically CRM < 1 mm from the cut margin (Royal College of Pathologists definition of R1) to a positive cut margin (College of American Pathologists definition of R1) and to ≥1 mm margin (R0) resections in patients with ypT3-esophageal tumors after neoadjuvant chemoradiotherapy. Between 2000 and 2014, 458 patients who received esophagectomy after neoadjuvant chemoradiation therapy were selected. Overall (OS) and disease-free survival (DFS) were calculated by means of Kaplan-Meier curves and compared by Cox regression analysis. There were 163 (35.9%) patients who had a ypT3 tumor; in 118 (72.4%) resection was complete (R0). In 37 (22.7%) patients a CRM < 1 mm was found and 8 (4.9%) had a circumferential R1-resection. CRM involvement was inversely correlated with tumor regression grading, lymph node capsular involvement, and number of positive lymph nodes. On univariate analysis, no statistically significant difference was found between R0-resection and CRM < 1 mm (P = 0.103) for OS, but DFS showed a significant difference (P = 0.025). Circumferential R1-resections showed a significant difference compared to R0-resections for OS and DFS (both P = 0.002). In multivariate analysis, extracapsular lymph node involvement and circumferential R1-resection were withheld as independent prognosticators for OS, whereas extracapsular lymph node involvement, absence of regression on the primary tumor and circumferential R1-resection were withheld for DFS. After correcting for different variables in the multivariate model, CRM < 1 mm showed no statistical difference compared to R0-resections neither for OS nor for DFS. After neoadjuvant chemoradiotherapy, CRM is correlated with biological behavior of the tumor and with therapy response. Furthermore it is an independent prognosticator for OS and DFS. However CRM < 1 mm itself is no independent prognosticator for OS nor DFS survival in multivariable analysis. These results suggest that the definition of R1-resection should be limited to true invasion of the section plane.

[R1 resection of esophageal carcinoma]

The microscopic identification of residual tumor tissue in the oral or aboral resection margins (R1 resection) of esophageal specimens following oncologic esophageal resection, increases the risk of tumor recurrence and disease-related morbidity. Esophageal resection with its associated risks is only meaningful, if an R0 situation can be safely achieved. The relevance of microscopic involvement of the circumferential resection margin (CRM) in esophageal carcinoma in its different definitions by the British and the American Societies of Pathology has up to now never been investigated in a prospective study. According to the German S3 guideline, radiochemotherapy should be performed in a postoperatively proven R1 situation, which cannot be converted by a curative extended re-resection into an R0 situation or in unfavorable conditions for an extended re-resection, independent of neoadjuvant therapy. In the case of an R1 situation in the region of the CRM, an extended re-resection is not simply possible on account of the anatomical conditions with corresponding limitations by the aorta and the spinal column, in contrast to extensions of the re-resection orally or aborally.

Positive esophageal proximal resection margin: an important prognostic factor for esophageal cancer that warrants adjuvant therapy

BACKGROUND

Positive esophageal proximal resection margin (ERM+) following esophagectomy was considered as incomplete or R1 resection. The clinicopathological data and long-term prognosis of esophageal cancer (EC) patients with ERM+ after esophagectomy were still unknown. Therefore, the aim of this study was to assess the clinical significance of ERM+ and its therapeutic option.

METHODS

From November 2008 to December 2014, 3,594 patients with histologically confirmed EC underwent radical resection in our department. Among them there were 37 patients (1.03%) who had ERM+. ERM+ was defined as carcinoma or atypical hyperplasia (severe or moderate) at the residual esophageal margin in our study. For comparison, another 74 patients with negative esophageal proximal resection margin (ERM-) were propensity-matched at a ratio of 1:2 as control group according to sex, age, tumor location and TNM staging. The relevant prognostic factors were investigated by univariate and multivariate regression analysis.

RESULTS

In this large cohort of patients, the rate of ERM+ was 1.03%. The median survival time was 35.000 months in patients with ERM+, significantly worse than 68.000 months in those with ERM- (Chi-square =4.064, P=0.044). Survival in patients with esophageal residual atypical hyperplasia (severe or moderate) was similar to those with esophageal residual carcinoma. Survival rate in stage I-II was higher than that in stage III-IV (Chi-square =27.598, P=0.000) in ERM-; But there was no difference between the two subgroups of patients in ERM+. Furthermore, in those patients with ERM+, survival was better in those who having adjuvant therapy, compared to those without adjuvant therapy (Chi-square =5.480, P=0.019). And the average survival time which was improved to a well situation for ERM+ patients who have adjuvant therapy was 68.556 months which is comparable to average survival time (65.815 months) of ERM- for those patients who are at earlier stages.

CONCLUSIONS

ERM+ after esophagectomy nowadays is of low incidence but still an important prognostic factor for patients with EC. Survival of ERM+ patients who have adjuvant therapy was improved to a well situation which is comparable to overall survival (OS) rate of ERM- for those patients who are at earlier stages.

Prediction of survival in patients with oesophageal or junctional cancer receiving neoadjuvant chemoradiotherapy and surgery

Background

The value of conventional prognostic factors is unclear in the era of multimodal treatment for oesophageal cancer. This study aimed to quantify the impact of neoadjuvant chemoradiotherapy (nCRT) and surgery on well established prognostic factors, and to develop and validate a prognostic model.

Methods

Patients treated with nCRT plus surgery were included. Multivariable Cox modelling was used to identify prognostic factors for overall survival. A prediction model for individual survival was developed using stepwise backward selection. The model was internally validated leading to a nomogram for use in clinical practice.

Results

Some 626 patients who underwent nCRT plus surgery were included. In the multivariable model, only pretreatment cN category and ypN category were independent prognostic factors. The final prognostic model included cN, ypT and ypN categories, and had moderate discrimination (c-index at internal validation 0·63).

Conclusion

In patients with oesophageal or oesophagogastric cancer treated with nCRT plus surgery, overall survival can best be estimated using a prediction model based on cN, ypT and ypN categories. Predicted survival according to this model showed only moderate correlation with observed survival, emphasizing the need for new prognostic factors to improve survival prediction.

Prognostic Value of the Circumferential Resection Margin in Esophageal Cancer Patients After Neoadjuvant Chemoradiotherapy

Background

Circumferential resection margins (CRM) for esophageal cancer (EC), defined by the College of American Pathologists (CAP; >0 mm) or the Royal College of Pathologists (RCP; >1 mm) as tumor-free (R0), are based on a surgery-alone approach. We evaluated the usefulness of both definitions in current practice with neoadjuvant chemoradiotherapy (nCRT).

Methods

CRMs were measured in 209 patients (104 with nCRT) with locally advanced EC after transthoracic esophagectomy. Local recurrence and cancer related death were scored as events. Patients were followed for at least 2 years or until death. Prognostic factors (P < 0.1 in univariate analyses) for 2-year disease-free survival (DFS) and local recurrence-free survival (LRFS) were incorporated in multivariate Cox regression analyses. Both CRM measurements were analyzed separately and prognostic cutoff values (0–1.0 mm) were assessed in both groups.

Results

Independent prognostic factors (P < 0.05) for 2-year DFS were tumor length, lymph node ratio, angioinvasion, and CAP R0 in the surgery-alone group and pN stage (P < 0.01) in the nCRT group. Prognostic factors (P < 0.05) for 2-year LRFS were CAP, lymph node ratio, and tumor length in the surgery-alone group, and CAP and grade in the nCRT group. Optimal CRM cutoff values between 0.0 and 0.2 mm were prognostic for 2-year DFS in the surgery-alone and at 0.3 mm for the nCRT group.

Conclusions

nCRT affected the CRM cutoff values. After nCRT, the CRM R0 according to the CAP was only prognostic for 2-year LRFS. However, in the surgery-alone group, it was prognostic for both the 2-year DFS and LRFS.

Surgical treatments for esophageal cancers

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high-grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long-term quality of life in patients following esophagectomy.

Longitudinal and circumferential resection margin in adenocarcinoma of distal esophagus and cardia

Multiple factors are implicated in the long-term survival of patients who have undergone esophagectomy, among these the involvement of longitudinal and circumferential resection margins are well known important prognostic factors. A few studies have assessed the impact of the operative approach on the status of the resection margins, and the data are not well reported, often unclear and, more importantly, there is no scientific evidence or published guideline on what the optimal proximal, distal or circumferential resection margin clearance should be. Owing to the lack of clarity on these points, we undertook a systematic literature review of the impact of longitudinal and circumferential resection margins in patients with operable esophageal cancer, the prognostic significance of margin involvement and the role of neoadjuvant therapy.

Prognostic significance of positive circumferential resection margin in esophageal cancer: a systematic review and meta-analysis

BACKGROUND

To assess the prognostic significance of positive circumferential resection margin on overall survival in patients with esophageal cancer, a systematic review and meta-analysis was performed.

METHODS

Studies were identified from PubMed, EMBASE, and Web of Science. Survival data were extracted from eligible studies to compare overall survival in patients with a positive circumferential resection margin with patients having a negative circumferential resection margin according to the Royal College of Pathologists (RCP) criteria and the College of American Pathologists (CAP) criteria. Survival data were pooled with hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs). A random-effects model meta-analysis on overall survival was performed.

RESULTS

The pooled HRs for survival were 1.510 (95% CI, 1.329-1.717; p<0.001) and 2.053 (95% CI, 1.597-2.638; p<0.001) according to the RCP and CAP criteria, respectively. Positive circumferential resection margin was associated with worse survival in patients with T3 stage disease according to the RCP (HR, 1.381; 95% CI, 1.028-1.584; p=0.001) and CAP (HR, 2.457; 95% CI, 1.902-3.175; p<0.001) criteria, respectively. Positive circumferential resection margin was associated with worse survival in patients receiving neoadjuvant therapy according to the RCP (HR, 1.676; 95% CI, 1.023-2.744; p=0.040) and CAP (HR, 1.847; 95% CI, 1.226-2.78; p=0.003) criteria, respectively.

CONCLUSIONS

Positive circumferential resection margin is associated with poor prognosis in patients with esophageal cancer, particularly in patients with T3 stage disease and patients receiving neoadjuvant therapy.

Defining a positive circumferential resection margin in oesophageal cancer and its implications for adjuvant treatment

Background

A positive circumferential resection margin (CRM) has been associated with a poorer prognosis in oesophageal and oesophagogastric junctional (OGJ) cancer. The College of American Pathologists defines the CRM as positive if tumour cells are present at the margin, whereas the Royal College of Pathologists also include tumour cells within 1 mm of this margin. The relevance of these differences is not clear and no study has investigated the impact of adjuvant therapy. The aim was to identify the optimal definition of an involved CRM in patients undergoing resection for oesophageal or OGJ cancer, and to determine whether adjuvant radiotherapy improved survival in patients with an involved CRM.

Methods

This was a single-centre retrospective study of patients who had undergone attempted curative resection for a pathological T3 oesophageal or OGJ cancer. Clinicopathological variables and distance from the tumour to the CRM, measured to ± 0.1 mm, were correlated with survival.

Results

A total of 226 patients were included. Sex (P = 0·018), tumour differentiation (P = 0·019), lymph node status (P &lt; 0·001), number of positive nodes (P &lt; 0·001), and CRM distance (P = 0·042) were independently predictive of prognosis. No significant survival difference was observed between positive CRM 0-mm and 0·1–0·9-mm groups after controlling for other prognostic variables. Both groups had poorer survival than matched patients with a CRM at least 1 mm clear of tumour cells. Among patients with a positive CRM of less than 1 mm, those undergoing observation alone had a median survival of 18·6 months, whereas survival was a median of 10 months longer in patients undergoing adjuvant radiotherapy, but otherwise matched for prognostic variables (P = 0·009).

Conclusion

A positive CRM of 1 mm or less should be regarded as involved. Adjuvant radiotherapy confers a significant survival benefit in selected patients with an involved CRM.

Oesophageal Chemoradiotherapy in the UK--current practice and future directions

The SCOPE 1 trial closed to recruitment in early 2012 and has demonstrably improved the quality of UK radiotherapy. It has also shown that there is an enthusiastic upper gastrointestinal clinical oncology community that can successfully complete trials and deliver high-quality radiotherapy. Following on from SCOPE 1, this paper, authored by a consensus of leading UK upper gastrointestinal radiotherapy specialists, attempts to define current best practice and the questions to be answered by future clinical studies. The two main roles for chemoradiotherapy (CRT) in the management of potentially curable oesophageal cancer are definitive (dCRT) and neoadjuvant (naCRT). The rates of local failure after dCRT are consistently high, showing the need to evaluate more effective treatments, both in terms of optimal local and systemic therapeutic components. This will be the primary objective of the next planned UK dCRT trial and here we discuss the role of dose escalation and systemic therapeutic options that will form the basis of that trial. The publication of the Dutch 'CROSS' trial of naCRT has shown that this pre-operative approach can both be given safely and offer a significant survival benefit over surgery alone. This has led to the development of the UK NeoSCOPE trial, due to open in 2013. There will be a translational substudy to this trial and currently available data on the role of biomarkers in predicting response to therapy are discussed. Postoperative reporting of the pathology specimen is discussed, with recommendations for the NeoSCOPE trial. Both of these CRT approaches may benefit from recent developments, such as positron emission tomography/computed tomography and four-dimensional computed tomography for target volume delineation, planning techniques such as intensity-modulated radiotherapy and 'type b' algorithms and new treatment verification methods, such as cone-beam computed tomography. These are discussed here and recommendations made for their use.

Lack of independent significance of a close (<1 mm) circumferential resection margin involvement in esophageal and junctional cancer

BACKGROUND

For rectal cancer, an involved circumferential resection margin (CRM), defined as tumor cells within 1 mm of the CRM, is of established prognostic significance. This definition for the esophagus, however, is controversial, with the UK Royal College of Pathologists (RCP) recommending the 1 mm definition, while the College of American Pathologists (CAP) advises that only tumor cells at the cut margin (0 mm) define an incomplete (R1) resection. The aim of this study was to compare the clinical significance of both definitions in patients with pT3 tumors.

METHODS

CAP- and RCP-defined CRM status in patients treated by surgery only or by multimodal therapy was recorded prospectively in a comprehensive database from May 2003 to May 2011. Kaplan-Meier survival curves were generated, and factors affecting survival were assessed by univariate and multivariate analysis.

RESULTS

A total of 157 of 340 patients had pT3 esophageal tumors, with RCP-positive CRM in 60 %, and 18 % by CAP. There were no significant differences between RCP-positive CRM and negative margins for node-positive disease, local recurrence, and survival. CAP-positive CRM was associated with positive nodes (P = 0.036) and poorer survival (P = 0.023). Multivariate analysis revealed nodal invasion to be the only independent prognostic variable (P = 0.004).

CONCLUSIONS

A CRM margin of <1 mm is common in pT3 esophageal tumors, a finding consistent with other reports. The <1 mm definition was not associated with node positivity, local recurrence, or survival, in contrast to actual involvement at the margin, suggesting lack of independent prognostic significance of the RCP definition and possible superiority of the CAP criteria for prospective registration of CRM.

Systematic review and meta-analysis of the influence of circumferential resection margin involvement on survival in patients with operable oesophageal cancer

Background

The prognostic role and definition of circumferential resection margin (CRM) involvement in operable oesophageal cancer remain controversial. The College of American Pathologists (CAP) and Royal College of Pathologists (RCP) define CRM involvement as tumour found at the cut resection margin and within 1 mm of the cut margin respectively. This systematic review and meta-analysis was performed to determine the influence of CRM involvement on survival in operable oesophageal cancer.

Methods

PubMed, MEDLINE and the Cochrane Library (January 1990 to June 2012) were searched for studies correlating CRM involvement with 5-year mortality. Statistical analysis of dichotomous variables was performed using the odds ratio (OR) as the summary statistic.

Results

Fourteen studies involving 2433 patients with oesophageal cancer who had undergone potentially curative oesophagectomy were analysed. Rates of CRM involvement were 15·3 per cent (173 of 1133) and 36·5 per cent (889 of 2433) according to the CAP and RCP criteria respectively. Overall 5-year mortality rates were significantly higher in patients with CRM involvement compared with CRM-negative patients according to both CAP (OR 4·02, 95 per cent confidence interval (c.i.) 2·25 to 7·20; P &lt; 0·001) and RCP (OR 2·52, 1·96 to 3·25; P &lt; 0·001) criteria. CRM involvement between 0·1 and 1 mm was associated with a significantly higher 5-year mortality rate than CRM-negative status (involvement more than 1 mm from CRM) (OR 2·05, 95 per cent c.i. 1·41 to 2·99; P &lt; 0·001).

Conclusion

CRM involvement is an important predictor of poor prognosis. CAP criteria differentiate a higher-risk group than RCP criteria, but overlook a patient group with similar poor outcomes.

Prognostic significance of circumferential resection margin involvement following oesophagectomy for cancer and the predictive role of endoluminal ultrasonography

Background:

The optimum multimodal treatment for oesophageal cancer, and the prognostic significance of histopathological tumour involvement of the circumferential resection margin (CRM+) are uncertain. The aims of this study were to determine the prognostic significance of CRM+ after oesophagectomy and to identify endosonographic (endoluminal ultrasonography (EUS)) features that predict a threatened CRM+.

Methods:

Two hundred and sixty-nine consecutive patients underwent potentially curative oesophagectomy (103 surgery alone, 124 neoadjuvant chemotherapy (CS) and 42 chemoradiotherapy (CRTS)). Primary outcome measures were disease-free survival (DFS) and overall survival (OS).

Results:

CRM+ was reported in 98 (38.0%) of all, and in 90 (62.5%) of pT3 patients. Multivariate analysis of pathological factors revealed: lymphovascular invasion (HR 2.087, 95% CI 1.396–3.122, P<0.0001), CRM+ (HR 1.762, 95% CI 1.201–2.586, P=0.004) and lymph node metastasis count (HR 1.563, 95% CI 1.018–2.400, P=0.041) to be independently and significantly associated with DFS. Lymphovascular invasion (HR 2.160, 95% CI 1.432–3.259, P<0.001) and CRM+ (HR 1.514, 95% CI 1.000–2.292, P=0.050) were also independently and significantly associated with OS. Multivariate analysis revealed EUS T stage (T3 or T4, OR 24.313, 95% CI 7.438–79.476, P<0.0001) and use or not of CRTS (OR 0.116, 95% CI 0.035–0.382, P<0.0001) were independently and significantly associated with CRM+.

Conclusion:

A positive CRM was a better predictor of DFS and OS than standard pTNM stage.