Predictive biomarkers for response of esophageal cancer to chemo(radio)therapy: A systematic review and meta-analysis

Computed tomography-based radiomic analysis for predicting pathological response and prognosis after neoadjuvant chemotherapy in patients with locally advanced esophageal cancer

PURPOSE

Accurate prediction of prognosis and pathological response to neoadjuvant chemotherapy (NAC) is crucial for optimizing treatment strategies for patients with locally advanced esophageal cancer (LA-EC). This study aimed to investigate the use of radiomics for pretreatment CT in predicting the pathological response of patients with LA-EC to NAC.

METHODS

Overall, 144 patients (145 lesions) with LA-EC who underwent pretreatment contrast-enhanced CT and then received NAC followed by surgery with pathological tumor regression grade (TRG) analysis were enrolled. The obtained dataset was randomly divided into training and validation cohorts using fivefold cross-validation. CT-based radiomic features were extracted followed by the feature selection process using the variance threshold, SelectKBest, and least absolute shrinkage and selection operator methods. The radiomic model was constructed using six machine learning classifiers, and predictive performance was evaluated using ROC curve analysis in the training and validation cohorts.

RESULTS

All patients were divided into responders (n = 40, 28%) and non-responders (n = 104, 72%) based on the TRG results and a statistically significant split by overall survival analysis (0.899 [0.754-0.961] vs. 0.630 [0.510-0.729], respectively). There were no significant differences between responders and non-responders in terms of age, sex, tumor size, tumor location, or histopathology. The mean AUC of fivefold in the validation cohort was 0.720 (confidence interval [CI]: 0.594-0.982), and the best AUC of the radiomic model using logistic regression to predict the non-responders was 0.815 (CI: 0.626-1.000, sensitivity 0.620, specificity 0.860).

CONCLUSION

A radiomic model derived from contrast-enhanced CT may help stratify chemotherapy effect prediction and improve clinical decision-making.

Investigating the predictive value of vascular endothelial growth factor in the evaluation of treatment efficacy and prognosis for patients with non-surgical esophageal squamous cell carcinoma

In this study, we aim to investigate the predictive value of serum vascular endothelial growth factor (VEGF) in evaluating treatment efficacy and long-term prognosis for patients with non-surgical esophageal squamous cell carcinoma (ESCC). The patients diagnosed with ESCC by histopathology who didn’t receive surgical treatment were retrospectively analyzed. Through follow-up and prognostic analysis, we explored the value of serum VEGF changes before, during, and after radiotherapy for predicting treatment efficacy, and identified important indicators to construct the predictive model. Eighty-four patients were enrolled in this study, and the objective response rate (ORR) after treatment was 75.0%. The serum VEGF before, during and after radiotherapy were 108.2 ± 38.4, 98.6 ± 20.3 and 96.9 ± 20.0pg/ml, respectively. Staging and serum VEGF during radiotherapy were the independent factors affecting the treatment efficacy of non-surgical ESCC patients (OR=0.182 and 0.959, P<0.05). The median overall survival (OS) and progression-free survival (PFS) were 24.4 and 15.8 months. The 3-year, 5-year, 10-year OS rates and PFS rates were 35.7%, 26.2%, 14.4%, and 26.2%, 22.6%, 12.3%, respectively. By performing COX regression analysis, we found that the TNM stage, changes of VEGF after radiotherapy (∆VEGF2), and endoscopic histopathological response were the independent prognostic factors for OS and PFS (P<0.05). The R² of the constructed prediction model was 0.328 and 0.362, and the C-index was 0.697 and 0.708, respectively. The follow-up time-dependent AUC showed that the predicted AUC was stable and greater than 0.7 as the follow-up time increased. For patients with non-surgical ESCC, those with low VEGF levels during radiotherapy had better treatment efficacy, and those with significant VEGF reduction after radiotherapy had a better prognosis. In summary, our results demonstrate that it is feasible to construct a model to evaluate and predict the efficacy and prognosis of patients with non-surgical ESCC based on serum VEGF measurement.

Cisplatin-induced pyroptosis is mediated via the CAPN1/CAPN2-BAK/BAX-caspase-9-caspase-3-GSDME axis in esophageal cancer

Esophageal cancer is the seventh most common cancer globally. Chemotherapy resistance remains a significant challenge in the treatment of esophageal cancer patients. Cisplatin can damage tumor cells by inducing pyroptosis. However, the underlying molecular mechanisms remain unclear. In this work, we aim to investigate pyroptosis-dependent molecular mechanisms underlying cisplatin sensitivity and find potential biomarkers to predict response to cisplatin-based chemotherapy for esophageal cancer patients. Pyroptosis-associated proteins were screened via proteomics for esophageal cancer (n = 124) and bioinformatics analysis. We observed that high calpain-1 (CAPN1) and calpain-2 (CAPN2) expression were associated with favorable clinical outcomes and prolonged survival in esophageal cancer patients. We employed immunohistochemistry to evaluate the expression of CAPN1 and CAPN2 in pretreatment tumor biopsies from 108 patients with esophageal cancer who received concurrent chemoradiotherapy (CCRT). These results suggested that esophageal cancer patients with high expression of both CAPN1 and CAPN2 are likely to experience a complete response to CCRT and have significantly better survival. Western blotting, LDH release, calpain activity and cell viability assays indicated that cisplatin could activate calpain activity, while calpain inhibition or knockout suppressed cisplatin-induced pyroptosis. Mechanistically, we uncovered a novel mechanism whereby cisplatin induced pyroptosis via activation of a CAPN1/CAPN2-BAK/BAX-caspase-9-caspase-3-GSDME signaling axis in esophageal cancer cells. Collectively, this study is the first to explore the effects of calpain on cisplatin-induced pyroptosis in esophageal cancer cells. Further, our findings also imply that the combination of CAPN1 and CAPN2 could be considered as a promising biomarker of cisplatin sensitivity and prognosis in patients with esophageal cancer, providing a possibility to guide individualized treatment.

Neoadjuvant Therapy for Locally Advanced Esophageal Cancers

Esophageal carcinoma is one of the most aggressive malignant diseases. At present, neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy are regarded as the standard modalities for the treatments of locally advanced esophageal cancers based on several landmark trials. However, the optimal regimen, radiation dose, and surgical intervals are uncertain and the rate of recurrence after neoadjuvant therapy is high. Patients receiving neoadjuvant therapy and reaching a pathological complete response have been reported to have a better survival benefit and a fewer recurrence risk than those non-pathological complete responses. Nevertheless, less than half of patients will reach a pathological complete response after neoadjuvant therapy, and the methods to evaluate the efficacy after neoadjuvant therapy accurately are limited. Immune checkpoint inhibitors have been recommended for the treatments of advanced esophageal cancers. Recently, research has been beginning to evaluate the safety and efficacy of immunotherapy combined with neoadjuvant therapy. Here, we will review and discuss the development of the neoadjuvant therapy of locally advanced esophageal cancers and unsolved clinical problems.

[Value of plasma SEPTIN9 methylation detection for diagnosis and predicting radiosensitivity of esophageal carcinoma]

OBJECTIVE

To investigate the value of plasma mSEPT9 detection in the diagnosis and prediction of radiosensitivity of esophageal carcinoma.

METHODS

This study was conducted in 72 patients with esophageal cancer who received radical radiotherapy in the Department of Radiotherapy of First Affiliated Hospital of Bengbu Medical College between January, 2019 and December, 2020.Plasma mSEPT9 of the patients were examined with PCR before and after radiotherapy, with 20 healthy subjects from the physical examination center as the controls.The receiver operating characteristic curve (ROC) was used to assess the value of mSEPT9 in diagnosis of esophageal cancer, and the correlation between mSEPT9 and clinicopathological characteristics of the patients was analyzed.According to their response to radiotherapy, the patients were divided into radiosensitive group and insensitive group, and their plasma mSEPT9 levels were compared before radiotherapy.All the patients were observed for dynamic changes of mSEPT9 levels after radiotherapy to analyze the association of mSEPT9 variation with radiosensitivity of the tumors.

RESULTS

The sensitivity and specificity of mSEPT9 for the diagnosis of esophageal carcinoma were 62.5% and 100%, respectively, with an area under the ROC curve of 0.813.Plasma mSEPT9 level was correlated with lymph node metastasis and clinical stages of esophageal carcinoma (P < 0.05), but not with gender, age, invasion site, tumor length, degree of differentiation, or depth of invasion (P > 0.05).The radiosensitive patients had a significantly lower positivity rate for mSEPT9 than the insensitive patients before radiotherapy(53.06% vs 82.61%, P=0.016).In the 72 patients, the positivity rate for mSEPT9 decreased significantly after radiotherapy (30.56% vs 62.5%, P < 0.001); the positivity rate was significantly lowered after radiotherapy in the radiosensitive group (14.29% vs 53.06%, P < 0.001), but the reduction was not significant in the insensitive group (65.22% vs 82.61%, P=0.125).

CONCLUSION

Detection of plasma mSEPT9 level is helpful for diagnosis and prediction of radiosensitivity of esophageal carcinoma.

3D Deep Learning Model for the Pretreatment Evaluation of Treatment Response in Esophageal Carcinoma: A Prospective Study (ChiCTR2000039279)

PURPOSE

To develop and validate a pretreatment computed tomography (CT)-based deep-learning (DL) model for predicting the treatment response to concurrent chemoradiation therapy (CCRT) among patients with locally advanced thoracic esophageal squamous cell carcinoma (TESCC).

METHODS AND MATERIALS

We conducted a prospective, multicenter study on the therapeutic efficacy of CCRT among TESCC patients across 9 hospitals in China (ChiCTR2000039279). A total of 306 patients with locally advanced TESCC diagnosed by histopathology from August 2015 to May 2020 were included in this study. A 3-dimensional DL radiomics model (3D-DLRM) was developed and validated based on pretreatment CT images to predict the response to CCRT. Furthermore, the prediction performance of the newly developed 3D-DLRM was analyzed according to 3 categories: radiation therapy plan, radiation field, and prescription dose used.

RESULTS

The 3D-DLRM achieved good prediction performance, with areas under the receiver operating characteristic curve of 0.897 (95% confidence interval, 0.840-0.959) for the training cohort and 0.833 (95% confidence interval, 0.654-1.000) for the validation cohort. Specifically, the 3D-DLRM accurately predicted patients who would not respond to CCRT, with a positive predictive value (PPV) of 100% for the validation cohort. Moreover, the 3D-DLRM performed well in all 3 categories, each with areas under the receiver operating characteristic curve of >0.8 and positive predictive values of approximately 100%.

CONCLUSION

The proposed pretreatment CT-based 3D-DLRM provides a potential tool for predicting the response to CCRT among patients with locally advanced TESCC. With the help of precise pretreatment prediction, we may guide the individualized treatment of patients and improve survival.

Prognostic value of microRNA-378 in esophageal cancer and its regulatory effect on tumor progression

The incidence and mortality rates of esophageal squamous cell carcinoma (ESCC) are high in China, which has increased the clinical and economic burden. The present study aimed to investigate the role of microRNA (miRNA/miR)-378 in ESCC. Reverse transcription-quantitative polymerase chain reaction analysis was performed to detect miR-378 expression in ESCC tissues and cell lines. Survival analysis was performed using the Kaplan-Meier method, while Cox regression analysis was performed to determine the prognostic value of miR-378 in ESCC. miR-378 mimic and miR-378 inhibitor was transfected into ESCC cells to overexpress or knockdown miR-378 expression levels in ESCC cells. The Cell Counting Kit-8 assay was performed to assess the proliferative ability of ESCC cells, while the Transwell assay was conducted to assess the effect of miR-378 on the migratory and invasive abilities of ESCC cells. The results demonstrated that miR-378 displayed significantly lower expression both in ESCC cells and tissues by comparison with those in normal cells and adjacent tissues. In addition, patients with low miR-378 expression had a worse prognosis and a shorter overall survival time than those with high miR-378 expression. Furthermore, low miR-378 expression promoted ESCC cell proliferation, migration and invasion. Taken together, the results of the present study suggest that miR-378 may act as a tumor suppressor in the occurrence and development of ESCC.

A validated nomogram integrating hematological indicators to predict response to neoadjuvant therapy in esophageal squamous cell carcinoma patients

BACKGROUND

The prognoses for advanced Esophageal squamous cell cancer (ESCC) was very poor. Neoadjuvant therapy was shown to improve overall survival of ESCC patients. However, there is still no effective indicator to predict the efficacy of neoadjuvant therapy. The present study intended to investigate the correlation between hematological parameters and the efficacy of neoadjuvant therapy so as to provide a reference for the prediction of cancer response to neoadjuvant therapy.

METHODS

This study included 197 ESCC patients in our center from January 2010 to December 2018. Response evaluation criteria in solid tumors (RECIST) criteria were used for the treatment evaluation. The results of univariate and multivariate logistic regression analysis were used to select independent factors for construction of the prediction model. The concordance index (C-index), receiver operating characteristic (ROC) curve, and calibration curve were used to evaluate the robustness of the model, while the bootstrap method was used for internal validation.

RESULTS

Among the 197 included ESCC patients, 94 patients achieved partial remission, 80 patients were in stable condition, and 23 patients had disease progression, 123 of whom underwent surgery. The comparisons of the dynamic hematological test results before and after treatment show that pre-PLT, pre-MONO%, post-Hb, △WBC, and the option of undergoing neoadjuvant chemoradiation were the potential predictors for the effectiveness of neoadjuvant therapy. The model in which the C-index was 0.803 (95% confidence interval: 0.742-0.864) showed good prediction performance, and still reach a C-index of 0.764 when internally validated.

CONCLUSIONS

For the neoadjuvant treatment of ESCC, hematological indexes are closely related to the efficacy of neoadjuvant therapy. The nomogram can be used to easily predict the efficacy of neoadjuvant therapy in patients.

The predictive value of microRNAs for pathological response after neoadjuvant treatment in esophageal squamous cell carcinoma: a systematic review

Neoadjuvant treatment followed by esophagectomy has been the standard strategy for resectable locally advanced esophageal squamous cell carcinoma (ESCC). Pathological response after neoadjuvant treatment is of vital importance in the determination of long-term survival. Due to the involvement of microRNAs (miRNAs) in ESCC, some studies have proposed miRNA models to predict the pathological response. We aimed to summarize current studies on the predictive value of the miRNA models. We searched the relevant studies on PubMed, Web of Science and Cochrane Library up to February 14, 2020, using the following search term: (esophageal OR esophagus OR oesophageal OR oesophagus) AND (miR OR miRNA OR microRNA) AND (neoadjuvant OR preoperative OR induction). The initial search retrieved 206 studies. We briefly summarized the involvement of miRNAs in the origin, development and chemo- and radioresistance in ESCC. Then, 9 studies were enrolled in the systematic review. A great heterogeneity was observed across these studies. Of the 6 studies with diagnostic tests, the area under curve varied a lot. Although much evidence demonstrated the correlation between miRNAs and pathological response after in ESCC, the current studies has not established any promising models. A well-designed prospective study is essential to investigate the potential predictive models for pathological response after neoadjuvant treatment in ESCC.

Transcriptomic biomarkers for predicting response to neoadjuvant treatment in oesophageal cancer

Oesophageal cancer is a devastating disease with poor outcomes and is the sixth leading cause of cancer death worldwide. In the setting of resectable disease, there is clear evidence that neoadjuvant chemotherapy and chemoradiotherapy result in improved survival. Disappointingly, only 15%-30% of patients obtain a histopathological response to neoadjuvant therapy, often at the expense of significant toxicity. There are no predictive biomarkers in routine clinical use in this setting and the ability to stratify patients for treatment could dramatically improve outcomes. In this review, we aim to outline current progress in evaluating predictive transcriptomic biomarkers for neoadjuvant therapy in oesophageal cancer and discuss the challenges facing biomarker development in this setting. We place these issues in the wider context of recommendations for biomarker development and reporting. The majority of studies focus on messenger RNA (mRNA) and microRNA (miRNA) biomarkers. These studies report a range of different genes involved in a wide variety of pathways and biological processes, and this is explained to a large extent by the different platforms and analysis methods used. Many studies are also vastly underpowered so are not suitable for identifying a candidate biomarker. Multiple molecular subtypes of oesophageal cancer have been proposed, although little is known about how these relate to clinical outcomes. We anticipate that the accumulating wealth of genomic and transcriptomic data and clinical trial collaborations in the coming years will provide unique opportunities to stratify patients in this poor-prognosis disease and recommend that future biomarker development incorporates well-designed retrospective and prospective analyses.

Integrative p53, micro-RNA and Cathepsin Protease Co-Regulatory Expression Networks in Cancer

Simple Summary

This article describes an emerging area of significant interest in cancer and cell death and the relationships shared by these through the transcriptional regulation of cathepsin protease genes by micro-RNAs that are connected to p53 activation. While it has been demonstrated that the p53 protein can directly regulate some cathepsin genes and the expression of their upstream regulatory micro-RNAs, very little is known about what input the p53 isoform proteins may have in regulating this relationship. Herein, we draw attention to this important regulatory aspect in the context of describing mechanisms that are being established for the micro-RNA regulation of cathepsin protease genes and their collective use in diagnostic or prognostic assays.

Abstract

As the direct regulatory role of p53 and some of its isoform proteins are becoming established in modulating gene expression in cancer research, another aspect of this mode of gene regulation that has captured significant interest over the years is the mechanistic interplay between p53 and micro-RNA transcriptional regulation. The input of this into modulating gene expression for some of the cathepsin family members has been viewed as carrying noticeable importance based on their biological effects during normal cellular homeostasis and cancer progression. While this area is still in its infancy in relation to general cathepsin gene regulation, we review the current p53-regulated micro-RNAs that are generating significant interest through their regulation of cathepsin proteases, thereby strengthening the link between activated p53 forms and cathepsin gene regulation. Additionally, we extend our understanding of this developing relationship to how such micro-RNAs are being utilized as diagnostic or prognostic tools and highlight their future uses in conjunction with cathepsin gene expression as potential biomarkers within a clinical setting.

The expression of PDGF-BB predicts curative effect in locally advanced esophageal squamous cell carcinoma treated by radiotherapy

Radiotherapy is the major approach and is well tolerated in locally advanced esophageal squamous cell carcinoma (ESCC). And nowadays, no effective biological markers have been identified for predicting the prognosis of patients with ESCC. Platelet-derived growth factor (PDGF) is associated with a poor prognosis of various malignancies. The present study aimed to assess the effect of PDGF-BB on radiotherapeutic responses of ESCC and the underlying mechanisms of its roles in ESCC. Serum from 68 cases that received neoadjuvant or radical radiotherapy was obtained before and during radiotherapy. Gene expression analyses were validated by enzyme linked immunosorbent assay. The prognosis of patients with significantly reduced PDGF-BB was probably better than that of the others found in the progression-free survival and overall survival groups. Depletion of PDGFB significantly suppressed the proliferation, invasion and migration of cancer cells. Inhibiting PDGFB induced cellular apoptosis and promoted the sensitivity to ionizing radiation (IR). Furthermore, IR inhibited PDGF-BB-induced migration by blocking the PI3K/AKT pathway in ESCC cells. We found that the expression of PDGF-BB provided a possible model for predicting ESCC radiotherapy. It can also be used as a prognostic indicator for locally advanced ESCC that was treated by radiotherapy.

P16 as a marker of carcinoma in effusions and peritoneal washing

BACKGROUND

Considering the potential of p16 as a marker for diagnosis, prognosis and therapeutic response, the aim of this study was to assess its presence, via immunocytochemistry, in metastatic carcinoma of different primary sites and histological types obtained from effusions and peritoneal washings. A total of 118 samples including 85 of metastatic carcinoma and 33 samples of benign effusion/peritoneal washing were prepared by the plasma/thromboplastin method. Immunocytochemistry reactions were performed on cell block sections using antibodies against p16, claudin-4, MOC-31, calretinin, HBME and CD68.

RESULTS

P16 overexpression was observed in 88.23% of all carcinoma samples. All cervix adenocarcinoma samples showed p16 overexpression. Overexpression in adenocarcinomas of ovary, lung and breast was observed in 93.75, 93.10 and 75% of the samples, respectively. Overexpression was observed in all different histological types analyzed: small cell carcinoma (lung), squamous cell carcinoma (cervical) and urothelial carcinoma (bladder). The specificity of p16 for carcinoma detection was of 96.96%.

CONCLUSION

Overexpression of p16 was observed in most metastatic carcinoma, from different primary sites and histological types, obtained from effusions and peritoneal washings. Due to its high frequency of overexpression in metastatic carcinoma, p16 may play a possible role in tumor progression and it may be considered as a complementary diagnostic marker depending on histological type and primary site of carcinoma.

Menadione reduces CDC25B expression and promotes tumor shrinkage in gastric cancer

BACKGROUND

Gastric cancer is one of the most incident types of cancer worldwide and presents high mortality rates and poor prognosis. MYC oncogene overexpression is a key event in gastric carcinogenesis and it is known that its protein positively regulates CDC25B expression which, in turn, plays an essential role in the cell division cycle progression. Menadione is a synthetic form of vitamin K that acts as a specific inhibitor of the CDC25 family of phosphatases.

METHODS

To better understand the menadione mechanism of action in gastric cancer, we evaluated its molecular and cellular effects in cell lines and in Sapajus apella, nonhuman primates from the new world which had gastric carcinogenesis induced by N-Methyl-N-nitrosourea. We tested CDC25B expression by western blot and RT-qPCR. In-vitro assays include proliferation, migration, invasion and flow cytometry to analyze cell cycle arrest. In in-vivo experiments, in addition to the expression analyses, we followed the preneoplastic lesions and the tumor progression by ultrasonography, endoscopy, biopsies, histopathology and immunohistochemistry.

RESULTS

Our tests demonstrated menadione reducing CDC25B expression in vivo and in vitro. It was able to reduce migration, invasion and proliferation rates, and induce cell cycle arrest in gastric cancer cell lines. Moreover, our in-vivo experiments demonstrated menadione inhibiting tumor development and progression.

CONCLUSIONS

We suggest this compound may be an important ally of chemotherapeutics in the treatment of gastric cancer. In addition, CDC25B has proven to be an effective target for investigation and development of new therapeutic strategies for this malignancy.

Neoadjuvant chemoradiotherapy for resectable oesophageal cancer

At present, treatment of potentially curable oesophageal cancer includes neoadjuvant chemoradiotherapy followed by oesophagectomy. Alternatively, neoadjuvant chemotherapy is used. To date, strong evidence on the superiority of one modality over the other has not been provided. Currently, up to one-third of patients show a pathologically complete response after neoadjuvant chemoradiotherapy. To optimise the efficacy of neoadjuvant treatment for individual patients, prediction of response to neoadjuvant treatment is highly desired. Therefore, several clinical diagnostic modalities have been investigated for early response evaluation, of which positron emission tomography (PET) has been studied most extensively. To identify patients who might benefit from postponing or even omitting surgery, recent advances have been made in evaluating response after completion of neoadjuvant chemoradiotherapy. This review provides an overview of current evidence and recent advances in neoadjuvant chemoradiotherapy for oesophageal cancer and discusses the use of neoadjuvant chemotherapy compared to chemoradiotherapy. Moreover, clinical response evaluation to neoadjuvant chemoradiotherapy is reviewed.

Recent advancements in esophageal cancer treatment in Japan

The 11th edition of the Japanese Classification of Esophageal Cancer (EC) was published in 2017. Some correction was made in the depth of tumor invasion to be consistent with the TNM classification by the Union for International Cancer Control (UICC). With regard to surgery, short-term safety and long-term effectiveness under thoracotomy/video-assisted thoracoscopic surgery are expected to be proven by the Japan Clinical Oncology Group (JCOG)1409 study. Results of nutritional management and countermeasures for adverse events not only during the perioperative period but also during EC chemotherapy were reported. From now on, the pursuit of low invasiveness and radicality is desired. Esophageal surgery is also expected to be safe at all institutions. To determine the optimal modality of preoperative treatment and a novel chemo(radio)therapy regimen for patients with distant metastasis, the results of the ongoing JCOG1109 and 0807 studies are being released. The effect of the addition of molecular targeted drugs on chemotherapy and concurrent chemoradiation has not yet improved overall survival. Immune checkpoint inhibitor drugs could offer a potential new treatment approach for patients with treatment-refractory advanced squamous cell carcinoma (SCC). The Cancer Genome Atlas Research Network reported the results of a comprehensive genome analysis and molecular analysis of SCC and adenocarcinoma of the esophagus. Further differentiation of SCC and adenocarcinoma by molecular characterization analysis may be useful for the development of clinical trials and targeted drug therapies as precision medicine. The era of ultimate minimally invasive surgery and personalized treatment has begun. Large, prospective studies will be required to confirm the value of these advancements.