Multimodality therapy for resectable cancer of the thoracic esophagus

Chinese herbal medicine for oesophageal cancer

BACKGROUND

Oesophageal cancer is the seventh leading cause of cancer death worldwide. Traditional Chinese herbal medicine is sometimes used as an adjunct to radiotherapy or chemotherapy for this type of cancer. This review was first published in 2007 and updated in 2009; this 2016 update is the latest version of the review.

OBJECTIVES

To assess the efficacy and possible adverse effects of the addition of Chinese herbal medicine to treatment with radiotherapy or chemotherapy for oesophageal cancer.

SEARCH METHODS

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register, the Cochrane Library, MEDLINE, EMBASE, Allied and Complementary Medicine Database (AMED), China National Knowledge Infrastructure (CNKI), VIP database, Wanfang database and the Chinese Cochrane Centre Controlled Trials Register up to 1 October, 2015. We also searched databases of ongoing trials, the Internet and reference lists.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the use of radiotherapy or chemotherapy with and without the addition of Chinese herbal medicine.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted data and assessed trial quality.

MAIN RESULTS

We tried to contact the 142 study authors by telephone, and finally included nine studies with 490 participants. All included studies were conducted in China, and allocated advanced oesophageal cancer patients to radiotherapy or chemotherapy groups, with and without additional Chinese herbal medicine. Quality of life, short-term therapeutic effects, TCM symptoms and adverse events caused by radiotherapy or chemotherapy were reported in these studies. Overall, we considered the trials to be at unclear or high risk of bias.The quality of life measure was conducted before and after the intervention; our analysis showed a beneficial effect, both in number of participants experiencing an improvement (risk ratio (RR) 2.20, 95% confidence interval (CI) 1.42 to 3.39; 5 RCTs, 233 participants, change of performance status score ≥ 10) and number of participants experiencing a deterioration (RR 0.41, 95% CI 0.27 to 0.62; 6 RCTs, 287 participants, change of performance status score ≤ 10). We judged this to have low quality evidence, downgrading quality of evidence for risk of bias and imprecision, and upgrading quality of evidence for the large effect.For short-term therapeutic effects, the results suggest that traditional Chinese medicine (TCM) has a positive impact on improvement (complete response + partial response) (RR 1.17, 95% CI 1.02 to 1.35; 8 RCTs, 450 participants), moderate quality evidence and downgrading for risk of bias. There was no significant difference for progressive disease (RR 0.73, 95% CI 0.52 to 1.01; 8 RCTs, 450 participants), low quality evidence and downgrading for risk of bias and imprecision. Three studies assessed this outcome after four weeks or three months' follow-up, the remaining studies gave no detailed information for this outcome. TCM symptoms, which was similar to short-term therapeutic effects evaluated with TCM clinical criteria, was diagnosed in two studies of 88 people at the end of the intervention. The results suggest that TCM has a positive impact on both total effectiveness (RR 1.84, 95% CI 1.20 to 2.81) and ineffectiveness (RR 0.22, 95% CI 0.05 to 0.93); we judged the studies to have very low quality evidence, downgrading for risk of bias and imprecision.Nine studies reported a series of adverse events caused by radiotherapy or chemotherapy at the end of the intervention, including mucositis, radiation oesophagitis, arrest of bone marrow, gastrointestinal reactions, renal and hepatic impairment, white blood cell descent, neurotoxicity, cardiac toxicity and anaemia. For those containing multiple studies, we conducted a pooled analysis. As a result, TCM showed a significant effect on radiation oesophagitis (RR 0.66, 95% CI 0.47 to 0.94; 2 RCTs, 90 participants), gastrointestinal reactions (RR 0.54, 95% CI 0.36 to 0.81; 4 RCTs, 268 participants) and white blood cell descent (RR 0.60, 95% CI 0.44 to 0.83; 4 RCTs, 224 participants). The quality of evidence was low or very low, downgrading for risk of bias and imprecision.

AUTHORS' CONCLUSIONS

We currently find no evidence to determine whether TCM is an effective treatment for oesophageal cancer. The effect of TCM on short-term therapeutic effects is uncertain. TCM probably has positive effects on quality of life and on some adverse events caused by radiotherapy or chemotherapy in advanced oesophageal cancer patients undergoing radiotherapy or chemotherapy. The results of the review need to be interpreted cautiously owing to overall low quality evidence. Future trials should be large and correctly designed to detect important clinical effects and minimise risk of bias.

Multidetector-computed tomography attenuation values between the tumor and aortic wall in response to induction therapy for esophageal cancer and its predictive value for aortic invasion

The objective of this study was to evaluate the multidetector computed tomography (MDCT) attenuation value between the tumor and aorta in response to the induction therapy for esophageal cancer. In advanced esophageal cancer, the main reason for unresectability is the local invasion of the tumor into the aorta or trachea. Despite remarkable advances in diagnostic modalities, pre-operative assessment of pathological response and local tumor extent in esophageal cancer remains difficult. MDCT attenuation values between the tumor and aorta, and the contact angle of the tumor to the aorta (Picus' angle) were retrospectively evaluated in patients with esophageal cancer who underwent induction therapy in terms of predicting the pathological response, aortic invasion and prognosis of esophageal cancer. The induction therapy may increase the tumor-to-aorta distance and decrease the maximum tumor size and Picus' angle. When the tumor-to-aorta cut-off value was set at <1.3 mm, the accuracy of this distance for aortic invasion was 94.6%. In terms of this distance, 14 out of 19 patients with a tumor-to-aorta distance of <1.3 mm prior to the induction therapy had a distance of >1.3 mm following therapy and underwent curative resection. The assessment of the MDCT attenuation value between the esophageal tumor and the aorta is simple and objectively assesses the response to the induction therapy and aortic invasion in esophageal cancer. This method should be applied to predict the response to the induction therapy and to prevent unnecessary surgery in patients with tumors involving the aorta.

Expression of insulin-like growth factor II mRNA-binding protein 3 in human esophageal adenocarcinoma and its precursor lesions

CONTEXT

Insulin-like growth factor II mRNA-binding protein 3 (IMP3) is an oncofetal protein highly expressed in fetal tissue and malignant tumors but only rarely within adult benign tissues. The expression of IMP3 in esophageal adenocarcinoma (EAC) and its precursor lesions including distinctive type Barrett mucosa (BM, intestinal metaplasia) and esophageal columnar dysplasia (ECD) is largely unknown.

OBJECTIVE

To characterize the patterns of IMP3 expression in EAC and its precursor lesions.

DESIGN

Samples from 132 cases of EAC, 28 cases of ECD (16 high-grade dysplasia and 12 low-grade dysplasia cases), 28 cases of BM without dysplasia, and 138 cases of nonneoplastic esophageal mucosa without dysplasia or BM within formalin-fixed, paraffin-embedded tissue microarray blocks were examined. Tissues were stained with mouse monoclonal anti-IMP3 antibody. The intensity (1-3+) and percent (0%-100%) of positive cytoplasmic and/or membranous IMP3 staining cells were determined.

RESULTS

Most of EAC cases (93 of 132; 70%) showed cytoplasmic and membranous IMP3 staining. Poorly and moderately differentiated EAC showed statistically significant higher IMP3 expression compared with well-differentiated EAC (P < .001). A subset of ECD cases (7 of 28; 25%) was positive for IMP3, including 3 low-grade dysplasia cases (focal 1+ IMP3 staining) and 4 high-grade dysplasia cases (more diffuse 1-2+ IMP3 staining). No IMP3 staining was observed in any nonneoplastic esophageal mucosa and BM tissues without dysplasia.

CONCLUSIONS

This study suggests that IMP3 may play a role in the carcinogenesis of EAC and has diagnostic utility in differentiating neoplastic and nonneoplastic lesions of the esophagus.

The use of the LigaSureTM in esophagectomy

This study aimed to evaluate the efficacy of the LigaSure vessel sealing system (LVSS) when used for esophagectomy. We compared 56 consecutive patients (32 male and 24 female, mean age: 56.64+/-12.61 years), who had undergone Ivor-Lewis esophagectomy for esophageal carcinoma between January 2005 and May 2009. Among them, from January 2005 to April 2007, 27 patients (group 1) were operated on with the conventional clamp-and-tie technique, whereas from April 2007 to May 2009, 29 patients (group 2) underwent total esophagectomy for esophageal cancer with the LVSS. Both groups were compared for operation duration, amount of intraoperative bleeding, postoperative hospitalization time, and intraoperative complications. In the evaluation of the patients, the two groups had similar distributions of age and gender. The duration of operation (349.44+/-46.82 min vs. 288.27+/-60.09 min, P<0.05) and the amount of intraoperative bleeding (414.82+/-137.04 ml vs. 217.41+/-111.78 ml, P<0.05) were significantly lower in LVSS group than in the conventional method group. There were no differences for hospitalization time and intraoperative complications between the groups. LVSS significantly shortens operation duration and decreases the amount of intraoperative bleeding compared with the conventional methods, but does not provide advantages for hospitalization time and/or intraoperative complications. We believe LVSS is an effective and reliable method for esophagus surgery.

Chinese herbal medicines for esophageal cancer

BACKGROUND

Esophageal cancer is the seventh leading cause of cancer death worldwide. Traditional Chinese herbal medicines are sometimes used as an adjunct to radiotherapy or chemotherapy for this type of cancer.

OBJECTIVES

To assess the efficacy and possible adverse effects of the addition of Chinese herbal medicines to treatment with radiotherapy or chemotherapy for esophageal cancer.

SEARCH STRATEGY

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register, The Cochrane Library, MEDLINE, EMBASE, AMED (Allied and Complementary Medicine Database), CBM (Chinese Biomedical Database), China National Knowledge Infrastructure, the Chinese Cochrane Centre Controlled Trials Register and CISCOM (The Research Council for Complementary Medicine) (up to 10 July, 2008). Databases of ongoing trials, the Internet and reference lists were also searched.

SELECTION CRITERIA

Randomised controlled trials comparing the use of radiotherapy or chemotherapy with and without the addition of Chinese herbal medicines.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data and assessed trial quality.

MAIN RESULTS

We identified 43 trials which claimed to use random allocation. The first authors of all the RCTs we initially identified were contacted by telephone and we discovered that the authors had misunderstood the randomisation procedure. Using this new information, we reassigned all the identified RCTs as non-randomised trials. Because we identified no authentic randomised controlled trials, we were unable to perform a meta-analysis.

AUTHORS' CONCLUSIONS

We were unable to find any evidence from RCTs on the effectiveness of TCM in the treatment of esophageal cancer. New trials should be carried out and we recommend that they are large scaled, correctly randomised and that the assessors of the results are blinded to the conditions of allocation.

WITHDRAWN: Medicinal herbs for esophageal cancer

BACKGROUND

Esophageal cancer is the seventh leading cause of cancer death worldwide. Traditional Chinese medicinal herbs are sometimes used as an adjunct to radiotherapy or chemotherapy for this type of cancer.

OBJECTIVES

To assess the efficacy and possible adverse effects of the addition of Chinese medicinal herbs to treatment with radiotherapy or chemotherapy for esophageal cancer.

SEARCH STRATEGY

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register, The Cochrane Library, MEDLINE, EMBASE, AMED (Allied and Complementary Medicine Database), CBM (Chinese Biomedical Database), China National Knowledge Infrastructure, the Chinese Cochrane Centre Controlled Trials Register and CISCOM (The Research Council for Complementary Medicine) (up to June 2004). Databases of ongoing trials, the internet and reference lists were also searched.

SELECTION CRITERIA

Randomised controlled trials comparing the use of radiotherapy or chemotherapy with and without the addition of Chinese medicinal herbs.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data and assessed trial quality.

MAIN RESULTS

We identified 43 trials which claimed to use random allocation. Sixteen study authors were contacted by telephone and we discovered that they misunderstood the randomisation procedure and the trials were identified as non-RCTs. The situation of lack of authentic randomised controlled trial leads us cannot draw a conclusion to recommend or against the use of TCM as a treatment for esophageal cancer.

AUTHORS' CONCLUSIONS

There was no evidence of effect of TCM in the treatment of esophageal cancer due to no any authentic RCT in this field yet. New trials should be large scaled, correctly randomised and results assessor blinded in the future.

Pathologic Nodal Status Predicts Disease-Free Survival After Neoadjuvant Chemoradiation for Gastroesophageal Junction Carcinoma

BACKGROUND

The incidence of carcinoma of the gastroesophageal junction (GEJ) is rapidly increasing, and the prognosis remains poor. We examined outcomes in patients who received neoadjuvant chemoradiation for GEJ tumors to identify factors that predict disease-free (DFS) and overall (OS) survival.

METHODS

A retrospective analysis was performed of 101 consecutive patients who received chemoradiation and surgery for GEJ carcinoma between 1992 and 2001.

RESULTS

The median DFS and OS of all patients were 16 and 25 months, respectively. Twenty-eight patients with a complete histological response (T0N0) experienced greater DFS compared with all others (P = .02). Node-negative patients, regardless of T stage, experienced improved median DFS (24 months) compared with N1 patients (9 months; P = .01). Preoperative stage, age, tumor location, or Barrett's esophagus did not independently predict OS by univariate analysis. Multivariate analysis demonstrated that only posttreatment nodal status (P = .03)-not the degree of primary tumor response-predicted DFS.

CONCLUSIONS

The nodal status of patients with GEJ tumors after neoadjuvant therapy is predictive of DFS after resection. The poor outcome in node-positive patients supports postneoadjuvant therapy nodal staging, because surgical aggressiveness should be tempered by the realization that cure is unlikely and median survival is short.

Neoadjuvant chemotherapy for oesophageal cancer: The need for accurate response prediction and evaluation

Primary surgical resection for locally advanced oesophageal cancer is associated with systemic failure and poor survival due to presence of micrometastatic disease at the time of diagnosis. Neoadjuvant chemotherapy prior to surgical resection aims to downstage these locally advanced tumours. A review of reported randomised controlled trials has shown only one sufficiently powered trial with a survival advantage for cisplatin-based chemotherapy. Published meta-analyses of neoadjuvant chemotherapy trials have shown little or no overall survival benefit. A subgroup of patients with biologically favourable tumours who respond to this treatment have been consistently shown to have a survival advantage. These patients need to be differentiated from non-responders preferably at an early stage of this potentially toxic treatment. Current clinical, endoscopic and radiological methods of response evaluation are all unreliable. Response evaluation with 18FDG-PET has been shown to accurately assess the pathological response and also to predict the risk of local recurrence and overall survival. The development of integrated PET/CT imaging may enhance the accuracy of this response evaluation. In the future, molecular markers of response prediction prior to initiation of treatment may allow the development of individualised treatment strategies. New emerging chemotherapeutic agents may prove to be more effective in eradicating micrometastatic disease.

Significance of post-chemoradiation biopsy in predicting residual esophageal carcinoma in the surgical specimen

Pathologic complete response in the resected esophagus can be achieved in approximately 30% of patients with locally advanced esophageal or gastroesophageal junction carcinoma after preoperative chemoradiation therapy. These patients tend to have a longer survival than those who have less than pathologic complete response. Post-chemoradiation esophageal biopsy (PCEB) is used to check for the presence of residual tumor before a definitive resection is performed, but the clinical significance of PCEB findings is not clear due to the possibility of sampling bias and the superficial nature of the specimen obtained. We evaluated the use of PCEB (defined as biopsy taken within 30 days before esophagectomy) in predicting residual cancer in post-treatment esophagectomy specimens. PCEB was performed in 65 of 183 (36%) patients with locally advanced esophageal or gastroesophageal junction carcinoma, who received preoperative chemoradiation therapy. The cancer status in PCEB was correlated with the residual cancer in the esophagectomy specimens. PCEB had no cancer in 80% (52 of 65) of patients (Bx-negative) and cancer in 20% (13 of 65) of patients (Bx-positive). There was no difference in the presence of residual cancer (either in esophagus or lymph node) in esophagectomy specimens between Bx-negative patients (77%, 40 of 52) or Bx-positive patients (92%, 12 of 13), P = 0.44. The positive predictive value of biopsy was 92% (12 of 13), negative predictive value 23% (12 of 52), sensitivity 23% (12 of 52) and specificity 92% (12 of 13). There was no difference in the residual cancer staging in the esophagectomy specimen between Bx-positive and Bx-negative patients. In contrast, residual metastatic carcinoma in lymph nodes was more frequent in Bx-positive patients (69.2%, 9 of 13) than in Bx-negative patients (28.8%, 15 of 52), P = 0.01. Our data suggest that PCEB is a specific but not a sensitive predictor of residual cancer following esophagectomy. Bx-positive patients tend to have more frequent residual tumor in lymph nodes. The utility of PCEB in predicting residual cancer in the lymph nodes needs to be explored further along with molecular predictors of response to preoperative therapy.

Multimodality Therapy for Thymic Carcinoma (TCA)

SUMMARY

The aim of this study was to correlate the clinicopathologic features and therapeutic approaches with the outcome of patients with thymic carcinoma (TCA), an aggressive, uncommon malignancy of the anterior mediastinum. TCA is morphologically distinct from thymoma, a cytologically bland, often encapsulated, locally invasive, rarely metastatic tumor. The Roswell Park Cancer Institute tumor registry was used to identify patients with TCA or invasive thymic neoplasm of the epithelial type (TNET). Between 1971 and 2001, 22 patients had a pathologic diagnosis of TCA and/or TNET. The mean age at diagnosis was 53 years (range: 19-77), and the male/female ratio was 3:1 (16/6). Initial symptoms were respiratory in about half the patients (10/22). Complete surgical resection was done in five patients. Postoperative cisplatin-based chemotherapy and radiation was administered to seven patients. Pathologic examination showed low grade(n = 14), intermediate grade (n = 7), and high grade (n = 1) TCA. Capsular invasion was present in 83% of the specimens. As of June 2002, nine patients are alive and eight are disease free. The median survival is 44.7 months. Locally invasive disease precluded complete surgical resection in more than half of our cases. Incomplete surgical resection did not preclude long-term survival if multimodality platinum-based therapy was used.

The replication-competent oncolytic herpes simplex mutant virus NV1066 is effective in the treatment of esophageal cancer

BACKGROUND

The oncolytic herpes simplex-1 virus, NV1066, is a replication-competent virus that has been engineered to infect and lyse tumor cells selectively and to carry a transgene for enhanced green fluorescent protein (EGFP). The purpose of this study was to determine viral cytotoxicity in an esophageal cancer cell line and to determine whether EGFP expression could be used as a marker of viral infection.

METHODS

BE3 esophageal adenocarcinoma cells were infected with NV1066 in vitro to determine cell kill and viral replication. EGFP expression was assessed by flow cytometry. The in vivo anti-tumor activity of NV1066 was tested in subcutaneous and intraperitoneal xenograft models. EGFP expression was localized in vivo by fluorescent microscopy and fluorescent laparoscopy.

RESULTS

NV1066 effectively replicated within and killed BE3 cells in vitro and in vivo. EGFP expression identified infected tumor cells. After NV1066 treatment in vivo, EGFP expression localized to the tumor. In an intraperitoneal tumor model, EGFP could be visualized endoscopically using a laparoscope with a fluorescent filter.

CONCLUSIONS

NV1066 has oncolytic activity against the BE3 cell line and may be a useful therapy against esophageal cancer. EGFP expression localizes the virus and may help to identify tumor deposits in vivo. Oncolytic activity with NV1066 against gastrointestinal cancers may potentially be tracked by endoscopy.

[Surgery for oesophageal cancer: current controversies]

Any attempt to define the present role of surgery in the treatment of oesophageal cancer should integrate the dramatic changes that occurred within this disease over the last 2 decades: major shift in the histologic type of tumours, improved staging methods, spectacular reduction of operative risks, standardization of oncologic principles focusing on the completeness of resection, and development of multimodality therapeutic strategies. Surgery has still a pivotal role. Esophagectomy should be performed by trained surgeons in high-volume institutions. Radical surgery with en-bloc resection and 2 fields lymphadenectomy, should be encouraged in low-risk patients with subcarinal tumors. Although multimodality treatment strategy is commonly applied for locally advanced disease, few data support its superiority over surgical resection alone, followed by adjuvant therapy when appropriate. One may thus hypothesize that the risk/benefit ratio of such strategies is probably optimal in case of early stage tumors, and future studies may further clarify this issue. Conversely, locally advanced tumors, particularly those located in the upper mediastinum and the neck, may be managed alternatively without surgery. However, surgery remains an important tool to ensure optimal palliation of dysphagia, to achieve local control, and finally to improve quality of life. In that way, video-assisted techniques and/or trans hiatal approaches aiming to minimize the surgical insult may have a place in the treatment of patients who have substantially responded to induction therapy. Tumors located close to the pharyngo-oesophageal junction are best managed with chemotherapy and radiotherapy. Finally, salvage surgery may be considered in highly selected patients in case of non-response or local relapse without distant metastases.

Factors predictive of complete resection of operable esophageal cancer: a prospective study

BACKGROUND

Esophagectomy remains a standard treatment for patients with resectable esophageal cancer, but the 5-year survival is only 20% to 25%. After complete resection survival is significantly longer than after incomplete resection with microscopic or macroscopic penetration. The purpose of this study was to prospectively identify the factors predictive of complete resection of operable esophageal cancers.

METHODS

Betwen January 1995 and January 2002, 372 patients with esophageal cancer underwent surgery with curative intent. Complete resection was performed in 304 patients (81.7%), incomplete resection with microscopic penetration in 28 (7.5%), and incomplete resection with macroscopic penetration in 40 (10.8%). Univariate and multivariate analysis included 16 preoperative and operative factors.

RESULTS

Factors predictive of complete resection were absence of any modification of the esophageal axis on the barium swallow (p = 0.019) and a partial or complete response to preoperative radiochemotherapy (p = 0.042). Three groups of patients were identified: group 1 had no deviation of the axis on the barium swallow (n = 253); group 2 had deviation of the axis on the barium swallow and partial or complete response to radiochemotherapy (n = 66); and group 3 had deviation of the axis on the barium swallow and no response to radiochemotherapy or no preoperative treatment (n = 53). Rates of complete resection were 90.1%, 74.2%, and 50.9%, and 5-year actuarial survivals were 46%, 37%, and 0%, respectively (p < 0.001).

CONCLUSIONS

Complete resection of esophageal cancer is predictable. Deviation axis on the barium swallow and morphologic response to neoadjuvant radiochemotherapy are variables available for all patients at onset of therapeutic management.

Accuracy of esophagoscopy performed by a non-physician endoscopist with a 4-mm diameter battery-powered endoscope

BACKGROUND

A cost-effective technique is needed for screening of a broad population at risk for esophageal cancer. A solution would be to have non-physician endoscopists perform esophagoscopy with small-caliber battery-powered endoscopes.

METHODS

In a prospective blinded study, the diagnostic accuracy of sedated esophagoscopy performed by a trained nurse practitioner with a battery-powered 4-mm diameter endoscope was compared with that for a sedated standard video-endoscopy performed by a gastroenterologist. Patients were recruited to undergo peroral esophagoscopy by the nurse practitioner followed by sedated standard endoscopy by the supervising gastroenterologist, each blinded to the findings of the other. Major esophageal findings of nurse practitioner and gastroenterologist were compared.

RESULTS

Findings in 40 patients were analyzed. In 4 patients both endoscopists could not assess the presence or absence of columnar-lined esophagus because of severe erosive esophagitis (n = 3) or severe candida-esophagitis (n = 1). By using sedated standard endoscopy as the standard, on a per finding basis, esophagoscopy by the nurse practitioner had a sensitivity for columnar-lined esophagus of 89%: 95% CI [75%, 97%] and specificity of 96%: 95% CI [84%, 99%]. The missed columnar epithelium was a 3 x 3-mm island. For all lesions, the sensitivity of endoscopy performed by the nurse practitioner with the battery-powered endoscope was 75%: 95% CI [67%, 82%] and specificity 98%: 95% CI [96%, 99%]. The nurse practitioner missed all of 4 rings (3 considered clinically irrelevant).

CONCLUSION

Esophagoscopy with a battery-powered 4-mm diameter endoscope by a non-physician endoscopist is feasible and accurate in detecting esophageal pathologies. It may be an efficient screening method for the detection of columnar-lined esophagus. There was a distinct underestimate of the presence of esophageal rings.