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

Postoperative complications and symptoms of anxiety and depression in patients with gastric and esophageal cancer: a retrospective cohort study

CONTEXT

Gastric and oesophageal cancers are common. They are also expected to increase in incidence in the next few years and are characterized by poor prognosis. Surprisingly, whereas the incidence of severe anxiety and depression is high in patients with gastric and oesophageal cancers, the influence of symptoms of depression and anxiety on postoperative complications has barely been explored.

METHODS

In a retrospective study based on a prospectively collected database, 629 cancer patients were enrolled. Symptoms of depression and anxiety (Hospital Anxiety and Depression Scale scores) and sociodemographic and medical information were collected immediately after diagnosis and before any treatment. The surgical approach (i.e. gastrectomy or oesophagectomy) and postoperative complications according to the Clavien-Dindo classification were collected after surgery.

RESULTS

After controlling for known medical predictors (i.e. surgical strategy, alcohol and tobacco consumption, American Society of Anaesthesiologists classification physical status score) of postoperative complications, no effect of symptoms of depression or anxiety was detected.

DISCUSSION

The observed results are surprising given the literature. However, several potential arguments can be put forwards regarding methods and measures, controlling variables, and conceptual distinctions. Despite the absence of significant results, this topic should be more deeply investigated by applying methodological and conceptual adjustments.

Impact of primary endoscopic resection on oncological outcomes after esophagectomy for cancer: a retrospective propensity score-based cohort study

BACKGROUND

Esophageal cancer posed significant global health challenges, particularly due to poor survival rates, especially in advanced stages. Primary endoscopic resection had emerged as an alternative treatment for early esophageal cancer, aiming to preserve organ function and reduce surgical morbidity.

METHODS

This retrospective multicenter cohort study included 334 patients with early esophageal cancer (T1a-b, N0) from 30 French-speaking European centers between 2000 and 2010. Patients underwent either primary endoscopic resection followed by esophagectomy (E group, n = 36) or esophagectomy alone (S group, n = 298). Cox proportional hazards models adjusted for TNM stage and propensity score weighting were used to assess the impact of primary endoscopic resection on recurrence-free survival (RFS), overall survival (OS), and postoperative complications.

RESULTS

Primary endoscopic resection did not significantly influence RFS (adjusted HR 0.92, 95% CI 0.31 to 2.68, p = 0.88) or OS (adjusted HR 1.06, 95% CI 0.35 to 3.13, p = 0.92) compared to esophagectomy alone. Initial higher thromboembolic complications in the endoscopic resection group were not significant after adjustment (adjusted OR 4.73, 95% CI 0.34 to 64.27, p = 0.24).

CONCLUSIONS

Primary endoscopic resection followed by esophagectomy for early esophageal cancer did not alter oncological outcomes or overall survival in this retrospective cohort. These findings supported the role of primary endoscopic resection as a safe initial treatment strategy, warranting validation in larger prospective studies.

REGISTRATION

Our study was registered retrospectively on the Clinicaltrials.com website under the identifier NCT01927016. We acknowledge the importance of prospective registration and regret that this was not done before the commencement of the study.

LPCAT1 reprogramming cholesterol metabolism promotes the progression of esophageal squamous cell carcinoma

Tumor cells require high levels of cholesterol for membrane biogenesis for rapid proliferation during development. Beyond the acquired cholesterol from low-density lipoprotein (LDL) taken up from circulation, tumor cells can also biosynthesize cholesterol. The molecular mechanism underlying cholesterol anabolism in esophageal squamous cell carcinoma (ESCC) and its effect on patient prognosis are unclear. Dysregulation of lipid metabolism is common in cancer. Lysophosphatidylcholine acyltransferase 1 (LPCAT1) has been implicated in various cancer types; however, its role in esophageal squamous cell carcinoma (ESCC) remains unclear. In this study, we identified that LPCAT1 is highly expressed in ESCC and that LPCAT1 reprograms cholesterol metabolism in ESCC. LPCAT1 expression was negatively correlated with patient prognosis. Cholesterol synthesis in ESCC cells was significantly inhibited following LPCAT1 knockdown; cell proliferation, invasion, and migration were significantly reduced, along with the growth of xenograft subcutaneous tumors. LPCAT1 could regulate the expression of the cholesterol synthesis enzyme, SQLE, by promoting the activation of PI3K, thereby regulating the entry of SP1/SREBPF2 into the nucleus. LPCAT1 also activates EGFR leading to the downregulation of INSIG-1 expression, facilitating the entry of SREBP-1 into the nucleus to promote cholesterol synthesis. Taken together, LPCAT1 reprograms tumor cell cholesterol metabolism in ESCC and can be used as a potential treatment target against ESCC.

The Role of Adjuvant Therapy in Patients With Margin-Positive (R1) Esophagectomy: A National Analysis

BACKGROUND

We performed a nationwide analysis to assess the impact of adjuvant therapy on survival after a microscopically margin-positive (R1) resection for esophageal cancer.

METHODS

The National Cancer Database was used to identify patients with R1 resection for esophageal cancer (2004-2015). Patients were grouped by type of adjuvant therapy. Patients who had other margin status, M1 disease, neoadjuvant chemotherapy and radiation, missing survival, and no or unknown treatment were excluded. The primary outcome was overall survival. A 1:1 propensity score-matched sensitivity analysis was also performed comparing patients who received no adjuvant therapy with those who received adjuvant chemoradiation.

RESULTS

Of 546 patients, 279 (51%) received adjuvant therapy and 267 (49%) did not. Patients receiving adjuvant therapy were more likely to be younger, have more advanced pathologic stage, have nonsquamous histology, and have shorter hospitalization. In multivariable analysis, adjuvant chemotherapy, radiation, and chemoradiation were all associated with improved survival compared with no adjuvant therapy. In a propensity score-matched analysis of 123 patient pairs, adjuvant chemoradiation was associated with improved survival compared with no adjuvant therapy (adjusted HR: 0.30; 95% CI: [0.22, 0.40]).

CONCLUSIONS

Adjuvant therapy is associated with improved survival compared with no adjuvant therapy in patients with R1 resection for esophageal cancer even after adjustment for pathologic stage. Adjuvant therapy should be considered in patients with incompletely resected esophageal cancer in concordance with national guidelines.

circGSK3β promotes metastasis in esophageal squamous cell carcinoma by augmenting β-catenin signaling

Background

Circular RNAs (circRNAs), a novel class of noncoding RNAs, have recently drawn much attention in the pathogenesis of human cancers. However, the role of circRNAs in esophageal squamous cell carcinoma (ESCC) remains unclear. In this study, we aimed to identify novel circRNAs that regulate ESCC progression and explored their regulatory mechanisms and clinical significance in ESCC.

Methods

Differentially expressed circRNAs between ESCC and paired adjacent normal tissues were identified using microarrays. The effects of a specific differentially expressed circRNA (circGSK3β) on tumor progression were explored in vitro and in vivo. Plasma samples from patients with ESCC, benign lesions and healthy controls were subjected to droplet digital PCR (ddPCR) analyses for circGSK3β, and the detection rates of plasma circGSK3β for ESCC were investigated.

Results

We demonstrated that upregulated expression of circGSK3β was positively associated with advanced clinical stage and poor outcome in patients with ESCC. We further revealed that circGSK3β promoted ESCC cell migration and invasion via direct interaction with GSK3β and inhibiting GSK3β activity, providing a novel mechanism of circRNA in cancer progression. Importantly, we identified that circGSK3β expression in plasma was a biomarker for detection of ESCC and early stage of ESCC with the area under curve (AUC) of 0.782 and 0.793, respectively.

Conclusions

CircGSK3β exerts critical roles in promoting ESCC metastasis and may serve as a novel therapeutic target for ESCC patients. The plasma level of circGSK3β have potential to serve as a novel diagnostic and prognostic biomarker for ESCC detection.

Neoadjuvant chemotherapy with irinotecan and nedaplatin in a single cycle followed by esophagectomy on cT4 resectable esophageal squamous cell carcinoma: a prospective nonrandomized trial for short-term outcomes

Neoadjuvant chemotherapy (NAC) significantly extends survival in advanced esophageal squamous cell carcinoma (ESCC), but the short-term outcomes for cT4 ESCC remain controversial. Many NAC regimens have been previously reported, although no study has reported a regimen of irinotecan and nedaplatin for cT4 potential resectable ESCC. We evaluated the short-term outcomes of NAC with irinotecan and nedaplatin in a single cycle followed by esophagectomy on cT4 resectable ESCC. A total of 51 patients with cT4 potentially resectable ESCC were eligible for this study. Twenty of these patients underwent NAC, and the other 31 patients underwent surgery alone. The toxicities and response of NAC were evaluated. The clinicopathologic characteristics, responses, toxicities, surgical outcomes, postoperative complications, and survival time between the two groups were analyzed. No significant differences were found in clinicopathologic characteristics between the groups (P > 0.05). The response rate of NAC was 75% (15/20). The differences in the long-axis diameter of the tumor and cT stage between pre- and post-NAC were significant (P < 0.05). Twenty-four toxic events occurred in 11 patients of the NAC group, and 20/24 of these were mild. The R0 resection rates in the NAC group and the surgery alone group were 85% and 64.5%, with no statistically significant difference (P > 0.05). Differences in the pathological T stage and pathological tumor-node-metastasis (TNM) stage were significant (P < 0.05). The overall survival (OS) time and mortality in the NAC group versus the surgery alone group were 31.57 ± 3.06 months versus 15.24 ± 1.46 months and 25% versus 61.3%, respectively. The differences in OS and mortality were significant (P < 0.05). The NAC group and R0 resection were significant and independent predictors of positive prognosis. NAC with irinotecan and nedaplatin in a single cycle followed by esophagectomy on cT4 resectable ESCC as a new NAC is safe and effective.

Neoadjuvant chemotherapy versus neoadjuvant chemoradiotherapy for cancer of the esophagus or the gastroesophageal junction: A meta-analysis based on clinical trials

Background

The benefit of neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy for treating cancer of the esophagus or the gastroesophageal junction remains controversial. In the present study, we conducted a comprehensive meta-analysis to examine the efficacy of these two management strategies.

Methods

The MEDLINE (PubMed), SinoMed, Embase, and Cochrane Library databases were searched for eligible studies. We searched for the most relevant studies published until the end of September 2017. Data were extracted independently and were analyzed using RevMan statistical software version 5.3 (Cochrane Collaboration, http://tech.cochrane.org/revman/download). Weighted mean differences, risk ratios (RRs), and 95% confidence intervals (CIs) were calculated. Cochrane Collaboration’s risk of bias tool was used to assess the risk of bias. In this comprehensive meta-analysis, we examined the efficiency of neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy for the treatment of cancer of the esophagus or the gastroesophageal junction as reported in qualified clinical trials.

Results

Six qualified articles that included a total of 866 patients were identified. The meta-analysis showed that for 3-year and 5-year survival rates in primary outcomes, the results favored neoadjuvant chemoradiotherapy strategies compared with neoadjuvant chemotherapy (RR = 0.78, 95% CI = 0.62–0.98, P = 0.03; RR = 0.69, 95% CI = 0.50–0.96, P = 0.03, respectively). In terms of secondary outcomes, neoadjuvant chemoradiotherapy significantly increased the rate of R0 resection and pathological complete response as well (RR = 0.87, 95% CI = 0.81–0.92, P < 0.0001; RR = 0.16, 95% CI = 0.09–0.28, P < 0.00001, respectively). However, there were no significant differences in postoperative mortality between the two groups (RR = 1.85, 95% CI = 0.93–3.65, P = 0.08). For the results of postoperative complications, revealed that there was a statistically significant difference between the two groups in the incidence of postoperative complications such as pulmonary, anastomotic leak and cardiovascular complications. The subgroup analysis of patients with esophageal adenocarcinoma or squamous cell carcinoma showed that both esophageal adenocarcinoma and squamous cell carcinoma patients achieved a high rate of R0 resection (RR = 0.85, 95% CI = 0.77–0.93, P = 0.0006; RR = 0.88, 95% CI = 0.81–0.96, P = 0.005, respectively) and pathological complete response benefit of neoadjuvant chemoradiotherapy (RR = 0.23, 95% CI = 0.09–0.57, P = 0.001; RR = 0.18, 95% CI = 0.03–0.96, P = 0.05, respectively).

Conclusion

Our findings suggested that compared with neoadjuvant chemotherapy, neoadjuvant chemoradiotherapy should be recommended with a significant long-term survival benefit in patients with cancer of the esophagus or the gastroesophageal junction. In view of the clinical heterogeneity, whether these conclusions are broadly applicable should be further determined.

Barium upper GI series in adults: a surgeon's perspective

Barium upper GI series performed by an interested and competent radiologist is still a very useful study to evaluate a variety of esophagogastric disorders. It usually provides information complementary to upper endoscopy and other foregut studies. Barium upper GI series is an important part of the diagnostic workup for gastroesophageal reflux disease, hiatal hernia, and esophageal motility disorders including achalasia. It is also an important part of the follow-up after operation for these common problems and after other operations such as resection or bariatric surgery. The GI radiologist should be an important member of the foregut surgery team.

Plasma microRNA-19a as a potential biomarker for esophageal squamous cell carcinoma diagnosis and prognosis

AIM

To investigate whether plasma miR-19a can serve as a biomarker for esophageal squamous cell carcinoma (ESCC) diagnosis and prognosis.

MATERIALS & METHODS

Plasma samples from 89 ESCC, 45 benign lesion patients and 80 healthy controls were subjected to RT-qPCR analyses for miR-19a. In addition, plasma samples from 30 patients were collected before and after surgery for the same analyses.

RESULTS

Plasma miR-19a was significantly increased in ESCC patients compared with healthy controls. The sensitivity of miR-19a for early stages of ESCC was 68.09%. Combination of miR-19a and cytokeratin 19 fragment 21-1 (Cyfra21-1) further improved the sensitivity to 78.70%. Moreover, plasma miR-19a level was decreased in patients after surgery.

CONCLUSION

Plasma miR-19a may serve as a potential biomarker that complements Cyfra21-1 in detecting early stages of ESCC.

Postoperative radiation in esophageal squamous cell carcinoma and target volume delineation

Esophageal cancer is the sixth leading cause of cancer death worldwide, and patients who are treated with surgery alone, without neoadjuvant therapies, experience frequent relapses. Whether postoperative therapies could reduce the recurrence or improve overall survival is still controversial for these patients. The purpose of our review is to figure out the value of postoperative adjuvant therapy and address the disputes about target volume delineation according to published data. Based on the evidence of increased morbidity and disadvantages on patient survival caused by postoperative chemotherapy or radiotherapy (RT) alone provided by studies in the early 1990s, the use of postoperative adjuvant therapies in cases of esophageal squamous cell carcinoma has diminished substantially and has been replaced gradually by neoadjuvant chemoradiation. With advances in surgery and RT, accumulating evidence has recently rekindled interest in the delivery of postoperative RT or chemoradiotherapy in patients with stage T3/T4 or N1 (lymph node positive) carcinomas after radical surgery. However, due to complications with the standard radiation field, a nonconforming modified field has been adopted in most studies. Therefore, we analyze different field applications and provide suggestions on the optimization of the radiation field based on the major sites of relapse and the surgical non-clearance area. For upper and middle thoracic esophageal carcinomas, the bilateral supraclavicular and superior mediastinal areas remain common sites of recurrence and should be encompassed within the clinical target volume. In contrast, a consensus has yet to be reached regarding lower thoracic esophageal carcinomas; the “standard” clinical target volume is still recommended. Further studies of larger sample sizes should focus on different recurrence patterns, categorized by tumor locations, refined classifications, and differing molecular biology, to provide more information on the delineation of target volumes.

A multicenter phase II study of induction chemotherapy with FOLFOX-4 and cetuximab followed by radiation and cetuximab in locally advanced oesophageal cancer

Background:

Preoperative chemoradiotherapy (CRT) improves the survival of patients with oesophageal cancer when compared with surgery alone.

Methods:

We conducted a phase II, multicenter trial of FOLFOX-4 and cetuximab in patients with locally advanced oesophageal cancer (LAEC) followed by daily radiotherapy (180 cGy fractions to 5040 cGy) with concurrent weekly cetuximab. Cytokines levels potentially related to cetuximab efficacy were assessed using multiplex-bead assays and enzyme-linked immunosorbent assay at baseline, at week 8 and at week 17. Primary end point was complete pathological response rate (pCR).

Results:

In all, 41 patients were enroled. Among 30 patients who underwent surgery, a pCR was observed in 8 patients corresponding to a rate of 27%. The most frequent grade 3/4 toxicity was skin (30%) and neutropenia (30%). The 36-month survival rates were 85 and 52% in patients with pathological CR or PR vs 38 and 33% in patients with SD or PD.

Conclusions:

Incorporating cetuximab into a preoperative regimen for LAEC is feasible; no correlation between cytokines changes and patient outcome was observed. Positron emission tomography/computed tomography study even if influenced by the small number of patients appears to be able to predict patients outcome both as early and late metabolic response.

Effects of neoadjuvant radiochemotherapy on pathological staging and prognosis for locally advanced esophageal squamous cell carcinoma

The role of neoadjuvant therapy in the treatment of locally advanced esophageal carcinoma still remains controversial. The aim of this study was to evaluate the effects of neoadjuvant radiochemotherapy on pathological staging and prognosis in the patients with locally advanced esophageal squamous cell carcinoma. Between January 1991 and December 2000, 473 patients with advanced esophageal carcinoma diagnosed by endoscopic biopsy underwent surgical resection in our center. With informed consent, they were randomized into four groups: neoadjuvant chemotherapy, neoadjuvant radiotherapy, neoadjuvant radiochemotherapy, and surgery alone (control group). The preoperative computed tomography staging criteria were the following: Stage I, the tumor limited to the esophageal lumen or the thickness of the esophageal wall varied between 3-5 mm; Stage II, the thickness exceeds 5 mm but no invasion to the mediastinum or distant metastasis; Stage III, the tumor invades adjacent mediastinal structure; and Stage IV, there is distant metastasis. The tumor resection rate, pathological stage, treatment-related complication, and survival among groups were compared. The radical resection rate for the patients in radiotherapy and radiochemotherapy groups was increased in comparison with the control group (P < 0.05). Their pathological stage after esophagectomy was regressed significantly than that of the control group (50.85%, 55.08% vs. 0%, P < 0.05). The adjuvant chemotherapy group did show significant improvement on resection rate and pathological staging compared with the control group. The treatment-related complication in the three neoadjuvant groups had no significant difference from that of the control group (P > 0.05). The 3-year survival rate of radiotherapy and radiochemotherapy groups were significantly higher than that of the control group (69.49%, 73.73% vs. 53.38%, P < 0.05). The 5-year survival rate of radiochemotherapy group was higher than that of the radiotherapy group although did not show a statistical difference (P > 0.05). Rational application of neoadjuvant radiochemotherapy seems to provide a modest benefit in radical resection and survival in patients with locally advanced esophageal carcinoma.

Neoadjuvant continuous infusion of weekly 5-fluorouracil and escalating doses of oxaliplatin plus concurrent radiation in locally advanced oesophageal squamous cell carcinoma: results of a phase I/II trial

Oxaliplatin and 5-fluorouracil have a significant activity in locally advanced oesophageal squamous cell cancer (OSCC). However, their optimal dosage and efficacy when combined with concurrent radiotherapy as neoadjuvant treatment are unknown. This non-randomised, phase I/II study aimed to define the maximum tolerated dose (MTD) and assessed the histopathological tumour response rate to neoadjuvant oxaliplatin in weekly escalating doses (40, 45, 50 mg m⁻²) and continuous infusional 5-fluorouracil (CI-5FU; 225 mg m⁻²) plus concurrent radiotherapy. Patients had resectable OSCC. Resection was scheduled for 4–6 weeks after chemoradiotherapy. During phase I (dose escalation; n=19), weekly oxaliplatin 45 mg m⁻² plus CI-5FU 225 mg m⁻² was established as the MTD and was the recommended dosage for phase II. Oesophageal mucositis was the dose-limiting toxicity at higher doses. During phase II, histopathological responses (<10% residual tumour cells within the specimen) were observed in 10 of 16 patients (63%; 95% confidence interval: 39–82%). Overall, 16 of the 25 patients (64%) who underwent resection had a histopathological response; tumour-free resection (R0) was achieved in 80%. Neoadjuvant weekly oxaliplatin 45 mg m⁻² plus CI-5FU 225 mg m⁻² with concurrent radiotherapy provides promising histological response rates and R0 resection rates in locally advanced OSCC.

The utility of FDG-PET in the preoperative staging of esophageal cancer

Accurate staging of esophageal cancer is important when determining which patients will potentially benefit from curative surgery. The aim of this study was to evaluate the incremental effect of 2-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) when used in addition to standard staging modalities. Patients referred to two surgeons in an Australian metropolitan teaching hospital with esophageal or esophago-gastric junction malignancy between May 2002 and December 2006 were included. Patients who had undergone prereferral treatment with chemotherapy or radiotherapy were excluded. Patients undergoing resection for gastrointestinal stromal tumors or high-grade dysplasia within Barrett's esophagus were also excluded. Clinical and non-clinical data were recorded prospectively. Pretreatment staging included routine CT scan and selective endoscopic ultrasound (EUS). FDG-PET was performed in patients judged to have curable disease on CT scanning and EUS. From a total of 130 eligible patients, 76 were judged to have curable disease on the basis of CT and EUS findings. Of these 76 patients, 19 (25%) were excluded from surgery due to additional information obtained from FDG-PET. The addition of FDG-PET to routine preoperative staging resulted in the exclusion from surgery of 19 (25%) patients who prior to the introduction of FDG-PET would have undergone attempted resection. FDG-PET should be performed in all patients under consideration for esophagogastric resection in order to avoid resection in patients with disseminated disease.

Patients with Locally Advanced Esophageal Carcinoma Nonresponder to Radiochemotherapy: Who Will Benefit From Surgery?

BACKGROUND

In patients who are nonresponders to primary radiochemotherapy (RCT), prognosis is poor, leading mostly to palliation. Salvage surgery may have a survival benefit otherwise complete. Our aim was to identify predictors of R0 resection in these patients.

METHODS

In 98 nonresponders with locally advanced infracarinal tumors, curative salvage surgery was attempted. Resection was R0 in 62.2% and incomplete in 37.8% of cases. Univariate and multivariate analyses included pre-RCT and post-RCT variables collected prospectively.

RESULTS

Overall survival was higher in the R0 resection group (18.4 vs 8.6 months, P < .001). Independent predictors of R0 resection were tumor height <or= 5 cm on barium swallow (P = .045) and aortic contact <or= 90 degrees on computed tomography (P = .039) evaluated after RCT. Three groups of patients were constructed: 1, tumor height <or= 5 cm with aortic contact <or= 90 degrees (n = 43); 2, tumor height between 6 and 10 cm with aortic contact <or= 90 degrees (n = 32); and 3, aortic contact > 90 degrees , irrespective of tumor height (n = 23). Rates of R0 resection were 81%, 53%, and 39%, respectively (P = .001).

CONCLUSION

Salvage esophagectomy should be systematically attempted in nonresponders with tumor height <or= 5 cm on barium swallow and aortic contact <or= 90 degrees on computed tomography and discussed case by case for other patients.

Prise en charge thérapeutique du cancer de l'œsophage

The prognosis for esophageal cancer remains grim despite recent progress in diagnosis and treatment. Surgery is the standard treatment for stages I and II (only). Neoadjuvant chemotherapy or combined radiation and chemotherapy may be considered for stages IIb and III. Palliative surgery is no longer considered useful. Neoadjuvant or adjuvant radiation treatment does not improve survival. Adjuvant chemotherapy does not improve survival, and the benefits of its neoadjuvant use remain controversial in view of the discordant results. There is strong evidence that a neoadjuvant combination of radiation and chemotherapy improves resection and survival rates compared with surgery alone, but definitive proof is not currently available. Combined radiation and chemotherapy may be considered for locally advanced tumors in responding patients, with curative salvage surgery if the tumor persists. For patients whose tumor is inoperable, a combination of radiation and chemotherapy is the standard treatment.

Symptomatic Responses to Neoadjuvant Chemotherapy for Carcinoma of the Oesophagus and Oesophagogastric Junction: Are They Worth Measuring?

AIMS

Neoadjuvant chemotherapy is used to downstage locally advanced oesophagogastric cancer. This study assessed whether changes in dysphagia and weight correlated with radiological and pathological assessment of response and surgical decision-making.

MATERIALS AND METHODS

All patients with locally advanced carcinoma of the lower oesophagus or oesophagogastric junction treated with neoadjuvant ECF (epirubicin, cisplatin, and 5-fluorouracil) chemotherapy from January 2000 to January 2003 were included in this study. Patients were considered to be operable depending upon their chemotherapy response. Weight and swallowing were assessed before and after chemotherapy. Statistical analysis was carried out using ANOVA, unpaired t test and Fisher's exact test.

RESULTS

Seventy-eight patients (male-female ratio: 6.8: 1; median age: 62.2 years; range: 44.1-78.0 years) underwent a median of three cycles (range: 1-7) of neoadjuvant ECF chemotherapy. Forty patients (51%) gained weight, and swallowing improved in 53 patients (68%). Radiological changes (based on computed tomography) were assessed according to WHO criteria: complete response (5%), partial response (27%), stable disease (46%) and progressive disease (15%). Patients whose swallowing improved gained significantly more weight (P < 0.0001). Swallowing (P = 0.0009) was significantly improved in radiological responders but not weight (P = 0.06); when radiological non-responders were separated into stable and progressive disease, patients with progressive disease were identified as failing to gain weight (P = 0.005). Both swallowing (P < 0.0001) and weight gain (P < 0.0001) were better in patients undergoing surgery. The use of changes of weight (P = 0.42) and swallowing (P = 0.61) failed to separate pathological responders from nonresponders in the subset of patients undergoing surgery.

CONCLUSIONS

Weight gain and improved swallowing are good but not absolute indicators of radiological response to chemotherapy and patient selection for surgery. However, changes in these variables are not sufficiently sensitive to identify pathological responders from non-responders.

Factors affecting postoperative course and survival after en bloc resection for esophageal carcinoma

BACKGROUND

To identify factors affecting postoperative course and survival after esophagectomy for cancer and reasons for improved survival over time.

METHODS

Complete esophageal resection was attempted for middle and lower third esophageal carcinomas in 386 consecutive patients between January 1982 and January 2002. Two study periods were analyzed: 1982 to 1993 and 1994 to 2002. Prognostic factors were identified by multivariate analysis and the two periods compared.

RESULTS

Hospital mortality rate decreased from 5.4% to 2.9% (p = 0.245). Both anastomotic leakage and pulmonary complications rates decreased from 9.8% to 2.2% (p = 0.001) and 24.1% to 19.3% (p = 0.295), respectively. An increased proportion of patients had R0 resection in the latter period, 78.5% versus 67.0%, (p = 0.028). Five-year survival rate after R0 resection increased from 29% to 46% (p = 0.001), with a decreased recurrence rate from 65.8% to 44.3% (p = 0.002). Three favorable prognostic factors were identified: low pT stage, pN0 stage, and operation during the 1994 to 2002 study period.

CONCLUSIONS

Short-term outcome and survival of patients with resected esophageal cancer have improved over time. Advances in perioperative technique, staging methods, and surgical management combined with higher patient selection and use of neoadjuvant chemoradiation may be responsible for this progress.

Complete response to neoadjuvant chemoradiotherapy in esophageal carcinoma is associated with significantly improved survival

PURPOSE

Attempts to improve survival of patients with esophageal cancer have been made using induction chemoradiotherapy (CRT) followed by surgery. A large single-center experience was reviewed to determine which treatment-related variables could predict survival and recurrence.

PATIENTS AND METHODS

All patients undergoing esophagectomy between January 1994 and December 2002 were reviewed. Univariate and multivariate analyses were performed using log-rank and Cox proportional hazards models, and survival curves were estimated using the Kaplan-Meier method.

RESULTS

Of 171 patients with invasive cancer, 131 (77%) underwent preoperative CRT. The average age was 60 years, and most patients were male (85%). Operations performed included Ivor-Lewis (60%), transhiatal (8%), three-hole (23%), or left thoracoabdominal (8%) esophagectomy. Perioperative mortality rate was 5%. Median overall survival (OS) of the entire group was 33 months, and the 5-year OS rate was 26%. Induction CRT was associated with a 33% 5-year survival rate compared with 11% for surgery alone (P = .43). Patients downstaged to pathologic stage 0 or I had an improved OS and disease-free survival (DFS) compared with those patients who were not downstaged (P = .022). Additionally, the ability to perform an R0 resection was a significant factor for OS and DFS (n = 130; P < .0001 and P <.0002, respectively).

CONCLUSION

Response to CRT and the ability to perform an R0 resection are associated with significantly improved survival in patients with esophageal carcinoma.

Diagnostic radiology and nuclear medicine

The diagnosis and accurate staging of esophageal adenocarcinoma remains one of the greatest challenges for non-invasive imaging techniques. All modalities have limitations and require a rational application of combined tools in order to assess the extent of loco-regional tumor and distant metastatic disease. The fundamental role remains defining organ-confined disease and mapping non-organ confined disease. Endoscopic ultrasound combined with multislice computed tomography (CT) is the mainstay of morphologic loco-regional staging. In recent years, functional metabolic 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET) has emerged as a particularly useful adjunct to detect occult metastatic disease, to predict response to neoadjuvant therapy and to document recurrent disease. The current imaging algorithm and new developments in imaging assessment will be reviewed.

Neoadjuvant chemoradiotherapy for esophageal carcinoma

SUMMARY. Neoadjuvant chemoradiotherapy is often administered to patients with esophageal carcinoma in the belief that this will improve survival. However, its role in the management of esophageal carcinoma remains controversial. In this study we evaluated our experience with neoadjuvant chemoradiotherapy for the treatment of esophageal carcinoma. The study group was 115 patients who underwent esophagectomies between January 1999 and January 2004. Eighty-nine patients had adenocarcinoma and 26 had squamous cell carcinoma. Fifty-six patients underwent neoadjuvant chemoradiotherapy (two cycles of cisplatin and 5-fluorouracil with 45 Gy radiation) followed by esophagectomy. The other 59 patients proceeded directly to esophagectomy. Outcomes were determined prospectively, and follow-up was available for all patients. Neoadjuvant chemoradiotherapy achieved down-staging of the esophageal cancer in 43%, 43% and 46% of patients, according to T, N and TNM classifications, respectively. Neoadjuvant chemoradiotherapy resulted in a complete pathological response in seven (13%) patients. The surgical morbidity rate was 37% (42/115), and in-hospital mortality was 5% (6/115). There were no differences between patients who did and did not undergo neoadjuvant chemoradiotherapy in regard to completeness of resection, perioperative mortality and postoperative morbidity. Four-year survival was 33% following neoadjuvant chemoradiotherapy, compared with 19% for patients undergoing surgery alone. The administration of neoadjuvant chemoradiotherapy in patients with esophageal carcinoma down-staged nearly 50% of tumors, and a complete pathological response occurred in some of these patients. It was not associated with any increase in postoperative morbidity or perioperative mortality. In this non-randomized study, it was also associated with a trend towards a better survival outcome.