Endoscopic ultrasound in restaging of esophageal cancer after neoadjuvant chemoradiation

Prospective evaluation of MR-TRG (Tumor Regression Grade) in esophageal cancer after neo-adjuvant therapy: Preliminary results

PURPOSE

To develop MRI-based criteria to assess tumor response to neoadjuvant therapies (NAT) of esophageal cancers (EC) and to evaluate its diagnostic performance in predicting the pathological Tumor Regression Grade (pTRG).

METHOD

From 2018 to 2022, patients with newly diagnosed locally advanced EC underwent MRI examinations for initial staging and restaging after NAT. Magnetic Resonance TRG (MR-TRG), equivalent to the Mandard and Becker classifications, were developed and independently assessed by two radiologists, blinded to pTRG, using T2W and DW-MR Images. All patients underwent surgery and benefited from a blinded pTRG evaluation by two pathologists. The agreement between readers and between MR-TRG and pTRG were assessed with Cohen's Kappa. The correlation of MR-TRG and pTRG was determined using Spearman's correlation.

RESULTS

28 patients were included. Interrater agreement was substantial between radiologists, improved when grouping grade 1 and 2 (κ = 0.78 rose to 0,84 for Mandard and 0.68 to 0,78 for Becker score). Agreement between pTRG and MR-TRG was moderate with a percentaged agreement (p) = 87.5 %, kappa (κ) = 0.54 and p = 83.3 %, κ = 0.49 for Mandard and Becker, respectively. Agreement was improved to substantial when grouping grades 1-2 for Mandard and 1a-1b for Becker with p = 89.3 %, κ = 0.65 and p = 85.2 %, κ = 0.65 respectively. Sensitivity and specificity of MR-TRG in predicting pTRG were 88.2 % and 72.7 % for Mandard system (scores 1-2 versus 3-5), and 83.3 % and 80 % for Becker system (scores 1a-1b versus 2-3).

CONCLUSION

A substantial agreement between MR-TRG and pTRG was achieved when grouping grade 1-2. Hence, MR-TRG could be used as a surrogate of complete and near-complete pTRG.

Endoscopic Ultrasound in Cancer Staging

The authors review the role of endoscopic ultrasound (EUS) in the staging of cancers throughout the gastrointestinal tract. EUS offers an advantage over cross-sectional imaging in locoregional tumor staging but is less sensitive in identifying distant metastasis. The addition of FNA increases diagnostic accuracy and provides a tissue diagnosis. EUS combined with cross-sectional imaging is important in accurately staging GI tumors and thereby reducing unnecessary procedures and health care costs.

Difference in Computed Tomography Image Quality between Central Vein and Peripheral Vein Enhancement in Treatment Naive Esophageal Cancer Patients

Simple Summary

A chest CT via central vein enhancement not only eliminates peripheral vein regurgitation but also provides better image quality that facilitates precise clinical staging. A chest CT via central vein enhancement may be considered after tissue proof in order to better discriminate disease severity.

Abstract

The differences in chest computed tomography (CT) image quality may affect the tumor stage. The aim of this study was to compare the image quality and accuracy of chest CT via central vein and peripheral vein enhancement. Fifty consecutive patients were enrolled from a tertiary medical center in Taiwan from May 2016 to March 2019. All the patients received a chest CT via central vein enhancement prior to neoadjuvant concurrent chemoradiation in order to compare the chest CT that was obtained via the peripheral vein. In addition, blind independent central reviews of chest CT via central vein and peripheral vein enhancement were conducted. For T and N stage, chest CT via central vein enhancement had a greater consistency with endoscopic ultrasonography and positron-emission tomography-computed tomography findings (kappa coefficients 0.4471 and 0.5564, respectively). In addition, chest CT via central vein enhancement also showed excellent agreement in the blind independent central review (kappa coefficient 0.9157). The changes in the T and N stage resulted in stage migration in 16 patients. Chest CT via central vein enhancement eliminated peripheral vein regurgitation and also provided more precise clinical staging. This study is registered under the registered NCT number 02887261.

Long-term outcomes of clinical and pathological-staged T3 N3 esophageal cancer

Locally advanced esophageal cancer is associated with poor long-term survival. Pre- and post-treatment stages may differ because of neoadjuvant therapy and inaccuracies in staging. The aim of this study was to determine the outcomes of patients staged with clinical T3 N3 and pathological T3 N3 carcinoma of the esophagus and determine differences between the groups. Consecutive patients from a single unit between 2010 and 2018 were included with either clinical (cT3 N3) or pathological (pT3 N3) esophageal cancer. Outcomes were compared between patients that underwent esophagectomy with or without neoadjuvant treatment and those patients staged cT3 N3 treated non-surgically (NSR). Patients were staged using the TNM 8. This study included 156 patients, 63 patients were staged cT3 N3 initially and had NSR treatment, only three of these had radical treatment. Of the remaining 93 patients who underwent esophagectomy, 34 were initially staged as cT3 N3, 54 were found to be pT3 N3 having been staged earlier initially, and five were unchanged before and after treatment. Median overall survival (OS) for surgical cT3 N3 patients was significantly longer than pT3 N3 and NSR (median: NR vs 19 vs 8 months, P < 0.001). Twenty-seven patients with cT3 N3 had lower staging following treatment, while three had a higher stage. T3 N3 disease carries a poor prognosis. Within this cohort, cT3 N3 disease treated surgically has a high 5-year OS suggesting possible over-staging and stage migration due to neoadjuvant therapy. Those not having surgery, have a dismal prognosis. The impact of neoadjuvant treatment cannot be predicted and, current staging modalities may be inaccurate. Clinical stage should be used with caution when counseling patients regarding management and prognosis.

Novel imaging techniques in staging oesophageal cancer

The survival of oesophageal cancer is poor as most patients present with advanced disease. Radiological staging of oesophageal cancer is complex but is fundamental to clinical management. Accurate staging investigations are vitally important to guide treatment decisions and optimise patient outcomes. A combination of baseline computed tomography (CT), endoscopic ultrasound (EUS) and positron emission tomography (PET) are currently used for initial treatment decisions. The potential value of these imaging modalities to re-stage disease, monitor response and alter treatment is currently being investigated. This review presents an essential update on the accuracy of oesophageal cancer staging investigations, their use in re-staging after neo-adjuvant therapy and introduces evolving imaging techniques, including novel biomarkers that have clinical potential in oesophageal cancer.

Clinical implication of the innovations of the 8th edition of the TNM classification for esophageal and esophago-gastric cancer

Epidemiology of esophageal cancer and esophagogastric junction (EGJ) has deeply changed for the past two decades with a dramatically increase of adenocarcinoma whereas squamous cell carcinoma (SCC) has slowly decreased. Moreover, the two histological types differ in a number of features including risks factors, tumor location, tumor biology and outcomes. In acknowledgement of these differences, the newest 8^th edition of the American Joint Committee on Cancer (AJCC) tumor, node and metastasis (TNM) staging classification of epithelial cancers of the esophagus and EGJ has refined this histology-specific disease stage with incorporation of new anatomic and non-anatomic categories. Based on data-driven of patients collected through the Worldwide Esophageal Cancer Collaboration (WECC) group, the 8^th edition database encompasses a six-continent cohort of 22,654 patients among 33 institutions including patients treated with surgery alone and, for the first time, patients treated after neoadjuvant treatment. Anatomic categories include T descriptors (tumor invasion), N descriptors (regional lymph node invasion) and M descriptors (distant site). Non anatomic categories include grade differentiation (G descriptors) and tumor location (L descriptors). Category descriptors are currently assessed by endoscopy with biopsy, by endoscopy ultrasound fine-needle aspiration (EUS-FNA), by thoracic-abdominal-pelvic computed tomography (CT) and whole body flurodeoxyglucose positron emission tomography (FDG-PET) fused with CT. The new 8^th edition considers separate and temporally related cancer classification based on the treatment strategy: clinical cTNM (before any treatment), pathologic pTNM (after surgery alone) and postneoadjuvant pathologic ypTNM (after neoadjuvant treatment followed by surgery). The 8th edition permits a more robust and reliable random forest-based machine learning analysis. Refinement of each T, N, M categories and subcategories makes the 8^th edition more accurate and more adaptable to the current practice including neoadjuvant regimen. The main objective of this review is to examine the current staging of esophageal cancer and the new aspects of the 8^th edition with its applications to clinical practice.

Endoscopic evaluation of the esophageal cancer patient after chemoradiotherapy for persistent/recurrent cancer

Endoscopy has an important role in the pre- and post-treatment staging of esophageal cancer. Complete pathologic response following neoadjuvant chemoradiation therapy occurs in approximately 25% of patients. However, the ability to accurately detect this preoperatively with currently available endoscopic modalities is limited such that the default pathway is for fit patients to proceed with surgical resection. This article discusses the available endoscopic modalities (primarily Esophagogastroduodenoscopy [EGD] with mucosal biopsies and endoscopic ultrasonography with or without fine needle aspiration) used for post-treatment staging of esophageal cancer. We present data regarding the benefits and limitations of endoscopic methods in assessing for residual disease. Unfortunately, endoscopic modalities are not accurate enough to identify complete pathological responsers who may avoid surgical resection.

Endoscopic and Imaging Predictors of Complete Pathologic Response After Chemoradiation for Esophageal Cancer

PURPOSE OF REVIEW

Locally advanced esophageal cancer is frequently treated preoperatively with chemotherapy and radiation. The degree of response to this preoperative therapy varies in different patients, and a complete pathological response (pCR) has important implications in the management and prognosis of these patients. This is a review of the different modalities currently available to detect pCR and the clinical context of their use.

RECENT FINDINGS

While research is still ongoing, no single technique has emerged as the modality of choice to reliably predict pCR in all patients. Studies investigating the sensitivity, specificity, and accuracy of these modalities have had promising results, but no single modality has been firmly validated as the modality if choice. The emergence of functional imaging techniques and the use of biomarkers are newer developments which need further evaluation before adoption in routine clinical practice. While no single technique reliably predicts pCR, a combination of imaging and diagnostic modalities (endoscopic appearance, biopsy, EUS, and PET/CT) may provide a better diagnostic yield rather than any of these modalities taken alone.

Prognostic relevance of serial endoscopic ultrasound after chemoradiation in esophageal cancer

The objective of this study is the feasibility of sequential endoscopic and endosonographic measurement of locoregional tumor load for the prediction of tumor recurrence in patients after neoadjuvant or definitive chemoradiotherapy, treated in curative intent for locally advanced esophageal carcinoma. In 67 patients with esophageal cancer, serial endoscopic ultrasound was performed before and after neoadjuvant (25) or definitive (42) chemoradiotherapy. Rate of complete endoscopic and endosonographic tumor response, reduction in tumor length or circumferential tumorous extension, maximal tumor thickness, lymph node size, and endosonographic uT- and uN-stage shift was measured. Results were correlated with tumor recurrence rate. After chemoradiotherapy, endosonography revealed a complete response of the primary tumor in 27 patients, and complete resolution of suspicious lymph nodes in 24 patients. According to uTN-stage, 43 patients showed a therapeutic response, with stage shift to a lower tumor stage. In patients with macroscopic residual disease, mean tumor thickness decreased from 13 to 9 mm, with nine patients presenting with a decrease of >50%. Mean tumor length decreased from 5.6 to 4.6 cm, with 10 patients showing a decrease of >50%. Mean lymph node size decreased from 14.5 to 12 mm, with four patients having a reduction in size of >50%. Tumor response was generally more pronounced after definitive than after neoadjuvant chemoradiotherapy. During follow-up, 33 patients developed a tumor recurrence. None of the endoscopic and endosonographic parameter analyzed was predictive for patient's prognosis, irrespective of the kind of chemoradiotherapy (neoadjuvant or definitive). Sequential measurement of locoregional tumor load with endoscopic ultrasound before and after chemoradiotherapy is not suitable for the prediction of tumor recurrence risk.

Endoscopic ultrasound in oncology: An update of clinical applications in the gastrointestinal tract

An accurate staging is necessary to select the best treatment and evaluate prognosis in oncology. Staging usually begins with noninvasive imaging such as computed tomography, magnetic resonance imaging or positron emission tomography. In the absence of distant metastases, endoscopic ultrasound plays an important role in the diagnosis and staging of gastrointestinal tumors, being the most accurate modality for local-regional staging. Its use for tumor and nodal involvement in pre-surgical evaluation has proven to reduce unnecessary surgeries. The aim of this article is to review the current role of endoscopic ultrasound in the diagnosis and staging of esophageal, gastric and colorectal cancer.

Persistent Dysphagia After Induction Chemotherapy in Patients with Esophageal Adenocarcinoma Predicts Poor Post-Operative Outcomes

PURPOSE

Preoperative therapy is frequently employed in the management of esophageal adenocarcinoma. However, many patients are found to have advanced pathologic stage and have poor outcomes. A prognostic factor which identifies this patient population before surgery would be desirable, as alternative treatment strategies may be warranted.

METHODS

Between 2/08 and 1/12, 60 evaluable patients with locally advanced esophageal adenocarcinoma enrolled in single-arm phase II trial of induction chemotherapy, surgery, and post-operative adjuvant chemo-radiotherapy (CRT). A clinical stage of T3, N1, or M1a (AJCC 6th) was required for eligibility. Induction chemotherapy with epirubicin 50 mg/m² d1, oxaliplatin 130 mg/m² d1, and fluorouracil 200 mg/m²/day continuous infusion for 3 weeks, was given every 21 days for 3 cycles and was followed by surgical resection. Adjuvant CRT consisted of 50-55 Gy @ 1.8-2.0 Gy/day and 2 cycles of cisplatin (20 mg/m²/day) and fluorouracil (1000 mg/m²/day) given as 96-h infusions during weeks 1 and 4 of radiotherapy. Dysphagia was assessed at baseline and after induction chemotherapy.

RESULTS

Persistent dysphagia was associated with worse distant metastatic control [HR 3.48 (1.43-8.43), p = 0.006], recurrence free survival [HR 3.04 (1.34-6.92), p = 0.008], and overall survival [HR 3.31 (1.43-7.66), p = 0.005]. Persistent dysphagia was associated with more advanced pathologic T descriptor (pT) (p = 0.048) and N descriptor (pN) (p = 0.002), a greater median number of involved lymph nodes (3 v 1, p = 0.003), and greater residual tumor viability (p = 0.05). No patients with persistent dysphagia had pT0-T2 or pN0 disease.

CONCLUSIONS

Persistent dysphagia after induction chemotherapy is associated with more advanced pathologic stage and inferior outcomes.

The 100 most cited articles investigating the radiological staging of oesophageal and junctional cancer: a bibliometric analysis

Objectives

Accurate staging of oesophageal cancer (OC) is vital. Bibliometric analysis highlights key topics and publications that have shaped understanding of a subject. The 100 most cited articles investigating radiological staging of OC are identified.

Methods

The Thomas Reuters Web of Science database with search terms including “CT, PET, EUS, oesophageal and gastro-oesophageal junction cancer” was used to identify all English language, full-script articles. The 100 most cited articles were further analysed by topic, journal, author, year and institution.

Results

A total of 5,500 eligible papers were returned. The most cited paper was Flamen et al. (n = 306), investigating the utility of positron emission tomography (PET) for the staging of patients with potentially operable OC. The most common research topic was accuracy of staging investigations (n = 63). The article with the highest citation rate (38.00), defined as the number of citations divided by the number of complete years published, was Tixier et al. investigating PET texture analysis to predict treatment response to neo-adjuvant chemo-radiotherapy, cited 114 times since publication in 2011.

Conclusion

This bibliometric analysis has identified key publications regarded as important in radiological OC staging. Articles with the highest citation rates all investigated PET imaging, suggesting this modality could be the focus of future research.

Main Messages

• This study identifies key articles that investigate radiological staging of oesophageal cancer.

• The most common topic was accuracy of staging investigations.

• The article with the highest citation rate investigated the use of texture analysis in PET images.

Endoscopic biopsy and EUS for the detection of pathologic complete response after neoadjuvant chemoradiotherapy in esophageal cancer: a systematic review and meta-analysis

BACKGROUND AND AIMS

Accurate determination of residual cancer status after neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer could assist in selecting the optimal treatment strategy. The aim of this study was to review the evidence on the diagnostic accuracy of endoscopic biopsy and EUS after nCRT for detecting residual cancer at the primary tumor site (ypT+) and regional lymph nodes (ypN+) as opposed to a pathologic complete response (ypT0 and ypN0).

METHODS

PubMed/Medline, Embase, and the Cochrane library were systematically searched. The analysis included diagnostic studies reporting on the accuracy of endoscopic biopsy or EUS in detecting residual cancer versus complete response after nCRT for esophageal cancer with histopathology as the reference standard. Bivariate random-effects models were used to estimate pooled sensitivities and specificities and examine sources of heterogeneity.

RESULTS

Twenty-three studies comprising 12 endoscopic biopsy studies (1281 patients), 11 EUS studies reporting on ypT status (593 patients), and 10 EUS studies reporting on ypN status (602 patients), were included. Pooled estimates for sensitivity of endoscopic biopsy after nCRT for predicting ypT+ were 34.5% (95% confidence interval [CI], 26.0%-44.1%) and for specificity 91.0% (95% CI, 85.6%-94.5%). Pooled estimates for sensitivity of EUS after nCRT were 96.4% (95% CI, 91.7%-98.5%) and for specificity were 10.9% (95% CI, 3.5%-29.0%) for detecting ypT+, and 62.0% (95% CI, 46.0%-75.7%) and 56.7% (95% CI, 41.8%-70.5%) for detecting ypN+, respectively.

CONCLUSIONS

Endoscopic biopsy after nCRT is a specific but not sensitive method for detecting residual esophageal cancer. Although EUS after nCRT yields a high sensitivity, only a limited number of patients will have negative findings at EUS with still a substantial false-negative rate. Furthermore, EUS provides only moderate accuracy for detecting residual lymph node involvement. Based on these findings, these endoscopic modalities cannot be used to withhold surgical treatment in test-negative patients after nCRT. (

CLINICAL TRIAL REGISTRATION NUMBER

CRD42015016527.).

Accuracy of Detecting Residual Disease After Cross Neoadjuvant Chemoradiotherapy for Esophageal Cancer (preSANO Trial): Rationale and Protocol

BACKGROUND

Results from the recent CROSS trial showed that neoadjuvant chemoradiotherapy (nCRT) significantly increased survival as compared to surgery alone in patients with potentially curable esophageal cancer. Furthermore, in the nCRT arm 49% of patients with a squamous cell carcinoma (SCC) and 23% of patients with an adenocarcinoma (AC) had a pathologically complete response in the resection specimen. These results provide a rationale to reconsider and study the timing and necessity of esophagectomy in (all) patients after application of the CROSS regimen.

OBJECTIVE

We propose a "surgery as needed" approach after completion of nCRT. In this approach, patients will undergo active surveillance after completion of nCRT. Surgical resection would be offered only to those patients in whom residual disease or a locoregional recurrence is highly suspected or proven. However, before a surgery as needed approach in oesophageal cancer patients (SANO) can be tested in a randomized controlled trial, we aim to determine the accuracy of detecting the presence or absence of residual disease after nCRT (preSANO trial).

METHODS

This study is set up as a prospective, single arm, multicenter, diagnostic trial. Operable patients with potentially curable SCC or AC of the esophagus or esophagogastric junction will be included. Approximately 4-6 weeks after completion of nCRT all included patients will undergo a first clinical response evaluation (CRE-I) including endoscopy with (random) conventional mucosal biopsies of the primary tumor site and of any other suspected lesions in the esophagus and radial endo-ultrasonography (EUS) for measurement of tumor thickness and area. Patients in whom no locoregional or disseminated disease can be proven by cytohistology will be offered a postponed surgical resection 6-8 weeks after CRE-I (ie, approximately 12-14 weeks after completion of nCRT). In the week preceding the postponed surgical resection, a second clinical response evaluation (CRE-II) will be planned that will include a whole body PET-CT, followed again by endoscopy with (random) conventional mucosal biopsies of the primary tumor site and any other suspected lesions in the esophagus, radial EUS for measurement of tumor thickness and area, and linear EUS plus fine needle aspiration of PET-positive lesions and/or suspected lymph nodes. The main study parameter is the correlation between the clinical response assessment during CRE-I and CRE-II and the final pathological response in the resection specimen.

RESULTS

The first patient was enrolled on July 23, 2013, and results are expected in January 2016.

CONCLUSIONS

If this preSANO trial shows that the presence or absence of residual tumor can be predicted reliably 6 or 12 weeks after completion of nCRT, a randomized trial comparing nCRT plus standard surgery versus chemoradiotherapy plus "surgery as needed" will be conducted (SANO trial).

TRIAL REGISTRATION

Netherlands Trial Register: NTR4834; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4834 (archived by Webcite at http://www.webcitation.org/6Ze7mn67B).

Prediction of survival by tumor area on endosonography after definitive chemoradiotherapy for locally advanced squamous cell carcinoma of the esophagus

BACKGROUND

Definitive chemoradiotherapy (CRT) is a reasonable approach for patients with locally advanced esophageal cancer who are not surgical candidates. This study was performed to investigate whether endosonography (EUS) assessment of tumor area response is a useful prognostic marker in patients with squamous cell carcinoma (SCC) of the esophagus who receive definitive CRT.

METHODS

A total of 33 patients who received definitive CRT for locally advanced esophageal SCC were enrolled. The maximal transverse cross-sectional area of the tumor was measured before and after definitive therapy. EUS response was defined as a ≥50% reduction of the tumor area after definitive CRT.

RESULTS

Based on EUS evaluation, there were 20 nonresponders (60.6%) and 13 responders (39.4%). The median progression-free survival (PFS) was significantly longer in EUS responders than EUS nonresponders (p = 0.005). However, there was no statistical significance in overall survival according to EUS response (p = 0.120). During multivariate analysis, EUS response to definitive CRT was the only significant factor associated with PFS (p = 0.045), whereas EUS response to definitive CRT was not associated with overall survival (p = 0.221).

CONCLUSIONS

A reduction of the maximal cross-sectional tumor area measured by EUS correlates with a superior prognosis in patients with locally advanced SCC of the esophagus after definitive CRT.

Response evaluation with endoscopic ultrasound and computed tomography in esophageal squamous cell carcinoma treated by definitive chemoradiotherapy

BACKGROUND AND AIM

We assessed the feasibility of combined endoscopic ultrasound and computed tomography on response evaluation in patients with esophageal squamous cell carcinoma treated by definitive chemoradiotherapy, and the impact of response on prognosis.

METHODS

Sixty patients treated by definitive chemoradiotherapy were followed by miniprobe endoscopic ultrasound and computed tomography. The post-treatment esophageal wall thickness was measured by miniprobe endoscopic ultrasound. Metastatic tumors were evaluated by computed tomography. The correlation between post-treatment image findings and prognosis was evaluated.

RESULTS

Twenty-four patients (40%) had esophageal stricture after chemoradiotherapy, which limited complete evaluation by endoscopy. Miniprobe successfully penetrated all strictures to measure post-treatment esophageal wall thickness. Both post-treatment esophageal wall thickness < 8 mm measured by endoscopic ultrasound and no enlargement of metastatic tumor foci on computed tomography predicted good prognosis (P = 0.001). Combined evaluation with these two modalities improved survival prediction (P < 0.001). Patients who met the above two criteria after chemoradiotherapy had the longest survival compared with those who met only one or none of the criteria. The corresponding median survivals were > 30 months, 16.8 months and 7.1 months, respectively (P < 0.001). On multivariate analysis, treatment response is the strongest independent prognostic factor (hazard ratio 3.65, P = 0.006) regardless of baseline tumor-node-metastasis staging and chemoradiation regimen.

CONCLUSIONS

Response evaluation by miniprobe endoscopic ultrasound and computed tomography can predict the prognosis of esophageal squamous cell carcinoma patients treated by definitive chemoradiotherapy. Those who were judged as poor responder should receive additional treatment to improve outcome.

Interim endoscopy results during neoadjuvant therapy for gastric cancer correlate with histopathological response and prognosis

BACKGROUND

Neoadjuvant chemotherapy for locally advanced gastric cancer leads to major histopathological response in less than 30 % of patients. Data on interim endoscopic response assessment do not exist. This exploratory prospective study evaluates early endoscopy after 50 % of the chemotherapy as predictor for later response and prognosis.

METHODS

Forty-seven consecutive patients were included (45 resected; 33 R0 resections). All patients received baseline endoscopy and CT scans, after 50 % of their chemotherapy (EGD-1, CT-1) and after completion of chemotherapy (EGD-2, CT-2). Interim endoscopic response (EGD-1) was assessed after having received 50 % (6 weeks) of the planned 12 weeks of neoadjuvant chemotherapy. Post-chemotherapy response was clinically assessed by a combination of CT scan (CT-2) and endoscopy (EGD-2). Histopathological response was determined by a standardized scoring system (Becker criteria). Endoscopic response was defined as a reduction of >75 % of the tumor mass.

RESULTS

Twelve patients were responders at EGD-1 and 13 at EGD-2. Nine patients (19.1 %) were clinical responders and 7 patients (15.6 %) were histopathological responders after chemotherapy. Specificity, accuracy, and negative predictive value of the interim EGD-1 for subsequent histopathological response were 31/38 (82 %), 36/47 (76 %), and 31/33 (93 %); and for recurrence or death, 28/30 (93.3 %), 38/47 (80.9 %), and 28/35 (80.0 %). Response at EGD-1 was significantly associated with histopathological response (p = 0.010), survival (p < 0.001), and recurrence-free survival (p = 0.009).

CONCLUSIONS

Interim endoscopy after 6 weeks predicts response and prognosis. Therefore, tailoring treatment according to interim endoscopic assessment could be feasible, but the findings of this study should be validated in a larger patient cohort.

A phase II trial of induction epirubicin, oxaliplatin, and fluorouracil, followed by surgery and postoperative concurrent cisplatin and fluorouracil chemoradiotherapy in patients with locoregionally advanced adenocarcinoma of the esophagus and gastroesophageal junction

INTRODUCTION

Preoperative chemoradiotherapy improves local control in patients with locoregionally advanced adenocarcinoma of the esophagus and gastroesophageal junction (GEJ). Distant failure remains common, however, suggesting potential benefit from additional chemotherapy. This phase II study investigated the addition of induction chemotherapy to surgery and adjuvant chemoradiotherapy.

METHODS

Patients with cT3-4 or N1 or M1a (American Joint Committee on Cancer 6th edition) adenocarcinoma of the esophagus and GEJ were eligible. Induction chemotherapy, with epirubicin 50 mg/m/d, oxaliplatin 130 mg/m/d, and fluorouracil 200 mg/m/d continuous infusion for 3 weeks, was given every 21 days for three courses, followed by surgery. Adjuvant chemoradiotherapy consisted of 50 to 55 Gy at 1.8 to 2.0 Gy/d and two courses of cisplatin (20 mg/m/d) and fluorouracil (1000 mg/m/d) during weeks 1 and 4 of radiotherapy.

RESULTS

Between February 2008 and January 2012, 60 evaluable patients enrolled. Resection was accomplished in 54 patients (90%) and adjuvant chemoradiotherapy in 48 (80%) patients. Toxicity included unplanned hospitalization in 18% of patients during induction chemotherapy and 19% of patients during adjuvant chemoradiotherapy. There was one chemotherapy-related and two postoperative deaths. With a median follow-up of 43 months, the projected 3-year locoregional control is 88%, distant metastatic control 46%, relapse-free survival 41%, and overall survival 47%. Symptomatic response to chemotherapy and the percentage of remaining viable tumor at surgery proved the strongest predictors of survival and distant control.

CONCLUSIONS

Chemotherapy, surgery, and adjuvant chemoradiotherapy are feasible and produce outcomes similar to other multimodality treatment schedules in locoregionally advanced adenocarcinoma of the esophagus and GEJ. Symptomatic response and less residual tumor at surgery were associated with improved outcomes.

Staging accuracy of endoscopic ultrasound for esophageal cancer after neoadjuvant chemotherapy: a meta-analysis and systematic review

This study aims to evaluate the accuracy of endoscopic ultrasound (EUS) in the staging of esophageal cancer after neoadjuvant chemotherapy (NAC). Articles were searched in Medline, Pubmed, Cochrane Database of Systemic Reviews, Google scholar, and EMBASE. Two reviewers independently searched and extracted data. Meta-analysis of the accuracy of EUS was analyzed by calculating pooled estimates of sensitivity, specificity, likelihood ratios (LR), and diagnostic odds ratio (DOR). Pooling was conducted using either fixed-effects model or random-effects model depending on the heterogeneity across studies. Sixteen studies (n = 724) were included in this analysis. The pooled sensitivity and specificity of EUS to diagnose T1 stage tumor was 23% (95% confidence interval [CI] 16-32%) and 95% (95%CI 93-97%), respectively. For T2 stage, EUS had a pooled sensitivity and specificity of 29% (95%CI 19-41%) and 84% (95%CI 77-88%). The pooled sensitivity and specificity of EUS were 81% (95%CI 72-88%) and 42% (95%CI 33-52%) in determining T3 stage tumor. To diagnose T4 stage tumor, EUS had a pooled sensitivity of 43% (95%CI 31-56%) and specificity of 96% (95%CI 94-97%), respectively. In determining N stage, the pooled sensitivity and specificity of EUS were 69% (95%CI 58-79%) and 52% (95%CI 42-62%). EUS is a moderately accurate technique in staging esophageal cancer after NAC. Its sensitivity is relatively high in T3 while specificity is high in other T stages (T1, T2, and T4). Tumors restaged by EUS as T4 should not be assigned to surgery because it is very likely to be inoperable. EUS is not reliable for N staging with its poor sensitivity and specificity. Subgroup analysis shows that staging accuracy did not improve with time.

Distant lymph node metastases in gastroesophageal junction adenocarcinoma: impact of endoscopic ultrasound-guided fine-needle aspiration

OBJECTIVE

Endoscopic ultrasound (EUS) is established as the most accurate technique for pre-operative locoregional staging of gastroesophageal junction (GEJ) adenocarcinoma, the purpose of the present study was to evaluate the distant lymph nodes (LNs) EUS-fine-needle aspiration (FNA) impact in therapeutic decision for patients with GEJ adenocarcinoma.

MATERIALS AND METHODS

Retrospective study was made, with cross-sectional, non-probabilistic analysis from prospectively collected database for all GEJ adenocarcinoma staging patients referred between January 2009 and August 2012 in Paoli-Calmette Institute in Marseille-France.

RESULTS

A total of 154 patients with GEJ adenocarcinoma were managed in our institution, of whom 113 (73.3%) had non-distant metastatic disease at computed tomography (CT) scan and underwent EUS for initial tumor staging prior to a treatment decision. On A total of 113 patients undergoing EUS, 8 (7%) patients underwent endoscopic resection and 6 (5.3%) underwent direct surgical resection. Of the remaining 99 patients (87.6%), 24 (21.2%) distant LN EUS-FNA were made. Seventeen LN had EUS malignant features, including 9 (52.9%) that were confirmed as malignant and underwent palliative treatment with chemotherapy. Ninety (79.6%) patients were treated with pre-operative neoadjuvant therapy and were revaluated after. 4 (4.4%) had metastatic disease at CT scan (underwent palliative treatment) and 65 (72.2%) underwent EUS restaging to treatment decision revaluation. Of these, twelve (18.4%) distant LN EUS-FNA were performed. Seven had LN EUS malignancy features, including 4 (57.1%) that were confirmed as malignant and underwent palliative treatment. The remaining 61 patients underwent surgery. As stated above, 21 patients (23.3%) did not undergo EUS restaging, including 10 (47.6%) that did not go to surgery because patient's age, poor general status and comorbidities, 6 (28.5%) had a loss of follow-up, 1 (4.7%) underwent to surgery due to chemotherapy collateral effects, 3 (14.2%) were still on pre-operative chemotherapy and 1 (4.7%) died for sepsis after mediastinal EUS-FNA, this was the only complication event evidenced. EUS-FNA changed clinical management in 54.2% of patients who met the criteria inclusion (distant LN with malignancies EUS features), which corresponds to 11.5% of patients with GEJ adenocarcinoma.

CONCLUSION

EUS-FNA was able to provide a different tumor staging and these differences were associated with treatment received. EUS-FNA had a significant impact on treatment decision.

Radiographic and endosonographic staging in esophageal cancer

Radiographic imaging using computed tomographic (CT) scan and positron emission tomography/CT are primarily helpful in identifying distant metastases. In general, if patients have evidence of lymph node involvement that is proved pathologically by endoscopic ultrasound/fine needle aspiration, this information is considered definitive, and the patient can be referred for the appropriate stage-specific therapy. Laparoscopy combined with laparoscopic ultrasound and peritoneal lavage has been shown to have sensitivity of 67% and specificity of 92% for lymph node disease. Thoracoscopy may help identify involved lymph node in the mediastinum before resection and help determine the field of radiation.

Distant lymph node metastases in gastroesophageal junction adenocarcinoma: impact of endoscopic ultrasound-guided fine-needle aspiration

OBJECTIVE

Endoscopic ultrasound (EUS) is established as the most accurate technique for pre-operative locoregional staging of gastroesophageal junction (GEJ) adenocarcinoma, the purpose of the present study was to evaluate the distant lymph nodes (LNs) EUS-fine-needle aspiration (FNA) impact in therapeutic decision for patients with GEJ adenocarcinoma.

MATERIALS AND METHODS

Retrospective study was made, with cross-sectional, non-probabilistic analysis from prospectively collected database for all GEJ adenocarcinoma staging patients referred between January 2009 and August 2012 in Paoli-Calmette Institute in Marseille-France.

RESULTS

A total of 154 patients with GEJ adenocarcinoma were managed in our institution, of whom 113 (73.3%) had non-distant metastatic disease at computed tomography (CT) scan and underwent EUS for initial tumor staging prior to a treatment decision. On A total of 113 patients undergoing EUS, 8 (7%) patients underwent endoscopic resection and 6 (5.3%) underwent direct surgical resection. Of the remaining 99 patients (87.6%), 24 (21.2%) distant LN EUS-FNA were made. Seventeen LN had EUS malignant features, including 9 (52.9%) that were confirmed as malignant and underwent palliative treatment with chemotherapy. Ninety (79.6%) patients were treated with pre-operative neoadjuvant therapy and were revaluated after. 4 (4.4%) had metastatic disease at CT scan (underwent palliative treatment) and 65 (72.2%) underwent EUS restaging to treatment decision revaluation. Of these, twelve (18.4%) distant LN EUS-FNA were performed. Seven had LN EUS malignancy features, including 4 (57.1%) that were confirmed as malignant and underwent palliative treatment. The remaining 61 patients underwent surgery. As stated above, 21 patients (23.3%) did not undergo EUS restaging, including 10 (47.6%) that did not go to surgery because patient's age, poor general status and comorbidities, 6 (28.5%) had a loss of follow-up, 1 (4.7%) underwent to surgery due to chemotherapy collateral effects, 3 (14.2%) were still on pre-operative chemotherapy and 1 (4.7%) died for sepsis after mediastinal EUS-FNA, this was the only complication event evidenced. EUS-FNA changed clinical management in 54.2% of patients who met the criteria inclusion (distant LN with malignancies EUS features), which corresponds to 11.5% of patients with GEJ adenocarcinoma.

CONCLUSION

EUS-FNA was able to provide a different tumor staging and these differences were associated with treatment received. EUS-FNA had a significant impact on treatment decision.

Diagnosis and staging of cancer of the esophagus and esophagogastric junction

Esophageal/esophagogastric junction cancer staging in the 7th edition of the AJCC staging manual is data driven and harmonized with gastric staging. New definitions are Tis, T4, regional lymph node, N, and M. Nonanatomic characteristics (histopathologic cell type, histologic grade, cancer location) and TNM classifications determine stage groupings. Classifications before treatment define clinical stage (cTNM or ycTNM). Current best clinical staging modalities include endoscopic ultrasonography for T and N and CT/PET for M. Classifications at resection define pathologic stage (pTNM or ypTNM). Accurate pathologic stage requires communication/cooperation between surgeon and pathologist. Classifications are defined at retreatment (rTNM) and autopsy (aTNM).

Comparative study between endoscopic ultrasonography and positron emission tomography-computed tomography in staging patients with esophageal squamous cell carcinoma

Treatment strategy of esophageal cancer mainly depends on accurate staging. At present, no single ideal staging modality is superior to another in preoperative tumor-node-metastasis (TNM) staging of patients with esophageal cancer. We aimed to investigate the efficacy of endoscopic ultrasonography (EUS) and positron emission tomography-computed tomography (PET-CT) for staging of esophageal cancer. We retrospectively studied 118 consecutive patients with esophageal squamous cell carcinoma who underwent esophagectomy with or without neoadjuvant chemoradiotherapy (CRT) over a near 3-year period between January 2005 and November 2008 at a tertiary hospital in Taiwan. Patients were separated into two groups: without neoadjuvant CRT (group 1, n= 28) and with CRT (group 2, n= 90). Medical records of demographic data and reports of EUS and PET-CT of patients before surgery were reviewed. A database of clinical staging by EUS and PET-CT was compared with one of pathological staging. The accuracies of T staging by EUS in groups 1 and 2 were 85.2% and 34.9%. The accuracies of N staging by EUS in groups 1 and 2 were 55.6% and 39.8%. The accuracies of T and N staging by means of PET-CT scan were 100% and 54.5% in group 1, and were 69.4% and 86.1% in group 2, respectively. In group 2, 38 of 90 patients (42.2%) achieved pathologic complete remission. Among them, two of 34 (5.9%) and 12 of 17 (70.6%) patients were identified as tumor-free by post-CRT EUS and PET-CT, respectively. EUS is useful for initial staging of esophageal cancer. PET-CT is a more reliable modality for monitoring treatment response and restaging. Furthermore, the accuracy of PET-CT with regard to N staging is higher in patients who have undergone CRT than those who have not.

Tumor length assessed by miniprobe endosonography can predict the survival of the advanced esophageal squamous cell carcinoma with stricture receiving concurrent chemoradiation

There were tumor strictures commonly encountered in the esophageal squamous cell carcinoma (ESCC) to limit the conventional echoendoscope for exact tumor staging and size measurements. This study evaluated the role of miniprobe endosonography (EUS) to predict the survival of ESCC patients after concurrent chemoradiation therapy (CCRT). This study prospectively enrolled ESCC patients to receive high-frequency miniprobe EUS for the assessments of the tumor size and tumor-node-metastasis (TNM) stage. For the patients defined with advanced stages to receive CCRT as initial therapy, the tumor size parameters assessed by EUS were analyzed for their correlation with the treatment response and the patients' survivals. Fifty-four patients, >96% with advanced TNM stage III or IV, were enrolled with a medium follow-up of 320.5 days. Almost all of the 54 cases had partial or complete stricture of the esophageal lumens due to the tumor obstructions at enrollment. The overall median survival was 18.6 months, and the 1- and the 2-year survival rates were 64.9 and 45.2%, respectively. Patients with initial tumor length <6 cm assessed by the pre-CCRT EUS had a better survival than those with length ≥6 cm (median survival: >56.5 months vs. 11.5 months, P= 0.006). The patients with initial tumor length <6 cm had a higher rate of downstage than those with tumor length ≥6 cm after the first course of CCRT (80.0% vs. 16.7%, P= 0.035). Multivariate Cox regression confirmed the initial tumor length (hazard ratio [HR]= 1.21, P= 0.034) as well as the presence of distal metastasis are both independent predictors of the survival in ESCC patients receiving CCRT. For the ESCC patients, commonly with tumor stricture, the miniprobe EUS to assess tumor length before CCRT can predict the treatment response and the survivals.

The role of endoscopic ultrasound in assessing tumor response and staging after neoadjuvant chemotherapy for esophageal cancer

BACKGROUND

Although the role of endoscopic ultrasound (EUS) in the initial staging of esophageal cancer is well established, its role in assessing tumor response and staging esophageal cancers after neoadjuvant chemotherapy (NAC) is controversial, and this study aimed to investigate this role.

METHODS

This study retrospectively analyzed 110 patients with esophageal cancer who underwent EUS by single surgeon before and after NAC. Tumor response was assessed before and after NAC. Patients with more than a 50% reduction in tumor size based on EUS evaluation were classified as having a significant response to chemotherapy, and those with less than a 50% reduction were categorized as having a partial response. Disease stage was established by tumor node metastasis (TNM) classification. Initial staging was performed using EUS and computed tomography (CT) scans of the chest and abdomen. The EUS-determined stage was compared with the postsurgical pathologic stage. χ(2) analysis and Fisher's exact testing were performed.

RESULTS

A response to NAC was shown by 96 patients (87.3%) and no response by 14 patients (12.7%). Of the 96 responding patients, 37 (38.5%) showed a significant response, whereas 43 (61.5%) of 69 patients showed a partial response. The EUS staging correlated well with the pathologic staging for 9 (64.3%) of the 14 nonresponders and for 34 (35.4%) of the 96 responders to NAC (P = 0.04). The EUS accurately predicted both the T and N status for 26 (23.6%) of the 110 patients. Prediction of N status was significantly more accurate than prediction of the T stage for the post-NAC patients. Of the 110 patients, 43 (39.1%) patients had an accurate T-stage prediction, and 64 (58.2%) had an accurate N stage match (P = 0.02). The T stage was overstaged for 60 (54.5%) of the patients and understaged for 7 of the patients (6.4%).The study found overstaging of the T stage to be more common among the patients who responded to chemotherapy. The N stage was overstaged for 25 (22.7%) and understaged for 21 (19.1%) of the 110 patients.

CONCLUSION

The findings showed EUS to be a useful tool for assessing response to chemotherapy and for evaluating the extent of disease, thus facilitating surgical decision making. However, EUS is an unreliable tool for staging esophageal cancer after NAC. Overstaging of the T stage is significantly more common and could be related to the inflammatory effect or fibrosis after NAC.

Endosonographic radial tumor thickness after neoadjuvant chemoradiation therapy to predict response and survival in patients with locally advanced esophageal cancer: a prospective multicenter phase ll study by the Swiss Group for Clinical Cancer Research (SAKK 75/02)

BACKGROUND

EUS response assessment in patients with locally advanced esophageal cancer undergoing neoadjuvant chemoradiation therapy (CRT) is limited by disintegration of the involved anatomic structures.

OBJECTIVE

Predictive and prognostic values of a prospectively defined maximum tumor thickness (MTT).

DESIGN

Prospective open-label phase ll study (SAKK 75/02).

SETTING

Multicenter, nationwide.

PATIENTS

Of 66 patients with primary CRT, 56 underwent en bloc esophagectomy.

INTERVENTIONS

EUS-measured MTT before and 2-5 weeks after CRT (yMTT).

MAIN OUTCOME MEASUREMENTS

Cutoffs: (1) absolute thickness (yMTT) after CRT < or = 6 mm; (2) relative reduction compared with baseline (ratio yMTT/MTT) < or = 50%. Correlation between EUS measurements and histopathologic tumor regression grade (TRG) and overall survival (OS).

RESULTS

Sixteen of 56 patients were not included for EUS evaluation (10 severe stenosis, 5 MTT not measured, 1 intolerance to second EUS). Characteristics (n = 40) were as follow: median age, 60 years; squamous cell carcinoma, 42%; and adenocarcinoma (AC), 58%. Initial stage was: 10 T2N1, 3 T3N0, 26 T3N1, 1 T3Nx; 14 of 23 AC Siewert type 1. Wilcoxon rank sum test showed significant correlation of TRG1 with yMTT < or = 6 mm (P = .008) and yMTT/MTT < or = 50% (P = .003). The effect of yMTT on TRG1 was significant (P = .0193; odds ratio, 0.687 [95% CI, 0.502-0.941]). The predefined cutoff of < or = 6 mm for yMTT was predictive for TRG1 (P = .0037; Fisher exact test). After a median follow-up of 28.6 months, there was a clear trend for benefit in OS with yMTT < or = 6 mm and yMTT/MTT < or = 50%.

LIMITATIONS

Small sample size.

CONCLUSION

In a multicenter setting, MTT measured by EUS after CRT was highly predictive for response and showed a clear trend for predicting survival.

Clinical utility of postchemoradiation endoscopic brush cytology and biopsy in predicting residual esophageal adenocarcinoma

BACKGROUND

Esophageal adenocarcinoma generally carries a poor prognosis. Treatment with combination chemoradiation (CRT) followed by esophagectomy is becoming common. A pathologic complete response is uncommon but predicts improved survival. Identifying the subset of patients with residual carcinoma has potential management implications. Post-CRT endoscopic brush cytology and biopsy may detect residual tumor; however, the accuracy and clinical value of these methods remain unclear.

METHODS

Sixty-seven patients with esophageal adenocarcinoma who underwent preoperative CRT and post-CRT endoscopic brush cytology and biopsy followed by esophagectomy were identified. By using esophagectomy histology as the gold standard, the performance of cytology and biopsy was evaluated in diagnosing residual carcinoma. Two pathologists independently reviewed all false-negative and false-positive cases and resolved disagreements by consensus.

RESULTS

The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of cytology for diagnosing residual carcinoma were 26%, 95%, 92%, 35%, and 45%, respectively. For biopsy, these rates were 13%, 90%, 75%, 31%, and 36%, respectively. Sampling error accounted for false-negative diagnoses in approximately 66% of cytology analyses and 98% of biopsy analyses. Approximately 33% of false-negative cytology analyses and 1 false-negative biopsy analysis were caused by the under-recognition of tumor cells. Major diagnostic pitfalls included obscuring acute inflammation, necrosis, tumor cells that mimicked benign cells with radiation/reactive atypia, and the under recognition of mucin-containing adenocarcinoma cells.

CONCLUSIONS

Brush cytology and biopsy were specific but not sensitive methods for predicting residual cancer after CRT. However, cytology was superior. The current results indicated that brush cytology can be used alone to diagnose residual esophageal carcinoma, and awareness of specific diagnostic pitfalls will help pathologists improve its accuracy.

Multimodality assessment of esophageal cancer: preoperative staging and monitoring of response to therapy

Esophageal cancer is a leading cause of cancer mortality worldwide. Complete resection of esophageal cancer and adjacent malignant lymph nodes is the only potentially curative treatment. Accurate preoperative staging and assessment of therapeutic response after neoadjuvant therapy are crucial in determining the most suitable therapy and avoiding inappropriate attempts at curative surgery. Computed tomography (CT) is recommended for initial imaging following confirmation of malignancy at pathologic analysis, primarily to rule out unresectable or distant metastatic disease. With the advent of multidetector CT, use of thin sections and multiplanar reformation allows more accurate staging of esophageal cancer. Endoscopic ultrasonography (US) is the best modality for determining the depth of tumor invasion and presence of regional lymph node involvement. Combined use of fine-needle aspiration and endoscopic US can improve assessment of lymph node involvement. Positron emission tomography (PET) is useful for assessment of distant metastases but is not appropriate for detecting and staging primary tumors. PET may also be helpful in restaging after neoadjuvant therapy, since it allows identification of early response to treatment and detection of interval distant metastases. Each imaging modality has its advantages and disadvantages; therefore, CT, endoscopic US, and PET should be considered complementary modalities for preoperative staging and therapeutic monitoring of patients with esophageal cancer.

Esophageal cancer: ultrasonography

Esophageal malignancy is a major source of morbidity and mortality, despite the recently increased attention to screening and early detection. Prognosis for esophageal cancer remains grim, with advanced tumor stage and lymph node metastases conferring even graver outcomes. Several studies have demonstrated that the addition of preoperative neoadjuvant chemoradiotherapy may improve survival in patients with locally advanced tumor (T3) disease or local lymph node metastases. It is here that endoscopic ultrasonography finds its niche in the precise staging of these tumors and the subsequent use of stage-dependent treatment protocols.

Positron emission tomography for monitoring response to neoadjuvant therapy in patients with oesophageal and gastro-oesophageal junction carcinoma

AIMS

The aim of this review is to consolidate our knowledge on an important and rapidly expanding area of expertise. Numerous methods for predicting response (in terms of pathological response and survival) to neoadjuvant therapy (chemotherapy/chemo-radiotherapy) in oesophageal and junctional cancers have been proposed. This review concerns itself only with the use of positron emission tomography for such a purpose. At present there are no standardised criteria amongst PET trials as to what determines a response according to PET, what is the optimal time to perform PET in relation to the timing of neoadjuvant therapy, and what is the ideal method of quantifying PET tracer uptake.

METHODS

An electronic search was performed of PubMed, Ovid and Embase websites to identify studies, in the English language, using the search terms: PET; oesophageal; oesophago-gastric; survival; cancer; response; chemotherapy and chemo-radiotherapy. The reference lists were searched manually to identify further relevant studies.

RESULTS

Twenty-two studies were identified, all using (18)FDG as the tracer, using PET to predict response in terms of pathological response and survival following neoadjuvant therapy (chemotherapy/chemo-radiotherapy). PET had a varying degree of success in predicting both pathological response and survival outcomes, with only one study using PET to influence management decisions.

CONCLUSIONS

PET seems a promising technique, but large-scale conclusions are hindered by small study numbers, lack of criteria as to what constitutes a response and markedly differing PET imaging times. A large randomised trial concerning a homogeneous group of patients and tumours is required before PET might be used to influence management.

Using Q-RT-PCR to measure cyclin D1, TS, TP, DPD, and Her-2/neu as predictors for response, survival, and recurrence in patients with esophageal squamous cell carcinoma following radiochemotherapy

PURPOSE

The purpose of this study was to evaluate the use of thymidilate synthetase (TS), thymidilate phosphorylase (TP), dihydropyrimidin dehydrogenase (DPD), Her-2/neu, and cyclin D1 as predictors of therapy response, survival, and recurrence in patients with esophageal squamous cell carcinoma (ESCC) following radiochemotherapy.

MATERIALS AND METHODS

Twenty-six patients with histologically proven intrathoracic, locally advanced ESCC (cT3, cN0/+, cM0) underwent preoperative, combined simultaneous radiochemotherapy followed by R0-transthoracic esophagectomy. Because R0 resection is the strongest known independent prognostic factor in this tumor entity, only R0-resected patients were included in this study. Pre-therapeutically taken, formalin-fixed, and paraffin-embedded tumor biopsies were used for laser-assisted microdissection of tumor cells and RNA extraction and subjected to real-time (TaqMan) quantitative reverse transcriptase-polymerase chain reaction (Q-RT-PCR).

RESULTS

No significant correlation between clinical or histopathological parameters and the relative gene expression of TS, TP, DPD, or Her-2/neu was observed. However, patients with relative cyclin D1 levels below the median gene expression did not reach median survival compared to the 19.9 months seen in patients with relative cyclin D1 gene expression above the median (P = 0.02). Patients with low cyclin D1 levels experienced significantly less frequent recurrence of the tumor (20% versus 63%; P = 0.006), and there was a significant difference in the recurrence-free interval (P = 0.003).

CONCLUSIONS

Despite the small number of investigated patients, our data seem to show that high levels of cyclin D1 measured by real-time Q-RT-PCR before neoadjuvant radiochemotherapy correlate significantly with patient survival, tumor recurrence, and recurrence-free-interval. Cyclin D1 might be useful in identifying patients at high risk of poor prognosis and suffering from recurrence after neoadjuvant radiochemotherapy treatment and R0 resection. Further investigations with a larger cohort are warranted.

Staging and restaging of advanced esophageal cancer

PURPOSE OF REVIEW

Esophageal cancer staging continues to evolve, especially for advanced cases. Computer tomography (CT) scan of the thorax and abdomen to detect metastatic disease, and endoscopic ultrasound with fine needle aspiration (EUS-FNA) remain the preferred methods. Several recent studies have evaluated alternative methods for locoregional and distant disease detection and staging.

RECENT FINDINGS

There seems to be emerging roles for fluorine-18 fluorodeoxyglucose (FDG)-PET, laparoscopic staging, and high-resolution T2-weighted MRI in esophageal cancer staging. Perfusion CT and FDG-PET and FDG-PET/CT may have an emerging role in assessing response to neoadjuvant therapy. Restaging following neoadjuvant therapy remains suboptimal. A 50% or more reduction of tumor thickness by EUS postchemotherapy continues to be the best measure for tumor downstaging survival, while FDG-PET/CT may be more accurate than EUS-FNA and CT scan for predicting nodal status and complete responders after neoadjuvant therapy. Potential methylation analysis, digital image analysis, and fluorescence in-situ hybridization on EUS-FNA samples may increase the yield and prove to be better than routine cytology.

SUMMARY

For advanced esophageal cancer, locoregional staging is best performed with EUS-FNA, with CT scan of the thorax and abdomen and FDG-PET, to detect metastatic disease. The role of EUS in restaging following neoadjuvant therapy remains controversial, with recent studies showing that FDG-PET/CT may be more accurate than EUS-FNA and CT scan for predicting nodal status and complete responders after neoadjuvant therapy.

A large series, resection controlled study to assess the value of radial EUS in restaging gastroesophageal cancer following neoadjuvant chemotherapy

The true value of endoscopic ultrasound (EUS) post-neoadjuvant chemotherapy for esophageal carcinoma is not established. Superior loco-regional detail may yield useful staging and prognostic information but information on its accuracy, as compared with computed tomography (CT), remains undefined and limited by small study size. We prospectively studied 109 patients with gastroesophageal cancer; 99 of whom were undergoing surgery. All had EUS and helical CT imaging before and after neoadjuvant chemotherapy and the results were compared with pathological staging of resected specimens. Tumor response was assessed by the reduction in maximal tumor depth at EUS and correlated with patient survival. There was no difference in T and N stage accuracies between EUS and CT following neoadjuvant chemotherapy. manova showed a reduction in maximal tumor depth by > 50% at EUS to be associated with longer survival (relative risk = 0.48, P < 0.05). EUS responders had a median survival of 38 months compared to 30 months for non-responders (P < 0.05). The identification of lymphadenopathy at radial EUS was not predictive of survival. This large series study demonstrates the staging accuracy of CT and non-biopsy EUS in the setting of neoadjuvant chemotherapy for gastroesophageal cancer to be equivalent and poor. An endosonography may contribute useful clinical information in respect of potential survival. It is questionable whether radial EUS should be included in protocols for restaging.

Value of complete metabolic response by 18F-fluorodeoxyglucose-positron emission tomography in oesophageal cancer for prediction of pathologic response and survival after preoperative chemoradiotherapy

We aimed to assess the ability of (18)F-fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan to predict pathologic complete response (CR) and survival in patients with oesophageal cancer treated with preoperative chemoradiotherapy (CRT). The study cohort consisted of 62 consecutive patients with operable oesophageal cancer who were treated with preoperative CRT followed by oesophagectomy. Endoscopy, computed tomography (CT) and PET were performed before and after CRT. Of the 62 patients, 56 (90%) patients responded to preoperative CRT. FDG-PET-determined complete metabolic response (CMR) was achieved by 33 patients (54.1%), whereas pathologic CR was achieved by 28 patients (45.2%). Compared with endoscopic biopsy or CT scan, CMR by FDG-PET showed the highest correlation with pathologic CR (concordance, 71%). At a median follow-up of 19.3 months (range, 3.9-57.1 months), median overall survival (OS) was not reached in patients with CMR compared to 22.4 months in patients who did not achieve CMR. Median disease free survival (DFS) was not reached in patients with CMR compared to 17.4 months in patients who did not achieve CMR. By multivariate analysis, CMR by FDG-PET was significantly associated with better DFS and OS (P=0.006, P=0.033, respectively). The variables associated with pre-CRT PET scan were not predictive of survival. In conclusion, CMR by FDG-PET has a significant correlation with pathologic CR and can predict the long-term outcome in oesophageal cancer patients undergoing CRT. Although surgery is standard treatment for respectable oesophageal cancer, currently even in patients with CMR, the addition of (18)F-FDG-PET could be used to select the patient subgroup not requiring surgery.

Role of positron emission tomography in the (re-)staging of oesophageal cancer

BACKGROUND

Various studies have demonstrated that 18F-Fluorodeoxyglucose-positron emission tomography (FDG-PET), measuring altered tissue glucose metabolism, is a promising non-invasive method for detecting both distant nodal and haematogenous metastases in patients with oesophageal carcinoma (OC) and might thus prevent futile esophagectomy. Moreover, FDG-PET is a promising tool in assessing response to non-surgical treatment, and might therefore be used for an early decision on whether treatment should be stopped or continued.

MATERIAL AND METHODS

Review of the recent literature regarding the diagnostic performance of FDG-PET in the preoperative staging of patients with OC and regarding diagnostic accuracy of FDG-PET in assessing response to neoadjuvant therapy in patients with OC compared to conventional techniques (especially computed tomography (CT) and endoscopic ultrasonography (EUS)).

RESULTS

A search of the literature resulted in the inclusion of 16 studies on the diagnostic value of FDG-PET. Sensitivity and specificity for the detection of locoregional metastases were moderate. Sensitivity and specificity were reasonable for distant metastases. The diagnostic accuracy of FDG-PET in assessing response to treatment was similar to the accuracy of EUS, but significantly higher than that of CT.

CONCLUSIONS

The staging value of FDG-PET in OC patients is limited in the detection of locoregional metastases; however; its value is higher in the detection of distant lymphatic and haematogenous metastases. Moreover, FDG-PET is a valuable tool for the non-invasive assessment of histopathologic tumour response after neoadjuvant therapy..

The preferred choice for radial endosonographic staging of esophageal cancer: standard echoendoscope or nonoptic esophagoprobe?

BACKGROUND

The nonoptic esophagoprobe has been reported to be comparable to the standard echoendoscope in esophageal cancer staging, with a superior advantage of traversing more stenotic tumors because of its smaller diameter. The aim of this study was to see whether its use in a general population of esophageal cancer patients confers any significant clinical benefit.

METHODS

Five hundred seventy-seven consecutive patients referred for initial locoregional staging of esophageal cancer were analyzed retrospectively. Comparisons were made between the standard echoendoscope and the esophagoprobe.

RESULTS

Complete staging (95.2% vs 77.5%; p < 0.001) was significantly higher in the esophagoprobe group compared with that of the standard echoendoscope group (315 and 262 patients, respectively). In 146 patients with histopathologic verification without prior chemotherapy or radiotherapy, the esophagoprobe was comparable in T-staging accuracy to the standard echoendoscope in those with traversable tumors (89.2% vs. 82.8%; p = 0.213). However, the presence of a nontraversable stricture significantly decreased standard echoendoscope T-staging accuracy compared with a traversable stricture (33.3% vs. 82.8%, respectively; p < 0.001). The esophagoprobe also picked more advanced tumors and distal nodes.

CONCLUSIONS

The esophagoprobe is more accurate than the standard echoendoscope in the T staging of esophageal cancer because of its higher likelihood of traversing tumor stenosis. It can potentially reduce the necessity for dilation in stenotic tumors by four to five times. We propose using the esophagoprobe as the first choice for radial endoscopic ultrasound staging of esophageal cancer.

Endoscopic ultrasonography in the diagnosis and management of cancer

Since its development and introduction to clinical practice, endoscopic ultrasonography (EUS) has progressed rapidly from being a purely imaging modality with limited use in the detection of small pancreatic cancers to one that can provide a tissue diagnosis by fine-needle aspiration (FNA) and deliver therapy. EUS has now firmly established a place as the investigation of choice in the diagnosis, locoregional staging and management of a wide range of gastrointestinal cancers. With the increasing use of FNA, the accuracy of EUS has substantially improved and may become a stand-alone investigation in some situations. However, it is recommended that a combination of information obtained from other imaging modalities and EUS is needed to maximize the accuracy, in particular to complete staging beyond locoregional stage. In addition to well-established indications, newer applications of EUS are emerging and are no longer limited to the gastrointestinal system. In lung cancer, EUS combined with endobronchial ultrasonography is emerging as an accurate, minimally invasive, nonsurgical alternative to staging of the mediastinum. Furthermore, the ability of EUS to acquire tissue safely and conveniently results in a potential role of the molecular diagnostics to enhance the performance of EUS-guided FNA. Besides a diagnostic role of EUS, there continues to be technological advances in the field of interventional EUS, with many potential applications under investigation. This review focuses on the current and future roles of EUS in the diagnosis and management of cancers.

Endoscopic ultrasound restaging after neoadjuvant chemotherapy in esophageal cancer

BACKGROUND

The role of endoscopic ultrasound (EUS) to evaluate treatment response postneoadjuvant therapy for restaging esophageal cancer prior to surgical resection is uncertain. Accuracy of EUS is lower but potential to predict response to chemoradiation indicates that EUS may be helpful prior to surgery.

OBJECTIVE

To determine staging accuracy of EUS after neoadjuvant chemotherapy, predictors of tumor response, and survival in locally advanced esophageal cancer.

METHODS

Single-center retrospective evaluation of patients with locally advanced esophageal cancer on a prospective chemotherapy study. Patients who underwent EUS without FNA pre- and postchemotherapy were included.

RESULTS

A total of 49 patients (43 men and 6 women) were evaluated with EUS pre- and postneoadjuvant chemotherapy. Forty-seven patients had tumor localized at the GE junction and two had mid-esophageal lesions. The median survival time was 53 months. Tumor and nodal staging accuracy postchemotherapy were 60% (27 of 45). T-stage accuracy postchemotherapy was superior in patients without a response to chemotherapy (95.7%vs 26.1%, p<0.0001). More than 50% in reduction of tumor thickness postchemotherapy was associated with tumor downstage and better survival. N0 disease on final pathology was the best predictor of improved survival.

CONCLUSION

Accuracy of EUS postchemotherapy is lower than initial staging accuracy; therefore the ability to predict downstaging based on EUS is marginal. Pathology N1 disease postchemotherapy is the best predictor of survival. EUS staging postneoadjuvant chemotherapy should focus on improving nodal staging accuracy with FNA.