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Cummings D, Wong J, Palm R, Hoffe S, Almhanna K, Vignesh S. Epidemiology, Diagnosis, Staging and Multimodal Therapy of Esophageal and Gastric Tumors. Cancers (Basel) 2021; 13:582. [PMID: 33540736 PMCID: PMC7867245 DOI: 10.3390/cancers13030582] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/14/2021] [Accepted: 01/25/2021] [Indexed: 02/06/2023] Open
Abstract
Gastric and esophageal tumors are diverse neoplasms that involve mucosal and submucosal tissue layers and include squamous cell carcinomas, adenocarcinomas, spindle cell neoplasms, neuroendocrine tumors, marginal B cell lymphomas, along with less common tumors. The worldwide burden of esophageal and gastric malignancies is significant, with esophageal and gastric cancer representing the ninth and fifth most common cancers, respectively. The approach to diagnosis and staging of these lesions is multimodal and includes a combination of gastrointestinal endoscopy, endoscopic ultrasound, and cross-sectional imaging. Likewise, therapy is multidisciplinary and combines therapeutic endoscopy, surgery, radiotherapy, and systemic chemotherapeutic tools. Future directions for diagnosis of esophageal and gastric malignancies are evolving rapidly and will involve advances in endoscopic and endosonographic techniques including tethered capsules, optical coherence tomography, along with targeted cytologic and serological analyses.
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Affiliation(s)
- Donelle Cummings
- Division of Gastroenterology and Hepatology, Department of Medicine, New York Medical College, New York City Health and Hospitals Corporation-Metropolitan Hospital Center, 1901 First Avenue, New York, NY 10029, USA;
| | - Joyce Wong
- Division of Surgery, Mid Atlantic Kaiser Permanente, 700 2nd St. NE, 6th Floor, Washington, DC 20002, USA;
| | - Russell Palm
- Department of Radiation Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (R.P.); (S.H.)
| | - Sarah Hoffe
- Department of Radiation Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (R.P.); (S.H.)
| | - Khaldoun Almhanna
- Division of Hematology/Oncology, Lifespan Cancer Institute, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, 593 Eddy St, George 312, Providence, RI 02903, USA;
| | - Shivakumar Vignesh
- Division of Gastroenterology and Hepatology, Department of Medicine, SUNY Downstate Health Sciences University, MSC 1196, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
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2
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Yang J, Liu X, Cao S, Dong X, Rao S, Cai K. Understanding Esophageal Cancer: The Challenges and Opportunities for the Next Decade. Front Oncol 2020; 10:1727. [PMID: 33014854 PMCID: PMC7511760 DOI: 10.3389/fonc.2020.01727] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/03/2020] [Indexed: 12/22/2022] Open
Abstract
Esophageal cancer (EC) is the seventh most common cancer worldwide with over 570,000 new cases annually. In China, the incidence of EC is particularly high where approximately 90% of cases are defined as esophageal squamous cell carcinoma (ESCC). Although various risk factors have been identified, the knowledge of genetic drivers for ESCC is still limited due to high mutational loading of the cancer and lack of appropriate EC models, resulting in inadequate treatment choices for EC patients. Currently, surgery, chemotherapy, radiation, and limited targeted therapy options can only bring dismal survival advantages; thus, the prognosis for ESCC is very poor. However, cancer immunotherapy has unleashed a new era of cancer treatment with extraordinary therapeutic benefits for cancer patients, including EC patients. This review discusses the latest understanding of the risk factors and clinical rational for EC treatment and provides accumulated information, which describes the ongoing development of immunotherapy for EC with a specific emphasis on ESCC, the most prevalent EC subtype in the Chinese population.
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Affiliation(s)
| | | | | | | | - Shuan Rao
- Department of Thoracic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Kaican Cai
- Department of Thoracic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
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3
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Tierney JF, Fisher DJ, Burdett S, Stewart LA, Parmar MKB. Comparison of aggregate and individual participant data approaches to meta-analysis of randomised trials: An observational study. PLoS Med 2020; 17:e1003019. [PMID: 32004320 PMCID: PMC6993967 DOI: 10.1371/journal.pmed.1003019] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 12/30/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND It remains unclear when standard systematic reviews and meta-analyses that rely on published aggregate data (AD) can provide robust clinical conclusions. We aimed to compare the results from a large cohort of systematic reviews and meta-analyses based on individual participant data (IPD) with meta-analyses of published AD, to establish when the latter are most likely to be reliable and when the IPD approach might be required. METHODS AND FINDINGS We used 18 cancer systematic reviews that included IPD meta-analyses: all of those completed and published by the Meta-analysis Group of the MRC Clinical Trials Unit from 1991 to 2010. We extracted or estimated hazard ratios (HRs) and standard errors (SEs) for survival from trial reports and compared these with IPD equivalents at both the trial and meta-analysis level. We also extracted or estimated the number of events. We used paired t tests to assess whether HRs and SEs from published AD differed on average from those from IPD. We assessed agreement, and whether this was associated with trial or meta-analysis characteristics, using the approach of Bland and Altman. The 18 systematic reviews comprised 238 unique trials or trial comparisons, including 37,082 participants. A HR and SE could be generated for 127 trials, representing 53% of the trials and approximately 79% of eligible participants. On average, trial HRs derived from published AD were slightly more in favour of the research interventions than those from IPD (HRAD to HRIPD ratio = 0.95, p = 0.007), but the limits of agreement show that for individual trials, the HRs could deviate substantially. These limits narrowed with an increasing number of participants (p < 0.001) or a greater number (p < 0.001) or proportion (p < 0.001) of events in the AD. On average, meta-analysis HRs from published AD slightly tended to favour the research interventions whether based on fixed-effect (HRAD to HRIPD ratio = 0.97, p = 0.088) or random-effects (HRAD to HRIPD ratio = 0.96, p = 0.044) models, but the limits of agreement show that for individual meta-analyses, agreement was much more variable. These limits tended to narrow with an increasing number (p = 0.077) or proportion of events (p = 0.11) in the AD. However, even when the information size of the AD was large, individual meta-analysis HRs could still differ from their IPD equivalents by a relative 10% in favour of the research intervention to 5% in favour of control. We utilised the results to construct a decision tree for assessing whether an AD meta-analysis includes sufficient information, and when estimates of effects are most likely to be reliable. A lack of power at the meta-analysis level may have prevented us identifying additional factors associated with the reliability of AD meta-analyses, and we cannot be sure that our results are generalisable to all outcomes and effect measures. CONCLUSIONS In this study we found that HRs from published AD were most likely to agree with those from IPD when the information size was large. Based on these findings, we provide guidance for determining systematically when standard AD meta-analysis will likely generate robust clinical conclusions, and when the IPD approach will add considerable value.
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Affiliation(s)
- Jayne F. Tierney
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - David J. Fisher
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Sarah Burdett
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
| | - Lesley A. Stewart
- Centre for Reviews and Dissemination, University of York, York, United Kingdom
| | - Mahesh K. B. Parmar
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, United Kingdom
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Moaven O, Wang TN. Combined Modality Therapy for Management of Esophageal Cancer: Current Approach Based on Experiences from East and West. Surg Clin North Am 2019; 99:479-499. [PMID: 31047037 DOI: 10.1016/j.suc.2019.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Human evolutionary genetic divergence and distinctive environmental exposures have contributed to the development of clinicopathologic variations of esophageal cancer in Eastern and Western countries. Different treatment strategies have derived from the disparate regional experiences. Treatment strategy is more standardized in the West. Trimodality treatment with neoadjuvant chemoradiation followed by surgery is widely accepted as the standard treatment of locally advanced esophageal adenocarcinoma and esophageal squamous cell carcinoma. Trimodality treatment has not been adopted in many Eastern countries, and standard treatment is neoadjuvant chemotherapy. Several randomized trials are ongoing that may alter the standard management of esophageal cancer worldwide.
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Affiliation(s)
- Omeed Moaven
- Division of Surgical Oncology, Department of Surgery, Wake Forest University, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Thomas N Wang
- Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, BDB 609, 1808 7th Avenue South, Birmingham, AL 35294-3411, USA.
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Chiappa A, Andreoni B, Dionigi R, Spaggiari L, Foschi D, Polvani G, Orecchia R, Fazio N, Pravettoni G, Cossu ML, Galetta D, Venturino M, Ferrari C, Macone L, Crosta C, Bonanni B, Biffi R. A rationale multidisciplinary approach for treatment of esophageal and gastroesophageal junction cancer: Accurate review of management and perspectives. Crit Rev Oncol Hematol 2018; 132:161-168. [PMID: 30447922 DOI: 10.1016/j.critrevonc.2018.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/22/2018] [Accepted: 10/09/2018] [Indexed: 01/28/2023] Open
Abstract
Cancer of the esophagus and of gastroesophageal junction can be cured, even if with lacking cure rate. Different approaches have been developed, mostly when carcinoma has loco-regional pattern. Multimodality therapy showed a survival rate superior than 10% if compared to a single approach. This is a systematic review, carried to assess the following matters: Which therapeutic opportunities are available? Who could benefit of them? Which adverse reactions could possibly verify? How can physicians definitely choose the proper strategy? Which is the role of surgery? We mean to give either General Practitioner or specialists clear and efficient updates about current treatment of this tumour, starting from physical examination. Four eminent guidelines were consulted for our study: Cancer Care Ontario's Program in Evidence-Based Care, NCCN, Belgian Health Care Knowledge Centre and Esmo.
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Affiliation(s)
- Antonio Chiappa
- Unit of Innovative Techniques in Surgery, European Institute of Oncology, University of Milan, Italy.
| | | | - Renzo Dionigi
- Department of Surgery, University of Insubria, Varese, Italy
| | - Lorenzo Spaggiari
- Department of Thoracic Surgery, European Institute of Oncology, University of Milan, Italy
| | - Diego Foschi
- Department of Surgery, "Luigi Sacco" Hospital, University of Milan, Italy
| | - Gianluca Polvani
- Cardiothoracic Surgery, "Monzino" Cardiologic Institute, University of Milan, Italy
| | - Roberto Orecchia
- Department of Radiotherapy, European Institute of Oncology, University of Milan, Italy
| | - Nicola Fazio
- Unit of Medical Oncology, European Institute of Oncology, Milan, Italy
| | - Gabriella Pravettoni
- Unit of Psycho-Oncology, European Institute of Oncology, University of Milan, Italy
| | - Maria Laura Cossu
- Division of General Surgery II, University Hospital of Sassari, Department of Clinical and Trial Medicine, University of Sassari, Italy
| | - Domenico Galetta
- Department of Thoracic Surgery, European Institute of Oncology, University of Milan, Italy
| | - Marco Venturino
- Division of Anaesthesiology European Institute of Oncology, Milan, Italy
| | - Carlo Ferrari
- Unit of Innovative Techniques in Surgery, European Institute of Oncology, University of Milan, Italy
| | - Lorenzo Macone
- Unit of Innovative Techniques in Surgery, European Institute of Oncology, University of Milan, Italy
| | - Cristiano Crosta
- Division of Endoscopy, European Institute of Oncology, Milan, Italy
| | - Bernardo Bonanni
- Division of Cancer Prevention, European Institute of Oncology, Milan, Italy
| | - Roberto Biffi
- Division of Digestive Tract Surgery, European Institute of Oncology, Milan, Italy
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6
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Tessa M, Rotta P, Ragona R, Sola B, Grassini M, Nassisi D, Sciacero P, Airoldi M, Filippi A, Gianello L, De Angelis C, Ozzello F, Trotti AB, Ricardi U, Sannazzari GL. Concomitant Chemotherapy and External Radiotherapy plus Brachytherapy for Locally Advanced Esophageal Cancer Results of a Retrospective Multicenter Study. TUMORI JOURNAL 2018; 91:406-14. [PMID: 16459637 DOI: 10.1177/030089160509100505] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims and Background In October 1995, the Piedmont AIRO (Italian Society of Radiation Oncology) Group started a multi-institutional study of radiochemotherapy on locally advanced esophageal cancer, characterized by external radiotherapy followed by an intraluminal high dose-rate brachytherapy boost. Most patients were re-evaluated for surgery at the end of the program. The primary aim of the study was to assess efficacy of curative radiochemotherapy regarding overall survival and local control rates. The secondary aim was to evaluate the ability of radiochemotherapy to make resectable lesions previously considered inoperable. Methods and Study Design Between January 1996 and March 2000, 75 patients with locally advanced esophageal cancer were enrolled. All were treated with definitive radiotherapy; due to age or high expected toxicity, chemotherapy was employed only in 53 of them. Treatment schedule consisted of 60 Gy external radiotherapy (180 cGy/d, 5 days/week for 7 weeks) concomitant with two 5-day cycles of chemotherapy with cisplatin and fluorouracil (weeks 1 and 5). One or two sessions of 5-7 Gy intraluminal high dose-rate brachytherapy were carried out on patients whose restaging showed a major tumor response. Surgery was performed in 14 patients. Results At the end of radiotherapy, dysphagia disappeared in 46/75 cases (61%), and in 20/75 (27%) a significant symptom reduction was recorded. Complete objective response at restaging after radiotherapy was obtained in 33% of patients and a partial response in 53%. At the end of the multimodal treatment program, including esophagectomy, complete responses were 34 (45%); 4 of 14 (28.5%) cases proved to be disease free (pTO) at pathological examination. No G3-G4 toxicity was recorded. Two- and 5-year overall survival rates of all patients were, respectively, 38% and 28%; 2- and 5-year local control rates were, respectively, 35% and 33%. In a subgroup of 20 nonsurgical patients in complete response after radiochemotherapy, the overall survival rate at 3 and 5 years was 65% and the local control rate at 3 and 5 years was 75%. According to multivariate analysis, prognostic factors for survival were Karnofsky index and esophagectomy. Conclusions For patients with locally advanced disease, radiochemotherapy showed improved clinical and pathologic tumor response and survival compared to surgery or radiotherapy alone. Intraluminal brachytherapy with a small fraction size allows an increased dose to the tumor without higher toxicity. Esophagectomy following radiochemotherapy could improve survival rates compared to definitive radiochemotherapy, but it is necessary to optimize selection criteria for surgery at the re-evaluation phase.
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Affiliation(s)
- Maria Tessa
- Department of Radiotherapy, University of Turin, Italy.
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7
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Tu CC, Hsu PK. The frontline of esophageal cancer treatment: questions to be asked and answered. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:83. [PMID: 29666806 DOI: 10.21037/atm.2017.10.31] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Achieving a good treatment for esophageal cancer is a great challenge. For early stage cancer, endoscopic treatment is considered the first line and a possible curative therapy. Chemotherapy, radiotherapy, and surgery are all used for the treatment of locally advanced esophageal cancer, administered either alone or combined. Some combinations have proven to be feasible, effective, and superior, such as neoadjuvant chemoradiation (CRT) plus surgery in the Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) trial. However, other strategies such as perioperative chemotherapy or definitive chemoradiation also have demonstrated substantial effectiveness. The current article addresses the following questions: (I) how can a choice between different multi-modality treatments be made; (II) is there enough evidence to compare the merits of the different strategies; and (III) is there any new evidence to improve the current practice. Moreover, in this article, existing evidence for treatment strategies for locally advanced esophageal cancer have been reviewed.
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Affiliation(s)
- Cheng-Che Tu
- Division of Thoracic Surgery, Department of Surgery, Chang Bing Show Chwan Memorial Hospital, Changhua
| | - Po-Kuei Hsu
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei
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8
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Franco P, Arcadipane F, Strignano P, Spadi R, Trino E, Martini S, Iorio GC, Satolli MA, Airoldi M, Romagnoli R, Camandona M, Ricardi U. Pre-operative treatments for adenocarcinoma of the lower oesophagus and gastro-oesophageal junction: a review of the current evidence from randomized trials. Med Oncol 2017; 34:40. [PMID: 28176241 DOI: 10.1007/s12032-017-0898-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 01/31/2017] [Indexed: 01/03/2023]
Abstract
Adenocarcinomas of the lower oesophagus and gastro-oesophageal junction are a complex clinico-pathological setting. Multimodality therapy is considered mandatory in most disease presentations. Nevertheless, the most appropriate treatment package has yet to be established. We herein summarize the evidence derived from randomized phase III trials on pre-operative treatments in this oncological scenario.
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Affiliation(s)
- Pierfrancesco Franco
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy.
| | - Francesca Arcadipane
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy
| | - Paolo Strignano
- Department of Surgical Sciences, General Surgery 2U and Liver Transplantation Center, University of Turin, Turin, Italy
| | - Rosella Spadi
- Department of Oncology, Medical Oncology 1, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Elisabetta Trino
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy
| | - Stefania Martini
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy
| | - Giuseppe Carlo Iorio
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy
| | | | - Mario Airoldi
- Department of Oncology, Medical Oncology 2, AOU Citta' della Salute e della Scienza, Turin, Italy
| | - Renato Romagnoli
- Department of Surgical Sciences, General Surgery 2U and Liver Transplantation Center, University of Turin, Turin, Italy
| | - Michele Camandona
- Department of Surgical Sciences, General Surgery 1U, University of Turin, Turin, Italy
| | - Umberto Ricardi
- Department of Oncology, Radiation Oncology, University of Turin, Via Genova 3, 10126, Turin, Italy
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9
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Cao J, Yuan P, Wang L, Wang Y, Ma H, Yuan X, Lv W, Hu J. Clinical Nomogram for Predicting Survival of Esophageal Cancer Patients after Esophagectomy. Sci Rep 2016; 6:26684. [PMID: 27215834 PMCID: PMC4877645 DOI: 10.1038/srep26684] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/04/2016] [Indexed: 12/22/2022] Open
Abstract
The aim of this study was to construct an effective clinical nomogram for predicting the survival of esophageal cancer patients after esophagectomy. We identified esophageal cancer patients (n = 4,281) who underwent esophagectomy between 1988 and 2007 from the Surveillance, Epidemiology, and End Results (SEER) 18 registries database. Clinically significant parameters for survival were used to construct a nomogram based on Cox regression analyses. The model was validated using bootstrap resampling and a Chinese cohort (n = 145). A total of 4,109 patients from the SEER database were included for analysis. The multivariate analyses showed that the factors of age, race, histology, tumor site, tumor size, grade and depth of invasion, and the numbers of metastases and retrieved nodes were independent prognostic factors. All of these factors were selected into the nomogram. The nomogram showed a clear prognostic superiority over the seventh AJCC-TNM classification (C-index: SEER cohort, 0.716 vs 0.693, respectively; P < 0.01; Chinese cohort, 0.699 vs 0.680, respectively; P < 0.01). Calibration of the nomogram predicted the probabilities of 3- and 5-year survival, which corresponded closely with the actual survival rates. This novel prognostic model may improve clinicians’ abilities to predict individualized survival and to make treatment recommendations.
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Affiliation(s)
- Jinlin Cao
- Department of Thoracic Surgery, The first Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ping Yuan
- Department of Thoracic Surgery, The first Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Luming Wang
- Department of Thoracic Surgery, The first Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yiqing Wang
- Department of Thoracic Surgery, The first Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Honghai Ma
- Department of Thoracic Surgery, The first Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaoshuai Yuan
- Department of Thoracic Surgery, The first Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wang Lv
- Department of Thoracic Surgery, The first Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jian Hu
- Department of Thoracic Surgery, The first Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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10
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Combined Modality Therapy for Thoracic and head and Neck Cancers: A Review of Updated Literature Based on a Consensus Meeting. TUMORI JOURNAL 2016; 102:459-471. [DOI: 10.5301/tj.5000525] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2016] [Indexed: 12/25/2022]
Abstract
Purpose Combined modality therapy is a mainstay option for thoracic malignancies and head and neck cancers. The integration of different strategies is based on the multidisciplinary approach of modern clinical oncology. Radiation oncologists have to be educated, trained, and updated to provide state-of-the-art care to cancer patients and thus educational meetings are crucial. Methods The Italian Association of Radiation Oncology Young Members Working Group (AIRO Giovani) organized its 8th national meeting, focused on combination therapy in lung, esophageal, and head and neck cancer (with a specific focus on larynx-preservation strategies for larynx/hypopharynx tumors), involving young professionals working in Italy. The meeting was addressed to young radiation oncologists, presenting state-of-the-art knowledge, based on the latest evidence in this field. We performed a review of the current literature based on the highlights of the Congress. Results The multimodality approach of head and neck and thoracic malignancies includes surgery, chemotherapy, and radiotherapy, but also has to take into account new information and data coming from basic and translational research and including molecular biology, genetics, and immunology. All these aspects are crucial for the treatment of non-small-cell lung cancer and esophageal, esophagogastric junction, and larynx/hypopharynx malignancies. The integration of different treatments in the clinical decision-making process to combine therapies is crucial. Conclusions Combination therapy has proved to be a consolidated approach in these specific oncologic settings, highlighting the importance of multimodality management in modern clinical oncology. Dedicated meetings on specific topics are helpful to improve knowledge and skills of young professionals in radiation oncology.
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11
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Ruffier-Loubière A, Janoray G, Chapet S, de Calan L, Dumont P, Dorval É, Orain I, Calais G. [Long-term outcome of neoadjuvant radiochemotherapy followed by surgery for esophageal cancer: a single institution retrospective study of 102 patients]. Cancer Radiother 2015. [PMID: 26215366 DOI: 10.1016/j.canrad.2015.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE AND OBJECTIVES To report survival and morbidity of a large homogeneous cohort of patients with a locally advanced esophageal or cardia carcinoma and put in evidence predictive factors of locoregional control and survival. PATIENTS AND METHODS Hundred and two patients were treated at the university hospital of Tours between 1990 and 2010 and received neo-adjuvant chemoradiation therapy with external irradiation (40Gy-44Gy) and two courses of chemotherapy (5-fluoro-uracile and cisplatine). Esophagectomy associated with lymph node dissection was performed about ten weeks after the end of chemoradiation therapy. RESULTS The median follow-up was 22.4 months [6-185 months]. The overall survival rates at 2 and 5years were 53% and 27%, respectively. The median overall survival was estimated at 27months. The overall 2-year survival between patients "responders" and patients "non-responders" was 67% vs 26%, respectively (P<0.0001). In case of histological response, there was a benefit in terms of overall survival (P<0.0001), locoregional control (P<0.0036) and disease-free survival (P<0.001). Overall survival at 2years was 64% for ypN0 group vs 32% for ypN1 group (P<0.0001). The median survival was estimated at 37months against 15months in the absence of lymph node involvement (P<0.0001). CONCLUSION Our results in terms of survival, tolerance and morbidity and mortality were comparable to those in the literature. Complete histological response of lymph node was associated with an improvement of local control, disease-free survival and overall survival.
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Affiliation(s)
- A Ruffier-Loubière
- Clinique d'oncologie-radiothérapie, hôpital Bretonneau, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France
| | - G Janoray
- Clinique d'oncologie-radiothérapie, hôpital Bretonneau, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France.
| | - S Chapet
- Clinique d'oncologie-radiothérapie, hôpital Bretonneau, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France
| | - L de Calan
- Service de chirurgie digestive, hôpital Trousseau, CHRU de Tours, avenue de la République, 37170 Chambray-les-Tours, France
| | - P Dumont
- Service de chirurgie thoracique, hôpital Trousseau, CHRU de Tours, avenue de la République, 37170 Chambray-les-Tours, France
| | - É Dorval
- Service de gastroentérologie, hôpital Trousseau, CHRU de Tours, avenue de la République, 37170 Chambray-les-Tours, France
| | - I Orain
- Service d'anatomopathologie, hôpital Trousseau, CHRU de Tours, avenue de la République, 37170 Chambray-les-Tours, France
| | - G Calais
- Clinique d'oncologie-radiothérapie, hôpital Bretonneau, CHRU de Tours, 2, boulevard Tonnellé, 37044 Tours cedex 9, France
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12
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Purwar P, Bambarkar S, Jiwnani S, Karimundackal G, Laskar SG, Pramesh CS. Multimodality management of esophageal cancer. Indian J Surg 2014; 76:494-503. [PMID: 25614726 PMCID: PMC4298001 DOI: 10.1007/s12262-014-1163-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 08/26/2014] [Indexed: 12/16/2022] Open
Abstract
Esophageal cancer is a morbid disease with a grim prognosis. The outcomes of treatment even in non-metastatic disease undergoing potentially curative surgery are poor with 5-year survival ranging from 20 to 35 %. Several multimodality treatment options have been investigated in well-conducted randomised trials and meta-analyses evaluating both neoadjuvant and adjuvant therapies. However, there is still lack of uniform practice in the management of operable esophageal cancer. We review the current evidence for multimodality treatment of esophageal cancer, critically analysing the evidence supporting the use of each strategy, the pros and cons of each approach and discuss our approach in management. Neoadjuvant chemotherapy or chemoradiotherapy are currently the standard of care in localised esophageal cancer.
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Affiliation(s)
- Pallavi Purwar
- />Thoracic Oncology Disease Management Group, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, 400012 India
| | - Supriya Bambarkar
- />Thoracic Oncology Disease Management Group, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, 400012 India
| | - Sabita Jiwnani
- />Thoracic Oncology Disease Management Group, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, 400012 India
| | - George Karimundackal
- />Thoracic Oncology Disease Management Group, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, 400012 India
| | - Sarbani Ghosh Laskar
- />Thoracic Oncology Disease Management Group, Department of Radiation Oncology, Tata Memorial Centre, Mumbai, 400012 India
| | - C. S. Pramesh
- />Thoracic Oncology Disease Management Group, Department of Surgical Oncology, Tata Memorial Centre, Mumbai, 400012 India
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13
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Cellini F, Morganti AG, Di Matteo FM, Mattiucci GC, Valentini V. Clinical management of gastroesophageal junction tumors: past and recent evidences for the role of radiotherapy in the multidisciplinary approach. Radiat Oncol 2014; 9:45. [PMID: 24499595 PMCID: PMC3942272 DOI: 10.1186/1748-717x-9-45] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 02/01/2014] [Indexed: 11/16/2022] Open
Abstract
Gastroesophageal cancers (such as esophageal, gastric and gastroesophageal-junction -GEJ- lesions) are worldwide a leading cause of death being relatively rare but highly aggressive. In the past years, a clear shift in the location of upper gastrointestinal tract tumors has been recorded, both affecting the scientific research and the modern clinical practice. The integration of pre- or peri-operative multimodal approaches, as radiotherapy and chemotherapy (often combined), seems promising to further improve clinical outcome for such presentations. In the past, the definition of GEJ led to controversies and confusion: GEJ tumors have been managed either grouped to gastric or esophageal lesions, following slightly different surgical, radiotherapeutic and systemic approaches. Recently, the American Joint Committee on Cancer (AJCC) changed the staging and classification system of GEJ to harmonize some staging issues for esophageal and gastric cancer. This review discusses the most relevant historical and recent evidences of neoadjuvant treatment involving Radiotherapy for GEJ tumors, and describes the efficacy of such treatment in the frame of multimodal integrated therapies, from the new point of view of the recent classification of such tumors.
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Affiliation(s)
- Francesco Cellini
- Radiation Oncology, Policlinico Universitario Campus Bio-Medico, Via Álvaro del Portillo, 200, 00144 Rome, Italy
| | - Alessio G Morganti
- Radiotherapy Department, Fondazione di Ricerca e Cura “Giovanni Paolo II”, Largo Agostino Gemelli 1, 86100 Campobasso, Italy
- Radiation Oncology Department, Policlinico Universitario “A. Gemelli”, Universita` Cattolica del Sacro Cuore, L.go Francesco Vito 1, 00168 Rome, Italy
| | - Francesco M Di Matteo
- GI Endoscopy Unit, Policlinico Universitario Campus Bio-Medico University, Via Alvaro del Portillo 200, 00128 Rome, Italy
| | - Gian Carlo Mattiucci
- Radiation Oncology Department, Policlinico Universitario “A. Gemelli”, Universita` Cattolica del Sacro Cuore, L.go Francesco Vito 1, 00168 Rome, Italy
| | - Vincenzo Valentini
- Radiation Oncology Department, Policlinico Universitario “A. Gemelli”, Universita` Cattolica del Sacro Cuore, L.go Francesco Vito 1, 00168 Rome, Italy
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14
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Abstract
Despite advances in treatment, long-term outcomes for esophageal cancer remain poor, with overall survival rates of between 15% and 35%. Poor long-term survival reflects locoregionally advanced disease or metastatic disease at presentation. Among patients undergoing surgical resection, 40% to 50% have stage III disease. Surgery alone results in poor locoregional control and poor long-term outcomes, with survival rates ranging from 10% to 30%. Induction therapy combining surgery with chemotherapy with or without radiotherapy attempts to improve long-term survival in these patients. This article examines the merits of various modalities of induction therapy for patients with locally advanced esophageal cancer.
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Affiliation(s)
- Subroto Paul
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY 10065, USA
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15
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Orditura M, Galizia G, Fabozzi A, Lieto E, Gambardella V, Morgillo F, Del Genio GM, Fei L, Di Martino N, Renda A, Ciardiello F, De Vita F. Preoperative treatment of locally advanced esophageal carcinoma (Review). Int J Oncol 2013; 43:1745-53. [PMID: 24100679 DOI: 10.3892/ijo.2013.2118] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 07/30/2013] [Indexed: 11/06/2022] Open
Abstract
Esophageal cancer (EC) is an aggressive malignancy with increasing incidence worldwide. Surgery is still the most effective treatment, however, both the high rate of local and distant recurrences and surgery-related complications led us to investigate new preoperative strategies. In this review, we discuss the role of neoadjuvant therapy for locally advanced EC with a focus on preoperative chemoradiation (trimodality treatment). Furthermore, the last fifteen years of published literature and our experience have been also reviewed. In the preoperative setting, few trials have reported a significant benefit with fluoropyrimidine and platinum compound-based neoadjuvant chemotherapy, compared to surgery alone. A large number of phase III trials and meta-analyses have demonstrated improved outcomes with preoperative chemoradiation vs. neoadjuvant chemotherapy or surgery alone. Therefore, trimodality therapy can be considered the most effective option in the management of locally advanced EC. Addition of drugs targeting VEGF or HER2 to standard chemotherapy appears to be feasible but needs to be explored more accurately. FDG-PET may predict both response to neoadjuvant treatments and prognosis.
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Affiliation(s)
- Michele Orditura
- Division of Medical Oncology, 'F. Magrassi - A. Lanzara' Department of Clinical and Experimental Medicine and Surgery, Second University of Naples, School of Medicine, Naples, Italy
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16
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Monjazeb AM, Blackstock AW. The impact of multimodality therapy of distal esophageal and gastroesophageal junction adenocarcinomas on treatment-related toxicity and complications. Semin Radiat Oncol 2013. [PMID: 23207048 DOI: 10.1016/j.semradonc.2012.09.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The benefit of multimodality therapy is clearly established for adenocarcinomas of the distal esophagus and gastroesophageal junction, but its impact on toxicity is not well defined. We reviewed data from prospective randomized trials to better define the risks of multimodality therapy. The rates of surgical mortality and complications range from 0% to 10% and 23% to 49%, respectively. Multimodality therapy increases acute toxicity. The rate of severe acute hematologic toxicity varies considerably between trials (3%-78%) and appears to be primarily attributable to chemotherapy. Common severe acute nonhematologic toxicities include esophagitis (16%-63%), infection (2%-30%), pain (3%-24%), and gastrointestinal (6%-60%) and cardiac (3%-19%) events. The individual contribution of each modality to nonhematologic toxicities is unclear, but toxicity is increased when adding radiosensitizing chemotherapy to radiotherapy. There is an acute decrease in quality of life with multimodality therapy; however, quality of life usually returns to, or exceeds, baseline by 12 months after therapy. Late toxicities are less well defined, but commonly include esophageal, pulmonary, and cardiac toxicities.
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Affiliation(s)
- Arta Monir Monjazeb
- Department of Radiation Oncology, UC Davis Comprehensive Cancer Center, Sacramento, CA 95816, USA.
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17
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Mcloughlin JM, Lewis JM, Meredith KL. The Impact of Age on Morbidity and Mortality following Esophagectomy for Esophageal Cancer. Cancer Control 2013; 20:144-50. [DOI: 10.1177/107327481302000208] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background In patients with esophageal cancer, treatment decisions often involve a balance between a high-risk procedure and the chance for long-term benefit. The decision can be additionally challenging for elderly patients since some studies have reported an increased incidence of morbidity and mortality in this age group, and data are not clear on the overall benefit of multimodality therapy. Methods To investigate the management and outcomes associated with esophagectomy in elderly patients with esophageal cancer, we performed a review of the literature as well as an analysis of our own institutional data, with a focus on the impact of age on surgical outcomes. We examined type of surgery, neoadjuvant and adjuvant therapy, postoperative complications, length of hospitalization, and mortality as variables in elderly patients with esophageal cancer. Results When assessing the impact of age on the success of esophagectomy, several studies have concluded that advanced age itself is not a predictor of outcomes as much as associated comorbidities are. Our own experience suggests that age is not associated with adverse outcomes when controlling for patient comorbidities. This finding is similar to data reported elsewhere. Conclusions When considering treatment for patients of advanced age, the risks of treatment should be compared with the survival benefits of the therapy prescribed, taking into account additional factors such as poor performance status, existing comorbidities, and residual tumor following neoadjuvant therapy. Many reports, as well as our own experience, have concluded that when adjusted for comorbidities, patient age does not significantly affect outcomes.
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Affiliation(s)
- James M. Mcloughlin
- Department of Surgery of the Division of Surgical Oncology, University of Tennessee, Knoxville, Tennessee
| | - James M. Lewis
- Department of Surgery of the Division of Surgical Oncology, University of Tennessee, Knoxville, Tennessee
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18
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Li BZ, Chen ZL, Shi SS, Feng XL, Tan XG, Zhou F, He J. Overexpression of Cdc25C predicts response to radiotherapy and survival in esophageal squamous cell carcinoma patients treated with radiotherapy followed by surgery. CHINESE JOURNAL OF CANCER 2013; 32:403-9. [PMID: 23470146 PMCID: PMC3845600 DOI: 10.5732/cjc.012.10233] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Biomarker identification is crucial for the selection of patients who might benefit from radiotherapy. To explore potential markers for response and prognosis in patients with locally advanced esophageal carcinoma treated with radiotherapy followed by surgery, we evaluated the expression of cell cycle checkpoint-related proteins Chk2, Cdc25C, and Cyclin D1. A total of 56 patients with locally advanced esophageal squamous cell carcinoma were treated with radiotherapy followed by surgery. Pretreatment tumor biopsy specimens were analyzed for Chk2, Cdc25C, and Cyclin D1 expression by immunohistochemistry. High expression of Chk2, Cyclin D1, and Cdc25C was observed in 44 (78.6%), 15 (26.8%), and 27 (48.2%) patients, respectively. The median survival was 16 months (range, 3–154 months), with a 5-year overall survival rate of 19.6%. Overexpression of Chk2 was associated with smoking (P = 0.021), overexpression of Cdc25C was associated with patient age (P = 0.033) and tumor length (P = 0.001), and overexpression of Cdc25C was associated with pathologic complete response (P = 0.038). Univariate analysis demonstrated that overexpression of Cdc25C and pathologic complete response was associated with better survival. In multivariate analysis, Cdc25C was the most significant independent predictor of better survival (P = 0.014) for patients treated with radiotherapy followed by surgery. Overexpression of Cdc25C was significantly associated with pathologic complete response and better survival of patients with locally advanced esophageal cancer treated with radiotherapy followed by surgery. These results suggest that Cdc25C may be a biomarker of treatment response and good prognosis for esophageal carcinoma patients. Thus, immunohistochemical staining of Cdc25C in a pretreatment specimen may be a useful method of identifying optimal treatment for patients with esophageal carcinoma.
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Affiliation(s)
- Bao-Zhong Li
- Departments of Thoracic Surgery, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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19
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Zhang Z, Li Y, Guan X, Yang X, Yang X, Li S, Zou X. Human leukocyte antigen class I on peripheral blood mononuclear cells as a non-invasive biomarker for esophageal cancer. Dis Esophagus 2012; 25:273-8. [PMID: 21951768 DOI: 10.1111/j.1442-2050.2011.01245.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal cancer (EC) is a common malignant cancer threatening people's health. There are no universally accepted parameters for its early diagnosis. The aim of this study was to observe the expression of human leukocyte antigen class I (HLA-I) on peripheral blood mononuclear cells (PBMCs) of EC patients and in individuals of high-incidence area of EC so as to evaluate the feasibility of using this parameter as a potential non-invasive biomarker for the early diagnosis of EC. The present study enrolled 58 pathological confirmed EC patients, 46 patients with benign esophageal disease, and 65 healthy volunteers. Expression levels of HLA-I protein and mRNA on PBMCs were determined by flow cytometry and quantitative reverse transcriptase polymerase chain reaction, respectively. Then, 181 volunteers from Lijiadian, a village with high morbidity of EC, and 153 age- and gender-matched health volunteers were involved in this study to observe HLA-I expressions in individuals of high-incidence area of EC. Compared with benign esophageal disease and health volunteers, the expressions of HLA-I protein and mRNA on PBMCs of EC patients are significantly decreased, especially in patients with stage III and IV EC, but was not influenced by patient's age and gender. Furthermore, individuals of high-incidence area of EC also show downregulated HLA-I protein, but not mRNA, expression on PBMCs. Altogether, HLA-I expression on PBMCs of EC patients and individuals from high-incidence area of EC is downregulated, and this parameter might be used as a potential predictor of EC.
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Affiliation(s)
- Z Zhang
- Department of Health Examination Center, Qilu Hospital, Shandong University, Jinan, China.
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20
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Retrospective review of patients with locally advanced esophageal cancer treated at the University of Pittsburgh. Am J Clin Oncol 2012; 34:587-92. [PMID: 22101387 DOI: 10.1097/coc.0b013e3181f942af] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES The management of locally advanced esophageal cancer is controversial. Treatment options include neoadjuvant chemotherapy or chemoradiation therapy (CRT) followed by definitive surgery or definitive chemoradiation. A single center experience was reviewed to determine the oncologic outcomes of these 3 approaches. METHODS We retrospectively reviewed records of 100 patients with adenocarcinoma and squamous cell carcinoma of the esophagus of which 22 patients received neoadjuvant chemotherapy, 49 patients received neoadjuvant CRT, and 18 patients received definitive CRT. The majority of patients underwent minimally invasive esophagectomy (74%). The mean follow-up was 34 months (median, 22 mo; range, 1 to 180 mo). RESULTS Median survival of the entire group was 22.9 months [95% confidence interval (CI) 19.3-30.4]. The 2-year and 5-year overall survival rates were 47.9% and 23.2%, respectively. Median survival of patients who received neoadjuvant chemotherapy, neoadjuvant CRT, and definitive CRT was 31.9 (95% CI 21.2-51.5), 28.7 (95% CI 20.2-40.7), and 8.9 (95% CI 5.7-14.4) months, respectively. Patients who received neoadjuvant CRT were more likely to have pathologic complete response (pCR) (20%) compared with patients who received neoadjuvant chemotherapy alone (0%; P=0.04). The 2-year and 5-year overall survival rates of patients with pCR were 75% and 50%, respectively. CONCLUSIONS There was no survival benefit or differences in failure pattern seen among the 3 treatment approaches in this series. However, patients who received neoadjuvant CRT were more likely to have pCR and these patients showed a trend toward improved survival.
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21
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Abstract
The incidence of esophageal adenocarcinoma is increasing in Western countries with a tendency to exceed that of squamous-cell carcinoma. Prognosis is unfavorable with 5-year survival less than 15%, irrespective of treatment and the stage. At the time of diagnosis, more than two thirds of patients have a non-operable cancer because of extension or associated co-morbidities. Most studies have included different tumoral locations (esophagus and stomach) and different histological types (adenocarcinoma and squamous-cell carcinoma), making it difficult to interpret results. Surgery is currently the standard treatment for small tumors. Surgery should be preceded by neo-adjuvant treatment for patients with locally advanced resectable tumors, either preoperative chemotherapy or preoperative chemoradiation therapy. The therapeutic choice should be decided during multidisciplinary meetings according to patient and tumor characteristics and the expertise of the center. For patients with contraindications to surgery, exclusive chemoradiation therapy is recommended. Herein we reviewed and synthesized the different therapeutic strategies for esophageal adenocarcinoma.
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22
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Wolf MC, Stahl M, Krause BJ, Bonavina L, Bruns C, Belka C, Zehentmayr F. Curative treatment of oesophageal carcinoma: current options and future developments. Radiat Oncol 2011; 6:55. [PMID: 21615894 PMCID: PMC3127782 DOI: 10.1186/1748-717x-6-55] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Accepted: 05/26/2011] [Indexed: 12/16/2022] Open
Abstract
Since the 1980s major advances in surgery, radiotherapy and chemotherapy have established multimodal approaches as curative treatment options for oesophageal cancer. In addition the introduction of functional imaging modalities such as PET-CT created new opportunities for a more adequate patient selection and therapy response assessment. The majority of oesophageal carcinomas are represented by two histologies: squamous cell carcinoma and adenocarcinoma. In recent years an epidemiological shift towards the latter was observed. From a surgical point of view, adenocarcinomas, which are usually located in the distal third of the oesophagus, may be treated with a transhiatal resection, whereas squamous cell carcinomas, which are typically found in the middle and the upper third, require a transthoracic approach. Since overall survival after surgery alone is poor, multimodality approaches have been developed. At least for patients with locally advanced tumors, surgery alone can no longer be advocated as routine treatment. Nowadays, scientific interest is focused on tumor response to induction radiochemotherapy. A neoadjuvant approach includes the early and accurate assessment of clinical response, optimally performed by repeated PET-CT imaging and endoscopic ultrasound, which may permit early adaption of the therapeutic concept. Patients with SCC that show clinical response by PET CT are considered to have a better prognosis, regardless of whether surgery will be performed or not. In non-responding patients salvage surgery improves survival, especially if complete resection is achieved.
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Affiliation(s)
- Maria C Wolf
- Klinik und Poliklinik für Strahlentherapie und Radioonkologie, Ludwig-Maximilians Universität München, Germany.
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23
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Bowden J, Tierney JF, Copas AJ, Burdett S. Quantifying, displaying and accounting for heterogeneity in the meta-analysis of RCTs using standard and generalised Q statistics. BMC Med Res Methodol 2011; 11:41. [PMID: 21473747 PMCID: PMC3102034 DOI: 10.1186/1471-2288-11-41] [Citation(s) in RCA: 354] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2010] [Accepted: 04/07/2011] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Clinical researchers have often preferred to use a fixed effects model for the primary interpretation of a meta-analysis. Heterogeneity is usually assessed via the well known Q and I2 statistics, along with the random effects estimate they imply. In recent years, alternative methods for quantifying heterogeneity have been proposed, that are based on a 'generalised' Q statistic. METHODS We review 18 IPD meta-analyses of RCTs into treatments for cancer, in order to quantify the amount of heterogeneity present and also to discuss practical methods for explaining heterogeneity. RESULTS Differing results were obtained when the standard Q and I2 statistics were used to test for the presence of heterogeneity. The two meta-analyses with the largest amount of heterogeneity were investigated further, and on inspection the straightforward application of a random effects model was not deemed appropriate. Compared to the standard Q statistic, the generalised Q statistic provided a more accurate platform for estimating the amount of heterogeneity in the 18 meta-analyses. CONCLUSIONS Explaining heterogeneity via the pre-specification of trial subgroups, graphical diagnostic tools and sensitivity analyses produced a more desirable outcome than an automatic application of the random effects model. Generalised Q statistic methods for quantifying and adjusting for heterogeneity should be incorporated as standard into statistical software. Software is provided to help achieve this aim.
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Affiliation(s)
- Jack Bowden
- MRC Clinical Trials Unit, 222 Euston Road, London NW1 2DA, UK
- MRC Biostatistics Unit, Robinson Way, Cambridge, CB2 0SR, UK
| | - Jayne F Tierney
- MRC Clinical Trials Unit, 222 Euston Road, London NW1 2DA, UK
| | - Andrew J Copas
- MRC Clinical Trials Unit, 222 Euston Road, London NW1 2DA, UK
| | - Sarah Burdett
- MRC Clinical Trials Unit, 222 Euston Road, London NW1 2DA, UK
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24
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Tsuchikawa T, Ikeda H, Cho Y, Miyamoto M, Shichinohe T, Hirano S, Kondo S. Association of CD8+ T cell infiltration in oesophageal carcinoma lesions with human leucocyte antigen (HLA) class I antigen expression and survival. Clin Exp Immunol 2011; 164:50-6. [PMID: 21352198 DOI: 10.1111/j.1365-2249.2010.04311.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Oesophageal cancer is one of the most aggressive tumours with a poor prognosis. However, little is known about the immune response in the tumour microenvironment. To investigate the role of immunosurveillance in the clinical course of oesophageal squamous cell carcinoma, 98 formalin-fixed, paraffin-embedded primary tumours were analysed using immunohistochemical methods for human leucocyte antigen (HLA) class I heavy chain and β2-microglobulin expression and for CD4-, CD8- and CD57-positive cell infiltration. HLA class I expression of tumour cells was correlated positively with infiltration of CD8(+) T cells into the cancer nest, but not with the clinical course of disease. However, CD8(+) and CD4(+) T cell infiltration was correlated with prognosis. These results suggest that tumour antigen-specific cellular immune response plays a role in the clinical course of the disease and that HLA class I antigen expressed on tumour cells contribute to this association most probably by mediating the interactions between tumour cells and CD8(+) T cells.
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Affiliation(s)
- T Tsuchikawa
- Department of Surgical Oncology, Division of Cancer Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
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Mukherjee K, Chakravarthy AB, Goff LW, El-Rifai W. Esophageal adenocarcinoma: treatment modalities in the era of targeted therapy. Dig Dis Sci 2010; 55:3304-14. [PMID: 20300841 PMCID: PMC2890301 DOI: 10.1007/s10620-010-1187-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Accepted: 03/01/2010] [Indexed: 12/16/2022]
Abstract
Esophageal adenocarcinoma is an aggressive malignancy with a poor outcome, and its incidence continues to rise at an alarming rate. Current treatment strategies combining chemotherapy, radiation, and surgery are plagued with high rates of recurrence and metastasis. Multiple molecular pathways including the epidermal growth factor receptor, vascular endothelial growth factor, v-erb-b2 erythroblastic leukemia viral oncogene homolog (ERBB2), and Aurora kinase pathways are activated in many esophageal adenocarcinomas. In many cases, these pathways have critical roles in tumor progression. Research on the mechanisms by which these pathways contribute to disease progression has resulted in numerous biologic agents and small molecules with the potential to improve outcome. The promise of targeted therapy and personalized medicine in improving the clinical outcome is now closer than it has ever been.
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Affiliation(s)
- Kaushik Mukherjee
- Department of Surgery, Vanderbilt University Medical Center and Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - A. Bapsi Chakravarthy
- Department of Radiation Oncology, Vanderbilt University Medical Center and Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Laura W. Goff
- Division of Medical Oncology, Vanderbilt University Medical Center and Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Wael El-Rifai
- Department of Surgery, Vanderbilt University Medical Center and Vanderbilt-Ingram Cancer Center, Nashville, TN, Department of Cancer Biology, Vanderbilt University Medical Center and Vanderbilt-Ingram Cancer Center, Nashville, TN
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26
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Khan N, Bangash A, Sadiq M. Prognostic indicators of surgery for esophageal cancer: a 5 year experience. Saudi J Gastroenterol 2010; 16:247-52. [PMID: 20871187 PMCID: PMC2995091 DOI: 10.4103/1319-3767.70607] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND/AIM To assess the prognostic indicators preoperatively presenting and influencing the mortality rate following esophagectomy for esophageal cancer. MATERIALS AND METHODS This study was a retrospective cohort study, conducted at the Department of Surgery, Lady Reading Hospital, Peshawar, from 1 January 2003 till 31 December 2008. Group 1 included patients who had undergone sub-total esophagectomy and were alive at completion of 12 months; whereas Group 2 included those patients who died by the completion of 12 months. Data were recollected from the Data Bank. A list of variables common to all patients from both groups was categorized and subsequently all data related to each individual patient were placed and analyzed on the version 13.0 of SPSS R for Windows. RESULTS Significant findings of a lower mean level of serum albumin from Group 2 were observed, whereas serum transferrin levels, also found lower in Group 2, were not statistically significant. Findings of serum pre-albumin, with a mean value of 16.12 mg/dl (P < 0.05) and Geansler's index for the evaluation of the presence of obstructive pulmonary disease prior to surgery showed a lower reading of mean ratio in Group 2. Anastamotic leak was not a common finding in the entire study. In most cases, the choice of conduit was the remodeled stomach. Nine patients from Group 2 were observed with evident leak on the fifth to seventh post-operative day following contrast swallow studies. This was statistically insignificant (P = 0.051) on multivariate analysis. CONCLUSION Pre-operative variables including weight loss, low serum albumin and pre-albumin, Geansler's index, postoperative chylothorax, pleural effusion, and hospital stay, are predictive of mortality in patients who undergo esophagectomy for esophageal cancer.
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Affiliation(s)
- Nadim Khan
- Department of Surgery, Lady Reading Hospital, Post Graduate Medical Institute, Peshawar, N.W.F.P, Pakistan
| | - Adil Bangash
- Department of Surgery, Lady Reading Hospital, Post Graduate Medical Institute, Peshawar, N.W.F.P, Pakistan,Address for correspondence: Dr. Adil Bangash, Department of Surgery, Lady Reading Hospital, Post Graduate Medical Institute, Peshawar, N.W.F.P, Pakistan. E-mail:
| | - Muzaffaruddin Sadiq
- Department of Surgery, Lady Reading Hospital, Post Graduate Medical Institute, Peshawar, N.W.F.P, Pakistan
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27
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Berger B, Belka C. Evidence-based radiation oncology: oesophagus. Radiother Oncol 2009; 92:276-90. [PMID: 19375187 DOI: 10.1016/j.radonc.2009.02.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Revised: 02/23/2009] [Accepted: 02/27/2009] [Indexed: 12/11/2022]
Abstract
Oesophageal cancer remains to be a therapeutic and diagnostic challenge in multidisciplinary oncology. Radiotherapy is a crucial component of most curative and palliative approaches for oesophageal cancer. Aim of this educational review is to summarize the available evidence and to define the role of radiation-based treatment options for oesophageal cancer.
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Affiliation(s)
- Bernhard Berger
- Department of Radiation Oncology, University of Tübingen, Tübingen, Germany
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28
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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. Int J Colorectal Dis 2009; 24:69-77. [PMID: 18704459 DOI: 10.1007/s00384-008-0562-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2008] [Indexed: 02/04/2023]
Abstract
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.
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Novel therapeutic strategies for treating esophageal adenocarcinoma: The potential of dendritic cell immunotherapy and combinatorial regimens. Hum Immunol 2008; 69:614-24. [DOI: 10.1016/j.humimm.2008.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Revised: 02/25/2008] [Accepted: 07/17/2008] [Indexed: 01/01/2023]
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Schwer AL, Ballonoff A, McCammon R, Rusthoven K, D'Agostino RB, Schefter TE. Survival effect of neoadjuvant radiotherapy before esophagectomy for patients with esophageal cancer: a surveillance, epidemiology, and end-results study. Int J Radiat Oncol Biol Phys 2008; 73:449-55. [PMID: 18538500 DOI: 10.1016/j.ijrobp.2008.04.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2008] [Revised: 04/21/2008] [Accepted: 04/21/2008] [Indexed: 11/17/2022]
Abstract
PURPOSE The role of neoadjuvant radiotherapy (NeoRT) before definitive surgery for esophageal cancer remains controversial. This study used a large population-based database to assess the effect of NeoRT on survival for patients treated with definitive surgery. METHODS AND MATERIALS The overall survival (OS) and cause-specific survival for patients with Stage T2-T4, any N, M0 (cT2-T4M0) esophageal cancer who had undergone definitive surgery between 1998 and 2004 were analyzed by querying the Surveillance, Epidemiology, and End-Results database. Kaplan-Meier survival curves were generated and univariate comparisons were made using the log-rank test. Cox proportional hazards survival regression multivariate analysis was performed with NeoRT, T stage (T2 vs. T3-T4), pathologic nodal status (pN0 vs. pN1), number of nodes dissected (>10 vs. </=10), histologic type (adenocarcinoma vs. squamous cell carcinoma), age (<65 vs. >/=65 years), and gender as covariates. RESULTS A total of 1,033 patients were identified. Of these, 441 patients received NeoRT and 592 underwent esophagectomy alone; 77% were men, 67% had adenocarcinoma, and 72% had Stage T3-T4 disease. The median OS and cause-specific survival were both significantly greater for patients who received NeoRT compared with esophagectomy alone (27 vs. 18 months and 35 vs. 21 months, respectively, p <0.0001). The 3-year OS rate was also significantly greater in the NeoRT group (43% vs. 30%). On multivariate analysis, NeoRT, age <65 years, adenocarcinoma histologic type, female gender, pN0 status, >10 nodes dissected, and Stage T2 disease were all independently correlated with increased OS. CONCLUSION These results support the use of NeoRT for patients with esophageal cancer. Prospective studies are needed to confirm these results.
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Affiliation(s)
- Amanda L Schwer
- Department of Radiation Oncology, University of Colorado Health Sciences Center, Aurora, Colorado, USA
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Radiation as an Adjunct to Surgery. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Urschel JD. Esophageal Cancer. Oncology 2007. [DOI: 10.1007/0-387-31056-8_40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Veuillez V, Rougier P, Seitz JF. The multidisciplinary management of gastrointestinal cancer. Multimodal treatment of oesophageal cancer. Best Pract Res Clin Gastroenterol 2007; 21:947-63. [PMID: 18070697 DOI: 10.1016/j.bpg.2007.10.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Treatment of oesophageal cancer requires a multidisciplinary approach. Single modality treatment, especially surgical excision, is only indicated in small tumours or in patients unable to support multimodal treatment. In Stage I-II adenocarcinoma, multimodal treatment using neoadjuvant therapy is indicated in the absence of contra-indications. However, this statement is not universally accepted. The choice between radio-chemotherapy and chemotherapy depends on patients' characteristics and the preferences of the treatment centre. In selected Stage III adenocarcinomas, especially from the lower oesophagus, neoadjuvant chemotherapy (with post-operative chemotherapy when feasible) may induce tumour regression, which may facilitate surgical resection and improve survival rates, as has been demonstrated for cancers of the oesophagogastric junction.
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Affiliation(s)
- Véronique Veuillez
- Service Hépato-Gastroentérologie et Oncologie Digestive, Hopital Ambroise Paré, AP-HP, 92100 Boulogne, France.
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Papp A, Cseke L, Pavlovics G, Farkas R, Varga G, Márton S, Pótó L, Esik O, Horváth OP. [The effect of preoperative chemo-radiotherapy in the treatment of locally advanced squamous cell carcinoma in the upper- and middle-thirds of the esophagus]. Magy Seb 2007; 60:123-9. [PMID: 17727214 DOI: 10.1556/maseb.60.2007.3.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
AIM The aim of this study was to compare the efficiency of the preoperative combined chemo-radiotherapy in the treatment of locally advanced squamous cell carcinoma in different locations of the oesophagus. METHODS Between 1997 and 2005, 102 patients with locally advanced (T3-4) squamous cell oesophageal cancer received preoperative chemo-radiotherapy. In 40 cases, the tumour was localised in the upper-third (Group I), while in 62 cases, in the middle-third of the oesophagus (Group II). Survival rates of patients receiving neoadjuvant therapy were compared with a historical control group. In addition, Group I and Group II were compared to each other, as well. RESULTS survival rate was significantly better after neoadjuvant therapy (p:0.0042) Resection was performed in 70% of the patients from Group I, and in 50% of those complete pathological remission (pCR) was observed. The perioperative morbidity and mortality rates were 43% and 14%, respectively. As far as Group II, 69% of the patients underwent oesophageal resection, with a perioperative mortality of 18% and morbidity rate of 62%. pCR was observed only in 7% of the cases. The median survivals (21 and 22 months) and the R0 resection rates (82 and 84%) were similar in the two groups. The pCR subgroup showed a significantly better survival rate. CONCLUSION In this study, we demonstrated that preoperative chemo-radiotherapy increases survival in locally advanced oesophageal cancer. A significantly higher rate of complete response was observed in patients with upper-third oesophageal cancer. It seems that this group has superior sensitivity to multimodal treatment; therefore, our results support a new prognostic factor in oesophageal cancer treatment.
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Abstract
The combination of chemotherapy, fluorouracil and cisplatin, and radiation has improved outcome for patients with esophageal cancer. A randomized controlled trial confirmed a long-term survival benefit when this chemotherapy was added to radiotherapy for squamous cell carcinoma, but the approach has not been definitively assessed in patients with adenocarcinoma. Preoperative chemoradiotherapy has been tested in numerous phase II studies and underpowered or flawed phase III studies. Nevertheless, collectively, the evidence strongly suggests that preoperative chemoradiotherapy improves outcome, and thus, this strategy has become a standard treatment option. Attempts to improve outcome by intensifying conventional cytotoxic drugs or increasing the radiation dose have not been successful. Camptothecin and taxane-based regimens combined with radiation have altered the toxicity profile, but substantial improvement in survival outcomes has yet to be demonstrated. Future improvements will likely require the incorporation of targeted agents that add minimally to existing toxicity, the use of molecular predictors of response to individualize selection of the chemotherapeutic regimen, and early identification of responders such that therapy might be altered dynamically.
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Affiliation(s)
- Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Sciences, Division of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21231-2410, USA.
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Gockel I, Sultanov FS, Domeyer M, Goenner U, Junginger T. Developments in esophageal surgery for adenocarcinoma: a comparison of two decades. BMC Cancer 2007; 7:114. [PMID: 17603896 PMCID: PMC1914077 DOI: 10.1186/1471-2407-7-114] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2007] [Accepted: 06/29/2007] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The objective of this study was to examine outcomes in patients undergoing esophageal resection for adenocarcinoma at our institution during a 20-year period and, in particular, to address temporal trends in long-term survival. METHODS Out of 470 patients who underwent esophagectomy for malignancy between September 1985 and September 2005, a total number of 175 patients presented with esophageal adenocarcinoma. Patients enrolled in this study included AEG (adenocarcinoma of the esophagogastric junction) type I tumors only. Time trends were studied comparing two decades, 9/1985 to 9/1995 (DI) and 10/1995 to 9/2005 (DII). RESULTS The overall survival was significantly more favourable in patients undergoing esophageal resection for adenocarcinoma in the recent time period (DII, 10/1995 to 9/2005) as compared to the early time period (DI, 9/1985 to 9/1995) (log rank test: p = 0.0329). Significant differences in the recent decade were seen based on lower ASA-classifications, earlier tumor stages, and the operative procedure with a higher frequency of transhiatal resections (p < 0.05). 30-day mortality improved from 8.3% to 3.1% during the 20-year time-interval, thus without statistical significance. CONCLUSION Based on our experience, overall survival is improving over time for adenocarcinoma of the esophagus. Factors that may play an important role in this trend include early diagnosis and improved patient selection through better preoperative staging, improved surgical technique with a tailored approach carefully evaluated by physiologic patient status, comorbidity and tumor extent.
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Affiliation(s)
- I Gockel
- Department of General and Abdominal Surgery, Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - FS Sultanov
- Department of General and Abdominal Surgery, Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - M Domeyer
- Department of General and Abdominal Surgery, Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - U Goenner
- Department of General and Abdominal Surgery, Johannes Gutenberg-University of Mainz, Mainz, Germany
| | - Th Junginger
- Department of General and Abdominal Surgery, Johannes Gutenberg-University of Mainz, Mainz, Germany
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Trivella M, Pezzella F, Pastorino U, Harris AL, Altman DG. Microvessel density as a prognostic factor in non-small-cell lung carcinoma: a meta-analysis of individual patient data. Lancet Oncol 2007; 8:488-99. [PMID: 17513172 DOI: 10.1016/s1470-2045(07)70145-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Angiogenesis is a potential prognostic factor that has been investigated in patients with non-small-cell lung carcinoma. However, published studies of the role of angiogenesis as a prognostic factor are inconclusive. We aimed to collect individual patient data to assess microvessel-density counts (ie, a measure of angiogenesis) as a prognostic factor in non-small-cell lung carcinoma. METHODS We obtained published and unpublished datasets and extracted appropriate data, taking particular care to ensure data quality. Detailed information was obtained for the laboratory methods used by every research centre that generated the data. The outcome of interest was overall survival. We did a meta-analysis to estimate the prognostic role of microvessel density by combining separately estimated hazard ratios (HR) from every study, which were adjusted for tumour stage and age. Analyses were done separately for studies that used the Chalkley method or for those that counted all microvessels. FINDINGS 17 centres provided data for 3200 patients, 2719 of which were included in the analysis. All but three centres (datasets 9, 10, and 13-367 cases) had already published their findings, and six had updated follow-up information (datasets 1, 2, 3, 6, 7, and 8-1273 cases). For all but three centres (datasets 4, 11, and 13) some data corrections were necessary. For microvessel density counts obtained by the Chalkley method, the HR for death per extra microvessel was 1.05 (95% CI 1.01-1.09, p=0.03) when analysed as a continuous variable. For microvessel density counts obtained by the all vessels method, the HR for death per ten extra microvessels was 1.03 (0.97-1.09, p=0.3) when analysed as a continuous variable. INTERPRETATION Microvessel density does not seem to be a prognostic factor in patients with non-metastatic surgically treated non-small-cell lung carcinoma. This conclusion contradicts the results of a meta-analysis of published data only. Therefore, the methodology used to assess prognostic factors should be assessed carefully.
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Kleinberg L, Gibson MK, Forastiere AA. Chemoradiotherapy for localized esophageal cancer: regimen selection and molecular mechanisms of radiosensitization. ACTA ACUST UNITED AC 2007; 4:282-94. [PMID: 17464336 DOI: 10.1038/ncponc0796] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Accepted: 12/19/2006] [Indexed: 11/09/2022]
Abstract
Concurrent chemoradiotherapy administered either before surgery or as definitive treatment has a central role in the multimodality treatment of locally advanced esophageal cancer. Initial studies of this combined-modality regimen were based on models of squamous-cell cancers from other primary sites; this approach progressed from use of bleomycin or fluorouracil plus cisplatin concurrent with radiation in early trials, to the integration of taxanes, camptothecins and platinum analogs in recent trials. These trials demonstrated the tumoricidal effect of concurrent chemotherapy and radiotherapy and showed the survival advantages of this approach. Preoperative concurrent chemoradiation is used to downstage the tumor, ideally to a pathological complete response status in which there is no residual tumor in the resected primary and nodal tissues. A pathological complete response is associated with long-term survival but occurs in a minority (30%) of patients. While clinical trials have demonstrated an improvement in survival with concurrent chemoradiotherapy this effect is limited, as indicated by the plateau in survival beyond 5 years of approximately 30% or less. The recent clinical development of biologic, targeted therapies provides a new avenue for the study of chemoradiotherapy and an opportunity to increase long-term survival.
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Seto Y, Chin K, Gomi K, Kozuka T, Fukuda T, Yamada K, Matsubara T, Tokunaga M, Kato Y, Yafune A, Yamaguchi T. Treatment of thoracic esophageal carcinoma invading adjacent structures. Cancer Sci 2007; 98:937-42. [PMID: 17441965 DOI: 10.1111/j.1349-7006.2007.00479.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
T4 esophageal cancer is defined as the tumor invading adjacent structures, using tumor-node-metastasis (TNM) staging. For clinically T4 thoracic esophageal carcinoma, multimodality therapy, that is, neoadjuvant chemoradiotherapy (CRT) followed by surgery or definitive CRT, has generally been performed. However, the prognosis of patients with these tumors remains poor. Another strategy is needed to achieve curative treatment. In the present article, the treatment strategies employed to date are reviewed. Furthermore, the strategies for these malignancies are reassessed, based on our experiences. R1/2 and R0 resections are regarded as those with residual and no tumor after surgery. The present data show that patients who underwent R1/2 resection after neoadjuvant CRT experienced little survival benefit, while complete response (CR) cases after definitive CRT had comparatively better results. Therefore, curative surgery should not be attempted without down-staging, and definitive CRT should be the initial treatment. Then surgery is indicated for the eradication of residual cancer cells. Close surveillance is essential for early detection of relapse even after CR, because the operation will gradually become increasingly difficult due to post-CRT fibrosis. In conclusion, multimodality therapy consists of definitive CRT followed by R0 resection, which can be the treatment of choice for T4 esophageal carcinoma. These challenging treatments have the potential to constitute the most effective therapeutic strategy.
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Affiliation(s)
- Yasuyuki Seto
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Tokyo 135-8550, Japan.
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Preoperative chemoradiation for the treatment of locoregional esophageal cancer: the standard of care? Semin Radiat Oncol 2007; 17:45-52. [PMID: 17185197 DOI: 10.1016/j.semradonc.2006.09.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Esophageal cancer has one of the highest mortality rates among patients with solid tumors. Surgical resection has been a cornerstone of treatment for localized esophageal cancer, but recently treatment strategies have become more aggressive and now include chemotherapy, radiation, and surgery. Two meta-analyses confirmed a survival benefit at 3 years from neoadjuvant concurrent chemoradiation without compromising the ability to undergo surgical resection and without an increase in peri-operative mortality negating the benefit seen. Some countries prefer to use pre-operative chemotherapy, although this is not standard in the United States. Patients who undergo initial esophagectomy with no pre-operative treatment may benefit from post-operative adjuvant chemoradiation depending on the final pathologic staging. Ultimately, treatment planning should include a multi-disciplinary evaluation of the patient, with consideration of available treatment options and their risks and benefits. There is no absolute standard that is best for all patients; rather, the physician and patient working in concert eventually determine which of several reasonable treatment options is best suited for that individual patient.
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Abstract
Radiation plays an important role in the treatment of thoracic tumors. During the last 10 years there have been several major advances in thoracic RT including the incorporation of concurrent chemotherapy and the application of con-formal radiation-delivery techniques (eg, stereotactic RT, three-dimensional conformal RT, and intensity-modulated RT) that allow radiation dose escalation. Radiation as a local measure remains the definitive treatment of medically inoperable or surgically unresectable disease in NSCLC and part of a multimodality regimen for locally advanced NSCLC, limited stage SCLC, esophageal cancer, thymoma, and mesothelioma.
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Affiliation(s)
- Feng-Ming Spring Kong
- Department of Radiation Therapy, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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Oehler C, Ciernik IF. Radiation therapy and combined modality treatment of gastrointestinal carcinomas. Cancer Treat Rev 2006; 32:119-38. [PMID: 16524667 DOI: 10.1016/j.ctrv.2006.01.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Ionizing radiation (IR) is a potent agent in enhancing tumor control of locally advanced cancer and has been shown to improve disease-free and overall survival in several entities. However, the role of radiotherapy (RT) in the treatment of gastrointestinal tumors remains controversial because of the marked radiation sensitivity of neighboring organs frequently compromising application of high doses of ionizing radiation. METHODS The Medline and the Cochrane Library from 1980 until 2005 were searched using subject heading (MeSH) terms including "esophageal neoplasm", "gastric neoplasm", "pancreatic neoplasm" and "rectal neoplasm", in combination with the subheadings "radiotherapy", "chemotherapy". The term, "randomized controlled trial", was used to identify randomized trials. The proceedings of the annual meeting of the American Society for Therapeutic Radiology and Oncology from 1999 to 2004 and the annual meeting of the American Society of Clinical Oncology from 1999 until 2005 were searched. Ongoing trials were identified through the Physician Data Query database (www.cancer.gov/search/clinical_trials). RESULTS RT in combination with surgery enhances tumor control of locally advanced cancer disease and has been shown to improve disease-free and overall survival in rectal cancer. In esophageal adenocarcinoma, survival was prolonged with pre-operative chemo-radiation in a meta-analysis. In gastric cancer, post-operative chemo-radiation can be considered after limited lymphadenectomy. Evidence for improving survival remains to be shown for pancreatic cancer and hepatobiliary carcinoma. In colon cancer, post-operative chemotherapy has proven to prolong survival. The impact of RT seems to be most prominent in the pre-operative setting in patients treated with curative intent. CONCLUSIONS Pre-operative RT or pre-operative chemo-radiation may be considered in individual cases, but should not be used routinely for gastro-intestinal carcinoma, except for rectal carcinoma. In many studies, pre-operative radiotherapy/chemo-radiation yielded promising results and merits validation in large controlled trials.
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Affiliation(s)
- Christoph Oehler
- Radiation Oncology, Zurich University Hospital, University of Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
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Affiliation(s)
- Eric Elton
- Evanston Northwestern Healthcare, Illinois, USA
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Geh JI, Bond SJ, Bentzen SM, Glynne-Jones R. Systematic overview of preoperative (neoadjuvant) chemoradiotherapy trials in oesophageal cancer: evidence of a radiation and chemotherapy dose response. Radiother Oncol 2006; 78:236-44. [PMID: 16545878 DOI: 10.1016/j.radonc.2006.01.009] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2005] [Revised: 01/16/2006] [Accepted: 01/31/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND PURPOSE Numerous trials have shown that pathological complete response (pCR) following preoperative chemoradiotherapy (CRT) and surgery for oesophageal cancer is associated with improved survival. However, different radiotherapy doses and fractionations and chemotherapy drugs, doses and scheduling were used, which may account for the differences in observed pCR and survival rates. A dose-response relationship may exist between radiotherapy and chemotherapy dose and pCR. PATIENTS AND METHODS Trials using a single radiotherapy and chemotherapy regimen (5FU, cisplatin or mitomycin C-based) and providing information on patient numbers, age, resection and pCR rates were eligible. The endpoint used was pCR and the covariates analysed were prescribed radiotherapy dose, radiotherapy dosexdose per fraction, radiotherapy treatment time, prescribed chemotherapy (5FU, cisplatin and mitomycin C) dose and median age of patients within the trial. The model used was a multivariate logistic regression. RESULTS Twenty-six trials were included (1335 patients) in which 311 patients (24%) achieved pCR. The probability of pCR improved with increasing dose of radiotherapy (P=0.006), 5FU (P=0.003) and cisplatin (P=0.018). Increasing radiotherapy treatment time (P=0.035) and increasing median age (P=0.019) reduced the probability of pCR. The estimated alpha/beta ratio of oesophageal cancer was 4.9 Gy (95% confidence interval (CI) 1.5-17 Gy) and the estimated radiotherapy dose lost per day was 0.59 Gy (95% CI 0.18-0.99 Gy). One gram per square metre of 5FU was estimated to be equivalent to 1.9 Gy (95% CI 0.8-5.2 Gy) of radiation and 100mg/m2 of cisplatin was estimated to be equivalent to 7.2 Gy (95% CI 2.1-28 Gy). Mitomycin C dose did not appear to influence pCR rates (P=0.60). CONCLUSIONS There was evidence of a dose-response relationship between increasing protocol prescribed radiotherapy, 5FU and cisplatin dose and pCR. Additional significant factors were radiotherapy treatment time and median age of patients within the trial.
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Affiliation(s)
- J Ian Geh
- The Cancer Centre at the Queen Elizabeth Hospital, Birmingham, UK.
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DeMeester SR. Adenocarcinoma of the esophagus and cardia: a review of the disease and its treatment. Ann Surg Oncol 2006; 13:12-30. [PMID: 16378161 DOI: 10.1245/aso.2005.12.025] [Citation(s) in RCA: 167] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2004] [Accepted: 07/20/2005] [Indexed: 02/06/2023]
Abstract
BACKGROUND Over the past 50 years there has been a remarkable change in the epidemiology of esophageal cancer. Previously rare, adenocarcinoma of the esophagus and gastroesophageal junction is now the most common esophageal cancer, and in the United States the incidence is increasing faster than that of any other malignancy. Surveillance in patients with Barrett's esophagus is identifying adenocarcinoma at an earlier, more curable stage in many patients, and at the same time new endoscopic and surgical options are available for the therapy of these localized tumors. METHODS This article is a review of the epidemiology, diagnosis, staging, and treatment options for esophageal and gastroesophageal junction adenocarcinoma. RESULTS The epidemiology, prognosis, patterns of lymphatic metastasis, and survival for esophageal and gastroesophageal junction adenocarcinoma suggest that these tumors are similar. New options for therapy, as well as the results of surgical resection with and without chemoradiotherapy, are reviewed. CONCLUSIONS Surveillance programs for Barrett's are identifying patients with early, curable adenocarcinoma of the esophagus or gastroesophageal junction. Therapy for more advanced tumors hinges on local control of the disease and the eradication of systemic metastases.
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Affiliation(s)
- Steven R DeMeester
- Department of Cardiothoracic Surgery, The University of Southern California, Keck School of Medicine, 1510 San Pablo Street, Suite 514, Los Angeles, California, 90033, USA.
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Lepage C, Bouvier AM, Manfredi S, Coatmeur O, Cheynel N, Faivre J. Trends in incidence and management of esophageal adenocarcinoma in a well-defined population. ACTA ACUST UNITED AC 2005; 29:1258-63. [PMID: 16518284 DOI: 10.1016/s0399-8320(05)82218-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Little epidemiological data is available concerning esophageal adenocarcinomas in France. The aim of this study was to study epidemiological characteristics and management of esophageal adenocarcinoma in a well-defined population. METHODS Data were collected by the Burgundy Digestive Cancer Registry covering a population of 1 052 000, over a 28-year period (1976-2001). Incidence, treatment and stage at diagnosis were noted. Univariate and multivariate analysis of survival was performed. RESULTS Age standardized incidence rates were 1.60/100,000 in men and 0.15/100,000 in women. The mean increase in incidence rates by 5-year periods were respectively + 68.1% (P<0.001) and + 97.4% (P<0.001). Overall, 69.9% of the cancers were located in the lower third of the esophagus. Surgical resection was performed in 32.1% of patients. Among the surgical patients, the tumor was limited to the esophageal wall in 11.4%, lymph node metastases were present in 18.1% and non-resectable distant metastases in 70.5%. There was no improvement of stage at diagnosis over time. Survival rates were 14.4% at 3 years and 9.2% at 5 years. Five-year survival rates varied from 38.4% for cases limited to the esophageal wall to 1.8% for metastatic and non resectable cases. Stage at diagnosis was the only significant prognostic factor in the multivariate analysis. CONCLUSION Esophageal adenocarcinomas are rare cancers characterized by a sharp rise in incidence over the past years in France. Stage at diagnosis and prognosis are worse than reported in hospital statistics.
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Affiliation(s)
- Côme Lepage
- Registre Bourguignon des Cancers Digestifs, INSERM EPI 0106
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Arnott SJ, Duncan W, Gignoux M, Girling D, Hansen H, Launois B, Nygaard K, Parmar MKB, Rousell A, Spiliopoulos G, Stewart L, Tierney J, Wang M, Rhugang Z. Preoperative radiotherapy for esophageal carcinoma. Cochrane Database Syst Rev 2005; 2005:CD001799. [PMID: 16235286 PMCID: PMC8407511 DOI: 10.1002/14651858.cd001799.pub2] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The existing randomized evidence has failed to conclusively demonstrate the benefit or otherwise of preoperative radiotherapy in treating patients with potentially resectable esophageal carcinoma. OBJECTIVES This meta-analysis aimed to assess whether there is benefit from adding radiotherapy prior to surgery and whether or not any pre-defined patient subgroups benefit more or less from preoperative radiotherapy SEARCH STRATEGY MEDLINE and CancerLit searches were supplemented by information from trial registers and by hand searching relevant meeting proceedings and by discussion with relevant trialists, organisations and industry. The search strategy was run again in MEDLINE, EMBASE and the Cochrane Library on 30th April 2001, two years after original publication. No new trials were found. The search strategy was re-run August 2002 and August 2003 on MEDLINE, EMBASE , CancerLit and The Cochrane Library, and July 2004 and 2005 on MEDLINE, EMBASE and the Cochrane Library. No new relevant trials were identified on any of these occasions. SELECTION CRITERIA Trials were eligible for inclusion in this meta-analysis provided they randomized patients with potentially resectable carcinoma of the esophagus (of any histological type) to receive radiotherapy or no radiotherapy prior to surgery. Trials must have used a randomization method which precluded prior knowledge of treatment assignment and completed accrual by December 1993, to ensure sufficient follow-up by the time of the first analysis (September 1995). DATA COLLECTION AND ANALYSIS A quantitative meta-analysis using updated data from individual patients from all properly randomized trials (published or unpublished) comprising 1147 patients (971 deaths) from five randomized trials. This approach was used to assess whether preoperative radiotherapy improves overall survival and whether it is differentially effective in patients defined by age, sex and tumour location. MAIN RESULTS With a median follow-up of 9 years, in a group patients with mostly squamous carcinomas, the hazard ratio (HR) of 0.89 (95% CI 0.78-1.01) suggests an overall reduction in the risk of death of 11% and an absolute survival benefit of 3% at 2 years and 4% at 5 years. This result is not conventionally statistically significant (p=0.062). No clear differences in the size of the effect by sex, age or tumor location were apparent. AUTHORS' CONCLUSIONS Based on existing trials, there was no clear evidence that preoperative radiotherapy improves the survival of patients with potentially resectable esophageal cancer. These results indicate that if such preoperative radiotherapy regimens do improve survival, then the effect is likely to be modest with an absolute improvement in survival of around 3 to 4%. Trials or a meta-analysis of around 2000 patients (90% power, 5% significance level) would be needed to reliably detect such an improvement (from 15 to 20%).
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Affiliation(s)
| | - W Duncan
- MRC Clinical Trials UnitMeta‐analysis Group222 Euston RoadLondonUKCB2 2BW
| | - M Gignoux
- Centre Hospitalier UniversitaireService de Chirurgie DigestiveNiveau 7Avenue de Cote de NacreCaenFrance14033 cedex
| | - David Girling
- MRC Clinical Trials UnitCancer Division222 Euston Road5 Shaftesbury RoadLondonUKNW1 2DA
| | - H Hansen
- MRC Clinical Trials UnitMeta‐analysis Group222 Euston RoadLondonUKCB2 2BW
| | - Bernard Launois
- Hospital PontchaillouDepartment of Digestive SurgeryRue Henri Le GuillouxRennesFrance35033 RENNES
| | - K Nygaard
- Kirurgisk AfdellingAker SygenhusOsloNorwayN‐0514
| | - Mahesh KB Parmar
- MRC Clinical Trials UnitCancer Division222 Euston Road5 Shaftesbury RoadLondonUKNW1 2DA
| | - A Rousell
- BallesseCentre Regional FrancoisCaenFrance
| | - G Spiliopoulos
- Hospitalier Regional et Universitaire De RennesCentre De Chirurgie Digestive Et Unite of TransplantationPontchailier 35033Rennes CedfxFrance
| | - Lesley Stewart
- University of YorkCentre for Reviews and DisseminationYorkUKYO10 5DD
| | - Jayne Tierney
- MRC Clinical Trials UnitAviation House125 KingswayLondonUKWC2B 6NH
| | - M Wang
- MRC Clinical Trials UnitMeta‐analysis Group222 Euston RoadLondonUKCB2 2BW
| | - Z Rhugang
- Cancer HospitalDepartment of Radiation OncologyP O Box 2258BeijingChina100021
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Burmeister BH, Smithers BM, Gebski V, Fitzgerald L, Simes RJ, Devitt P, Ackland S, Gotley DC, Joseph D, Millar J, North J, Walpole ET, Denham JW. Surgery alone versus chemoradiotherapy followed by surgery for resectable cancer of the oesophagus: a randomised controlled phase III trial. Lancet Oncol 2005; 6:659-68. [PMID: 16129366 DOI: 10.1016/s1470-2045(05)70288-6] [Citation(s) in RCA: 756] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Resection remains the best treatment for carcinoma of the oesophagus in terms of local control, but local recurrence and distant metastasis remain an issue after surgery. We aimed to assess whether a short preoperative chemoradiotherapy regimen improves outcomes for patients with resectable oesophageal cancer. METHODS 128 patients were randomly assigned to surgery alone and 128 patients to surgery after 80 mg/m(2) cisplatin on day 1, 800 mg/m(2) fluorouracil on days 1-4, with concurrent radiotherapy of 35 Gy given in 15 fractions. The primary endpoint was progression-free survival. Secondary endpoints were overall survival, tumour response, toxic effects, patterns of failure, and quality of life. Analysis was done by intention to treat. FINDINGS Neither progression-free survival nor overall survival differed between groups (hazard ratio [HR] 0.82 [95% CI 0.61-1.10] and 0.89 [0.67-1.19], respectively). The chemoradiotherapy-and-surgery group had more complete resections with clear margins than did the surgery-alone group (103 of 128 [80%] vs 76 of 128 [59%], p=0.0002), and had fewer positive lymph nodes (44 of 103 [43%] vs 69 of 103 [67%], p=0.003). Subgroup analysis showed that patients with squamous-cell tumours had better progression-free survival with chemoradiotherapy than did those with non-squamous tumours (HR 0.47 [0.25-0.86] vs 1.02 [0.72-1.44]). However, the trial was underpowered to determine the real magnitude of benefit in this subgroup. INTERPRETATION Preoperative chemoradiotherapy with cisplatin and fluorouracil does not significantly improve progression-free or overall survival for patients with resectable oesophageal cancer compared with surgery alone. However, further assessment is warranted of the role of chemoradiotherapy in patients with squamous-cell tumours.
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Affiliation(s)
- Bryan H Burmeister
- University of Queensland, Princess Alexandra Hospital, Brisbane, Australia.
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Ohigashi Y, Sho M, Yamada Y, Tsurui Y, Hamada K, Ikeda N, Mizuno T, Yoriki R, Kashizuka H, Yane K, Tsushima F, Otsuki N, Yagita H, Azuma M, Nakajima Y. Clinical significance of programmed death-1 ligand-1 and programmed death-1 ligand-2 expression in human esophageal cancer. Clin Cancer Res 2005; 11:2947-53. [PMID: 15837746 DOI: 10.1158/1078-0432.ccr-04-1469] [Citation(s) in RCA: 620] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE The negative regulatory programmed death-1/programmed death-1 ligand (PD-1/PD-L) pathway in T-cell activation has been suggested to play an important role in tumor evasion from host immunity. In this study, we investigated the expression of PD-L1 and PD-L2 in human esophageal cancer to define their clinical significance in patients' prognosis after surgery. EXPERIMENTAL DESIGN PD-L1 and PD-L2 gene expression was evaluated in 41 esophagectomy patients by real-time quantitative PCR. The protein expression was also evaluated with newly generated monoclonal antibodies that recognize human PD-L1 (MIH1) and PD-L2 (MIH18). RESULTS The protein and the mRNA levels of determination by immunohistochemistry and real-time quantitative PCR were closely correlated. PD-L-positive patients had a significantly poorer prognosis than the negative patients. This was more pronounced in the advanced stage of tumor than in the early stage. Furthermore, multivariate analysis indicated that PD-L status was an independent prognostic factor. Although there was no significant correlation between PD-L1 expression and tumor-infiltrating T lymphocytes, PD-L2 expression was inversely correlated with tumor-infiltrating CD8(+) T cells. CONCLUSIONS These data suggest that PD-L1 and PD-L2 status may be a new predictor of prognosis for patients with esophageal cancer and provide the rationale for developing novel immunotherapy of targeting PD-1/PD-L pathway.
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Affiliation(s)
- Yuichiro Ohigashi
- Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
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Abstract
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.
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Affiliation(s)
- X Zhang
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
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