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Wakita A, Motoyama S, Sato Y, Nagaki Y, Fujita H, Kemuriyama K, Hayashi K, Imai K, Nanjo H, Minamiya Y. Preoperative neoadjuvant chemoradiotherapy provides borderline resectable thoracic esophageal cancer with equivalent treatment results as clinically T3 thoracic esophageal cancer. Ann Gastroenterol Surg 2023; 7:904-912. [PMID: 37927919 PMCID: PMC10623951 DOI: 10.1002/ags3.12706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/20/2023] [Accepted: 05/28/2023] [Indexed: 11/07/2023] Open
Abstract
Aim Because the optimal treatment strategy for borderline resectable (cT3br) thoracic esophageal cancer patients remains unclear, it is of great interest whether preoperative neoadjuvant therapy for cT3br could achieve results comparable to those seen with resectable T3 cancer (cT3r). We speculated that preoperative neoadjuvant chemoradiotherapy (NACRT) would be particularly effective in cT3br thoracic esophageal cancer patients and compared to cT3br and cT3r. Methods Of 186 cT3 thoracic esophageal cancer patients treated with intended NACRT, 162 received radical esophagectomy. More than 97% were squamous cell carcinomas. Patients were partitioned into two groups according to whether invasion of adjacent organs was suspected (cT3br and cT3r). Treatment outcomes and survival were analyzed. Results Sixty-eight patients (36.6%) were classified as cT3br and 118 (63.4%) as cT3r. The cT3br group had significantly more tumors in the upper and middle mediastinum (p < 0.0001) and more cases with cM1 (lymph node) (p = 0.0104) than the cT3r group. In addition, the cT3br patients receiving esophagectomy exhibited a significantly lower pathological complete response rate than the cT3r patients (p = 0.0374). However, the R0 resection rate did not differ between the cT3br and cT3r patients (p = 0.0978), and the two groups treated with intended NACRT had similar 5-year overall (OS) and disease-specific survival (DSS) (p = 0.3831 and p = 0.9020). In addition, the incidence and patterns of recurrence did not differ between the cT3br and cT3r patients receiving esophagectomy (p = 0.8109 and p = 0.3128). Conclusions Preoperative neoadjuvant chemoradiotherapy appears to be a promising treatment for patients with borderline resectable thoracic esophageal squamous cell carcinoma.
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Affiliation(s)
- Akiyuki Wakita
- Division of Esophageal SurgeryAkita University HospitalAkitaJapan
- Department of Thoracic SurgeryAkita University Graduate School of MedicineAkitaJapan
| | - Satoru Motoyama
- Department of Gastroenterological SurgeryJapanese Red Cross Akita HospitalAkitaJapan
| | - Yusuke Sato
- Division of Esophageal SurgeryAkita University HospitalAkitaJapan
- Department of Thoracic SurgeryAkita University Graduate School of MedicineAkitaJapan
| | - Yushi Nagaki
- Division of Esophageal SurgeryAkita University HospitalAkitaJapan
- Department of Thoracic SurgeryAkita University Graduate School of MedicineAkitaJapan
| | - Hiromu Fujita
- Division of Esophageal SurgeryAkita University HospitalAkitaJapan
- Department of Thoracic SurgeryAkita University Graduate School of MedicineAkitaJapan
| | - Kohei Kemuriyama
- Division of Esophageal SurgeryAkita University HospitalAkitaJapan
- Department of Thoracic SurgeryAkita University Graduate School of MedicineAkitaJapan
| | - Kenjiro Hayashi
- Division of Esophageal SurgeryAkita University HospitalAkitaJapan
- Department of Thoracic SurgeryAkita University Graduate School of MedicineAkitaJapan
| | - Kazuhiro Imai
- Department of Thoracic SurgeryAkita University Graduate School of MedicineAkitaJapan
| | - Hiroshi Nanjo
- Division of Clinical PathologyAkita University HospitalAkitaJapan
| | - Yoshihiro Minamiya
- Division of Esophageal SurgeryAkita University HospitalAkitaJapan
- Department of Thoracic SurgeryAkita University Graduate School of MedicineAkitaJapan
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Higuchi T, Shoji Y, Koyanagi K, Tajima K, Kanamori K, Ogimi M, Yatabe K, Ninomiya Y, Yamamoto M, Kazuno A, Nabeshima K, Nakamura K. Multimodal Treatment Strategies to Improve the Prognosis of Locally Advanced Thoracic Esophageal Squamous Cell Carcinoma: A Narrative Review. Cancers (Basel) 2022; 15:cancers15010010. [PMID: 36612007 PMCID: PMC9817845 DOI: 10.3390/cancers15010010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/17/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022] Open
Abstract
Esophageal cancer is the seventh most common malignancy and sixth most common cause of cancer-related death globally. Esophageal squamous cell carcinoma (ESCC) with aortic or tracheal invasion is considered unresectable, and has an extremely poor prognosis; its standard treatment is definitive chemoradiotherapy (dCRT). In recent years, induction chemotherapy (ICT) has been reported to yield high response rates for locally advanced ESCC, and the efficacy and safety of ICT followed by conversion surgery (CS) have been investigated. Multimodal treatment, combining surgery with induction chemoradiotherapy (ICRT) or ICT, is necessary to improve ESCC prognosis. CS is generally performed for locally advanced ECC after ICRT or ICT when tumor downstaging is achieved, although its prognostic benefit remains controversial. The Japan Clinical Oncology Group (JCOG) has conducted a three-arm phase III randomized controlled trial (JCOG1510) to confirm the superiority of DCF (docetaxel, cisplatin, and 5-fluorouracil) ICT, over conventional dCRT, among patients with initially unresectable ESCC. In recent years, researchers have reported favorable outcomes of induction therapy followed by CS and salvage surgery, after dCRT or systemic immunochemotherapy. In this review, we will describe the latest developments in the multimodal treatment including chemotherapy, CRT, surgery, and immunotherapy, which may improve oncological and survival outcomes for patients with cT4 ESCC.
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Lee CC, Soon YY, Vellayappan B, Ho F, Tey JCS. Survival rates and safety associated with chemoradiotherapy followed by surgery and chemoradiotherapy alone for patients with T4 esophageal cancer: a systematic review and meta-analysis. Acta Oncol 2022; 61:738-748. [PMID: 35450511 DOI: 10.1080/0284186x.2022.2062680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The optimal treatment approach for T4 esophageal cancer is not well established. We aimed to perform a systematic review and meta-analysis to determine the survival rates and safety of chemoradiotherapy followed by surgery (CRT-S) and chemoradiotherapy alone (CRT) in patients with T4 Nany M0 esophageal cancer. MATERIALS AND METHODS We searched databases for eligible prospective or retrospective studies. The outcomes of interest were overall survival (OS) at 1, 3 and 5 years, treatment-related fistula formation and mortality rates. Meta-analyses were performed using the random effects models separately for studies evaluating CRT-S and CRT. Subgroup analyses were performed based on histology, radiation dose, chemotherapy regimen and duration of the interval between CRT and surgery. RESULTS We identified 23 studies including 1,119 patients with predominantly squamous cell carcinoma (93%) and adenocarcinoma (3%) histology. The OS rates of patients receiving CRT-S were 65%, 36% and 20% at 1, 3 and 5 years, respectively. The OS rates of patients receiving CRT were 30%, 11% and 10% at 1, 3 and 5 years, respectively. Treatment-related fistula formation rates were 4% for CRT-S and 9% for CRT. Treatment-related mortality rates were 3% for both groups. Subgroup analyses showed that the interval of >2 months between CRT and surgery was associated with significantly improved OS rates at 1, 3 and 5 years. CONCLUSION Chemoradiotherapy is an efficacious treatment approach for T4 esophageal cancer, with clinically acceptable rates of treatment-related fistula formation and mortality. Tri-modality approach with surgery can be considered in carefully selected patients. Our study findings should be interpreted with caution due to the lack of high-quality evidence. Randomized controlled trials are warranted to confirm these findings.
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Affiliation(s)
- Chia Ching Lee
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore; National University Hospital, Singapore, Singapore; National University Health System, Singapore, Singapore; National University of Singapore, Singapore, Singapore
| | - Yu Yang Soon
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore; National University Hospital, Singapore, Singapore; National University Health System, Singapore, Singapore; National University of Singapore, Singapore, Singapore
| | - Balamurugan Vellayappan
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore; National University Hospital, Singapore, Singapore; National University Health System, Singapore, Singapore; National University of Singapore, Singapore, Singapore
| | - Francis Ho
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore; National University Hospital, Singapore, Singapore; National University Health System, Singapore, Singapore; National University of Singapore, Singapore, Singapore
| | - Jeremy C. S. Tey
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore; National University Hospital, Singapore, Singapore; National University Health System, Singapore, Singapore; National University of Singapore, Singapore, Singapore
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Yamada K, Nohara K, Enomoto N, Wake H, Yagi S, Terayama M, Kato D, Yokoi C, Kojima Y, Nakayama H, Kokudo N. Surgical strategies for treatment of clinical T4 esophageal cancer in Japan. Glob Health Med 2021; 3:371-377. [PMID: 35036618 PMCID: PMC8692096 DOI: 10.35772/ghm.2020.01090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 04/29/2021] [Accepted: 05/10/2021] [Indexed: 05/14/2023]
Abstract
Definitive chemoradiation (dCRT) is the mainstay treatment for cStage IVa esophageal squamous cell carcinoma (ESCC) with good performance status (PS), according to standard practice guidelines. Salvage surgery may incur operation complications and risk of mortality. According to the esophageal cancer practice guidelines outlined by the Japan Esophageal Society, when a tumor is residual and recurrent, chemotherapy and palliative symptomatic treatment is continued. However, salvage operation has been selected as a therapeutic option for recurrent or residual tumors after dCRT. There is weak evidence for not recommending surgery for cStage IVa ESCC exhibiting residual disease following dCRT. It has been reported that during salvage surgery the only prognostic factor that is thought to be performed is complete resection (R0), but at the same time, salvage esophagectomy increases the incidence of postoperative complications and mortality. The phase II chemoselection study by Yokota T et al. in Japan showed that multidisciplinary treatment initiated by induction therapy, in which docetaxel is added to cisplatin and 5-fluorouracil, resulted in a good prognosis in the short term. In this review, we discuss the surgical strategy and future of unresectable clinical T4 (cT4) ESCC.
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Affiliation(s)
- Kazuhiko Yamada
- Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
- Address correspondence to:Kazuhiko Yamada, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan. E-mail:
| | - Kyoko Nohara
- Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Naoki Enomoto
- Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hitomi Wake
- Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Syusuke Yagi
- Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masayoshi Terayama
- Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Daiki Kato
- Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Chizu Yokoi
- Department of Gastroenterology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yasushi Kojima
- Department of Gastroenterology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hidetsugu Nakayama
- Department of Radiation Therapy, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norihiro Kokudo
- Department of Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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Kubo K, Kanematsu K, Kurita D, Ishiyama K, Oguma J, Itami J, Daiko H. Feasibility of conversion thoracoscopic esophagectomy after induction therapy for locally advanced unresectable esophageal squamous cell carcinoma. Jpn J Clin Oncol 2021; 51:1225-1231. [PMID: 34109411 DOI: 10.1093/jjco/hyab085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/24/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Recently, patients with cT4b esophageal cancer often require conversion surgery following induction therapy, for which the standard procedure is open esophagectomy. However, thoracoscopic esophagectomy, including thoracoscopic esophagectomy in the prone position, is increasingly used. We compared short-term outcomes of thoracoscopic esophagectomy and open esophagectomy in this setting. METHODS We retrospectively analyzed 14 patients who underwent thoracoscopic esophagectomy, and 10 who underwent open esophagectomy, for locally advanced unresectable esophageal cancer after induction therapy between March 2007 and July 2020. RESULTS The two groups did not significantly differ in patient background. Median total and thoracic surgical times were both significantly longer for open esophagectomy than for thoracoscopic esophagectomy. Median blood loss was also greater in the open esophagectomy group than in the thoracoscopic esophagectomy group. The thoracoscopic esophagectomy group also had significantly shorter median chest drain duration; and lower C-reactive protein levels on the second and third postoperative days. The two groups did not significantly differ in total complications or postoperative hospital stay. CONCLUSIONS Thoracoscopic esophagectomy is as safe and feasible as open esophagectomy for conversion surgery after induction therapy for locally advanced unresectable esophageal squamous cell carcinoma.
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Affiliation(s)
- Kentaro Kubo
- Department of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Kyohei Kanematsu
- Department of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Daisuke Kurita
- Department of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Koshiro Ishiyama
- Department of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Junya Oguma
- Department of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Jun Itami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroyuki Daiko
- Department of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
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Shiraishi O. ASO Author Reflections: Comparison of Aggressive Planned Salvage Surgery versus Neoadjuvant Chemoradiotherapy Plus Surgery for Borderline Resectable T4 Squamous Cell Carcinoma. Ann Surg Oncol 2021; 28:6376-6377. [PMID: 33830358 DOI: 10.1245/s10434-021-09955-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 03/24/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Osamu Shiraishi
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-sayama, Japan.
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Shiraishi O, Yasuda T, Kato H, Momose K, Hiraki Y, Yasuda A, Shinkai M, Kimura Y, Imano M. Comparison of Aggressive Planned Salvage Surgery Versus Neoadjuvant Chemoradiotherapy Plus Surgery for Borderline Resectable T4 Squamous Cell Carcinoma. Ann Surg Oncol 2021; 28:6366-6375. [PMID: 33768398 DOI: 10.1245/s10434-021-09875-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/26/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION We compare planned salvage surgery after definitive chemoradiotherapy (SALV) versus neoadjuvant chemoradiotherapy plus surgery (NCRS) for borderline resectable T4 esophageal squamous cell carcinoma. PATIENTS AND METHODS A total of 37 patients underwent planned SALV, and 20 underwent NCRS from 2004 to 2017. The short-term outcome measures were the R0 resection rate, complications, and treatment-related mortality. The long-term outcome measures were the 5-year overall survival rate and causes of death. RESULTS R0 resection rate was similar between the SALV and NCRS groups (81% versus 85%). The incidence of postoperative pneumonia (35% versus 18%) and treatment-related mortality rate (9% versus 0%) tended to be higher in the SALV. ypT grade 2-3 (65% versus 30%, p = 0.012) and Clavien-Dindo grade ≥ IIIb complications (32% versus 0%, p = 0.008) were significantly more frequent in the SALV group. The groups had similar 5-year overall survival (26% versus 27%). The causes of death in the SALV and NCRS groups were primary esophageal cancer in 35% and 55% of patients, respectively, and pulmonary-related mortality in 24% and 5%, respectively. Multivariable Cox regression analysis revealed the following significant poor prognostic factors: stable disease as the clinical response, preoperative body mass index (BMI) of < 18.5 kg/m2, ypN stage 1-3, and R1-2 resection. CONCLUSIONS SALV was associated with a higher incidence of late pulmonary-related mortality but had a stronger antitumor effect than NCRS. Consequently, the survival rate was similar between the groups. Surgery is recommended for patients with a partial response and preoperative BMI of ≥ 18.5 kg/m2.
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Affiliation(s)
- Osamu Shiraishi
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan.
| | - Takushi Yasuda
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Hiroaki Kato
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Kota Momose
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Yoko Hiraki
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Atsushi Yasuda
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Masayuki Shinkai
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Yutaka Kimura
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
| | - Motohiro Imano
- Department of Surgery, Faculty of Medicine, Kindai University, Osaka-Sayama, Japan
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Huang TT, Li SH, Chen YH, Lu HI, Lo CM, Fang FM, Chou SY, Chiu YC, Chou YP, Wang YM. Definitive chemoradiotherapy for clinical T4b esophageal cancer - Treatment outcomes, failure patterns, and prognostic factors. Radiother Oncol 2021; 157:56-62. [PMID: 33482233 DOI: 10.1016/j.radonc.2021.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 01/07/2021] [Accepted: 01/07/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE The management of cT4b thoracic esophageal cancer (EC) is challenging. The optimal treatment remains unclear, and prospective or large-scale retrospective reports on treatment outcomes are lacking. The present study was conducted to investigate the treatment outcomes, failure patterns, treatment responses, and prognostic factors focusing on cT4b thoracic EC treated by definitive concurrent chemoradiotherapy (dCRT). METHODS A retrospective review of cT4b thoracic EC patients treated with curative intent dCRT at our institution between 2009 and 2017 was conducted. Survival analysis was calculated using the Kaplan-Meier method, and prognostic factors were examined by the Cox proportional hazards model. RESULTS A total of 95 cT4b EC patients were included, and the median survival was 11.4 months. The 1-year, 3-year, and 5-year survival rates were 49.4%, 22.2%, and 19.0%, respectively. Forty-six patients (48.4%) experienced locoregional failure, 3 patients (3.2%) developed distant metastasis, and 11 patients had synchronous locoregional and distant failure. The corresponding 1-year, 3-year, and 5-year locoregional failure rates were 62.6%, 74.5%, and 79.2%, respectively. The treatment response rate was 76.9%, and clinical complete response was achieved in 25.3% of patients. Multivariable analysis revealed that age ≤ 65 (p = 0.003), pre-dCRT body mass index (BMI) > 21 (p < 0.001), clinical N stage 0-1 (p = 0.014), and tumor length ≤ 6 cm (p = 0.026) were independent prognosticators for better survival. CONCLUSION Our study revealed that long-term survival is achievable for cT4b EC patients treated by dCRT, with a 3-year survival rate of more than 20%. Locoregional recurrence was the most common failure pattern. Age, BMI, N stage, and tumor length were significant prognosticators for survival in this group of patients.
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Affiliation(s)
- Tzu-Ting Huang
- Department of Radiation Oncology and Proton & Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shau-Hsuan Li
- Department of Hematology-Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yen-Hao Chen
- Department of Hematology-Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hung-I Lu
- Department of Thoracic & Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chien-Ming Lo
- Department of Thoracic & Cardiovascular Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Fu-Min Fang
- Department of Radiation Oncology and Proton & Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shang-Yu Chou
- Department of Radiation Oncology and Proton & Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Chun Chiu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yeh-Pin Chou
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Ming Wang
- Department of Radiation Oncology and Proton & Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; School of Traditional Chinese Medicine, Chang Gung University, Taoyuan, Taiwan.
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Lee CC, Yeo CM, Ng WK, Verma A, Tey JCS. T4 cervical esophageal cancer cured with modern chemoradiotherapy: A case report. World J Clin Cases 2020; 8:1950-1957. [PMID: 32518786 PMCID: PMC7262722 DOI: 10.12998/wjcc.v8.i10.1950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/01/2020] [Accepted: 04/27/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND T4 esophageal cancer portends a poor prognosis, particularly when it is complicated by a tracheoesophageal fistula (TEF) either resulting from disease or occurring as a complication of treatment. Patients with TEF that occurs during treatment are commonly treated with palliative intent because fistula-associated treatment complications such as aspiration pneumonia and mediastinitis are associated with high morbidity and mortality. To date, there is no clear evidence on the optimal treatment of T4 esophageal cancer, particularly when a TEF formation occurs.
CASE SUMMARY A 67-year-old gentleman who presented with dysphagia and weight loss. Endoscopy and imaging revealed a T4N1M0 cervical esophageal squamous cell carcinoma. He received image-guided intensity-modulated radiation therapy, with concurrent weekly carboplatin (area under curve 2 mg/mL per minute) and paclitaxel (50 mg/m2 of body surface area). One week after treatment initiation (16.2 Gy thus far), he developed cough on swallowing. A TEF was detected on image-guided radiation therapy using cone-beam computed tomography during the treatment course, for which a tracheal stent was inserted. After discussing the risks and morbidity of continuing treatment, he resumed chemoradiotherapy with an additional radiation dose of 45 Gy in 25 fractions. Three months after completion of chemoradiotherapy, he developed an esophageal stricture that required esophageal stenting and dilatation. The patient remains cancer-free at two year on follow-up. Complete response of esophageal cancer was evident on post-treatment endoscopy and computed tomography imaging, with successful closure of TEF.
CONCLUSION This case highlights that successful curative treatment for esophageal cancer complicated by a TEF is possible using novel chemotherapeutic regimens and modern radiation technologies.
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Affiliation(s)
- Chia Ching Lee
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Tan Tock Seng Hospital, Singapore 119228, Singapore
| | - Chong Ming Yeo
- Department of Medical Oncology, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Wee Khoon Ng
- Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Akash Verma
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Jeremy CS Tey
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Tan Tock Seng Hospital, Singapore 119228, Singapore
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Ishikura S, Kondo T, Murai T, Ozawa Y, Yanagi T, Sugie C, Miyakawa A, Shibamoto Y. Definitive chemoradiotherapy for squamous cell carcinoma of the esophagus: outcomes for borderline-resectable disease. JOURNAL OF RADIATION RESEARCH 2020; 61:464-469. [PMID: 32249307 PMCID: PMC7299256 DOI: 10.1093/jrr/rraa008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 01/15/2020] [Indexed: 05/14/2023]
Abstract
Definitive chemoradiotherapy (dCRT) is the standard treatment for unresectable esophageal cancer. Induction chemotherapy has been actively investigated for borderline-resectable and unresectable disease, but the superiority over dCRT has yet to be confirmed. The purpose of this study was to evaluate the outcome of dCRT with special interest in borderline-resectable disease. Patients with esophageal cancer treated with dCRT between January 2004 and November 2016 were included in this retrospective analysis. Chemotherapy consisted of two cycles of cisplatin (70-75 mg/m2) on day 1 and 5-fluorouracil (700-1000 mg/m2 per day) on days 1-4 or low-dose cisplatin (10 mg/m2 per day) and 5-fluorouracil (175 mg/m2 per day) for 20 days. Radiotherapy was given with a daily fraction of 1.8-2 Gy to a total dose of 50-70 Gy. A total of 104 patients were included: 34 were resectable, 35 were borderline-resectable and 35 were unresectable. Complete response was achieved in 44 patients (42%). Eighteen patients (17%) suffered Grade 2 or greater cardiopulmonary toxicity and seven patients (7%) suffered Grade 3 cardiopulmonary toxicity. At the time of this analysis, 59 patients were dead and 45 were censored. The 3-year overall survival proportions for resectable, borderline-resectable and unresectable patients were 64%, 46% and 21%, respectively. The overall survival for borderline-resectable patients with complete response and noncomplete response was significantly different (P < 0.001), with 3-year survival of 70% and 8%, respectively. The overall survival for complete response patients with borderline-resectable disease was encouraging. Further investigation to find a subgroup fit for esophagus-preserving treatment is warranted.
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Affiliation(s)
- Satoshi Ishikura
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
- Corresponding author. Department of Radiology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi 467-8601, Japan. Tel: +81-52-853-8276; Fax: +81-52-852-5244;
| | - Takuhito Kondo
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Taro Murai
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Yoshiyuki Ozawa
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
| | - Takeshi Yanagi
- Department of Proton, Narita Memorial Proton Center, Toyohashi, Aichi 441-8021, Japan
| | - Chikao Sugie
- Department of Radiology, Nagoya Daini Red Cross Hospital, Nagoya, Aichi 466-8650, Japan
| | - Akifumi Miyakawa
- Department of Radiation Oncology, National Hospital Organization Nagoya Medical Center, Nagoya, Aichi 460-0001, Japan
| | - Yuta Shibamoto
- Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi 467-8601, Japan
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Yamasaki M, Yamashita K, Saito T, Tanaka K, Makino T, Miyazaki Y, Takahashi T, Kurokawa Y, Nakajima K, Motoori M, Kimura Y, Mori M, Doki Y. Tracheal resection and anterior mediastinal tracheostomy in the multidisciplinary treatment of esophageal cancer with tracheal invasion. Dis Esophagus 2020; 33:5735623. [PMID: 32055845 DOI: 10.1093/dote/doz101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 11/04/2019] [Indexed: 12/11/2022]
Abstract
Combined tracheal resection and anterior mediastinal tracheostomy (AMT) for esophageal cancer with tracheal invasion is a challenging treatment because of its high morbidity and the lack of evidence regarding long-term outcomes. The aim of this study was to assess the short- and long-term outcomes of AMT as part of the multidisciplinary treatment for esophageal cancer with tracheal invasion. This retrospective study included 27 consecutive patients with esophageal cancer with tracheal invasion who underwent combined tracheal resection and AMT in their multidisciplinary treatment for esophageal cancer. We evaluated postoperative complications, body weight loss, and survival and examined the prognostic value of preoperative factors. All patients underwent chemotherapy and/or chemoradiotherapy as prior treatment. R0 resection was achieved in all cases. Clavien-Dindo grade I or greater complications occurred in 17 patients (63%), and grade III or greater complications occurred in 12 (44%). Overall in-hospital mortality was 4%, with one patient dying on postoperative day 48 when the brachiocephalic artery ruptured from tracheal compression. The 30- and 90-day mortality rates were 0% and 4%, respectively. Median weight change in patients without recurrence in the year after surgery was -1.7% (-9.6-21%). All of these patients received nutrition by oral intake and were living independently at home without public assistance. The 3- and 5-year disease-free survival rates were 25.9% and 18.5%, respectively; 3- and 5-year overall survival rates were 38.6% and 25.7%, respectively. Multivariate analysis identified response to prior treatment as an independent prognostic factor in these patients. Combined tracheal resection and AMT may be adapted as part of the multidisciplinary treatment of esophageal cancer with tracheal invasion. Improving AMT safety and optimizing patient selection may improve prognosis among patients with this cancer.
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Affiliation(s)
- Makoto Yamasaki
- Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kotaro Yamashita
- Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Takuro Saito
- Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Koji Tanaka
- Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Tomoki Makino
- Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yasuhiro Miyazaki
- Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Tsuyoshi Takahashi
- Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yukinori Kurokawa
- Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Kiyokazu Nakajima
- Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Masaaki Motoori
- Department of Surgery, Osaka General Medical Center, Osaka, Japan
| | - Yutaka Kimura
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Masaki Mori
- Department of Surgery and Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yuichiro Doki
- Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
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12
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Watanabe M. Salvage Esophagectomy for Residual Tumor After Definitive Chemoradiotherapy for Esophageal Squamous Cell Carcinoma Invading the Neighboring Organs: Is it a Feasible Choice? Ann Surg Oncol 2020; 27:3107-3108. [PMID: 32382893 DOI: 10.1245/s10434-020-08571-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
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13
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Booka E, Haneda R, Ishii K, Kawakami T, Tsushima T, Yasui H, Onoe T, Ogawa H, Tsubosa Y. Appropriate Candidates for Salvage Esophagectomy of Initially Unresectable Locally Advanced T4 Esophageal Squamous Cell Carcinoma. Ann Surg Oncol 2020; 27:3163-3170. [PMID: 32314159 DOI: 10.1245/s10434-020-08440-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Standard treatment for unresectable locally advanced esophageal cancer is definitive chemoradiotherapy (dCRT). Although salvage esophagectomy is the only curative treatment available following dCRT failure, the appropriate candidates for salvage esophagectomy remain unclear. PATIENTS AND METHODS Three hundred seventeen patients who underwent dCRT from April 2004 to December 2016 were stratified into three study groups-a complete response (CR) group, chemotherapy or best supportive care (BSC) group, and salvage esophagectomy group-and compared. We also investigated the clinical outcomes and prognostic factors of salvage esophagectomy. RESULTS Seventy-one patients (22.4%) achieved CR after dCRT, 18 patients (5.7%) underwent salvage esophagectomy, and 228 patients (71.9%) underwent palliative chemotherapy or BSC. The 5-year overall survival (OS) rates of the CR group, salvage esophagectomy group, and chemotherapy or BSC group were 83.0%, 51.6%, and 1.3%, respectively. Salvage esophagectomy recipients had a worse OS rate than CR patients (p < 0.001) but a better OS rate than those in the chemotherapy or BSC group (p < 0.001). Incomplete resection was the only significant variable associated with poor OS on univariate Cox proportional-hazards analysis (hazard ratio: 7.633, 95% confidence interval: 1.692-34.482; p = 0.008). Patients with tumors in the upper thoracic esophagus were more likely to undergo incomplete resection (p = 0.011). CONCLUSIONS Patients who achieve R0 resection are good candidates for salvage esophagectomy regardless of their response to dCRT. Those with upper thoracic esophageal tumors are at risk of incomplete resection; careful attention is required when considering these patients for salvage esophagectomy.
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Affiliation(s)
- Eisuke Booka
- Divisions of Esophageal Surgery, Shizuoka Cancer Center Hospital, Nagaizumi, Japan
| | - Ryoma Haneda
- Divisions of Esophageal Surgery, Shizuoka Cancer Center Hospital, Nagaizumi, Japan.,Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kenjiro Ishii
- Divisions of Esophageal Surgery, Shizuoka Cancer Center Hospital, Nagaizumi, Japan
| | - Takeshi Kawakami
- Gastrointestinal Oncology, Shizuoka Cancer Center Hospital, Nagaizumi, Japan
| | - Takahiro Tsushima
- Gastrointestinal Oncology, Shizuoka Cancer Center Hospital, Nagaizumi, Japan
| | - Hirofumi Yasui
- Gastrointestinal Oncology, Shizuoka Cancer Center Hospital, Nagaizumi, Japan
| | - Tsuyoshi Onoe
- Radiation Oncology and Proton Therapy, Shizuoka Cancer Center Hospital, Nagaizumi, Japan
| | - Hirofumi Ogawa
- Radiation Oncology and Proton Therapy, Shizuoka Cancer Center Hospital, Nagaizumi, Japan
| | - Yasuhiro Tsubosa
- Divisions of Esophageal Surgery, Shizuoka Cancer Center Hospital, Nagaizumi, Japan.
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14
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Akiyama Y, Iwaya T, Endo F, Nikai H, Baba S, Chiba T, Kimura T, Takahara T, Otsuka K, Nitta H, Mizuno M, Kimura Y, Koeda K, Sasaki A. Safety of thoracoscopic esophagectomy after induction chemotherapy for locally advanced unresectable esophageal squamous cell carcinoma. Asian J Endosc Surg 2020; 13:152-159. [PMID: 31313511 DOI: 10.1111/ases.12731] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 05/03/2019] [Accepted: 06/09/2019] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Recent studies have reported that induction chemotherapy with docetaxel plus cisplatin and 5-fluorouracil (DCF) is an effective treatment for unresectable, locally advanced esophageal cancer. The aim of this study was to investigate the safety and feasibility of thoracoscopic esophagectomy (TE) after DCF for initially unresectable esophageal squamous cell carcinoma (ESCC). METHODS Twenty-three patients with initially unresectable T4 thoracic ESCC underwent TE after induction DCF. RESULTS The neighboring organs with tumors were the tracheobronchus in nine patients, thoracic aorta in 13, and pericardium and diaphragm in three each (concurrent overlapping invasion occurred in five patients). The mean total operation time was 556.3 ± 107.2 minutes, and the mean time of the thoracic procedure was 258.9 ± 83.9 minutes. The mean total blood loss was 166.2 ± 117.8 mL, and the loss during the thoracic procedure was 33.5 ± 24.6 mL. All patients achieved complete R0 resection under TE. No conversions to open thoracotomy were performed. The postoperative morbidity rate was 34.8%. The postoperative hospital stay was 24.3 (range, 13-38) days. Five patients had recurrence: four had distant metastasis (lung, two; liver, three; and one with overlap), and one had mediastinal lymph node recurrence. No local recurrence was noted at the site of the primary T4 tumor. CONCLUSIONS TE was safely performed in 23 patients after DCF therapy for locally advanced unresectable ESCC. Induction DCF, followed by TE, could be an alternative treatment for unresectable T4 ESCC.
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Affiliation(s)
- Yuji Akiyama
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Takeshi Iwaya
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Fumitaka Endo
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Haruka Nikai
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Shigeaki Baba
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Takehiro Chiba
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Toshimoto Kimura
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Takeshi Takahara
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Koki Otsuka
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Masaru Mizuno
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | - Yusuke Kimura
- Department of Palliative Medicine, Iwate Medical University School of Medicine, Morioka, Japan
| | - Keisuke Koeda
- Department of Medical Safety Science, Iwate Medical University School of Medicine, Morioka, Japan
| | - Akira Sasaki
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
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15
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Terada M, Hara H, Daiko H, Mizusawa J, Kadota T, Hori K, Ogawa H, Ogata T, Sakanaka K, Sakamoto T, Kato K, Kitagawa Y. Phase III study of tri-modality combination therapy with induction docetaxel plus cisplatin and 5-fluorouracil versus definitive chemoradiotherapy for locally advanced unresectable squamous-cell carcinoma of the thoracic esophagus (JCOG1510: TRIANgLE). Jpn J Clin Oncol 2020; 49:1055-1060. [PMID: 31411696 DOI: 10.1093/jjco/hyz112] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/08/2019] [Indexed: 12/23/2022] Open
Abstract
A randomized phase III trial commenced in Japan in February 2018. Definitive chemoradiotherapy (CRT) with cisplatin plus 5-fluorouracil is the current standard treatment for locally advanced unresectable esophageal carcinoma. The purpose of this study is to confirm the superiority of induction chemotherapy with docetaxel plus cisplatin and 5-fluorouracil (DCF) followed by conversion surgery or definitive CRT over definitive CRT alone for overall survival (OS) in patients with locally advanced unresectable squamous-cell carcinoma of thoracic esophagus. A total of 230 patients will be accrued from 47 Japanese institutions over 4.5 years. The primary endpoint is OS, and the secondary endpoints are progression-free survival, complete response rate of CRT, response rate of DCF, adverse events of DCF and CRT, late adverse events and surgical complications. This trial has been registered at the Japan Registry of Clinical Trials as jRCTs031180181.
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Affiliation(s)
- Mitsumi Terada
- International Trials Management Section, Clinical Research Support Office, National Cancer Center Hospital, Japan.,Medical Department, EORTC Headquarters, Belgium
| | - Hiroki Hara
- Department of Gastroenterology, Saitama Cancer Center, Saitama
| | - Hiroyuki Daiko
- Esophageal Surgery Division, National Cancer Center Hospital, Japan
| | - Junki Mizusawa
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Tokyo
| | - Tomohiro Kadota
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Tokyo
| | - Keisuke Hori
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Kashiwa, Chiba
| | - Hirofumi Ogawa
- Division of Radiation Oncology, Shizuoka Cancer Center, Shizuoka
| | - Takashi Ogata
- Department of Gastrointestinal Surgery, Kanagawa Cancer Center, Kanagawa
| | - Katsuyuki Sakanaka
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University
| | | | - Ken Kato
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, Tokyo
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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16
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Okamura A, Hayami M, Kozuki R, Takahashi K, Toihata T, Imamura Y, Mine S, Watanabe M. Salvage esophagectomy for initially unresectable locally advanced T4 esophageal squamous cell carcinoma. Esophagus 2020; 17:59-66. [PMID: 31595397 DOI: 10.1007/s10388-019-00700-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/01/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Definitive chemoradiotherapy (dCRT) for esophageal squamous cell carcinoma (ESCC) is a potentially curative treatment modality, even for patients with unresectable T4 tumors. For patients who fail dCRT, salvage esophagectomy is known to be a high-risk procedure. However, the efficacy and safety of salvage surgery for these patients remain unclear. METHODS A total of 35 patients who underwent salvage esophagectomy after dCRT for initially unresectable locally advanced T4 ESCC were assessed, and both outcomes and prognostic factors after surgery were investigated. RESULTS Among the study population, R0 resection was achieved in 19 patients (54.3%). Postoperatively, 8 patients (22.9%) experienced Clavien-Dindo grade IIIb or higher complications, and 3 patients (8.6%) registered surgery-related mortality. Overall survival rates were 45.7%, 28.6%, and 5.7% at 1, 2, and 5 years, respectively. In Cox regression analysis, residual or relapsed tumor limited to T2 or less was an independent prognostic factor for better survival (P = 0.010). On the other hand, postoperative pneumonia and incomplete resection were negative prognostic factors (P < 0.001 and P = 0.019, respectively). Nodal involvement and extent of lymph node dissection did not impact patient survival. CONCLUSIONS Although salvage esophagectomy for initially unresectable T4 ESCC is considered a high-risk surgery with poor prognosis, long-term survival may be achieved in patients with ≤ T2 residual tumors. In addition, R0 resection and postoperative pneumonia prevention are crucial to improve patient survival.
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Affiliation(s)
- Akihiko Okamura
- Department of Gastroenterological Surgery, Gastroenterology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Masaru Hayami
- Department of Gastroenterological Surgery, Gastroenterology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Ryotaro Kozuki
- Department of Gastroenterological Surgery, Gastroenterology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Keita Takahashi
- Department of Gastroenterological Surgery, Gastroenterology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Tasuku Toihata
- Department of Gastroenterological Surgery, Gastroenterology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Gastroenterology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Shinji Mine
- Department of Esophageal and Gastroenterological Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Gastroenterology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
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17
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Anderegg MCJ, Ruurda JP, Gisbertz SS, Blom RLGM, Sosef MN, Wijnhoven BPL, Hulshof MCCM, Bergman JJGHM, van Laarhoven HWM, van Berge Henegouwen MI. Feasibility of extended chemoradiotherapy plus surgery for patients with cT4b esophageal carcinoma. Eur J Surg Oncol 2019; 46:626-631. [PMID: 31706717 DOI: 10.1016/j.ejso.2019.10.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 09/02/2019] [Accepted: 10/17/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Treatment of cT4b esophageal carcinoma usually consists of definitive chemoradiotherapy (dCRT). However, outcome after dCRT in these patients is poor. Whether surgery should have a place in the treatment of cT4b esophageal cancer is still subject to debate. Goal of this study was to evaluate the feasibility of esophagectomy after extended chemoradiotherapy in patients with cT4b esophageal cancer. METHODS Patients with cT4b esophageal carcinoma, as determined by endoscopic ultrasound and (PET-)CT, were eligible for this phase-2 study. Patients were treated with weekly carboplatin + paclitaxel with 50.4 Gy radiotherapy in 28 fractions for 5.5 weeks followed by an explorative thoracotomy and esophagectomy if deemed feasible. RESULTS From July 2011 through March 2013, 16 patients were enrolled. Five patients did not undergo surgery because of detection of distant metastases during/after CRT (n = 3), unwillingness to undergo surgery (n = 1) or death before start of CRT (n = 1). Of the 13 patients who completed CRT, 3 patients experienced major hematologic toxicity (grade 3). A radical (R0) resection was achieved in 9 of 11 patients. Postoperative complications occurred in 9 patients. A reoperation was performed in 2 patients and 2 patients died in hospital after surgery. Three patients developed recurrent disease (1 locoregional and 2 systemic) after a mean interval of 17 months. Median overall survival of all included patients was 14.3 months. CONCLUSIONS In certain patients with cT4b esophageal carcinoma a radical resection can be accomplished after chemoradiotherapy. However, this treatment is associated with considerable complications and should therefore be reserved for physically fit patients. NETHERLANDS TRIAL REGISTER NUMBER NTR3060.
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Affiliation(s)
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center, Utrecht, the Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Rachel L G M Blom
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Meindert N Sosef
- Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
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18
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Miyata H, Sugimura K, Motoori M, Omori T, Yamamoto K, Yanagimoto Y, Shinno N, Yasui M, Takahashi H, Wada H, Ohue M, Yano M. Clinical Implications of Conversion Surgery After Induction Therapy for T4b Thoracic Esophageal Squamous Cell Carcinoma. Ann Surg Oncol 2019; 26:4737-4743. [PMID: 31414291 DOI: 10.1245/s10434-019-07727-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Definitive chemoradiation therapy or chemotherapy alone is generally recommended for patients with unresectable cT4b esophageal cancer. However, conversion surgery has emerged as a therapeutic option when downstaging is achieved by induction therapy. METHODS We studied 169 patients with cT4 esophageal cancer who underwent induction therapy. Survival and prognostic factors were examined. RESULTS Of 169 patients, 25 who achieved a clinical complete response (cCR) underwent surveillance, 72 patients underwent conversion surgery, while another 72 patients whose tumors were regarded as unresectable after induction therapy did not undergo surgery. Among 169 patients, the 3- and 5-year survival rates were 31.0% and 25.9%, respectively. Sixty-four patients who underwent curative resection showed better survival comparable with survival of 25 patients who achieved cCR (3- and 5-year survival; 56.8% and 48.6% versus 64.0% and 52.0%, respectively). However, the survival of eight patients who underwent noncurative resection was as dismal as that of patients who did not undergo conversion surgery. Multivariate analysis in 169 patients identified female sex and achieving cCR or R0 resection as independent prognostic factors. Multivariate analysis in 72 patients who underwent conversion surgery identified sex, lymph node status, and R0 resection as independent prognostic factors in patients with cT4b esophageal cancer. CONCLUSIONS The present study showed that conversion surgery after induction therapy can be a potentially curative treatment option for select patients with cT4b esophageal cancer. An important issue for further research is to establish a method for more accurately diagnosing tumor resectability after induction therapy for cT4b esophageal cancer.
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Affiliation(s)
- Hiroshi Miyata
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan.
| | - Keijirou Sugimura
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masaaki Motoori
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Takeshi Omori
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Kazuyoshi Yamamoto
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Yoshitomo Yanagimoto
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Naoki Shinno
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masayoshi Yasui
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Hidenori Takahashi
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroshi Wada
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masayuki Ohue
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masahiko Yano
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
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19
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Raman V, Jawitz OK, Voigt SL, Farrow NE, Yang CFJ, D'Amico TA, Harpole DH. Surgery Is Associated With Survival Benefit in T4a Esophageal Adenocarcinoma: A National Analysis. Ann Thorac Surg 2019; 108:1633-1639. [PMID: 31356800 DOI: 10.1016/j.athoracsur.2019.05.091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 05/23/2019] [Accepted: 05/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The National Comprehensive Cancer Network guidelines recommend consideration of surgery for clinical T4a esophageal adenocarcinoma. There are limited data on the outcomes of patients with T4a adenocarcinoma treated with surgery vs definitive chemoradiation, however. METHODS The National Cancer Database was used to identify patients from 2010-2015 with clinical T4aN0-3M0 esophageal adenocarcinoma, and grouped by receipt of surgery (with or without perioperative therapy) or definitive, concurrent chemoradiation. Patients receiving incomplete definitive therapy or with missing survival information were excluded. Overall survival was evaluated with Kaplan-Meier and Cox proportional hazard analyses. RESULTS Of 182 patients in the study, 85 (47%) underwent esophagectomy and 97 (53%) underwent chemoradiation. In the surgery cohort, 79 patients (93%) received perioperative chemotherapy. Unadjusted and multivariable analyses demonstrated a significant survival benefit associated with surgery compared with definitive chemoradiotherapy (adjusted hazard ratio 0.32; 95% confidence interval 0.21, 0.50). A 1:1 propensity score-matched analysis of 63 patient pairs also revealed a significant overall survival benefit with surgery compared with chemoradiotherapy alone (hazard ratio 0.26; 95% confidence interval 0.16, 0.43). CONCLUSIONS In this national analysis, surgery for cT4a esophageal adenocarcinoma was associated with improved outcomes when compared with definitive chemoradiation. Surgery should be considered for medically fit patients with cT4aN0-3M0 esophageal adenocarcinoma.
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Affiliation(s)
- Vignesh Raman
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Oliver K Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Soraya L Voigt
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Norma E Farrow
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Chi-Fu J Yang
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Palo Alto, California
| | - Thomas A D'Amico
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - David H Harpole
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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20
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Makino T, Yamasaki M, Tanaka K, Miyazaki Y, Takahashi T, Kurokawa Y, Motoori M, Kimura Y, Nakajima K, Mori M, Doki Y. Treatment and clinical outcome of clinical T4 esophageal cancer: A systematic review. Ann Gastroenterol Surg 2019; 3:169-180. [PMID: 30923786 PMCID: PMC6422802 DOI: 10.1002/ags3.12222] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/29/2018] [Accepted: 11/12/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Survival of patients with cT4 esophageal cancer is dismal. Although the optimal treatment strategy remains to be established, two treatment options are available for cT4 esophageal cancers: definitive chemoradiation (dCRT) and induction treatment followed by conversion surgery (CS). However, little is known concerning the differences in clinical outcome between patients with T4 esophageal tumors treated with dCRT and those eventually treated with CS. METHODS A systematic search of the scientific literature on PubMed/MEDLINE was carried out using the keywords "T4 esophageal cancer," "invading (involving) adjacent organ," "definitive chemoradiation," "induction therapy," "salvage surgery," and "conversion surgery," obtaining 28 reports published up to July 2018. RESULTS/CONCLUSION We found that CS was superior to dCRT with respect to local disease control and short-term survival; however, CS was associated with relatively higher perioperative mortality and morbidity. Alternatively, although dCRT might often cause fistula formation, a clinical complete response to dCRT is likely to lead to a better prognosis. Recent advances in chemotherapeutic agents have led to triple induction chemotherapy, with docetaxel, cisplatin, and 5-fluorouracil (DCF), which has shown promise as an initial induction treatment for cT4 esophageal cancer. Indeed, this regimen could control both local and systemic disease, which enables curative resection without preoperative CRT. Moreover, some appropriate changes in perioperative management and intensive systemic chemotherapy might enhance patient outcome. Randomized controlled trials with a large sample size are needed to establish the standard treatment for cT4 esophageal cancer.
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Affiliation(s)
- Tomoki Makino
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Makoto Yamasaki
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Koji Tanaka
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Yasuhiro Miyazaki
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Tsuyoshi Takahashi
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Yukinori Kurokawa
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | | | - Yutaka Kimura
- Department of SurgeryFaculty of MedicineKindai UniversityOsakaJapan
| | - Kiyokazu Nakajima
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Masaki Mori
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
| | - Yuichiro Doki
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversityOsakaJapan
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21
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Kitagawa Y, Uno T, Oyama T, Kato K, Kato H, Kawakubo H, Kawamura O, Kusano M, Kuwano H, Takeuchi H, Toh Y, Doki Y, Naomoto Y, Nemoto K, Booka E, Matsubara H, Miyazaki T, Muto M, Yanagisawa A, Yoshida M. Esophageal cancer practice guidelines 2017 edited by the Japan Esophageal Society: part 1. Esophagus 2019; 16:1-24. [PMID: 30171413 PMCID: PMC6510883 DOI: 10.1007/s10388-018-0641-9] [Citation(s) in RCA: 345] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 08/22/2018] [Indexed: 02/03/2023]
Affiliation(s)
- Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Takashi Uno
- Department of Radiology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tsuneo Oyama
- Department of Gastroenterology, Saku Central Hospital, Nagano, Japan
| | - Ken Kato
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroyuki Kato
- Department of Gastrointestinal Tract Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Osamu Kawamura
- Department of Endoscopy and Endoscopic Surgery, Gunma University Hospital, Maebashi, Gunma, Japan
| | - Motoyasu Kusano
- Department of Endoscopy and Endoscopic Surgery, Gunma University Hospital, Maebashi, Gunma, Japan
| | - Hiroyuki Kuwano
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Yasushi Toh
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshio Naomoto
- Department of General Surgery, Kawasaki Medical School, Okayama, Japan
| | - Kenji Nemoto
- Department of Radiation Oncology, Yamagata University School of Medicine, Yonezawa, Japan
| | - Eisuke Booka
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hisahiro Matsubara
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tatsuya Miyazaki
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Manabu Muto
- Department of Clinical Oncology, Kyoto University Hospital, Kyoto, Japan
| | - Akio Yanagisawa
- Department of Pathology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiro Yoshida
- Department of Hemodialysis and Surgery, Chemotherapy Research Institute, International University of Health and Welfare, Ichikawa, Japan
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22
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Yamaguchi S, Morita M, Yamamoto M, Egashira A, Kawano H, Kinjo N, Tsujita E, Minami K, Ikebe M, Ikeda Y, Kunitake N, Toh Y. Long-Term Outcome of Definitive Chemoradiotherapy and Induction Chemoradiotherapy Followed by Surgery for T4 Esophageal Cancer with Tracheobronchial Invasion. Ann Surg Oncol 2018; 25:3280-3287. [PMID: 30051363 DOI: 10.1245/s10434-018-6656-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND T4 esophageal cancer (EC) that invades the trachea or bronchus often has poorer prognosis than other T4 ECs. We investigated the long-term results of definitive chemoradiotherapy (dCRT) or induction chemoradiotherapy followed by surgery (iCRT-S) in patients with T4 EC with tracheobronchial invasion (TBI). PATIENTS AND METHODS From 2003 to 2013, 71 patients with T4 EC with TBI were treated in our institution; 58 underwent dCRT, and 13 underwent iCRT-S. The long-term results associated with survival were retrospectively analyzed, and prognostic factors were examined by univariable and multivariable analysis. RESULTS The 1-, 2-, and 5-year overall survival for all patients with T4 EC with TBI treated by dCRT or iCRT-S was 57, 29, and 19%, respectively. Multivariable analysis revealed that clinical lymph node (LN) metastasis and the treatment period were significant prognostic factors. Clinical LN positivity had significantly poorer prognosis than LN negativity. The treatment outcome in the later period was significantly better than that in the earlier period. In particular, the outcome after dCRT revealed significantly better prognosis in the later compared with the earlier period, whereas the outcome after iCRT-S did not show such a difference. With respect to treatment modality, no significant difference in survival was observed between dCRT and iCRT-S. CONCLUSIONS Clinical LN negativity and later treatment period were significantly good prognostic factors for T4 EC with TBI. The recent improvements in dCRT outcomes may help to achieve survival comparable to that of iCRT-S.
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Affiliation(s)
- Shohei Yamaguchi
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan. .,Department of Surgery, Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital, Hiroshima, Japan.
| | - Masaru Morita
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan
| | - Manabu Yamamoto
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan
| | - Akinori Egashira
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan
| | - Hiroyuki Kawano
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan
| | - Nao Kinjo
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan
| | - Eiji Tsujita
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan
| | - Kazuhito Minami
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan
| | - Masahiko Ikebe
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan
| | - Yasuharu Ikeda
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan
| | - Naonobu Kunitake
- Department of Radiology, National Kyushu Cancer Center, Fukuoka, Japan
| | - Yasushi Toh
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan
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23
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Makino T, Yamasaki M, Miyazaki Y, Wada N, Takahashi T, Kurokawa Y, Nakajima K, Takiguchi S, Mori M, Doki Y. Utility of initial induction chemotherapy with 5-fluorouracil, cisplatin, and docetaxel (DCF) for T4 esophageal cancer: a propensity score-matched analysis. Dis Esophagus 2018; 31:4670862. [PMID: 29190316 DOI: 10.1093/dote/dox130] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 10/10/2017] [Indexed: 12/11/2022]
Abstract
Although no consensus is available on the treatment of esophageal squamous cell carcinoma (ESCC) invading adjacent organs (T4), establishing effective induction treatments is crucial to altering an unresectable status and achieving curative resection. Here, we evaluated the efficacy of chemotherapy using 5-fluorouracil, cisplatin, and docetaxel (DCF) as the initial induction treatment for T4 ESCC. Fifty patients without distant metastasis who underwent initial induction chemotherapy using DCF for T4 ESCC were propensity score-matched with 50 patients who underwent radiotherapy concurrent with cisplatin and 5-fluorouracil (CRT). In the DCF group, 24 (48.0%) patients underwent surgery, achieving a 64% clinical response rate compared to 72.0% for induction CRT. CRT was also performed in another 24 (48.0%) patients in the DCF group in whom surgical resection was not indicated. The DCF group had significantly higher overall resectability than the CRT group (78.0% vs. 48.0%, P = 0.0017). The esophageal perforation rate during induction treatments was significantly lower in the DCF group than the CRT group (4.0% vs. 18.0%, P = 0.0205). Prognosis was significantly better in the DCF group than the CRT group (5-year cancer-specific survival 42.1% vs. 22.2%, P = 0.0146). Thus, induction DCF chemotherapy in patients with T4 ESCC reduced esophageal perforation and increased overall resectability, leading to better survival than CRT alone. Therefore, DCF chemotherapy may be an effective and safe option for initial induction treatment of T4 ESCC.
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Affiliation(s)
- T Makino
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - M Yamasaki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Y Miyazaki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - N Wada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - T Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Y Kurokawa
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - K Nakajima
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - S Takiguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - M Mori
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Y Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
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24
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Okuno T, Wakabayashi M, Kato K, Shinoda M, Katayama H, Igaki H, Tsubosa Y, Kojima T, Okabe H, Kimura Y, Kawano T, Kosugi S, Toh Y, Kato H, Nakamura K, Fukuda H, Ishikura S, Ando N, Kitagawa Y. Esophageal stenosis and the Glasgow Prognostic Score as independent factors of poor prognosis for patients with locally advanced unresectable esophageal cancer treated with chemoradiotherapy (exploratory analysis of JCOG0303). Int J Clin Oncol 2017; 22:1042-1049. [PMID: 28717855 PMCID: PMC5676839 DOI: 10.1007/s10147-017-1154-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 06/14/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of this study was to investigate the possible prognostic factors and predictive accuracy of the Glasgow Prognostic Score (GPS) for patients with unresectable locally advanced esophageal squamous cell carcinoma (LAESCC) treated with chemoradiotherapy. METHODS One hundred forty-two patients were enrolled in JCOG0303 and assigned to the standard cisplatin and 5-fluorouracil (PF)-radiotherapy (RT) group or the low-dose PF-RT group. One hundred thirty-one patients with sufficient data were included in this analysis. A Cox regression model was used to analyze the prognostic factors of patients with unresectable LAESCC treated with PF-RT. The GPS was classified based on the baseline C-reactive protein (CRP) and serum albumin levels. Patients with CRP ≤1.0 mg/dL and albumin ≥3.5 g/dL were classified as GPS0. If only CRP was increased or only albumin was decreased, the patients were classified as GPS1, and the patients with CRP >1.0 mg/dL and albumin <3.5 g/dL were classified as GPS2. RESULTS The patients' backgrounds were as follows: median age (range), 62 (37-75); male/female, 119/12; ECOG PS 0/1/2, 64/65/2; and clinical stage (UICC 5th) IIB/III/IVA/IVB, 3/75/22/31. Multivariable analyses indicated only esophageal stenosis as a common factor for poor prognosis. In addition, overall survival tended to decrease according to the GPS subgroups (median survival time (months): GPS0/GPS1/GPS2 16.1/14.9/8.7). CONCLUSIONS Esophageal stenosis was identified as a candidate stratification factor for randomized trials of unresectable LAESCC patients. Furthermore, GPS represents a prognostic factor for LAESCC patients treated with chemoradiotherapy. CLINICAL TRIAL INFORMATION UMIN000000861.
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Affiliation(s)
- Tatsuya Okuno
- Division of Gastroenterology, Department of Internal Medicine, Graduate School of Medicine, Kobe University, 7-5-1 Kusunoki Chuo, Kobe, 650-0017, Japan.
| | - Masashi Wakabayashi
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center, Tokyo, Japan
| | - Ken Kato
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, Tokyo, Japan
| | - Masayuki Shinoda
- Department of Gastrointestinal Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Hiroshi Katayama
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center, Tokyo, Japan
| | - Hiroyasu Igaki
- Esophageal Surgery Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuhiro Tsubosa
- Division of Esophageal Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Takashi Kojima
- Gastrointestinal Oncology Division, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hiroshi Okabe
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yusuke Kimura
- Department of Surgery, Iwate Medical University School of Medicine, Morioka, Japan
| | | | - Shinichi Kosugi
- Department of Surgery, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Yasushi Toh
- Department of Gastroenterological Surgery, National Kyushu Cancer Center, Fukuoka, Japan
| | - Hoichi Kato
- Esophageal Surgery Division, National Cancer Center Hospital, Tokyo, Japan
| | - Kenichi Nakamura
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center, Tokyo, Japan
| | - Haruhiko Fukuda
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center, Tokyo, Japan
| | - Satoshi Ishikura
- Department of Radiology, Koshigaya Municipal Hospital, Koshigaya, Saitama, Japan
| | - Nobutoshi Ando
- Department of Surgery, International Goodwill Hospital, Yokohama, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University, School of Medicine, Tokyo, Japan
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25
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Morimoto H, Fujiwara Y, Lee S, Amano K, Hosono M, Miki Y, Osugi H. Treatment results of neoadjuvant chemoradiotherapy followed by radical esophagectomy in patients with initially inoperable thoracic esophageal cancer. Jpn J Radiol 2017; 36:23-29. [PMID: 29080946 DOI: 10.1007/s11604-017-0693-0] [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] [Received: 06/27/2017] [Accepted: 10/06/2017] [Indexed: 02/08/2023]
Abstract
PURPOSE We evaluated the effectiveness of neoadjuvant chemoradiotherapy (CRT) followed by esophagectomy for cT4 esophageal cancer or lymph node metastases (LNM) invading adjacent structures. MATERIALS AND METHODS We retrospectively evaluated 42 consecutive patients with thoracic esophageal cancer who underwent CRT followed by esophagectomy between 2008 and 2013. All were initially considered to be unresectable because of cT4 (n = 32) disease or LN invasion (n = 10). Radiotherapy was administered at 41.4 Gy/23 fr with concurrent chemotherapy. At completion of CRT, restaging was performed using computed tomography (CT). RESULTS All cT4 tumors were downstaged, LNM invading to adjacent structures were considered to be released, and subtotal esophagectomy was performed. The median follow-up period was 42 months. The curative resection (R0) rate was 94% in cT4 group and 70% in LN invasion group. The 3-year overall survival (OS) and 3-year locoregional control (LRC) rates were 65-80% in the cT4 group and 50-67% in LN invasion group, respectively. CONCLUSIONS The cT4 group showed good rates of R0, OS, and LRC. Surgical resection should be an effective option when downstaging is achieved by CRT for patients with initially inoperable thoracic esophageal cancer.
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Affiliation(s)
- Hideyuki Morimoto
- Department of Radiation Oncology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Yushi Fujiwara
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Shigeru Lee
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Kosuke Amano
- Department of Radiation Oncology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Masako Hosono
- Department of Radiation Oncology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Yukio Miki
- Department of Radiation Oncology, Graduate School of Medicine, Osaka City University, 1-4-3, Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Harushi Osugi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
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26
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Saeed NA, Mellon EA, Meredith KL, Hoffe SE, Shridhar R, Frakes J, Fontaine JP, Pimiento JM, Kothari N, Almhanna K. Adjuvant chemotherapy and outcomes in esophageal carcinoma. J Gastrointest Oncol 2017; 8:816-824. [PMID: 29184685 DOI: 10.21037/jgo.2017.07.10] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background Standard treatment for locally advanced esophageal cancer is neoadjuvant chemoradiation followed by surgery. The role of postoperative chemotherapy is unclear. We sought to determine the indications, patterns, and outcomes for adjuvant chemotherapy in esophageal carcinoma. Methods This single institution retrospective review included patients with esophageal cancer who received neoadjuvant chemoradiation and surgery at Moffitt. We identified patients in this cohort who additionally received adjuvant chemotherapy. Medical records were reviewed for demographic/clinical information. Survival was estimated using the Kaplan-Meier method and compared by log-rank. Case-control analysis was performed using a 2:1 nearest neighbor propensity score matching algorithm, which included 92 without adjuvant chemotherapy and 46 with adjuvant chemotherapy. Results We identified 382 patients, 46 of whom received adjuvant chemotherapy. Patients who received adjuvant chemotherapy were younger (60.2 vs. 63.8 years; P=0.047), more likely to have adenocarcinoma (91% vs. 85%; P=0.034), had more advanced ypT and ypN classifications (P<0.001), less response to neoadjuvant therapy (P<0.001), and more margin positivity (15% vs. 4%; P=0.007). With propensity score matching analysis, no variables were significantly different between the two matched groups. Median follow-up times for the entire cohort and for case-control analysis were 2.9 and 2.4 years, respectively. There were no significant differences in overall or recurrence-free survival (RFS) between groups in either analysis. Conclusions The role of adjuvant chemotherapy following neoadjuvant chemoradiation and surgery in esophageal cancer is unclear. We found no significant difference in survival based on adjuvant chemotherapy. Future prospective studies should further investigate potential survival benefits and morbidity.
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Affiliation(s)
- Nadia A Saeed
- Department of Gastrointestinal Oncology H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA.,Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Eric A Mellon
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA.,Department of Radiation Oncology, Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Kenneth L Meredith
- Department of Gastrointestinal Oncology, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Sarah E Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Ravi Shridhar
- Department of Radiation Oncology, Florida Hospital, Orlando, FL, USA
| | - Jessica Frakes
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Jacque-Pierre Fontaine
- Department of Gastrointestinal Oncology H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Jose M Pimiento
- Department of Gastrointestinal Oncology H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Nishi Kothari
- Department of Gastrointestinal Oncology H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Khaldoun Almhanna
- Department of Gastrointestinal Oncology H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
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27
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Sugimura K, Miyata H, Yano M, Yanagimoto Y, Ho MJ, Kobayashi S, Takahashi H, Omori T, Ohue M, Sakon M. Is 18F-FDG-PET useful for predicting R0 resection after induction therapy for initially unresectable locally advanced esophageal carcinoma? Gen Thorac Cardiovasc Surg 2017; 65:455-462. [PMID: 28585161 DOI: 10.1007/s11748-017-0786-9] [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: 01/19/2017] [Accepted: 05/18/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Induction therapy followed by surgery is a promising strategy for esophageal cancer patients with invasion of the trachea/bronchus or aorta. However, no diagnostic criteria have been established to diagnose whether R0 resection can be performed. We investigated whether 18F-2-deoxy-D-glucose positron emission tomography (18F-FDG-PET) and other modalities are useful for predicting R0 resection. METHODS Fifty-seven patients with esophageal cancer invading the trachea/bronchus or aorta who underwent induction therapy followed by surgery were enrolled. We divided the participants into two groups, an R0 resection group (n = 43) and a non-R0 resection group (n = 14), and then compared the between-group results of three modalities, including computed tomography (CT), endoscopy and 18F-FDG-PET, before and after induction therapy. RESULTS The post-maximal standardized uptake value (SUVmax) after induction therapy in the R0 resection group was significantly lower than that in the non-R0 resection group (4.4 vs. 6.6, p = 0.005). The receiver operating characteristic curve analysis showed that the cut-off value for the post-SUVmax based on 18F-FDG-PET prediction of R0 resection was 4.7. Furthermore, a tumor reduction rate of ≥44% on CT, no residual stenosis, and no deep ulcer on endoscopy were associated with R0 resection after induction therapy (p = 0.002, p = 0.091, and p = 0.059, respectively). Multivariate logistic analyses revealed that the tumor reduction rate on CT and post-SUVmax <4.7 in 18F-FDG-PET were independent factors for R0 resection. CONCLUSIONS The post-SUVmax determined by 18F-FDG-PET and the volume reduction rate based on CT scans were useful for predicting R0 resection after induction therapy for initially unresectable locally advanced esophageal carcinoma.
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Affiliation(s)
- Keijiro Sugimura
- Department of Digestive Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Higashinari-ku, Osaka, 537-8511, Japan.
| | - Hiroshi Miyata
- Department of Digestive Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Higashinari-ku, Osaka, 537-8511, Japan
| | - Masahiko Yano
- Department of Digestive Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Higashinari-ku, Osaka, 537-8511, Japan
| | - Yoshitomo Yanagimoto
- Department of Digestive Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Higashinari-ku, Osaka, 537-8511, Japan
| | - Moon Jeong Ho
- Department of Digestive Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Higashinari-ku, Osaka, 537-8511, Japan
| | - Shogo Kobayashi
- Department of Digestive Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Higashinari-ku, Osaka, 537-8511, Japan
| | - Hidenori Takahashi
- Department of Digestive Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Higashinari-ku, Osaka, 537-8511, Japan
| | - Takeshi Omori
- Department of Digestive Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Higashinari-ku, Osaka, 537-8511, Japan
| | - Masayuki Ohue
- Department of Digestive Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Higashinari-ku, Osaka, 537-8511, Japan
| | - Masato Sakon
- Department of Digestive Surgery, Osaka Medical Center for Cancer and Cardiovascular Diseases, Higashinari-ku, Osaka, 537-8511, Japan
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28
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So B, Marcu L, Olver I, Gowda R, Bezak E. Oesophageal cancer: Which treatment is the easiest to swallow? A review of combined modality treatments for resectable carcinomas. Crit Rev Oncol Hematol 2017; 113:135-150. [PMID: 28427503 DOI: 10.1016/j.critrevonc.2017.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 12/17/2016] [Accepted: 03/08/2017] [Indexed: 01/31/2023] Open
Abstract
Oesophageal cancer is a relatively uncommon malignancy, but with poor prognosis. Despite several treatment options that are available, the 5-year survival rates rarely exceed 40%. This review discusses the main challenges of oesophageal cancer, the available treatment options, and the most effective treatment in terms of overall survival. The outcomes of clinical trials show that neo-adjuvant chemo-radiotherapy using cisplatin and 5-fluorouracil followed by oesophagectomy results in the greatest survival. However, the optimal chemotherapy and radiotherapy schedule remains unclear. There is no satisfactory treatment to date, particularly for patients with co-morbidities or advanced tumours.
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Affiliation(s)
- Bianca So
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; School of Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Loredana Marcu
- Faculty of Science, University of Oradea, Oradea 410087, Romania; School of Physical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Ian Olver
- Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - Raghu Gowda
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Eva Bezak
- School of Health Sciences, University of South Australia, Adelaide, SA, Australia; School of Physical Sciences, University of Adelaide, Adelaide, SA, Australia; Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia.
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29
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Hamamoto Y, Nojima M, Aoki Y, Suzuki T, Kawasaki K, Hirata K, Sukawa Y, Kasuga A, Kawakubo H, Takeuchi H, Murakami K, Takaishi H, Kanai T, Kitagawa Y. Inter-evaluator heterogeneity of clinical diagnosis for locally advanced esophageal squamous cell carcinoma. Esophagus 2017; 14:324-332. [PMID: 28983229 PMCID: PMC5603637 DOI: 10.1007/s10388-017-0580-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 05/18/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Identifying clinical resectability of locally advanced esophageal squamous cell carcinoma (ESCC) is important, although inter-evaluator heterogeneity (IEH) could exist, especially in borderline resectable (BLR) cases. To investigate the extent of heterogeneity, we conducted clinical diagnostic imaging questionnaires. MATERIALS AND METHODS Five cases with clinical T3 or T4 cases, which were treated with neo-adjuvant triplet chemotherapy followed by surgery, were selected as the model. These cases were divided into two groups: curative resected cases (#1-#3) and non-curative resected cases (#4 and #5). Only imaging slides were shown without any information about patient characteristics or clinical course. The evaluators consisted of surgeons (staff and non-staff), medical oncologists, and an imaging radiologist; a total of 25 medical staff answered the questionnaire. Two questions (1: clinical T stage before chemotherapy, 2: resectability after chemotherapy) were answered. Occupational differences were assessed by comparing the results to the imaging radiologist. RESULTS IEH was observed for clinical diagnosis before chemotherapy in one case (clinical T4: 52%, clinical T3: 48%). In the other cases, most evaluators diagnosed them as clinical T4, with 76-88% agreement. IEH for clinical resectability after chemotherapy was relatively small. Occupational IEH was observed in both before and after chemotherapy. CONCLUSION IEH in decisions about treating BLR cases in ESCC should be considered in clinical practice. Multi-disciplinary teams are essential to overcome this problem.
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Affiliation(s)
- Yasuo Hamamoto
- 0000 0004 1936 9959grid.26091.3cKeio Cancer Center, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, Japan
| | - Masanori Nojima
- 0000 0001 2151 536Xgrid.26999.3dCenter for Translational Research, The Institute of Medical Science Hospital, The University of Tokyo, Tokyo, Japan
| | - Yu Aoki
- 0000 0004 1936 9959grid.26091.3cDivision of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Tokyo, Japan
| | - Takeshi Suzuki
- 0000 0004 1936 9959grid.26091.3cDivision of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Tokyo, Japan
| | - Kenta Kawasaki
- 0000 0004 1936 9959grid.26091.3cDivision of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Tokyo, Japan
| | - Kenro Hirata
- 0000 0004 1936 9959grid.26091.3cDivision of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Tokyo, Japan
| | - Yasutaka Sukawa
- 0000 0004 1936 9959grid.26091.3cDivision of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Tokyo, Japan
| | - Akira Kasuga
- 0000 0004 1936 9959grid.26091.3cDivision of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Tokyo, Japan
| | - Hirofumi Kawakubo
- 0000 0004 1936 9959grid.26091.3cDivision of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, Japan
| | - Hiroya Takeuchi
- 0000 0004 1936 9959grid.26091.3cDivision of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, Japan
| | - Koji Murakami
- 0000 0004 1936 9959grid.26091.3cDepartment of Radiology, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, Japan
| | - Hiromasa Takaishi
- 0000 0004 1936 9959grid.26091.3cDivision of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, Japan
| | - Takanori Kanai
- 0000 0004 1936 9959grid.26091.3cDivision of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Tokyo, Japan
| | - Yuko Kitagawa
- 0000 0004 1936 9959grid.26091.3cDivision of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo, Japan
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A prospective, multicenter phase I/II study of induction chemotherapy with docetaxel, cisplatin and fluorouracil (DCF) followed by chemoradiotherapy in patients with unresectable locally advanced esophageal carcinoma. Cancer Chemother Pharmacol 2016; 78:91-9. [PMID: 27193097 PMCID: PMC4921115 DOI: 10.1007/s00280-016-3062-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 05/11/2016] [Indexed: 12/30/2022]
Abstract
Purpose Standard care for unresectable locally advanced esophageal squamous cell carcinoma (ESCC) is concurrent chemoradiotherapy, but survival remains limited. Neoadjuvant chemotherapy with docetaxel, cisplatin and fluorouracil (DCF) has demonstrated promising activity, with a pathological complete response (CR) of 17 % for resectable stage II/III ESCC. Here, we conducted a multicenter study to assess the efficacy and safety of induction chemotherapy with DCF followed by CRT in patients with unresectable locally advanced ESCC. Methods Eligibility criteria included clinical T4 and/or M1 lymph node ESCC, PS 0–1 and age 20–70 years. Treatment consisted of docetaxel 70 mg/m2 and cisplatin 70 mg/m2 on day 1, and fluorouracil 750 mg/m2 on days 1–5, repeated every 3 weeks for three cycles, followed by cisplatin 70 mg/m2 on days 64 and 92, and fluorouracil 700 mg/m2 on days 64–67 and 92–95, concurrently with radiotherapy (60 Gy in 30 fractions, 5 days/week). Primary endpoint of the phase II part was CR rate. Results Thirty-three patients were enrolled. The completion rate of protocol treatment was 88 %. Thirteen patients (39.4 %) achieved a CR. With a median follow-up period of 41 months (range 24–49 months), median progression-free survival was 12.2 months, and median survival was 26.0 months, with a survival rate of 40.4 % at 3 years. The most common grade 3 or 4 toxicities were neutropenia, leukopenia, anorexia and dysphagia. No treatment-related death was observed. Conclusion Induction chemotherapy with DCF followed by CRT is tolerable and shows promising efficacy for unresectable locally advanced ESCC.
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Tanaka Y, Yoshida K, Tanahashi T, Okumura N, Matsuhashi N, Yamaguchi K. Phase II trial of neoadjuvant chemotherapy with docetaxel, nedaplatin, and S1 for advanced esophageal squamous cell carcinoma. Cancer Sci 2016; 107:764-72. [PMID: 27061001 PMCID: PMC4968606 DOI: 10.1111/cas.12943] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 04/03/2016] [Accepted: 04/05/2016] [Indexed: 12/16/2022] Open
Abstract
Although standard chemotherapy for esophageal cancer patients is fluorouracil and cisplatin, the prognosis is still unsatisfactory. A new therapeutic regimen combining docetaxel, cisplatin, and 5‐fluorouracil was recently developed to improve both local and distant tumor control. We developed a new regimen of docetaxel, nedaplatin, and S1 (DGS) and previously reported the recommended dose in a phase I dose‐escalation study. We then undertook a phase II study of DGS for advanced esophageal squamous cell carcinoma. Patients with clinical stage IB/II/III disease were eligible. Patients received two courses of chemotherapy: docetaxel 35 mg/m2 with nedaplatin 40 mg/m2 on day 8, 80 mg/m2 S1 on days 1–14, and 2 weeks off. After completion of chemotherapy, patients underwent esophagectomy. The primary endpoint was the completion rate of protocol treatment (completion of two courses of preoperative chemotherapy and R0 surgery [no residual tumor]). We enrolled 32 patients. The completion rate of protocol treatment was 96.9%. During chemotherapy, the most common grade 3 or 4 toxicity was neutropenia (25.0%). No treatment‐related deaths were observed, and the incidence of operative morbidity was tolerable. The overall response rate after chemotherapy was 83.3%. This DGS regimen was well tolerated and highly active. This trial is registered with the University Hospital Medical Information Network (UMIN ID: 000014626).
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Affiliation(s)
- Yoshihiro Tanaka
- Department of Surgical Oncology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kazuhiro Yoshida
- Department of Surgical Oncology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Toshiyuki Tanahashi
- Department of Surgical Oncology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Naoki Okumura
- Department of Surgical Oncology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Nobuhisa Matsuhashi
- Department of Surgical Oncology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kazuya Yamaguchi
- Department of Surgical Oncology, Gifu University Graduate School of Medicine, Gifu, Japan
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Tsushima T, Mizusawa J, Sudo K, Honma Y, Kato K, Igaki H, Tsubosa Y, Shinoda M, Nakamura K, Fukuda H, Kitagawa Y. Risk Factors for Esophageal Fistula Associated With Chemoradiotherapy for Locally Advanced Unresectable Esophageal Cancer: A Supplementary Analysis of JCOG0303. Medicine (Baltimore) 2016; 95:e3699. [PMID: 27196482 PMCID: PMC4902424 DOI: 10.1097/md.0000000000003699] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Esophageal fistula is a critical adverse event in patients treated with chemoradiotherapy (CRT) for locally advanced esophageal cancer. However, risk factors associated with esophageal fistula formation in patients receiving CRT have not yet been elucidated.We retrospectively analyzed data obtained from 140 patients who were enrolled in a phase II/III trial comparing low-dose cisplatin with standard-dose cisplatin administered in combination with 5-flurouracil and concomitant radiotherapy. Inclusion criteria were performance status (PS) 0 to 2 and histologically proven thoracic esophageal cancer clinically diagnosed as T4 and/or unresectable lymph node metastasis for which definitive CRT was applicable. Risk factors for esophageal fistula were examined with univariate analysis using Fisher exact test and multivariate analysis using logistic regression models.Esophageal fistula was observed in 31 patients (22%). Of these, 6 patients developed fistula during CRT. Median time interval between the date of CRT initiation and that of fistula diagnosis was 100 days (inter quartile range, 45-171). Esophageal stenosis was the only significant risk factor for esophageal fistula formation both in univariate (P = 0.026) and in multivariate analyses (odds ratio, 2.59; 95% confidence interval, 1.13-5.92, P = 0.025). Other clinicopathological factors, namely treatment arm, age, sex, PS, primary tumor location, T stage, lymph node invasion to adjacent organs, blood cell count, albumin level, and body mass index, were not risk factors fistula formation.Esophageal stenosis was a significant risk factor for esophageal fistula formation in patients treated with CRT for unresectable locally advanced thoracic esophageal squamous cell carcinoma.
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Affiliation(s)
- Takahiro Tsushima
- From the Division of Gastrointestinal Oncology (TT) and Division of Esophageal Surgery (YT), Shizuoka Cancer Center, Sunto-gun, Shizuoka; JCOG Data Center/Operation Office, National Cancer Center (JM, KN, HF); Gastrointestinal Medical Oncology Division (KS, YH, KK) and Division of Esophageal Surgery (HI), National Cancer Center Hospital; Department of Thoracic Surgery, Aichi Cancer Center (MS); and Department of Surgery, Keio University School of Medicine (YK) Japan
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Saeed N, Shridhar R, Hoffe S, Almhanna K, Meredith KL. AKT expression is associated with degree of pathologic response in adenocarcinoma of the esophagus treated with neoadjuvant therapy. J Gastrointest Oncol 2016; 7:158-65. [PMID: 27034781 DOI: 10.3978/j.issn.2078-6891.2015.067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Neoadjuvant chemoradiation (NCRT) has become standard in the treatment of locally advanced esophageal adenocarcinoma (EAC) with survival correlated to degree of pathologic response. The phosphatidyl inositol 3 kinase (PI3K)/protein kinase B (AKT)/mTOR pathway plays an important role in tumorgenesis and resistance. We sought to elucidate the role of this pathway in patients with EAC who received NCRT. METHODS After IRB approval, a prospective trial was initiated in which patients with EAC underwent endoscopic biopsies of normal and tumor tissue prior to instituting NCRT. Patients then proceeded to esophagectomy. The pre-treatment tissues underwent gene expression profiling. SAM method was used to analyze expression of AKT within normal and tumor tissue. Expression was then correlated to degree of pathologic response. RESULTS One-hundred patients were consented for the study, of which 67 met final eligibility. Nineteen patient's tumors ultimately underwent gene expression profiling via microarray. The differential expression of all AKT isoforms in tumor tissue was markedly overexpressed compared to normal tissue (P=6×10(-5)). There were 3 patients designated as pNR, 6 as pPR, and 10 as pCR. Partial and non-responders had higher expressions of AKT compared to pCR with the non-responders consistently illustrated the highest expression of AKT (P=0.02). There was a significant correlation between individual isoforms of AKT-1, AKT-2, and AKT-3 and degree of pathologic response (P=0.002, 0.04, and 0.04 respectively). CONCLUSIONS AKT is overexpressed in patients with AC of the esophagus. Moreover, pathologic response to NCRT may be correlated with degree of AKT expression. Additional data is needed to clarify this relationship to potentially add targeted therapies to the neoadjuvant regimen.
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Affiliation(s)
- Nadia Saeed
- 1 Department of Gastrointestinal Oncology, 2 Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA ; 3 Department of Surgery, College of Medicine Florida State University, FL, USA
| | - Ravi Shridhar
- 1 Department of Gastrointestinal Oncology, 2 Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA ; 3 Department of Surgery, College of Medicine Florida State University, FL, USA
| | - Sarah Hoffe
- 1 Department of Gastrointestinal Oncology, 2 Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA ; 3 Department of Surgery, College of Medicine Florida State University, FL, USA
| | - Khaldoun Almhanna
- 1 Department of Gastrointestinal Oncology, 2 Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA ; 3 Department of Surgery, College of Medicine Florida State University, FL, USA
| | - Kenneth L Meredith
- 1 Department of Gastrointestinal Oncology, 2 Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, USA ; 3 Department of Surgery, College of Medicine Florida State University, FL, USA
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Phase II trial of biweekly docetaxel, cisplatin, and 5-fluorouracil chemotherapy for advanced esophageal squamous cell carcinoma. Cancer Chemother Pharmacol 2016; 77:1143-52. [PMID: 26896963 PMCID: PMC4882360 DOI: 10.1007/s00280-016-2985-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/04/2016] [Indexed: 01/27/2023]
Abstract
The prognosis of esophageal cancer patients is still unsatisfactory. Although a docetaxel, cisplatin, and 5-Fu (DCF) regimen has been reported, it is often difficult to accomplish because of severe toxicity. Therefore, we developed a new biweekly DCF (Bi-DCF) regimen and previously reported the recommended dose in a phase I dose-escalation study. We then performed a phase II study of Bi-DCF for advanced esophageal squamous cell carcinoma (SCC). Patients with clinical stage II/III were eligible. Patients received 2 courses of chemotherapy: docetaxel 35 mg/m2 with cisplatin 40 mg/m2 on days 1 and 15 and 400 mg/m2 5-fluorouracil on days 1–5 and 15–19 every 4 weeks. After completion of the chemotherapy, patients received esophagectomy. The primary endpoint was the completion rate of protocol treatment. Thirty-two patients were enrolled. The completion rate of protocol treatment (completion of two courses of preoperative chemotherapy and R0 surgery) was 100 %. During chemotherapy, the most common grade 3 or 4 toxicities were neutropenia (31.3 %). No treatment-related death was observed, and the incidence of operative morbidity was tolerable. The overall response rate after the chemotherapy was 90.3 %. This Bi-DCF regimen was well tolerated and highly active. This trial was registered with the University Hospital Medical Information Network (No. UMIN 000014625).
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Hamamoto Y, Mizusawa J, Katayama H, Nakamura K, Kato K, Tsubosa Y, Ishikura S, Igaki H, Shinoda M, Fukuda H, Kitagawa Y, Ando N. Inter-institutional survival heterogeneity in chemoradiation therapy for esophageal cancer: exploratory analysis of the JCOG0303 study. Jpn J Clin Oncol 2016; 46:389-92. [PMID: 26830150 DOI: 10.1093/jjco/hyv211] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 12/21/2015] [Indexed: 11/12/2022] Open
Abstract
It is important to examine variation in the treatment effects of patients with esophageal cancer in order to generalize treatment outcomes. We aimed to investigate the range of prognostic differences among hospitals in the treatment of locally advanced esophageal cancer. The JCOG0303 study compared the efficacy of radiotherapy plus low-dose cisplatin and 5-fluorouracil with that of high-dose cisplatin and 5-fluorouracil for unresectable esophageal cancer. Of 32 institutions participating in the JCOG0303 study, the 18 institutions that enrolled three or more patients were included in this study. We predicted the 1-year survival in each institution by using a mixed-effect model. We found that the predicted 1-year survival in the 18 institutions with three or more patients was a median of 60.9%, with a range of 60.9-60.9%. This study is the first to investigated heterogeneity of survival in patients who received definitive chemoradiotherapy for locally advanced esophageal squamous cell carcinoma.
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Affiliation(s)
- Yasuo Hamamoto
- Cancer Center, Keio University School of Medicine, Tokyo
| | - Junki Mizusawa
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center, Tokyo
| | - Hiroshi Katayama
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center, Tokyo
| | - Kenichi Nakamura
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center, Tokyo
| | - Ken Kato
- Gastrointestinal Medical Oncology Division, National Cancer Center Hospital, Tokyo
| | - Yasuhiro Tsubosa
- Esophageal Surgical Division, Shizuoka Cancer Center, Shunto-gun
| | - Satoshi Ishikura
- Department of Radiology, Koshigaya Municipal Hospital, Koshigaya
| | - Hiroyasu Igaki
- Esophageal Surgical Division, National Cancer Center Hospital, Tokyo
| | | | - Haruhiko Fukuda
- Japan Clinical Oncology Group Data Center/Operations Office, National Cancer Center, Tokyo
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo
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Shinoda M, Ando N, Kato K, Ishikura S, Kato H, Tsubosa Y, Minashi K, Okabe H, Kimura Y, Kawano T, Kosugi SI, Toh Y, Nakamura K, Fukuda H. Randomized study of low-dose versus standard-dose chemoradiotherapy for unresectable esophageal squamous cell carcinoma (JCOG0303). Cancer Sci 2015; 106:407-12. [PMID: 25640628 PMCID: PMC4409884 DOI: 10.1111/cas.12622] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Revised: 01/20/2015] [Accepted: 01/24/2015] [Indexed: 01/11/2023] Open
Abstract
Low-dose cisplatin and 5-fluorouracil (LDPF) chemotherapy with daily radiotherapy (RT) is used as an alternative chemoradiotherapy regimen for locally advanced esophageal carcinoma. We evaluated whether RT plus LDPF chemotherapy had an advantage in terms of survival and/or toxicity over RT plus standard-dose cisplatin and 5-fluorouracil (SDPF) chemotherapy in this study. This multicenter trial included esophageal cancer patients with clinical T4 disease and/or unresectable regional lymph node metastasis. Patients were randomly assigned to receive RT (2 Gy/fraction, total dose of 60 Gy) with SDPF (arm A) or LDPF (arm B) chemotherapy. The primary endpoint was overall survival (OS). A total of 142 patients (arm A/B, 71/71) from 41 institutions were enrolled between April 2004 and September 2009. The OS hazard ratio in arm B versus arm A was 1.05 (80% confidence interval, 0.78-1.41). There were no differences in toxicities in either arm. Arm B was judged as not promising for further evaluation in the phase III setting. Thus, the Data and Safety Monitoring Committee recommended that the study be terminated. In the updated analyses, median OS and 3-year OS were 13.1 months and 25.9%, respectively, for arm A and 14.4 months and 25.7%, respectively, for arm B. Daily RT plus LDPF chemotherapy did not qualify for further evaluation as a new treatment option for patients with locally advanced unresectable esophageal cancer. This study was registered at the UMIN Clinical Trials Registry as UMIN000000861.
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Affiliation(s)
- Masayuki Shinoda
- Department of Thoracic Surgery, Aichi Cancer Center, Nagoya, Japan
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Akutsu Y, Matsubara H. Chemoradiotherapy and surgery for T4 esophageal cancer in Japan. Surg Today 2015; 45:1360-5. [PMID: 25583206 DOI: 10.1007/s00595-015-1116-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 12/23/2014] [Indexed: 01/06/2023]
Abstract
Esophageal cancer is thought to be the most malignant neoplasm due to its biological aggressiveness. The most effective treatment modality for esophageal cancer, particularly T4 esophageal cancer, is chemoradiotherapy (CRT). Some T4 patients show long-term survival after receiving CRT, suggesting that even T4 esophageal cancer can be cured with this modality. Although surgery is performed after CRT in some T4 cases, its prognostic benefit is controversial. In this paper, we review the status of CRT and conversion surgery as well as the development of new regimens and discuss the future prospects of CRT in the treatment of T4 esophageal cancer in Japan.
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Affiliation(s)
- Yasunori Akutsu
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuoku, Chiba, 260-8670, Japan.
| | - Hisahiro Matsubara
- Department of Frontier Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuoku, Chiba, 260-8670, Japan
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Fujita H. A history of surgery for locally-advanced (T4) cancer of the thoracic esophagus in Japan and a personal perspective. Ann Thorac Cardiovasc Surg 2013; 19:409-15. [PMID: 24284505 DOI: 10.5761/atcs.ra.13-00085] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The history of esophageal surgery in Japan can be divided into three periods, an era of safety from 1930 to 1980, an era of radicality from 1980 to 2000, and the era of quality of life (QOL) from 2000 to the present. The treatment for T4 cancers of the thoracic esophagus has also changed over time from preoperative radiotherapy, combined resection of the neighboring organs with esophagectomy, and to definitive chemoradiotherapy (dCRT) with salvage surgery. At present, almost all patients with an unresectable T4 esophageal cancer receives dCRT. However, there are many patients with a residual or recurrent tumor after dCRT. Salvage surgery for such patients often results in incomplete resection of the tumor because the tumor involves the trachea and/or aorta. New techniques to enable the resection of such neighboring organs even during salvage surgery are needed. In the future, the mainstay of treatment for esophageal cancer will be CRT with the foreseeable progress in new drugs and new techniques of radiotherapy. Surgery will be indicated for a local failure after CRT, while combined resection of the neighboring organs will be necessary to treat a local failure after CRT for T4 cancers. New surgical techniques have to be developed through some application of new devices and equipment.
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Affiliation(s)
- Hiromasa Fujita
- Department of Surgery, Kurume University School of Medicine, Kurume, Fukuoka, Japan
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Pimiento JM, Weber J, Hoffe SE, Shridhar R, Almhanna K, Vignesh S, Karl RC, Meredith KL. Outcomes associated with surgery for T4 esophageal cancer. Ann Surg Oncol 2013; 20:2706-12. [PMID: 23504118 DOI: 10.1245/s10434-013-2885-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND T4 esophageal cancer often portends a dismal prognosis even after surgical resection. Historical incomplete resections and poor survival rates often make surgery palliative rather than curative. METHODS Using a comprehensive esophageal cancer database, we identified patients who underwent an esophagectomy for T4 tumors between 1994 and 2011. Neoadjuvant treatment (NT) and pathologic response variables were recorded, and response was denoted as complete response (pCR), partial response (pPR), and nonresponse (NR). Clinical and pathologic data were compared. Survival was calculated using Kaplan-Meier curves with log-rank tests for significance. RESULTS We identified 45 patients with T4 tumors all who underwent NT. The median age was 60 years (range, 31-79 years) with a median follow-up of 27 months (range, 0-122 months). There were 19 pCR (42 %), 22 pPR (49 %), and 4 NR (9 %). R0 resections were accomplished in 43 (96 %). There were 18 recurrences (40 %) with a median time to recurrence of 13.5 months (2.2-71 months). In this group pCR represented 7 (38.9 %), whereas pPR and NR represented 10 (55.5 %), and 1 (5.5 %) respectively. The overall and disease-free survival for all patients with T4 tumors were 35 and 36 %, respectively. Patients achieving a pCR had a 5 year overall and disease-free survival of 53 and 54 %, compared with pPR 23 and 28 %, while there were no 5 year survivors in the NR cohort. CONCLUSION We have demonstrated that neoadjuvant therapy and downstaging of T4 tumors leads to increased R0 resections and improvements in overall and disease-free survival.
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Affiliation(s)
- Jose M Pimiento
- Program of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
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Abstract
The incidence of esophageal cancer is increasing in the developed world, with a relative increase in adenocarcinoma compared with squamous cell carcinoma. The distensible nature of the esophagus results in delayed development of symptoms associated with esophageal cancer; hence many patients have locally advanced or metastatic cancer at the time of initial presentation. Although resection remains the treatment of choice for early-stage esophageal cancer, the best treatment strategy for locally advanced esophageal cancer is debatable and, consequently, varies at different centers. This article discusses the published literature on various available therapeutic options for the treatment of locally advanced esophageal cancer.
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Affiliation(s)
- Ankit Bharat
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, St Louis, MO 63110-1013, USA
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Comparison Between Concurrent Chemoradiation Followed by Surgery vs. Surgery for Locally Advanced Cancer of Esophagus. Indian J Surg 2012; 73:111-5. [PMID: 22468059 DOI: 10.1007/s12262-010-0182-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Accepted: 10/31/2010] [Indexed: 10/18/2022] Open
Abstract
Surgery is an accepted standard in the treatment of localized stage cancer of esophagus. But the ideal approach for locally advanced lesions still remains unknown. Patients with locally advanced lesions (cT3-4N1M0) on the basis of CT chest were subjected either to primary surgery or to preoperative chemoradiation followed by surgery. Major postoperative complications (mortality, anastomotic leak and recurrent laryngeal nerve palsy) did not differ in either arm (P = not significant). Complete pathological response was achieved in 31.2% cases in multimodality arm. Four year overall survival was 10% for whole group. Median survival was 14 months and 20 months in surgery and multimodality arm, respectively (p = .288). In multimodal arm, there was significant survival difference between complete responders and nonresponders (p = .02). For locally advanced lesions, surgery alone gives poor outcome and preoperative chemoradiation followed by surgery should be considered for complete responders.
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Miyata H, Yamasaki M, Kurokawa Y, Takiguchi S, Nakajima K, Fujiwara Y, Mori M, Doki Y. Clinical relevance of induction triplet chemotherapy for esophageal cancer invading adjacent organs. J Surg Oncol 2012; 106:441-7. [PMID: 22371189 DOI: 10.1002/jso.23081] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 02/08/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES There is no consensus on treatment for esophageal cancer invading adjacent organs (T4), but induction multidrug chemotherapy may be a beneficial, especially when surgery is considered as adjuvant treatment. METHODS We classified 169 patients with T4 esophageal cancer without distant metastasis into those undergoing chemotherapy using cisplatin and 5-FU (CF) plus adriamycin or CF plus docetaxel (79 patients) and those undergoing chemoradiotherapy using CF (90 patients). For the former group, chemoradiation was subsequently applied when surgical resection was not indicated. RESULTS Thirty-four patients in the chemotherapy group (43.0%) received chemoradiotherapy following chemotherapy. Although the response rate tended to be higher in the chemoradiotherapy group, there was no significant difference in the response rate between the groups (63.3% vs. 68.9%). Esophageal perforation during treatment was more frequent among the chemoradiotherapy group than the chemotherapy group (16.7% vs. 6.3%, P=0.0379). The rate of surgical resection was consequently higher for the induction chemotherapy group compared to the chemoradiotherapy group (72.1% vs. 45.6%, P=0.0005). CONCLUSIONS Induction triplet chemotherapy reduced esophageal perforation and increased the resectability of T4 esophageal cancers by combining second-line chemoradiotherapy. This strategy might increase the chance of curative resection for patients with T4 esophageal cancer.
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Affiliation(s)
- Hiroshi Miyata
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan.
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Makino T, Doki Y. Treatment of T4 esophageal cancer. Definitive chemo-radiotherapy vs chemo-radiotherapy followed by surgery. Ann Thorac Cardiovasc Surg 2011; 17:221-8. [PMID: 21697781 DOI: 10.5761/atcs.ra.11.01676] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 02/15/2011] [Indexed: 11/16/2022] Open
Abstract
The outcome of patients with T4 esophageal cancer, defined as a tumor that invades neighboring structures (e.g., aorta, trachea, bronchus, and lung), is extremely poor. Despite recent advances in surgical techniques, these tumors are usually considered inoperable. Two distinct therapeutic options are currently available for T4 esophageal cancers: chemo-radiotherapy followed by surgery (CRT-S), which comprises esophagectomy following down-staging of the tumor by CRT, and definitive chemo-radiotherapy (D-CRT), which is designed to avoid esophagectomy by using maximum doses of irradiation. CRT-S is superior to D-CRT with respect to local control and short-term survival although CRT-S is associated with relatively higher perioperative mortality and morbidity. On the other hand, it is sometimes difficult to achieve local control with D-CRT and the treatment often results in fistula formation, though a complete response to CRT is often associated with better prognosis. Admittedly, the difference in the survival rate between the two modalities is marginal at long-term follow-up due to operative morbidity and inadequate control of distant metastasis in CRT-S. Changes in perioperative management and intensive systemic chemotherapy may enhance the outcome. Randomized controlled trials involving large population samples are needed to define the standard treatment for T4 esophageal cancer.
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Affiliation(s)
- Tomoki Makino
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan.
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Yamasaki M, Miyata H, Tanaka K, Shiraishi O, Motoori M, Peng YF, Yasuda T, Yano M, Shiozaki H, Mori M, Doki Y. Multicenter phase I/II study of docetaxel, cisplatin and fluorouracil combination chemotherapy in patients with advanced or recurrent squamous cell carcinoma of the esophagus. Oncology 2011; 80:307-13. [PMID: 21778771 DOI: 10.1159/000329806] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 05/09/2011] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Esophageal squamous cell carcinoma (ESCC) is refractory to current therapeutic regimens and more effective therapies are imperative. To this end, we conducted a multicenter phase I/II trial of docetaxel, cisplatin, and fluorouracil (DCF) combination chemotherapy for ESCC. METHODS The study subjects were 46 patients with advanced or recurrent ESCC. Treatment included docetaxel at 60, 70, and 75 mg/m(2), cisplatin at 70 mg/m(2) on day 1, and daily fluorouracil at 700 mg/m(2) on days 1 through 5. The recommended dose of docetaxel was determined in phase I, while the response rate (RR) and progression-free survival rates were analyzed in phase II. RESULTS The recommended dose was determined to be 70 mg/m(2) in phase I. In phase II, the RR was 72.5%. Interim analysis showed median and 1-year progression-free survival of 14 months and 55.6%, respectively. Grade 3/4 toxicities of leukopenia and neutropenia occurred in 72.5 and 90% of patients, respectively. No treatment-related death was recorded. Surgical resection was subsequently performed in 20 patients after chemotherapy, and curative resection was achieved in 19. CONCLUSION DCF was tolerable and effective for advanced and recurrent ESCC. Such findings might encourage a change in the treatment strategy for ESCC.
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Affiliation(s)
- Makoto Yamasaki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, 2-2-E2 Yamadaoka, Suita, Osaka, Japan.
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Taniguchi H, Yamazaki K, Boku N, Funakoshi T, Hamauchi S, Tsushima T, Todaka A, Sakamoto T, Tomita H, Machida N, Taku K, Fukutomi A, Onozawa Y, Tsubosa Y, Sato H, Nishimura T, Yasui H. Risk factors and clinical courses of chemoradiation-related arterio-esophageal fistula in esophageal cancer patients with clinical invasion of the aorta. Int J Clin Oncol 2011; 16:359-65. [PMID: 21347631 DOI: 10.1007/s10147-011-0192-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 01/17/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although concurrent chemoradiotherapy (CRT) is a standard treatment for esophageal cancer invading adjacent structures (T4-EC), arterio-esophageal fistula (AEF) occurs occasionally as a critical adverse event of T4-EC with CRT. The frequency, clinical course, and risk factors of AEF related to CRT are not well known. METHODS We retrospectively analyzed 48 patients with T4-EC invasion of the aorta who were treated with 5-fluorouracil, cisplatin, and concurrent radiotherapy at our institution between September 2002 and April 2009. Treatment-related AEF was defined as AEF without obvious tumor progression. We evaluated the frequency, clinical courses, and risk factors of AEF. RESULTS The median survival time was 10.6 months with a median follow-up time of 33.3 months. The 2-year survival rate was 25%. Treatment-related AEF was observed in 7 patients (14.6%) and 4 of them died of massive bleeding due to aortic AEF. In the other 3 patients with non-aortic AEF, hemorrhage could be arrested by transcatheter arterial embolization (TAE). In the univariate analysis of risk factors for AEF, lower serum cholesterol level was a risk factor for AEF (OR 14.7; 95% CI 1.58-137; P = 0.008). CONCLUSIONS Although CRT has a curative potential even for patients with T4-EC invading the aorta, we should be aware of the relatively high incidence of treatment-related AEF. TAE may be successful in rescuing a non-aortic AEF patient. Low serum cholesterol level may be a risk factor for AEF, but further investigation is needed.
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Affiliation(s)
- Hiroya Taniguchi
- Division of Gastrointestinal Oncology, Shizuoka Cancer Center, Sunto-gun, Shizuoka, 411-8777, Japan.
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Abstract
Preoperative or definitive chemoradiotherapy defines today the standard treatment of patients with localized or locally advanced esophageal cancer. Preliminary results of our study are presented. 46 patients with locally advanced squamous cell esophageal cancer (T3-4, N0-1, M0) were enrolled. All patients recieved concomitant chemotherapy (Cisplatin/5FU/LV) and radiotherapy (45-50, 4Gy). Clinical response rate was 59% (3 patients (7%) complete response, 24 patients (52%) partial regression, 13 (28%) stabile disease, 6 patients (13%) disease progression). Out of 46 patients, 12 were operated (26%), all with R0 resection. Complete patohistolgical regression (TRG 1) was noted in 5 patients (42%). TRG 2 i TRG 3 in one (8%) and 3 patients (25%), and TRG 4 in 3 patients (25%). Mean survival time in operated group of patients was 9.3 months, and in nonoperated group 5.5 months. Studies show improved survival rate in patients with complete response to chemoradiotherapy and R0 resection. Individualy tailored therapy is essential.
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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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Motoyama S, Sugiyama T, Ueno Y, Okamoto H, Takasawa S, Nanjo H, Watanabe H, Maruyama K, Okuyama M, Ogawa JI. REG I expression predicts long-term survival among locally advanced thoracic squamous cell esophageal cancer patients treated with neoadjuvant chemoradiotherapy followed by esophagectomy. Ann Surg Oncol 2006; 13:1724-31. [PMID: 17009160 DOI: 10.1245/s10434-006-9075-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2006] [Revised: 03/25/2006] [Accepted: 05/19/2006] [Indexed: 02/06/2023]
Abstract
BACKGROUND The prognosis for patients with locally advanced thoracic esophageal cancer is extremely unfavorable. We have been administering neoadjuvant chemoradiotherapy (CRT) followed by esophagectomy to these patients and studying whether REG I expression in untreated endoscopic biopsy specimens is predictive of patient responsiveness to CRT and/or survival after treatment. METHODS Between 1992 and 2003, 47 patients with T4 (direct invasion of adjacent organs) thoracic esophageal cancers were administered neoadjuvant CRT followed by esophagectomy. REG I expression was assessed in untreated endoscopic biopsy specimens and correlated with clinical and histological responses and survival in 37 patients who had also undergone curative surgery. RESULTS Among the 37 cases that received CRT followed by surgery, the therapeutic response rate for neoadjuvant CRT was 68%, and a complete histological response in resected specimens from the primary lesion was achieved in 8 (22%) patients. These clinical and histological responses to neoadjuvant CRT did not significantly correlate with survival, however. By contrast, 9 patients were judged REG-positive based on analysis of their untreated endoscopic biopsy specimens, and their cumulative survival rate was significantly higher than that of the 28 REG-negative patients (P = 0.0073). Univariate analysis showed REG I expression to be a prognostic factor (P = 0.0386) that increased the risk of death 8.4-fold. CONCLUSIONS Evaluation of REG I expression in untreated endoscopic biopsy specimens may provide a basis for new treatments of locally advanced thoracic squamous cell esophageal cancers.
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Affiliation(s)
- Satoru Motoyama
- Department of Surgery, Akita University School of Medicine, Akita, Japan.
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Sasahara H, Sueyoshi S, Tanaka T, Fujita H, Shirouzu K. Evaluation of an aortic stent graft for use in surgery on esophageal cancer involving the thoracic aorta. ACTA ACUST UNITED AC 2004; 52:231-9. [PMID: 15195745 DOI: 10.1007/s11748-004-0116-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The purpose of this experimental study was to investigate whether aortic stent grafting can be applied to the treatment of an esophageal cancer involving the thoracic aorta. METHODS The canine thoracic aorta was partially resected without aorta being clamped after emplacement of an endovascular stent graft. Study I; The aortic whole layer of 1 cm in length and 1/4 of the circumference was resected and was covered by a free fascia patch of the abdominal rectal muscle immediately after stent graft placement. Study II; The aortic adventitia and the outer half of the media of the same size was resected on day 3, 7, 14, 21, and on day 28, after the stent graft placement. The resected portion was covered by the free fascia patch in half experimental dogs, and was uncovered in the others. Study III; The aortic adventitia and the outer half of the media of 1 cm in length and 1/2 of the circumference was resected and was uncovered on day 7 after stent graft placement. Histological examinations were performed on day 28 and at one year after aortic resection. RESULTS The aortic wall could be resected in all cases with no complication, except in resection of 1/2 the circumference where the aorta had become narrow. There was no difference in healing of the resected portion of the aorta between with and without fascia covering. CONCLUSION An aortic endovascular stent graft could be applied to surgery for an esophageal cancer involving the aorta.
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Affiliation(s)
- Hiroko Sasahara
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan
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Takeuchi H, Ozawa S, Ando N, Kitagawa Y, Ueda M, Kitajima M. Cell-cycle regulators and the Ki-67 labeling index can predict the response to chemoradiotherapy and the survival of patients with locally advanced squamous cell carcinoma of the esophagus. Ann Surg Oncol 2003; 10:792-800. [PMID: 12900371 DOI: 10.1245/aso.2003.10.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND We investigated whether aberrant p53 and p16 expression, the Ki-67 labeling index (LI), and int-2/cyclin D1 gene amplification predict the response to chemoradiotherapy (CRT) in patients with locally advanced esophageal squamous cell carcinoma (ESCC). METHODS p53 and p16 expression status, the Ki-67 LI, and int-2/cyclin D1 amplification were assessed by immunohistochemical staining and slot blot analysis in pretreatment endoscopic biopsy specimens of 41 patients with T4 or M1 Lym (distant lymph node metastasis) ESCC. All patients received a course of chemotherapy (5-fluorouracil and cisplatin) with radiotherapy. RESULTS The CRT therapeutic response rate was 71%, and resection after CRT was successful in 15 of the cases in which the CRT effect was significant. The cumulative survival rate after CRT in the p53-negative patients was significantly higher than in the p53-positive patients (P =.037). The mean Ki-67 LI in the CRT response cases was significantly higher than in the CRT no-response cases (P =.023). Multivariate regression analysis revealed high Ki-67 LI to be an independent variable linked to a pathologic complete response to CRT (P =.033). The cumulative survival rate after CRT in the group that was p53-negative and int-2/cyclin D1 amplification-positive was significantly higher than in the other groups (P =.008). CONCLUSIONS Evaluating predictive factors in pretreatment endoscopic biopsy specimens may allow selection of more suitable multimodal treatment for ESCC patients and improve their quality of life.
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Affiliation(s)
- Hiroya Takeuchi
- Department of Surgery, School of Medicine, Keio University, Tokyo, Japan
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