Association of C-reactive protein levels and long-term survival after neoadjuvant therapy and esophagectomy for esophageal cancer

BACKGROUND

Preoperative C-reactive protein (CRP) levels have been shown to be prognostic markers of survival in patients undergoing esophagectomy for cancer. No study has evaluated the predictive value for survival of CRP levels after neoadjuvant chemoradiotherapy.

METHODS

Preoperative CRP levels were assessed in patients undergoing neoadjuvant therapy and esophagectomy for cancer. Groups were defined according to normal value cutoffs of the CRP measurements.

RESULTS

Seventy patients had normal CRP, and 20 patients had raised CRP. The groups did not differ in descriptives, comorbidities, white cell counts, pathological data, or morbidity. In-hospital death was higher in the raised CRP group (three versus one patient, p = 0.048). The Kaplan-Meier survival analysis showed a significant survival advantage of patients with normal CRP compared to patients with raised CRP levels (median survival, 65.4 versus 18.7 months; log rank test, p = 0.027). The Cox regression analysis identified three independent prognostic factors for survival: UICC stage (IIB/III versus I/IIA, HR 3.48, p = 0.007), completeness of resection (HR 6.33, p = 0.002), and CRP levels (raised versus normal, HR 5.07, p = 0.001).

CONCLUSION

Preoperative CRP levels are an independent prognostic marker for survival after neoadjuvant treatment in patients with esophageal cancer and may be of value in the re-staging process after neoadjuvant treatment.

Treatment of thoracic esophageal carcinoma invading adjacent structures

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.

Salvage esophagectomy after definitive chemotherapy and radiotherapy for advanced esophageal cancer

BACKGROUND

Although local recurrence of advanced esophageal cancer is frequent after definitive chemoradiotherapy (CRT), the clinical benefit of salvage esophagectomy has not been elucidated.

METHODS

We reviewed 27 patients with squamous-cell cancer who underwent esophagectomy after definitive CRT (> or = 50 Gy) (salvage group) and 28 patients who underwent planned esophagectomy after neoadjuvant CRT (30 to 45 Gy) (neoadjuvant group).

RESULTS

The preoperative albumin level and vital capacity were significantly lower in the salvage group than in the neoadjuvant group. Two patients (7.4%) from the salvage group who underwent extended esophagectomy with three-field lymphadenectomy died of postoperative complications, but no deaths occurred after less-invasive surgery. There was no difference of overall postoperative survival between the salvage and neoadjuvant groups.

CONCLUSIONS

The outcome of salvage esophagectomy after definitive CRT was similar to that of planned esophagectomy after neoadjuvant CRT. Less-invasive procedures might be better for salvage esophagectomy because of the high operative risk.

Surgery after induction chemoradiotherapy for oesophageal cancer

AIM

We discuss the role of surgery after induction chemoradiotherapy, when a complete response is apparent.

METHODS

We enrolled 247 consecutive patients who underwent chemoradiotherapy and oesophagectomy for cancer. Patients were classified in two groups as to whether they had chemoradiotherapy (n = 60) or not (n = 187) before surgery.

RESULTS

The 5-year survival rate of patients with complete response was 54% and was significantly higher than that of the other group (P = 0.018). Of the 60 patients responding, 34 (56.7%) were found to have a complete pathological tumour response (pT0). The overall sensitivity and specificity of the post-chemoradiotherapy restaging were 60.7% and 86.4%.

CONCLUSIONS

Complete response after induction chemoradiotherapy is not a reliable tool in the management of oesophageal cancer. We need to improve postchemoradiotherapy restaging to be sure that chemoradiotherapy will provide the same long-term survival rates as surgery.

Multimodality therapy for esophageal cancer

Esophageal cancer is undergoing a major shift in its epidemiology. Its incidence is dramatically growing and it more commonly affects younger and healthier patients. Based on the published data, there is no strong evidence to recommend routine preoperative chemotherapy for the treatment of surgically resectable esophageal carcinoma. It might be that a large-scale randomized study-which will be published in the near future-will shed some different light on this subject. The role of preoperative CRT remains undetermined. To settle this issue, larger, clinical, controlled trials are needed. Improvement in the preoperative regimen and use of new drugs should be evaluated. Concomitant CRT should be considered for potential benefit in survival and local control in patients who have localized disease and are candidates for radical non-surgical treatment. Patients with pCR following neoadjuvant therapy have a consistent, substantial survival benefit. Biologic markers can be used to predict response to therapy and might allow designation of treatment based on the individual tumor. Pretreatment staging is necessary for standardization of patients undergoing treatment protocols and for outcome evaluation. Pretreatment staging will be even more important in the future for adjusting treatment to individual patient. Video-assisted thoracoscopy and laparoscopy have been found to be the most accurate lymph node staging techniques.

The use of chemoradiotherapy in oesophageal cancer

The results of treatment for oesophageal carcinoma remain poor and few patients are curable by surgery alone. The use of chemoradiotherapy (CRT) given as a definitive treatment or in combination with surgery may improve locoregional control and survival, when compared with radiotherapy or surgery alone. Using the keywords "chemoradiotherapy" and "radiochemotherapy", a Medline-based literature review (1980-2001) was performed. Additional literature was obtained from original papers and published meeting abstracts. Two-year survival rates of 28-72% in squamous cell carcinoma and 14-29% in adenocarcinoma from definitive CRT were reported. This is comparable to results achievable by surgery alone. The use of preoperative CRT followed by surgery may further improve survival, but current data are insufficient to justify this approach within routine clinical practice. Acute treatment-related toxicity is increased with CRT. In selected patients with localised unresectable oesophageal cancer, definitive CRT is recommended. There are uncertainties about the role of routine surgery following CRT in patients with resectable disease. For the future, the pretreatment staging of patients needs to be improved and standardised, the optimal CRT regimen needs to be defined and the role of predictive markers for CRT response needs to be developed.

Preoperative (neoadjuvant) chemoradiotherapy in oesophageal cancer

BACKGROUND

Oesophageal cancer carries a poor prognosis. The 5-year survival rate following resection ranges from 10 to 35 per cent. Recent evidence suggests that the addition of non-surgical treatments to surgery may improve resection rates, reduce the risk of recurrence and improve survival. This review examines the role of preoperative chemoradiotherapy (CRT) in oesophageal cancer.

METHODS

A Medline-based literature review (1980-2000) was performed using the key words 'neoadjuvant or preoperative' and 'chemoradiotherapy or radiochemotherapy'. Additional literature was obtained from original papers and published meeting abstracts.

RESULTS

Forty-six non-randomized and six randomized trials of preoperative CRT were found. Resection rates, pathological complete response (pCR), treatment-related mortality rates and relapse patterns are documented. Improved 5-year survival rates approaching 60 per cent may be achieved following pCR. Three of the six randomized trials show a benefit in either overall survival or disease-free survival compared with surgery alone. Treatment-related toxicity can be significant.

CONCLUSION

Preoperative CRT may improve survival. Emerging evidence suggests that CRT alone can achieve similar survival rates to surgery alone. New imaging modalities may help to select which patients require surgery. Larger randomized trials of preoperative CRT or chemotherapy are needed to define optimal regimens and produce higher pCR rates with acceptable toxicity.

Radiation treatment for cervical esophagus: patterns of practice study in Canada, 1996

PURPOSE

To assess the patterns of practice among Canadian radiation oncologists who treat esophageal cancers, using a trans-Canada survey, completed at the end of 1996.

METHODS AND MATERIALS

One of 3 case presentations of different stages of cervical esophageal cancer was randomly assigned and sent to participating radiation oncologists by mail. Respondents were asked to fill in questionnaires regarding treatment techniques and to outline target volumes for the boost phase of radiotherapy. Radiation oncologists from 26 of 27 (96%) of all Canadian centers participated.

RESULTS

High-energy X-rays (>/= 10 MV) were employed by 68% of the respondents in part of the treatment course. The majority (83%) of the radiation oncologists used at least two phases of treatment. Very few, 10 of 59 (17%), responses started with multifield treatment. The most frequently used prescription dose was 60 Gy/30 fractions/6 weeks, given with concurrent chemotherapy. Dose prescriptions were to the isocenter in 39 of 48 (81%) or to a particular isodose line in 9 of 48 (19%) of respondents.

CONCLUSION

There was a variety of radiation treatment techniques in this trans-Canada survey. The majority of the patients had combined cisplatin-based chemoradiation. The isocenter was not used consistently as a dose prescription point.

Preoperative chemotherapy for advanced esophageal cancer and relation with histological effect

The results of surgical treatment for advanced esophageal cancer remain extremely poor. Irradiation and chemotherapy are not superior to surgery. Perioperative morbidity and the influence on long-term survival of a combination of surgery and preoperative chemotherapy were investigated in patients with advanced esophageal cancer. Forty-nine patients with advanced esophageal squamous cell carcinoma were subjected to preoperative chemotherapy of cisplatin-5-fluorouracil. Fifty-seven patients were chosen as a historical control group who had not undergone chemotherapy before surgery but had the same histological stages as the chemotherapy group. The response to chemotherapy was assessed by histological studies of surgical specimens. The survival rates noted no significant difference between preoperative chemotherapy plus surgery and a resection alone. However, subclassification according to the grading of chemotherapeutic effectiveness showed that, compared with control, preoperative chemotherapy was beneficial to high responders (P = 0.01), ineffective in low responders (P = 0.61), and detrimental to nonresponders (P = 0.03). Postoperative morbidity was significantly higher in the chemotherapy group than in the control group (P = 0.02). These findings suggest that preoperative chemotherapy is necessary only for high responders and we therefore need to reliably identify non-, low, and high responders before chemotherapy to improve the survival and quality of life of patients with advanced esophageal cancer.

Oesophageal cancer treatment: studies, strategies and facts

Esophageal cancer is among the ten most frequent cancers in the world. Once diagnosis is established prognosis is poor with five-year survival rates below 10%. Over the last few years, the evidence--base for treatment of oesophageal cancer has changed with the publication of several important articles in this field. This article reviews these and other relevant publications with focus on current evidence which holds potential for an improvement in survival in oesophageal cancer patients. Prevention and early detection represent the mainstay in the ongoing struggle to improve prognosis, which is most stringently linked to tumor stage. Other efforts have been dedicated to optimise surgical treatment, radiotherapy and chemotherapy and to discover the most efficient combinations of these treatment modalities. Strong but not unanimous evidence in favour of a multimodality approach with chemoradiotherapy followed by surgery has accumulated in recent years, and confirmatory trials are presently ongoing. A pathological complete response to chemoradiotherapy has been identified to significantly enhance survival. Among the strategies to achieve higher response rates, variations in the administration of the most commonly used drugs rather than higher drug and radiation dosages seem promising. Occult lymphatic spread has been recognized as a major source of recurrence and has been successfully targeted by three field surgical dissection and extended field radiotherapy. In search of the optimal treatment for patients with oesophageal cancer, a variety of different tracks are being pursued. This review outlines and analyses current treatment approaches and investigates how recent advances may impact on patient management.