Induction therapy for clinical stage T2N0M0 esophageal cancer: A systematic review and meta-analysis

Clinical T2N0M0 Esophageal Cancer-Is Treatment Pathway Associated With Overall Survival?

INTRODUCTION

Esophageal cancer therapy is commonly multimodal. The CROSS trial demonstrated a survival benefit of neoadjuvant chemoradiation versus surgery alone in T1N1 or T2-3N0-1 patients. Theoretically, chemoradiation should be most beneficial to patients with advanced disease. Treating the intermediary stage, T2N0M0, is challenging as national guidelines offer multiple options. This study aims to compare survival outcomes and associated factors in clinical T2N0M0 esophageal cancer via treatment modality and compare clinical to pathological stage. The authors conclude that neoadjuvant therapy use has increased; however, there is no associated survival benefit, which may be due to over- or under-staging.

METHODS

A retrospective study was performed using the National Cancer Database (2006-2016). Patients who underwent neoadjuvant chemoradiation followed by surgery (NCRT + ESOPH) were compared to patients who underwent esophagectomy first (ESOPH). Multivariable logistic regression was used to determine factors associated with treatment pathway. Overall survival was compared using Kaplan-Meier estimates and log-rank tests at 1-, 3-, and 5-y post-treatment. Additionally, a multiple logistic regression analysis was conducted to identify factors associated with adjuvant therapy in ESOPH patients.

RESULTS

There were 1662 patients (NCRT + ESOPH: 904 [54.4%], ESOPH: 758 [45.6%]). There was no difference in 5-y survival between NCRT + ESOPH and ESOPH patients. Despite this, NCRT + ESOPH treatment rates rose from 33% to 74% between 2006 and 2016. Patients who received NCRT + ESOPH were younger and more commonly had no Charlson-Deyo comorbidities. Notably, 41% of patients were over-staged (T1 or lower), and 32.8% were under-staged (N ≥ 1).

CONCLUSIONS

T2N0M0 remains difficult to characterize, and pathological staging corresponds poorly to clinical staging. Neoadjuvant therapy use has increased; however, the lack of a significant survival benefit to correlate with such may be secondary to over- or under-staging.

A clinical prognostic model for patients with esophageal squamous cell carcinoma based on circulating tumor DNA mutation features

Background

Few predictive models have included circulating tumor DNA (ctDNA) indicators to predict prognosis of esophageal squamous cell carcinoma (ESCC) patients. Here, we aimed to explore whether ctDNA can be used as a predictive biomarker in nomogram models to predict the prognosis of patients with ESCC.

Methods

We included 57 patients who underwent surgery and completed a 5-year follow-up. With next-generation sequencing, a 61-gene panel was used to evaluate plasma cell-free DNA and white blood cell genomic DNA from patients with ESCC. We analyzed the relationship between the mutation features of ctDNA and the prognosis of patients with ESCC, identified candidate risk predictors by Cox analysis, and developed nomogram models to predict the 2- and 5-year disease-free survival (DFS) and overall survival (OS). The area under the curve of the receiver operating characteristic (ROC) curve, concordance index (C-index), calibration plot, and integrated discrimination improvement (IDI) were used to evaluate the performance of the nomogram model. The model was compared with the traditional tumor-nodes-metastasis (TNM) staging system.

Results

The ROC curve showed that the average mutant allele frequency (MAF) of ctDNA variants and the number of ctDNA variants were potential biomarkers for predicting the prognosis of patients with ESCC. The predictors included in the models were common candidate predictors of ESCC, such as lymph node stage, angiolymphatic invasion, drinking history, and ctDNA characteristics. The calibration curve demonstrated consistency between the observed and predicted results. Moreover, our nomogram models showed clear prognostic superiority over the traditional TNM staging system (based on C-index, 2-year DFS: 0.82 vs. 0.64; 5-year DFS: 0.78 vs. 0.65; 2-year OS: 0.80 vs. 0.66; 5-year OS: 0.77 vs. 0.66; based on IDI, 2-year DFS: 0.33, p <0.001; 5-year DFS: 0.18, p = 0.04; 2-year OS: 0.28, p <0.001; 5-year OS: 0.15, p = 0.04). The comprehensive scores of the nomogram models could be used to stratify patients with ESCC.

Conclusions

The novel nomogram incorporating ctDNA features may help predict the prognosis of patients with resectable ESCC. This model can potentially be used to guide the postoperative management of ESCC patients in the future, such as adjuvant therapy and follow-up.

Effect of preoperative radiotherapy on the prognosis of patients with stage cTxN0M0 esophageal squamous cell carcinoma: propensity score matching analysis based on SEER database

Objective

The aim of this study was to investigate the effect of preoperative radiotherapy (RT) on overall survival (OS) in patients with stage cTxN0M0 esophageal squamous cell carcinoma (ESCC).

Methods

A total of 467 patients with ESCC diagnosed as cTxN0M0 and undergoing esophagectomy between 2004 and 2016 were downloaded from the Surveillance, Epidemiology, and End Results (SEER) database. According to the presence or absence of preoperative RT, the patients were divided into preoperative RT group and non-preoperative RT group. Propensity score matching (PSM) was performed to equalize baseline levels between groups. Univariate and multivariate Cox regression analyses were used to compare the survival differences between the two groups.

Results

Using PSM, 162 pairs of patients were selected. Preoperative RT was not a prognostic factor for OS in all patients with cTx stage. After PSM, for patients with cT1-2 stage, univariate Cox regression analysis showed that preoperative RT was an influencing factor of OS, and multivariate Cox regression analysis confirmed that preoperative RT was an independent predictor of OS. Compared with non-preoperative RT, preoperative RT significantly decreased OS (HR = 1.556, 95%CI 1.008-2.464, p = 0.046). For patients with cT3-4, univariate Cox regression analysis showed that preoperative RT was an influencing factor for OS, and multivariate Cox regression analysis determined that preoperative RT was independent predictors of survival. Compared with non-preoperative RT, preoperative RT significantly improved the OS (HR = 0.479, 95%CI 0.272-0.841, p = 0.010).

Conclusion

For ESCC, preoperative RT can improve the OS of patients with cT3-4N0M0. However, preoperative RT is not suitable for patients with cT1-2N0M0.

Development and Validation of a Clinical Prognostic Nomogram for Esophageal Adenocarcinoma Patients

Background

Clinical staging is essential for clinical decisions but remains imprecise. We purposed to construct a novel survival prediction model for improving clinical staging system (cTNM) for patients with esophageal adenocarcioma (EAC).

Methods

A total of 4180 patients diagnosed with EAC were extracted from the Surveillance, Epidemiology, and End Results (SEER) database and included as the training cohort. Significant prognostic variables were identified for nomogram model development using multivariable Cox regression. The model was validated internally by bootstrap resampling, and then subjected to external validation with a separate cohort of 886 patients from 2 institutions in China. The prognostic performance was measured by concordance index (C-index), Akaike information criterion (AIC) and calibration plots. Different risk groups were stratified by the nomogram scores.

Results

A total of six variables were determined related with survival and entered into the nomogram construction. The calibration curves showed satisfied agreement between nomogram-predicted survival and actual observed survival for 1-, 3-, and 5-year overall survival. By calculating the AIC and C-index values, our nomogram presented superior discriminative and risk-stratifying ability than current TNM staging system. Significant distinctions in survival curves were observed between different risk subgroups stratified by nomogram scores.

Conclusion

The established and validated nomogram presented better risk-stratifying ability than current clinical staging system, and could provide a convenient and reliable tool for individual survival prediction and treatment strategy making.

Echoendoscopy in Preoperative Evaluation of Esophageal Adenocarcinoma and Gastroesophageal Junction: Systematic Review and Meta-analysis

Esophageal adenocarcinomas of the esophagus and esophagogastric junction constitute a global health problem, the incidence of which has increased in recent decades. It has a poor prognosis and a low 5-year survival rate. Its treatment is based on preoperative clinical staging, in which echoendoscopy plays an essential role. The aim of this study was to evaluate the current accuracy of echoendoscopy in the staging of esophageal and esophogogastric junction adenocarcinomas. A systematic review was performed in PubMed, Embase and Portal BVS using the search terms Esophageal Neoplasm, Esophagus Neoplasms, Esophagus Cancers, Esophageal Cancers, EUS, EUS-FNA, Endoscopic Ultrasonography, Echo Endoscopy, Endosonographies and Endoscopic Ultrasound, with subsequent meta-analysis of the data found. The accuracy of tumor (T) staging was 65.55%. For T1, sensitivity was 64.7%, and specificity 89.1%, with an accuracy of 89.6%. For T2, sensitivity and specificity were 35.7% and 89.2%, respectively, with an accuracy of 87.1%. For T3, sensitivity and specificity were 82.5% and 83%, respectively, with an accuracy of 87%. For T4, sensitivity and specificity were 38.6% and 94%, respectively, with an accuracy of 66.4%. For node (N) staging, sensitivity was 77.3% and specificity 67.4%, with an accuracy of 77.9%. Echoendoscopy exhibits suboptimal accuracy in preoperative staging of esophageal adenocarcinoma and esophagogastric junction.

Survival benefit of perioperative chemotherapy for T1-3N0M0 stage esophageal cancer: a SEER database analysis

Background

The effect of perioperative chemotherapy on patients with lymph node-negative esophageal cancer (EC) is controversial. This study explored which EC patients, staged under the T1-3N0M0, would benefit from perioperative chemotherapy.

Methods

Data on patients with diagnosed primary EC were retrieved from Surveillance, Epidemiology and End Results (SEER) database. Propensity score-matched (PSM) method was performed to balance baseline covariates. Multivariate Cox regression analysis and Kaplan-Meier curve were used to assess potential survival difference between patients undergoing surgery plus perioperative chemotherapy (SA + CT) and those undergoing surgery alone (SA).

Results

In a total of 2,711 EC patients (T1–3N0M0), 166 patients underwent SA + CT and 2,545 patients received SA. In the multivariable analysis, T stage was significantly related to prognosis of EC patients before and after matching. Subgroup analysis showed that perioperative chemotherapy was associated with poor cancer-specific survival (CSS) for stage T1 patients. There was no effect of perioperative chemotherapy on overall survival (OS) or CSS for T2 patients, whereas a remarkable improvement in OS and CSS was observed for T3 patients. Survival analysis showed that T3 stage EC patients obtained survival benefit from SA + CT. Prognosis in the SA group was significantly better than in the SA + CT group for T1 patients. However, T2 patients showed no significant increase in survival after undergoing SA + CT compared with SA.

Conclusions

T3 patients benefit more from SA + CT. However, perioperative chemotherapy does not present survival benefit to T1–2 patients, and it is an adverse prognostic factor for T1 patients.

Development and validation of a new clinical staging system to predict survival for esophageal squamous cell carcinoma patients: Application of the nomogram

INTRODUCTION

Survival of patients with the same clinical stage varies widely and effective tools to evaluate the prognosis utilizing clinical staging information is lacking. This study aimed to develop a clinical nomogram for predicting survival of patients with Esophageal Squamous Cell Carcinoma (ESCC).

MATERIALS AND METHODS

On the basis of data extracted from the SEER database (training cohort, n = 3375), we identified and integrated significant prognostic factors for nomogram development and internal validation. The model was then subjected to external validation with a separate dataset obtained from Jinling Hospital of Nanjing Medical University (validation cohort, n = 1187). The predictive accuracy and discriminative ability of the nomogram were determined by concordance index (C-index), Akaike information criterion (AIC) and calibration curves. And risk group stratification was performed basing on the nomogram scores.

RESULTS

On multivariable analysis of the training cohort, seven independent prognostic factors were identified and included into the nomogram. Calibration curves presented good consistency between the nomogram prediction and actual observation for 1-, 3-, and 5-year OS. The AIC value of the nomogram was lower than that of the 8th edition American Joint Committee on Cancer TNM (AJCC) staging system, whereas the C-index of the nomogram was significantly higher than that of the AJCC staging system. The risk groups stratified by CART allowed significant distinction between survival curves within respective clinical TNM categories.

CONCLUSIONS

The risk stratification system presented better discriminative ability for survival prediction than current clinical staging system and might help clinicians in decision making.

Executive Summary of the American Radium Society Appropriate Use Criteria for Operable Esophageal and Gastroesophageal Junction Adenocarcinoma: Systematic Review and Guidelines

PURPOSE

Limited guidance exists regarding the relative effectiveness of treatment options for nonmetastatic, operable patients with adenocarcinoma of the esophagus or gastroesophageal junction (GEJ). In this systematic review, the American Radium Society (ARS) gastrointestinal expert panel convened to develop Appropriate Use Criteria (AUC) evaluating how neoadjuvant and/or adjuvant treatment regimens compared with each other, surgery alone, or definitive chemoradiation in terms of response to therapy, quality of life, and oncologic outcomes.

METHODS AND MATERIALS

Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology was used to develop an extensive analysis of peer-reviewed phase 2R and phase 3 randomized controlled trials as well as meta-analyses found within the Ovid Medline, Cochrane Central, and Embase databases between 2009 to 2019. These studies were used to inform the expert panel, which then rated the appropriateness of various treatments in 4 broadly representative clinical scenarios through a well-established consensus methodology (modified Delphi).

RESULTS

For a medically operable nonmetastatic patient with a cT3 and/or cN+ adenocarcinoma of the esophagus or GEJ (Siewert I-II), the panel most strongly recommends neoadjuvant chemoradiation. For a cT2N0M0 patient with high-risk features, the panel recommends neoadjuvant chemoradiation as usually appropriate. For patients found to have pathologically involved nodes (pN+) who did not receive any neoadjuvant therapy, the panel recommends adjuvant chemoradiation as usually appropriate. These guidelines assess the appropriateness of various dose-fractionating schemes and target volumes.

CONCLUSIONS

Chemotherapy and/or radiation regimens for esophageal cancer are still evolving with many areas of active investigation. These guidelines are intended for the use of practitioners and patients who desire information about the management of operable esophageal adenocarcinoma.

An artificial neural network model predicting pathologic nodal metastases in clinical stage I-II esophageal squamous cell carcinoma patients

Background

Current preoperative staging for lymph nodal status remains inaccurate. The purpose of this study was to build an artificial neural network (ANN) model to predict pathologic nodal involvement in clinical stage I–II esophageal squamous cell carcinoma (ESCC) patients and then validated the performance of the model.

Methods

A total of 523 patients (training set: 350; test set: 173) with clinical staging I–II ESCC who underwent esophagectomy and reconstruction were enrolled in this study. Their post-surgical pathological results were assessed and analysed. An ANN model was established for predicting pathologic nodal positive patients in the training set, which was validated in the test set. A receiver operating characteristic (ROC) curve was also created to illustrate the performance of the predictive model.

Results

Of the enrolled 523 patients with ESCC, 41.3% of the patients were confirmed pathologic nodal positive (216/523). The ANN staging system identified the tumour invasion depth, tumour length, dysphagia, tumour differentiation and lymphovascular invasion (LVI) as predictors for pathologic lymph node metastases. The C-index for the ANN model verified in the test set was 0.852, which demonstrated that the ANN model had a good predictive performance.

Conclusions

The ANN model presented good performance for predicting pathologic lymph node metastasis and added indicators not included in current staging criteria and might help improve the staging strategies.

Role of Perioperative Chemotherapy in Lymph Node-negative Esophageal Cancer After Resection: A Population-based Study With Propensity Score-matched Analysis

BACKGROUND

Multimodality treatment is increasingly accepted and becoming the standard care for local advanced esophageal cancer (EC) patients. However, for early stage lymph node-negative EC patients, surgery alone is still the primary treatment approach, and the role of perioperative chemotherapy remains unclear.

METHODS

Patients with lymph node-negative EC were identified from the Surveillance, Epidemiology, and End Results (SEER) database from 2004 to 2013. Survival was compared by the log-rank test. Cox proportional hazards analysis was used to identify covariates associated with overall survival (OS). Propensity score-matched analysis was also performed to control for confounding.

RESULTS

A total of 3071 patients (T1-4N0M0) were identified, 1363 (44.4%) of which received perioperative chemotherapy. The effect of chemotherapy on OS was remarkably dependent on the T stage. For stage T1 patients, chemotherapy was inversely associated with OS (hazard ratio [HR]=1.54; 95% confidence interval [CI], 1.27-1.86), and no impact of chemotherapy on OS was found for T2 patients (HR=0.92; 95% CI, 0.712-1.18), whereas a significant improvement in OS was observed with the addition of chemotherapy for patients with stages T3 (HR=0.52; 95% CI, 0.43-0.62) and T4 (HR=0.60; 95% CI, 0.36-0.98) disease. Multivariable analysis with demonstrated that chemotherapy usage, age, sex, tumor grade, and T stage (P<0.05) were significantly associated with OS in T3-T4 patients. The results were similar in subgroup analyses stratified by confounding covariates, and the propensity score-matched analysis.

CONCLUSIONS

This population-based study indicates perioperative chemotherapy is associated with improved survival in stage T3-4N0M0 patients with EC, which needs to be further validated by randomized trials.

Current status of esophageal cancer treatment

Esophageal cancer (EC) remains one of the most common and aggressive diseases worldwide. This review discusses some debates in the modern management of the disease. Endoscopic procedures for early cancer (T1a−b) are now embedded in routine care and the challenge will be to more accurately select patients for endoscopic resection with or without adjuvant therapy. Perioperative multimodal therapies are associated with improved survival compared to surgery alone for locally advanced esophageal cancer. However, there is no global consensus on the optimal regimen. Furthermore, histological subtype (adenocarcinomavs. squamous cell cancer) plays a role in the choice for treatment. New studies are underway to resolve some issues. The extent of the lymphadenectomy during esophagectomy remains controversial especially after neoadjuvant chemoradiation. The ideal operation balances between limiting surgical trauma and optimizing survival. Minimally invasive esophagectomy and enhanced recovery pathways are associated with decreased morbidity and faster recovery albeit there is no consensus yet what approach should be used. Finally, immune checkpoint inhibitors present promising preliminary results in the novel treatment of advanced or metastatic EC but their widespread application in clinical practice is still awaited.

Potential Role of circPVT1 as a proliferative factor and treatment target in esophageal carcinoma

Background

Many circRNAs have been reported to play important roles in cancer development and have the potential to serve as a novel class of biomarkers for clinical diagnosis. However, the role of circRNAs in esophageal carcinoma (EC) remains unclear. In the current study, we investigated the potential role of circPVT1 in esophageal carcinoma.

Methods

Quantitative real-time PCR was performed to detect circPVT1 levels. CircPVT1-specific siRNA or plasmids were used to knock down or overexpression the target RNA. Hoechst Staining was implemented to evaluate the ratio of cell apoptosis. Transwell migration assays were carried out to study the effects of circPVT1 on esophageal squamous cell carcinoma cell invasion. RegRNA 2.0 was used for bioinformatics analysis. The expression levels of Pax-4, Pax-6, PPARα and PPAR-γ were assessed using Western blot.

Results

In the present study, we demonstrated a significant up-regulation of circPVT1 levels in EC tissues and cancer cell lines. The levels of circPVT1 decreased significantly when the cells were maintained to over-confluence. These results suggested a potential role for circPVT1 in cell proliferation. In addition, overexpressing circPVT1 in TE-10 cell promoted invasive ability of cancer cell. In contrast, siRNA knockdown of circPVT1 inhibited this phenomenon, leading to increased apoptosis levels of TE-10 cell. What’s more, miR-4663 had the effect of inhibiting tumor growth by downregulated Paxs and upregulated PPARs. Whereas, after the addition of circPVT1, this effect no longer worked, suggesting that circPVT1 may affect the malignancy of the tumor by affecting miRNA and regulating the levels of Paxs and PPARs.

Conclusions

Collectively, our study reveals a critical role for circPVT1 in esophageal carcinoma, which may provide new insights of this circRNA as a biomarker for the diagnosis and treatment target of EC.

Predicting lymph node metastases with endoscopic resection in cT2N0M0 oesophageal cancer: A systematic review and meta-analysis

Background

Despite modern imaging modalities, staging of clinically staged T2N0M0 (cT2N0M0) oesophageal cancer is suboptimal, often leading to overtreatment. Endoscopic resection – the first-line therapy for early localised tumours – could be used to improve staging and to attain predictors of nodal upstaging enabling more stage-guided treatment decisions.

Objective

A systematic literature review and a meta-analysis were conducted to assess the prevalence and the pathological risk factors of lymph node metastases in cT2N0M0 oesophageal cancer.

Methods

Databases of PUBMED, EMBASE and Cochrane were searched for literature. The primary outcome was lymph node metastases determined after primary surgical resection.

Results

Nine studies with a total of 1650 cT2N0M0 patients were included. The prevalence of lymph node metastases was 43% (95% confidence interval: 35–50%) with heterogeneity being high across studies (I² = 0.86, p < 0.001). Factors potentially attainable by endoscopic resection and having a significant association with lymph node metastases were invasion depth, differentiation grade, tumour size, depth of invasion in the muscularis propria and lymphovascular invasion.

Conclusions

Clinical lymph node staging is inaccurate in almost half of cT2N0M0 oesophageal cancer. Endoscopic resection is a promising diagnostic modality that might even be a valid alternative to surgery in selected patients without high-risk features, but further evidence is warranted.