Preoperative chemotherapy for clinically node-positive patients with squamous cell carcinoma of the esophagus

Neutrophil-to-lymphocyte ratio after neoadjuvant chemotherapy as an independent prognostic factor in patients with esophageal squamous cell carcinoma

Studies have shown that neoadjuvant chemotherapy (NAC) followed by surgical resection improves the survival of patients with esophageal squamous cell carcinoma (ESCC), and that the neutrophil-to-lymphocyte ratio (NLR) nay be a prognostic biomarker in various types of cancer. Despite the noTable changes in the tumor and its microenvironment during NAC, it remains unclear how the NLR changes and which values (before or after NAC) best predict prognosis. The present study aimed to analyze changes in the NLR before and after NAC, and to determine which was a better prognostic factor. This study retrospectively analyzed 338 consecutive patients with ESCC who received NAC followed by curative resection. NLRs before (pre-NLR) and after (post-NLR) NAC were calculated, after which the impact of NAC on NLR, overall survival (OS) and recurrence-free survival (RFS), as well as the relationship between hematological toxicities and NLR, was evaluated. Cutoff values for pre- and post-NLR were 3.7 and 2.5, respectively. Patients with high post-NLR had a worse OS (P=0.0001) and 3-year RFS (P=0.03) than those with low post-NLR. Multivariate analysis identified high post-NLR, pN1 and clinical response as independent prognostic factors. In conclusion, post-NLR was revealed as a better prognostic factor than pre-NLR for patients receiving NAC followed by surgical resection.

The Negative Survival Impact of Infectious Complications After Surgery is Canceled Out by the Response of Neoadjuvant Chemotherapy in Patients with Esophageal Cancer

BACKGROUND

This study was designed to investigate whether postoperative infectious complications (ICs) are a risk factor for the prognosis in esophageal cancer patients who receive neoadjuvant chemotherapy by stratifying the response to neoadjuvant chemotherapy.

METHODS

The present study retrospectively examined patients who received neoadjuvant chemotherapy followed by esophagectomy between January 2011 and September 2015. Risk factors for overall survival (OS) were examined by Cox proportional hazard analyses. Pathological responders to neoadjuvant chemotherapy were defined as those with a tumor disappearance of more than one-third of the initial tumor. Postoperative ICs were defined using the Clavien-Dindo classification.

RESULTS

Of the 111 patients examined, 45 (40.5%) developed postoperative ICs. A pathological response to neoadjuvant chemotherapy was observed in 54 (48.6%) patients. The multivariate analysis demonstrated that postoperative ICs were a significant independent risk factor for the OS (hazard ratio [HR] 2.359; 95% confidence interval [CI] 1.057-5.263, p = 0.036). In the subset analysis, postoperative ICs were a marginally significant independent risk factor for OS in the nonresponders (HR 2.862; 95% CI 0.942-8.696, p = 0.063) but not in the responders (HR 0.867; 95% CI 0.122-6.153, p = 0.886).

CONCLUSIONS

These results suggested that the negative survival impact of postoperative ICs can be canceled out in esophageal cancer patients who respond to neoadjuvant chemotherapy.

Plasma microRNA profiles: identification of miR-23a as a novel biomarker for chemoresistance in esophageal squamous cell carcinoma

BACKGROUND

This study aims to explore novel microRNAs in plasma for predicting chemoresistance in preoperative chemotherapy of patients with esophageal squamous cell carcinoma (ESCC) using a microRNA array-based approach.

RESULTS

(1) Four candidate microRNAs (miR-223, 103a, 23b and 23a), which were highly expressed in the pretreatment plasma of patients with a low histopathologic response, were selected. (2) In a large-scale validation analysis by quantitative RT–PCR, plasma levels of miR-223, miR-23b and miR-23a were significantly higher in patients with a low histopathologic response than in those with a high histopathologic response (p = 0.0345, p = 0.0125 and p = 0.0114). (3) Of all candidate microRNAs, miR-23a expression of pretreatment ESCC tumor tissues was significantly higher in ESCC patients with a low histopathologic response than in those with a high histopathologic response (p = 0.0278). (4) After overexpressing each candidate in ESCC cells, miR-23a induced significant chemoresistance to both 5-fluorouracil and cisplatin, and miR-223 to cisplatin in vitro. (5) A high level of plasma miR-23a, which tended to correlate with lymphatic invasion (p = 0.0808) and deep depth of invasion (p = 0.0658), was an independent risk factor for chemoresistance in ESCC (p = 0.0222; odds ratio: 12.4; range 1.46–105).

MATERIALS AND METHODS

We used the Toray^® 3D-Gene microRNA array-based approach to compare plasma microRNA levels between patients with a high or a low histopathologic response to chemotherapy. All patients underwent a preoperative chemotherapy regimen with cisplatin plus 5-fluorouracil.

CONCLUSIONS

Plasma miR-23a might be a useful biomarker for predicting chemoresistance in ESCC patients.

The Presence of Serum p53 Antibody Predicts the Pathological Tumor Response to Neoadjuvant Chemotherapy with Docetaxel, Cisplatin and Fluorouracil (DCF) in Esophageal Squamous Cell Carcinoma

BACKGROUND

Docetaxel, cisplatin and fluorouracil (DCF) is a candidate neoadjuvant chemotherapy (NAC) regimen for esophageal squamous cell carcinoma (ESCC). Although the efficacy and safety of DCF have been reported, the markers that predict the patient's response are still unknown. The aim of this study was to identify the predictive markers for a response to NAC with DCF in patients with ESCC.

METHODS

A total of 79 patients who received preoperative DCF followed by esophagectomy between August 2008 and December 2014 were enrolled in this study. All of the patients completed 2 preoperative courses of DCF. The clinical and pathological responses to DCF were investigated, and the associations between the pathological response, the clinicopathological factors and the prognosis were retrospectively analyzed.

RESULTS

Among the 79 patients, the pathological response to DCF (evaluated according to the Japanese Classification of Esophageal Cancer) was grade 3 (complete pathological response) in 7 patients (8.9 %), grade 2 in 13 patients (16.5 %), grade 1b in 8 patients (10.1 %) and grade 1a in 51 patients (64.6 %). A good pathological response (grade 2-3) was significantly associated with both favorable disease-free survival (P = 0.0051) and favorable cancer-specific survival (P = 0.0366). A multivariate analysis revealed that a good clinical response (HR 13.743, 95 % CI 2.455-76.917) and the presence of serum p53 antibody before treatment (HR 3.987, 95 % CI 1.103-14.416) were independent predictors of good pathological response.

CONCLUSIONS

The presence of serum p53 antibody can be used as a novel, noninvasive predictor of the pathological tumor response to NAC with DCF in ESCC patients.

Negative influence of programmed death-1-ligands on the survival of esophageal cancer patients treated with chemotherapy

The programmed death‐1/programmed death‐1 ligands (PD‐1/PD‐L) pathway plays an important role in immunological tumor evasion. However, the clinical significance of the PD‐L (L1 and L2) expression in esophageal cancer treated with chemotherapy has not been fully investigated. We examined the expression of PD‐L of the primary tumors obtained from 180 esophageal cancer patients who underwent radical resection with or without neoadjuvant chemotherapy (NAC) using immunohistochemical staining. The relationship between the expression patterns and clinico‐pathological characteristics was examined. In the present study, 53 patients (29.4%) and 88 patients (48.3%) were classified into positive for PD‐L1 and PD‐L2 expression, respectively. In all the patients examined, overall survival rates of the patients with tumors positive for PD‐L1 or PD‐L2 were significantly worse than those with tumors negative for PD‐L1 or PD‐L2 (P = 0.0010 and P = 0.0237, respectively). However, subgroup analysis showed that these tendencies are only found in the patients treated with NAC, and not in those without NAC. The patients with positive PD‐L1 expression had a significantly higher rate of NAC history (P = 0.0139), but those with positive PD‐L2 expression did not have a significantly high rate of NAC history (P = 0.6127). There is no significant relationship between PD‐L1 expression and response to chemotherapy (P = 0.3118), but patients with positive PD‐L2 expression had significantly inferior responses to chemotherapy (P = 0.0034). The PD‐1/PD‐L pathway might be an immunological mechanism associated with the long‐term effectiveness of chemotherapy in esophageal cancer patients. Further investigation into the roles of PD‐1 pathway in chemotherapy could lead to the development of better treatment options for this disease.

Prognostic significance of tumor regression grade for patients with esophageal squamous cell carcinoma after neoadjuvant chemotherapy followed by surgery

BACKGROUND AND OBJECTIVES

To clarify prognostic factors for the patients with esophageal squamous cell carcinoma (ESCC) through an assessment of surgically resected specimens modified by neoadjuvant chemotherapy (nCT).

METHODS

We retrospectively reviewed the clinicopathological data of 143 consecutive patients with ESCC who underwent nCT followed by surgery between 2008 and 2012 at our institution and conducted survival analysis. The tumor regression grade (TRG) was classified based on the proportion of residual tumor cells in the area where the tumor was thought to have existed before nCT as follows: Grade 0 (no therapeutic effect), Grade 1a (residual tumor cells ≥2/3), Grade 1b (1/3≤ residual tumor cells <2/3), Grade 2 (residual tumor cells <1/3), and Grade 3 (no residual tumor).

RESULTS

The 3-year OS and RFS of patients with tumor regression grade 0/1a/1b-3 were 53.6%/73.3%/88.6% and 37.7%/60.5%/83.8%, respectively. A multivariate analysis demonstrated that TRG was an independent predictor of OS (TRG 1a-3: HR, 0.46; 95%CI, 0.23-0.89), in addition to venous invasion, and of RFS (TRG 1a-3: HR, 0.49; 95%CI, 0.28-0.84), in addition to ypT factor, and venous invasion.

CONCLUSIONS

TRG is a critical prognostic factor in patients with ESCC who had undergone nCT followed by surgery. J. Surg. Oncol. 2016;113:390-396. © 2016 Wiley Periodicals, Inc.

Effects of neutropenia and histological responses in esophageal squamous cell carcinoma with neo-adjuvant chemotherapy

BACKGROUND

Neo-adjuvant chemotherapy (NAC) followed by radical esophagectomy has been shown to prolong survival in patients with locally advanced esophageal squamous cell carcinoma (ESCC). However, neutropenia, one of the major adverse events due to NAC, influences the therapeutic course. The aim of this study is to clarify the relationship between neutropenia and therapeutic response in ESCC with NAC.

METHODS

A total of 117 patients with clinical stage II/III ESCC who had undergone NAC followed by radical esophagectomy were retrospectively analyzed in terms of the relationship between neutropenia and clinicopathological features or outcomes.

RESULTS

Neutropenia was the major adverse event observed in 56 % (66/117) and grade 3/4 neutropenia occurred in 29 % of patients. Grade 3/4 neutropenia correlated with a high histological response (Grade 1b-3) (p < 0.01). Correlative analysis identified grade 3/4 neutropenia and poor differentiation as independent predictors of a high histological response (odds ratio 5.13 and 3.25, p < 0.01 and p = 0.01, respectively). Survival analysis showed that patients with a high histological response had significantly longer survival than those with a low histological response (Grade 0-1a) (p = 0.03), whereas no significant differences were found for survival according to the grade of neutropenia (p = 0.45). In a subgroup analysis according to histological response, grade 3/4 neutropenia correlated with worse survival in patients with a low histological response (p = 0.05).

CONCLUSION

Severe neutropenia due to NAC correlates with a high histological response in ESCC. However, severe neutropenia may also result in a worse prognosis for patients with a low histological response.

miR-27 is associated with chemoresistance in esophageal cancer through transformation of normal fibroblasts to cancer-associated fibroblasts

There is increasing evidence that the expression of microRNA (miRNA) in cancer is associated with chemosensitivity but the mechanism of miRNA-induced chemoresistance has not been fully elucidated. The aim of this study was to examine the role of extracellular miRNA in the response to chemotherapy in esophageal cancer. First, serum expression of miRNAs selected by miRNA array was measured by quantitative reverse transcription-polymerase chain reaction in 68 patients with esophageal cancer who received cisplatin-based chemotherapy to examine the relationship between miRNA expression and response to chemotherapy. The serum expression levels of 18 miRNAs were different between responders and non-responders by miRNA array. Of these, high expression levels of miR-27a/b correlated with poor response to chemotherapy in patients with esophageal cancer. Next, in vitro assays were conducted to investigate the mechanism of miRNA-induced chemoresistance. Although transfection of miR-27a/b to cancer cells had no significant impact on chemosensitivity, esophageal cancer cells cultured in supernatant of miR-27a/b-transfected normal fibroblast showed reduced chemosensitivity to cisplatin, compared with cancer cells cultured in supernatant of normal fibroblast. MiR-27a/b-transfected normal fibroblast showed α-smooth muscle actin (α-SMA) expression, a marker of cancer-associated fibroblasts (CAF) and increased production of transforming growth factor-β (TGF-β). Chemosensitivity recovered after administration of neutralizing antibody of TGF-β to the supernatant transfer experiments. Our results indicated that miR-27a/b is involved in resistance to chemotherapy in esophageal cancer, through miR-27a/b-induced transformation of normal fibroblast into CAF.

Mesenchymal phenotype after chemotherapy is associated with chemoresistance and poor clinical outcome in esophageal cancer

The relationship between the epithelial-mesenchymal transition (EMT) and resistance to anticancer treatment has attracted attention in recent years. However, to date, there is no direct clinical evidence for a link between the mesenchymal phenotype and chemoresistance in human malignancies. The expression of EMT-related markers, including E-cadherin, Snail, vimentin, ZEB1, β-catenin and N-cadherin was examined immunohistochemically in 185 tissue samples from patients with esophageal cancer (including 93 patients who received preoperative chemotherapy followed by surgery and 92 patients who underwent surgery without preoperative therapy). The relationship between the expression of the above markers and clinical outcome including prognosis and response to chemotherapy was also examined. The expression of E-cadherin, a marker of epithelial cells, was significantly lower in residual tumors than chemo-naive tumors (P=0.003). The expression of Snail (P=0.028), ZEB1 (P<0.001) and N-cadherin (P=0.001), markers of mesenchymal cells, was higher in residual tumors than in chemonaive tumors. The expression of E-cadherin correlated inversely with that of Snail (P<0.001). Reduced expression of E-cadherin and increased expression of Snail in residual tumors from patients who received chemotherapy correlated significantly with poor response to chemotherapy and short survival time. Multivariate analysis identified Snail expression as an independent prognostic factor, along with tumor depth, in patients who received preoperative chemotherapy for esophageal cancer. The results suggest transition of residual esophageal cancer cells to mesenchymal phenotype after chemotherapy and this contributes to resistance to chemotherapy and poor prognosis in patients with esophageal cancer.

Early response to neoadjuvant chemotherapy in advanced esophageal cancer evaluated by computed tomography predicts the utility of a second cycle of chemotherapy

Multi-course neoadjuvant chemotherapy (NACT) followed by surgery is a promising treatment for advanced esophageal cancer. However, non-responders may continue to receive ineffective treatment, since there are no definitive criteria for early discontinuation of NACT. In this study, we analyzed 103 advanced esophageal cancer patients treated with 2 cycles of NACT followed by surgery. Patients with >20% decrease in the size of the primary tumor as evaluated by computed tomography (CT) following the first cycle of chemotherapy, were defined as early responders and the remainder as early non-responders. Clinicopathological factors and prognosis were compared between the 2 groups. The reduction rate of the second cycle and progression-free survival (PFS) of early non-responders were significantly worse than those of early responders (p=0.0001 and 0.0375, respectively). In addition, pathological T stage, pathological assessment of tumor regression and number of metastatic lymph nodes were significantly unfavorable in early non-responders (p=0.023, 0.007 and 0.0041, respectively). Among the clinical factors that were available prior to administration of the second cycle, clinical T3 stage and early non-responder status were the only independent unfavorable factors (p=0.028 and 0.0062, respectively). Patients with both unfavorable factors had a significantly poorer PFS compared to the remaining patients and a PFS similar to those who had both factors but received only 1 cycle of NACT. In conclusion, the reduction rate of the primary tumor as evaluated by CT following the first cycle of NACT, may aid physicians in determining whether to administer a second cycle. In early non-responders bearing T3 tumors, NACT should be discontinued after the first cycle.

Overexpression of PFTK1 predicts resistance to chemotherapy in patients with oesophageal squamous cell carcinoma

Background:

Recently, PFTK1 was identified as a member of the cyclin-dependent kinase family; however, its expression and clinical significance in oesophageal squamous cell carcinoma (ESCC) have not been evaluated.

Methods:

PFTK1 expression was initially examined by expression microarray in 77 ESCC patients. Using independent samples of 223 patients, PFTK1 expression was evaluated immunohistochemically to assess the relationship between expression and various clinicopathological parameters. The association between PFTK1 and the response to chemotherapy was also investigated in pretreatment samples of 85 patients who received chemotherapy as first treatment.

Results:

Significant upregulation of PFTK1 expression was noted in ESCC compared with normal epithelium. PFTK1 expression was positive in 51.6% (115 out of 223) of the tumours, but did not correlate with any clinicopathological parameter. The 5-year overall survival rate was poorer in patients positive for PFTK1 (43.6%) than those with negative expression (66.2%, P<0.001). Uni- and multivariate analyses identified PFTK1 as an independent marker of prognosis (RR=2.428, 95% CI=1.615–3.711, P<0.001). Out of 85 biopsy samples, 40 (47.1%) tumours showed PFTK1-positive expression, and the response rate to chemotherapy was significantly lower than PFTK1-negative tumours (27.9% vs 72.1%, P<0.001).

Conclusion:

PFTK1 is not only useful as a prognostic marker, but also as a predictor of the response to chemotherapy.

Assessment of stanniocalcin-1 as a prognostic marker in human esophageal squamous cell carcinoma

Stanniocalcin-1 (STC1) is a secreted glycoprotein hormone and highly expressed in various types of human malignancies. Although evidence points to the role of STC1 in human cancers, the clinical significance of STC1 expression in esophageal cancer has not been well established. Quantitative reverse transcriptase-polymerase chain reaction and immunohistochemistry were performed to assess the expression of STC1 in the cancer cell line TE8 and esophageal cancer tissues from 229 esophageal squamous cell carcinomas (ESCC). Surgically-resected tissue sections were immunostained for potential regulators of STC1 expression, hypoxia-inducible factor-1α (HIF-1α) and p53. Marked increase in STC1 mRNA and protein expression was noted in TE8 cells cultured under hypoxic conditions. Overexpression of STC1 mRNA was noted in ESCC tumors compared to normal counterparts. Positive immunohistochemical staining for STC1 protein was observed in 38.9% of patients, and correlated significantly with advanced pT status (P=0.019), poor prognosis [overall survival (P<0.0006) and disease-free survival (P<0.0002) of ESCC patients who had undergone curative surgery]. Positive staining for HIF-1α and p53 proteins in ESCC did not correlate with STC1 expression. The results showed marked induction of STC1 expression under hypoxia in cultured cells and in esophageal cancer cells and that overexpression of STC1 was an independent prognostic factor in patients with esophageal cancer who had undergone curative surgery. STC1 is a potentially useful biomarker for ESCC treatment.

Prognostic value of an inflammation-based score in patients undergoing pre-operative chemotherapy followed by surgery for esophageal cancer

Recent studies have shown that the presence of systemic inflammation is associated with poor outcome in patients with malignancy. However, whether systemic inflammation affects the response to pre-operative therapy and survival of patients undergoing multimodal treatment for esophageal cancer is not clear. We studied 152 patients who underwent pre-operative chemotherapy followed by surgery for esophageal cancer. The correlation between various clinicopathological factors, including hematological markers of systemic inflammatory response, and survival or response to chemotherapy was examined. Among various hematological factors, leucocyte count, hemoglobin level, albumin level, neutrophil-lymphocyte ratio and CEA, but not serum concentration of C-reactive protein, were significantly associated with survival. Multivariate analysis revealed that the clinical response to chemotherapy, number of metastatic lymph nodes, operative complications and systemic inflammation score (SI score), comprising leucocyte count, albumin and hemoglobin levels, were independent prognostic factors, and identified the SI score as the most significant prognostic factor. There was no significant relationship between hematological markers of systemic inflammation, including the SI score, and the response to chemotherapy. In conclusion, in patients scheduled for chemotherapy followed by surgery for esophageal cancer, systemic inflammation, reflected by SI, predicts poor outcome, but not the response to chemotherapy.

Role of multidrug resistance protein 2 (MRP2) in chemoresistance and clinical outcome in oesophageal squamous cell carcinoma

BACKGROUND

Although multidrug resistance protein 2 (MRP2) confers chemoresistance in some cancer types, its implication on oesophageal squamous cell carcinoma (ESCC) remains unclear.

METHODS

We evaluated MRP2 expression by immunohistochemistry and RT-PCR using 81 resected specimens from ESCC patients who did or did not receive neo-adjuvant chemotherapy (NACT), including 5-fluorouracil, doxorubicin, and cisplatin (CDDP). Correlation between MRP2 expression and response to chemotherapy was also examined in 42 pre-therapeutic biopsy samples and eight ESCC cell lines.

RESULTS

MRP2-positive immunostaining was more frequently observed in ESCCs with NACT than in those without NACT (27.3 vs 5.4%). The MRP2-positive patients showed poorer prognosis than MRP2-negative patients (5-year survival rate, 25.6 vs 55.7%). Concordantly, ESCC with NACT showed 2.1-fold higher mRNA expression of MRP2 than those without NACT (P=0.0350). In pre-therapeutic biopsy samples of patients with NACT, non-responders showed 2.9-fold higher mRNA expression of MRP2 than responders (P=0.0035). Among the panel of ESCC cell lines, TE14 showed the highest MRP2 mRNA expression along with the strongest resistance to CDDP. Inhibition of MRP2 expression by small-interfering RNA reduced chemoresistance to CDDP.

CONCLUSION

Our data suggested that MRP2 is one of molecules, which regulate the sensitivity to chemotherapy including CDDP in advanced ESCC patients.

Doxorubicin, cisplatin, and fluorouracil combination therapy for metastatic esophageal squamous cell carcinoma

The chemotherapy regimen currently used for treating esophageal and gastric carcinoma has been either epirubicin, cisplatin, and fluorouracil (5-FU) or docetaxel, cisplatin, and 5-FU. Here, we report the efficacy and toxicity of doxorubicin, cisplatin, and 5-FU for only esophageal squamous cell carcinoma (ESCC). Between January 2000 and October 2008, a total of 41 ESCC patients with a distant metastasis were enrolled. The most common sites of metastasis were liver (26, 63.4%), lung (9, 22.0%), and bone (8, 19.5%). Doxorubicin was administered on day 1 at 30 mg/m(2) , cisplatin on days 1-5 at 14 mg/m(2)/day, and 5-FU on days 1-5 at 700 mg/m(2)/day. The median number of cycles was 2.0 (range 1-8). The dose intensities of doxorubicin, cisplatin, and 5-FU were 92.9, 92.4, and 92.5%, respectively. The overall response rate was 43.9%; one showed complete response, 17 showed partial response, 13 showed a stable disease, and 10 showed progressive disease (PD). The median survival time was 306 days (95% CI = 74-935) and the 1-year survival rate was 37.6%. Grade 3 neutropenia was seen in seven patients and grade 4 in one patient. Grade 3 fatigue, anorexia, mucositis, and diarrhea were observed in three, two, two, and one patient, respectively. This regimen is effective as a first-line therapy for ESCC with distant metastasis.

Management of the hepatic lymph nodes during resection of liver metastases from colorectal cancer: a systematic review

BACKGROUND

Hepatic lymph node involvement is generally considered a contraindication for liver resection performed for colorectal liver metastases. However, some advocate hepatic lymphadenectomy in the presence of macroscopic involvement and others routine lymphadenectomy. The aim of this review is to assess the role of lymphadenectomy in resection of liver metastases from colorectal cancer.

METHODS

Medline, Embase and Central databases were searched using a formal search strategy. Trials with survival data with a minimum follow-up of 1 year were considered for inclusion. Meta-analysis was performed using Revman.

RESULTS

A total of 4230 references were identified. Ten reports of nine studies including 926 patients qualified for the review. The prevalence of nodal metastases after routine lymphadenectomy was 16.3%. The overall 3-year and 5-year survival rates in node-positive patients were 9/151 (11.3%) and 2/137 (1.5%), respectively, compared to 3-year and 5-year survival rates of 424/787 (53.9%) and 246/767 (32.1%) in node-negative patients. The odds ratios for 3-year and 5-year survivals in node positive disease compared to node-negative disease were 0.12 (95% CI 0.06 to 0.24) and 0.08 (95% CI 0.03 to 0.22). There was no randomized controlled trial which assessed the survival benefit of routine or "selective" lymphadenectomy.

CONCLUSION

Currently, there is no evidence of survival benefit for routine or selective lymphadenectomy. Survival rates are low in patients with positive lymph nodes draining the liver irrespective of whether they are detected by routine lymphadenectomy or by macroscopic involvement. Further trials in this patient group are required.

Utility of response evaluation to neo-adjuvant chemotherapy by (18)F-fluorodeoxyglucose-positron emission tomography in locally advanced esophageal squamous cell carcinoma

BACKGROUND

Neoadjuvant chemotherapy (NACT) has been frequently used for locally advanced esophageal squamous cell cancer (ESCC). It is therefore important to establish criteria for evaluating the response to NACT based on survival analysis.

METHODS

This study analyzed 100 patients with ESCC (cT1, 2/3/4:25/57/18, cN0/1/M1lym: 5/59/36) who received NACT (5-fluorouracil, adriamycin, and cisplatin) followed by surgical resection. NACT response was monitored using (18)F-fluorodeoxyglucose-positron emission tomography (PET) and computed tomography by measuring pre- and post-NACT maximal standardized uptake value (SUVmax) and area of primary tumor, respectively. The associations between NACT and clinicopathological factors including prognosis were analyzed.

RESULTS

The mean ± SEM values of pre- and post-NACT SUVmax were 12.23 ± 4.62 and 6.31 ± 5.41, respectively, and the mean/median SUVmax reduction was 59.50%/73.45%. The most significant difference in survival between responders and non-responders was at 70% of cutoff value based on every 10% stepwise cutoff analysis (2-year progression-free survival [PFS]: 57.7% vs 25.1%; hazard ratio [HR] = 2.864; P = .0004). Univariate analysis indicated a correlation between PFS and number of cN before NACT, SUVmax reduction, decrease in tumor area, pT, and number of pN, while cT before NACT and pathological response to NACT showed no association. Multivariate analysis identified number of cN before NACT (HR = 2.537; P = .0092), SUVmax reduction (HR = 3.202; P = .0072), and number of pN (HR = 2.226; P = .0146) as independent prognostic predictors.

CONCLUSION

By determining the optimal cutoff value based on survival analysis, we evaluated patient responses to NACT using PET. Such evaluation could be valuable in formulating treatment strategies for ESCC.

Surgical resection versus non-surgical treatment for hepatic node positive patients with colorectal liver metastases

BACKGROUND

Involvement of hepatic lymph node in patients with colorectal liver metastases is associated with poor prognosis.

OBJECTIVES

To determine the benefits and harms of curative liver resection with lymphadenectomy versus other treatments for colorectal liver metastases with hepatic node involvement.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and LILACS until September 2009 for identifying the randomised trials.

SELECTION CRITERIA

We considered only randomised clinical trials (irrespective of language, blinding, or publication status) comparing liver resection (alone or in combination with radiofrequency ablation or cryoablation) versus other treatments (neo-adjuvant chemotherapy, chemotherapy, or radiofrequency ablation) in patients with colorectal liver metastases with hepatic node involvement.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials for inclusion.

MAIN RESULTS

We were unable to identify any randomised clinical trial fulfilling the inclusion criteria of this review. We were also unable to identify any quasi-randomised or cohort studies, which could meaningfully answer this important issue.

AUTHORS' CONCLUSIONS

There is no evidence in the literature to assess the role of surgery versus other treatments for patients with colorectal liver metastases with hepatic node involvement. High quality randomised clinical trials are feasible and are necessary to determine the optimal management of patients with colorectal liver metastases with hepatic node involvement.

p53 genotype predicts response to chemotherapy in patients with squamous cell carcinoma of the esophagus

BACKGROUND

Response to chemotherapy and anatomical spread are significant prognostic factors in patients with esophageal squamous cell carcinoma (ESCC) treated by chemotherapy then surgery. Predicting the response to chemotherapy would allow significant optimization of cancer treatment.

METHODS

Genomic mutation and protein expression of p53 were investigated retrospectively by polymerase chain reaction (PCR) single-strand conformation polymorphism (SSCP) and immunohistochemistry (IHC) using biopsy specimens from 77 ESCC patients before chemotherapy with 5-fluorouracil, adriamycin, and cisplatin. p53 status was correlated with various clinicopathological factors. Thereafter, we performed a prospective study of 20 consecutive patients to test our prediction model.

RESULTS

The retrospective study showed mutant p53 genotype and positive p53 IHC staining in 46.8 and 55.8% of patients, respectively, which was not associated with patient's clinicopathological findings including initial tumor stage. Objective response to chemotherapy was observed in 65.9% of patients with wild genotype, but in only 16.7% of patients with mutant genotype. Patients with mutations in p53 therefore showed significantly poorer prognosis than those without mutant p53. In contrast, p53 IHC staining did not correlate with response to chemotherapy, curative resection rate or prognosis. In the prospective study, p53 mutation was seen in 50% (10/20) of patients and was again consistently associated with poorer response to chemotherapy and poorer prognosis.

CONCLUSIONS

p53 genotype of pretreatment biopsy is a potentially useful predictor of response to chemotherapy and prognosis in ESCC patients. This information might be valuable to clinicians in deciding on the optimal clinical strategy in patients with ESCC.

Cytokeratins 18 and 8 are poor prognostic markers in patients with squamous cell carcinoma of the oesophagus

Background:

Cytokeratins (CKs) are structural marker proteins specific for epithelial cells. However, recent studies indicate their involvement in cancer progression.

Methods:

We evaluated CK18 and its filament partner, CK8 expression, by immunohistochemistry in 210 resected specimens from patients with oesophageal squamous cell carcinoma (OSCC). We also analysed the relationship between their expression and various clinicopathological parameters including prognosis.

Results:

Neither CK18 nor CK8 was expressed in non-cancerous squamous epithelium whereas proper oesophageal glands expressed both CKs. Ninety (42.9%) tumours were CK18 positive and 85 (40.5%) CK8 positive, and the concordance rate for immunohistochemical classification for CK18 and CK8 was 82.4%. CK18 expression correlated with poorly differentiated tumours, use of neo-adjuvant chemotherapy, and advanced stage. Prognosis of patients with CK18-positive tumours was poorer than that of patients with negative OSCC (P<0.001). A similar trend was noted for CK8 expression. Multivariate analysis identified pT (P=0.020), pN number (P=0.001), and CK18 expression (P=0.004) as independent prognostic factors. CK18 expression in 83 pretreatment biopsy specimens was detected in 47 cases (56.6%) and also correlated with prognosis (P=0.045).

Conclusion:

CK18/CK8 expression correlated with progression of OSCC. The significant correlation with prognosis and stable expression in biopsy specimen suggest usefulness of CK18 in selection of treatment strategies for OSCC.

Tumor budding in tumor invasive front predicts prognosis and survival of patients with esophageal squamous cell carcinomas receiving neoadjuvant chemotherapy

BACKGROUND

In neoadjuvant chemotherapy for advanced esophageal cancers, complete tumor regression has been difficult to achieve, and tumor often remained after chemotherapy. However, the best method for evaluating the response to chemotherapy based on histopathologic examination of residual tumors has not been established.

METHODS

Studied were 74 patients who received neoadjuvant chemotherapy (5-fluorouracil, cisplatin, and doxorubicin), followed by surgery for advanced esophageal squamous cell carcinoma. The correlation between various histopathologic factors and clinical response with survival was examined, including the importance of tumor budding in the invasive front of tumors on clinical response and survival.

RESULTS

Among 74 patients, 3 achieved a pathologic complete response, and 29 (41%) of 71 residual tumors demonstrated high-grade budding in the invasive front. The 5-year survival rate of patients with low-grade budding tumors was 49%, compared with 17% for those with high-grade budding (P < .001). Budding correlated inversely with good response, which was observed in 44 (60%) of 74 patients. Univariate analysis showed that pathologic tumor depth, number of lymph node metastases, pathologic stage, lymphatic invasion, budding and clinical response were significant prognostic factors. Multivariate analysis identified budding as the most important prognostic factor followed by number of lymph node metastases.

CONCLUSIONS

The results of the current study indicated that tumor budding in the invasive front of tumors correlated significantly with clinical response and prognosis of patients with esophageal squamous cell carcinomas who received neoadjuvant chemotherapy. However, the mechanism of tumor budding in the invasion front of esophageal squamous cell carcinomas treated with chemotherapy was not clarified.

Dickkopf-1 expression as a marker for predicting clinical outcome in esophageal squamous cell carcinoma

BACKGROUND AND OBJECTIVES

Dickkopf-1 (DKK1) is the inhibitor of the canonical Wnt signaling pathway, however it is highly transactivated in various cancers, suggesting the presence of unknown mechanism. Its implication in human esophageal squamous cell carcinoma (ESCC) has not been sufficiently investigated.

PATIENTS AND METHODS

We evaluated DKK1 protein expression in resected specimens from 170 patients with ESCC by immunohistochemistry. Tumors were categorized as positive or negative for DKK1. The relationships between DKK1 expression in ESCC and various clinicopathological parameters and prognosis (disease-free survival; DFS) were analyzed separately.

RESULTS

Immunohistochemically, 72 (42.4%) tumors were DKK1 positive while no significant staining was observed in the normal squamous epithelium except for few basal cells. There was no significant relationship between DKK1 expression in ESCC and any of the clinicopathological parameters tested in this study. Patients with DKK1-positive tumors had poorer DFS than those with negative ESCC (5-year DFS; 31.5% versus 53.6%, P = 0.0062). Univariate analysis showed a significant relationship between pT [hazard ratio (HR) = 2.944, 95% confidence interval (CI) = 1.713-5.059, P < 0.0001], number of pN (HR = 2.836, 95% CI = 1.866-4.309, P < 0.0001), lymphatic invasion (HR = 2.892, 95% CI = 1.336-6.262, P = 0.0070), and DKK1 expression (HR = 1.763, 95% CI = 1.167-2.663, P = 0.0071) and DFS. Multivariate analysis including the above four parameters identified pT (HR = 2.053, 95% CI = 1.157-3.645, P = 0.0140), pN number (HR = 2.107, 95% CI = 1.362-3.260, P = 0.0008), and DKK1 expression (HR = 1.813, 95% CI = 1.195-2.751, P = 0.0052) as independent and significant prognostic factors for DFS.

CONCLUSION

Our data suggest the usefulness of DKK1 as a novel predictor of poor prognosis of patients with ESCC after curative resection and also as a therapeutic target for future tailored therapies against ESCC.

Effects of neoadjuvant chemotherapy on primary tumor and lymph node metastasis in esophageal squamous cell carcinoma: additive association with prognosis

Neoadjuvant chemotherapy (NACT) is widely used to treat esophageal squamous cell carcinoma with lymph node metastasis (ESCC). However, NACT frequently has differential effects on primary tumor (PT) and lymph node metastasis (LNM). The clinical significance of this phenomenon remains unclear. Reduction in tumor size of PT and LNM was evaluated separately in 47 node-positive ESCC patients undergoing NACT, followed by surgical resection. We analyzed the prognostic significance and various clinicopathological parameters. NACT resulted in an average reduction rate of 45.5% for PT and 36.6% for LNM; the correlation between these rates was weak but significant (r(2) = 0.122, P = 0.016). The reduction rates in both PT and LNM were significant prognostic factors, with the maximal significance with cut-off at 30% size reduction for PT (3-year survival, 47.3 vs. 8.3%, P = 0.0004) and 20% for LNM (51.3 vs. 7.1%, P = 0.0013). When these cut-off values were used to define NACT response, 28 patients (59%) were deemed responders for both PT and LNM, while 7 (15%) were nonresponders for both, and the response was inconsistent in 12 patients (26%). Only both PT/LNM responders showed good survival rates, with the remaining categories showing poor survival (3-year survival 60.5 vs. 5.3% P < 0.0001). Multivariate analysis identified neither the PT nor the LNM response alone as an independent prognostic factor; however the combined PT/LNM response was identified as an independent prognostic factor (hazard ratio [HR] 2.861, P = 0.0255) in addition to the number of histological lymph node metastases (HR 2.551, P = 0.0328). The response to NACT in LNM and PT correlates closely with postoperative survival. A good response in both enhances the postoperative prognosis.

Use of (18)F-fluorodeoxyglucose-positron emission tomography to evaluate responses to neo-adjuvant chemotherapy for primary tumor and lymph node metastasis in esophageal squamous cell carcinoma

BACKGROUND

Neoadjuvant chemotherapy (NACT) targets lymph node metastasis (LN), as well as the primary tumor (PT) in esophageal squamous cell carcinomas (ESCC). (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET) reflects viable tumor volume and may be more useful for evaluating NACT responses than conventional radiography. Moreover, FDG-PET may elucidate the clinical significance of NACT responses for LN, which is not always identical to those for PT.

PATIENTS AND METHODS

We retrospectively investigated prognostic factors in 38 node-positive ESCC patients who had undergone NACT (5-fluorouracil, adriamycin, and cisplatin) and surgical resection. The NACT response was evaluated separately by both PET and computed tomography (CT) for each PT and LN.

RESULTS

Although NACT effect for PT and LN was similar by PET evaluation (SUVmax reduction; average 70.58% vs 71.57%), they did not show significant correlation, revealing discordance for 13 (34.2%) patients when SUVmax reduction of more than 70% was classified as a PET responder. An opposite relationship existed in that the pre-NACT SUVmax of PT was significantly lower in PET responders than in PET non-responders (9.92 +/- 4.3 vs 12.96 +/- 3.8, P = .032), while that of LN tended to be higher in responders than in non-responders (5.70 +/- 3.2 vs 3.77 +/- 0.9, P = .072). Multivariate analysis identified the number of PET-positive LN (P = .018, HR = 5.464) and PET response for PT (P = .015, HR = 4.620) and for LN (P = .028, HR = 3.854) as independent prognostic predictors. The NACT response for PT or LN on CT evaluation was not a significant prognostic predictor.

CONCLUSION

PET is superior to CT for evaluating the NACT response from the viewpoint of survival analysis. The NACT response should be evaluated for both LN and PT because of their different behaviors during chemotherapy. Further studies of larger sample number should be conducted in the future.

Correlation between pretherapeutic d-dimer levels and response to neoadjuvant chemotherapy in patients with advanced esophageal cancer

Neoadjuvant chemotherapy may improve survival of responders in esophageal cancer patients but is useless and harmful in non-responders. Thus, it is important to predict the effect of the chemotherapy, and that any predictor must be applicable clinically. The aim of this study is to examine the correlation between pretherapeutic hypercoagulopathy as determined by plasma d-dimer levels and response to chemotherapy. In 71 patients with esophageal cancer who underwent neoadjuvant chemotherapy (cisplatin, adriamycin and 5-fluorouracil) followed by surgery, plasma d-dimer levels were measured before chemotherapy and the clinical and pathological responses to chemotherapy were assessed at 4 weeks after therapy (after surgery). Pretherapeutic plasma d-dimer level was significantly lower in clinical responders (complete response/partial response [CR/PR]; 0.62 +/- 1.10 microg/mL, mean +/- SD) than in non-responders (no change/progressive disease [NC/PD]; 1.15 +/- 1.08 microg/mL, P = 0.0491), and in pathological responders (Grade 1b-3; 0.62 +/- 1.11 microg/mL) and non-responders (Grade 0-1a; 1.15 +/- 1.05 microg/mL, P = 0.0107). The optimal cut-off level of the plasma d-dimer levels for predicting clinical and pathological responses was 0.6 microg/mL. Then, sensitivity and specificity for the prediction of CR/PR were 68% and 73%, and those for Grade 1b-3 were 91% and 69%, respectively. Our results suggested that pretherapeutic plasma d-dimer level correlated significantly with clinical and pathological responses to chemotherapy. Pretherapeutic plasma d-dimer level can be used as a predictor for chemosensitivity.