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Yan CY, Gu YM, Shi GD, Shang QX, Zhang HL, Yang YS, Wang WP, Yuan Y, Chen LQ. Impact of deep muscle invasion on nodal status and survival in patients with pT2 esophageal squamous cancer. J Surg Oncol 2024; 129:1056-1062. [PMID: 38314575 DOI: 10.1002/jso.27593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 12/24/2023] [Accepted: 01/15/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND Whether T2 esophageal squamous cell carcinoma should be subclassified remains controversial. We aimed to investigate the impact of the depth of muscularis propria invasion on nodal status and survival outcomes. METHODS We identified patients with pT2 esophageal squamous cell carcinoma who underwent primary surgery from January 2009 to June 2017. Clinical data were extracted from prospectively maintained databases. Tumor muscularis propria invasion was stratified into superficial or deep. Binary logistic regression was used to determine risk factors for lymph node metastases. The impact of the depth of muscularis propria invasion on survival was investigated using Kaplan‒Meier analysis and a Cox proportional hazard regression model. RESULTS A total of 750 patients from three institutes were investigated. The depth of muscularis propria invasion (odds ratio [OR]: 3.95, 95% confidence interval [CI]: 2.46-6.35; p < 0.001) was correlated with lymph node metastases using logistic regression. T substage (hazard ratio [HR]: 1.37, 95% CI: 1.05-1.79; p < 0.001) and N status (HR: 1.51, 95% CI: 1.05-2.17; p < 0.001) were independent risk factors in multivariate Cox regression analysis. The deep muscle invasion was associated with worse overall survival (HR: 1.52, 95% CI: 1.19-1.94; p = 0.001) than superficial, specifically in T2N0 patients (HR: 1.38, 95% CI: 1.08-1.94; p = 0.035). CONCLUSIONS We found that deep muscle invasion was associated with significantly worse outcomes and recommended the substaging of pT2 esophageal squamous cell carcinoma in routine pathological examination.
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Affiliation(s)
- Cheng-Yi Yan
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Cardiothoracic Surgery, Changsha Central Hospital, University of South China, Changsha, Hunan, China
| | - Yi-Min Gu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Gui-Dong Shi
- Department of Cardiothoracic Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Qi-Xin Shang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Han-Lu Zhang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yu-Shang Yang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wen-Ping Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yong Yuan
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Long-Qi Chen
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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da Costa WL, Gu X, Farjah F, Groth SS, Burt BM, Ripley RT, Massarweh NN. Clinical Understaging, Treatment Response, and Survival Among Esophageal Adenocarcinoma Patients. J Surg Res 2022; 279:256-264. [PMID: 35797753 DOI: 10.1016/j.jss.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/09/2022] [Accepted: 06/04/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Selecting appropriate management for patients with esophageal adenocarcinoma (EA) is predicated on accurate clinical staging information. Inaccurate information could lead to inappropriate treatment and suboptimal survival. We investigated the relationship between staging accuracy, treatment, and survival. METHODS This was a national cohort study of EA patients in the National Cancer Data Base (2006-2015) treated with upfront resection or neoadjuvant therapy (NAT). Clinical and pathological staging information was used to ascertain staging concordance for each patient. For NAT patients, Bayesian analysis was used to account for potential downstaging. We evaluated the association between staging concordance, receipt of NAT, and survival through hierarchical logistic regression and multivariable Cox regression. RESULTS Among 7635 EA patients treated at 877 hospitals, 3038 had upfront resection and 4597 NAT followed by surgery. Relative to accurately staged patients, understaging was associated with a lower likelihood (odds ratio [OR] 0.04 95% confidence interval [CI] 0.02-0.05) while overstaging was associated with a greater likelihood of receiving NAT (OR 1.98 [1.53-2.56]). Relative to upfront surgery, treatment of cT1N0 patients with NAT was associated with a higher risk of death (HR 3.08 [2.36-4.02]). For accurately or overstaged cT3-T4 patients, NAT was associated with a lower risk of death whether downstaging occurred (ypN0 disease-HR 0.67 [0.49-0.92]; N+ disease-HR 0.55 [0.45-0.66]) or not (ypN + disease-HR 0.78 [95% CI 0.65-0.93]). CONCLUSIONS Clinical understaging is associated with receipt of NAT which in turn may have a stage-specific impact on patients' survival regardless of treatment response. Guidelines should account for the possibility of inaccurate clinical staging.
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Kroese TE, Ruurda JP, Bakker AS, Jairam J, Mook S, van der Horst S, Meijer GJ, Haj Mohammad N, van Rossum PS, van Hillegersberg R. Detecting Interval Distant Metastases With 18F-FDG PET/CT After Neoadjuvant Chemoradiotherapy for Locally Advanced Esophageal Cancer. Clin Nucl Med 2022; 47:496-502. [PMID: 35384907 PMCID: PMC9071035 DOI: 10.1097/rlu.0000000000004191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 02/19/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Patients with esophageal cancer can develop distant metastases between the start of neoadjuvant chemoradiotherapy (nCRT) and planned surgery (ie, interval distant metastases). 18F-FDG PET/CT restaging after nCRT detects interval distant metastases in ~8% of patients. This study aimed to identify patients for whom 18F-FDG PET/CT restaging after nCRT could be omitted using an existing prediction model predicting for interval distant metastases or by using clinical stage groups. PATIENTS AND METHODS Patients with locally advanced esophageal cancer who underwent baseline and restaging 18F-FDG PET/CT, nCRT, and were planned for esophagectomy between 2017 and 2021 were eligible for inclusion in this retrospective study. The primary outcome was the existing model's external performance (ie, discrimination and calibration) for predicting interval distant metastases. The existing model predictors included tumor length, cN status, squamous cell carcinoma histology, and baseline SUVmax. The secondary outcome determined the clinical stage groups (AJCC/UICC eighth edition) for adenocarcinoma and squamous cell carcinoma for which the incidence of interval distant metastases was <10%. RESULTS In total, 127 patients were included, of whom 17 patients developed interval distant metastases (13%; 95% confidence interval [CI], 8%-21%) and 9 patients were deemed to have false-positive lesions on 18F-FDG PET/CT (7%; 95% CI, 2%-11%). Applying the existing model to this cohort yielded a discriminatory c-statistic of 0.56 (95% CI, 0.40-0.72). The calibration of the existing model was poor (ie, mostly underestimating the actual risk). The incidence of true-positive versus false-positive interval distant metastases for patients with clinical stage II disease was 5% versus 0%; clinical stage III, 14% versus 8%; and clinical stage IVa, 22% versus 9%. CONCLUSIONS The existing prediction model cannot reliably identify patients at risk for developing interval distant metastases after nCRT for esophageal cancer. Omission of 18F-FDG PET/CT restaging after nCRT could be considered in patients with clinical stage II esophageal cancer.
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Affiliation(s)
| | | | | | | | | | | | | | - Nadia Haj Mohammad
- Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Wolfson P, Ho KMA, Bassett P, Haidry R, Olivo A, Lovat L, Sami SS. Accuracy of clinical staging for T2N0 oesophageal cancer: systematic review and meta-analysis. Dis Esophagus 2021; 34:6146603. [PMID: 33618359 DOI: 10.1093/dote/doab002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/24/2020] [Accepted: 01/03/2021] [Indexed: 12/24/2022]
Abstract
Oesophageal cancer is the sixth commonest cause of overall cancer mortality. Clinical staging utilizes multiple imaging modalities to guide treatment and prognostication. T2N0 oesophageal cancer is a treatment threshold for neoadjuvant therapy. Data on accuracy of current clinical staging tests for this disease subgroup are conflicting. We performed a meta-analysis of all primary studies comparing clinical staging accuracy using multiple imaging modalities (index test) to histopathological staging following oesophagectomy (reference standard) in T2N0 oesophageal cancer. Patients that underwent neoadjuvant therapy were excluded. Electronic databases (MEDLINE, Embase, Cochrane Library) were searched up to September 2019. The primary outcome was diagnostic accuracy of combined T&N clinical staging. Publication date, first recruitment date, number of centers, sample size and geographical location main histological subtype were evaluated as potential sources of heterogeneity. The search strategy identified 1,199 studies. Twenty studies containing 5,213 patients met the inclusion criteria. Combined T&N staging accuracy was 19% (95% CI, 15-24); T staging accuracy was 29% (95% CI, 24-35); percentage of patients with T downstaging was 41% (95% CI, 33-50); percentage of patients with T upstaging was 28% (95% CI, 24-32) and percentage of patients with N upstaging was 34% (95% CI, 30-39). Significant sources of heterogeneity included the number of centers, sample size and study region. T2N0 oesophageal cancer staging remains inaccurate. A significant proportion of patients were downstaged (could have received endotherapy) or upstaged (should have received neoadjuvant chemotherapy). These findings were largely unchanged over the past two decades highlighting an urgent need for more accurate staging tests for this subgroup of patients.
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Affiliation(s)
- Paul Wolfson
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | - Kai Man Alexander Ho
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | | | - Rehan Haidry
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | - Alessandro Olivo
- Department of Medical Physics and Bioengineering, University College London, London, UK
| | - Laurence Lovat
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | - Sarmed S Sami
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
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Klamt AL, Neyeloff JL, Santos LM, Mazzini GDS, Campos VJ, Gurski RR. Echoendoscopy in Preoperative Evaluation of Esophageal Adenocarcinoma and Gastroesophageal Junction: Systematic Review and Meta-analysis. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:1657-1669. [PMID: 33896677 DOI: 10.1016/j.ultrasmedbio.2021.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/23/2021] [Accepted: 03/13/2021] [Indexed: 06/12/2023]
Abstract
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.
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Affiliation(s)
- Alexandre Luis Klamt
- Gastroenterology Service of the Hospital de Clínicas de Porto Alegre (HCPA), Graduate Program in Medicine: Surgical Sciences, Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil.
| | - Jeruza Lavanholi Neyeloff
- Graduate Program in Health Sciences: Cardiology and Cardiovascular Sciences, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil
| | - Letícia Maffazzioli Santos
- Radiology Service of the Hospital de Clínicas de Porto Alegre (HCPA), Graduate Program in Medicine: Surgical Sciences, Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil
| | - Guilherme da Silva Mazzini
- Digestive Tract Surgery Service of the Hospital de Clínicas de Porto Alegre (HCPA), Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil
| | - Vinicius Jardim Campos
- Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil
| | - Richard Ricachenevsky Gurski
- Digestive Tract Surgery Service and Surgery Group of the Esophagus and Stomach of the Hospital de Clínicas de Porto Alegre (HCPA), Port Alegre, Rio Grande do Sul, Brazil; Department of Surgery, Faculty of Medicine, Federal University of Rio Grande do Sul (UFRGS), Port Alegre, Rio Grande do Sul, Brazil
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Capovilla G, Moletta L, Pierobon ES, Salvador R, Provenzano L, Zanchettin G, Costantini M, Merigliano S, Valmasoni M. Optimal Treatment of cT2N0 Esophageal Carcinoma: Is Upfront Surgery Really the Way? Ann Surg Oncol 2021; 28:8387-8397. [PMID: 34142286 DOI: 10.1245/s10434-021-10194-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/19/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Staging is inaccurate for cT2N0 esophageal cancer, and patients often are clinically mis-staged. This study aimed to evaluate the outcome after upfront surgery or neoadjuvant therapy, considering the impact of clinical "mis-staging." METHODS This study reviewed patients with squamous cell carcinoma (SCC) or adenocarcinoma (ADK) of the esophagus who underwent upfront surgery (S group) or neoadjuvant treatment (chemoradiotherapy [CRT] group) for cT2N0 cancer. Overall survival (OS), disease-free survival (DFS), morbidity, and mortality were evaluated. Correctly staged (cTNM = pTNM), understaged (cTNM < pTNM), and overstaged (cTNM > pTNM) patients in the S group and the CRT group were analyzed. Risk factors for unexpected lymph-node involvement were identified in the S group and for cancer-related death in the whole study cohort. RESULTS The study enrolled 229 patients with cT2N0 esophageal cancer. The 5-year OS rate was 34.2% in the S group versus 55.7% in the CRT group (p = 0.0088). The DFS also was significantly higher (p = 0.01). The morbidity and mortality rates were similar. In the S group, the cTNM was correctly staged for 21.4% and understaged for 63.4% of the patients, with 48.7% of the patients showing unexpected nodal involvement. A tumor length of 3 cm or more was an independent predictor of nodal metastases in SCC (p = 0.03), as was lymphovascular invasion (LVI) in ADK (p < 0.01). Cancer-related mortality was independently associated with lymph-node metastases (p = 0.03) and treatment by upfront surgery (p = 0.01). CONCLUSION Given the high rate of understaged patients in this study (63.4%), the authors advocate for combining the induction therapy with surgery in cT2N0, achieving better survival with similar morbidity and mortality.
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Affiliation(s)
- Giovanni Capovilla
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
| | - Lucia Moletta
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
| | - Elisa Sefora Pierobon
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy.
| | - Renato Salvador
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
| | - Luca Provenzano
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
| | - Gianpietro Zanchettin
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
| | - Mario Costantini
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
| | - Stefano Merigliano
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
| | - Michele Valmasoni
- Clinica Chirurgica 3, Department of Surgical, Oncological and Gastroenterological Sciences, Università di Padova, Padova, Italy
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de Nucci G, Petrone MC, Imperatore N, Asti E, Rossi G, Manes G, Vecchi M, Pastorelli L, Bonavina L, Arcidiacono PG. Staging esophageal cancer: low EUS accuracy in t2n0 patients. Endosc Int Open 2021; 9:E313-E318. [PMID: 33655027 PMCID: PMC7892275 DOI: 10.1055/a-1336-2505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/14/2020] [Indexed: 12/23/2022] Open
Abstract
Background and study aims Esophageal cancer (EC) is one of the most lethal malignancies worldwide. Staging of EC is performed with computed tomography (CT), positron-emission tomography (PET), and endoscopic ultrasonography (EUS). Patient management mostly depends on lymph node status. Compared to histopathology, the accuracy of EUS for T and N parameters is about 85 % and 75 %, respectively. Errors in staging may change prognosis. The aim of this study was to assess the role of EUS in T2-N0 EC considering the experience of two high-volume digestive endoscopic centers. Methods Two prospectively collected databases were queried to identify all patients with EC, staged as cT2N0 by EUS, with no distant metastases at CT/PET scan and who underwent transthoracic esophagectomy. Preoperative EUS staging (cTNM) was compared to histopathology of the surgical specimen (pTNM) to evaluate accuracy. Results Of 729 consecutive patients with EC between January 2011 and September 2018, 72 (49 men) had cT2N0 disease. CT and PET scans confirmed the absence of distant metastasis. In 43 of 72 patients (60 %), the evaluation was correct, 23 of 72 (31,7 %) were understaged, and six of 72 patients (8,3 %) were overstaged. Among the understaged patients, eight were understaged by tumor depth (35 %), seven by nodal involvement (30 %), and eight by both (35 %). All six patients who were overstaged had T1b-N0 disease. EUS accuracy was 77 % in staging for tumor depth and 82 % in staging for nodal metastases. The positive predictive value (PPV) for cT2N0 EC was 60 % (43 pT2N0 /72 cT2N). Conclusions The accuracy of EUS staging of T2N0 EC is low, with only 60 % of patients undergoing appropriate therapy based on histopathology.
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Affiliation(s)
- Germana de Nucci
- Gastroenterology and Endoscopy Unit, ASST Rhodense, Garbagnate Milanese-Milan, Italy
| | - Maria Chiara Petrone
- Bilio-pancreatic Endoscopy and Endoscopic Ultrasound Unit, San Raffaele Hospital, Milan, Italy
| | | | - Emanuele Asti
- Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milano, Milan, Italy
| | - Gemma Rossi
- Bilio-pancreatic Endoscopy and Endoscopic Ultrasound Unit, San Raffaele Hospital, Milan, Italy
| | - Giampiero Manes
- Gastroenterology and Endoscopy Unit, ASST Rhodense, Garbagnate Milanese-Milan, Italy
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Ca Granda Policlinic Major Hospital, Milan, Italy
| | - Luca Pastorelli
- Gastroenterology Unit, IRCCS Policlinico San Donato and Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Luigi Bonavina
- Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milano, Milan, Italy
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Rhodin KE, Raman V, Jawitz OK, Voigt SL, Farrow NE, Harpole DH, Tong BC, D'Amico TA. Patterns of Use of Induction Therapy for T2N0 Esophageal Cancer. Ann Thorac Surg 2020; 111:440-447. [PMID: 32681837 DOI: 10.1016/j.athoracsur.2020.05.089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/21/2020] [Accepted: 05/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Induction therapy for patients with cT2N0M0 esophageal cancer is controversial. We performed a retrospective cohort analysis of the National Cancer Database to examine the patterns of use of induction therapy for this population. METHODS The National Cancer Database was queried for patients with cT2N0M0 esophageal cancer who underwent esophagectomy (2004-2015). Patients were stratified by upfront surgery or induction therapy. Overall survival was analyzed and a multivariable logistic regression performed to identify factors associated with receipt of induction therapy. RESULTS Overall 2540 patients met study criteria: 1177 (46%) received upfront esophagectomy and 1363 (53%) received induction therapy. Patients receiving induction therapy were more likely to be younger, male, without comorbidities, privately insured, and treated at a nonacademic center. These patients were also less likely to be treated in highest volume surgery centers. In multivariable regression, factors independently associated with receipt of induction therapy included later year of diagnosis, increasing tumor size, and increasing tumor grade. Factors associated with upfront esophagectomy included advancing age, comorbidities, lack of insurance, geographic location, and highest volume centers. The receipt of induction chemotherapy was not associated with a survival benefit compared with no induction therapy. CONCLUSIONS Several patient-, treatment center-, and tumor-related factors are associated with receipt of induction therapy for cT2N0M0 esophageal cancer, although induction therapy is not associated with a survival benefit. Further inquiry into these differences and the potential benefit or lack thereof of induction therapy should be conducted to provide more equitable and appropriate care for patients with esophageal cancer.
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Affiliation(s)
- Kristen E Rhodin
- Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Vignesh Raman
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Oliver K Jawitz
- 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
- 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
| | - Betty C Tong
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Thomas A D'Amico
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Role of Perioperative Chemotherapy in Lymph Node-negative Esophageal Cancer After Resection: A Population-based Study With Propensity Score-matched Analysis. Am J Clin Oncol 2020; 42:924-931. [PMID: 31651453 DOI: 10.1097/coc.0000000000000624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Nelson DB, Mitchell KG, Weston BR, Betancourt S, Maru D, Rice DC, Mehran RJ, Sepesi B, Antonoff MB, Walsh GL, Swisher SG, Roth JA, Vaporciyan AA, Blum M, Hofstetter WL. Should endoscopic mucosal resection be attempted for cT2N0 esophageal cancer? Dis Esophagus 2019; 32:1-6. [PMID: 30888418 DOI: 10.1093/dote/doz016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 02/11/2019] [Accepted: 02/21/2019] [Indexed: 12/11/2022]
Abstract
Endoscopic mucosal resection (EMR) can be an effective therapy for superficial esophageal cancer. Many patients with cT2 invasion by endoscopic ultrasound (EUS) receive surgery but are subsequently found to have superficial disease. The purpose of this study was to investigate the safety profile and the added value of attempting EMR for EUS-staged cT2N0 esophageal cancer. A retrospective review was performed at a single institution from 2008 to 2017. Patients who were staged cT2N0 by EUS were identified from a prospectively maintained surgical database. Among 75 patients identified for analysis, 30 underwent an attempt at EMR. No perforations or other immediate complications occurred. EMR was more likely to be attempted among older patients (P = 0.001) with smaller tumor size (P < 0.001) and diminished SUVmax (P = 0.001). At the time of treatment, EMR was successful in clearing all known disease among 17/30 patients, with 12 representing pT1a or less and 5 representing pT1b with negative margins. Among the 17 patients for whom EMR was able to clear all known disease, there were no recurrences or cancer-related deaths. Although all the patients were staged as cT2N0 by EUS, many patients were identified by EMR to have superficial disease. There were no perforations or other adverse events related to EMR. Furthermore, EMR cleared all known disease among 17 patients with no known recurrences or cancer-related deaths. The results indicate that EMR for cT2N0 esophageal cancer is a safe diagnostic option that is therapeutic for some.
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Affiliation(s)
| | | | - Brian R Weston
- Department of GastroenterologyThe University of Texas MD Anderson Cancer Center
| | - Sonia Betancourt
- Department of Diagnostic ImagingThe University of Texas MD Anderson Cancer Center
| | - Dipen Maru
- Department of PathologyThe University of Texas MD Anderson Cancer Center
| | - David C Rice
- Department of Thoracic and Cardiovascular Surgery
| | | | - Boris Sepesi
- Department of Thoracic and Cardiovascular Surgery
| | | | | | | | - Jack A Roth
- Department of Thoracic and Cardiovascular Surgery
| | | | - Mariela Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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11
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Rice TW, Lu M, Ishwaran H, Blackstone EH. Precision Surgical Therapy for Adenocarcinoma of the Esophagus and Esophagogastric Junction. J Thorac Oncol 2019; 14:2164-2175. [PMID: 31442498 PMCID: PMC6876319 DOI: 10.1016/j.jtho.2019.08.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 07/31/2019] [Accepted: 08/05/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION To facilitate the initial clinical decision regarding whether to use esophagectomy alone or neoadjuvant therapy in surgical care for individual patients with adenocarcinoma of the esophagus and esophagogastric junction-information not available from randomized trials-a machine-learning analysis was performed using worldwide real-world data on patients undergoing different therapies for this rare adenocarcinoma. METHODS Using random forest technology in a sequential analysis, we (1) identified eligibility for each of four therapies among 13,365 patients: esophagectomy alone (n = 6649), neoadjuvant therapy (n = 4706), esophagectomy and adjuvant therapy (n = 998), and neoadjuvant and adjuvant therapy (n = 1022); (2) performed survival analyses incorporating interactions of patient and cancer characteristics with therapy; (3) determined optimal therapy as that predicted to maximize lifetime within 10 years (restricted mean survival time; RMST) for each patient; and (4) compared lifetime gained from optimal versus actual therapies. RESULTS Actual therapy was optimal in 61% of those receiving esophagectomy alone; neoadjuvant therapy was optimal for 36% receiving neoadjuvant therapy. Many patients were predicted to benefit from postoperative adjuvant therapy. Total RMST for actual therapy received was 58,825 years. Had patients received optimal therapy, total RMST was predicted to be 62,982 years, a 7% gain. CONCLUSIONS Average treatment effect for adenocarcinoma of the esophagus yields only crude evidence-based therapy guidelines. However, patient response to therapy is widely variable, and survival after data-driven predicted optimal therapy often differs from actual therapy received. Therapy must address an individual patient's cancer and clinical characteristics to provide precision surgical therapy for adenocarcinoma of the esophagus and esophagogastric junction.
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Affiliation(s)
- Thomas W Rice
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Min Lu
- Department of Public Health Sciences, Division of Biostatistics, University of Miami, Coral Gables, Florida
| | - Hemant Ishwaran
- Department of Public Health Sciences, Division of Biostatistics, University of Miami, Coral Gables, Florida
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.
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12
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Al-Kaabi A, van der Post RS, Huising J, Rosman C, Nagtegaal ID, Siersema PD. Predicting lymph node metastases with endoscopic resection in cT2N0M0 oesophageal cancer: A systematic review and meta-analysis. United European Gastroenterol J 2019; 8:35-43. [PMID: 32213055 PMCID: PMC7006011 DOI: 10.1177/2050640619879007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Ali Al-Kaabi
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rachel S van der Post
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jonathan Huising
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
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13
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Kidane B, Korst RJ, Weksler B, Farrell A, Darling GE, Martin LW, Reddy R, Sarkaria IS. Neoadjuvant Therapy Vs Upfront Surgery for Clinical T2N0 Esophageal Cancer: A Systematic Review. Ann Thorac Surg 2019; 108:935-944. [DOI: 10.1016/j.athoracsur.2019.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 03/30/2019] [Accepted: 04/02/2019] [Indexed: 12/20/2022]
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14
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Abstract
While management of locally advanced esophageal cancer has mostly involved multimodality therapy, management of clinical T2N0 patients has been more controversial, primarily as a result of inaccurate clinical staging with existing modalities. This review article examines current literature on this topic and provides recommendations for management of individual patients.
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Affiliation(s)
- Patrick Vining
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Thomas J Birdas
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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15
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Fox M. T2N0 esophageal cancer—We can't know where to go unless we know where we've been. J Thorac Cardiovasc Surg 2019; 157:1273-1274. [DOI: 10.1016/j.jtcvs.2018.11.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 01/25/2023]
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16
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Atay SM, Correa A, Hofstetter WL, Swisher SG, Ajani J, Altorki NK, Blackmon SH, Blackstone EH, Rice TW, Crabtree TD, D'Amico TA, Darling GE, DeMeester SR, DeMeester TR, Worrell SG, Ferri LE, Gaissert HA, Krasna MJ, Lerut A, Nafteux P, Moons J, Little AG, Low DE, Carrott PW, Schmidt HM, Miller D, Nason KS, Luketich JD, Orringer MB, Chang AC, Rizk NP, Salo JA, Schneider PM, Smithers BM, Vallböhmer D, van Lanschot J, Varghese TK, Watson TJ, Peters JH, Yang SC. Predictors of staging accuracy, pathologic nodal involvement, and overall survival for cT2N0 carcinoma of the esophagus. J Thorac Cardiovasc Surg 2019; 157:1264-1272.e6. [DOI: 10.1016/j.jtcvs.2018.10.057] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 10/01/2018] [Accepted: 10/10/2018] [Indexed: 11/28/2022]
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17
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Lv HW, Xing WQ, Shen SN, Cheng JW. Induction therapy for clinical stage T2N0M0 esophageal cancer: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e12651. [PMID: 30290643 PMCID: PMC6200548 DOI: 10.1097/md.0000000000012651] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE It is still controversial whether patients with clinical T2N0M0 (cT2N0M0) esophageal cancer are treated with induction therapy. The aim of this study was to determine the effect of induction therapy on cT2N0M0 esophageal cancer. METHODS AND MATERIALS We searched PubMed, Embase, the Cochrane Library, and Medline databases from inception up to May 1, 2017. This meta-analysis was performed to compare odds ratios (OR) for 5-year overall survival (OS), pathologically understaged and overstaged after esophagectomy. RESULTS Eight retrospective studies of 2646 patients were included in the meta-analysis. Data showed that no statistically significant difference in 5-year over survival was observed between induction therapy group and direct operation group. The pooled OR and 95% confidence interval (CI) for 5-year OS were 0.92 (95% CI = 0.72-1.18; P = .52). Whereas, compared with induction therapy group, direct operation group had more pathologically understaged and less overstaged after esophagectomy. CONCLUSIONS Currentclinical staging for T2N0M0 esophageal carcinoma remains inaccurate. In this study, we found that direct operation group had more pathologically understaged and less overstaged after esophagectomy compared with induction therapy group. Induction therapy could degrade the tumor staging but not improve the patient's survival.
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Affiliation(s)
- Hong-Wei Lv
- Department of Thoracic Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital Zhengzhou, Henan, P. R. China
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18
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Shridhar R, Huston J, Meredith KL. Accuracy of endoscopic ultrasound staging for T2N0 esophageal cancer: a National Cancer Database analysis. J Gastrointest Oncol 2018; 9:887-893. [PMID: 30505591 DOI: 10.21037/jgo.2018.01.16] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background To determine accuracy of clinical staging of T2N0 esophageal cancer from the National Cancer Database (NCDB). Methods The NCDB was accessed to identify patients with T2N0M0 esophageal cancer (adenocarcinoma or squamous cell carcinoma) treated between 2004-2013 that underwent esophagectomy. Pathologic staging was compared to clinical stage. Univariate (UVA) and multivariate analysis (MVA) was performed to identify factors related to pathologic upstaging using Cox proportional hazard ratio. Results We identified 1,840 patients with T2N0 esophageal cancer who underwent esophagectomy as first line therapy. The median age was 67 years. The vast majority of patients were male and had distal adenocarcinomas. Clinical staging in was accurate pathologically in 30.7% of patients. While there was a trend for worse accuracy with increasing year of diagnosis, there rate of pT0-2N0 was stable. Tumor length >3 cm was significantly associated with tumor upstaging, while poor differentiation was significantly associated with nodal upstaging. UVA and MVA identified younger age, tumor length >3 cm, and poor differentiation were significantly associated with overall upstaging. Gender, tumor location, and tumor histology were not prognostic. Conclusions Clinical staging for T2N0M0 esophageal cancer continues to remain highly inaccurate, however, rates of pT0-2N0 have steadily remained over 50%. Tumor length >3 cm and poor differentiation are strongly associated with pathologic upstaging.
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Affiliation(s)
- Ravi Shridhar
- Department of Radiation Oncology, Florida Hospital Orlando, Orlando, FL, USA
| | - Jamie Huston
- Division of Surgical Oncology, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Kenneth L Meredith
- Division of Surgical Oncology, Sarasota Memorial Hospital, Sarasota, FL, USA
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19
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Haque W, Verma V, Bernicker E, Butler EB, Teh BS. Management of pathologic node-positive disease following initial surgery for clinical T1-2 N0 esophageal cancer: patterns of care and outcomes from the national cancer data base. Acta Oncol 2018; 57:782-789. [PMID: 29188742 DOI: 10.1080/0284186x.2017.1409435] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Although clinical T1-2N0 esophageal cancer (EC) is often initially surgically resected (without neoadjuvant therapy), several studies have illustrated substantial rates of discovering pathologically node-positive disease. This study evaluated national practice patterns of adjuvant therapy for this population. METHODS The National Cancer Database (NCDB) was queried (2004-2013) for patients with cT1-2N0M0 EC that received up-front surgery (esophagectomy/local techniques) with subsequent discovery of nodal metastasis. Patients receiving any neoadjuvant therapy were excluded. Multivariable logistic regression determined factors predictive of receiving adjuvant therapy. Kaplan-Meier analysis evaluated overall survival (OS), and Cox proportional hazards modeling determined variables associated with OS. Propensity score matching assessed groups in a balanced manner while reducing indication biases. RESULTS Altogether, 715 patients met inclusion criteria; 114 (16%) underwent adjuvant chemotherapy, 183 (26%) chemoradiation, 16 (2%) radiotherapy alone, and 402 (56%) observation. Observation was more likely performed with advanced age (p = .002) and at nonacademic centers (p = .001). Median OS in the respective cohorts were 42.6, 35.1, 22.2, and 27.0 months. Both chemotherapy and chemoradiation were statistically similar (p = .462) but superior to observation (p < .05 for both). There was a survival benefit to any adjuvant treatment (median OS 38.5 vs. 27.0 months, p < .001), which persisted after propensity matching (median OS 35.1 vs. 24.3 months, p < .001). On multivariable analysis, any adjuvant treatment was independently associated with improved OS, along with treatment at an academic center (p < .05 for all). CONCLUSIONS In the largest study to date evaluating patterns of care for pN + disease following resection of cT1-2N0 EC, a strikingly high proportion of patients were observed. Adjuvant treatment, ideally chemotherapy or chemoradiation, independently correlated with higher survival, and should be considered in able patients. Treatment at academic facilities also associated with higher survival, which has implications for patient counseling.
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Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Eric Bernicker
- Department of Medical Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - E. Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Bin S. Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, TX, USA
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20
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Mota FC, Cecconello I, Takeda FR, Tustumi F, Sallum RAA, Bernardo WM. Neoadjuvant therapy or upfront surgery? A systematic review and meta-analysis of T2N0 esophageal cancer treatment options. Int J Surg 2018; 54:176-181. [PMID: 29730075 DOI: 10.1016/j.ijsu.2018.04.053] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/24/2018] [Accepted: 04/28/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Esophageal carcinoma usually shows poor long-term survival rates, even when esophagectomy, the standard curative treatment is performed. As a result, there has been increasing interest in the neoadjuvant therapy, which could potentially downstage cancer, eliminate micrometastasis and ergo increase resectability and curative (R0) resection. Currently, for the earliest stage esophageal cancers, most guidelines point out to the role of endoscopic treatment, and for T1bN0 upfront surgery. For locally advanced cases, several studies have demonstrated the benefits of neoadjuvant therapy to increase resectability. For clinical stage T2N0 esophageal cancer, there is no consensus as to the optimal treatment strategy. METHODS A systematic review and meta-analysis was performed to compare neoadjuvant therapy with surgery alone on clinical stage T2N0 esophageal cancer patients, concerning overall survival, recurrence, post-operative mortality, anastomotic leak, and R0 resection rate. RESULTS For overall survival at the mean follow-up point, the neoadjuvant therapy was not associated to a higher probability of survival than upfront surgery in cT2N0 patients (risk difference: 0.00; 95% CI: -0.09, 0.09). There was no difference between neoadjuvant therapy and primary surgery concerning recurrence (risk difference: 0.21; 95% CI: -0.03, 0.45); perioperative mortality (risk difference: 0.00; 95% CI: -0.02, 0.01); and risk for anastomotic leak (risk difference: -0.08; 95% CI: -0.21, 0.05). Pooled data showed that neoadjuvant therapy was associated to a higher risk for positive margins after resection (risk difference: 0.04; 95% CI: 0.02, 0.06). CONCLUSIONS This review showed that neoadjuvant therapy is not associated to better results than surgery alone, for the management of clinical stage T2N0 esophageal cancer patients, concerning overall survival, recurrence rate, perioperative mortality, anastomotic leak, and seems to be associated to a higher risk for resection with positive margins.
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Affiliation(s)
- F C Mota
- Digestive Surgery Division, Department of Gastroenterology, Sao Paulo School of Medicine, Brazil
| | - I Cecconello
- Esophageal Surgery Group, Digestive Surgery Division, Department of Gastroenterology, Sao Paulo School of Medicine, Brazil
| | - F R Takeda
- Medical Assistant of São Paulo Institute of Cancer, Esophageal Surgery Group, Digestive Surgery Division, Department of Gastroenterology, São Paulo School of Medicine, Brazil
| | - F Tustumi
- Digestive Surgery Division, Department of Gastroenterology, Sao Paulo School of Medicine, Brazil.
| | - R A A Sallum
- Director of Esophageal Surgery Group, Digestive Surgery Division, Department of Gastroenterology, Sao Paulo School of Medicine, Brazil
| | - W M Bernardo
- Department of Gastroenterology, Digestive Surgery Division, São Paulo School of Medicine, Brazil
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21
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Yang J, Luo GY, Liang RB, Zeng TS, Long H, Fu JH, Xu GL, Yang MZ, Li S, Zhang LJ, Lin P, Wang X, Hou X, Yang HX. Efficacy of Endoscopic Ultrasonography for Determining Clinical T Category for Esophageal Squamous Cell Carcinoma: Data From 1434 Surgical Cases. Ann Surg Oncol 2018; 25:2075-2082. [PMID: 29667114 DOI: 10.1245/s10434-018-6406-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND The efficacy of endoscopic ultrasonography (EUS) for determining T category is variable for esophageal squamous cell carcinoma (ESCC). We aimed to assess the efficacy of EUS in accurately identifying T category for ESCC based on the 8th AJCC Cancer Staging Manual. METHODS A retrospective analysis was conducted using a prospectively collected ESCC database from January 2003 to December 2015, in which all patients underwent EUS examination followed by esophagectomy. The efficacy of EUS was evaluated by sensitivity, specificity, and accuracy compared with pathological T category as gold standard. Overall survival of different EUS-T (uT) categories was assessed. RESULTS In total, 1434 patients were included, of whom 58.2% were correctly classified by EUS, with 17.9% being overstaged and 23.9% being understaged. The sensitivity and accuracy of EUS for Tis, T1a, T1b, T2, T3, and T4a categories were 15.8 and 98.8%, 16.3 and 95.7%, 33.1 and 89.3%, 56.8 and 65.0%, 65.8 and 70.0%, and 27.3 and 97.5%, respectively. The survival difference between uT1a and uT1b was not statistically significant (p = 0.90), nor was that between uT4a and uT4b (p = 0.34). However, when uT category was integrated as uTis, uT1, uT2, uT3, and uT4, overall survival was clearly distinguished between the categories (p < 0.01). CONCLUSIONS EUS is in general feasible for classifying clinical T category for ESCC. However, EUS should be used with caution for discriminating between Tis, T1a, and T1b disease, as well as T4 disease.
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Affiliation(s)
- Jie Yang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Guang-Yu Luo
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.,Department of Endoscopy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Run-Bin Liang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Tai-Shan Zeng
- School of Mathematical Sciences, South China Normal University, Guangzhou, Guangdong, China
| | - Hao Long
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Jian-Hua Fu
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Guo-Liang Xu
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.,Department of Endoscopy, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Mu-Zi Yang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Shuo Li
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Lan-Jun Zhang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Peng Lin
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Xin Wang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China.,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China
| | - Xue Hou
- State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China. .,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China. .,Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.
| | - Hao-Xian Yang
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China. .,State Key Laboratory of Oncology in South China, Guangzhou, Guangdong, China. .,Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China.
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22
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Goense L, Visser E, Haj Mohammad N, Mook S, Verhoeven RHA, Meijer GJ, van Rossum PSN, Ruurda JP, van Hillegersberg R. Role of neoadjuvant chemoradiotherapy in clinical T2N0M0 esophageal cancer: A population-based cohort study. Eur J Surg Oncol 2018; 44:620-625. [PMID: 29478739 DOI: 10.1016/j.ejso.2018.02.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 01/23/2018] [Accepted: 02/06/2018] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The aim of this population-based cohort study was to determine whether the addition of neoadjuvant chemoradiotherapy (nCRT) to surgery is associated with improved pathologic outcomes and survival in patients with cT2N0M0 esophageal cancer. METHODS Patients who underwent nCRT followed by surgery or surgery alone for cT2N0M0 esophageal cancer were identified from The Netherlands Cancer Registry database (2005-2014). Accuracy of clinical staging was assessed using the resection specimen as gold standard. After propensity score matching, influences of both treatment strategies on radical resection (R0) rates and overall survival were compared. RESULTS In total 533 patients were included; 353 underwent nCRT followed by surgery and 180 underwent surgery alone. In the nCRT group 32% of patients achieved a pathologic complete response. Clinical understaging was observed in 62% of the patients in the surgery alone group based on pT-stage (n = 30, 27%), pN-stage (n = 26, 23%), or both (n = 55, 50%). Propensity score matching resulted in 78 patients who underwent nCRT plus surgery versus 78 who underwent surgery alone. In the nCRT group radical resections were more frequently observed (99% vs. 89% p = 0.031) and resulted in improved 5-year overall survival (46% vs. 33%, p = 0.017). CONCLUSION In this population-based study, clinical staging of cT2N0M0 esophageal cancer was highly inaccurate. Compared to surgery alone, neoadjuvant chemoradiotherapy was associated with higher radical resection rates and improved overall survival.
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Affiliation(s)
- Lucas Goense
- Department of Surgery, University Medical Center, Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Els Visser
- Department of Surgery, University Medical Center, Utrecht, The Netherlands.
| | - Nadia Haj Mohammad
- Department of Medical Oncology, University Medical Center, Utrecht, The Netherlands
| | - Stella Mook
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Rob H A Verhoeven
- Netherlands Cancer Registry, Netherlands Comprehensive Cancer Organization (IKNL), The Netherlands
| | - Gert J Meijer
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Peter S N van Rossum
- Department of Surgery, University Medical Center, Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center, Utrecht, The Netherlands
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23
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Semenkovich TR, Panni RZ, Hudson JL, Thomas T, Elmore LC, Chang SH, Meyers BF, Kozower BD, Puri V. Comparative effectiveness of upfront esophagectomy versus induction chemoradiation in clinical stage T2N0 esophageal cancer: A decision analysis. J Thorac Cardiovasc Surg 2018; 155:2221-2230.e1. [PMID: 29428700 DOI: 10.1016/j.jtcvs.2018.01.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 12/13/2017] [Accepted: 01/02/2018] [Indexed: 01/02/2023]
Abstract
OBJECTIVES We compared the effectiveness of upfront esophagectomy versus induction chemoradiation followed by esophagectomy for overall survival in patients with clinical T2N0 (cT2N0) esophageal cancer. We also assessed the influence of the diagnostic uncertainty of endoscopic ultrasound on the expected benefit of chemoradiation. METHODS We created a decision analysis model representing 2 treatment strategies for cT2N0 esophageal cancer: upfront esophagectomy that may be followed by adjuvant therapy for upstaged patients and induction chemoradiation for all patients with cT2N0 esophageal cancer followed by esophagectomy. Parameter values within the model were obtained from published data, and median survival for pathologic subgroups was derived from the National Cancer Database. In sensitivity analyses, staging uncertainty of endoscopic ultrasound was introduced by varying the probability of pathologic upstaging. RESULTS The baseline model showed comparable median survival for both strategies: 48.3 months for upfront esophagectomy versus 45.9 months for induction chemoradiation and surgery. The sensitivity analysis demonstrated induction chemoradiation was beneficial, with probability of upstaging > 48.1%, which is within the published range of 32% to 65% probability of pathologic upstaging after cT2N0 diagnosis. The presence of any of 3 key variables (size larger than 3 cm, high grade, or lymphovascular invasion) was associated with > 48.1% risk of upstaging, thus conferring a survival advantage to induction chemoradiation. CONCLUSIONS The optimal treatment strategy for cT2N0 esophageal cancer depends on the accuracy of endoscopic ultrasound staging. High-risk features that confer increased probability of upstaging can inform clinical decision making to recommend induction chemoradiation for select cT2N0 patients.
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Affiliation(s)
| | - Roheena Z Panni
- Division of Surgical Oncology, Department of Surgery, Washington University, St Louis, Mo
| | - Jessica L Hudson
- Division of Cardiothoracic Surgery, Washington University, St Louis, Mo
| | - Theodore Thomas
- Division of Oncology, Department of Medicine, Washington University, St Louis, Mo
| | - Leisha C Elmore
- Division of Surgical Oncology, Department of Surgery, Washington University, St Louis, Mo
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University, St Louis, Mo
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Washington University, St Louis, Mo
| | | | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University, St Louis, Mo.
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Ilson DH, van Hillegersberg R. Management of Patients With Adenocarcinoma or Squamous Cancer of the Esophagus. Gastroenterology 2018; 154:437-451. [PMID: 29037469 DOI: 10.1053/j.gastro.2017.09.048] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 09/09/2017] [Accepted: 09/12/2017] [Indexed: 02/07/2023]
Abstract
Esophageal cancer is characterized by early and frequent metastasis. Surgery is the primary treatment for early-stage disease, whereas patients with patients with locally advanced disease receive perioperative chemotherapy or chemoradiotherapy. Squamous cancers can be treated with primary chemoradiotherapy without surgery, depending on their response to therapy and patient tolerance for subsequent surgery. Chemotherapy with a fluorinated pyrimidine and a platinum agent, followed by later treatment with taxanes and irinotecan, provides some benefit. Agents that inhibit the erb-b2 receptor tyrosine kinase 2 (ERBB2 or HER2), or vascular endothelial growth factor, including trastuzumab, ramucirumab, and apatinib, increase response and survival times. Esophageal adenocarcinomas have mutations in tumor protein p53 and mutations that activate receptor-associated tyrosine kinase, vascular endothelial growth factor, and cell cycle pathways, whereas esophageal squamous tumors have a distinct set of mutations. Esophageal cancers develop systems to evade anti-tumor immune responses, but studies are needed to determine how immune checkpoint modification contributes to esophageal tumor development.
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Affiliation(s)
- David H Ilson
- Memorial Sloan Kettering Cancer Center, New York, New York.
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25
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Rice TW, Patil DT, Blackstone EH. 8th edition AJCC/UICC staging of cancers of the esophagus and esophagogastric junction: application to clinical practice. Ann Cardiothorac Surg 2017; 6:119-130. [PMID: 28447000 DOI: 10.21037/acs.2017.03.14] [Citation(s) in RCA: 420] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The 8th edition of the American Joint Committee on Cancer (AJCC) staging of epithelial cancers of the esophagus and esophagogastric junction (EGJ) presents separate classifications for clinical (cTNM), pathologic (pTNM), and postneoadjuvant (ypTNM) stage groups. Histopathologic cell type markedly affects survival of clinically and pathologically staged patients, requiring separate groupings for each cell type, but ypTNM groupings are identical for both cell types. Clinical categories, typically obtained by imaging with minimal histologic information, are limited by resolution of each method. Strengths and shortcomings of clinical staging methods should be recognized. Complementary cytology or histopathology findings may augment imaging and aid initial treatment decision-making. However, prognostication using clinical stage groups remains coarse and inaccurate compared with pTNM. Pathologic staging is losing its relevance for advanced-stage cancer as neoadjuvant therapy replaces esophagectomy alone. However, it remains relevant for early-stage cancers and as a staging and survival reference point. Although pathologic stage could facilitate decision-making, its use to direct postoperative adjuvant therapy awaits more effective treatment. Prognostication using pathologic stage groups is the most refined of all classifications. Postneoadjuvant staging (ypTNM) is introduced by the AJCC but not adopted by the Union for International Cancer Control (UICC). Drivers of this addition include absence of equivalent pathologic (pTNM) categories for categories peculiar to the postneoadjuvant state (ypT0N0-3M0 and ypTisN0-3M0), dissimilar stage group compositions, and markedly different survival profiles. Thus, prognostication is specific for patients undergoing neoadjuvant therapy. The role of ypTNM classification in additional treatment decision-making is currently limited. Precision cancer care advances are necessary for this information to be clinically useful.
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Affiliation(s)
- Thomas W Rice
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Deepa T Patil
- Department of Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Boniface MM, Wani SB, Schefter TE, Koo PJ, Meguid C, Leong S, Kaplan JB, Wingrove LJ, McCarter MD. Multidisciplinary management for esophageal and gastric cancer. Cancer Manag Res 2016; 8:39-44. [PMID: 27217796 PMCID: PMC4853141 DOI: 10.2147/cmar.s101169] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The management of esophageal and gastric cancer is complex and involves multiple specialists in an effort to optimize patient outcomes. Utilizing a multidisciplinary team approach starting from the initial staging evaluation ensures that all members are in agreement with the plan of care. Treatment selection for esophageal and gastric cancer often involves a combination of chemotherapy, radiation, surgery, and palliative interventions (endoscopic and surgical), and direct communication between specialists in these fields is needed to ensure appropriate clinical decision making. At the University of Colorado, the Esophageal and Gastric Multidisciplinary Clinic was created to bring together all experts involved in treating these diseases at a weekly conference in order to provide patients with coordinated, individualized, and patient-centered care. This review details the essential elements and benefits of building a multidisciplinary program focused on treating esophageal and gastric cancer patients.
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Affiliation(s)
- Megan M Boniface
- Section of Surgical Oncology, Division of GI, Tumor and Endocrine Surgery, Department of Surgery, University of Colorado Denver, Aurora, CO, USA
| | - Sachin B Wani
- Division of Gastroenterology and Hepatology, Department of Therapeutic and Interventional Endoscopy, University of Colorado Denver, Aurora, CO, USA
| | - Tracey E Schefter
- Department of Radiation Oncology, University of Colorado Denver, Aurora, CO, USA
| | - Phillip J Koo
- Division of Radiology-Nuclear Medicine, Department of Radiology, University of Colorado Denver, Aurora, CO, USA
| | - Cheryl Meguid
- Section of Surgical Oncology, Division of GI, Tumor and Endocrine Surgery, Department of Surgery, University of Colorado Denver, Aurora, CO, USA
| | - Stephen Leong
- Division of Medical Oncology, University of Colorado Denver, Aurora, CO, USA
| | - Jeffrey B Kaplan
- Department of Pathology, University of Colorado Denver, Aurora, CO, USA
| | - Lisa J Wingrove
- Department of Food and Nutrition Services, University of Colorado Hospital Cancer Center, Aurora, CO, USA
| | - Martin D McCarter
- Section of Surgical Oncology, Division of GI, Tumor and Endocrine Surgery, Department of Surgery, University of Colorado Denver, Aurora, CO, USA
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27
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Samson P, Puri V, Robinson C, Lockhart C, Carpenter D, Broderick S, Kreisel D, Krupnick AS, Patterson GA, Meyers B, Crabtree T. Clinical T2N0 Esophageal Cancer: Identifying Pretreatment Characteristics Associated With Pathologic Upstaging and the Potential Role for Induction Therapy. Ann Thorac Surg 2016; 101:2102-11. [PMID: 27083246 DOI: 10.1016/j.athoracsur.2016.01.033] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 12/30/2015] [Accepted: 01/06/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although studies have suggested standard therapy for clinical T2N0 esophageal cancer should be primary surgery, we hypothesize there is a subgroup for whom induction therapy may result in improved overall survival. METHODS Patients with cT2N0 esophageal cancer receiving induction therapy or upfront esophagectomy (UE) were identified in the National Cancer Data Base. The UE patients were dichotomized as (1) pathologically upstaged, or (2) same-staged or downstaged. Logistic regression models identified variables associated with upstaging, and Kaplan-Meier analysis compared median overall survival. RESULTS From 2006 to 2012, 932 cT2N0 patients (52.2%) received UE, and 853 (47.8%) received induction therapy first. In all, 326 of 713 UE patients (45.7%) were upstaged: 87 of 326 (26.7%) had T upstaging; 98 of 326 (30.1%) had N upstaging; and 141 of 326 (43.3%) had both. Patients upstaged after UE had a higher tumor grade (35.1% versus 57.1% grade 3), and a higher rate of lymphovascular invasion (57.1% versus 17.7%; both p < 0.001). Variables associated with upstaging included lymphovascular invasion (odds ratio 6.0, 95% confidence interval: 2.9 to 12.5, p < 0.001) and tumor grade 3 (odds ratio 9.4, 95% confidence interval: 1.8 to 48.4, p = 0.007). Of upstaged UE patients, only 144 (44.2%) received adjuvant therapy. The median overall survival for cT2N0 patients upstaged after UE was 27.5 ± 2.5 months versus 43.9 ± 2.9 months for induction therapy patients (any resultant pathologic stage, p < 0.001). CONCLUSIONS Half of all cT2N0 patients were pathologically upstaged after UE, with worse survival compared with patients receiving induction therapy. Refining an upstaging model would help select patients for induction therapy and increase the rate of chemotherapy in patients at risk for systemic disease.
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Affiliation(s)
- Pamela Samson
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Clifford Robinson
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, Missouri
| | - Craig Lockhart
- Division of Medical Oncology, Washington University in St. Louis, St. Louis, Missouri
| | - Danielle Carpenter
- Department of Pathology and Immunology, Washington University in St. Louis, St. Louis, Missouri
| | - Stephen Broderick
- Division of Cardiothoracic Surgery, St. Luke's Hospital, Chesterfield, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - A Sasha Krupnick
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Bryan Meyers
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Traves Crabtree
- Division of Cardiothoracic Surgery, Washington University in St. Louis, St. Louis, Missouri.
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28
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FDG-PET nodal staging does not correlate with histopathological nodal stage for oesophageal cancers. Int J Surg 2015; 20:113-7. [PMID: 26118612 DOI: 10.1016/j.ijsu.2015.06.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 05/22/2015] [Accepted: 06/02/2015] [Indexed: 12/21/2022]
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