Predictive factors of survival in patients treated with definitive chemoradiotherapy for squamous cell esophageal carcinoma

Impacts of sarcopenia on adverse events and prognosis in Chinese patients with esophageal cancer undergoing chemoradiotherapy

Background

Sarcopenia is a common indicator of systemic nutritional status in patients with cancer progression. This study investigated the impacts of sarcopenia on adverse effects and prognosis of sarcopenia on patients with esophageal cancer receiving chemoradiotherapy.

Methods

The clinical data of 158 patients with initially diagnosed esophageal cancer who received chemoradiotherapy were collected, and nutritional indexes and inflammatory markers were calculated. The cross-sectional areas of the skeletal muscle, subcutaneous fat and visceral fat were calculated using computed tomography (CT) images of the midpoint of the third lumbar (L3) vertebra. The incidence of adverse events, response evaluation, 1-year and 3-year overall survival (OS) and progression-free survival (PFS) were compared between sarcopenia group and non-sarcopenia groups.

Results

This study included 158 patients, 103 (71.5%) in the sarcopenia group and 45 (28.5%) in the non-sarcopenia group. The last follow-up date was January 31, 2024. The median follow-up time was 36 months for all patients. The chi-square test revealed no significant difference in the incidence of serious adverse events between the two groups. The complete response rates (CR) of patients in the sarcopenia and non-sarcopenia groups 1 month after chemoradiotherapy were 2.7 and 13.3%, respectively, p = 0.017, and the difference was statistically significant. Moreover, the objective response rates (ORR) were 38.9 and 60.0%, respectively (χ2 = 5.770, p = 0.016). The median survival time for all patients was 36 months [95% Confidence Interval CI 24-48]. Univariate analysis (Cox proportional risk model) showed that sarcopenia, KPS score, albumin level, T stage, and N stage were correlated with patients' OS. Multivariate analysis showed that sarcopenia (Hazard Ratio HR 2.84, 95%CI [1.45-5.57], p = 0.002), KPS score, albumin level and N stage were independent prognostic factors for OS.

Conclusion

Sarcopenia reduced OS in patients with EC treated with chemoradiotherapy. It can be used as an independent indicator to predict the OS of such patients, which may help in developing optimal treatment strategies.

The Association of Change in Weight During Radiotherapy Treatment With Clinical Outcomes in Patients With Stage I-III Esophageal Cancer

Esophageal carcinoma (EC) and nutritional status are strongly linked due to swallowing disruptions and treatment-related toxicities. Therefore, malnutrition and weight loss (WL) occur in 85% and 79% of EC patients, respectively. WL is frequently associated with worse EC patient outcomes, however, WL during radiation therapy (RT) and EC patient outcomes have not been well established. The purpose of this study is to retrospectively review the association of WL during RT treatment of EC with clinical outcomes. Non-metastatic EC patients from our institution treated between 2010 and 2018, receiving total prescribed dose >40 Gy and aged >18 years, were included. Patients were analyzed by WL during RT, with categories of ≥5% vs. <5% and ≥10% vs. <10%. Patient characteristics and treatment regimens were similar across all WL groups. In univariate analysis, ≥5% and ≥10% WL were significantly associated with both worse overall survival (OS) and progression-free survival (PFS), and ≥10% WL was significantly associated with increased local recurrence. In multivariate analysis, ≥5% WL was significantly associated with OS and PFS. With both ≥5% and ≥10% WL throughout the radiation treatment being detrimental to OS and PFS. The importance of nutritional support in EC patients receiving radiotherapy is further validated.

The prognostic value of the controlling nutritional status (CONUT) score in predicting outcomes of esophageal cancer patients receiving radiotherapy with or without chemotherapy

Background

Controlling nutritional status (CONUT) scores and systemic immune-inflammation index (SII) values are associated with the prognosis of several common malignancies. The current study aimed to explore the prognostic value of CONUT scores and SII values in patients with esophageal cancer (EC) receiving radical radiotherapy (RT) or concurrent chemoradiotherapy (CCRT).

Methods

We calculated the pre-RT CONUT scores and SII values of 62 patients with EC receiving RT or CCRT. Receiver operating characteristic (ROC) curves were used to determine the adequate cut-off values. The Kaplan-Meier method and Cox proportional hazard model were used to analyze the association between CONUT scores and SII values and prognosis.

Results

The 1-year progression-free survival (PFS) and 1-year overall survival (OS) rates of the 62 patients were 51.61% and 66.13%, respectively. Based on the time-dependent ROC curve for the 1-year OS of all patients, the optimal cut-off value was 622.02 for the SII and a score of 1 for the CONUT score. The univariate analysis showed that the CONUT score (P=0.036), tumor-nodal-metastasis (TNM) stage (P<0.01), and CCRT (P=0.008) significantly affected the survival of EC patients. The multifactorial analysis showed that the CONUT score (P=0.041) and TNM stage (P<0.01) were independent prognostic factors affecting clinical outcomes in patients with EC undergoing radical RT or CCRT.

Conclusions

The pre-RT CONUT score could be an effective predictor of prognosis in patients with EC receiving radical RT or CCRT; however, the pre-RT SII value had no clinical value in predicting survival in our study.

Survival Status of Esophageal Cancer Patients and its Determinants in Ethiopia: A Facility Based Retrospective Cohort Study

Background

Globally, the incidence and mortality due to esophageal cancer are increasing, particularly in low- and middle-income countries. Cancer of the esophagus is the eighth in incidence and seventh in cancer mortality in Ethiopia. A few studies have shown an increasing burden, however, little is known about the survival pattern and its determinants among esophageal cancer patients in Ethiopia. Therefore, we assessed the survival pattern and its determinants among esophageal cancer patients.

Methods

We conducted a retrospective cohort study among 349 esophageal cancer patients who were diagnosed at or referred to Tikur Anbessa Specialized Hospital, Ethiopia from January 2010 to May 2017. Using an abstraction form, nurses who were working at the oncology department extracted the data from patient charts. To estimate and compare the probability of survival among covariate categories, we performed a Kaplan-Meier survival analysis with the log-rank test. To identify the prognostic determinants of survival, we performed a multivariable Cox proportional regression analysis.

Results

The median follow-up time was 32 months with interquartile range of 15 to 42. Overall, the median survival time after diagnosis with esophageal cancer was 4 months with one-, two- and three-year survival of 14.4, 6.3, and 2.4% respectively. In the multivariable Cox proportional hazards model, receiving chemotherapy [Adjusted Hazard Ratio (AHR)=0.36, 95%CI: 0.27-0.49], radiotherapy [AHR=0.38, 95%CI: 0.23-0.63] and surgery [AHR=0.70, 95%CI: 0.54-0.89] were statistically significant.

Conclusions

In Ethiopia, esophageal cancer patients have a very low one-, two- and three-year survival. Despite a very low overall survival, patients who received either chemotherapy, radiotherapy or surgery showed a better survival compared with those who did not receive any treatment. Hence, it is essential to improve the survival of patients with esophageal cancer through early detection and timely initiation of the available treatment options.

Outcomes of Definitive Chemoradiotherapy for Stage IVa (T4b vs. N4) Esophageal Squamous Cell Carcinoma Based on the Japanese Classification System: A Retrospective Single-Center Study

The differences in prognoses or progression patterns between T4b non-N4 and non-T4b N4 esophageal squamous cell carcinoma post chemoradiotherapy (CRT) is unclear. This study compared the outcomes of CRT for stage IVa esophageal squamous cell carcinoma according to T/N factors. We retrospectively identified 66 patients with stage IVa esophageal squamous cell carcinoma who underwent definitive CRT at our center between January 2009 and March 2013. The treatment outcomes, i.e., progression patterns, prognostic factors, and toxicities based on version 5.0 of the National Cancer Institute Common Terminology Criteria for Adverse Events, were studied. The patients (56 men and 10 women) had a median age of 67 (range: 37-87) years. The T/N classifications were T4b non-N4 (28/66), non-T4b N4 (24/66), and T4b N4 (14/66). Objective response was achieved in 57 patients (86.4%, (95% confidence interval, 74.6-94.1%)). There were no significant differences between the T/N groups in terms of overall survival, progression-free survival, and progression pattern. We found no significant differences in prognoses or progression patterns among patients with T4b non-N4, non-T4b N4, and T4b N4 esophageal squamous cell carcinoma. Thus, it seems impractical to modify CRT regimens based on T/N factors.

Single-Agent Versus Double-Agent Chemotherapy in Concurrent Chemoradiotherapy for Esophageal Squamous Cell Carcinoma: Prospective, Randomized, Multicenter Phase II Clinical Trial

LESSONS LEARNED

The efficacy of single-agent chemotherapy was not significantly different from that of double-agent chemotherapy in concurrent chemoradiotherapy for inoperable esophageal squamous cell carcinoma. Single-agent concurrent chemoradiotherapy had lower gastrointestinal and hematologic toxicity. Overall survival and progression-free survival were not significantly different between single- and double-agent concurrent chemoradiotherapy.

BACKGROUND

This multicenter, randomized, phase II trial aimed to compare the efficacy and safety of single-agent concurrent chemoradiotherapy using the oral fluoropyrimidine S-1 with those of double-agent concurrent chemoradiotherapy using S-1 and cisplatin in patients with inoperable esophageal squamous cell carcinoma.

METHODS

Patients with inoperable esophageal squamous cell carcinoma (clinical stages I to III) were randomly allocated to the single-agent group (S-1) or the double-agent group (S-1/cisplatin). The concurrent intensity-modulated radiation therapy plan was similar for both groups: planning target volume 1.8 Gy/f*30-33f and planning gross target volume of 2 Gy/f*30-33f. The primary outcome measure was the endoscopic complete response rate.

RESULTS

Of the 105 patients randomized, 89 were assessable. The endoscopic complete response rate was 46.9% (23/49) in the single-agent group and 52.5% (21/40) in double-agent group. The median progression-free survival within a median follow-up of 23 months was 20 and 21 months, respectively. The median overall survival was 26 months and not reached, respectively. Grade 3 hematological toxicities occurred in 4.1% and 27.5% of the patients in the single- and the double-agent group, respectively.

CONCLUSION

Single-agent chemotherapy in concurrent chemoradiotherapy for inoperable esophageal squamous cell carcinoma has good efficacy and safety, thus warranting a phase III trial.

Nutritional Status in Patients with Esophageal Cancer Receiving Chemoradiation and Assessing the Efficacy of Usual Care for Nutritional Managements

BACKGROUND

Malnutrition is prevalent in esophageal cancer patients which affects cancer prognosis. The purpose of this study was a comprehensive assessment of nutritional status during Chemoradiation (CRT).

METHODS

Newly diagnosed adults with esophageal cancer were recruited for this study. Patient-Generated- Subjective Global Assessment (PG-SGA), anthropometric indices, body composition, dietary intake, laboratory tests, and nutritional-related complications were assessed before, after, and 4 to 6 weeks after CRT.

RESULTS

Seventy-one cases were enrolled. The mean age was 66.8±12 years. Patients' mean weight loss was 2.42±2.4 kilograms during treatment. A significant reduction observed in mean MUAC (26.68±4.9 vs. 25.42±5.1 cm), fat mass percentage (24.11±11.8 vs. 22.8±12.5), fat free mass index (16.87±2.4 vs. 16.47±2.6 kg/m2) and hand grip strength (43.2±19 vs. 36.1±20 kg) during CRT (all p-values <0.0001). We had also a non-significant change in mean energy intake (19.5±11 vs. 18.3±11 kcal/kgw. day) and protein intake (0.56±0.4 vs. 0.66±0.5 g/kgw.day) during CRT.  In our assessment before, immediately after and 4-6 weeks following CRT, we recorded energy intake insufficiency in 55.7%, 58.7% and 27.3% and protein intake inadequacy in 89.8%, 89.1% and 72.7% of cases, respectively. The most common complications were dysphagia (56.7%), anorexia (25%), and constipation (47.9%) at admission. Dysphagia improved in some cases (42%), but anorexia (35%), early satiety (25%), Esophagitis (25%), dysosmia (21%) and dysgeusia (17%) were increased as CRT complication. yet, 25% of patients had dysphagia and 34.4% had constipation 4-6 weeks after CRT. The twelve-months mortality was significantly associated with lower BMI after CRT, primary PG-SGA score, weight loss, BMI<18.5, MUAC, physical performance, living in rural or urban areas, addiction.

CONCLUSION

Our study demonstrated a high prevalence of malnutrition among esophageal cancer patients which worsened during Chemoradiotherapy. Our findings warrant early screening and monitoring of nutritional status and effective nutritional interventions with symptoms management during treatment in these patients.
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Clinical Factors to Predict the Response to Concurrent Chemoradiotherapy and Survival in Esophageal Cancer Patients

Background/Aims

Several clinical factors have been used to predict the response for concurrent chemoradiotherapy (CCRT); however, these factors are insufficient for prognostic predictions. We investigated clinical factors to assess whether they could be used to predict the response to CCRT and the survival of patients with esophageal cancer.

Methods

Patients with esophageal cancer underwent CCRT from January 2005 to December 2015. Response to CCRT was classified as progressive disease (PD), stationary disease (SD), partial remission (PR), or complete remission (CR). Factors to predict the response to CCRT and patient survival were subsequently investigated.

Results

A total of 535 esophageal cancer patients underwent CCRT. Four hundred ninety-three patients were followed up, and patient outcomes were investigated. In the adjusted analysis, patients with advanced stage disease (relative risk [RR], 0.28 in stage III and 0.12 in stage IV compared to stage I), poor performance status, circumferential involvement (RR, 0.61), and male sex (RR, 0.31) were less likely to achieve CR. Advanced stage disease (hazard ratio [HR], 1.71 in stage III/IV), poor CCRT response (HR, 2.82 in PR, 4.47 in SD, 4.77 in PD compared to CR), and poor performance status (HR, 1.38 in ECOG 2–4) were found to increase mortality.

Conclusions

Advanced stage disease, poor performance status, male sex, and circumferential involvement were independent predictive factors for a poor response to CCRT. Advanced stage, poor performance status, and poor CCRT response were independent factors for decreased survival.

SOX17 overexpression sensitizes chemoradiation response in esophageal cancer by transcriptional down-regulation of DNA repair and damage response genes

Background

Prognosis of esophageal squamous cell carcinoma (ESCC) patients is poor and the concurrent chemoradiation therapy (CCRT) provided to ESCC patients often failed due to resistance. Therefore, development of biomarkers for predicting CCRT response is immensely important. In this study, we evaluated the predicting value of SRY (sex determining region Y)-box 17 (SOX17) protein during CCRT and its dysregulation of transcriptional targets in CCRT resistance in ESCC.

Methods

Pyrosequencing methylation, RT-qPCR and immunohistochemistry assays were performed to examine the DNA methylation, mRNA expression and protein expression levels of SOX17 in endoscopic biopsy from a total of 70 ESCC patients received CCRT. Cell proliferation, clonogenic survival and xenograft growth were used to confirm the sensitization of ESCC cell line KYSE510 in response to cisplatin, radiation or CCRT treatment by SOX17 overexpression in vitro and in vivo. Luciferase activity, RT-qPCR and ChIP-qPCR assays were conducted to examine transcription regulation of SOX17 in KYSE510 parental, KYSE510 radio-resistant cells and their derived xenografts.

Results

High DNA methylation coincided with low mRNA and protein expression levels of SOX17 in pre-treatment endoscopic biopsy from ESCC patients with poor CCRT response. SOX17 protein expression exhibited a good prediction performance in discriminating poor CCRT responders from good responder. Overexpression of SOX17 sensitized KYSE510 radio-resistant cells to cisplatin, radiation or CCRT treatment in cell and xenograft models. Importantly, SOX17 transcriptionally down-regulated DNA repair and damage response-related genes including BRCA1, BRCA2, RAD51, KU80 DNAPK, p21, SIRT1, NFAT5 and REV3L in KYSE510 radio-resistant cells to achieve the sensitization effect to anti-cancer treatment. Low expression of BRCA1, DNAPK, p21, RAD51 and SIRT1 was confirmed in SOX17 sensitized xenograft tissues derived from radio-resistant ESCC cells.

Conclusions

Our study reveals a novel mechanism by which SOX17 transcriptionally inactivates DNA repair and damage response-related genes to sensitize ESCC cell or xenograft to CCRT treatment. In addition, we establish a proof-of-concept CCRT prediction biomarker using SOX17 immunohistochemical staining in pre-treatment endoscopic biopsies to identify ESCC patients who are at high risk of CCRT failure and need intensive care.

Electronic supplementary material

The online version of this article (10.1186/s12929-019-0510-4) contains supplementary material, which is available to authorized users.

Elective nodal irradiation or involved-field irradiation in definitive chemoradiotherapy for esophageal squamous cell cancer: a retrospective analysis in clinical N0 patients

Objective

We compared failure patterns and survival after elective nodal irradiation (eni) or involved-field irradiation (ifi) in patients with thoracic esophageal squamous cell carcinoma (escc), clinical stage T2-4N0M0, to determine whether ifi is feasible for such patients.

Methods

Between 2005 and 2015, 126 patients with clinical stage T2-4N0M0 thoracic escc who received definitive concurrent chemoradiotherapy in Shandong Cancer Hospital and Institute and who had complete data, were analyzed retrospectively. Of those patients, 49 received ifi, and 77 received eni. In the ifi group, the radiation field included the primary tumour, with a 3-cm to 4-cm margin in the craniocaudal direction, and the elective irradiation was delivered to the adjacent regional lymphatics according to the location of the primary tumour. Patterns of failure were classified using the first site of failure, which included primary tumour failure, regional lymph node failure, and distant metastasis.

Results

Median progression-free survival was 20 months [95% confidence interval (ci): 7.87 months to 39.2 months] in the ifi group and 30 months (95% ci: 17.4 months to 44.6 months) in the eni group (p = 0.580). Median overall survival (os) was 36 months (95% ci: 21.9 months to 50.1 months) in the ifi group and 38 months (95% ci: 26.1 months to 49.9 months) in the eni group (p = 0.761). The estimated 1-year, 3-year, and 5-year os rates were, respectively, 87.8%, 49.4%, and 32.3% for the ifi patients and 92.2%, 52.0%, and 28.9% for the eni patients. Disease persistence and primary lesion recurrence after complete remission (cr) were the most frequent causes of treatment failure in the patients overall (83 of 124, 66.9%). Of the 66 patients achieving a clinical cr, 25 experienced recurrence of the primary lesion, 12 experienced distant relapse, 10 experienced regional nodal failure, and 2 experienced an isolated recurrence. No significant differences in the pattern of failure or in the incidences of grade 3 or greater treatment-related myelosuppression or esophagitis were found between the ifi and eni groups.

Conclusions

In patients with thoracic escc clinical stage T2-4N0M0 receiving definitive chemoradiotherapy, failure patterns and os were similar with either eni or ifi. Large prospective randomized studies are needed to further investigate and verify those results in this subgroup of patients.

Impact of Sarcopenia in Patients with Unresectable Locally Advanced Esophageal Cancer Receiving Chemoradiotherapy

BACKGROUND

Esophageal cancer often involves direct invasion of adjacent organs and patient survival rates are low. Sarcopenia has been reported to be associated with a poor prognosis in several types of malignancies. However, the impact of sarcopenia on the long-term survival of patients with unresectable locally advanced esophageal cancer remains unclear.

PATIENTS AND METHODS

A total of 48 patients undergoing definitive chemoradiotherapy at our Institution from October 2012 to December 2015 were enrolled; their data were compared according to patient skeletal muscle index (SMI): low SMI (sarcopenia group), n=34; normal SMI (non-sarcopenia group), n=14.

RESULTS

There were no significant differences in the incidence of severe adverse events and dose reduction rate between the two groups. The incidence of nutritional support was significantly higher in the groups with sarcopenia than in the non-sarcopenia group (44.1% vs. 7.1%, p=0.077). Response rates were significantly lower in the sarcopenia group than in the non-sarcopenia group (43.8% vs. 78.6%, p=0.025). The overall survival rate in the group with sarcopenia was significantly lower than that in the non-sarcopenia group (3-year: 36.95% vs. 63.9%, p=0.018).

CONCLUSION

Sarcopenia prior to treatment may worsen the long-term survival of patients with unresectable locally advanced esophageal cancer. Further well-designed prospective trials are needed to estimate whether adequate nutritional support has a favorable impact on therapeutic outcomes in this population.

Dose-escalated radiotherapy improved survival for esophageal cancer patients with a clinical complete response after standard-dose radiotherapy with concurrent chemotherapy

Purpose

For esophageal cancer patients with a clinical complete response (cCR) after standard-dose radiotherapy with concurrent chemotherapy, data on the survival outcomes and recurrence patterns remain scarce. To evaluate the impact of dose escalation on overall survival for this subset of patients, we carried out the current investigation.

Materials and methods

Medical records of 80 esophageal cancer patients with a cCR after standard-dose radiotherapy with concurrent chemotherapy at our center from 2010 to 2014 were allocated into the standard-dose group (50.4 Gy, observation group) or the radiation dose-escalation group (59.4 Gy, control group). In this cohort study, we compared the outcomes between the 2 groups.

Results

There were no differences in patient characteristics between the 2 groups. The median recurrence-free survival and overall survival times for all patients were 38 and 54 months, respectively. Patients in the control group had significantly better 5-year recurrence-free survival rate (12% vs 0%, p=0.019) and 5-year overall survival rate (42.8% vs 21.0%, p=0.028) than the observation group. Additionally, local control rate was significantly higher in the control group (p=0.04), and ~60% of treatment failures were local failures even for patients achieving cCR after chemoradiotherapy. There were no significant differences in treatment-related toxicities between the groups.

Conclusion

The results of the current study suggest that for esophageal cancer patients with a cCR after standard-dose radiotherapy with concurrent chemotherapy, those with dose-escalated radiotherapy showed significantly better local control, recurrence-free survival, and overall survival than patients receiving 50.4 Gy radiotherapy.

Comparison of the prognosis of neoadjuvant chemoradiotherapy treatment with surgery alone in esophageal carcinoma: a meta-analysis

Background

Resection remains the best treatment for carcinoma of the esophagus in terms of local control, but local recurrence and distant metastasis remain an issue after surgery. Chemo-radiotherapy (CRT) followed by surgery was associated with significantly improved survival benefit, but the effectiveness of neoadjuvant therapy in patients with resectable esophageal carcinoma remains controversial. The aim of this study was to evaluate the effects of neoadjuvant chemoradiotherapy in resectable esophageal carcinoma compared to surgery alone (SA).

Methods

A search for publications that compared the efficacy of CRT with SA in resectable esophageal carcinoma was conducted. After a rigorous review of the quality, the data were extracted from eligible trials. The major outcomes measures were odds ratios (ORs). The ORs with their corresponding 95% confidence intervals were the principal measure of effects. For the meta-analysis, Revman 5.3 software was used to analyze the combined pooled ORs using fixed- or random-effects models according to the heterogeneity.

Results

Our findings revealed that, compared with SA, neoadjuvant CRT was associated with improved overall survival (OS) and progression-free survival times, but the 3- and 5-year OS did not show a statistical difference (P≥0.05). The adjuvant chemotherapy group did not show significant improvement on reference rate and metastasis rate compared with the control group.

Conclusion

CRT does significantly improve progression-free survival and OS in patients with esophageal cancer compared with SA. However, further assessment is still warranted on the role of CRT in future trials with well-selected patients.

Impact of Sarcopenia in Patients with Unresectable Locally Advanced Esophageal Cancer Receiving Chemoradiotherapy

BACKGROUND

Esophageal cancer often involves direct invasion of adjacent organs and patient survival rates are low. Sarcopenia has been reported to be associated with a poor prognosis in several types of malignancies. However, the impact of sarcopenia on the long-term survival of patients with unresectable locally advanced esophageal cancer remains unclear.

PATIENTS AND METHODS

A total of 48 patients undergoing definitive chemoradiotherapy at our Institution from October 2012 to December 2015 were enrolled; their data were compared according to patient skeletal muscle index (SMI): low SMI (sarcopenia group), n=34; normal SMI (non-sarcopenia group), n=14.

RESULTS

There were no significant differences in the incidence of severe adverse events and dose reduction rate between the two groups. The incidence of nutritional support was significantly higher in the groups with sarcopenia than in the non-sarcopenia group (44.1% vs. 7.1%, p=0.077). Response rates were significantly lower in the sarcopenia group than in the non-sarcopenia group (43.8% vs. 78.6%, p=0.025). The overall survival rate in the group with sarcopenia was significantly lower than that in the non-sarcopenia group (3-year: 36.95% vs. 63.9%, p=0.018).

CONCLUSION

Sarcopenia prior to treatment may worsen the long-term survival of patients with unresectable locally advanced esophageal cancer. Further well-designed prospective trials are needed to estimate whether adequate nutritional support has a favorable impact on therapeutic outcomes in this population.

Excessive Pretreatment Weight Loss Is a Risk Factor for the Survival Outcome of Esophageal Carcinoma Patients Undergoing Radical Surgery and Postoperative Adjuvant Chemotherapy

BACKGROUND

The prognostic values of weight loss and body mass index (BMI) in esophageal carcinoma remain controversial. This study aimed to evaluate the impacts of weight loss on the survival of patients undergoing radical surgery and adjuvant chemotherapy.

METHODS

The medical records of 189 consecutive patients with nonmetastatic esophageal carcinoma treated in our hospital between January 2012 and December 2013 were reviewed, and 121 patients were included for analysis.

RESULTS

Kaplan-Meier analysis revealed that the 3-year overall survival rate was significantly higher in the low pretreatment weight loss (pre-LWL) group than in the high pretreatment weight loss (pre-HWL) group (P < 0.001). In addition, the 3-year overall survival rate of normal weight group was higher than that of overweight and underweight groups (P = 0.007). Multivariate Cox proportional hazards analysis showed that pre-LWL group had a significantly better 3-year overall survival than pre-HWL group (P = 0.027, HR = 1.89, and 95% CI = 1.07-3.32). pN stage and age were also the survival prognostic factors.

CONCLUSIONS

Our study showed that low pretreatment weight loss predicted a better survival outcome in the esophageal carcinoma patients with radical surgery and adjuvant chemotherapy. However, BMI and weight loss during treatment had no impact on the survival outcome.

Definitive chemoradiotherapy with low-dose continuous 5-fluorouracil reduces hematological toxicity without compromising survival in esophageal squamous cell carcinoma patients

Background and purpose

To compare chemoradiotherapy (CRT) with low-dose continuous 5-fluorouracil (5FU) to CRT with 5FU+cisplatin (CDDP) for esophageal squamous cell carcinoma (ESCC) in a retrospective cohort study.

Methods and materials

We reviewed the cases of Stage I–IV ESCC patients who underwent definitive CRT in 2000–2014. Concomitant chemotherapy was one of the three regimens: (1) high-dose intermittent 5FU and CDDP (standard-dose FP: SDFP), (2) low-dose continuous 5FU and CDDP (LDFP), or (3) low-dose continuous 5FU (LD5FU). The general selection criteria for chemotherapy were: SDFP for patients aged <70 yrs; LDFP for those aged 70–74 yrs; LD5FU for those aged ≥75 yrs or with performance status (PS) ≥3. Propensity scores were derived with chemotherapy (LD5FU vs. 5FU+CDDP) as the dependent variable.

Results

In a multivariate analysis, chemotherapy (LD5FU vs. SDFP, p = .24; LDFP vs. SDFP, p = .52) did not affect the overall survival (OS). LD5FU caused significantly less grade 3–4 leukopenia (9%) compared to SDFP (47%) and LDFP (44%) (p < .001). In a propensity-matched analysis, LD5FU affected neither OS (HR 1.06; 95%CI 0.55–2.05; p = .87) nor progression-free survival (HR 0.95, 95%CI 0.50–1.81; p = .87).

Conclusion

CRT with low-dose continuous 5FU may be a less toxic option for elderly ESCC patients.

Endoscopic traversability in patients with locally advanced esophageal squamous cell carcinoma: Is it a significant prognostic factor?

The purpose of this study was to evaluate the prognostic impact of endoscopic traversability in patients with locally advanced esophageal squamous cell carcinoma.This retrospective study was based on medical records from a single tertiary medical center. The records of 317 patients with esophageal squamous cell carcinoma treated with surgery or definitive chemoradiotherapy (CRT) between January 2009 and March 2016 were reviewed. Finally, we retrieved the data on 168 consecutive patients. These 168 patients were divided into 2 groups based on their endoscopic traversability findings: Group A (the endoscope traversable group), and Group B (the endoscope non-traversable group). We then retrospectively compared the clinical characteristics of these 2 groups.The endoscope non-traversable group (Group B) revealed an advanced clinical stage, a poor Eastern Cooperative Oncology Group (ECOG) score, a lower serum albumin level, a higher rate of requirement for esophageal stent insertion and definitive CRT as initial treatment than the endoscope traversable group (Group A). Patients with endoscope traversable cancer showed a significantly higher 3-year overall survival and 3-year relapse-free survival than patients who were endoscope non-traversable (53.8% vs 17.3%, P < .001 and 71.1% vs 45.3%, P = .003, respectively). Upon multivariate analysis of patients with locally advanced esophageal squamous cell carcinoma treated with definitive CRT, the serum albumin level <3.5 g/dL and endoscopic non-traversability were significant negative factors of survival.Endoscopic traversability in patients with locally advanced esophageal squamous cell carcinoma treated with definitive CRT is a significant prognostic factor.

Shifting practice in definitive chemoradiation for localized esophageal cancer

BACKGROUND

The efficacy of carboplatin-paclitaxel in the trimodality setting was demonstrated in the cross trial. Because of better tolerance, that regimen has been adopted as an alternative for patients receiving definitive chemoradiation (dcrt). The purpose of our study was to compare outcomes in patients with localized esophageal and gastroesophageal junction (gej) cancer who received dcrt using either platinum-5-fluorouracil (5fu) or carboplatin-paclitaxel.

METHODS

Medical records and outcomes for all patients diagnosed with localized carcinoma of the esophagus and gej at our centre between 2008 and 2015 were reviewed. All patients who underwent dcrt using cisplatin-5fu, carboplatin-5fu, or carboplatin-paclitaxel were included.

RESULTS

The 73 identified patients (34 cisplatin-5fu, 13 carboplatin-5fu, 26 carboplatin-paclitaxel) were all prescribed concomitant radiotherapy of 50 Gy in 25 daily fractions. The diagnosis was adenocarcinoma in 64% and squamous cell carcinoma in 36%. Median overall survival (os) duration for the cisplatin-5fu group was 28 months [95% confidence interval (ci): 19 to 41 months], with a 3-year os rate of 44%, in contrast to the 15 months (95% ci: 11 to 17 months) and 15% in the carboplatin-paclitaxel group (log-rank p = 0.0047). Median os duration for the carboplatin-5fu group was 17 months (95% ci: 11 to 68 months) with a 3-year os rate of 31%. Adjusting for patient and disease factors, better os durations and rates were associated with cisplatin-5fu (hazard ratio: 0.34; p = 0.0016) and carboplatin-5fu (hazard ratio: 0.55; p = 0.20) than with carboplatin-paclitaxel.

CONCLUSIONS

In a dcrt regimen, a better os is associated with cisplatin-5fu than with carboplatin-paclitaxel. Clinical trials to determine optimal chemotherapy regimens are warranted for patients who are not suitable for surgery.

A six-CpG panel with DNA methylation biomarkers predicting treatment response of chemoradiation in esophageal squamous cell carcinoma

BACKGROUND

Prognosis of esophageal squamous cell carcinoma (ESCC) patients remains poor, and the chemoradiotherapy (CRT) applied to ESCC patients often failed. Therefore, development of biomarkers to predict CRT response is immensely important for choosing the best treatment strategy of an individual patient.

METHODS

The methylation array and pyrosequencing methylation assay were performed in pre-treatment endoscopic biopsies to identify probes with differential CpG methylation levels between good and poor CRT responders in a cohort of 12 ESCC patients. Receiver operating characteristic curves and multivariate logistic regressions were conducted to build the risk score equation of selected CpG probes in another cohort of 91 ESCC patients to predict CRT response. Kaplan-Meier analysis was used to estimate progression-free survival or time-to-progression of patients predicted with good and poor CRT responses.

RESULTS

Nine differentially methylated CpG probes were identified to be associated with CRT response. A risk score equation comprising six CpG probes located in IFNGR2, KCNK4, NOTCH4, NPY, PAX6, and SOX17 genes were built. The risk score was derived from the sum of each probe multiplied by its corresponding coefficient. Such a risk score has a good prediction performance in discriminating poor CRT responders from good responders (AUC: 0.930). Moreover, poor CRT responders predicted by risk score significantly had poorer prognosis in terms of shorter progression-free survival and time-to-progression (p = 0.004-0.008).

CONCLUSION

We established a proof-of-concept CRT response prediction panel consisting of six-CpG methylation biomarkers in identifying ESCC patients who are at high risk of CRT failure and need intensive care.

A systematic review and network meta-analysis of neoadjuvant therapy combined with surgery for patients with resectable esophageal squamous cell carcinoma

BACKGROUND

The role of neoadjuvant therapy combined with surgery for treating esophageal squamous cell carcinoma (ESCC) remains controversial. We performed a network meta-analysis to synthesize direct and indirect evidence to identify the optimal therapeutic method for ESCC.

METHODS

We identified 15 randomized controlled trials that compared any of the following 4 therapeutic measures: surgery alone (S), preoperative chemotherapy followed by surgery (CTS), preoperative radiotherapy followed by surgery (RTS), and preoperative chemoradiotherapy followed by surgery (CRTS). The main outcomes were 5-year survival, rate of radical resection, operative mortality and postoperative complications.

RESULTS

Network meta-analysis showed that CRTS was associated with improved survival as compared with S (OR = 1.50 [95% CI 1.21 to 1.97]) and decreased occurrence of complications as compared with RTS (OR = 0.50 [95% CI 0.22 to 0.99]). Direct evidence revealed CRTS associated with improved survival (OR = 1.61 [95% CI 1.01 to 2.57]) and radical resection (OR = 4.01 [95% CI 1.66 to 9.69]) as compared with S. In terms of radical resection, CTS was more effective than S (OR = 1.73 [95% CI 1.09 to 2.76]). Findings for CTS and RTS did not differ for 5-year survival, operative mortality and postoperative complications.

CONCLUSIONS

Overall, CRTS might be the best choice for resectable ESCC because it could increase the radical resection rate and lower the occurrence of complications, thereby prolonging survival time.

Prognostic factors in clinical T1N0M0 thoracic esophageal squamous cell carcinoma invading the muscularis mucosa or submucosa

BACKGROUND

Multimodality treatment is widely performed for clinical T1N0M0 (UICC-TNM classification, 7th edition) thoracic esophageal squamous cell carcinoma (ESCC), but available articles regarding treatment results are limited. This study assessed the outcomes of clinical T1N0M0 thoracic ESCC invading the muscularis mucosa (MM) or submucosa (SM) treated with radiotherapy (RT) or chemoradiotherapy (CRT).

METHODS

We retrospectively reviewed the medical charts of 90 patients with clinical T1N0M0 thoracic ESCC treated with RT or CRT in our hospital in 2004-2011. Of these 90 patients, we analyzed the cases of 71 patients who met our inclusion criteria. All 71 patients had MM or SM cancer. In the 47 patients treated with CRT, the chemotherapy regimen of 5-fluorouracil (5-FU) plus cisplatin (CDDP) was used for 46 patients and 5-FU and nedaplatin was used for one patient. Forty-five patients underwent endoscopic resection (ER) followed by RT or CRT as an additional treatment. Elective nodal irradiation (ENI) was used in 39 patients. For all analyses, statistical significance was defined as 0.05, and the Bonferroni correction was used for the multivariate analysis.

RESULTS

The median age was 70 years (range 47-84). With a median follow-up of 43.6 months (range 1.5-124.2), the 5-year overall survival (OS), disease-specific survival (DSS) and disease-free survival (DFS) rates were 64.0, 72.8 and 50.0 %, respectively. The multivariate analysis showed that performance status (PS) was an independent prognostic factors for DSS and DFS (DSS, p < 0.001; DFS, p < 0.001). Chemotherapy in addition to RT showed a trend for better DSS (p = 0.032) but was not significant following Bonferroni correction. ER and ENI were not significant predictive factors for DSS and DFS.

CONCLUSIONS

PS was an independent prognostic factor for DSS and DFS. ER and ENI had no significant relationship with DSS or DFS. The present results may be helpful in treatment decisions for clinical T1N0M0 thoracic ESCC.

Correlation between insulin‑like growth factor binding protein 3 and metastasis‑associated gene 1 protein in esophageal squamous cell carcinoma

The present study aimed to investigate the correlation between insulin‑like growth factor binding protein 3 (IGFBP‑3) and metastasis‑associated gene 1 (MTA1) protein, and the clinicopathological features and prognosis of esophageal squamous cell carcinoma (ESCC). Patients with ESCC who underwent surgical resection were enrolled in the current study, ESCC tissues and adjacent normal tissues (control) were obtained from 197 patients. The protein expression levels of IGFBP‑3 and MTA1 were detected using immunohistochemistry. The results demonstrated that the expression of IGFBP‑3 in ESCC tissues was significantly lower than in the adjacent normal tissues (27.4 vs. 40.6%; P<0.05), and was negatively correlated with smoking status, degree of tumor differentiation and lymph node metastasis (P<0.05). The expression of MTA1 protein in ESCC tissues was significantly higher than that of the adjacent tissues (42.1 vs. 11.2%; P<0.05), and was positively correlated with the tumor size, extent of tumor invasion and lymph node metastasis (P<0.05). No association was identified between the protein expression levels of IGFBP‑3 and MTA1. The protein expression levels of IGFBP‑3 and MTA1 were not independent risk factors for ESCC prognosis; however, the degree of tumor invasion (P=0.02) and rate of lymph node metastasis (P=0.027) were. IGFBP‑3 inhibits the proliferation and metastasis of ESCC; however, MTA1 promotes the proliferation and metastasis of ESCC. There is no interaction between IGFBP‑3 and MTA1 in ESCC, and they are not independent risk factors for ESCC prognosis.

Four Distinct Health Profiles in Older Patients With Cancer: Latent Class Analysis of the Prospective ELCAPA Cohort

BACKGROUND

Several studies have evaluated the independent prognostic value of impairments in single geriatric-assessment (GA) components in elderly cancer patients. None identified homogeneous subgroups. Our aims were to identify such subgroups based on combinations of GA components and to assess their associations with treatment decisions, admission, and death.

METHODS

We prospectively included 1,021 patients aged ≥70 years who had solid or hematologic malignancies and who underwent a GA in one of two French teaching hospitals. Two geriatricians independently selected candidate GA parameters for latent class analysis, which was then performed on the 821 cases without missing data. Age, gender, tumor site, metastatic status, and inpatient versus outpatient status were used as active covariates and predictors of class membership. Outcomes were cancer treatment decisions, overall 1-year mortality, and 6-month unscheduled admissions. Sensitivity analyses were performed on the overall population of 1,021 patients and on 375 newly enrolled patients.

RESULTS

We identified four classes: relatively healthy (LC1, 28%), malnourished (LC2, 36%), cognitive and mood impaired (LC3, 15%), and globally impaired (LC4, 21%). Tumor site, metastatic status, age, and in/outpatient status independently predicted class membership (p < .001). In adjusted pairwise comparisons, compared to LC1, the three other LCs were associated with higher risks of palliative treatment, death, and unscheduled admission (p ≤ .05). LC4 was associated with 1-year mortality and palliative treatment compared to LC2 and LC3 (p ≤ .05).

CONCLUSION

We identified four health profiles that may help physicians select cancer treatments and geriatric interventions. Researchers may find these profiles useful for stratifying patients in clinical trials.

Involved-field radiotherapy for esophageal squamous cell carcinoma: theory and practice

Esophageal carcinoma (EC) is characterized by a high rate of lymph node metastasis and its spread pattern is not always predictable. Chemoradiotherapy has an important role in the treatment of EC in both the inoperable and the pre-operative settings. However, regarding the target volume for radiation, different clinical practices exist. Theoretically, in addition to the clinical target volume administered to the gross lesion, it might seem logical to deliver a certain dose to the uninvolved regional lymph node area at risk for microscopic disease. However, in practice, it is difficult because of the intolerance of normal tissue to radiotherapy (RT), particularly if all regions containing the cervical, mediastinal, and upper abdominal nodes are covered. To date, the use of elective nodal irradiation (ENI) is still controversial in the field of radiotherapy. Some investigators use involved-field radiotherapy (IFRT) in order to reduce treatment-related toxicities. It is thought that micrometastases can be controlled, to some extent, by chemotherapy and the abscopal effects of radiation. It is the presence of overtly involved lymph nodes rather than the micrometastatic nodes negatively affects survival in patients with EC. In another hand, lymph nodes stationed near primary tumors also receive considerable incidental irradiation doses that may contribute to the elimination of subclinical lesions. These data indicate that an irradiation volume covering only the gross tumor is appropriate. When using ENI or IFRT, very few patients experience solitary regional node failure and out-of-field lymph node failure is not common. Primary tumor recurrence and distant metastases, rather than regional lymph node failure, affect the overall survival in patients with EC. The available evidence indicates that the use of ENI seems to prevent or delay regional nodal relapse rather than improve survival. In a word, these data suggest that IFRT is feasible in EC patients.

Polymorphisms of insulin-like growth factor binding protein-3 as a predictor for risk and patient survival in esophageal squamous cell carcinoma

BACKGROUND AND PURPOSE

Genetic single nucleotide polymorphisms (SNP) play a critical role in the development of esophageal squamous cell carcinoma (ESCC). The aim of this study is to investigate the associations between insulin-like growth factor binding protein-3 (IGFBP-3) gene polymorphisms and ESCC patients risk and survival after definitive chemoradiotherapy (CRT).

MATERIALS AND METHODS

We undertook a case-control study to analyze two IGFBP-3 polymorphisms (rs2854744 A>C and rs2854746 G>C) in an Han Chinese population, by extraction of genomic DNA from the peripheral blood of 110 ESCC patients treated with CRT and 128 control participants, and performed IGFBP-3 genotyping using DNA sequencing.

RESULTS

The obtained results indicated that overall, no statistically significant association was observed in rs2854746 G>C. However, rs2854744 A>C genotype was at increased risk of ESCCs (P=0.032; odds ratio (OR)=1.201, CI 95%:1.014-1.423). Moreover, rs2854744 A>C genotype ESCCs were more significantly common in patients with tumor size of >6cm than A allele ESCC and in cases of lower T stage. Furthermore, ESCC patients with rs2854744CC genotype have the poorer CRT response and shorter survival time than GG+GC genotype ESCC.

CONCLUSIONS

In conclusion, polymorphism in IGFBP-3 rs2854744 A>C might be a potential predictor of ESCC risk and patient survival. Nevertheless, further investigation with a larger sample size is needed to support our results.

Predictors of 1-Year Mortality in a Prospective Cohort of Elderly Patients With Cancer

BACKGROUND

Mortality prediction is crucial to select the optimal treatment in elderly cancer patients. Our objective was to identify cancer-related factors and Comprehensive Geriatric Assessment (CGA) findings associated with 1-year mortality in elderly inpatients and outpatients with cancer.

METHODS

We prospectively included patients aged ≥70 years who had solid or hematologic malignancies and in whom the CGA was performed by geriatricians in two French teaching hospitals. We identified independent predictors of 1-year mortality after study inclusion, using multivariate Cox models stratified on inpatient/outpatient status. We built three multivariate Cox models, since strong correlations linked activities of daily living (ADL), Eastern Cooperative Oncology Group Performance Status (ECOG-PS), and timed get-up-and-go test (GUG) results; and since physicians' preferences for these three assessments vary. A sensitivity analysis was performed using multiple imputation.

RESULTS

Of the 993 patients (mean age, 80.2 years; 51.2% men), 58.2% were outpatients and 46% had metastatic disease. Colorectal cancer was the most common malignancy (21.4%). Mortality rates after 6 and 12 months were 30.1% and 41.2%, respectively. In all models, tumor site and metastatic status (p < .001), age >80 years (p < .05), higher number of severe comorbidities (p < .05), and malnutrition (p < .001) were associated with death independently from impaired ECOG-PS (p < .001), ADL (p < .001), and GUG (p < .001). The adverse effect of metastatic status differed significantly across tumor sites, being greatest for breast and prostate cancer (p < .001). Multiple imputation produced similar results.

CONCLUSION

The predictors of 1-year mortality identified in our study may help physicians select the optimal cancer-treatment strategy in elderly patients.

Role of EZH2 polymorphisms in esophageal squamous cell carcinoma risk in Han Chinese population

Gene single nucleotide polymorphisms play a critical role in the development of esophageal squamous cell carcinoma (ESCC). The aim of this study is to investigate the associations between EZH2 gene polymorphisms and ESCC risk. We undertook a case-control study to analyze three EZH2 polymorphisms (148505302C>T, 2110+6A>C and 626-394T>C) in an Han Chinese population, by extraction of genomic DNA from the peripheral blood of 476 patients with ESCC and 492 control participants, and performed EZH2 genotyping using DNA sequencing. The obtained results indicated that overall, no statistically significant association was observed in 148505302C>T and 2110+6A>C. However, 626-394T>C genotype was at increased risk of ESCCs (p=0.006; odds ratio (OR)=1.131, CI 95%: 1.034-1.236). Moreover, 626-394C/C genotype ESCCs were more significantly common in patients with tumor size of >5 cm than T allele ESCC and in cases of poor differentiation and lower advanced pathological stage. In conclusion, polymorphism in 626-394T>C was observed to be associated with susceptibility of ESCC. Nevertheless, further investigation with a larger sample size is needed to support our results.

Assessment of nutritional status and quality of life in patients treated for head and neck cancer

The purpose of this study was to identify tools for the assessment of nutritional status in head and neck cancer patients, to evaluate the impact of malnutrition on therapeutic management and quality of life and to propose a simple screening approach adapted to routine clinical practice. The authors conducted a review of the literature to identify tools for the assessment of nutritional status in head and neck cancer patients published in French and English. Articles were obtained from the PubMed database and from the references of these articles and selected journals, using the keywords: "nutritional assessment", and "head and neck" and "cancer". Anthropometric indices, laboratory parameters, dietary intake assessment, clinical scores and nutritional risk scores used in patients with head and neck cancers are presented. The relevance of these tools in clinical practice and in research is discussed, together with the links between nutritional status and quality of life. This article is designed to help teams involved in the management of patients with head and neck cancer to choose the most appropriate tools for assessment of nutritional status according to their resources and their objectives.

Clinical prognostic factors for locally advanced esophageal squamous carcinoma treated after definitive chemoradiotherapy

PURPOSE

Locally advanced esophageal cancers are generally treated with neoadjuvant chemoradiotherapy, followed by surgery in operable candidates. However, even if the patients were diagnosed as operable disease, surgery could not be performed on patients with poor condition or other comorbidity. In this case, definitive chemoradiotherapy (dCRT) is the other option for localized esophageal cancer. Therefore, the purpose of this study was to evaluate the efficacy and clinical prognostic factors for dCRT in locally advanced esophageal cancer.

MATERIALS AND METHODS

We conducted a review of patients who received dCRT for locally advanced squamous esophageal cancer from 2004 to 2010, focusing on stages III and IVa. All patients received at least two cycles of platinum-based chemotherapy during radiation, and all tumor burdens were included in the radiation field. The treatment results were analyzed for patterns of failure and prognostic factors associated with survival.

RESULTS

In total, 63 patients were enrolled in this study. The overall response rate was 84.1%. Relief from dysphagia after dCRT was achieved in 48 patients. The most frequent failure was local recurrence. The median overall survival (OS) was 23.0 months, and the 2-year survival rate was 45.4%. Similar results were observed for elderly study patients. Significant prognostic factors for OS were duration of smoking, high grade of dysphagia (score of 3 or 4), and shorter duration of progression-free and dysphagia-free survival. Maintenance chemotherapy after dCRT did not influence OS. However, "good risk" patients receiving maintenance chemotherapy showed better OS than those who did not receive maintenance chemotherapy (30.4 months vs. 12.0 months, p=0.002).

CONCLUSION

dCRT has a major role in improving survival and palliation of dysphagia in inoperable advanced esophageal cancer, even in elderly patients. Maintenance chemotherapy after dCRT may be effective in prolonging survival in "good risk" patients.

Safety and efficacy of radiation and chemoradiation in patients over 70 years old with inoperable esophageal squamous cell carcinoma

The aim of the present study was to perform a retrospective analysis to investigate the outcome and toxicity of radiation (RT) and chemoradiation (CRT) in elderly, inoperable patients >70 years old. Between 2003 and 2012, 1,024 patients with squamous cell carcinoma (SCC) of the esophagus were treated at the Department of Thoracic Cancer, West China Hospital (Chengdu, China). Of these patients, 37 were >70 years old and had not undergone surgery, and were selected for analysis. Of these 37 patients, CRT had been administered to 20 (54%). Actuarial survival rates were determined by the Kaplan-Meier method. The one-year survival rate in the CRT group (n=20) was 85%, while 35% of patients in the RT group (n=17) survived for more than one year. The overall and progression-free survival in the CRT group versus the RT group were 17 months [95% confidence interval (CI), 11.861-22.139] versus eight months (95% CI, 6.674-9.326) (P=0.013) and 14 months (95% CI, 9.617-18.383) versus five months (95% CI, 2.311-7.689) (P=0.01), respectively. Patients irradiated with a dose of >50 Gy exhibited an improved survival rate compared with patients who received a dose of ≤50 Gy (18 vs. 14 months; P=0.049). Furthermore, patients with an Eastern Cooperative Oncology Group (ECOG) score of ≤1 had an improved prognosis compared with those with an ECOG score of 2 (14 vs. seven months; P=0.006). The two regimens were well-tolerated and there were no therapy-associated mortalities. The current retrospective study indicated that patients of >70 years old with inoperable esophageal SCC and a good ECOG score exhibit comparably better safety levels with CRT and improved survival rates compared with RT alone.

Management of advanced-stage operable esophageal cancer

The incidence of esophageal cancer is increasing in the developed world, with a relative increase in adenocarcinoma compared with squamous cell carcinoma. The distensible nature of the esophagus results in delayed development of symptoms associated with esophageal cancer; hence many patients have locally advanced or metastatic cancer at the time of initial presentation. Although resection remains the treatment of choice for early-stage esophageal cancer, the best treatment strategy for locally advanced esophageal cancer is debatable and, consequently, varies at different centers. This article discusses the published literature on various available therapeutic options for the treatment of locally advanced esophageal cancer.

Definitive chemoradiotherapy in patients with esophageal adenocarcinoma: an alternative to surgery?

BACKGROUND AND OBJECTIVES

Definitive chemoradiotherapy (CRT) is considered curative intent treatment for locally advanced esophageal squamous cell carcinoma. Data concerning the usefulness of definitive CRT in patients with esophageal adenocarcinoma (ADC) are lacking. The aim of the study was to compare the results of definitive CRT versus surgery in patients with an ADC.

METHODS

All consecutive patients with a non-metastatic ADC treated between 1994 and 2008 were retrospectively assessed. Patients were divided into two groups: surgery group (±pre-operative treatment) versus definitive CRT group.

RESULTS

In surgery and definitive CRT groups, 67 and 79 patients were evaluated, respectively. A complete resection was achieved in 92.5% of patients in surgery group and a clinical complete response was observed in 49.4% of patients in definitive CRT group. Overall survival was 36.2 ± 2.0 months in surgery group versus 16.5 ± 0.8 months in definitive CRT group (P = 0.02). The predictive factors of survival were age (P < 0.01), stage (P = 0.04), WHO performance status (P < 0.01), initial weight loss (P < 0.01), and the treatment group (P < 0.01).

CONCLUSIONS

The results of the study do not support definitive CRT as an alternative to surgery in esophageal ADC treatment. Definitive CRT should be reserved for patients with a major operative risk.

Low expression of IGFBP-3 predicts poor prognosis in patients with esophageal squamous cell carcinoma

Previous studies have suggested that insulin-like growth factor binding protein-3 (IGFBP-3) acts as a tumor suppressor in human esophageal squamous cell carcinoma (ESCC). The present study was designed to investigate the clinical and prognostic significance of IGFBP-3 in ESCC patients. In this study, IGFBP-3 was detected by immunohistochemistry (IHC) in paraffin-embedded tissues from 110 ESCC patients, of which 110 were from primary cancer sites and 56 from matched adjacent non-malignant sites. Differences in IGFBP-3 expression and clinical characteristics were compared by χ2 test. Correlations between prognostic outcomes and with IGFBP-3 expression were investigated using Kaplan-Meier analysis and the Cox proportional hazards model. Among adjacent non-malignant tissues, 83.9% of individual tissue staining was scored as either high for IGFBP-3. However, among ESCC cases, only 51.8% of the cancer tissues were scored as high IGFBP-3 expression. In addition, IGFBP-3 expression inversely correlated with pathological classification (P<0.05 for T, N, and M classifications) and clinical staging (P=0.006). Furthermore, patients with higher levels of IGFBP-3 had prolonged overall survival (P<0.001). In conclusion, reduced IGFBP-3 expression may be a risk factor for advanced clinicopathological classification and poor patient survival. These findings suggest that IGFBP-3 may serve as a useful marker for the prognostic evaluation of ESCC patients.

Lugol chromo-endoscopy versus narrow band imaging for endoscopic screening of esophageal squamous-cell carcinoma in patients with a history of cured esophageal cancer: a feasibility study

To date, Lugol chromo-endoscopy is the reference technique to detect an esophageal neoplasia in patients with prior esophageal squamous-cell carcinoma (ESCC), but is not easy to perform without general anesthesia, which can limit its use in routine practice. The objective of this study were to compare the accuracy of white light, narrow band imaging (NBI), and Lugol to detect esophageal neoplasia in patients with a history of cured ESCC, in a prospective study. Thirty patients were prospectively included between June 2006 and June 2009. They all had a history of cured ESCC. Esophageal mucosa was examined first using white light, second NBI, and third after Lugol staining. Histology was obtained in all abnormalities detected by white light, NBI, and/or Lugol. Five neoplastic lesions in five different patients were identified at histology, four cancers, and one high-grade dysplasia. NBI and Lugol both detected all esophageal neoplastic lesions, whereas white light detected the four cancers but missed the high-grade dysplasia. In this feasibility study, NBI and Lugol both detected all identified esophageal neoplasia in very high-risk patients of ESCC. This result suggests that NBI could be used instead of Lugol to detect an esophageal neoplasia in patients with high risk of ESCC, but needs to be confirmed in a larger study.

Management of esophageal adenocarcinoma

The incidence of esophageal adenocarcinoma is increasing in Western countries with a tendency to exceed that of squamous-cell carcinoma. Prognosis is unfavorable with 5-year survival less than 15%, irrespective of treatment and the stage. At the time of diagnosis, more than two thirds of patients have a non-operable cancer because of extension or associated co-morbidities. Most studies have included different tumoral locations (esophagus and stomach) and different histological types (adenocarcinoma and squamous-cell carcinoma), making it difficult to interpret results. Surgery is currently the standard treatment for small tumors. Surgery should be preceded by neo-adjuvant treatment for patients with locally advanced resectable tumors, either preoperative chemotherapy or preoperative chemoradiation therapy. The therapeutic choice should be decided during multidisciplinary meetings according to patient and tumor characteristics and the expertise of the center. For patients with contraindications to surgery, exclusive chemoradiation therapy is recommended. Herein we reviewed and synthesized the different therapeutic strategies for esophageal adenocarcinoma.

Important aspects of nutrition in children with cancer

Adequate nutrition during cancer plays a decisive role in several clinical outcome measures, such as treatment response, quality of life, and cost of care. However, the importance of nutrition in children and young adults with malignancies is still an underestimated topic within pediatric oncology. The importance of our work is to reinforce and indicate that malnutrition in children with cancer should not be accepted at any stage of the disease or tolerated as an inevitable process. Unique to our manuscript is the close collaboration, the exchange of knowledge and expertise between pediatric oncologists and a nutritional specialist, as well as the comprehension of the mechanisms during cancer cachexia and malnutrition. We provide a critical review of the current state of research and new knowledge related to nutritional management in childhood cancer.

Full costs of dispensing and administering fluorouracil chemotherapy for outpatients: A microcosting study

BACKGROUND

Although full costs (including direct and indirect costs) that incurred during the process of chemotherapy administration should be measured, many studies estimate only direct labor and medication costs associated with various chemotherapy delivery systems.

OBJECTIVES

To estimate the total costs for dispensing and administration of fluorouracil when administered with leucovorin, by intravenous infusion or bolus, using a microcosting approach from the perspective of a provider or health system.

METHODS

A time-and-motion study was used to measure the time spent by (1) pharmacy staff in the handling, admixture, and dispensing of fluorouracil and (2) patients in the clinic. The study was performed at The Cancer Institute of New Jersey for an 8-month period. Costs of dispensing and administering fluorouracil were calculated per patient visit on the basis of resources used in the processing of fluorouracil and time spent by pharmacy staff and patient. All costs were standardized to 2005 dollars.

RESULTS

A total of 275 observations were made, and 74 (26.9%) of these were associated with fluorouracil-based chemotherapy. Pharmacy staff spent an average of 11 minutes for bolus fluorouracil with leucovorin infusion (fluorouracil/LCV-IV) and 8 minutes for bolus fluorouracil with bolus leucovorin (fluorouracil/LCV-B). Patients who received fluorouracil/LCV-IV spent an average of 203 minutes in the clinic, whereas patients who received fluorouracil/LCV-B spent 110 minutes. The average cost of administering fluorouracil/LCV-IV was $933, which comprised drug costs ($279), dispensing costs ($189), and administration costs ($465). The average cost of fluorouracil/LCV-B was $474, which comprised drug costs ($65), dispensing costs ($141), and administration costs ($268).

CONCLUSIONS

This is the first study to formally demonstrate the high cost of administering the injectable form of fluorouracil chemotherapy with leucovorin, despite relatively low drug acquisition cost. Therefore, reimbursement rates for fluorouracil should be calculated in such a way that covers all costs, including overhead costs for the department.

Long-term efficacy of perioperative chemoradiotherapy on esophageal squamous cell carcinoma

AIM: To investigate the role of perioperative chemoradiotherapy (CRT) in the treatment of locally advanced thoracic esophageal squamous cell carcinoma (ESCC).

METHODS: Using preoperative computed tomography (CT)-based staging criteria, 238 patients with ESCC (stage II-III) were enrolled in this prospective study between January 1997 and June 2004. With informed consent, patients were randomized into 3 groups: preoperative CRT (80 cases), postoperative CRT (78 cases) and surgery alone (S) (80 cases). The 1-, 3-, 5- and 10-year survival were followed up. Progression-free survival (PFS) was chosen as the primary endpoint by treatment arm measured from study entry until documented progression of disease or death from any cause. The secondary endpoint was overall survival (OS) determined as the time (in months) between the date of therapy and the date of death. Other objectives were surgical and adjuvant therapy complications.

RESULTS: With median follow-up of 45 mo for all the enrolled patients, significant differences in the 1-, 3-, 5-, 10-year OS (91.3%, 63.5%, 43.5%, 24.5% vs 91%, 62.8%, 42.3%, 24.4% vs 87.5%, 51.3%, 33.8%, 12.5%, P = 0.0176) and PFS (89.3%, 61.3%, 37.5%, 18.1% vs 89.1%, 61.1%, 37.2%, 17.8% vs 84.5%, 49.3%, 25.9%, 6.2%, P = 0.0151) were detected among the 3 arms. There were no significant differences in OS and PFS between the preoperative CRT and postoperative CRT arm (P > 0.05). For the patients who had radical resection, significant differences in median PFS (48 mo vs 61 mo vs 39.5 mo, P = 0.0331) and median OS (56.5 mo vs 72 mo vs 41.5 mo, P = 0.0153) were detected among the 3 arms, but there were no significant differences in OS and PFS between the preoperative CRT and postoperative CRT arm (P > 0.05). The local recurrence rates in the preoperative CRT, postoperative CRT group and S group were 11.3%, 14.1% and 35%, respectively (P < 0.05). No significant differences were detected among the 3 groups when comparing complications but tended to be in favor of the postoperative CRT and S groups (P > 0.05). Toxicities of CRT in the preoperative or postoperative CRT arms were mostly moderate, and could be quickly alleviated by adequate therapy.

CONCLUSION: Rational application of preoperative or postoperative CRT can provide a benefit in PFS and OS in patients with locally advanced ESCC.

High-dose definitive concomitant chemoradiotherapy in non-metastatic locally advanced esophageal cancer: toxicity and outcome

This study is a retrospective analysis of high-dose definitive concomitant chemoradiotherapy in locally advanced esophageal cancer in a single institution. The aim of the study was to identify and quantify the toxicity associated with the high-dose treatment and to analyze the outcome of this treatment. Forty-six patients (41 men and 5 women, median age of 67.5 years) with disease stage IIA-III esophageal cancer were treated with high-dose definitive chemoradiotherapy. Thirty patients had squamous cell carcinomas and 16 had adenocarcinomas. The patients were treated with three courses of chemotherapy. Each chemotherapy course consisted of cisplatin 100 mg/m(2), day 1 and 5-Fluorouracil 1000 mg/m(2)/day, day 1-5. One course was given every 3 weeks. Concurrent radiotherapy (66 Gy/33 fractions) was administered during the last two courses of chemotherapy. Toxicity grades three and four were seen in 47.5% and 40% of the patients, respectively. Treatment related mortality occurred in one patient (2.5%) due to neutropenic septicemia. Follow-up time for surviving patients (2/46) was 45 and 112 months. For the entire study population, the median time to local recurrence in the radiotherapy field was 33 months and the median time to distant metastasis was 8.7 months, whereas median overall survival was 10.8 months and median disease-specific survival 11 months. For responders to chemoradiotherapy, the median time to local recurrence was 76 months, the median time to distant metastasis 16.8 months, the median overall survival and the median disease-specific survival for the responders were both 17 months. The 2, 3 and 5-year survival rates were 22%, 15% and 11% for the entire study population, and 31%, 24% and 17% for the responders to chemoradiotherapy, respectively. By multivariate analysis response to chemoradiotherapy and lower disease stage were positive prognostic factors for survival. The results of our study have shown that concurrent high-dose chemoradiotherapy provides long-term local tumor control in locally advanced esophageal cancer. However, toxicities following this high-dose treatment, while manageable, were significant. Survival rates were not improved by high-dose chemoradiotherapy compared with what is reported in previous studies applying lower doses of definitive chemoradiotherapy.

Effects of neoadjuvant radiochemotherapy on pathological staging and prognosis for locally advanced esophageal squamous cell carcinoma

The role of neoadjuvant therapy in the treatment of locally advanced esophageal carcinoma still remains controversial. The aim of this study was to evaluate the effects of neoadjuvant radiochemotherapy on pathological staging and prognosis in the patients with locally advanced esophageal squamous cell carcinoma. Between January 1991 and December 2000, 473 patients with advanced esophageal carcinoma diagnosed by endoscopic biopsy underwent surgical resection in our center. With informed consent, they were randomized into four groups: neoadjuvant chemotherapy, neoadjuvant radiotherapy, neoadjuvant radiochemotherapy, and surgery alone (control group). The preoperative computed tomography staging criteria were the following: Stage I, the tumor limited to the esophageal lumen or the thickness of the esophageal wall varied between 3-5 mm; Stage II, the thickness exceeds 5 mm but no invasion to the mediastinum or distant metastasis; Stage III, the tumor invades adjacent mediastinal structure; and Stage IV, there is distant metastasis. The tumor resection rate, pathological stage, treatment-related complication, and survival among groups were compared. The radical resection rate for the patients in radiotherapy and radiochemotherapy groups was increased in comparison with the control group (P < 0.05). Their pathological stage after esophagectomy was regressed significantly than that of the control group (50.85%, 55.08% vs. 0%, P < 0.05). The adjuvant chemotherapy group did show significant improvement on resection rate and pathological staging compared with the control group. The treatment-related complication in the three neoadjuvant groups had no significant difference from that of the control group (P > 0.05). The 3-year survival rate of radiotherapy and radiochemotherapy groups were significantly higher than that of the control group (69.49%, 73.73% vs. 53.38%, P < 0.05). The 5-year survival rate of radiochemotherapy group was higher than that of the radiotherapy group although did not show a statistical difference (P > 0.05). Rational application of neoadjuvant radiochemotherapy seems to provide a modest benefit in radical resection and survival in patients with locally advanced esophageal carcinoma.

Overexpression of AIB1 predicts resistance to chemoradiotherapy and poor prognosis in patients with primary esophageal squamous cell carcinoma

AIB1 (amplified in breast cancer 1) is frequently overexpressed in esophageal squamous cell carcinoma (ESCC), but the significance of AIB1 expression in chemoradiotherapy (CRT) sensitivity and its effect on prognosis are still unclear. In this study, the expression of AIB1 was examined by immunohistochemistry in 98 biopsy specimens of primary ESCC patients treated with definitive CRT. AIB1 overexpression was found in 63/98 (64.3%) of the ESCCs. There was a significant association between AIB1 overexpression and distant lymph node metastases (P = 0.011), but not regional lymph node metastases. In the M0 subgroup, overexpression of AIB1 was observed more frequently in stage T4 than in stage T2-3 (66.7%vs 38.5%, P = 0.031). In addition, AIB1 expression was the only factor that showed a significant correlation with CRT response, in which overexpression of AIB1 was observed more frequently in the CRT resistant group than in the CRT effective group (86.5%vs 50.8%, P < 0.001). Univariate analysis revealed that AIB1 overexpression was associated with poor progression-free survival (PFS) (P < 0.001) and poor disease-specific survival (DSS) (P <0.001). Furthermore, AIB1 expression could stratify patient survival in stages T2-3, T4, N1, and M0 (P < 0.05), as well as in the CRT effective group (P < 0.05), and AIB1 overexpression and CRT resistance were evaluated as significant independent prognostic factors for both PFS and DSS in multivariate analysis. These findings suggest that overexpression of AIB1 is a useful predictor of CRT resistance and an independent molecular marker of poor prognosis for ESCC patients.

Pretreatment health behaviors predict survival among patients with head and neck squamous cell carcinoma

PURPOSE

Our prior work has shown that the health behaviors of head and neck cancer patients are interrelated and are associated with quality of life; however, other than smoking, the relationship between health behaviors and survival is unclear.

PATIENTS AND METHODS

A prospective cohort study was conducted to determine the relationship between five pretreatment health behaviors (smoking, alcohol, diet, physical activity, and sleep) and all-cause survival among 504 head and neck cancer patients.

RESULTS

Smoking status was the strongest predictor of survival, with both current smokers (hazard ratio [HR] = 2.4; 95% CI, 1.3 to 4.4) and former smokers (HR = 2.0; 95% CI, 1.2 to 3.5) showing significant associations with poor survival. Problem drinking was associated with survival in the univariate analysis (HR = 1.4; 95% CI, 1.0 to 2.0) but lost significance when controlling for other factors. Low fruit intake was negatively associated with survival in the univariate analysis only (HR = 1.6; 95% CI, 1.1 to 2.1), whereas vegetable intake was not significant in either univariate or multivariate analyses. Although physical activity was associated with survival in the univariate analysis (HR = 0.95; 95% CI, 0.93 to 0.97), it was not significant in the multivariate model. Sleep was not significantly associated with survival in either univariate or multivariate analysis. Control variables that were also independently associated with survival in the multivariate analysis were age, education, tumor site, cancer stage, and surgical treatment.

CONCLUSION

Variation in selected pretreatment health behaviors (eg, smoking, fruit intake, and physical activity) in this population is associated with variation in survival.

The effect of preoperative weight loss and body mass index on postoperative outcome in patients with esophagogastric carcinoma

Studies have shown that weight loss is associated with adverse outcomes in all treatment modalities for esophagogastric carcinoma. Because of the increased prevalence of obesity and the effectiveness of perioperative nutrition, a number of patients are now obese or have normal body mass index (BMI) at the time of treatment. We investigated the relationship between weight loss, BMI, and outcome of surgery for patients with esophagogastric carcinoma. Data were collected over a 38-month period for all patients diagnosed with operable esophagogastric cancer at two UK centers. All patients underwent resection by a single Consultant Upper Gastrointestinal Surgeon and the use of perioperative jejunal feeding was universal. Ninety-three patients (57 male) underwent esophagogastric resection; 48 had no preoperative weight loss (34 with a BMI > 25 and 14 with a BMI < 25). Forty-five patients had preoperative weight loss (20 with BMI > 25 and 25 with BMI < 25). There was no significant difference in complication rates, median hospital stay, or mortality between the four groups. A significantly higher number of patients displaying preoperative weight loss were found to have stage III disease, but difference in survival of up to 3 years did not reach statistical significance on multivariate analysis. Preoperative weight loss and low BMI did not significantly influence the complication rate, perioperative mortality rate, length of hospital stay, or short-term prognosis. We conclude that preoperative weight loss can not be reliably used as an independent predictor of poor outcome in patients undergoing surgery for esophagogastric carcinoma. However, patients with preoperative weight loss and low BMI are more likely to have advanced disease.

Outcome for esophageal cancer following treatment with chemotherapy and radiotherapy but not esophagectomy: Nonsurgical treatment of esophageal cancer

Background:

More than 50% of patients with esophageal cancer are not suitable for surgery. The aim of this study was to analyze the outcome of patients undergoing standard nonsurgical treatment.

Methods:

Data of all patients undergoing nonsurgical treatment for esophageal cancer were identified from a prospective database.

Results:

Seventy-five patients were treated for localized disease, and 52 for metastatic disease at diagnosis. Except for age, which was higher in patients without metastases, there were no significant differences between the patients with vs. without metastatic disease. Kaplan–Meier analysis showed a median survival of 10.8 months for all patients. There was a significant difference in survival (p < 0.001) between the groups with versus without metastases, with median survival in the patients without metastases 13.6 months versus 6.5 months in patients with metastases. Patients undergoing nonsurgical treatment for localized disease had a five-year survival of 12%. No significant difference between adenocarcinoma and squamous cell carcinoma was identified. Subanalysis of patients who received chemoradiotherapy revealed similar results to the overall group of patients.

Conclusion:

In patients with localized disease at diagnosis, long-term survival can be achieved in some patients, whereas five-year survival is rare in patients who present with metastatic disease.