A nomogram that predicts pathologic complete response to neoadjuvant chemoradiation also predicts survival outcomes after definitive chemoradiation for esophageal cancer

Nomograms for predicting risk of locoregional recurrence and distant metastases for esophageal cancer patients after radical esophagectomy

Background

The aim of this study was to develop nomograms for predicting the risk of locoregional recurrence or distant metastasis in esophageal cancer patients who were treated with esophagectomy and regional lymphadenectomy.

Methods

The clinicopathologic data of 408 esophageal cancer patients after esophagectomy and regional lymphadenectomy were analyzed in this study. Univariate and multivariate COX regression analyses were used to test the association between the clinicopathologic data and the risk of locoregional recurrence or distant metastasis. The nomograms were built from the COX regression model.

Results

Univariate analyses revealed that tumor length, tumor width, T-staging and perineural invasion(PNI) were significantly associated with locoregional recurrence, and that tumor length, tumor width, differentiation, T-staging, N-staging, lymph vascular space invasion(LVSI), PNI and adjuvant chemotherapy were significantly associated with distant metastasis. Multivariate analyses revealed that tumor length, tumor width and T-staging were predictors of risk of locoregional recurrence, and that differentiation, N-staging, LVSI and PNI were predictors of risk of distant metastasis. Two nomograms were constructed for a visual explanation of these two COX regression models. The bias-corrected curve showed no significant departure from the ideal curve in these two nomograms.

Conclusions

Two nomograms were developed and validated to predict the risk of locoregional recurrence and distant metastasis in esophageal cancer patients after radical esophagectomy. The calculation outcome will help oncologists to choose adjuvant treatment regimens.

18F-fluorodeoxyglucose positron emission tomography predicts lymph node responses to definitive chemoradiotherapy in esophageal squamous cell carcinoma patients

Purpose

To evaluate the capability of ¹⁸F-fluorodeoxyglucose positron emission tomography/ computed tomography (¹⁸F-FDG-PET/CT) to predict the clinical response of metastatic lymph node (mLN) to definitive chemoradiotherapy (dCRT) and guide personalized radiation dose in esophageal squamous cell carcinoma (ESCC) patients.

Patients and methods

One hundred and forty-three mLNs from 59 patients with ESCC treated with dCRT and who had undergone a pretreatment ¹⁸F-FDG-PET/CT scan were included in the study. All defined mLNs were contoured by nuclear medicine radiologists. Response was evaluated by contrast-enhanced computed tomography and ¹⁸F-FDG-PET/CT.

Results

Sixty-nine mLNs showed complete response (CR), and 74 mLNs showed non-complete response. The 143 mLNs were divided into 4 groups (Groups 1–4) based on the quartiles of maximum standardized uptake value (SUVmax-G1, SUVmax-G2, SUVmax-G3, and SUVmax-G4) and metabolic tumor volume (MTV-G1, MTV-G2, MTV-G3, and MTV-G4). The CR rate of SUVmax-G2 was significantly higher than the other 3 groups. The escalated radiation dose improved the CR rate of lymph nodes in SUVmax-G3 (55 Gy) and SUVmax-G4 (61 Gy). The lowest CR rate was found in MTV-G4 (the group with the largest MTV). The escalated radiation dose (59.7 Gy) improved the CR rate of lymph node in MTV-Groups 3 and 4.

Conclusion

Pretreatment metabolic parameters can predict the response of mLNs to dCRT for patients with ESCC. The parameters could also be used to guide personalized dose to mLNs.

A prognostic nomogram for overall survival after neoadjuvant radiotherapy or chemoradiotherapy in thoracic esophageal squamous cell carcinoma: a retrospective analysis

BACKGROUND

Currently, the AJCC staging system or pathological complete response (pCR) are considered not sufficiently accurate to evaluate the survival of patients with esophageal squamous cell carcinoma after neoadjuvant radiotherapy or chemoradiotherapy. This study aimed to establish a nomogram and a recursive partitioning analysis (RPA) model to estimate prognosis and to provide advice for subsequent treatments.

METHODS

We analyzed retrospectively 407 patients that were diagnosed with thoracic esophageal squamous cell carcinoma (TESCC) and received neoadjuvant radiotherapy or chemoradiotherapy. Hazard ratios and 95% confidence intervals of categorical clinicopathological characteristics with overall survival (OS) were calculated using the Cox proportional hazard model. The nomogram and RPA model were then established and total scores according to each variable were calculated and stratified to predict OS.

RESULTS

Patients were followed-up over a median 49.9 months. AJCC did not perform well in distinguishing OS among each stage except for IIB and IIIA. Patients were divided into 4 groups according to the total scores based on nomogram (low risk: ≤180; intermediate risk: 180-270; high risk: 270-340; very high risk: >340). The 5-year OS was 57.3%, 40.7%, 18.3%, 6.1% respectively (p<0.05). RPA model also divide the patients into 4 groups, though group2 and group3 were not statistically significant (p=0.574).

CONCLUSION

The nomogram is a good evaluation model for estimating the prognosis of patients with TESCC after neoadjuvant radiotherapy or chemoradiotherapy compared with the AJCC and RPA. The results of this study also suggested that the high-risk subgroups need further treatments.

Surveillance versus esophagectomy in esophageal cancer patients with a clinical complete response after induction chemoradiation

There currently exists an area of controversy in treatment of esophageal cancer for patients who have an apparent clinical complete response (cCR) after induction chemoradiation. A standard treatment is to offer these patients an esophagectomy, but increasingly there is interest from both the patient and provider for active surveillance with so-called "salvage" esophagectomies for local recurrence as an alternative treatment paradigm. In this article, we review the existing evidence that stakeholders should consider for clinical decision-making in this specific patient population, including: the accuracy of post-induction clinical restaging, the reliability of operative risk assessment, the feasibility and adherence to surveillance strategies, and the observed outcomes in these patients after salvage esophagectomy or continued active surveillance. We also briefly discuss quality of life and future directions for this field.

Definitive chemoradiotherapy

Definitive chemoradiotherapy (dCRT) is reflecting a treatment standard in oesophageal cancer. For irresectable localised tumours and for inoperable patients, dCRT can change the treatment intent from palliative to curative. In patients with squamous cell carcinoma (SCC), in particular in those of cervical location, dCRT is a proper alternative for treatment that may include radical surgery. Patients with localised locoregional recurrence after primary surgery can survive for long-term after salvage CRT.

Predictive factors in the evaluation of treatment response to neoadjuvant chemoradiotherapy in patients with advanced esophageal squamous cell cancer

Neoadjuvant therapy before esophagectomy is evidence-based, and is a standard-of-care for locally advanced and operable esophageal cancer. However response to such treatment varies in individual patients, from no clinical response to pathological complete response. It has been consistently shown that a good pathological responses is of prognostic value, but perhaps in the expense of those who do not. It is important to identify suitable predictive factors for response, so that patients are not exposed to potentially harmful chemotherapy and/or radiotherapy without benefits. Alternative management strategies can be devised. Various clinical, radiological, serological and potential molecular markers have been studied. None has been shown to be sufficiently reliable to be used in daily practice. Certainly more understanding of the molecular basis for response to chemotherapy/radiotherapy is needed, so that patient treatment can be tailored and individualized.

The emerging field of radiomics in esophageal cancer: current evidence and future potential

'Radiomics' is the name given to the emerging field of extracting additional information from standard medical images using advanced feature analysis. This innovative form of quantitative image analysis appears to have future potential for clinical practice in patients with esophageal cancer by providing an additional layer of information to the standard imaging assessment. There is a growing body of evidence suggesting that radiomics may provide incremental value for staging, predicting treatment response, and predicting survival in esophageal cancer, for which the current work-up has substantial limitations. This review outlines the available evidence and future potential for the application of radiomics in the management of patients with esophageal cancer. In addition, an overview of the current evidence on the importance of reproducibility of image features and the substantial influence of varying smoothing scales, quantization levels, and segmentation methods is provided.

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.

Prognostic nomogram for previously untreated patients with esophageal squamous cell carcinoma after esophagectomy followed by adjuvant chemotherapy

OBJECTIVE

The aim of the study was to establish an effective prognostic nomogram for esophageal squamous cell carcinoma after radical esophagectomy followed by adjuvant chemotherapy in those previously untreated patients.

METHODS

The clinicopathological data from 328 patients who underwent radical esophagectomy followed by adjuvant chemotherapy or not at the Tianjin Medical University Cancer Institute and Hospital between 2006 and 2010 were retrospectively studied. Nomograms which predicted survival of esophageal squamous cell carcinoma were established based on the Cox proportional hazards regression model. To determine its predictive accuracy and discriminatory capacity, the concordance index and calibration curve were calculated after bootstrapping in the internal validation. An external validation of 76 patients in 2011 was prospectively studied at the same institution. To verify the performance of the nomogram, the comparison between the nomogram and Tumor-Node-Metastasis staging system was conducted.

RESULTS

The 5-year overall survival was 43.1% in the primary cohort. Based on multivariate analyses, five independent prognostic variables including gender, tumor length, T stage, N stage and chemotherapy cycles were selected to build the nomograms to predict disease-free survival and overall survival. The concordance index of the nomogram to predict overall survival was 0.71 (95% confidence interval, 0.63-0.79), which was superior to the predictive power of Tumor-Node-Metastasis staging system (0.64) in the primary cohort. Meanwhile, the calibration curve showed good accuracy between predictive and actual overall survival. In the validation cohort, the concordance index (0.77) and calibration plot displayed favorable performances. The other nomogram to predict disease-free survival also performed well.

CONCLUSIONS

The prognostic nomogram provided individualized risk estimate of survival in patients after esophagectomy followed by adjuvant chemotherapy.

Understanding Complete Pathologic Response in Oesophageal Cancer: Implications for Management and Survival

Despite significant improvement over recent decades, oesophageal cancer survival rates remain poor. Neoadjuvant chemoradiotherapy followed by oesophageal resection is mainstay of therapy for resectable oesophageal tumours. Operative morbidity and mortality associated with oesophagectomy remain high and complications arise in up to 60% of patients. Management strategies have moved towards definitive chemoradiotherapy for a number of tumour sites (head and neck, cervical, and rectal) particularly for squamous pathology. We undertook to perform a review of the current status of morbidity and mortality associated with oesophagectomy, grading systems determining pathologic response, and data from clinical trials managing patients with definitive chemoradiotherapy to inform a discussion on the topic.