Role of postoperative radiotherapy for microscopic margin involvement in the squamous cell carcinoma of esophagus

Efficacy of postoperative radiotherapy in esophageal squamous cell carcinoma patients with positive circumferential resection margin

BACKGROUND

The significance of postoperative radiotherapy for residual disease after esophageal cancer surgery remains controversial. The purpose of this study was to elucidate the efficacy of postoperative radiotherapy in esophageal squamous cell carcinoma (ESCC) patients with positive circumferential resection margin (CRM).

METHODS

We retrospectively analyzed data from 1190 patients who underwent esophagectomy for ESCC at our hospital from 2005 to 2018, of whom 61 (5.1%) patients were diagnosed with positive CRM of ESCC. Overall survival (OS), progression-specific survival (PSS), local progression-specific survival (LPSS), and clinicopathological factors were compared between patients with and without postoperative radiotherapy. The efficacy of additional radiotherapy on patient outcomes was evaluated.

RESULTS

Among the 61 patients analyzed, 29 (47.5%) underwent radiotherapy (RT group) and 32 (52.5%) did not (NRT group). In the RT group, 22 patients (75.9%) received radiotherapy and 7 patients (24.1%) received chemoradiotherapy. The RT group included younger patients, a greater number of upper-esophageal tumors, and a greater rate of R2 resections than the NRT group. The LPSS and PSS of the RT group were significantly better than those of the NRT group (P = 0.007, P < 0.001, respectively). In multivariate analysis, postoperative radiotherapy was an independent factor for LPSS [P < 0.001; hazard ratio (HR) 0.17; 95% confidence interval (CI) 0.06-0.46] and PSS (P < 0.001; HR 0.31; 95% CI 0.16-0.60).

CONCLUSIONS

Postoperative radiotherapy contributed to the control of residual tumor and was significantly associated with better LPSS and PSS among patients with positive CRM after esophagectomy for ESCC.

Adjuvant radiotherapy in oesophageal cancer with positive circumferential resection margins-recurrence and survival outcomes

Background

The role of adjuvant radiotherapy in patients with microscopically positive circumferential resection margins (CRM), R1 specimen, in oesophageal resections for cancer with curative intent remains unclear. However, R1 specimens are associated with poorer survival outcomes. The aim was to assess the benefit of adjuvant radiotherapy on recurrence and survival in these patients.

Methods

Patients were identified in a single centre between July 2000 and December 2016. Patient demographics, tumour characteristics and survival outcomes were assimilated and compared between those who received adjuvant therapy and those who did not.

Results

Sixty-eight patients were included in the study; 57 (83.8%) male and 11 (16.2%) female with a median age of 67 years. The adjuvant radiotherapy regimen used was 40-50 Gy in 25 fractions over 5 weeks. Median follow-up was 13 months (interquartile range, 6-27 months). Twenty-five (36.8%) patients received adjuvant radiotherapy. There was no statistically significant correlation between administration of adjuvant radiotherapy and local recurrence (P=0.148), distant metastases (P=0.605), overall disease progression (P=0.561), progression-free survival (P=0.663) and overall survival (P=0.538).

Conclusions

This study detects no benefit to oncological outcomes with the use of adjuvant radiotherapy in patients with microscopically positive CRM. Larger randomized studies are needed to further confirm these results.

Post-operative radiotherapy is associated with improved survival in esophageal cancer with positive surgical margins

Background

The optimal treatment for early-stage esophageal cancer with positive surgical margins after an upfront esophagectomy is not well-defined. This study investigates the effect of post-operative radiotherapy (PORT) on overall survival (OS) in clinical stage I-II patients with positive margins.

Methods

We identified patients diagnosed between 2004 and 2012 with clinical stage I-II esophageal carcinoma from the National Cancer Data Base (NCDB) who underwent an upfront esophagectomy. For those patients with positive margins, administration of PORT was recorded, and OS was compared by the Kaplan-Meier estimator and log-rank test. Multivariable Cox regression analysis was performed to identify variables associated with improved survival.

Results

Among the 3,490 patients identified, 209 (5.8%) had positive margins. One hundred forty-two (67.9%) patients did not receive PORT while 67 (32.1%) did receive PORT. Compared to those receiving PORT, patients who did not receive PORT were significantly older (68.5 vs. 64.0 years, P=0.003), more likely to have pN0 disease (50.7% vs. 35.4%, P=0.026), and less likely to receive postoperative chemotherapy (21.1% vs. 86.6%, P<0.001). On multivariable logistic regression, only receipt of chemotherapy predicted for receipt of PORT (OR: 25.6, 95% CI: 9.9-65.8, P<0.001). OS was significantly higher for patients receiving PORT compared to those who did not (median OS: 32.2 vs. 16.9 months, log-rank P=0.008). Multivariable analysis confirmed an association with PORT and improved OS (HR: 0.39, 95% CI: 0.27-0.60, P<0.001). Subset analysis demonstrated that the OS benefit of PORT persisted in those patients who received adjuvant chemotherapy (HR: 0.33, 95% CI: 0.19-0.57, P<0.001).

Conclusions

PORT is associated with improved OS in clinical stage I-II esophageal cancer patients after an upfront esophagectomy with positive margins. In the absence of prospective randomized data, our findings suggest that PORT should be strongly considered in the setting of early-stage esophageal cancer resected with positive margins.

The Impact of Adjuvant Postoperative Radiation Therapy and Chemotherapy on Survival After Esophagectomy for Esophageal Carcinoma

OBJECTIVE

The objective of this study was to analyze the impact on overall survival (OS) from the addition of postoperative radiation with or without chemotherapy after esophagectomy, using a large, hospital-based dataset.

BACKGROUND

Previous retrospective studies have suggested an OS advantage for postoperative chemoradiation over surgery alone, although prospective data are lacking.

METHODS

The National Cancer Data Base was queried to select patients diagnosed with stage pT3-4Nx-0M0 or pT1-4N1-3M0 esophageal carcinoma (squamous cell or adenocarcinoma) from 1998 to 2011 treated with definitive esophagectomy ± postoperative radiation and/or chemotherapy. OS was analyzed using the Kaplan-Meier method and compared using the log-rank test. Multivariate Cox regression analysis was used to identify covariates associated with OS.

RESULTS

There were 4893 patients selected, of whom 1153 (23.6%) received postoperative radiation. Most patients receiving radiation also received sequential/concomitant chemotherapy (89.9%). For the entire cohort, postoperative radiation was associated with a statistically significant but modest absolute improvement in survival (hazard ratio 0.77; 95% CI, 0.71-0.83; P < 0.001). On subgroup analysis, postoperative radiation was associated with improved OS for patients with node-positive disease (3-yr OS 34.3 % vs 27.8%, P < 0.001) or positive margins (3-yr OS 36.4% vs 18.0%, P < 0.001). When chemotherapy usage was incorporated, sequential chemotherapy was associated with the best survival (P < 0.001). Multivariate analysis revealed that the addition of chemotherapy to radiation therapy, whether sequentially or concurrently, was a strong prognostic factor for OS.

CONCLUSIONS

In this hospital-based study, the addition of postoperative chemoradiation (either sequentially or concomitantly) after esophagectomy was associated with improved OS for patients with node-positive disease or positive margins.

Positive esophageal proximal resection margin: an important prognostic factor for esophageal cancer that warrants adjuvant therapy

BACKGROUND

Positive esophageal proximal resection margin (ERM+) following esophagectomy was considered as incomplete or R1 resection. The clinicopathological data and long-term prognosis of esophageal cancer (EC) patients with ERM+ after esophagectomy were still unknown. Therefore, the aim of this study was to assess the clinical significance of ERM+ and its therapeutic option.

METHODS

From November 2008 to December 2014, 3,594 patients with histologically confirmed EC underwent radical resection in our department. Among them there were 37 patients (1.03%) who had ERM+. ERM+ was defined as carcinoma or atypical hyperplasia (severe or moderate) at the residual esophageal margin in our study. For comparison, another 74 patients with negative esophageal proximal resection margin (ERM-) were propensity-matched at a ratio of 1:2 as control group according to sex, age, tumor location and TNM staging. The relevant prognostic factors were investigated by univariate and multivariate regression analysis.

RESULTS

In this large cohort of patients, the rate of ERM+ was 1.03%. The median survival time was 35.000 months in patients with ERM+, significantly worse than 68.000 months in those with ERM- (Chi-square =4.064, P=0.044). Survival in patients with esophageal residual atypical hyperplasia (severe or moderate) was similar to those with esophageal residual carcinoma. Survival rate in stage I-II was higher than that in stage III-IV (Chi-square =27.598, P=0.000) in ERM-; But there was no difference between the two subgroups of patients in ERM+. Furthermore, in those patients with ERM+, survival was better in those who having adjuvant therapy, compared to those without adjuvant therapy (Chi-square =5.480, P=0.019). And the average survival time which was improved to a well situation for ERM+ patients who have adjuvant therapy was 68.556 months which is comparable to average survival time (65.815 months) of ERM- for those patients who are at earlier stages.

CONCLUSIONS

ERM+ after esophagectomy nowadays is of low incidence but still an important prognostic factor for patients with EC. Survival of ERM+ patients who have adjuvant therapy was improved to a well situation which is comparable to overall survival (OS) rate of ERM- for those patients who are at earlier stages.

Alpha linolenic acid and oleic acid additively down-regulate malignant potential and positively cross-regulate AMPK/S6 axis in OE19 and OE33 esophageal cancer cells

OBJECTIVE

Both oleic acid (OA) and alpha-linolenic acid (ALA) have been proposed to down-regulate cell proliferation of prostate, breast, and bladder cancer cells. However, direct evidence that OA and/or ALA suppresses to the development of esophageal cancer has not been studied. Also, no previous studies have evaluated how OA and/or ALA regulates malignant potential (cell proliferation, migration, colony formation and adhesion) and intracellular signaling pathways, and whether their effects might be synergistic and/or additive in esophageal cancer cells has not yet been elucidated.

MATERIALS/METHODS

We conducted in vitro studies and evaluated whether OA and ALA alone or in combination may regulate malignant potential in OE19 and OE33 esophageal cancer cell lines.

RESULTS

Both OA and ALA significantly down-regulated cell proliferation, adhesion and/or migration. OA and/or ALA did not change the number of colonies but decrease colony sizes when compared to control. Also, we observed that OA and/or ALA positively cross-regulates the expression levels of AMPK/S6 axis. Moreover, OA and ALA up-regulated tumor suppressor genes (p53, p21, and p27) and these effects are abolished by AMPK siRNA administration. Importantly, we observed that these effects are additively regulated by OA and ALA in combination when compared to control in OE19 and OE33 esophageal cancer cell lines.

CONCLUSIONS

Our novel mechanistic studies provide evidence for an important role for OA and ALA in esophageal cancer, and suggest that OA and/or ALA might be useful agents in the management or chemoprevention of esophageal cancer.