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Lubbers M, Kouwenhoven EA, Smit JK, van Det MJ. Hiatal Hernia with Acute Obstructive Symptoms After Minimally Invasive Oesophagectomy. J Gastrointest Surg 2021; 25:603-608. [PMID: 32710135 DOI: 10.1007/s11605-020-04745-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/14/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND To evaluate the incidence, treatment and postoperative outcomes of an acute hiatal hernia (HH) after totally minimally invasive esophagectomy (tMIE) for oesophageal cancer. METHODS The incidence and treatment of acute HH were analysed from our prospective database including all patients that were surgically treated for oesophageal cancer in the period between January 2011 and December 2018. RESULTS Within the study period, the database contained 307 patients that underwent minimally invasive oesophagectomy. Patients' characteristics were in line with the literature of Western data. The incidence of acute HH was 2.6% (N = 8). All patients presented with gastro-intestinal obstruction symptoms, that required acute operation, repositioning of the intrathoracic organs in combination with a crural repair. Mesh reinforcement was used in 38% (N = 3). In two patients, the intestines were partially resected due to ischemia. Postoperative complications, as atrial fibrillation, respiratory failure and anastomotic leakage, were seen in 63% (N = 5). Recurrence-rate was 38% (N = 3). CONCLUSIONS This present study demonstrates that an acute HH after tMIE is a serious complication with an incidence of 2.6%. When symptomatic and acute, HH requires surgical intervention and has high postoperative morbidity and recurrence-rate. Therefore, this requires treatment in a centre specialised in oesophageal surgery.
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Affiliation(s)
- Merel Lubbers
- Department of Surgery, Hospital Group Twente (ZGT), Almelo, the Netherlands.
| | | | - Justin K Smit
- Department of Surgery, Hospital Group Twente (ZGT), Almelo, the Netherlands
| | - Marc J van Det
- Department of Surgery, Hospital Group Twente (ZGT), Almelo, the Netherlands
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Faiz Z, Dijksterhuis WPM, Burgerhof JGM, Muijs CT, Mul VEM, Wijnhoven BPL, Smit JK, Plukker JTM. A meta-analysis on salvage surgery as a potentially curative procedure in patients with isolated local recurrent or persistent esophageal cancer after chemoradiotherapy. Eur J Surg Oncol 2018; 45:931-940. [PMID: 30447937 DOI: 10.1016/j.ejso.2018.11.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 10/01/2018] [Accepted: 11/02/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Isolated local recurrent or persistent esophageal cancer (EC) after curative intended definitive (dCRT) or neoadjuvant chemoradiotherapy (nCRT) with initially omitted surgery, is a potential indication for salvage surgery. We aimed to evaluate safety and efficacy of salvage surgery in these patients. MATERIAL AND METHODS A systematic literature search following PRISMA guidelines was performed using databases of PubMed/Medline. All included studies were performed in patients with persistent or recurrent EC after initial treatment with dCRT or nCRT, between 2007 and 2017. Survival analysis was performed with an inverse-variance weighting method. RESULTS Of the 278 identified studies, 28 were eligible, including a total of 1076 patients. Postoperative complications after salvage esophagectomy were significantly more common among patients with isolated persistent than in those with locoregional recurrent EC, including respiratory (36.6% versus 22.7%; difference in proportion 10.9 with 95% confidence interval (CI) [3.1; 18.7]) and cardiovascular complications (10.4% versus 4.5%; difference in proportion 5.9 with 95% CI [1.5; 10.2]). The pooled estimated 30- and 90-day mortality was 2.6% [1.6; 3.6] and 8.0% [6.3; 9.8], respectively. The pooled estimated 3-year and 5-year overall survival (OS) were 39.0% (95% CI: [35.8; 42.2]) and 19.4% [95% CI:16.5; 22.4], respectively. Patients with isolated persistent or recurrent EC after initial CRT had similar 5-year OS (14.0% versus 19.7%, difference in proportion -5.7, 95% CI [-13.7; 2.3]). CONCLUSIONS Salvage surgery is a potentially curative procedure in patients with locally recurrent or persistent esophageal cancer and can be performed safely after definitive or neoadjuvant chemoradiotherapy when surgery was initially omitted.
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Affiliation(s)
- Z Faiz
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - W P M Dijksterhuis
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - J G M Burgerhof
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - C T Muijs
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - V E M Mul
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - B P L Wijnhoven
- Department of Surgery, University of Rotterdam, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - J K Smit
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Surgery, Ziekenhuis Groep Twente, Almelo, the Netherlands
| | - J T M Plukker
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
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den Bakker CM, Smit JK, Bruynzeel AME, van Grieken NCT, Daams F, Derks S, Cuesta MA, Plukker JTM, van der Peet DL. Non responders to neoadjuvant chemoradiation for esophageal cancer: why better prediction is necessary. J Thorac Dis 2017; 9:S843-S850. [PMID: 28815082 PMCID: PMC5538978 DOI: 10.21037/jtd.2017.06.123] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 06/21/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Patients with pathologic limited or no response (pNR) to neoadjuvant chemoradiation (nCRT) are subjected to curative intended esophagectomy with subsequent perioperative morbidity and mortality, but potentially only harm from nCRT. The primary aim of this study was to compare the overall survival (OS) of patients with pNR and patients who underwent primary esophagectomy to evaluate potentially benefits of nCRT in these patients. The secondary aim was to identify predictive clinicopathologic factors for pNR and pathologic complete response (pCR) to nCRT with the goal to preselect these patients before the start of treatment. METHODS From the period 2005 to 2016, 206 esophageal cancer (EC) patients treated with Carboplatin/Paclitaxel and radiotherapy with complementary esophagectomy were included in this cohort. OS of patients with pNR was compared with a historical cohort of primary surgically treated patients (n=218) after a propensity score matching resulting in a group of 68 patients with pNR after nCRT versus a group of 68 primary esophagectomy patients. RESULTS The OS in the pNR group and the primary esophagectomy group was comparable (P=0.986). No predictive factors were found in this cohort for pNR. Female gender (OR 2.5, 95% CI 1.2-5.3) and squamous cell carcinoma (SCC) (OR 2.6, 95% CI 1.3-5.3) were identified as independent predictive factors for pCR. CONCLUSIONS Patients with a pNR do not benefit from nCRT followed by resection. These patients had a similar OS as those who had a primary esophagectomy alone. Although this indicates that nCRT does not negatively impact the OS of patients with pNR, patients still have an increased morbidity because of nCRT. Hence, it is important to identify factors that predict pNR. The ability to predict pNR (and pCR) will enable tailored and personalized care preventing unnecessary nCRT with increased morbidity.
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Affiliation(s)
| | - Justin K. Smit
- Department of Surgery, Ziekenhuisgroep Twente, Almelo, The Netherlands
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Anna M. E. Bruynzeel
- Department of Radiotherapy, VU University medical center, Amsterdam, The Netherlands
| | | | - Freek Daams
- Department of Surgery, VU University medical center, Amsterdam, The Netherlands
| | - Sarah Derks
- Department of Medical Oncology, VU University medical center, Amsterdam, The Netherlands
| | - Miguel A. Cuesta
- Department of Surgery, VU University medical center, Amsterdam, The Netherlands
| | - John T. M. Plukker
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
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Honing J, Pavlov KV, Mul VE, Karrenbeld A, Meijer C, Faiz Z, Smit JK, Hospers GA, Burgerhof JG, Kruyt FA, Kleibeuker JH, Plukker JT. CD44, SHH and SOX2 as novel biomarkers in esophageal cancer patients treated with neoadjuvant chemoradiotherapy. Radiother Oncol 2015; 117:152-8. [DOI: 10.1016/j.radonc.2015.08.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 08/26/2015] [Accepted: 08/29/2015] [Indexed: 02/04/2023]
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Hulshoff JB, Faiz Z, Karrenbeld A, Kats-Ugurlu G, Burgerhof JGM, Smit JK, Plukker JTM. Prognostic Value of the Circumferential Resection Margin in Esophageal Cancer Patients After Neoadjuvant Chemoradiotherapy. Ann Surg Oncol 2015; 22 Suppl 3:S1301-9. [PMID: 26314875 PMCID: PMC4686561 DOI: 10.1245/s10434-015-4827-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Indexed: 12/13/2022]
Abstract
Background Circumferential resection margins (CRM) for esophageal cancer (EC), defined by the College of American Pathologists (CAP; >0 mm) or the Royal College of Pathologists (RCP; >1 mm) as tumor-free (R0), are based on a surgery-alone approach. We evaluated the usefulness of both definitions in current practice with neoadjuvant chemoradiotherapy (nCRT). Methods CRMs were measured in 209 patients (104 with nCRT) with locally advanced EC after transthoracic esophagectomy. Local recurrence and cancer related death were scored as events. Patients were followed for at least 2 years or until death. Prognostic factors (P < 0.1 in univariate analyses) for 2-year disease-free survival (DFS) and local recurrence-free survival (LRFS) were incorporated in multivariate Cox regression analyses. Both CRM measurements were analyzed separately and prognostic cutoff values (0–1.0 mm) were assessed in both groups. Results Independent prognostic factors (P < 0.05) for 2-year DFS were tumor length, lymph node ratio, angioinvasion, and CAP R0 in the surgery-alone group and pN stage (P < 0.01) in the nCRT group. Prognostic factors (P < 0.05) for 2-year LRFS were CAP, lymph node ratio, and tumor length in the surgery-alone group, and CAP and grade in the nCRT group. Optimal CRM cutoff values between 0.0 and 0.2 mm were prognostic for 2-year DFS in the surgery-alone and at 0.3 mm for the nCRT group. Conclusions nCRT affected the CRM cutoff values. After nCRT, the CRM R0 according to the CAP was only prognostic for 2-year LRFS. However, in the surgery-alone group, it was prognostic for both the 2-year DFS and LRFS.
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Affiliation(s)
- J B Hulshoff
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, 9713 AV, Groningen, The Netherlands
| | - Z Faiz
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, 9713 AV, Groningen, The Netherlands
| | - A Karrenbeld
- Department of Pathology, University of Groningen, University Medical Center Groningen, 9713 AV, Groningen, The Netherlands
| | - G Kats-Ugurlu
- Department of Pathology, University of Groningen, University Medical Center Groningen, 9713 AV, Groningen, The Netherlands
| | - J G M Burgerhof
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, 9713 AV, Groningen, The Netherlands
| | - J K Smit
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, 9713 AV, Groningen, The Netherlands
| | - J Th M Plukker
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, 9713 AV, Groningen, The Netherlands.
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Honing J, Pavlov KV, Meijer C, Smit JK, Boersma-van Ek W, Karrenbeld A, Burgerhof JGM, Kruyt FAE, Plukker JTM. Loss of CD44 and SOX2 Expression is Correlated with a Poor Prognosis in Esophageal Adenocarcinoma Patients. Ann Surg Oncol 2014; 21 Suppl 4:S657-64. [DOI: 10.1245/s10434-014-3763-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Indexed: 12/13/2022]
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Honing J, Smit JK, Muijs CT, Burgerhof JGM, de Groot JW, Paardekooper G, Muller K, Woutersen D, Legdeur MJC, Fiets WE, Slot A, Beukema JC, Plukker JTM, Hospers GAP. A comparison of carboplatin and paclitaxel with cisplatinum and 5-fluorouracil in definitive chemoradiation in esophageal cancer patients. Ann Oncol 2014; 25:638-643. [PMID: 24492674 PMCID: PMC4433521 DOI: 10.1093/annonc/mdt589] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Revised: 12/09/2013] [Accepted: 12/10/2013] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND In esophageal cancer (EC) patients who are not eligible for surgery, definitive chemoradiation (dCRT) with curative intent using cisplatinum with 5-fluorouracil (5-FU) is the standard chemotherapy regimen. Nowadays carboplatin/paclitaxel is also often used. In this study, we compared survival and toxicity rates between both regimens. PATIENTS AND METHODS This multicenter study included 102 patients treated in five centers in the Northeast Netherlands from 1996 till 2008. Forty-seven patients received cisplatinum/5-FU (75 mg/m(2) and 1 g/m(2)) and 55 patients carboplatin/paclitaxel (AUC2 and 50 mg/m(2)). RESULTS Overall survival (OS) was not different between the cisplatinum/5-FU and carboplatin/paclitaxel group {[P = 0.879, hazard ratio (HR) 0.97 [confidence interval (CI) 0.62-1.51]}, with a median survival of 16.1 (CI 11.8-20.5) and 13.8 months (CI 10.8-16.9). Median disease-free survival (DFS) was comparable [P = 0.760, HR 0.93 (CI 0.60-1.45)] between the cisplatinum/5-FU group [11.1 months (CI 6.9-15.3)] and the carboplatin/paclitaxel group [9.7 months (CI 5.1-14.4)]. Groups were comparable except clinical T stage was higher in the carboplatin/paclitaxel group (P = 0.008). High clinical T stage (cT4) was not related to OS and DFS in a univariate analysis (P = 0.250 and P = 0.201). A higher percentage of patients completed the carboplatin/paclitaxel regimen (82% versus 57%, P = 0.010). Hematological and nonhematological toxicity (≥grade 3) in the carboplatin/paclitaxel group (4% and 18%) was significantly lower than in the cisplatinum/5-FU (19% and 38%, P = 0.001). CONCLUSIONS In this study, we showed comparable outcome, in terms of DFS and OS for carboplatin/paclitaxel compared with cisplatinum/5-FU as dCRT treatment in EC patients. Toxicity rates were lower in the carboplatin/paclitaxel group together with higher treatment compliance. Carboplatin/paclitaxel as an alternative treatment of cisplatinum/5-FU is a good candidate regimen for further evaluation.
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Affiliation(s)
- J Honing
- Departments of Surgical Oncology
| | - J K Smit
- Departments of Surgical Oncology
| | | | | | | | | | - K Muller
- Department of Radiotherapy, Institute Stedendriehoek en Omstreken, Deventer
| | | | | | - W E Fiets
- Department of Medical Oncology, Medisch Centrum Leeuwarden, Leeuwarden
| | - A Slot
- Department of Radiation Oncology, Radiotherapeutic Institute Friesland, Leeuwarden, The Netherlands
| | | | | | - G A P Hospers
- Medical Oncology, University of Groningen, University Medical Center Groningen, Groningen.
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Hulshoff JB, Smit JK, van der Jagt EJ, Plukker JT. Evaluation of progression prior to surgery after neoadjuvant chemoradiotherapy with computed tomography in esophageal cancer patients. Am J Surg 2014; 208:73-9. [PMID: 24476969 DOI: 10.1016/j.amjsurg.2013.08.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 08/25/2013] [Accepted: 08/26/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND The risk of tumor progression during neoadjuvant chemoradiotherapy (CRT) in esophageal cancer (EC) is around 8% to 17%. We assessed the efficacy of computed tomography (CT) to identify these patients before esophagectomy. METHODS Ninety-seven patients with locally advanced EC treated with Carboplatin/Paclitaxel and 41.4 Gy neoadjuvantly were restaged with CT. Two radiologists reviewed pre- and post-CRT CT images. The primary outcome was detection of clinically relevant progressive disease. Missed metastases were defined as metastatic disease found during surgery or within 3 months after post-CRT CT. RESULTS Progressive disease was detected in 9 patients (9%). Both radiologists detected 5 patients with distant metastases (liver, n = 4; lung metastasis, n = 1), but missed progressive disease in 4 cases. One radiologist falsely assessed 2 metastatic lesions, but after agreement progressive disease was detected with sensitivity and specificity of 56% and 100%, respectively. CONCLUSION CT is effective in detecting clinically relevant progressive disease in EC patients, after neoadjuvant treatment.
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Affiliation(s)
- Jan B Hulshoff
- Department of Surgical Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - Justin K Smit
- Department of Surgical Oncology, University Medical Center Groningen, Groningen, The Netherlands
| | - Eric J van der Jagt
- Department of Radiology, University Medical Center Groningen, Groningen, The Netherlands
| | - John T Plukker
- Department of Surgical Oncology, University Medical Center Groningen, Groningen, The Netherlands.
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Wang D, Smit JK, Zwaan E, Muijs CT, Groen H, Hollema H, Plukker JT. Neoadjuvant therapy reduces the incidence of nodal micrometastases in esophageal adenocarcinoma. Am J Surg 2013; 206:732-8. [DOI: 10.1016/j.amjsurg.2013.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 02/12/2013] [Accepted: 03/21/2013] [Indexed: 12/20/2022]
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Smit JK, Güler S, Beukema JC, Mul VE, Burgerhof JGM, Hospers GAP, Plukker JTM. Different recurrence pattern after neoadjuvant chemoradiotherapy compared to surgery alone in esophageal cancer patients. Ann Surg Oncol 2013; 20:4008-15. [PMID: 23838922 DOI: 10.1245/s10434-013-3102-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Indexed: 01/20/2023]
Abstract
PURPOSE To evaluate the rate and pattern of recurrences after neoadjuvant chemoradiotherapy (CRT) in esophageal cancer patients. METHODS We described survival and differences in recurrences from a single center between neoadjuvant CRT (carboplatin/paclitaxel and 41.4 Gy) and surgery alone for the period 2000-2011. To reduce bias, we performed a propensity score matched analysis. RESULTS A total of 204 patients were analyzed, 75 treated with neoadjuvant CRT and 129 with surgery alone. The pathologic response to neoadjuvant CRT was 69% with a complete response rate of 25%. After matching, baseline characteristics between the groups (both n = 75) were equally distributed. The 3- and 5-year disease-free survival was 53 and 42% in the neoadjuvant CRT group compared with 24 and 18% in the surgery-alone group (P = 0.011). After 3 and 5 years' CRT, patients had an estimated locoregional recurrence-free survival of 83 and 73% compared with 52 and 49% in the surgery-alone group (P = 0.015). The distant recurrence-free survival was comparable in both groups. Locoregional recurrences were located less in the paraesophageal lymph nodes in the CRT group than in the surgery-alone group, 9 versus 21%, respectively (P = 0.041). With respect to differences in distant recurrences, we observed more skeletal recurrences in the surgery-alone group compared to CRT, 12 versus 1% (P = 0.009). CONCLUSIONS The neoadjuvant CRT regimen we used offers a significant improvement in outcome, with a different recurrence pattern compared with surgery alone. This effect is probably due to both the pathologic complete response and eradication of micrometastases in CRT group.
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Affiliation(s)
- Justin K Smit
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Smit JK, Faber H, Niemantsverdriet M, Baanstra M, Bussink J, Hollema H, van Os RP, Plukker JTM, Coppes RP. Prediction of response to radiotherapy in the treatment of esophageal cancer using stem cell markers. Radiother Oncol 2013; 107:434-41. [PMID: 23684587 DOI: 10.1016/j.radonc.2013.03.027] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 03/20/2013] [Accepted: 03/24/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE In this study, we investigated whether cancer stem cell marker expressing cells can be identified that predict for the response of esophageal cancer (EC) to CRT. MATERIALS AND METHODS EC cell-lines OE-33 and OE-21 were used to assess in vitro, stem cell activity, proliferative capacity and radiation response. Xenograft tumors were generated using NOD/SCID mice to assess in vivo proliferative capacity and tumor hypoxia. Archival and fresh EC biopsy tissue was used to confirm our in vitro and in vivo results. RESULTS We showed that the CD44+/CD24- subpopulation of EC cells exerts a higher proliferation rate and sphere forming potential and is more radioresistant in vitro, when compared to unselected or CD44+/CD24+ cells. Moreover, CD44+/CD24- cells formed xenograft tumors faster and were often located in hypoxic tumor areas. In a study of archival pre-neoadjuvant CRT biopsy material from EC adenocarcinoma patients (N=27), this population could only be identified in 50% (9/18) of reduced-responders to neoadjuvant CRT, but never (0/9) in the complete responders (P=0.009). CONCLUSION These results warrant further investigation into the possible clinical benefit of CD44+/CD24- as a predictive marker in EC patients for the response to chemoradiation.
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Affiliation(s)
- Justin K Smit
- University of Groningen, University Medical Center Groningen, Department of Surgery, Section of Surgical Oncology, The Netherlands
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Smit JK, Muijs CT, Burgerhof JGM, Paardekooper G, Timmer PR, Muller K, Woutersen D, Mul VE, Beukema JC, Hospers GAP, van Dijk BAC, Langendijk JA, Plukker JTM. Survival after Definitive (Chemo)Radiotherapy in Esophageal Cancer Patients: A Population-Based Study in the North-East Netherlands. Ann Surg Oncol 2012; 20:1985-92. [DOI: 10.1245/s10434-012-2824-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2012] [Indexed: 11/18/2022]
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Muijs CT, Smit JK, Karrenbeld A, Beukema JC, Langendijk JA, Plukker JT. Standardized pathologic evaluation of the esophagus after neoadjuvant chemoradiation. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.4_suppl.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
136 Background: The main objective of this study was to develop and validate a method to reconstruct the gross and clinical tumor volume (GTV and CTV) on the esophageal specimen in order to facilitate a good pathologic examination of the original tumor area after neo-adjuvant chemoradiation (CRT). Methods: The GTV and CTV borders of 25 patients were defined by a radiation oncologist on the planning CT in relation to 5 anatomical reference points. After CRT, the GTV and CTV borders were marked in vivo on the esophagus during surgical resection. Finally, the pathologist evaluated the presence of macroscopic and microscopic tumor in- and outside the GTV and CTV. The radiation tumor response was scored according to the standardized 5-tier Mandard classification. Radiation induced side effects were scored as well. Results: The Mandard classification could be scored on basis of the GTV alone in 68% of the cases (N=17). For the other patients (N=8), the GTV and the CTV should both be incorporated for correct evaluation of the tumor response. Five patients (20%) showed complete tumor response (Mandard 1), 68% (N=17) showed partial response (Mandard 2-3) and 12% (N=3) showed hardly any response (Mandard 4-5). In the partial responders, macroscopic tumor was found within the delineated GTV and microscopic tumor remained within the CTV both in 100% of the cases. In two patients (40%) with hardly any response, microscopic tumor was also found outside the CTV. This might be caused by tumor growth during the neo-adjuvant treatment or by geographical miss. Nine patients turned out to have positive lymph nodes. On average 18 (range 8-30) lymph nodes were evaluated per patients. Giant cell reactions, lymphocyte infiltration, and fibrosis, which indicate tumor regression were seen in the CTV and GTV, and were most pronounced in the GTV. Conclusions: This study suggested that demarcation of the GTV and CTV on the esophagus in vivo is important for standardized pathologic evaluation of the esophagus after neo-adjuvant chemoradiation. Furthermore using this method we determined microscopic tumor outside the CTV in 40% of the cases (N=2) of the bad responders (Mandard 4-5), illustrating the importance of our method in this patient category.
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Affiliation(s)
| | - Justin K. Smit
- University Medical Center Groningen, Groningen, Netherlands
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Pultrum BB, Honing J, Smit JK, van Dullemen HM, van Dam GM, Groen H, Hollema H, Plukker JTM. A critical appraisal of circumferential resection margins in esophageal carcinoma. Ann Surg Oncol 2010; 17:812-20. [PMID: 19924487 PMCID: PMC2820690 DOI: 10.1245/s10434-009-0827-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Indexed: 11/18/2022]
Abstract
Background In esophageal cancer, circumferential resection margins (CRMs) are considered to be of relevant prognostic value, but a reliable definition of tumor-free CRM is still unclear. The aim of this study was to appraise the clinical prognostic value of microscopic CRM involvement and to determine the optimal limit of CRM. Methods To define the optimal tumor-free CRM we included 98 consecutive patients who underwent extended esophagectomy with microscopic tumor-free resection margins (R0) between 1997 and 2006. CRMs were measured in tenths of millimeters with inked lateral margins. Outcome of patients with CRM involvement was compared with a statistically comparable control group of 21 patients with microscopic positive resection margins (R1). Results A cutoff point of CRM at ≤1.0 mm and >1.0 mm appeared to be an adequate marker for survival and prognosis (both P < 0.001). The outcome in patients with CRMs ≤1.0 and >0 mm was equal to that in patients with CRM of 0 mm (P = 0.43). CRM involvement was an independent prognostic factor for both recurrent disease (P = 0.001) and survival (P < 0.001). Survival of patients with positive CRMs (≤1 mm) did not significantly differ from patients with an R1 resection (P = 0.12). Conclusion Involvement of the circumferential resection margins is an independent prognostic factor for recurrent disease and survival in esophageal cancer. The optimal limit for a positive CRM is ≤1 mm and for a free CRM is >1.0 mm. Patients with unfavorable CRM should be approached as patients with R1 resection with corresponding outcome.
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Affiliation(s)
- Bareld B Pultrum
- Department of Surgery, Division of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Smit JK, Pultrum BB, van Dullemen HM, Van Dam GM, Groen H, Plukker JTM. Prognostic factors and patterns of recurrence in esophageal cancer assert arguments for extended two-field transthoracic esophagectomy. Am J Surg 2010; 200:446-53. [PMID: 20409512 DOI: 10.1016/j.amjsurg.2009.12.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Revised: 12/04/2009] [Accepted: 12/04/2009] [Indexed: 01/29/2023]
Abstract
BACKGROUND High recurrence rates determine the dismal outcome in esophageal cancer. We reviewed our experiences and defined prognostic factors and patterns of recurrences after curatively intended transthoracic esophagectomy. METHODS Between January 1991 and December 2005, 212 consecutive patients underwent a radical transthoracic esophagectomy with extended 2-field lymphadenectomy. Recurrence rates, survival, and prognostic factors were analyzed (minimal follow-up period, 2 y). RESULTS Radicality was obtained in 85.6%. The median follow-up period was 26.6 months. The overall recurrence rate at 1, 3, and 5 years was 28%, 44%, and 64%, respectively, and locoregional recurrence rate was 17%, 27%, and 43%, respectively. Overall survival rates, including postoperative deaths, were 45% and 34% at 3 and 5 years, respectively. pT stage and lymph node (LN) ratio greater than .20 were independent prognostic factors for survival and recurrences. Radicality was most prognostic for survival, and for N+ greater than 4 positive LN for recurrences. CONCLUSIONS Radicality and LN ratio are strong prognostic factors. High radicality and adequate nodal assessment are guaranteed by an extended transthoracic approach.
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Affiliation(s)
- Justin K Smit
- Department of Surgical Oncology, PO Box 30001, 9700 RB, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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