Can CT-PET and Endoscopic Assessment Post-Neoadjuvant Chemoradiotherapy Predict Residual Disease in Esophageal Cancer?

OBJECTIVE: The aim of this study is to assess CT-PET and endoscopic assessment postneoadjuvant chemoradiotherapy (nCRT) in predicting complete pathologic response (pCR) in locally advanced esophageal cancer (LAEC). DESIGN: A prospective cohort study. BACKGROUND: nCRT is increasingly standard of care in LAEC, with pCR a surrogate for excellent outcome. Predicting pCR before surgery, with metabolic imaging and endoscopy, may spare patients' operative intervention. METHODS: One hundred thirty-eight consecutive patients [mean age 61 ±â€Š8, 99 male (72%), 103 (75%) adenocarcinoma] underwent nCRT with CT-PET and endoscopy 4 to 6 weeks later, and surgery subsequently. A complete metabolic response (cMR) was defined as SUVmax of <4. A complete endoscopic response (cER) was no residual mucosal abnormality. The association of pCR with cMR and cER was analyzed. RESULTS: pCR was achieved in 30 patients (22%); 37% SCC and 17% adenocarcinoma. A cMR was evident in 63 (46%), of whom 17 (27%) had a pCR and 17(27%) were ypN+. A cER was observed in 45 (33%). The Spearman correlation for cER and cMR was 0.066 (P = 0.479), for cER and pCR was 0.004 (P = 0.969), and cMR and pCR -0.120 (P = 0.160). The sensitivity, specificity, positive predictive value, and negative predictive value of cMR was 57%, 57%, 27%, and 82%, respectively, and for combined cMR and cER was 24%, 83%, 28%, and 79%, respectively. CONCLUSIONS: The prediction of pCR through CT-PET and endoscopy independently or combined is limited by low sensitivity and poor positive predictive value. Protocols to avoid surgery in patients with apparent complete clinical complete based on these criteria should be adopted with considerable caution.

Evidence-based selective application of transhiatal esophagectomy in a high-volume esophageal center.

BACKGROUND: Transthoracic esophagectomy (TTE) with lymphadenectomy represents the gold standard of operative approaches to esophageal cancer. The TTE procedure carries significant operative risk, particularly in patients with co-morbidities, and the possible oncologic benefit of a mediastinal lymph node dissection in certain subgroups of patients with esophageal cancer is controversial. Transhiatal esophagectomy (THE), which avoids a thoracotomy, may reduce morbidity and mortality below levels seen with TTE, and there is no proof from randomized studies of any oncologic inferiority to TTE in patients with early tumors. Accordingly, the selective use of THE has increased in our high-volume center in recent years, and this study audits that experience over the last decade METHODS: Between 2000 and 2009 inclusive, 584 patients were treated surgically with curative intent. The standard operative approach in our unit is en bloc TTE, and THE represents 5.5% overall, and 11.1% in the second 5-year period (2004-2009), compared with 2% previously. The present study details the selection of these cases (n = 32) treated with THE and their outcomes, as well as the outcomes in the TTE (n = 438) group RESULT: Transhiatal esophagectomy was used for early stage carcinoma (n = 18) and for patients of advanced age who also had co-morbidities (n = 14). Patients undergoing THE were significantly older (68.46 versus 63.07 years of age; p = 0.002), and were at higher operative risk based on ASA grade (grade 3: 53.1% versus 17.3%; p < 0.001), compared with TTE patients. The THE cohort also included more patients with early cancers compared with the TTE cohort (56.3% versus 17.6%; p < 0.001). There were no differences in R0 resection rates for patients with early tumors or advanced co-morbidity. Nodal yields were lower in THE patients (p = 0.005). The overall complication rate was lower in the THE group (31.6% versus 44.2%; p = 0.021), and there were no postoperative deaths in the transhiatal group, whereas the in-hospital mortality rate for the TTE group was 3% (p < 0.001). Disease-specific survival was equivalent with each approach. CONCLUSIONS: Transhiatal esophagectomy has a role in a pragmatic individualized approach to esophageal cancer. As an alternative to a standardized en bloc transthoracic esophagectomy, the transhiatal approach may be suitable for patients with predicted node-negative cancers or those with resectable disease who are not candidates for TTE because of co-morbidity.

Multimodality therapy for adenocarcinoma of the esophagus, gastric cardia, and upper gastric third.

There is considerable controversy over the level of recommendations from randomized trials underpinning management decisions for patients presenting with localized adenocarcinoma of the esophagus and esophagogastric junction. Despite a paucity of Level 1 recommendations compared with other gastrointestinal sites, in particular rectal cancer, there is an emerging consensus in practice to consider multimodal approaches in all cases that present with T3 or node-positive disease. There is also an optimism that new approaches, including response prediction based on sequential 18FDG-PET scanning following induction chemotherapy, and novel drugs targeted at EGF, EGFR, VEGF, and tyrosine kinase inhibition may improve treatment pathways and outcomes. In this review, we assess the level of recommendations from the major published trials and -discuss new trials and approaches.

Treatment options for esophageal cancer.

There is considerable controversy over the level of evidence from randomized trials underpinning management decisions for patients presenting with localized cancer of the esophagus and esophago-gastric junction. There is also an optimism that new drugs and new approaches, including response prediction based on sequential (18)FDG-PET scanning following induction chemotherapy, may improve treatments pathways and outcomes. In this review we assess the level of evidence from the major published trials, and discuss new trials and approaches.