Quality of Life During Neoadjuvant Treatment and After Surgery for Resectable Esophageal Carcinoma

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作者：Esther van Meerten ; Ate van der Gaast ; Caspar W.N. Looman ; Hugo W.G. Tilanus ; Karin Muller ; Marie-Louise Essink-Bot
关键词：Esophageal cancer ; Neoadjuvant chemoradiotherapy ; Health-related quality of life ; Esophagectomy ; Combined-modality treatment
刊名：International Journal of Radiation Oncology*Biology*Physics
出版年：2008
期刊代码：136_03603016
类别：med
出版时间：1 May 2008
卷：71
期：1
页码：160-166
文件大小：226 K

摘要

Clinical and histopathological factors (Ki67, p53 and EGFR expression) were studied in 56 patients presenting with esophageal cancer between September 2000 and March 2006 (35 squamous cell carcinomas, 20 adenocarcinomas, one undifferentiated carcinoma). The response to chemoradiotherapy was evaluated endoscopically and by histological examination in 16 patients who underwent surgical resection.

Results

Independent factors predictive of a complete endoscopic response were good performance status (RR = 15.75; CI: 1.74–142.58; P = 0.01) and overexpression of Ki67 (RR = 4.46; CI: 1.08–18.31; P = 0.04). In patients who underwent surgery, a major histopathological response was associated with complete endoscopic response (P < 0.01), complete CT-scan response (P = 0.04) and good performance status (WHO = 0) (P = 0.04). The mean survival was 40 months. Adenocarcinoma histology (RR = 3.18, CI: 1.13–8.54; P = 0.02) and an impaired performance status (RR = 4.79; CI: 1.07–21.41; P = 0.04) were independently associated with poor survival.

Conclusion

In the present study, good performance status and overexpression of Ki67 were two independent factors for complete endoscopic response after chemoradiotherapy for esophageal cancer. Independent risk factors for poor survival were adenocarcinoma histological type and impaired performance status. Further prospective studies are necessary to complete the present results.

Résumé

Objectif

Le but de ce travail était d’identifier des facteurs prédictifs de réponse à la radiochimiothérapie concomitante dans le cancer de l’œsophage.

Malades et méthodes

Les caractéristiques anatomocliniques et immunohistochimiques (expression de p53, EGF-R et Ki67) ont été étudiées rétrospectivement chez 56 patients (35 carcinomes épidermoïdes, 20 adénocarcinomes, un carcinome indifférencié) traités par radiochimiothérapie concomitante entre septembre 2000 et mars 2006. La réponse à la radiochimiothérapie était évaluée par endoscopie avec biopsies et par analyse histologique de la pièce d’exérèse chez les 16 patients opérés.

Résultats

Les facteurs prédictifs indépendants de réponse endoscopique complète étaient un bon état général (OMS = 0) (RR = 15,75 ; IC :1,74–142,58 ; p = 0,01) et la surexpression de Ki67 (RR = 4,46 ; IC : 1,08–18,31 ; p = 0,04). Chez les patients opérés, les facteurs prédictifs de réponse histologique majeure étaient une réponse endoscopique complète (p = 0,001), une réponse tomodensitométrique complète (p = 0,04) et le grade OMS à 0 (p = 0,04). Les facteurs indépendants de mauvais pronostic pour la survie globale étaient le type histologique adénocarcinome (RR = 3,11 ; IC :1,13–8,54 ; p = 0,03) et l’état général OMS 1 ou 2 (RR = 4,79 ; IC : 1,07–21,41 ; p = 0,04).

Conclusion

Notre étude montre que la surexpression de Ki67 et un bon état général (OMS = 0) sont prédictifs de réponse à la radiochimiothérapie. Le type histologique adénocarcinome et un OMS > 0 sont des facteurs indépendants de mauvais pronostic. Des études prospectives sont nécessaires pour confirmer ces résultats.

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Objective: Some patients with localised oesophageal cancer are treated with definitive chemoradiotherapy (CRT) rather than surgery. A subset of these patients experiences local failure, relapse or treatment-related complication without distant metastases, with no other curative treatment option but salvage oesophagectomy. The aim of this study was to assess the benefit/risk ratio of surgery in such context. Methods: Review of a single institution experience with 24 patients: 18 men and 6 women, with a mean age of 59 years (±9). Histology was squamous cell carcinoma in 18 cases and adenocarcinoma in 6. Initial stages were cIIA (n = 5), cIIB (n = 1) and cIII (n = 18). CRT consisted of 2–6 sessions of the association 5-fluorouracil/cisplatin concomitantly with a 50–75 Gy radiation therapy. Salvage oesophagectomy was considered for the following reasons: relapse of the disease with conclusive (n = 11) or inconclusive biopsies (n = 7), intractable stenosis (n = 3), and perforation or severe oesophagitis (n = 3), at a mean delay of 74 days (14–240 days) following completion of CRT. Results: All patients underwent a transthoracic en-bloc oesophagectomy with 2-field lymphadenectomy. Thirty-day and 90-day mortality rates were 21%and 25%, respectively. Anastomotic leakage (p = 0.05), cardiac failure (p = 0.05), length of stay (p = 0.03) and the number of packed red blood cells (p = 0.02) were more frequent in patients who received more than 55 Gy, leading to a doubled in-hospital mortality when compared to that of patients having received lower doses. A R0 resection was achieved in 21 patients (87.5%). A complete pathological response (ypT0N0) was observed in 3 patients (12.5%). Overall and disease-free 5-year survival rates were 35%and 21%, respectively. There was no long-term survivor following R1–R2 resections. Functional results were good in more than 80%of the long-term survivors. Conclusion: Salvage surgery is a highly invasive and morbid operation after a volume dose of radiation exceeding 55 Gy. The indication must be carefully considered, with care taken to avoid incomplete resections. Given that long-term survival with a fair quality of life can be achieved, such high-risk surgery should be considered in selected patients at an experienced centre.

Aims

To evaluate a single centre's experience with pancreatic carcinoma focused on preoperative chemoradiation therapy (CRT) for treatment of locally advanced pancreatic carcinoma. The aim of the present analysis was to evaluate the median overall survival time (OS) after preoperative CRT and to compare it with OS after primary resection of pancreatic carcinoma. In conclusion a new treatment strategy was developed using multimodality treatment for pancreatic carcinoma deemed to be resectable by CT-scan.

Patients and methods

Between 1995 and 2003, 302 patients with ductal adenocarcinoma of the pancreatic head and body were recorded prospectively and OS was analysed with regard to therapy.

Results

Fifty-eight patients were resected without any pretreatment and had an OS of 21 months. Twenty-one patients with initially unresectable tumours underwent CRT followed by resection and had an OS of 54 months, which was not significantly different from primary resection (p = 0.315). Lymph node metastasis was significantly reduced after CRT (p = 0.0029). OS for patients whose tumours could not be resected was 3–10 months, depending on tumour stage and consecutive therapy.

Conclusion

CRT pretreatment was effective in locally advanced pancreatic carcinoma and resulted in resection of tumours otherwise staged as non-resectable. This experience led to a randomized trial for patients who by CT are staged to have resectable cancer of the pancreatic head with the intent to increase curative resectability and survival by neoadjuvant CRT (ISRCTN78805636/NCT00335543).

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