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Surveillance Implications of Recurrence Patterns in Early Node-Negative Esophageal Adenocarcinoma.

ABSTRACT: BACKGROUND:There are limited data regarding optimal surveillance after curative resection for esophageal cancer. Once disease recurrence is diagnosed, the prognosis is poor. The purpose of this article was to characterize disease recurrence in patients with early esophageal adenocarcinoma. METHODS:Two hundred sixty patients were identified from a prospective institutional database with pathologic T1 and T2 node-negative disease therapy treated with curative esophagectomy alone for esophageal adenocarcinoma between 1995 and 2017. Competing risk analysis was used to analyze factors associated with recurrence. RESULTS:The 5-year cumulative incidence of recurrence was 12%. Predictive factors for increased risk of recurrence included increasing tumor size, poor differentiation, and pathologic T2 disease (P < .05), whereas presence of Barrett's esophagus on pathology was protective. Recurrence within 2 years was 2.5%, 6.1%, and 12% for T1a, T1b, and T2 disease, respectively. At 5 years cumulative incidence of recurrence was 8.2%, 11.5% and 22.2%, respectively. Median overall survival after recurrence was 1.04 years (95% confidence interval, 0.7-2.4). There were 14 subclinical and 13 symptomatic recurrences; patients with symptomatic recurrence had a significantly shorter overall survival after recurrence occurred (0.31 vs 0.71 years, P = .018). CONCLUSIONS:Among early node-negative patients with esophageal cancer undergoing curative resection, 5-year recurrence was 12%. Survival after recurrence was poor, and only a few patients had isolated locoregional recurrence at time of diagnosis, suggesting that scheduled surveillance may have an important role.

SUBMITTER: Nobel TB

PROVIDER: S-EPMC6878144 | biostudies-literature | 2019 Dec

REPOSITORIES: biostudies-literature

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Surveillance Implications of Recurrence Patterns in Early Node-Negative Esophageal Adenocarcinoma.

Nobel Tamar B TB Livschitz Jennifer J Xing Xin Xin XX Barbetta Arianna A Hsu Meier M Tan Kay See KS Sihag Smita S Jones David R DR Molena Daniela D

The Annals of thoracic surgery 20190716 6

<h4>Background</h4>There are limited data regarding optimal surveillance after curative resection for esophageal cancer. Once disease recurrence is diagnosed, the prognosis is poor. The purpose of this article was to characterize disease recurrence in patients with early esophageal adenocarcinoma.<h4>Methods</h4>Two hundred sixty patients were identified from a prospective institutional database with pathologic T1 and T2 node-negative disease therapy treated with curative esophagectomy alone for ...[more]

PMID: 31323215

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Project description:ImportanceWhile neoadjuvant chemoradiation for esophageal cancer improves oncologic outcomes for a broad group of patients with locally advanced and/or node-positive tumors, it is less clear which specific subset of patients derives most benefit in terms of overall survival (OS).ObjectiveTo determine whether neoadjuvant chemoradiation based on esophageal adenocarcinoma histology has similar oncologic outcomes for patients treated with surgery alone when stratified by clinical nodal status.Design, setting, and participantsA retrospective analysis using the American College of Surgeons National Cancer Database from 1998 to 2006. Patients with esophageal adenocarcinoma histology and clinical stage T1bN1-N3 or T2-T4aN-/+M0 were divided into 2 treatment groups: (1) neoadjuvant chemoradiation followed by surgery and (2) surgery alone. Subset analysis within each treatment group was performed for clinically node-negative patients (cN-) vs node-positive patients (cN+) in conjunction with pathological nodal status. A propensity score-adjusted analysis, which included patient demographics, comorbidity status, and clinical T stage, was also performed.Main outcome and measuresThe primary outcome was 3-year OS. Secondary outcomes included margin status, postoperative length of stay, unplanned readmission rate, and 30-day mortality.ResultsA total of 1309 patients were identified, of whom 539 received neoadjuvant chemoradiation followed by surgery and 770 received surgery alone. Of the 1309 patients, 41.2% (n = 539) received neoadjuvant chemoradiation and 47.2% (n = 618) were cN+. Median follow-up for the entire cohort was 73.3 months (interquartile range, 64.1-93.5 months). The 3-year OS was better for neoadjuvant chemoradiation followed by surgery compared with surgery alone (49% vs 38%, respectively; P < .001). Stratifying based on clinical nodal status, the propensity score-adjusted OS was significantly better for cN+ patients who received neoadjuvant chemoradiation (hazard ratio, 0.52; 95% CI, 0.42-0.66; P < .001). In contrast, there was no difference in OS for cN- patients based on treatment (hazard ratio, 0.84; 95% CI, 0.65-1.10; P = .22).Conclusions and relevancePatients with cN+ esophageal adenocarcinoma benefit significantly from neoadjuvant chemoradiation. However, patients with cN- tumors treated with neoadjuvant chemoradiation plus surgery do not derive a significant OS benefit compared with surgery alone. This finding may have significant implications on the use of neoadjuvant chemoradiation in patients with cN- disease.

Project description:Although endoscopic surveillance of patients with Barrett's esophagus (BE) has been widely implemented for early detection of esophageal adenocarcinoma (EAC), its justification has been debated. This systematic review aimed to evaluate benefits, safety, and cost effectiveness of surveillance for patients with BE.MEDLINE, EMBASE, EconLit, Scopus, Cochrane, and CINAHL were searched for published human studies that examined screening practices, benefits, safety, and cost effectiveness of surveillance among patients with BE. Reviewers independently reviewed eligible full-text study articles and conducted data extraction and quality assessment, with disagreements resolved by consensus. Random effects meta-analyses were performed to assess the incidence of EAC, EAC/high-grade dysplasia (HGD), and annual stage-specific transition probabilities detected among BE patients under surveillance, and relative risk of mortality among EAC patients detected during surveillance compared with those not under surveillance.A total of 51 studies with 11,028 subjects were eligible; the majority were of high quality based on the Newcastle-Ottawa quality scale. Among BE patients undergoing endoscopic surveillance, pooled EAC incidence per 1,000 person-years of surveillance follow-up was 5.5 (95% confidence interval (CI): 4.2-6.8) and pooled EAC/HGD incidence was 7.7 (95% CI: 5.7-9.7). Pooled relative mortality risk among surveillance-detected EAC patients compared with nonsurveillance-detected EAC patients was 0.386 (95% CI: 0.242-0.617). Pooled annual stage-specific transition probabilities from nondysplastic BE to low-grade dysplasia, high-grade dysplasia, and EAC were 0.019, 0.003, and 0.004, respectively. There was, however, insufficient scientific evidence on safety and cost effectiveness of surveillance for BE patients.Our findings confirmed a low incidence rate of EAC among BE patients undergoing surveillance and a reduction in mortality by 61% among those who received regular surveillance and developed EAC. Because of knowledge gaps, it is important to assess safety of surveillance and health-care resource use and costs to supplement existing evidence and inform a future policy decision for surveillance programs.

Project description:BackgroundA key barrier to controlling esophageal adenocarcinoma (EAC) is identifying those most likely to benefit from screening and surveillance. We aimed to develop an online educational tool, termed IC-RISC™, for providers and patients to estimate more precisely their absolute risk of developing EAC, interpret this estimate in the context of risk of dying from other causes, and aid in decision-making.ResultsU.S. incidence and mortality data and published relative risk estimates from observational studies and clinical trials were used to calculate absolute risk of EAC over 10 years adjusting for competing risks. These input parameters varied depending on presence of the key precursor, Barrett's esophagus. The open source application works across common devices to gather risk factor data and graphically illustrate estimated risk on a single page. Changes to input data are immediately reflected in the colored graphs. We used the calculator to compare the risk distribution between EAC cases and controls from six population-based studies to gain insight into the discrimination metrics of current practice guidelines for screening, observing that current guidelines sacrifice a significant amount of specificity to identify 78-86% of eventual cases in the US population.ConclusionsThis educational tool provides a simple and rapid means to graphically communicate risk of EAC in the context of other health risks, facilitates "what-if" scenarios regarding potential preventative actions, and can inform discussions regarding screening, surveillance and treatment options. Its generic architecture lends itself to being easily extended to other cancers with distinct pathways and/or intermediate stages, such as hepatocellular cancer. IC-RISC™ extends current qualitative clinical practice guidelines into a quantitative assessment, which brings the possibility of preventative actions being offered to persons not currently targeted for screening and, conversely, reducing unnecessary procedures in those at low risk. Prospective validation and application to existing well-characterized cohort studies are needed.

Dataset Information

Surveillance Implications of Recurrence Patterns in Early Node-Negative Esophageal Adenocarcinoma.

Publications

Surveillance Implications of Recurrence Patterns in Early Node-Negative Esophageal Adenocarcinoma.

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