Elsevier

Surgery

Volume 164, Issue 1, July 2018, Pages 40-48
Surgery

Esophagus
Preoperative prediction of a pathologic complete response of esophageal squamous cell carcinoma to neoadjuvant chemoradiotherapy

https://doi.org/10.1016/j.surg.2018.01.011Get rights and content

Abstract

Background

The accurate prediction of a pathologic complete response (ypT0N0M [LYM] 0 ypStage 0) before operation is essential for selecting appropriate strategies for treating esophageal cancer after neoadjuvant chemoradiotherapy.

Methods

We reviewed 130 consecutive patients with esophageal squamous cell carcinoma who were evaluated preoperatively using upper gastrointestinal endoscopy, computed tomography, and 18F-fluorodeoxyglucose-positron emission tomography after neoadjuvant chemoradiotherapy and subsequently underwent esophagectomy. Our aim was to determine the diagnostic abilities of computed tomography, 18F-fluorodeoxyglucose-positron emission tomography, and endoscopy to predict preoperatively a pathologic complete response of the primary site of the locally advanced esophageal squamous cell carcinoma and associated lymph nodes to trimodal neoadjuvant chemoradiotherapy. Associations between clinical complete response (ycT0N0M [LYM] 0 ycStage 0) and pathologic complete response were investigated preoperatively.

Results

Twenty-nine (22.3%) and 43 (33.1%) patients, respectively, achieved clinical complete response and pathologic complete response, which were associated (P=.001). The sensitivity and specificity, as well as the positive and negative predictive values of clinical complete response to define pathologic complete response were 39.5%, 86.2%, 58.6%, and 74.3%, respectively. Univariate and multivariate analyses selected clinical complete response as the sole independent preoperative predictor of pathologic complete response (clinical complete responses versus non–clinical complete responses: odds ratio: 0.26, 95% confidence interval, 0.10–0.65, P=.004). Recurrence-free and overall survival (OS) rates were better in patients with than in those without clinical complete response (5-year recurrence-free and overall survival: 69.0% vs 41.4% and 75.9% vs 45.0%, respectively, both P=.02). Furthermore, clinical complete response was an independent preoperative predictor of recurrence-free survival (clinical complete response versus nonclinical complete response: hazard ratio: 2.20, 95% confidence interval, 1.08–4.45, P=.03).

Conclusion

Although pathologic complete response was predictable preoperatively to some extent, the accuracy was somewhat low. Considerable caution should be exercised when selecting the watch-and-wait approach with operation as needed and omitting planned operative intervention even for patients who achieve clinical complete response after neoadjuvant chemoradiotherapy.

Section snippets

Patients

We reviewed 130 consecutive patients with ESCC who were evaluated preoperatively before and after NCRT using CT, PET, and endoscopy and who later underwent esophagectomy between October 2006 and December 2016. All histologic tumor types were diagnosed as squamous cell carcinoma from biopsy samples obtained before treatment. Table I shows the clinicopathologic characteristics of patients. The clinicopathologic profiles of the tumors (cStage, ycStage, and ypStage: c, y and p determined by

Assessment of ypT0 using endoscopy and PET after NCRT

Fifty-three (40.8%) and 49 (37.7%) patients achieved disappearance of the primary tumor by endoscopy and PET, respectively, and were associated with ypT0 (Table II , P =.01 and P=.001, respectively). Furthermore, 33 (25.4%) patients achieved ycT0 (clinical complete disappearance of the primary tumor evaluated by both endoscopy and PET after NCRT) and were associated with ypT0 (Table II, P=.001).

The sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values of

Discussion

Esophageal cancer was diagnosed in resected specimens from some patients who achieved a pCR after NCRT followed by esophageal resection. Furthermore, adding the esophagectomy after induction CRT does not appear to confer any benefit compared with continuing additional CRT when patients with locally advanced thoracic ESCC respond to induction CRT.14 Therefore, definitive CRT might be an alternative treatment for patients with ESCC who respond very well to NCRT. These findings provided a basis

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