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Shanda H Blackmon,
Elizabeth H Stephens,
Arlene M Correa, Wayne Hofstetter,
Min P Kim,
Reza J Mehran,
David C Rice,
Jack A Roth,
Stephen G Swisher,
Garrett L Walsh,
Ara A Vaporciyan
[show abstract]
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ABSTRACT: BACKGROUND: Resection of pulmonary colorectal carcinoma metastases may provide long-term benefit, but patient selection remains controversial. The objective of this study was to identify preoperative predictors of survival and lung recurrence for patients undergoing resection of such lesions. METHODS: A prospectively collected database was retrospectively reviewed to identify patients who underwent their first colorectal carcinoma pulmonary metastasectomy. Two multivariate logistic analyses were performed to identify preoperative predictors of survival and lung recurrence. Preoperative factors, pathologic colorectal carcinoma stage, additional sites of metastases, timing of metastatic occurrence, and premetastasectomy disease-free interval were included in the univariate analyses. RESULTS: From January 2000 to December 2010, 229 patients met inclusion criteria. The mean age was 60 years, and 100 patients (43.7%) were women. The overall median time and 5-year survival rate were 70.1 months and 55.4%, respectively, after the first pulmonary metastasectomy. Median follow-up was 37.2 months. Age older than 60 years (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.005 to 1.052; p = 0.016), male sex (HR, 1.84; 95% CI, 1.089 to 3.094; p = 0.023), and more than three lung metastases (HR, 1.15; 95% CI, 1.024 to 1.282; p = 0.018) predicted survival at 5 years in one multivariate analysis. In the second, more than three lung metastases present at first metastasectomy (HR, 1.19; 95% CI, 1.071 to 1.321; p = 0.001) and the preoperative disease-free interval of less than 3 years (HR, 0.99; 95% CI, 0.973 to 0.997; p = 0.013) predicted lung recurrence. CONCLUSIONS: Older age, male sex, and more lung metastases predict poorer survival after resection of pulmonary colorectal cancer metastases. The number of lung metastases present at the first metastasectomy and the preoperative disease-free interval predicted recurrence in the lung.
The Annals of thoracic surgery 10/2012; · 3.74 Impact Factor
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The Lancet 09/2012; 380(9845):883; author reply 885-6. · 38.28 Impact Factor
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Jenifer L Marks, Wayne Hofstetter,
Arlene M Correa,
Reza J Mehran,
David Rice,
Jack Roth,
Garrett Walsh,
Ara Vaporciyan,
Jeremy Erasmus,
Joe Chang,
Dipen Maru,
Jeffrey H Lee,
Jared Lee,
Jaffer A Ajani,
Stephen G Swisher
[show abstract]
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ABSTRACT: Outcomes of salvage esophagectomy after definitive chemoradiation (CRT) for squamous cell carcinoma are well defined. Previous reports of salvage esophagectomy in patients with recurrent adenocarcinoma after definitive CRT are limited by small numbers and high morbidity and mortality rates.
We reviewed our experience of 65 patients with esophageal adenocarcinoma treated from 1997 to 2010 who underwent salvage esophagectomy after failed definitive CRT. We then compared this group to 65 matched patients of 521 total patients with esophageal adenocarcinoma who received preoperative CRT followed by planned esophagectomy. Propensity matching and multivariable analysis were performed.
Median time to surgery from completion of therapy for the salvage group was 216 days. Major postoperative events (major pulmonary event, conduit loss, leak, readmission to intensive care unit) occurred in 35% (23 of 65) of salvage patients and 31% (20 of 65) of the planned resection matched group. Anastomotic leak occurred in 18.5% (12 of 65) and 11.3 (59 of 521) of salvage and planned groups, respectively. Thirty-day mortality was 3.1% (2 of 65) after salvage resection and 4.6% (3 of 65) after planned resection. There was no difference in 3-year overall or median survival between the two groups of patients (32 months, 48% salvage, versus 40 months, 57% planned resection). Multivariable analysis did not identify salvage strategy or time from completion of therapy to resection as a predictor of major event or death.
Postoperative morbidity, mortality, and overall survival of patients after salvage esophagectomy are comparable to matched patients after planned resection. These results suggest that patients with esophageal adenocarcinoma who fail definitive CRT and recur locoregionally should be considered for salvage esophagectomy at experienced esophageal centers.
The Annals of thoracic surgery 08/2012; 94(4):1126-33. · 3.74 Impact Factor
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[show abstract]
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ABSTRACT: Local failure after definitive chemoradiation therapy for unresectable esophageal cancer remains problematic. Little is known about the failure pattern based on modern-day radiation treatment volumes. We hypothesized that most local failures would be within the gross tumor volume (GTV), where the bulk of the tumor burden resides.
We reviewed treatment volumes for 239 patients who underwent definitive chemoradiation therapy and compared this information with failure patterns on follow-up positron emission tomography (PET). Failures were categorized as within the GTV, the larger clinical target volume (CTV, which encompasses microscopic disease), or the still larger planning target volume (PTV, which encompasses setup variability) or outside the radiation field.
At a median follow-up time of 52.6 months (95% confidence interval, 46.1-56.7 months), 119 patients (50%) had experienced local failure, 114 (48%) had distant failure, and 74 (31%) had no evidence of failure. Of all local failures, 107 (90%) were within the GTV, 27 (23%) were within the CTV, and 14 (12%) were within in the PTV. On multivariate analysis, GTV failure was associated with tumor status (T3/T4 vs T1/T2; odds ratio, 6.35; P = .002), change in standardized uptake value on PET before and after treatment (decrease >52%: odds ratio, 0.368; P = .003), and tumor size (>8 cm, 4.08; P = .009).
Most local failures after definitive chemoradiation for unresectable esophageal cancer occur in the GTV. Future therapeutic strategies should focus on enhancing local control.
Cancer 05/2012; 118(10):2632-40. · 4.77 Impact Factor
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Arya Amini,
Lianchun Xiao,
Pamela K Allen,
Akihiro Suzuki,
Yuki Hayashi,
Zhongxing Liao, Wayne Hofstetter,
Christopher Crane,
Ritsuko Komaki,
Manoop S Bhutani,
Jeffrey H Lee,
Jaffer A Ajani,
James Welsh
[show abstract]
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ABSTRACT: The celiac lymph node axis acts as a gateway for metastatic systemic spread. The need for prophylactic celiac nodal coverage in chemoradiation therapy for esophageal cancer is controversial. Given the improved ability to evaluate lymph node status before treatment via positron emission tomography (PET) and endoscopic ultrasound, we hypothesized that prophylactic celiac node irradiation may not be needed for patients with localized esophageal carcinoma.
We reviewed the radiation treatment volumes for 131 patients who underwent definitive chemoradiation for esophageal cancer. Patients with celiac lymph node involvement at baseline were excluded. Median radiation dose was 50.4 Gy. The location of all celiac node failures was compared with the radiation treatment plan to determine whether the failures occurred within or outside the radiation treatment field.
At a median follow-up time of 52.6 months (95% CI 46.1-56.7 months), 6 of 60 patients (10%) without celiac node coverage had celiac nodal failure; in 5 of these patients, the failures represented the first site of recurrence. Of the 71 patients who had celiac coverage, only 5 patients (7%) had celiac region relapse. In multivariate analyses, having a pretreatment-to-post-treatment change in standardized uptake value on PET >52% (odds ratio [OR] 0.198, p = 0.0327) and having failure in the clinical target volume (OR 10.72, p = 0.001) were associated with risk of celiac region relapse. Of those without celiac coverage, the 6 patients that later developed celiac failure had a worse median overall survival time compared with the other 54 patients who did not fail (median overall survival time: 16.5 months vs. 31.5 months, p = 0.041). Acute and late toxicities were similar in both groups.
Although celiac lymph node failures occur in approximately 1 of 10 patients, the lack of effective salvage treatments and subsequent low morbidity may justify prophylactic treatment in distal esophageal cancer patients.
International journal of radiation oncology, biology, physics 03/2012; 83(2):e231-9. · 4.59 Impact Factor
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John A Harvin,
Guy Lahat,
Arlene M Correa,
Jared Lee,
Dipen Maru,
Jaffer Ajani,
Edith M Marom,
James Welsh,
Manoop S Bhutani,
Garret Walsh,
Jack Roth,
Reza Mehran,
Ara Vaporciyan,
David Rice,
Stephen Swisher, Wayne Hofstetter
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ABSTRACT: The incidence and consequence of an isolated involved circumferential radial margin (CRM) after resection for esophageal adenocarcinoma in the setting of neoadjuvant chemoradiotherapy (CRT) has not been reported. We aimed to determine the frequency and significance of a close (<1 mm) or involved CRM in patients undergoing esophagectomy after CRT.
We retrospectively analyzed the data from patients undergoing resection from 1997 to 2008 for esophageal adenocarcinoma after neoadjuvant CRT. A positive CRM was defined as microscopic tumor at or less than 1 mm of the radial margin. An R1 resection was tumor at the radial margin. Only patients with ypT3 or greater tumors were included. R2 resections were excluded. Statistical comparisons were performed using Cox regression and Kaplan-Meier analyses.
A total of 160 patients met the inclusion criteria, 42 (26%) had a positive CRM. The median survival did not significantly differ between the CRM-negative and -positive groups (28 vs 50 months, P = .84). A propensity score matching analysis also failed to find a significant difference in outcomes. When analyzed by tumor present at the margin (R1), R0 patients had a longer median survival compared with R1 patients (28 vs 8 months, P = .01). This difference, however, was not seen on propensity score matching.
Resections of locally advanced esophageal adenocarcinoma with residual transmural viable tumor after CRT frequently showed involvement of the radial margin with tumor either close to or at the margin. Tumor close (<1 mm) to the radial margin did not result in a significant decrease in overall or disease-free survival or increase in local recurrence.
The Journal of thoracic and cardiovascular surgery 12/2011; 143(2):412-20. · 3.41 Impact Factor
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Elizabeth H Stephens,
Shanda H Blackmon,
Arlene M Correa,
Jack A Roth,
David C Rice, Wayne Hofstetter,
Robert Benjamin,
Reza Mehran,
Stephen G Swisher,
Garrett L Walsh,
Ara A Vaporciyan
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ABSTRACT: Sarcoma patients with pulmonary metastases frequently receive chemotherapy before resection. We hypothesized that measurable progression after chemotherapy is a novel predictor of poor outcomes in sarcoma patients undergoing pulmonary metastasectomy.
We conducted a retrospective review of patients between 1998 and 2006 identifying those with sarcoma in whom lung metastases developed as their first site of recurrence, received chemotherapy for their metastases, and then underwent pulmonary metastasectomy. Multivariable analysis of preoperative factors was performed to identify predictors of poor survival. Progression after chemotherapy was defined as either an increase in the size of the nodules or the number of nodules on 2 CT scans before resection. All operations were performed within 3 months of completion of chemotherapy.
Eighty-one sarcoma patients underwent pulmonary metastasectomy after chemotherapy (45 men, mean age 43 years). Multivariable analysis suggested disease-free interval ≥2 years versus <2 years (hazard ratio = 0.375; 95% CI, 0.206-0.682; p = 0.001) and progression after chemotherapy (hazard ratio = 4.025; 95% CI, 1.089-14.881; p = 0.04) were significant predictors of survival. Five-year survival after metastasectomy in patients whose disease progressed after neoadjuvant chemotherapy was substantially worse compared with patients without measurable progression (0% versus 32%). Median survival for those with no progression was 35.5 ± 15.7 months, compared with 17.2 ± 4.8 months for those with progression.
Progression of pulmonary metastases after chemotherapy is a novel prognostic factor for survival in patients with sarcoma undergoing metastasectomy, even when controlled for known factors such as disease-free interval and number of metastases.
Journal of the American College of Surgeons 03/2011; 212(5):821-6. · 4.55 Impact Factor
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Stephen G Swisher, Wayne Hofstetter,
Ritsuko Komaki,
Arlene M Correa,
Jeremy Erasmus,
Jeffrey H Lee,
Zhongxing Liao,
Dipen Maru,
Reza Mehran,
Shital Patel,
David C Rice,
Jack A Roth,
Ara A Vaporciyan,
Garrett L Walsh,
Jaffer A Ajani
[show abstract]
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ABSTRACT: Controversy currently exists about the optimum preoperative treatment platform for locoregionally advanced esophageal cancer, namely, preoperative chemoradiotherapy (preoperative C/RT) or preoperative chemotherapy alone. We therefore reviewed sequential phase II/III trials performed at a single institution to assess the impact of preoperative chemotherapy versus preoperative C/RT strategies.
In all, 157 esophageal cancer patients were sequentially enrolled in phase II/III trials at the University of Texas M.D. Anderson Cancer Center from March 27, 1990, to March 8, 2005. The treatment approaches included preoperative chemotherapy, n = 76 (INT 113 and ID90-01); preoperative C/RT, n = 81 (ID96-189 and DM98-349). Analysis was by intention to treat. Factors evaluated included demographics, preoperative staging, type of surgery, pathology, adjuvant therapies, and long-term outcome.
Adenocarcinoma predominated (85%), with cT3 (73%) and cN1 (43%). No significant difference was noted between groups in demographics or perioperative mortality. More patients with preoperative C/RT were staged with endoscopic ultrasound (52% versus 9%, p < 0.001). Preoperative C/RT demonstrated increased pathologic complete response (28% versus 4%, p < 0.001) and overall survival (3 years, 48% versus 29%, p = 0.04). Preoperative C/RT was a significant independent predictor of improved overall survival (hazard ratio 0.58, 95% confidence interval: 0.37 to 0.90, p = 0.015) and disease-free survival (hazard ratio 0.55, 95% confidence interval: 0.35 to 0.85, p = 0.007) in multivariable regression.
In sequential phase II/III trials involving locoregionally advanced esophageal cancer patients, preoperative C/RT was associated with improved overall and disease-free survival rates (p = 0.046 and p = 0.015, respectively) and increased pathologic complete response (p < 0.001) compared with preoperative chemotherapy.
The Annals of thoracic surgery 09/2010; 90(3):892-8; discussion 898-9. · 3.74 Impact Factor
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ABSTRACT: Vascular endothelial growth factor (VEGF) targeted therapy, either alone or in combination with chemotherapy, has become the standard of care in several solid tumours, including colorectal cancer, renal-cell carcinoma, breast cancer, non-small-cell lung cancer, and glioblastoma. VEGF is crucial in the process of angiogenesis and wound healing and, thus, its inhibition has the potential to affect wound healing in patients undergoing surgery. In this review, we summarise the data available on the use of VEGF-targeted therapies, and their effect on perioperative wound complications. Surgery in patients receiving VEGF-targeted therapies seems to be safe when an appropriate interval of time is allowed between surgical procedures and treatment. Recommendations regarding this interval are provided in a disease and agent site-specific manner. We also discuss complications arising from the use of VEGF-directed therapies that might require surgical intervention and the considerations important in their management. At this juncture, safety data on the use of VEGF-targeted therapies in the perioperative period are sparse, and investigators are urged to continue to study this issue prospectively in current and future clinical trials to establish firm guidelines.
The lancet oncology 02/2010; 11(4):373-82. · 14.47 Impact Factor
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Wayne Hofstetter
The Annals of thoracic surgery 10/2009; 88(3):973. · 3.74 Impact Factor
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Shanda H Blackmon,
Nipam Shah,
Jack A Roth,
Arlene M Correa,
Ara A Vaporciyan,
David C Rice, Wayne Hofstetter,
Garrett L Walsh,
Robert Benjamin,
Raphael Pollock,
Stephen G Swisher,
Reza Mehran
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ABSTRACT: The presence of extrapulmonary sarcomatous metastases has traditionally been a contraindication for the resection of pulmonary metastases. We, therefore, reviewed our experience with resection of pulmonary metastases in patients who had documented extrapulmonary metastases to determine long-term outcome.
From 1998 to 2006, 234 patients underwent pulmonary metastasectomy. They were grouped as follows: group A (lung metastasectomy only); group B1 (with either synchronous or prior extrapulmonary metastasectomy); group B2 (with nonsurgical treatment of synchronous or prior extrapulmonary metastases); group C1 (with later extrapulmonary metastasectomy); group C2 (with later extrapulmonary metastasis which was not resected).
Groups A, B1, and B2 consisted of 147 (62.8%), 26 (11.1%), and 13 (5.6%) patients, respectively. The median survival from lung metastasectomy date was 35.5, 37.8, and 13.5 months in groups A, B1, and B2, respectively. Comparison among the three groups showed no significant survival difference in groups A versus B1 (p = 0.96), but a survival difference was found comparing groups A versus B2 (p < 0.001) and B1 versus B2 (p < 0.001). Prognostic factors for increased survival included 3 or greater redo pulmonary operations, greater than 12 month mean time between pulmonary recurrences, greater than 24 month mean time between extrathoracic recurrences, and a prolonged disease-free interval. Prognostic factors for decreased survival included 3 or greater pulmonary metastases and group B2 patients.
These results suggest extrapulmonary metastases should no longer be viewed as a contraindication to resection of sarcomatous pulmonary metastases. Long-term survival can be achieved when a complete resection is possible for both the pulmonary and extrapulmonary metastases.
The Annals of thoracic surgery 09/2009; 88(3):877-84; discussion 884-5. · 3.74 Impact Factor
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Heta Javeri,
Lianchun Xiao,
Eric Rohren,
Jeffrey H Lee,
Zhongxing Liao, Wayne Hofstetter,
Dipen Maru,
Manoop S Bhutani,
Stephen G Swisher,
Homer Macapinlac,
Xuemei Wang,
Jaffer A Ajani
[show abstract]
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ABSTRACT: Postchemoradiation percentage decrease in standardized uptake value (SUV) of positron emission tomography (PET) from baseline correlates with overall survival (OS) and pathologic response. Analyses of dichotomized data are commonly reported. The authors analyzed percentage SUV decrease as both dichotomized and continuous variables.
The authors assessed 151 consecutive patients with gastroesophageal adenocarcinoma who had chemoradiation and surgery. Baseline and postchemoradiation PET/computed tomography imaging was performed. The log-rank test and Cox proportional hazards models were used to associate percentage SUV changes and OS, and logistic regression models were used to detect the association between percentage SUV changes and pathologic response.
A >52% SUV decrease (dichotomized analysis) was associated with a longer OS (log-rank test, P = .023). The univariate Cox proportional hazards model indicated that greater percentage SUV decrease (as a continuous variable) was associated with a lower risk of death (hazard ratio [HR], 0.99; P = .01). Pathologic response (< or =50% residual cancer) was associated with longer OS (P = .003). Patients with chemoradiation resistance (>50% residual cancer) tended to have a higher risk of death than those with chemoradiation sensitivity (0-50% residual cancer; HR, 2.12; P = .099). In the multivariate model, the percentage SUV decrease (as a continuous variable) was the only prognosticator of OS (P = .01). The percentage SUV decrease was nonsignificantly associated with pathologic complete response (univariate odds ratio [OR], 1.01; P = .06 and multivariate OR, 1.03; P = .07).
The greater the decline in SUV after chemoradiation, the longer is the OS of gastroesophageal adenocarcinoma patients. The percentage SUV decrease as a continuous variable is a better prognosticator of OS than its dichotomized assessments.
Cancer 08/2009; 115(22):5184-92. · 4.77 Impact Factor
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William D Bolton,
David C Rice,
Arlene M Correa, Wayne Hofstetter,
Ritsuko Komaki,
Reza Mehran,
Katherine Pisters,
Jack A Roth,
Ara A Vaporciyan,
Garrett L Walsh,
Stephen G Swisher
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ABSTRACT: United States census data predict expansion of the elderly population until 2050 and nonsmall lung cancer (NSCLC) incidence is expected to rise accordingly. This study examines trends of lung cancer management and outcomes for pulmonary resection of primary NSCLC in the elderly. An institutional data set (n = 5950) was examined to determine patterns of management. A separate surgical dataset (n = 1756) was examined to determine surgical outcomes. "Elderly" was defined as 70 years old or older. Twenty-four per cent of patients in the institutional data set underwent surgery. Patients in the youngest age quartile (younger than 62 years) were more likely to undergo surgery, whereas the oldest quartile (older than 74 years) were less likely. In the surgical data set, 643 patients were elderly. No difference in combined 30-day/in-hospital mortality was noted (4 vs 2.9%). Five-year survival was 59.1 per cent for younger and 49.9 per cent for elderly patients. On multivariable analysis, age 70 years or older, male gender, increasing Charlson Comorbidity Index score, and pathologic stage were predictors of worse survival. Increasing age is an independent rick factor for surgical outcome and long-term survival after pulmonary resection for NSCLC, age appears to influence choice of initial treatment and extent of resection. Although surgery in the elderly carries higher risk, long-term cure can still be achieved in a significant number of patients.
The American surgeon 08/2009; 75(7):598-603; discussion 603-4. · 1.28 Impact Factor
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William D Bolton,
David C Rice,
Adam Goodyear,
Arlene M Correa,
Jeremy Erasmus, Wayne Hofstetter,
Ritsuko Komaki,
Reza Mehran,
Katherine Pisters,
Jack A Roth,
Stephen G Swisher,
Ara A Vaporciyan,
Garrett L Walsh,
Jason Weaver,
Laurence Rhines
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ABSTRACT: Superior sulcus tumors with involvement of the spine have historically been considered unresectable. We have previously documented a 2-year survival of 54% in patients treated with a multimodality approach. This work builds on our previous experience and examines the long-term outcomes.
A retrospective review was performed on patients with superior sulcus non-small cell lung cancer tumors with involvement of the vertebral column (n = 39) treated at The University of Texas MD Anderson Cancer Center from 1990 to 2006. Their clinical and pathologic data were analyzed for short- and long-term outcomes.
Group 1 included 8 (21%) patients with neuroforamen or transverse process involvement, group 2 had 16 (41%) patients with partial vertebrectomy, and group 3 had 15 (38%) patients with total vertebrectomy. There were 2 (5%) postoperative deaths, and 11 (28%) patients had major complications. Margins were positive in 17 (44%) patients. Recurrence occurred in 23 (59%) patients and was local in 11 (28%) patients, distant in 11 (28%) patients, and both in 1 (3%) patient. Median time to local recurrence was 7 months in patients with positive margins and has not been reached for patients with negative margins (P = .007). Median, 2-year, and 5-year overall survival was 18 months, 47%, and 27%, respectively. On multivariate analysis, the only independent predictor of shorter survival was nodal metastases (P = .001; hazard ratio, 6.5; 95% confidence interval, 2.2-19.2).
An aggressive multimodality approach involving surgical resection can be performed with acceptable morbidity in highly selected patients with superior sulcus tumors and vertebral invasion at a specialized center. Encouraging long-term survival can be achieved in patients with negative margins and no lymph node involvement.
The Journal of thoracic and cardiovascular surgery 07/2009; 137(6):1379-87. · 3.41 Impact Factor
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Zhen Zhang,
Yuan Chen,
Yanzhi Chen,
Melenda Jeter, Wayne L Hofstetter,
Jaffer Ajani,
Stephen G Swisher,
Joe Y Chang,
Pamela K Allen,
James D Cox,
Ritsuko Komaki,
Zhongxing X Liao
[show abstract]
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ABSTRACT: Esophageal cancer is the seventh leading cause of cancer death worldwide and is responsible for 4% of the cancer deaths in the United States annually. Changing epidemiologic patterns and expanded treatment options have brought this often deadly cancer to the forefront.
To characterize epidemiological changes, the effect of treatment advances, and patient outcomes over time, we retrospectively reviewed 756 consecutive esophageal cancer cases treated between 1985 to 2003 at The University of Texas M. D. Anderson Cancer Center in Houston. For purposes of evaluation, cases were divided into four cohorts of approximately 5 years each. Men make up 75% or more of the patients with esophageal cancer, most patients have adenocarcinoma in the gastroesophageal junction, and almost 75% have stage II or III disease.
Three-year overall survival improved from 16.7% (1985-1989) to 35.2% (2000-2003). By multivariate Cox regression analysis, significant reductions in relative risk were associated with having good performance status (relative risk [RR] = 0.68 [95% confidence interval (CI) = 0.56-0.83]; p < 0.001), being treated in the most recent interval (2000-2003) than in the first (1985-1989) (RR = 0.63 [95% CI = 0.44-0.88]; p = 0.007), with improved therapies, including induction chemotherapy plus concurrent chemoradiotherapy (RR = 0.68 [CI = 0.56-0.84]; p < 0.001), explaining the reductions.
Although fully delineated comparisons must await incorporation and study of data through 2007, this analysis suggests that multimodality management that has been adapted in recent years may be associated with the improvements in outcomes of these cases of largely stage II and III esophageal adenocarcinoma found at the gastroesophageal junction.
Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 06/2009; 4(7):880-8. · 4.55 Impact Factor
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Heta Javeri,
Lianchun Xiao,
Eric Rohren,
Ritsuko Komaki, Wayne Hofstetter,
Jeffrey H Lee,
Dipen Maru,
Manoop S Bhutani,
Stephen G Swisher,
Xuemei Wang,
Jaffer A Ajani
[show abstract]
[hide abstract]
ABSTRACT: In patients with esophageal cancer who receive chemoradiation, tools to predict/prognosticate outcome before administering therapy are lacking. The authors evaluated initial standardized unit value (iSUV) of 18F-fluoro-2-deoxy-D-glucose positron emission tomography and its association with overall survival and the degree of pathologic response after surgery.
The authors analyzed 161 patients with esophageal adenocarcinoma who had chemoradiation followed by surgery. The log-rank test, univariate Cox proportional hazards model, Kaplan-Meier survival plot, and Fisher exact test were used to analyze dichotomized iSUV and its association with overall survival and pathologic response.
The median age of 161 patients was 61 years (range, 26-80 years) and the majority of patients had lower esophageal or gastroesophageal junction involvement. All patients received fluoropyrimidine and, most commonly, a taxane or platinum compound with concomitant radiation. The median radiation dose was 45 grays (Gy) (range, 45 Gy-50.4 Gy). The median iSUV for all patients was 10.1 (range, 0-58). Using the Fisher exact test, iSUV was not found to be associated with the location of the primary cancer. iSUV higher than the median (10.1) was associated with a better pathologic response (P = .06). Patients with primary cancer with iSUV >10.1 had a lower risk for death (hazards ratio of 0.56) compared with those with iSUV < or = 10.1. Higher iSUV was nonsignificantly associated with improved survival (P = .07).
Data from the current study suggest that lower iSUV is associated with poor survival and lower probability of response to chemoradiation. iSUV needs to be further evaluated because it may be used to complement other imaging or biomarker assessments to individualize therapy.
Cancer 02/2009; 115(3):624-30. · 4.77 Impact Factor
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David Rice,
Stephen Swisher,
Katherine Pisters,
Frank Fossella,
Roy Herbst, Wayne Hofstetter,
Merrill Kies,
Ritsuko Komaki,
Scott Lippman,
Reza Mehran,
Jack Roth,
David Stewart,
Ara Vaporciyan,
Garrett Walsh,
James Cox
Chest 01/2009; 134(6):1349; author reply 1350. · 5.25 Impact Factor
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Sai Yendamuri,
Stephen G Swisher,
Arlene M Correa, Wayne Hofstetter,
Jaffer A Ajani,
Ashleigh Francis,
Dipen Maru,
Reza J Mehran,
David C Rice,
Jack A Roth,
Garrett L Walsh,
Ara A Vaporciyan
[show abstract]
[hide abstract]
ABSTRACT: Esophageal cancer staging uses tumor depth as the sole criterion for assessment of the primary tumor (pT). To the authors' knowledge the impact of esophageal tumor length on long-term outcome and the esophageal cancer staging system has not been fully evaluated in the current era.
All esophageal cancer patients (n = 209) undergoing surgery from 1995 to 2005 who did not receive preoperative chemotherapy or radiotherapy were reviewed. Maximum esophageal tumor length along a craniocaudal axis was determined pathologically after surgical resection. Univariate and multivariate analyses were used to assess the impact of esophageal tumor length (< or = 3 cm vs >3 cm) on long-term survival.
Esophageal tumor length was closely associated with long-term survival (hazards ratio [HR] of 6.14 [95% confidence interval (95% CI), 4.1-9.25]; 5-year survival: < or = 3 cm = 68%, >3 cm = 10% [P < .001]). Multivariate Cox regression analyses demonstrated tumor length (HR of 2.13 [95% CI, 1.26-3.63]) was found to be a significant independent predictor of long-term survival even when controlled for sex, age, tumor location, histology, margin positivity, surgical procedure, and current pTNM criteria. The incorporation of tumor length in pTNM staging significantly improves the ability to predict the long-term survival of patients (5-year survival for patients with tumors < or = 3 cm and stages I, IIA, IIB, and III disease = 86%, 62%, 49%, and 22%, respectively; survival for patients with tumors measuring >3 cm and stages I, IIA, IIB, and III disease = 27%, 22%, 0%, and 8%, respectively [P < .1]).
Esophageal tumor length is an independent predictor of long-term survival in the current era and should be considered for incorporation into the current esophageal cancer staging system to better predict long-term survival and identify high-risk patients for postoperative therapy.
Cancer 01/2009; 115(3):508-16. · 4.77 Impact Factor
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Journal of Clinical Gastroenterology 09/2007; 41(7):644-6. · 3.16 Impact Factor
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Wayne Hofstetter,
Arlene M Correa,
Neby Bekele,
Jaffer A Ajani,
Alexandria Phan,
Ritsuko R Komaki,
Zhongxing Liao,
Dipen Maru,
Tsung T Wu,
Reza J Mehran,
David C Rice,
Jack A Roth,
Ara A Vaporciyan,
Garrett L Walsh,
Ashleigh Francis,
Shanda Blackmon,
Stephen G Swisher
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ABSTRACT: The current American Joint Committee on Cancer (AJCC) esophageal cancer staging for nodal status is difficult to interpret and is based solely on lymph node location relative to the primary tumor's esophageal location. Recent reports suggest that the number of lymph nodes involved is also an important factor. We reviewed our esophageal experience to propose an improved nodal staging system.
In all, 1,027 patients with resected esophageal cancer from 1970 to 2005 were reviewed. Lymph nodes stations were assigned according to AJCC criteria. Overall survival was assessed by Kaplan-Meier analysis. The impact of location, number of involved lymph nodes, and use of preoperative chemotherapy or radiation therapy, or both, was assessed.
Nonregional nodal involvement (n = 17) was associated with decreased survival compared with regional (n = 441) or celiac nodal (n = 73) involvement (3-year: 0% versus 24% and 23%; p < 0.001). The number of involved lymph nodes was strongly associated with survival (3-year: 0 nodes = 63%, 1 to 3 nodes = 31%, more than 3 nodes = 13%; p < 0.001), and multivariable Cox proportional-hazards analysis suggested that the location and number of involved lymph nodes were independent predictors of survival (p < 0.001). We propose a modified nodal staging system that designates celiac nodes as regional and includes number of involved nodes: pN0, no nodes (3 years = 63%, n = 496); pN1-regional, 1 to 3 nodes (3 years = 32%, n = 292); pN2-regional, more than 3 nodes (3 years = 14%, n = 222); pN3-nonregional node (3 years = 0%, n = 17 [p < 0.0001]). This modified nodal staging system better predicts survival than the current AJCC nodal staging system in which survival for pN1 (3 years = 24%) and pM1a (3 years = 23%) do not differ (p = 0.67). The use of induction before surgical resection did not alter the predictive effect of the new nodal staging system.
Modification of the AJCC nodal classification system to incorporate the number of involved lymph nodes with regional and nonregional node location simplifies and better predicts long-term survival than does the current AJCC nodal system.
The Annals of thoracic surgery 09/2007; 84(2):365-73; discussion 374-5. · 3.74 Impact Factor
