William R C Knight1, Cara R Baker1, Nyree Griffin2, Wahyu Wulaningsih3, Mark Kelly1, Andrew R Davies1,3,4, James A Gossage5,6,7. 1. Department of Surgery, Guy's & St Thomas' Oesophago-Gastric Centre, London, UK. 2. Department of Radiology, Guy's and St Thomas' Hospital, London, UK. 3. Division of Cancer Studies, King's College London, London, UK. 4. Unit of Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden. 5. Department of Surgery, Guy's & St Thomas' Oesophago-Gastric Centre, London, UK. jgossage@doctors.org.uk. 6. Division of Cancer Studies, King's College London, London, UK. jgossage@doctors.org.uk. 7. Unit of Gastrointestinal Research, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden. jgossage@doctors.org.uk.
Abstract
BACKGROUND: A high Mandard score implies a non-response to chemotherapy in oesophageal adenocarcinoma. However, some patients exhibit tumour volume reduction and a nodal response despite a high score. This study examines survival and recurrence patterns in these patients. METHODS: Clinicopathological factors were analysed using multivariable Cox regression assessing time to death and recurrence. Computed tomography-estimated tumour volume change was examined in a subgroup of consecutive patients. RESULTS: Five hundred and fifty-five patients were included. Median survival was 55 months (Mandard 1-3) and 21 months (Mandard 4 and 5). In the Mandard 4 and 5 group (332 patients), comparison between complete nodal responders and persistent nodal disease showed improved survival (90 vs 18 months), recurrence rates (locoregional 14.75 vs 28.74%, systemic 24.59 vs 48.42%) and circumferential resection margin positivity (22.95 vs 68.11%). Complete nodal response independently predicted improved survival (hazard ratio 0.34 (0.16-0.74). Post-chemotherapy tumour volume reduction was greater in patients with a complete nodal response (-16.3 vs -7.7 cm3, p = 0.033) with no significant difference between Mandard groups. CONCLUSION: Patients with a complete nodal response to chemotherapy have significantly improved outcomes despite a poor Mandard score. High Mandard score does not correspond with a non-response to chemotherapy in all cases and patients with nodal downstaging may still benefit from adjuvant chemotherapy.
BACKGROUND: A high Mandard score implies a non-response to chemotherapy in oesophageal adenocarcinoma. However, some patients exhibit tumour volume reduction and a nodal response despite a high score. This study examines survival and recurrence patterns in these patients. METHODS: Clinicopathological factors were analysed using multivariable Cox regression assessing time to death and recurrence. Computed tomography-estimated tumour volume change was examined in a subgroup of consecutive patients. RESULTS: Five hundred and fifty-five patients were included. Median survival was 55 months (Mandard 1-3) and 21 months (Mandard 4 and 5). In the Mandard 4 and 5 group (332 patients), comparison between complete nodal responders and persistent nodal disease showed improved survival (90 vs 18 months), recurrence rates (locoregional 14.75 vs 28.74%, systemic 24.59 vs 48.42%) and circumferential resection margin positivity (22.95 vs 68.11%). Complete nodal response independently predicted improved survival (hazard ratio 0.34 (0.16-0.74). Post-chemotherapy tumour volume reduction was greater in patients with a complete nodal response (-16.3 vs -7.7 cm3, p = 0.033) with no significant difference between Mandard groups. CONCLUSION: Patients with a complete nodal response to chemotherapy have significantly improved outcomes despite a poor Mandard score. High Mandard score does not correspond with a non-response to chemotherapy in all cases and patients with nodal downstaging may still benefit from adjuvant chemotherapy.