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HIGH-RISK FEATURES OF ESOPHAGEAL ADENOCARCINOMA FOLLOWING NEOADJUVANT CHEMORADIATION: PATIENTS FOR WHOM SURGERY SHOULD NOT BE DELAYED
Erin M. Bayley*1, Megan Ivy2, Phillip S. Ge1, Jitesh Shewale1, Mara B. Antonoff1, Ashleigh Francis1, Wayne L. Hofstetter1, Reza J. Mehran1, Ravi Rajaram1, David C. Rice1, Jack A. Roth1, Boris Sepesi1, Ara A. Vaporciyan1, Garrett L. Walsh1, J. Jack Lee1, Brian E. Louie2, Stephen G. Swisher1
1Department of Thoracic and Cardiovascular Surgery, University of Texas - MDAnderson Cancer Center, Houston, TX; 2Swedish Medical Center, Seattle, WA

Objectives
Prior works have aimed to identify clinical predictors of pathological complete response among esophageal cancer patients treated with neoadjuvant chemoradiation, such that an organ-sparing approach may be undertaken with surveillance. However, this endeavor has proven perplexing. We instead aimed to define reliable predictors of residual carcinoma which may identify a high-risk cohort for whom esophagectomy should be immediately undertaken.
Methods
Patients treated with concurrent chemoradiation followed by esophagectomy from 2000-2018 for esophageal adenocarcinoma were identified. Correlation between clinical and pathologic complete response was examined. Multivariable logistic regression was completed to identify covariates associated with residual carcinoma, and recursive partitioning was performed to classify patients according to risk for residual disease. External validation was completed.
Results
326 patients were identified. Clinical complete response was noted in 104 (32%), among whom pathologic complete response was confirmed in 33/104 (32%). Multivariable analysis identified that the presence of stricture (p=0.011), positive biopsy (p=0.010), and signet ring cell histology (p=0.019) were associated with residual cancer. Recursive partitioning corroborated a 94% probability of residual disease, or greater, for each of these high-risk features. The positive predictive value was greater than 90% for these characteristics, as well as a maximum standard uptake value of 5.4 or greater in the absence of esophagitis (Figure 1). Secondary external validation among a similar patient population demonstrated similarly high probabilities of residual carcinoma among patients with at least one high-risk feature present (Figure 2).
Conclusions
Several features were found to be high-risk markers of residual carcinoma following neoadjuvant therapy: positive biopsy, signet ring cell histology, stricture, and esophagitis in the absence of significant radiotracer avidity. Though classic clinical parameters believed to be suggestive of pathologic complete response may not be useful in selecting candidates for active surveillance following neoadjuvant therapy, these high-risk features may guide the thoracic multidisciplinary team in identifying patients for whom esophagectomy should not be delayed.




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