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PET scans can informand improve treatment of oesophageal
adenocarcinoma
P
ET scans can be used to assess tumour response
to initial chemotherapy and may allow for the tai-
loring of further chemotherapy in patients with
oesophageal adenocarcinoma.
This conclusion was based on initial results of a ran-
domised, phase II, federally fundedAlliance for Clinical
Trials in Oncology, Cancer and Leukemia Group B trial
of PET scan-directed combined modality therapy for
oesophageal cancer.
KarynA. Goodman, MD, of the University of Colorado
School of Medicine, Aurora, explained that, despite
aggressive chemoradiotherapy, and surgery, the prog-
nosis for patients with oesophageal cancer is poor, with
fewer than 50% surviving 5 years after diagnosis. Ways
to monitor treatment effectiveness are urgently needed
to improve outcomes.
PET scans are routinely used to guide therapy decisions
in lymphoma but are only beginning to be explored for
this purpose in solid tumours. The study is among the
first to show the benefit of PET imaging in directing
presurgery treatment decisions in oesophageal cancer.
Patients with stage 2–3 oesophageal and gastroesoph-
ageal junction adenocarcinoma typically receive 5.5
weeks of chemoradiotherapy, followed by surgery. Neo-
adjuvant chemoradiation has been shown to improve
survival over surgery alone. Several chemotherapy reg-
imens are available for use during chemoradiation,
yet no reliable method predicts whether a particular
chemotherapy will be effective in a given patient.
Following an initial PET scan, 257 patients with stage
2–3 oesophageal and gastroesophageal junction ade-
nocarcinoma were randomised to one of two induction
chemotherapy regimens: modified fluorouracil + leu-
covorin and oxaliplatin (FOLFOX-6) or carboplatin/
paclitaxel.
A PET scan was repeated after the first few cycles
of induction therapy. If the PET scan suggested that
the induction chemotherapy had worked, patients con-
tinued with the same chemotherapy regimen during
chemoradiation.
If the PET scan revealed that the induction chemo-
therapy regimen was not effective, chemotherapy
was changed to the other of the two regimens dur-
ing chemoradiation. Overall, 39 of 129 patients who
received FOLFOX-6 induction chemotherapy and 49
of 128 who received carboplatin/paclitaxel switched
chemotherapy regimens after the PET scan.
Among patients who switched to an alternative chemo-
therapy after induction therapy, 15.6% ultimately
achieved a pathologic complete response. In prior stud-
ies, where presurgery chemotherapy was not changed
based on a PET scan, the complete pathologic response
rate among patients with tumours not responsive to
induction chemotherapy as measured by PET scan
was only 5%. Prior research suggested a link between
pathologic complete response and longer survival in
oesophageal cancer.
Dr Goodman said, “In this study, we are adding
induction chemotherapy before chemoradiation and
showing that PET scanning after induction chemother-
apy to assess response helps guide course corrections
quickly to maximise patient benefit from chemother-
apy. Though our approach does lengthen a patient’s
time before surgery, we found that assessing treatment
efficacy with PET scanning can improve efficacy as
shown by the ability to achieve a pathologic complete
response.”
PET scans are covered byMedicare in the US for staging
and evaluation of treatment response for oesophageal and
gastroesophageal junction cancers. The study showed
that PET scans can be used to help guide therapy deci-
sions for patients with oesophageal and gastroesophageal
junction cancers. “We still need, however,” said Dr Good-
man, “to further refine what is the most effective regimen
for oesophageal cancer.”
PracticeUpdate Editorial Team
In this study, we are adding
induction chemotherapy
before chemoradiation and
showing that PET scanning
after induction chemotherapy
to assess response helps
guide course corrections
quickly to maximise patient
benefit from chemotherapy.
Though our approach does
lengthen a patient’s time
before surgery, we found that
assessing treatment efficacy
with PET scanning can
improve efficacy as shown
by the ability to achieve a
pathologic complete response.
We still need, however, to
further refine what is the
most effective regimen
for oesophageal cancer.
ASCO GI 2017
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VOL. 2 • NO. 2 • 2017