Gastric cancer is the fifth most common malignancy in the world, with nearly one million new cases of gastric cancer diagnosed every year. 1 Curative treatment of gastric adenocarcinoma consists of partial or total resection of the stomach combined with lymphadenectomy. 2 Over the last years, multimodality treatment strategies such as neoadjuvant chemo(radio)therapy, perioperative chemotherapy and adjuvant chemotherapy have gained importance in the treatment of gastric cancer by improving the likelihood of a radical tumor resection, disease free survival and overall survival. 3-8 Unfortunately, the overall 5 year survival rate still remains poor (35-45%). 4,9 Accurate staging of gastric cancer allows for selection of the most appropriate therapy, minimizes unnecessary surgery and maximizes the likelihood of benefit from the selected treatment. After initial diagnosis by gastroscopy with tumor biopsy, diagnostic work-up can consist of endoscopic ultrasonography (EUS), computed tomography (CT) and 18 F-fluorodeoxyglucose positron emission tomography (18 F-FDG PET). However, these techniques all have their limitations. EUS is an invasive, highly operator-dependent technique and does not detect distant metastases. 10,11 CT exposes patients to ionizing radiation and has poor soft-tissue contrast. 18 F-FDG PET is impaired by the fact that not all gastric carcinomas are 18 F-FDG-avid (avidity ranging from 42-96%) and has a low spatial resolution. 12 Historically, the role of magnetic resonance imaging (MRI) in gastric cancer has been limited, since relatively long acquisition times and technical challenges of peristaltic motion and respiration artifacts resulted in poor imaging quality. 13,14 With the continuous technical improvements in MRI scanning, including fast imaging techniques, (respiratory) motion compensation techniques, use of anti peristaltic agents and the introduction of functional MRI

Over the last decades, the treatment of resectable esophageal cancer has evolved into a multidisciplinary process in which all players are essential for treatment to be successful. Medical oncologists and radiation oncologists have been increasingly involved since the implementation of neoadjuvant therapy, which has been shown to improve survival. Although esophagectomy is still considered the cornerstone of curative treatment for locally advanced esophageal cancer, it remains associated with considerable postoperative morbidity, despite promising results of minimally invasive techniques. In this light, both physical status and response to neoadjuvant therapy may be important factors for selecting patients who will benefit from surgery. Furthermore, it is important to optimize the entire perioperative trajectory: from the initial outpatient clinic visit to postoperative discharge. Enhanced recovery after surgery is increasingly recognized for esophagectomy and emphasizes perioperative aspects, such as nutrition, physiotherapy, and pain management. To date, several facets of esophageal cancer treatment remain topics of debate, such as the preferred neoadjuvant treatment, anastomotic technique, extent of lymphadenectomy, organization of postoperative care, and the role of surgery beyond locally advanced disease. Here, we describe the current and future perspectives in the surgical treatment of patients with esophageal cancer in the context of the available literature.

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BackgroundNearly one third of patients undergoing neoadjuvant chemoradiotherapy (nCRT) for locally advanced esophageal cancer have a pathologic complete response (pCR) of the primary tumor upon histopathological evaluation of the resection specimen. The primary aim of this study is to develop a model that predicts the probability of pCR to nCRT in esophageal cancer, based on diffusion-weighted magnetic resonance imaging (DW-MRI), dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and 18F-fluorodeoxyglucose positron emission tomography with computed tomography (18F-FDG PET-CT). Accurate response prediction could lead to a patient-tailored approach with omission of surgery in the future in case of predicted pCR or additional neoadjuvant treatment in case of non-pCR.MethodsThe PRIDE study is a prospective, single arm, observational multicenter study designed to develop a multimodal prediction model for histopathological response to nCRT for esophageal cancer. A total of 200 patients with locally advanced esophageal cancer - of which at least 130 patients with adenocarcinoma and at least 61 patients with squamous cell carcinoma - scheduled to receive nCRT followed by esophagectomy will be included. The primary modalities to be incorporated in the prediction model are quantitative parameters derived from MRI and 18F-FDG PET-CT scans, which will be acquired at fixed intervals before, during and after nCRT. Secondary modalities include blood samples for analysis of the presence of circulating tumor DNA (ctDNA) at 3 time-points (before, during and after nCRT), and an endoscopy with (random) bite-on-bite biopsies of the primary tumor site and other suspected lesions in the esophagus as well as an endoscopic ultrasonography (EUS) with fine needle aspiration of suspected lymph nodes after finishing nCRT. The main study endpoint is the performance of the model for pCR prediction. Secondary endpoints include progression-free and overall survival.DiscussionIf the multimodal PRIDE concept provides high predictive performance for pCR, the results of this study will play an important role in accurate identification of esophageal cancer patients with a pCR to nCRT. These patients might benefit from a patient-tailored approach with omission of surgery in the future. Vice versa, patients with non-pCR might benefit from additional neoadjuvant treatment, or ineffective therapy could be stopped.Trial registrationThe article reports on a health care intervention on human participants and was prospectively registered on March 22, 2018 under ClinicalTrials.gov Identifier: NCT03474341.

Both DW-MRI and DCE-MRI are promising in predicting response to nCRT in esophageal cancer. Combining both modalities provides complementary information, resulting in a higher predictive value.

Risk assessment is relevant to predict outcomes in patients with gastric cancer. This systematic review aimed to investigate the predictive value of low muscle mass for postoperative complications in gastric cancer patients. A systematic literature search was performed to identify all articles reporting on muscle mass as measured on computed tomography (CT) scans in patients with gastric cancer. After full text screening, 15 articles reporting on 4887 patients were included. Meta-analysis demonstrated that patients with low muscle mass had significantly higher odds of postoperative complications (odds ratio (OR): 2.09, 95% confidence interval (CI): 1.55–2.83) and severe postoperative complications (Clavien–Dindo grade ≥III, OR: 1.73, 95% CI: 1.14–2.63). Moreover, patients with low muscle mass had a significantly higher overall mortality (hazard ratio (HR): 1.81, 95% CI: 1.52–2.14) and disease-specific mortality (HR: 1.58, 95% CI: 1.36–1.84). In conclusion, assessment of muscle mass on CT scans is a potential relevant clinical tool for risk prediction in gastric cancer patients. Considering the heterogeneity in definitions applied for low muscle mass on CT scans in the included studies, a universal cutoff value of CT-based low muscle mass is required for more reliable conclusions.

Objective This study was conducted in order to determine the optimal timing of diffusion-weighted magnetic resonance imaging (DW-MRI) for prediction of pathologic complete response (pCR) to neoadjuvant chemoradiotherapy (nCRT) for esophageal cancer. Methods Patients with esophageal adenocarcinoma or squamous cell carcinoma who planned to undergo nCRT followed by surgery were enrolled in this prospective study. Patients underwent six DW-MRI scans: one baseline scan before the start of nCRT and weekly scans during 5 weeks of nCRT. Relative changes in mean apparent diffusion coefficient (ADC) values between the baseline scans and the scans during nCRT (ΔADC(%)) were compared between pathologic complete responders (pCR) and non-pCR (tumor regression grades 2-5). The discriminative ability of ΔADC(%) was determined based on the c-statistic. Results A total of 24 patients with 142 DW-MRI scans were included. pCR was observed in seven patients (29%). ΔADC(%) from baseline to week 2 was significantly higher in patients with pCR versus non-pCR (median [IQR], 36% [30%, 41%] for pCR versus 16% [14%, 29%] for non-pCR, p = 0.004). The ΔADC(%) of the second week in combination with histology resulted in the highest c-statistic for the prediction of pCR versus non-pCR (0.87). The c-statistic of this model increased to 0.97 after additional exclusion of patients with a small tumor volume (< 7 mL, n = 3) and tumor histology of the resection specimen other than adenocarcinoma or squamous cell carcinoma (n = 1). Conclusion The relative change in tumor ADC (ΔADC(%)) during the first 2 weeks of nCRT is the most predictive for pathologic complete response to nCRT in esophageal cancer patients. Key Points • DW-MRI during the second week of neoadjuvant chemoradiotherapy is most predictive for pathologic complete response in esophageal cancer. • A model including ΔADC week 2 was able to discriminate between pathologic complete responders and non-pathologic complete responders in 87%. • Improvements in future MRI studies for esophageal cancer may be obtained by incorporating motion management techniques.