Treatment Of Oesophagogastric Cancer Research Articles

O214: The tumour immune microenvironment and its response to exercise during treatment for Oesophagogastric cancer

Abstract Introduction Pre-clinical studies suggest that exercise during cancer treatment may enhance tumour regression and promote an anti-tumorigenic immune microenvironment. Considering the evolution of immunotherapy in oesophagogastric cancer, further understanding of the host-tumour immune response to exercise therapy is of significant interest. Methods Using multiplex immunofluorescence, resection specimens of 30 patients with oesophageal adenocarcinoma were labelled for CD3, CD4, CD8, PD-1, PD-L1, FOXP3, CD68, and PanCK to characterise tumour and peri-tumoral immune infiltrate. All patients received the same neoadjuvant chemotherapy prior to oesophagectomy. 14 patients who engaged with a structured prehabilitation exercise program (mixed aerobic and resistance training twice-weekly) were case-matched with 16 control patients who did not. Results The prehabilitation group had a significant increase (per mm2 ) in cytotoxic T-cells (99.4 vs 13.8, p=0.003). There was also a significant increase in immune suppressive macrophages, exhausted T-helper and cytotoxic T-cells. The only significant change in the peritumoural sections was an increase in exhausted CD8 cytotoxic-T cells in the prehabilitation group (3.3 vs 1.4, p=0.043). There was no difference in the number of Treg or T-helper cells within, or around the tumour sections. Conclusions This study is the ‘first-in-man’ to show that exercise prehabilitation during chemotherapy impacts on the tumour immune microenvironment in patients with oesophageal adenocarcinoma. Exercise results in an increased abundance of both anti-tumorigenic and immunosuppressive cell types. These finding warrant further investigation, especially in the context of modern immunotherapy treatments, to understand the clinical impact that exercise oncology has on tumour regression.

P-OGC43 Morbidity and unplanned hospital attendance among patients with oesophagogastric cancer treated with home enteral nutrition

Abstract Background Nutritional optimisation is an essential component of prehabilitation and enhanced recovery for patients with oesophageal and gastric cancer, but may be associated with increased burden of inpatient care. The aim of this study was to determine risk factors associated with complications and unplanned hospital attendance among patients treated with home enteral nutrition. Methods Consecutive patients with oesophageal or gastric cancer commencing home enteral nutrition from March 2020-June 2021 were prospectively studied. The primary outcome measure was the incidence of complications associated with home enteral feeding requiring unplanned hospital attendance. Univariable and multivariable linear and logistic regression were used to determine factors independently associated with enteral feeding associated morbidity and healthcare utilisation. Results 70 patients were studied (27% pre neoadjuvant therapy, 63% postoperative; 19% gastrostomy, 81% jejunostomy). Tube complications requiring unplanned hospital attendance occurred in 33% of patients (25% gastrostomy, 38% jejunostomy, P = 0.405), most commonly dislodgement (15%), fixation problem (13%), and blockage (6%). Small bowel obstruction was rare (1.4%). Inpatient length of stay (LOS) following feeding tube placement and training was 5.1±2.4 days (gastrostomy: 5.5±2.7, jejunostomy: 4.4±1.9 days, P = 0.074). 17 unplanned hospital visits among nine patients (13.0%) occurred with a cumulative LOS of 71 inpatient days. On multivariable analysis patients undergoing neoadjuvant therapy were at the greatest risk of overall enteral feeding tube morbidity (OR19.34 [3.29–113.56], P = 0.001), dislodgement (OR19.09 [2.35-155.11], P = 0.006) and unplanned hospital attendance (P < 0.001). Older patients were at increased risk of tube dislodgement (OR1.14 [1.02–1.28], P=0.024) and unplanned hospital attendance (P = 0.034). Conclusions Unplanned hospital attendance is common among patients undergoing supplemental home enteral nutrition during treatment for oesophagogastric cancer. Fixation problems and dislodgement account for the majority of presentations, and are more common among older patients and those undergoing neoadjuvant therapy. Pragmatic strategies to optimise tube fixation and minimise the need for unplanned hospital visits among patients receiving home enteral nutrition are urgently needed.

ReStOre@Home: Feasibility study of a virtually delivered 12-week multidisciplinary rehabilitation programme for survivors of upper gastrointestinal (UGI) cancer - study protocol

Background: Exercise rehabilitation programmes, traditionally involving supervised exercise sessions, have had to rapidly adapt to virtual delivery in response to the coronavirus disease 2019 (COVID-19) pandemic to minimise patient contacts. In the absence of an effective vaccine, the pandemic is likely to persist in the medium term and during this time it is important that the feasibility and effectiveness of remote solutions is considered. We have previously established the feasibility of the Rehabilitation Strategies following Oesophago-gastric Cancer (ReStOre) intervention - a face to face multidisciplinary rehabilitation programme for upper gastrointestinal (UGI) cancer survivors. This study will examine the feasibility of a virtually delivered 12-week multi-component ReStOre@Home programme. Methods: This single arm feasibility study will recruit 12 patients who have completed curative treatment for oesophago-gastric cancer. Participants will complete the 12-week ReStOre@Home programme consisting of exercise (aerobic and resistance training), 1:1 dietary counselling and group education sessions through virtual delivery. Underpinned by the Medical Research Council (MRC) Framework, feasibility will be determined by recruitment rates, adherence, retention, incidents, and acceptability. Acceptability will be assessed qualitatively through post-intervention interview and the Telehealth Usability Questionnaire. Secondary outcomes will be assessed pre and post-intervention and will include measures of physical performance (cardiopulmonary exercise test, short physical performance battery, hand grip strength, Godin Leisure Time Questionnaire, and body composition), health related quality of life (European Organisation for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC-QLQ-C30) and oesophago-gastric cancer specific subscale (EORTC-QLQ-OG25), fatigue (Multidimensional Fatigue Inventory (MFI-20), and venous blood samples will be collected for the UGI Cancer Survivorship Biobank. Discussion: The ReStOre@Home feasibility study will provide important data regarding the amenability of a multidisciplinary programme designed for UGI cancer survivors to virtual delivery. Trial registration: ClinicalTrials.gov NCT04603339 (26/10/2020).

Using textbook outcome as a measure of quality of care in oesophagogastric cancer surgery

Textbook outcome is a multidimensional measure representing an ideal course after oesophagogastric cancer surgery. It comprises ten perioperative quality-of-care parameters and has been developed recently using population-based data. Its association with long-term outcome is unknown. The objectives of this study were to validate the clinical relevance of textbook outcome at a hospital level, and to assess its relation with long-term survival after treatment for oesophagogastric cancer. All patients with oesophageal or gastric cancer scheduled for surgery with curative intent between January 2009 and June 2015 were selected from an institutional database. A Cox model was used to study the association between textbook outcome and survival. A textbook outcome was achieved in 58 of 144 patients (40·3 per cent) with oesophageal cancer and in 48 of 105 (45·7 per cent) with gastric cancer. Factors associated with not achieving a textbook outcome were failure to achieve a lymph node yield of at least 15 (after oesophagectomy) and postoperative complications of grade II or more. After oesophagectomy, median overall survival was longer for patients with a textbook outcome than for patients without (median not reached versus 33 months; P = 0·012). After gastrectomy, median survival was 54 versus 33 months respectively (P = 0·018). In multivariable analysis, textbook outcome was associated with overall survival after oesophagectomy (hazard ratio 2·38, 95 per cent c.i. 1·29 to 4·42) and gastrectomy (hazard ratio 2·58, 1·25 to 5·32). Textbook outcome is a clinically relevant measure in patients undergoing oesophagogastric cancer surgery as it can identify underperforming parameters in a hospital setting. Overall survival in patients with a textbook outcome is better than in patients without a textbook outcome.

PTH-146 Impact of haemoglobin on survival in oesophagogastric cancer: haemoglobin at diagnosis and prior to surgery predicts survival

<h3>Introduction</h3> Anaemia is common in oesophagogastric cancer. Major operations performed for these cancers are associated with significant blood loss and need for transfusions. Concerns exist about the side effects of blood transfusion, cost and availability of donated blood. Our study aims to identify incidence of anaemia, change in haemoglobin, rates of blood transfusion and mortality associated with the diagnosis and treatment of oesophagogastric cancer. <h3>Method</h3> We conducted a retrospective analysis of all patients diagnosed with oesophagogastric cancer in 2012–2013 at a single high-volume referral centre. Data was collected on site, histology, staging, haemoglobin, blood transfusions, survival and treatment. WHO definitions were used to define anaemia. <h3>Results</h3> 550 patients were included in the study. Median haemoglobin at time of diagnosis was 127 g/L (37–188 g/L). 227 patients (45%) were anaemic at diagnosis. Higher haemoglobin at diagnosis improved survival (irrespective of a diagnosis of anaemia) with high normal haemoglobin (&gt;150 g/L) showing significantly better survival than low normal haemoglobin (130–150 g/L), p &lt; 0.001. Mild anaemia (110–130 g/L) had significantly poorer survival again but superior to moderate and severe anaemia (p &lt; 0.05 Breslow-Wilcoxon). Anaemia prior to surgery was also associated with poorer survival (p &lt; 0.05). In the 233 patients treated with surgery, 86 (38.9%) were anaemic at diagnosis. However, this increases to 144 patients (66.9%) prior to surgery and 203 (93.9%) post-operatively. If anaemic prior to curative surgery patients were 29.5% more likely to receive a blood transfusions. Logistic regression analysis revealed male sex, anaemia at diagnosis and neoadjuvant chemotherapy correlated with pre-operative anaemia (p &lt; 0.05). Staging was not a predictor of anaemia. Neo-adjuvant chemotherapy increased the number of patients who were anaemic prior to surgery by 26.5% and the average drop in haemoglobin to 15 g/L compared to 5 g/L for those who went straight to surgery. <h3>Conclusion</h3> Anaemia is common in oesophagogastric cancer and becomes worse during treatment. Neoadjuvant treatment increases the rates and severity of anaemia. Lower haemoglobin at diagnosis and anaemia prior to surgery are both associated with poorer survival and more blood transfusions. A more proactive strategy to the management of anaemia is required if we are to attempt to avoid the excess mortality and blood transfusions seen here in oesophagogastric cancer. <h3>Disclosure of interest</h3> None Declared.

544 ECF is a highly active regimen with low toxicity suitable for neoadjuvant treatment of oesophagogastric cancer

Initial trials with ECF demonstrated a 71% response in oesophagogastric cancer with modest toxicity, renewing interest in neoadjuvant therapy. We now report our experience of 235 consecutive patients treated between 1989 and 1994. All diagnoses were histologically proven. The regimen comprises epirubicin 50 mg/m 2 and cisplatin 60 mg/m 2 3 weekly × 6–8 with protracted venous infusion 5-FU 200 mg/m 2 /d throughout. Responses were evaluated with CT scan and gastroscopy. 173 patients had metastatic disease and 62 had locally advanced disease (LAD). Measurable response occurred in 135/220 (61%, 95% CI 55–68%) with CR in 11% and PR in 50%. Symptomatic response occurred in 50–85%. Quality of life was improved or maintained in most patients. Toxicity was modest; 22% grade 3/4 leucopenia and 14% grade 3/4 non-haematological toxicity. There were 6 treatment related deaths, all during the first 3 years. 29 patients with LAD who responded proceeded to surgery. 19 (66%) had a potentially curative resection; histological CR was demonstrated in 6 (32%). Overall median survival was 256 days. Patients with LAD and ECOG performance status 0–2 had a median survival of 404 days with a 1 year failure free rate of 40%. We conclude ECF is a highly active regimen with acceptable toxicity that can render locally advanced tumours operable. This potential is being evaluated in the MRC ″MAGIC″ trial comparing ECF before surgery with surgery alone.

Palliative treatment for oesophagogastric cancer by laser photocoagulation

Over a 10 year period, 149 non-surgical patients were treated for palliation of an oesophageal cancer. One hundred and twenty-nine patients had an advanced cancer; 20 had a small cancer. The initial success rate was 81% and the complications rate was 3.1% for advanced cancers. Average duration of improvement after initial improvement was 138 days. Location was the only factor affecting the initial results in advanced cancers. Improvement duration was affected by the reason for treatment and an association of treatments during follow up. A complete local destruction of the small cancers was obtained in 18 patients. Three patients had a local recurrence during follow up.