Esophageal cancer practice guidelines 2022 edited by the Japan esophageal society: part 1

Treatment strategies and long-term outcomes for patients with oligometastasis in esophageal squamous cell carcinoma after radical esophagectomy

BACKGROUND

Advancements in esophageal cancer treatment have not substantially reduced the high recurrence rate and poor survival outcomes following esophagectomy; however, patients with oligometastasis may benefit from aggressive local treatments.

METHODS

We performed curative esophagectomy in 714 patients with esophageal squamous cell carcinoma between 2007 and 2022. In total, 206 patients with recurrent lesions were enrolled in this study. Oligometastasis was defined as ≤ 5 lesions in a single organ or lymph node station. Treatments included surgery, chemoradiotherapy (CRT), chemotherapy, and radiotherapy. Disease-specific survival (DSS) was defined as the time from the initial recurrence to disease-related death or the last observation.

RESULTS

Among the patients, 109 had oligometastasis, most commonly in the lymph nodes (N = 84), followed by the lung (N = 8) and liver (N = 7). The DSS rate in patients with oligometastasis (5-year DSS: 37.5%) was significantly higher than that in patients with multiple metastases (3.3%) (P < 0.001). Metastatic lesions are more likely to be oligometastatic when a disease-free interval (DFI) is prolonged. In the oligometastasis cohort, surgery or CRT was associated with significantly improved survival outcomes, particularly among patients with a DFI of less than 9 months. The selection of treatment modalities was significantly influenced by the patient's performance status (PS), with better PS being associated with a greater likelihood of receiving surgery or CRT.

CONCLUSION

Aggressive local treatment should be considered for oligometastasis after esophagectomy to improve long-term survival. A good PS after esophagectomy is crucial for the effective treatment of oligometastatic lesions.

Post-endoscopy esophageal squamous cell carcinoma with invasion of the muscularis mucosa or deeper detected in surveillance endoscopy after esophageal endoscopic resection

BACKGROUND

Surveillance endoscopy is recommended after endoscopic resection of esophageal squamous cell carcinomas (ESCCs). However, surveillance endoscopy sometimes detects advanced subsequent ESCCs with invasion of the muscularis mucosa (MM) or deeper. We aimed to clarify the clinicopathological features of these advanced subsequent ESCCs.

METHODS

This single-center retrospective study identified subsequent ESCCs detected during surveillance endoscopy. ESCCs that invaded the MM or deeper and were detected within 24 months after the previous endoscopy were defined as post-endoscopy esophageal advanced lesions (PEEALs), while the first ESCC detected in the patient was defined as the primary lesion. Study 1 compared the clinicopathological characteristics of PEEALs versus non-advanced lesions. Study 2 compared the endoscopic features of pT1a-MM PEEALs versus pT1a-MM primary lesions.

RESULTS

A total of 307 subsequent ESCCs were analyzed in Study 1. Of these, 20 were PEEALs and 287 were non-advanced lesions (pT1a-EP/LPM). The median intervals from the previous endoscopy for PEEALs and non-advanced lesions were 6.1 months and 6.7 months, respectively (P = 0.283). The morphological feature of marginal elevation was seen in 60% of PEEALs. In Study 2, 15 pT1a-MM PEEALs were compared with 149 pT1a-MM primary lesions. Compared with primary lesions, pT1a-MM PEEALs were smaller (median 10 mm vs. 30 mm, P < 0.001) and had a higher prevalence of marginal elevation morphology (53.3% vs. 10.1%, P < 0.001).

CONCLUSIONS

The specific feature of PEEALs was marginal elevation. Surveillance endoscopy with careful observation for these lesions is recommended after endoscopic resection of ESCCs.

Initial reduction of the primary tumor or lymph nodes: which is the better prognostic factor in patients with esophageal squamous cell carcinoma receiving neoadjuvant chemotherapy followed by surgery?

BACKGROUND

Early response of the primary tumor (PT) to neoadjuvant chemotherapy (NAC) in patients with esophageal squamous cell carcinoma (ESCC) is considered a potential predictor of postoperative prognosis. However, the role of metastatic lymph nodes (LNs) remains poorly understood. This study aimed to compare the predictive value of early response in PT and LNs for postoperative prognosis.

METHODS

We enrolled 124 consecutive patients who received NAC-docetaxel, cisplatin, 5-fluorouracil (DCF) followed by surgery for ESCC between April 2010 and March 2020. Initial tumor reduction of the PT (ITR-PT) and LN (ITR-LN), defined as the percentage decrease in tumor shorter diameter after the first course of NAC-DCF, was evaluated using computed tomography. The optimal cut-off values of ITRs were determined using receiver operating characteristic curves and Cox regression models, and their relationship with recurrence-free survival (RFS) was analyzed.

RESULTS

The median ITR-PT and ITR-LN were 21.77% and -0.88%, respectively. The optimal cut-off values for predicting prognosis were approximately 10% for ITR-PT (hazard ratio [HR], 3.23; 95% confidence interval [CI], 1.84-5.64) and -10% for ITR-LN (HR, 2.20; 95% CI, 1.27-3.80). ITR-PT showed a greater impact on RFS (3-year RFS: ITR-PT ≥ 10%, 66.1%; ITR-PT < 10%, 18.4%; log-rank P < 0.001) compared with ITR-LN (3-year RFS: ITR-LN ≥ -10%, 64.1%; ITR-PT < -10%, 34.3%; log-rank P = 0.004). Multivariate analysis of RFS identified ypN, ITR-PT, and ITR-LN as independent prognostic factors.

CONCLUSIONS

Both ITR-PT and ITR-LN are promising predictors of survival in patients with ESCC who underwent NAC-DCF plus surgery. ITR-PT may be a stronger prognostic factor than ITR-LN.

Relationship of phase angle with postoperative pneumonia and survival prognosis in patients with esophageal cancer: A retrospective cohort study

OBJECTIVES

Phase angle (PhA), derived from bioelectrical impedance analysis (BIA), is an indicator of cell membrane health. Low PhA values reflect poor cellular function and low muscle mass. However, consensus regarding the appropriate cutoff value of PhA remains insufficient, and its impact on outcomes after esophagectomy in patients with esophageal malignancies is not well studied. We aimed to investigate whether preoperative PhA is associated with postoperative complication risk and survival prognosis and whether PhA decrease during the surgical preparation period is a prognostic factor in patients with esophageal cancer.

METHODS

This retrospective cohort study analyzed data from 194 patients who had undergone esophagectomy for esophageal malignancies. A PhA measured several days before surgery, with cutoff values of 5.0° for men and 4.2° for women, was used. The relationship between postoperative pneumonia and clinicopathological factors and between low PhA and postoperative outcomes and survival prognosis was investigated. The preoperative PhA decline and survival prognosis were analyzed in 134 patients whose PhA was measured twice before surgery.

RESULTS

Overall, 93 and 101 patients were classified into the low and high PhA groups, respectively. A multivariate analysis showed that a serum albumin level lower than 3.5 g/dL and low PhA were independent risk factors for pneumonia (odds ratio [OR] = 3.40, P = 0.03; OR = 3.42, P = 0.03, respectively). The low PhA group exhibited significantly higher intraoperative fluid balance (6.7 versus 6.0 mL/kg/h, P = 0.01) and a higher proportion of patients who failed to achieve early mobilization on the first postoperative day (46 versus 32%, P = 0.04) than did the high PhA group. Multivariate analysis using a Cox proportional hazards model revealed that low PhA was a poor survival prognostic factor, independent of the clinical stage of esophageal cancer (hazard ratio = 2.61, P < 0.01). In patients whose PhA was measured twice preoperatively, a decrease in PhA during the preoperative period was a significant indicator of poor survival (hazard ratio = 2.59, P < 0.01). The group with a decrease in PhA during the preoperative period had significantly fewer steps than the group with an increase in PhA (6220 ± 2880 versus 8200 ± 2850, P < 0.01).

CONCLUSIONS

Low PhA was a risk factor for postoperative pneumonia in patients who had undergone esophagectomy and was associated with poor survival prognosis. A decrease in PhA during the preoperative period was a significant poor prognostic factor. Increasing physical activity before surgery may lead to an increase in PhA. Thus, it is important to measure and evaluate PhA changes sequentially in patients with esophageal cancer.

Current status of prehabilitation before esophagectomy for patients with esophageal cancer among board-certified hospitals by the Japan Esophageal Society

BACKGROUND

Prehabilitation has been shown to prevent postoperative pneumonia and physical function decline after esophagectomy in recent systematic reviews and meta-analyses. However, the implementation status of prehabilitation for esophagectomy remains unknown. This nationwide survey was performed to investigate the current status of and barriers to prehabilitation before esophagectomy among Japanese hospitals.

METHODS

This multicenter nationwide survey was performed using the postal mail method. The eligible facilities were 155 Japanese hospitals that had been certified as Authorized Institutes for Board-Certified Esophageal Surgeons by the Japan Esophageal Society within the past 10 years. We administered the original questionnaire to investigate the current status of prehabilitation before esophagectomy, excluding neoadjuvant therapy.

RESULTS

The response rate was 75% (117/155 facilities). The number of facilities providing prehabilitation for esophagectomy was 77 (66%), including prehabilitation in the preoperative outpatient setting in 39 (33%) and in the preoperative inpatient setting in 53 (45%). Among the facilities that did not provide prehabilitation, the most common reasons for not providing prehabilitation (i.e., responses of "agree" and "strongly agree" on questionnaire) were a lack of human resources, preoperative period too short to provide prehabilitation, difficultly using reimbursed medical fees, and no establishment of a standard prehabilitation program.

CONCLUSIONS

We elucidated the current implementation status of prehabilitation, identified the critical gap between evidence and practice. This information will contribute to building an effective medical system and framework of prehabilitation for patients with esophageal cancer in Japan and other countries.

The usefulness of combining narrow-band imaging with magnifying endoscopy and 18F-fluorodeoxyglucose positron emission tomography for predicting the depth of invasion in superficial esophageal squamous cell carcinoma

BACKGROUND

To ascertain the indication of endoscopic resection (ER) for esophageal squamous cell carcinoma (ESCC), accurate preoperative diagnosis of the tumor depth beyond cT1b-SM2 is crucial. This study aimed to assess the efficacy of the combined approach utilizing narrow-band imaging with magnifying endoscopy (NBI-ME) and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) for accurate discrimination of lesions of pT1b-SM2 or deeper.

METHODS

Between 2016 and 2023, we retrospectively enrolled 127 cases (137 lesions) of superficial, treatment-naïve ESCC at Akita University Hospital, involving patients who underwent either ER alone or surgery alone. All patients underwent preoperative NBI-ME and FDG-PET. Preoperative tumor depth was estimated using type B vessels based on NBI-ME and SUVmax based on FDG-PET, and we confirmed the final tumor depth through histopathological evaluation of resected samples. The diagnostic performance of the tests in discriminating pT1b-SM2 or deeper was evaluated in terms of sensitivity, specificity, and accuracy.

RESULTS

Treatment consisted of ER in 97 lesions and surgery in the remaining 40. Fifty-three lesions (44.7%) had pT1b-SM2 or deeper invasion. The sensitivity, specificity, and accuracy of NBI-ME using type B3 vessels were 41.5%, 97.6%, and 75.9%, respectively. For FDG-PET with a cutoff SUVmax of ≥ 2.4, these were 79.2%, 69.0%, and 73.0%, respectively. Combining both tests substantially improved diagnostic performance, with sensitivity, specificity, and accuracy of 83.0%, 89.3%, and 86.9%, respectively.

CONCLUSION

The combination of FDG-PET and NBI-ME offers enhanced diagnostic performance for ESCC with ≥ pT1b-SM2, thereby facilitating a more efficacious preoperative narrowing of the indications for ER of superficial ESCC.

Nutritional management during chemotherapy and chemoradiotherapy for advanced esophageal cancer

Advanced esophageal cancer is treated by chemotherapy, radiation therapy, chemoradiotherapy, and immunotherapy. However, the stenosis caused by the tumor and cancer-related chronic inflammation leads to inadequate food intake, weight loss, and nutrition problems. Given that poor pre-treatment nutritional status increases the risks of treatment-related adverse events and a poor prognosis, the nutrition guidelines recommend a pre-treatment nutritional assessment. When malnutrition is present, nutritional interventions, such as dietary guidance and enteral nutrition supplements, provided by the medical team may reduce treatment-related adverse events. However, whether nutritional intervention improves the prognosis is a topic for future research, including randomized controlled trials. This review discusses the literature on nutritional management in patients undergoing chemotherapy and chemoradiotherapy for advanced esophageal cancer.

Celastrol alleviates esophageal stricture in rats by inhibiting NLR family pyrin domain containing 3 activation

BACKGROUND

The role of NLR family pyrin domain containing 3 (NLRP3) in post-endoscopic submucosal dissection (ESD) esophageal stricture remains incompletely understood. The effect of celastrol (CEL) on the prevention of esophageal strictures has not yet been investigated.

AIM

To explore the effect of CEL on the prevention of esophageal stricture in rats.

METHODS

NLRP3, interleukin (IL)-1β, and IL-18 mRNA levels were measured in patients’ tissues after esophageal ESD. NLRP3 expression in esophageal fibroblasts was determined using immunohistochemistry and immunofluorescence staining. Lentiviral transfection was used to induce NLRP3 overexpression and thioredoxin reductase 1 (TXNRD1) silencing. The CCK8 assay was used to determine the optimal CEL concentration. Reactive oxygen species (ROS) generation was detected via fluorescence and flow cytometry. Masson’s trichrome staining and barium esophagography were performed to assess collagen deposition and esophageal stenosis.

RESULTS

The mRNA levels of NLRP3 and IL-1β were higher in human tissues from the ESD resection bed than in normal esophageal mucosa. NLRP3 overexpression in primary rat esophageal fibroblasts led to high collagen 1 expression. Thus, NLRP3 participated in esophageal inflammation and tissue repair after ESD. Comparable to prednisolone, CEL significantly inhibited NLRP3 activation in vitro and in vivo, and esophageal strictures were markedly alleviated. Mechanistically, CEL upregulated TXNRD1 expression and reduced ROS production, thereby inhibiting NLRP3 expression. This effect was reversed by TXNRD1 silencing. Furthermore, TXNRD1 interacted with NLRP3 and promoted its ubiquitination.

CONCLUSION

CEL is a promising alternative therapeutic agent for the prevention of post-ESD esophageal strictures.

Development in Esophagectomy for Esophageal Cancer: The Current Standing Point of Robotic Surgery

Despite advancements in multidisciplinary treatment, esophagectomy remains the primary curative treatment for esophageal cancer. Given that lymph node metastases can spread from the cervical to abdominal regions, three-field lymph node dissection has been established as a standard approach. However, this highly invasive procedure involves multiple anatomical regions-thoracic, abdominal, and cervical-leading to significant surgical burden. To reduce surgical invasiveness, minimally invasive esophagectomy (MIE) has become increasingly common worldwide. With its adoption and advancements in multidisciplinary therapy, discussions have emerged regarding the potential omission of lymph node dissection in selected cases. Since the introduction of robot-assisted minimally invasive esophagectomy (RAMIE) in 2004, this technique has progressively replaced conventional MIE. Robotic systems-equipped with a magnified 3D camera, articulated instruments, and tremor filtering-allow surgeons to perform complex procedures with greater precision than manual techniques. One randomized controlled trial (RCT) has demonstrated fewer postoperative complications with RAMIE compared to open esophagectomy. Additionally, RAMIE has been shown to enable more extensive lymph node dissection around the left recurrent laryngeal nerve than conventional MIE. However, the long-term oncological benefits of RAMIE remain unproven, as no RCTs have definitely confirmed its impact on long-term survival in esophageal cancer patients. Ongoing randomized trials are expected to provide further insights into its prognostic benefits.

Concurrent pathological scar: independent risk factor for esophageal stricture after endoscopic submucosal dissection

BACKGROUND AND AIMS

Esophageal stricture is a common complication after esophageal endoscopic submucosal dissection (ESD). Pathological scars may predict stricture development, but clinical studies exploring their relationship are limited. This study aimed to investigate the link between concurrent pathological scarring and post-ESD esophageal stricture and develop a predictive risk model.

METHODS

This retrospective single-center study included patients who underwent ESD for superficial esophageal lesions (SELs) over the past decade. Data on demographics, endoscopy, pathology, and concurrent scarring were collected. Multivariate logistic regression identified risk factors, followed by validation using subgroup analysis and propensity score matching. A nomogram was developed and internally validated.

RESULTS

Of 255 patients, 28 (11.0%) developed esophageal stricture. Multivariate logistic regression identified concurrent pathological scarring as an independent risk factor for stricture development (OR 96.520 [10.641-875.536], p < 0.001). Additional risk factors included lesions in the upper esophagus, lesions longer than 4 cm, circumferential involvement over 50%, infiltration depth beyond the epithelium, and muscular layer injury during the procedure. A predictive model incorporating these factors was developed, demonstrating high discriminative ability (AUC 0.943 [0.902-0.984]) with an optimal cutoff of 135.6, sensitivity of 82.4%, and specificity of 94.3%. The calibration curve showed good accuracy.

CONCLUSIONS

Concurrent pathological scarring is an independent risk factor for post-ESD esophageal stricture.

Impact of preoperative comorbidities on elderly patients with esophageal squamous cell carcinoma following esophagectomy: a propensity score matching analysis

OBJECTIVE

Elderly patients, particularly those aged 70 and above, often present with comorbidities such as coronary heart disease (CHD), chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), and high blood pressure (HBP). These comorbid diseases complicate treatment. However, the impact of these comorbidities on survival outcomes and complications in elderly patients undergoing esophagectomy for esophageal squamous cell carcinoma (ESCC) remains under-researched.

METHODS

This cohort study examined ESCC patients aged 70 and older who underwent esophagectomy. Patients were divided into two cohorts: those without preoperative comorbid diseases (NCD group) and those with preoperative comorbid diseases (CD group). Data were obtained from the Sichuan Cancer Hospital and Institute Esophageal Cancer Case Management Database between May 2016 and August 2021, with follow-up concluding on December 20, 2023.

RESULTS

A total of 469 patients met the inclusion criteria, with 206 patients in the comorbid diseases (CD group) and 263 patients without (NCD group). The median follow-up period was 47.5 months, the median overall survival (OS) was 51.6 months and median disease-free survival (DFS) was 33.0 months, with no statistically significant difference in OS and DFS in 2 groups. The incidence of grade 3 or higher complications in the NCD and CD groups was similar, with no statistically significant difference. The most common grade 3 or higher complications were pulmonary infection, hydrothorax, anastomotic stenosis, and anastomotic leakage.

CONCLUSIONS

Preoperative comorbidities, including CHD, COPD, DM, and HBP, did not significantly impact the long-term survival or disease-free survival of elderly ESCC patients undergoing esophagectomy.

Perioperative nivolumab and chemotherapy in locally advanced squamous cell carcinoma of the oesophagus: a randomized multicentre phase 2 study with circulating tumor DNA dynamics monitoring

BACKGROUND

Although neoadjuvant chemotherapy and immunotherapy show promise in treating oesophageal squamous cell carcinoma (OSCC), long-term survival data are limited. This randomized, multicenter phase 2 study evaluated the efficacy of perioperative Nivolumab with chemotherapy, followed by surgery and adjuvant immunotherapy, in patients with locally advanced resectable OSCC, and explored the prognostic role of circulating tumor DNA (ctDNA) status.

METHODS

In this trial, participants recruited from five centers were randomly assigned in a 2:1 ratio to receive either perioperative Nivolumab or a placebo in addition to chemotherapy (cisplatin and paclitaxel), followed by minimally invasive esophagectomy. For those who did not achieve a pathological complete response (pCR), adjuvant treatment with Nivolumab was administered. The main measure of success was the pCR rate, with secondary endpoints including the R0 resection rate, event-free survival, and overall survival. All outcomes and safety measures were assessed based on the intention-to-treat population. ctDNA levels were monitored as exploratory endpoints.

RESULTS

Ninety patients were enrolled and randomized to Nivolumab or placebo plus chemotherapy. The pCR rate was slightly higher in the Nivolumab group (15%) compared to the control group (13.3%) (relative risk, 1.13; 95% CI, 0.38 to 3.36). No significant differences were observed in R0 resection rates (96.4% vs. 96.6%; P > 0.05). The median follow-up duration was 24.9 months (interquartile range: 22.8 to 26.7 months). Two-year event-free survival rates were 63.11% in the Nivolumab group versus 60.47% in the chemo group (hazard ratio, 0.97; 95% CI, 0.49 to 1.92). Two-year overall survival rates were 83.32% and 79.4%, respectively (hazard ratio, 0.82; 95% CI, 0.29 to 2.31). All participants were ctDNA positive at baseline, but post-treatment, 89% of the Nivolumab group and 62.5% of the placebo group turned ctDNA negative (P = 0.01). Those negative for ctDNA at all testing points showed significantly better disease-free survival (P < 0.001).

CONCLUSIONS

Perioperative Nivolumab plus chemotherapy is a viable and safe option for systemically treating locally advanced resectable OSCC. Monitoring minimal residual disease through ctDNA could be potentially valuable for assessing the effectiveness of adjuvant therapy and for prognostic evaluation in a systemic manner.

TRIAL REGISTRATION

ClinicalTrials.gov registration NCT05213312.

The prognostic effect of recurrent laryngeal nerve palsy after esophagectomy in locally advanced esophageal squamous cell carcinoma: A multi-center retrospective study

BACKGROUND

Postoperative pneumonia following esophagectomy has been shown to adversely affect prognosis, whereas the prognostic significance of recurrent laryngeal nerve palsy (RLNP) remains unclear. This multicenter Japanese study aimed to evaluate the impact of RLNP on prognosis in patients undergoing esophagectomy for locally advanced esophageal squamous cell carcinoma (ESCC).

METHODS

A total of 343 patients with clinical Stage I-IVA ESCC who underwent esophagectomy between 2010 and 2019 at five Japanese specialized esophageal cancer centers was retrospectively collected. The occurrence of RLNP was assessed for its association with short- and long-term outcomes.

RESULTS

RLNP was observed in 65 patients (19.0 %). The 3-year overall survival (OS) rates were 69.8 % in the RLNP+ group and 70.5 % in the RLNP- group, with no significant difference (hazard ratio [HR]: 1.02, 95 % confidence interval [CI]: 0.65-1.59, p = 0.95). RLNP was significantly associated with clinical N-positive status (p = 0.04) and intrathoracic anastomosis (p = 0.03) but was not correlated with other clinicopathological or perioperative factors. Although RLNP+ patients had longer postoperative hospital stays, there were no significant differences in operative time, blood loss, number of harvested lymph nodes, or rates of postoperative complications, including pneumonia and anastomotic leakage. Multivariable analysis identified postoperative pneumonia as a poor prognostic factor for OS (HR: 1.60, 95 % CI: 1.06-2.41, p = 0.03), whereas RLNP was not (HR: 0.91, 95 % CI: 0.58-1.43, p = 0.69).

CONCLUSIONS

This study demonstrated that RLNP following esophagectomy for locally advanced ESCC does not significantly affect long-term survival.

Postoperative Recurrence Pattern of Clinical Stage I Esophageal Cancer After Esophagectomy with Two- or Three-Field Lymph Node Dissection: Supplementary Analysis from JCOG0502

BACKGROUND

Although recurrence after curative surgery for cT1bN0M0 clinical stage I (cStage I) esophageal squamous cell carcinoma (ESCC) is not rare, reports of recurrence analyses are sparse. Detailed data on optimal postoperative follow-up evaluation of cStage I ESCC are lacking. This study aimed to evaluate the frequency, characteristics, and predictors of postoperative recurrence in patients with cT1bN0M0 cStage I ESCC.

METHODS

The study analyzed 210 patients who underwent surgery for cT1bN0M0 cStage I ESCC and a follow-up computed tomography (CT) examination in the prospective multicenter study, JCOG0502. The study categorized the characteristics of postoperative recurrences such as the recurrence sites and whether regional/non-regional lymph nodes (LNs) and single/multiple organs were involved. Backward elimination was applied (p < 0.2) to identify postoperative recurrence predictors and obtained hazard ratios (HRs) based on Fine and Gray's model.

RESULTS

Postoperative recurrence was experienced by 31 patients (14.8%) at one or more of the following sites: regional LNs (n = 18), non-regional LNs (n = 10), lung (n = 2); bone (n = 2), and liver, local recurrence, skin, pleura, pericardium, and other (n = 1 each). In four patients, the first recurrence developed in multiple organs. The median interval between trial registration and the first recurrence was 18.6 months. In multivariable analyses, pathologic nodal metastasis (hazard ratio [HR], 3.29; p = 0.003), tumor location in the upper-thoracic esophagus versus lower-thoracic esophagus (HR, 6.71; p = 0.013), and two-field lymphadenectomy (HR, 4.31; p = 0.001) were independently associated with the development of postoperative recurrence.

CONCLUSION

The main postoperative recurrence sites of cT1bN0M0 ESCC are the LNs, but recurrence in non-regional LNs or distant organs is also quite common, indicating the importance of post-surgery systemic follow-up evaluation.

Effectiveness of chemotherapy with/without radiotherapy for stage IVb esophageal squamous cell carcinoma: a population-based target trial emulation study

BACKGROUND

The role of radiation therapy in combination with systemic treatment for stage IVb esophageal squamous cell carcinoma (ESCC) is unclear. We aimed to investigate the effectiveness of primary chemoradiotherapy for these patients and compare it to that chemotherapy alone.

MATERIALS AND METHODS

In this retrospective cohort study, we adopted a target trial emulation framework to identify eligible patients in the Taiwan Cancer Registry diagnosed between 2011 and 2021. In the primary analysis, overall survival (OS) was the primary endpoint, whereas the incidence of esophageal cancer mortality was the secondary endpoint. Extensive supplementary analyses were also conducted.

RESULTS

We included 5294 patients in the primary analysis and found that OS was significantly better for those treated with chemoradiotherapy (n = 5065) than for those treated with chemotherapy only (n = 229). The propensity score weighting adjusted hazard ratio of death was 0.46 (95% confidence interval 0.41-0.52, p < 0.0001). The secondary endpoint and supplementary analyses also favored the chemoradiotherapy group.

CONCLUSION

The OS of stage IVb ESCC patients treated with chemoradiotherapy was significantly better than that of patients treated with chemotherapy alone. The results of relevant ongoing clinical trials are eagerly awaited.

Effects of immunoenteric nutrition versus general enteral nutrition on prognosis in patients with squamous cell carcinoma undergoing radical esophagectomy post neoadjuvant chemotherapy

Malnutrition is a common complication among patients with esophageal cancer, significantly increasing the risk of postoperative complications and mortality. Multiple studies have shown that immunoenteric nutrition (IEN) can reduce postoperative infectious complications in patients with esophageal cancer. However, its prognostic impact on patients undergoing radical surgery following neoadjuvant therapy remains unclear. This study aimed to compare the prognostic effects of IEN versus standard enteral nutrition (EN) in patients with esophageal squamous cell carcinoma (ESCC) following radical esophageal cancer surgery after neoadjuvant therapy. This retrospective study included 197 patients with ESCC who underwent radical esophagectomy following neoadjuvant therapy between 2016 and 2022. Of these, 133 patients received postoperative standard EN, while 64 patients received IEN. The primary endpoints were overall survival (OS) and progression-free survival (PFS). The secondary endpoints included the incidence of postoperative complications and changes in relevant blood markers before and after surgery. No significant differences were observed in postoperative hospitalization duration or complications between the two groups. Postoperative C-reactive protein and immunoglobulin M levels were significantly lower in the IEN group compared to the EN group (P = 0.018 and 0.042). Kaplan-Meier survival curves were plotted for 1, 2, 3, and 5 years to compare the effects of IEN and EN on OS and PFS. The log-rank test revealed the following survival rates: 90.6% versus 77.2% (1-year PFS, P = 0.023); 95.3% versus 82.7% (1-year OS, P = 0.015); 71.9% versus 56.7% (2-year PFS, P = 0.035); 76.6% versus 62.4% (2-year OS, P = 0.03); 54.6% versus 41.7% (3-year PFS, P = 0.064); 61.4% versus 49.3% (3-year OS, P = 0.08); 39.4% versus 30.7% (5-year PFS, P = 0.093); and 41.5% versus 32.6% (5-year OS, P = 0.104). Univariate and multivariate analyses identified several independent predictors of 2-year PFS and OS. For 2-year PFS, the independent predictors included body mass index (P = 0.005), ypTNM stage (Pathologic TNM-staging after neoadjuvant therapy) (P = 0.045), ypT stage (Pathologic T-staging after neoadjuvant therapy) (P = 0.030), ypN stage (Pathologic N-staging after neoadjuvant therapy) (P = 0.007), tumor differentiation (P = 0.031), and type of EN (P = 0.004). For 2-year OS, the independent predictors were age (P = 0.015), body mass index (P = 0.004), ypTNM stage (P = 0.013), ypT stage (P = 0.010), ypN stage (P = 0.009), tumor differentiation (P = 0.026), and type of EN (P = 0.001). In patients with ESCC undergoing esophagectomy after neoadjuvant therapy, postoperative IEN accelerates the resolution of the inflammatory state and improves short-term survival, though its long-term benefits remain uncertain. Furthermore, IEN does not significantly affect the postoperative hospitalization duration or the incidence of complications.

Clinical outcomes of pembrolizumab plus chemotherapy for postoperative recurrent esophageal squamous cell carcinoma

BACKGROUND

Immunotherapy combined with chemotherapy has been the first-line treatment for metastatic or unresectable locally advanced esophageal cancer. However, postoperative recurrences have not been sufficiently investigated. We investigated the clinical outcomes of pembrolizumab plus cisplatin plus 5-fluorouracil (CF) therapy for postoperative recurrent esophageal squamous cell carcinoma.

METHODS

We retrospectively analyzed 100 consecutive patients with postoperative recurrence and compared their treatment response and survival outcomes in response to pembrolizumab plus CF therapy and conventional CF therapy.

RESULTS

Pembrolizumab plus CF therapy had higher response and objective response rates (41% vs. 27%, 77% vs. 57%, respectively) and prolonged progression-free survival (median 6.5 vs. 4.9 months, P = 0.011) and overall survival (not reached [NR] vs. 14.0 months, P = 0.087) compared to CF therapy. Early tumor shrinkage (ETS) ≧20% had a longer duration of response with pembrolizumab plus CF therapy compared with conventional CF therapy (NR vs. 10.2 months, P = 0.007). Conversely, the additional benefit of pembrolizumab in CF therapy was limited when ETS was <20% (4.0 vs. 3.4 months, P = 0.814). CF therapy was associated with worse survival outcomes for recurrences within 6 months post-surgery compared to those after 6 months. Pembrolizumab plus CF therapy provided comparable survival outcomes regardless of the timing of recurrence; however, it was less effective in combined positive score < 10 within the first 6 months.

CONCLUSION

First-line pembrolizumab plus chemotherapy for postoperative recurrent esophageal cancer improved clinical outcomes compared to conventional CF therapy and can be expected to be one of the treatment options even in early postoperative recurrence.

Survival Impact of Adjuvant Nivolumab Therapy for Locally Advanced Esophageal Squamous Cell Carcinoma Treated with Neoadjuvant Chemotherapy with Docetaxel Plus 5-Fluorouracil and Cisplatin

BACKGROUND

The efficacy of adjuvant nivolumab following neoadjuvant chemotherapy in managing locally advanced esophageal cancer remains unclear. This study evaluated the survival benefits of adjuvant nivolumab after neoadjuvant chemotherapy with a docetaxel, 5-fluorouracil, and cisplatin (DCF) regimen in patients with locally advanced esophageal squamous cell carcinoma (ESCC).

METHODS

This single-center, retrospective study included 439 consecutive patients with locally advanced ESCC who underwent radical esophagectomy following neoadjuvant DCF chemotherapy. The approval of adjuvant nivolumab has led to patients with pathological lymph node metastasis following preoperative treatment becoming eligible for treatment.

RESULTS

Among the 439 patients included, 379 and 60 received neoadjuvant DCF (neoDCF group) and adjuvant nivolumab after neoadjuvant DCF (neoDCF+AdNivo group), respectively. Disease-free survival (DFS) remained comparable despite differences in pathological lymph node metastasis (53% vs. 100%). After propensity score matching, adjuvant nivolumab yielded a significant improvement in DFS and overall survival (OS) (2-year DFS: 60.2% vs. 44.9%, hazard ratio [HR] 0.49, 95% confidence interval [CI] 0.28-0.83, p = 0.009; 2-year OS: 94.1% vs. 64.0%, HR 0.17, 95% CI 0.06-0.50, p = 0.001). The 1-year postoperative recurrence rate in the neoDCF+AdNivo group was lower (23% vs. 47%, p = 0.007). Subgroup analysis revealed a marked improvement in DFS in patients with ypT3 or ypN2 disease, particularly in those with ypStage III disease. Adjuvant nivolumab and ypN stage were identified as independent prognostic factors for DFS.

CONCLUSION

Adjuvant nivolumab therapy following neoadjuvant DCF chemotherapy may improve survival outcomes in patients with locally advanced ESCC, with particularly strong benefits being observed in ypStage III.

Association between prognostic immune nutritional index and disease-free survival in adults with esophageal cancer following surgery: A retrospective cohort study

INTRODUCTION

The clinical significance of the prognostic immune nutritional index in esophageal cancer has not been elucidated. The aim of this study was to evaluate the utility of the preoperative prognostic immune nutritional index in predicting oncological outcomes and the incidence of surgical site infection in patients with esophageal cancer.

METHODS

We analyzed preoperative prognostic immune nutritional index from 150 esophageal cancer patients who underwent surgical treatment between 2008 and 2018 to clarify its clinical relevance.

RESULTS

Patients with low preoperative prognostic immune nutritional index exhibited poor disease-free survival and overall survival (P = 0.030 and P < 0.001, respectively). Although statistical significance was not observed in the multivariate analysis, low prognostic immune nutritional index showed a tendency toward poorer disease-free survival (hazard ratio [HR]: 2.02; 95% confidence interval [CI]: 0.88-4.61; P = 0.096). Regarding overall survival, multivariate analysis revealed that low preoperative prognostic immune nutritional index was an independent prognostic factor for overall survival (HR: 2.67; 95% CI: 1.39-5.16; P = 0.003). Moreover, the low preoperative prognostic immune nutritional index was associated with a tendency toward an increased risk of surgical site infection (odds ratio: 2.38; 95% CI: 0.96-5.91; P = 0.062). In the subgroup analysis of patients who did not receive neoadjuvant therapy, low preoperative prognostic immune nutritional index was identified as an independent prognostic factor for disease-free survival (HR: 3.11; 95% CI: 1.00-9.71; P = 0.050) and overall survival (HR: 5.04; 95% CI: 1.80-14.13; P = 0.002).

CONCLUSION

The preoperative prognostic immune nutritional index is a useful marker for perioperative and oncological management of esophageal cancer patients.

Visual Endoscopic Retrograde Appendicitis Therapy Vs Antibiotic Therapy for Treatment of Uncomplicated Acute Appendicitis

INTRODUCTION

Visual endoscopic retrograde appendicitis therapy (V-ERAT) involves a single-use video scope, allowing for real-time visualization of the appendiceal lumen during the procedure to treat uncomplicated acute appendicitis (AA). This study aims to compare V-ERAT to antibiotic therapy in treating uncomplicated AA.

METHODS

This multicenter, retrospective cohort study was conducted at 9 hospitals in China from August 2021 to July 2023. Propensity score matching was performed to minimize selection bias. A total of 692 uncomplicated AA patients were included, with 188 undergoing V-ERAT and 504 receiving antibiotic therapy. The primary outcome was treatment success rate. The secondary outcomes included recurrent appendicitis rate, the appendectomy rate during the initial hospitalization, length of initial hospitalization, time to disease recurrence, and overall adverse events.

RESULTS

The treatment success rate did not differ between the V-ERAT and antibiotic groups (93.6%; 95% confidence interval [CI] 89.1%-96.7% vs 90.5%; 95% CI, 87.6%-92.9%) ( P = 0.225). However, V-ERAT demonstrated a significantly lower risk of appendicitis recurrence compared with antibiotic therapy during the follow-up (log-rank P < 0.001), with a hazard ratio of 0.14 (95% CI, 0.07-0.29, P < 0.001). V-ERAT was associated with a lower appendectomy rate during the initial hospitalization (4.3%; 95% CI, 1.9%-8.2% vs 9.5%; 95% CI, 7.1%-12.4%) ( P = 0.027), a shorter length of initial hospitalization (3 [interquartile range (IQR), 3-4] vs 4 [IQR, 4-6] days, P < 0.001), and a longer time to recurrence (269 [IQR, 210-318] vs 70 [IQR, 21-103] days, P < 0.001). The overall adverse event rates did not differ between the 2 groups (log-rank P = 0.064).

DISCUSSION

V-ERAT seems to be a safe and effective alternative to antibiotic therapy in treating uncomplicated AA, significantly reducing the risk of appendicitis recurrence.

Is radix ligation of the inferior mesenteric artery effective in Japanese-Style D3 radical lymph node dissection for sigmoid colon and rectal cancer surgery?-a single-center retrospective analysis since 2002

Background

The Japanese treatment guidelines recommend treatment of the root of the inferior mesenteric artery (IMA) (#253) to ensure ligation and dissection of the root of the IMA (#253) in descending colon cancer/sigmoid colon cancer deeper than in T2 [muscularis propria (MP)] cancer. However, #253 complete D3 dissection with IMA root ligation has been reported to increase postoperative complications, such as colonic ischemia, and to have a worse prognosis compared to IMA-preserving D3 system dissection. Therefore, we decided to compare complete IMA dissection with ligation and dissection of the IMA root and preserving the left colonic artery (LCA) preserving group.

Methods

A total of 172 patients with stage II/III primary sigmoid colorectal cancer who had undergone radical curative resection were categorized into two groups: the IMA root ligation group (#253 complete D3 dissection group) and the LCA preservation group (94/78 cases), in which the IMA root was preserved and either lymph node sampling dissection or peripheral ligation of the left colorectal artery bifurcation was performed. The 5-year recurrence-free survival (5Y-RFS) and 5-year overall survival (5Y-OS) rates were compared.

Results

The overall 5-year follow-up rate was 70.23%. 5Y-RFS and 5Y-OS were tested, and no significant differences were found. Similarly, there were no significant differences in the background factors. In the laparotomy/hand-assisted laparoscopic surgery (HALS)/laparoscopic surgery procedure, complete IMA ligation tended to be more common in the HALS group, whereas LCA preservation tended to be more prevalent in the laparoscopic surgery group. There were no significant differences in the postoperative complications between the groups. Anastomotic failure occurred in 6/3 patients in the IMA complete ligation/LCA preservation groups; bowel obstruction in 5/4; wound infection in 10/5; posterior hemorrhage in 1/4; dysuria in 5/1; and urinary tract infection (including cystitis) in 2/1. Postoperative cerebral infarction, ureteral injury, and thigh paresthesia were each observed in only one case in the complete ligation group.

Conclusions

These results showed no significant differences in the 5Y-OS or 5Y-RFS. There was no significant difference in prognosis between patients with and without lymph node dissection at the root of the IMA. Thus, there was no significant difference in prognosis between the complete IMA ligation and LCA preservation groups, with or without IMA dissection. There were no significant differences in complications in the complete ligation group; however, the number of cases seemed large. These results suggest that preservation of the IMA may be safe and effective for stage II/III lymph node dissection in primary sigmoid colorectal cancer.

Photodynamic therapy as a promising treatment for long-segment and whole-circumferential early esophageal cancer

Background

Photodynamic therapy (PDT) is an effective endoscopic therapy indicated for early esophageal cancer, but there have been few reports of PDT for circumferential lesions so far. The objective of this study is to investigate the clinical outcome of PDT for patients with whole-circumferential early esophageal squamous cell carcinoma (ESCC), especially the subsequent process of esophageal stricture.

Methods

Twelve patients with whole-circumferential early ESCC, who received PDT between January 2020 and July 2022 at the First Affiliated Hospital with Nanjing Medical University were retrospectively evaluated. An analysis for comparisons between the results of PDT and contemporaneous endoscopic submucosal dissection (ESD) for similar esophageal lesions was conducted.

Results

The complete response (CR) rate was 83.33% after PDT treatment for a median tumor length of 9.5 cm. A longer tumor length (>10 cm) was the risk factor of PDT failure (P=0.045). Compared to the ESD group, the procedure was significantly shorter for PDT, and postoperative fever and bleeding seemed to occur less. Without prophylactic measures, the esophageal stricture rate was 80% after PDT, which was close to that in the ESD group with steroid administration (76.9%, P>0.99). The mean onset time of obvious dysphagia was 7.63±4.34 and 4.29±2.49 weeks respectively after PDT and ESD (P=0.02). The post-PDT esophageal strictures were easily resolved with a simpler dilation modality and the estimated dysphagia duration tended to be shorter than that after ESD (12.72±3.04 vs. 23.69±3.24 months, P=0.08). Nevertheless, chest pain appeared more frequently in PDT than that in ESD.

Conclusions

PDT can be expected to be an effective and safe endoscopic modality for long-segment and whole-circumferential early ESCC.

Impact of occupation on survival of esophageal squamous cell carcinoma patients following esophagectomy: a long-term survival analysis

BACKGROUND

Esophageal cancer (EC), particularly esophageal squamous cell carcinoma (ESCC), is a major global health issue with high incidence and mortality rates in Asia. This study examines the impact of occupational background on the long-term survival of ESCC patients following esophagectomy.

METHODS

Data were obtained from the Sichuan Cancer Hospital & Institute Esophageal Cancer Case Management Database (SCCH-ECCM Database), focusing on patients with ESCC who underwent esophagectomy between 2010 and 2017. Patients were classified into four occupational groups: Farmer, Civil Servant, Teacher, and Factory Worker. The primary outcome measured was overall survival (OS), which was analyzed using Kaplan-Meier survival curves, Cox proportional hazards models, and restricted mean survival time (RMST). To account for potential confounding factors, propensity score matching (PSM) was employed.

RESULTS

Among the cohort, 67.5% were Farmers, 9.0% Civil Servants, 1.9% Teachers, and 21.6% Factory Workers. The median follow-up was 72.2 months, with a median OS of 49.8 months. One-, three-, and five-year OS rates varied slightly by occupation, with Factory Workers displaying the highest one-year survival rate at 91%. Significant survival differences were noted between Farmers and Civil Servants (HR: 1.291; 95% CI: 1.030 - 1.618; P = 0.027),the significance persisted even after PSM (HR: 1.376; 95% CI: 1.004 - 1.885; P = 0.047). Civil Servants, who presented with more advanced disease stages, had the lowest crude RMST, aligning more closely with other groups after adjustment.

CONCLUSIONS

The results revealed that ESCC patients categorized as Civil Servants exhibited a poorer prognosis compared to those classified as Farmers.

Endoscopic treatment versus surgical treatment for T1b esophageal cancer: a systematic review and meta-analysis

BACKGROUND

Endoscopic and surgical treatment are the two most common treatment strategies for resectable esophageal cancer (EC), but the optimal treatment for T1b EC remains controversial. This study aims to compare the efficacy and safety of endoscopic treatment versus esophagectomy for T1b EC.

METHODS

Web of Science, MEDLINE, Scopus, and EMBASE were searched from their inception to December 2023. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines, we used the fixed- and random-effect models for this meta-analysis by RevMan. The primary outcomes included overall survival (OS), recurrence, lymph node metastasis, complete resection rate and positive resection margin. The secondary outcomes were 1-year survival, 3-year survival, 5-year survival, overall mortality rate, EC-specific mortality rate and lymphovascular invasion.

RESULTS

Nine studies with a population of 1637 patients (endoscopic treatment: 715 patients; surgical treatment: 922 patients) were included. The pooled results showed that surgical treatment was associated with a significantly better OS than endoscopic treatment (Hazard Ratio [HR] = 0.78; 95 % confidence interval [CI]: [0.62, 1.00]; P = 0.05). There was also significant difference in positive resection margin (Relative Risk [RR] = 0.13; 95 % CI: [0.09, 0.20]; P < 0.00001) between the two treatment strategies.

CONCLUSION

The pooled results of this study indicated that surgical treatment had better OS than endoscopic treatment for T1b EC. Furthermore, endoscopic treatment also had significantly higher risk of margin positivity than surgical treatment for T1b EC.

The role of CST2 in the pathogenesis and prognosis of esophageal squamous cell carcinoma

PURPOSE

Cystatin SA (CST2) is a cysteine protease inhibitor that is overexpressed in several malignancies; however, its involvement in esophageal squamous cell carcinoma (ESCC) has yet to be investigated. This study evaluates CST2 expression, its association with clinicopathological parameters, and its prognostic significance in ESCC. We further investigate the biological functions of CST2 to assess CST2 impact on tumor progression and its potential as a prognostic marker.

METHODS

CST2 expression was quantified in 16 ESCC cell lines and 165 paired tumor and adjacent non-cancerous tissues using quantitative reverse-transcription PCR (qRT-PCR). siRNA-mediated CST2 knockdown assays were performed to assess cellular functions in vitro and in vivo. Associations between CST2 expression and clinicopathological features, recurrence patterns, and survival outcomes, including disease-specific survival (DSS) and disease-free survival (DFS), were analyzed using statistical methods.

RESULTS

CST2 mRNA levels were significantly elevated in ESCC tissues compared to normal mucosa. Knockdown of CST2 reduced proliferation, migration, and invasion in vitro, while in vivo models demonstrated smaller tumor volumes in CST2 knockdown groups compared to controls. High CST2 expression correlated with worse DSS and DFS. Multivariable analysis confirmed high CST2 expression as an independent prognostic factor for DSS.

CONCLUSION

CST2 plays a critical role in ESCC pathogenesis and progression. Its overexpression is associated with poor clinical outcomes, suggesting CST2 as a potential prognostic biomarker for recurrence and survival in ESCC.

Sex-based analysis of clinical outcomes in elderly patients with esophageal squamous cell carcinoma post-esophagectomy: a propensity score matching analysis

Background

Esophageal squamous cell carcinoma (ESCC) is a common and aggressive form of esophageal cancer, particularly prevalent in East Asia. This study aimed to investigate the impact of sex on clinical outcomes, including survival and postoperative complications, in elderly ESCC patients following esophagectomy.

Methods

We conducted a retrospective cohort study using data from the Sichuan Cancer Hospital & Institute Esophageal Cancer Case Management Database, involving patients aged 70 years and older who underwent esophagectomy from May 2016 and August 2021. Patients were grouped by sex, and subgroup analyses were performed on non-smoking, non-drinking patients. OS and DFS were analyzed using the Kaplan-Meier method, and between-group comparisons were conducted using the log-rank test. Propensity score matching (PSM) was applied to adjust for potential confounders.

Results

Although females showed a longer median OS (60.2 months) compared to males (40.0 months), the difference was not statistically significant after PSM (HR = 0.885, P = 0.573). Similarly, no significant differences were observed in DFS between sexes. In non-smoking, non-drinking subgroups, OS and DFS remained higher but without significant sex-based differences. Postoperative adverse events such as pulmonary infection and anastomotic leakage were common across groups.

Conclusions

While sex does not significantly affect OS and DFS in elderly ESCC patients, male patients may experience higher rates of certain postoperative complications, such as abnormal liver function and pneumothorax.

Real-world safety and efficacy of neoadjuvant docetaxel, cisplatin, and 5-fluorouracil therapy for locally advanced esophageal squamous cell carcinoma

BACKGROUND

Neoadjuvant chemotherapy with docetaxel, cisplatin plus 5-FU (DCF) has become the new standard of care for locally advanced esophageal squamous cell carcinoma (ESCC). In a real-world setting, the efficacy, recurrence, and adverse events (AEs) remain unclear.

METHODS

This retrospective cohort study included 86 patients who received neoadjuvant DCF followed by esophagectomy for resectable ESCC.

RESULTS

Following neoadjuvant DCF treatment, 75 patients underwent R0 curative resection. At the median follow-up of 19.2 months, the median disease-free survival (DFS)/recurrence-free survival (RFS) was not yet reached, with estimated 3-year DFS/RFS rates of 65.2%, respectively. The incidence of primary tumor regression grading (TRG) grade 1a and pathological complete response (pCR) were 21.3% (16/75) and 14.7% (11/75), respectively. The estimated 1-year DFS/RFS rates were 93.8% for primary TRG grade 1a and 100% for pCR. Baseline elevated serum SCC-antigen levels were inversely associated with achieving primary TRG grade 1a or pCR. In 64 patients who did not achieve pCR, residual tumor cells in the lymph nodes (ypN; HR, 16.96; 95% CI, 2.11-136.12; P < 0.01) and Glasgow prognostic score (GPS; HR, 8.34; 95% CI, 1.73-40.31; P < 0.01) were independent predictors of shorter DFS/RFS. The most common grade ≥ 3 AEs were neutropenia (61.6%) and febrile neutropenia (26.7%), which were not associated with clinicopathological factors. The most common non-hematological AEs were appetite loss (9.3%), pulmonary embolism (8.1%), diarrhea (7.0%), and nausea (2.3%). Nine patients discontinued neoadjuvant DCF due to toxicities.

CONCLUSIONS

Neoadjuvant DCF was effective and well-tolerated in real-world ESCC patients. Primary TRG grade 1a or pCR showed a favorable DFS/RFS, while positive ypN and GPS were independent risk factors for worse DFS/RFS.

Impact of preceding treatment for head and neck squamous cell carcinoma on synchronous superficial esophageal squamous cell carcinoma

BACKGROUND

Patients with esophageal squamous cell carcinoma (ESCC) frequently develop synchronous head and neck squamous cell carcinoma (HNSCC). With advances in endoscopic technology and widespread screening of synchronous cancers, the detection of synchronous HNSCC and superficial ESCC (SESCC) is increasing. We aimed to evaluate the impact of preceding HNSCC treatment on synchronous SESCC.

METHODS

This single-center retrospective study enrolled patients with synchronous HNSCC and SESCC who were treated between January 2010 and December 2023. Tumor size and depth of SESCC before and after HNSCC treatment were evaluated. The factors associated with SESCC progression were investigated.

RESULTS

Of the 299 patients with synchronous HNSCC and SESCC, 134 who underwent preceding HNSCC treatment with follow-up esophagogastroduodenoscopy (EGD) for SESCC were evaluated. Chemoradiotherapy was the most common treatment for HNSCC (56.0%), followed by surgery (17.2%), radiotherapy (14.9%), local resection (7.5%), and chemotherapy (4.5%). The tumor size of SESCC increased after HNSCC treatment in 18 patients (13.4%). Multivariate analysis revealed that an EGD interval of ≥ 120 days was significantly associated with increased tumor size in SESCC (odds ratio, 6.64; 95% confidence interval, 1.91-23.1). Tumor regrowth was observed in 70.6% of SESCCs that shrank with HNSCC treatment, mostly within six months. Tumor depth aggravation was rare (2.2%), but progression to advanced ESCC was observed in two patients.

CONCLUSIONS

Timely endoscopic follow-up, preferably within 120 days, is crucial for managing synchronous SESCC after HNSCC treatment to prevent tumor progression. Tumor regrowth should be monitored when SESCC shrinks with HNSCC treatment.

Lymph-node ratio as a risk factor for recurrence following neoadjuvant docetaxel, cisplatin, and 5-fluorouracil therapy for locally advanced esophageal squamous cell carcinoma

BACKGROUND AND PURPOSE

It remains unclear whether the lymph-node ratio (LNR) is a relevant factor for the risk of recurrence following neoadjuvant chemotherapy (nCT) with docetaxel, cisplatin, and 5-fluorouracil (DCF), which is a new standard of care for locally advanced esophageal squamous cell carcinoma (ESCC) in Japan. This study aimed to evaluate the clinical utility of LNR as a risk factor for recurrence.

MATERIALS AND METHODS

We retrospectively analyzed 75 patients who underwent nCT-DCF followed by curative surgery for resectable ESCC. The cut-off for the LNR was determined using receiver-operating characteristic curve analysis for recurrence.

RESULTS

A higher LNR was observed in 34 (45.3%) patients. At a median follow-up of 19.2 months, the median disease-free survival (DFS)/recurrence-free survival (RFS) rate was not reached in patients with a lower LNR and was 8.0 months in those with a higher LNR (P < 0.01). The estimated 1-year DFS/RFS rate was 47.8% and 100% for patients with a higher LNR and lower LNR, respectively. LNR remained a risk factor, even when stratified by non-pathological complete response, the presence of positive ypN, or ypStage III. In those with a higher LNR, the median DFS/RFS was 18.3 versus 8.0 months with and without adjuvant nivolumab treatment, respectively.

CONCLUSIONS

Higher LNR indicates a more aggressive phenotype with worse DFS/RFS rates and increased recurrence following nCT-DCF treatment and curative surgery for ESCC.

Successful staged surgery for advanced esophageal cancer after conversion pancreatoduodenectomy with pancreaticogastrostomy

BACKGROUND

Complex surgery during initial cancer treatment can limit surgical options when planning management of a secondary malignancy. Subtotal esophagectomy and pancreatoduodenectomy are the most invasive and difficult procedures in gastroenterological surgery. Surgical cases in which subtotal esophagectomy was performed after pancreatoduodenectomy with pancreaticogastrostomy are extremely rare and challenging procedures due to the resulting complicated anatomical changes.

CASE PRESENTATION

A 60-year-old man with a history of conversion pancreatoduodenectomy with pancreaticogastrostomy for advanced pancreatic head cancer was diagnosed as having advanced thoracic esophageal squamous cell carcinoma. After neoadjuvant chemotherapy, we chose a two-staged surgery with thoracoscopic subtotal esophagectomy. Following percutaneous endoscopic gastrostomy, we performed subtotal esophagectomy, systematic lymph-node dissection, and esophagostomy as the first-stage operation. Fifty-six days later, we performed gastrointestinal reconstruction with pedicle jejunum and microvascular anastomosis by the percutaneous route as the second-stage operation. Postoperatively, the patient was relieved without major complications, and the tumors were amenable to curative pathologic resection.

CONCLUSIONS

The greatest advantages of staged surgery are to reduce surgical invasiveness and to circumvent the lower rate of curability. Our procedure reported here may be recommended as an option for staged resection and reconstruction in patients with advanced esophageal cancer after pancreatoduodenectomy with pancreaticogastrostomy.

Impact of time from diagnosis to endoscopic submucosal dissection on curability in superficial esophageal squamous cell carcinoma

Objective

To investigate the time delay effect from initial diagnosis to endoscopic submucosal dissection on superficial esophageal squamous cell carcinoma curability, considering the preoperative invasion depth.

Methods

This study included superficial esophageal squamous cell carcinoma diagnosed as T1a-epithelial/lamina propria mucosa cancer (cEP/LPM; cancer invading up to the lamina propria mucosa) or cT1a-muscularis mucosa (MM)/T1b-submucosal cancer (cMM/SM1; cancer invading up to 200 µm into the submucosa) and treated using endoscopic submucosal dissection from January 2017 to December 2021. We compared curability in lesions treated within three months (early treatment group) versus those treated ≥7 months post-diagnosis (delayed treatment group). Curative resection criteria included lesions confined within the muscularis mucosae, with negative vertical margins, and with absence of lymphovascular invasion. Non-curative resection included all other cases.

Results

Among the 231 and 75 lesions in the early and delayed treatment groups, respectively, no significant difference was observed in non-curative resections for all lesions and cEP/LPM lesions (early: 194, delayed: 70). Conversely, the proportions were significantly higher in the delayed treatment group than in the early treatment group for cMM/SM1 lesions (early: 37, delayed: 5; p = 0.018).

Conclusions

This study suggests that delayed endoscopic submucosal dissection does not significantly affect cEP/LPM lesions curability but is associated with reduced cMM/SM1 lesions curability. Prompt treatment is important for cMM/SM1, whereas delayed treatment may be acceptable for cEP/LPM.

Long-term Survival in Esophageal Cancer: Comparison of Minimally Invasive and Open Esophagectomy

BACKGROUND

Thoracoscopic esophagectomy is a less invasive surgical procedure; however, evidence of its effect on long-term survival is limited. We evaluated long-term survival after the procedure in patients with esophageal carcinoma.

METHODS

This retrospective multicenter study involved 1559 consecutive patients with esophageal carcinoma who underwent thoracoscopic esophagectomy or open esophagectomy between 2012 and 2019 at 2 Japanese high-volume cancer centers. Propensity score matching analysis was performed to compare short- and long-term outcomes. In addition, stage-specific survival rates were compared between the groups.

RESULTS

There were 313 patients who were matched and analyzed. The 1-, 3-, and 5-year overall survival rates were 84.5%, 60.5%, and 52.1%, respectively, in the matched open esophagectomy group; and 87.2%, 68.6%, and 61.8%, respectively, in the matched thoracoscopic esophagectomy group. The weighted Cox regression model showed significantly better survival in the thoracoscopic esophagectomy group than in the open esophagectomy group (hazard ratio, 0.74; 95% CI, 0.582-0.941). Deaths from other causes occurred more frequently in the open esophagectomy group than in the thoracoscopic esophagectomy group. Stratified analysis showed no significant survival differences between clinical stage I or II and pathologic stage 0 or I subgroups. However, the thoracoscopic esophagectomy groups with clinical stage III or IV and pathologic stage II, III, or IV had significantly better overall survival.

CONCLUSIONS

This study demonstrated the survival benefits of thoracoscopic esophagectomy, particularly for highly advanced esophageal carcinoma.

A case report of Barrett's esophageal adenocarcinoma in a young adult aged 20 years

In Japan, the prevalence of Barrett's esophageal adenocarcinoma (BEA) has recently increased owing to a decrease in the number of patients with Helicobacter pylori infection, westernization of the diet, and an increase in obesity prevalence. However, BEA in patients in their 20s is extremely rare. Our patient was a 20-year-old Japanese woman with chief complaints of vomiting and nausea. Esophagogastroduodenoscopy was performed to investigate the cause of vomiting, and a raised lesion was found in the gastroesophageal junctional zone. In the magnified observation, the mucosal pattern of the lesion was partially invisible, and the vascular pattern was irregular; the lesion was diagnosed based on the Japan Esophageal Society classification for Barrett's esophagus -related superficial neoplasia. Endocytoscopic observations revealed a highly irregular glandular structure. Computed tomography showed no distant metastasis. Based on these results, we diagnosed BEA as short-segment Barrett's esophagus and performed an endoscopic submucosal dissection. The pathological diagnosis was pT1a-DMM. It was a well-differentiated adenocarcinoma and was treated with curative resection. BEA is extremely rare in young adults in their 20s. Nonetheless, appropriate surveillance is required for patients with multiple risk factors, including obesity and exposure to acid and bile resulting from persistent vomiting.

Visibility of esophageal squamous cell carcinoma under iodine staining on texture and color enhancement imaging

OBJECTIVE

Iodine staining on white light imaging (WLI) is the gold standard for detecting and demarcating esophageal squamous cell carcinoma (ESCC). We examined the effects of texture and color enhancement imaging (TXI) on improving the endoscopic visibility of ESCC under iodine staining.

METHODS

Twenty ESCC lesions that underwent endoscopic submucosal dissection were retrospectively included. The color difference between ESCC and the surrounding mucosa (ΔEe) on WLI, TXI, and narrow-band imaging was assessed, and ΔEe under 1% iodine staining on WLI and TXI. Furthermore, the visibility grade determined by endoscopists was evaluated on each imaging.

RESULT

The median ΔEe was greater on TXI than on WLI (14.53 vs. 10.71, respectively; p < 0.005). Moreover, the median ΔEe on TXI under iodine staining was greater than the median ΔEe on TXI and narrow-band imaging (39.20 vs. 14.53 vs. 16.42, respectively; p < 0.005 for both). A positive correlation in ΔEe under iodine staining was found between TXI and WLI (correlation coefficient = 0.61, p < 0.01). Moreover, ΔEe under iodine staining on TXI in each lesion was greater than the corresponding ΔEe on WLI. The visibility grade assessed by endoscopists on TXI was also significantly greater than that on WLI under iodine staining (p < 0.01).

CONCLUSIONS

The visibility of ESCC after iodine staining was greater on TXI than on WLI.

Whole stomach versus narrow gastric tube reconstruction after esophagectomy for esophageal cancer (ATHLETE trial): study protocol for a randomized controlled trial

BACKGROUND

There are two types of methods of creating a gastric conduit after esophagectomy for patients with esophageal cancer: narrow gastric tube reconstruction or whole stomach reconstruction. Whole stomach reconstruction with good blood perfusion was reported in a prospective cohort study to be safe and that it has the possibility to prevent anastomotic leakage (AL). We therefore planned a randomized controlled phase III study to investigate the superiority of whole stomach reconstruction over narrow gastric tube reconstruction after esophagectomy for esophageal cancer.

METHODS

This is a single center, two-arm, open-label, randomized phase III trial. We calculated that 65 patients in each arm of this study and total study population of 130 patients are required according to our historical data on narrow gastric tube reconstruction and prospective data on whole stomach reconstruction. In the narrow gastric tube group, a 3.5-cm-wide gastric tube is made along the greater curvature of the stomach using linear staplers. Otherwise, in the whole stomach group, after the lymphadenectomy of the lesser curvature and No.2, the stomach is cut just below the esophagogastric junction using a linear stapler. The primary endpoint of this study is the incidence of AL. Secondary endpoints are the occurrence rate of anastomotic stenosis, the occurrence rate of pneumonia, the occurrence rate of all postoperative complications, the occurrence rate of reflux esophagitis, quality of life evaluation by EORTC QLQ-C30 and EORTC OES-18, nutritional evaluation, the amount of blood loss, postoperative hospital stays, and blood flow evaluation. Complications are evaluated using the Clavien-Dindo classification (version 2.0), and those of grade II or higher are considered to be postoperative complications.

DISCUSSION

If the optimal method for creating a gastric conduit after esophagectomy is clarified, it may be possible to contribute to improving short-term and long-term surgical outcomes for patients undergoing surgery for esophageal cancer.

TRIAL REGISTRATION

The protocol of ATHLETE trial was registered in the UMIN Clinical Trials Registry as UMIN000050677 ( http://www.umin.ac.jp/ctr/index.htm ). Date of registration: March 26, 2023. Date of first participant enrollment: March 27, 2023.

Quantifying CD73 expression after chemotherapy or chemoradiotherapy in esophageal squamous cell carcinoma

BACKGROUND

CD73 and CD39, key components of the adenosine axis, are expressed in multiple malignancies; the impact of standard-of-care treatment on their expression and antitumor immunity in esophageal squamous cell carcinoma (ESCC) remains unclear. We evaluated the adenosine axis in the context of neoadjuvant therapy received and its relationship to immune markers in ESCC tumor samples.

METHODS

Samples from patients who underwent surgical resection at the National Cancer Center Hospital, Tokyo, Japan, between January 2002 and July 2019 following no neoadjuvant therapy (n = 55; treatment-naïve), chemotherapy (n = 200), or chemoradiotherapy (CRT; n = 20) were immunohistochemically stained for CD73, CD39, PD-L1, FoxP3, and CD8; markers were quantified across tumor microenvironment (TME) compartments.

RESULTS

Median CD73 TME expression was lower in the treatment-naïve (2.8%) versus chemotherapy (7.2%; p < 0.0001) and CRT (6.4%; p < 0.01) cohorts, most profoundly in the stroma (median 4.1% vs 9.4% [p < 0.0001] and 8.1% [p < 0.01]). Median intraepithelial CD8-positive cell density was higher in the treatment-naïve (200.7 cells/mm2) versus chemotherapy (93.9 cells/mm2; p < 0.0001) and CRT (30.5 cells/mm2; p < 0.001) cohorts. Three-year recurrence-free survival (RFS) was 73.0%, 58.0%, and 30.0%, and 3-year overall survival (OS) was 78.2%, 71.4%, and 33.5%, in the treatment-naïve, chemotherapy, and CRT cohorts, respectively. High versus low CD73 TME expression was prognostic for longer RFS (treatment-naïve cohort: hazard ratio [HR] 0.16, 95% confidence interval [CI] 0.05-0.58, p = 0.0014; chemotherapy cohort: HR 0.52, 95% CI 0.34-0.78, p = 0.0012) and OS.

CONCLUSIONS

These translational data demonstrating higher CD73 expression in tumors after neoadjuvant chemotherapy or CRT support potential combination strategies with CD73-targeted treatment in ESCC.

Recent Advances in Gastrointestinal Cancer Endoscopic Diagnosis and Treatment: Focusing on Older Adults

Recent advances in endoscopic equipment have improved the diagnosis of gastrointestinal tumors. Image-enhanced endoscopy, including narrow-band imaging, blue light imaging, and linked color imaging, has unified magnifying observation classification methods and significantly improved the qualitative and quantitative diagnostic performance of gastrointestinal epithelial tumors. Endoscopic submucosal dissection (ESD), a minimally invasive treatment for early-stage gastrointestinal cancer, is widely used. The aging population in Japan has been gradually increasing. Despite this, ESD has shown good outcomes in older adults. However, long-term prognostic analyses should take into account the high mortality rate from other illnesses. Prognostic indicators such as the Charlson Comorbidity Index (CCI) and the Prognostic Nutrition Index (PNI) should be used to determine whether ESD should be performed. Even in cases of noncurative resection, follow-up without additional surgical resection is an option if there are other comorbidities that affect the prognosis.

Characteristics and Neoplastic Progression in Barrett's Esophagus: A Large Population-Based Study from Iceland

Background: Barrett's esophagus (BE) is a known precursor to esophageal adenocarcinoma (EAC). However, reports on incidence and progression-to-neoplasm rates have been very variable and conflicting. The aims of the study were to evaluate the characteristics of BE and its progression to neoplasm in a large homogeneous population. Methods: This was a retrospective population-based study with patients identified from 11 institutions through the databases in two centralized pathology laboratories. Demographics and relevant clinicopathological features were obtained from medical records among patients with a pathologically confirmed BE by the presence of intestinal metaplasia between 2003 and 2022. Results: A total of 1388 patients were identified with BE: 948 were men (69%); the median age at diagnosis was 62 years (IQR, 53-72). The ratio of long-segment BE to short-segment BE was significantly higher in patients ≥ 60 years (1.15, 284/248) than those ≤ 60 years (0.77, 205/265) (p = 0.0025). At BE diagnosis, 9.4% had neoplasms: LGD (n = 65), HGD (n = 16), and EAC (n = 49). Among 1258 non-dysplastic BE (NDBE) patients, 4.6% developed a neoplasm-LGD (n = 35), HGD (n = 8), and EAC (n = 15)-with a median observation-period of 5 years (IQR, 3-7). Overall, 160 cases with neoplasms were diagnosed in this BE cohort; 130 (74%) were present at initial BE diagnosis, and 58 (26%) progressed to neoplasms from NDBE. Conclusions: The ratio of long-segment BE was found to be significantly higher in patients ≥ 60 years. Around 9% of the patients were diagnosed as harboring a neoplasm concomitantly with BE, accounting for approximately 74% of all neoplasms. After a median follow-up of 5 years, about 5% of BE showed dysplastic or malignant progression.

Long-term survival outcomes of esophageal squamous cell carcinoma with intraoperative thoracic duct ligation: a large-scale propensity score matching analysis

Background

Esophagectomy is the primary treatment for localized esophageal squamous cell carcinoma (ESCC). Intraoperative thoracic duct ligation (TDL) has been suggested as an adjunct to reduce the risk of postoperative chylothorax in patients with ESCC, but its effect on long-term oncologic outcomes remains uncertain.

Methods

Data from the Sichuan Cancer Hospital and Institute Esophageal Cancer Case Management Database were analyzed for patients treated between 2010 and 2017. Participants were classified into TDL and non-TDL groups. Univariate Cox regression analyses and propensity score matching (PSM) were used to identify independent risk factors for overall survival (OS).

Results

A total of 2,510 patients were included, with 2,095 in the TDL group and 415 in the non-TDL group. The median follow-up was 63.97 months. No significant differences in OS were observed between the TDL and non-TDL groups (HR: 1.13; 95% CI: 0.96-1.31; P = 0.13). After PSM, the analysis continued to show no significant differences between the groups (P = 0.72).

Conclusion

Intraoperative TDL during esophagectomy did not significantly impact long-term OS in patients with ESCC.

The Hemoglobin, Albumin, Lymphocyte and Platelet (HALP) Score as an Independent Prognostic Factor for Esophageal Cancer Patients who Received Curative Treatment

BACKGROUND/AIM

Esophageal cancer (EC) is a malignant tumor with poor prognosis. Prognostic factors that may be used in the treatment and management of EC are important. The purpose of this study was to evaluate the impact of the hemoglobin, albumin, lymphocyte, and platelet (HALP) score on the long-term oncological prognosis of patients with EC who have undergone curative treatment.

PATIENTS AND METHODS

Patients with EC who underwent curative resection at Yokohama City University between 2000 and 2020 were included. Clinical data were retrospectively retrieved from medical records and analyzed. The HALP score was determined as follows: HALP=[hemoglobin (g/l)×albumin (g/l)×lymphocytes (/l)]/platelets (/l). Kaplan-Meier method and Cox regression model were used to assess the overall (OS) and recurrence-free survival (RFS) and to evaluate the prognostic value of the HALP score.

RESULTS

In total, 180 patients were included in this study. They were classified into the HALP-low (n=110) and HALP-high (n=70) groups using a cutoff value of 40. The 5-year OS rate was 46.9% in the HALP-low group and 66.0% in the HALP-high group (p=0.012). The 5-year RFS rate was 31.1% in the HALP-low group and 51.4% in the HALP-high group (p=0.006). The HALP score was found to be an independent prognostic factor for OS [odds ratio (OR)=1.954, 95% confidence interval (CI)=1.157-3.299, p=0.012] and RFS (OR=1.852, 95% CI=1.197-2.866, p=0.006).

CONCLUSION

The HALP score is a factor that predicts the oncological prognosis in patients with EC who have undergone radical resection.

Optimal treatment strategy for older patients with esophageal squamous cell carcinoma: A multicenter retrospective study

The appropriate treatment strategy for esophageal squamous cell carcinoma (ESCC) in older patients remains unclear. The efficacy of preoperative chemotherapy using a divided-dose regimen of biweekly docetaxel, cisplatin and 5-fluorouracil (DCF) neoadjuvant chemotherapy (NAC) was compared with upfront surgery (US) in patients aged ≥70 years with ESCC. The present study retrospectively analyzed the multicenter data of patients who received esophagectomy for ESCC between January 2015 and December 2021. The present study investigated patient prognosis using inverse probability weighting analysis and psoas muscle index (PMI) as a background factor for older patients with ESCC potentially deriving greater benefit from this NAC regimen. Among 86 eligible patients, 47 received NAC (NAC group) and 39 underwent US (US group). No significant differences were observed between the groups in 3-year overall survival [OS; hazard ratio (HR), 0.576; P=0.325) and 3-year recurrence-free survival (HR, 0.483; P=0.141). Among the patients with low PMI, 3-year OS was significantly prolonged in the NAC group vs. the US group (HR, 0.342; 95% CI, 0.144-0.812; P=0.015). In the older patients with ESCC, a divided-dose regimen of DCF did not improve prognosis. When the PMI is low, a biweekly DCF regimen may contribute to extending OS. Future prospective large studies are needed.

Clinical usefulness of four-dimensional dynamic ventilation CT for borderline resectable locally advanced esophageal cancer

PURPOSE

This study aimed to evaluate the clinical significance of four-dimensional dynamic ventilation CT (4DCT) for assessing resectability in borderline resectable locally advanced esophageal cancer (BR-LAEC) and confirmed the pathological validity of the 4DCT results in surgery without prior treatment.

MATERIALS AND METHODS

We retrospectively reviewed 128 patients (107 men; median age, 68 [range, 43-89] years) diagnosed with BR-LAEC on initial conventional CT (i-CT). These patients were initially classified into three categories: BR1 (closer to resectable), BR2 (resectability not assessable), or BR3 (closer to unresectable). Subsequent 4DCT reclassified patients as either resectable or unresectable within 1 week of i-CT. We analyzed the diagnostic shift induced by 4DCT. Additionally, 18 patients who underwent surgery without prior treatment were evaluated using 4DCT and pathological outcomes.

RESULTS

4DCT reclassified patients with BR-LAEC as resectable (57.0%; 73/128) and unresectable (43.0%; 55/128). Of 53 patients initially classified as BR1, 32.1% (17/53) were reclassified as unresectable, and of 47 patients initially classified as BR3, 46.8% (22/47) were reclassified as resectable. Among 28 patients initially classified as BR2, 53.6% (15/27) were reclassified as resectable and 46.4% (13/27) as unresectable. In the surgery-only cohort of 18 patients, 9 were initially classified as BR1 and 9 as BR2, and all were reclassified as resectable. These patients were pathologically confirmed to have resectable disease.

CONCLUSIONS

4DCT may provide information complementary to that provided by initial conventional CT in assessing resectability among patients with BR-LAEC, and could be a useful adjunct tool for guiding clinical decisions in this patient population.

Iodine Staining With Distance Countdown Improving the Safety for Reduction of Adverse Events: A Randomized Controlled Trial

INTRODUCTION

Lugol chromoendoscopy (LCE) is valuable, cost-effective, and widely used in early esophageal cancer screening, yet it suffers from low compliance because of adverse events after LCE. In addition, the reflux of iodine during iodine staining in the upper esophagus brings the risk of bucking and aspiration. We introduced a new model called distance countdown (DC) aimed to reduce reflux during iodine staining in upper esophageal LCE.

METHODS

In this randomized controlled trial, 204 patients were randomized into the DC and No-DC groups. The primary end point was the difference in the incidence of positive starch reagent reaction (iodine solution reflux) between the 2 groups. The secondary end points were the comparisons of the incidence of other adverse events after LCE between the 2 groups.

RESULTS

The rate of iodine solution reflux was 1.0% in the DC group and 26.5% in the No-DC group ( P < 0.001). Furthermore, the incidences of bucking between the 2 groups were 1.0% and 9.8% ( P = 0.005). LCE satisfaction rates were 78.4% and 76.5% in the DC and No-DC groups ( P = 0.363), respectively. Concerning symptoms after LCE, incidences of sore throat, pharyngeal discomfort or odor, bitter taste, and heartburn were also reduced in the DC group (all P < 0.05).

DISCUSSION

Adding DC as an auxiliary effect during LCE would reduce the risk of iodine solution reflux, as well as other adverse events after LCE. Implementing this measure could be beneficial in improving the safety of LCE in early esophageal cancer screening.

Comparison of enteral nutrition methods with weight improvement in patients with T4b esophageal squamous cell carcinoma

Enteral nutrition is the preferred method for providing nutrition to patients who can consume food orally or via a feeding tube. In the case of patients with advanced esophageal cancer, tracking nutritional status is critical and weight is a key factor in this regard. Monitoring weight changes is a simple and non-invasive approach that can be easily incorporated into clinical settings. Therefore, the present study aimed to compare different enteral nutrition techniques and assess the efficacy of weight changes in patients with advanced esophageal cancer. A retrospective study was conducted on patients with advanced esophageal squamous cell carcinoma who received enteral nutrition between January 2012 and December 2022, and included the collection of various data, including baseline characteristics, comorbidities, BMI, route of enteral nutrition, tolerable enteral nutrition, total calories per day and mode of treatment via methods such as nasogastric tube (NG), esophageal stent, percutaneous endoscopic gastrostomy (PEG) or open gastrostomy (OG). The study assessed the impact of enteral nutrition on body weight at the 0-, 1-, 3- and 6-month follow-up, as well as the 1-year survival. After a 3-month follow-up, it was observed that patients with advanced esophageal cancer who underwent enteral nutrition exhibited a significant improvement in weight. This improvement trended to be sustained up to the 6-month follow-up. At 3 months, the groups that underwent NG, OG and PEG exhibited significant optimal results compared with the esophageal stent group (P=0.027, P=0.009 and P=0.001, respectively). No significant differences were observed among the NG, OG and PEG methods. The enteral nutrition can aid in weight improvement for patients who suffer from advanced esophageal cancer. Enteral feeding tubes have been demonstrated to be safe and effective options. Within 3 months of beginning nutrition support, there was a trend of weight improvement, which could be maintained up to the 6-month follow-up.

Survival Impacts of Mitochondrial Status in Esophageal Squamous Cell Carcinoma Patients

BACKGROUND

Little is known about the survival impacts of mitochondrial status in esophageal squamous cell carcinoma (ESCC) patients who undergo neoadjuvant chemotherapy (NAC) followed by surgery.

METHODS

In total, 260 pre-NAC samples from ESCC patients were analyzed. Mitochondrial status was estimated employing an objective, immunohistochemistry-based system (Mito-score). Mito-scores were dichotomized according to the median value of our cohort. We also evaluated the immune microenvironment (CD4, CD8, Foxp3, HLA class-1, Ki-67 and programmed death ligand-1) on pre-NAC specimens. Multivariate Cox hazards models were applied to determine independent predictors of poor overall survival (OS).

RESULTS

Patients with cT3-4 tumors had higher Mito-scores than those with cT1-2 tumors (p = 0.06), and good responders to NAC had significantly higher Mito-scores than poor responders to NAC (p = 0.04). CD8 cells and Ki-67 expression were significantly higher in Mito-high than Mito-low tumors (p = 0.017 and p < 0.001, respectively). Patients with low Mito-scores had significantly poorer OS than those with high Mito-scores (3-year OS: 57.6% vs. 68.2%; p = 0.03). A survival difference by Mito-score was evident in cStage III-IV patients (3-year OS: low 50.6% vs. high 66.1%; p = 0.006). Multivariable analysis revealed that a low Mito-score (hazard ratio 1.59, 95% confidence interval 1.12-2.24; p = 0.009) as well as pT3-4 disease (p < 0.001) and pN2-3 disease (p < 0.001) were independently associated with poor OS outcomes.

CONCLUSIONS

A low Mito-score before NAC had a significant survival impact in ESCC patients, especially in those with advanced disease. Mitochondrial status might be associated with tumor aggressiveness and responsiveness to NAC, thereby possibly affecting the survival outcomes of ESCC patients.

Is endoscopic submucosal tunnel dissection better than endoscopic submucosal dissection in treating large superficial esophageal neoplastic lesions? A systematic review and meta-analysis

Background

The resection of large superficial esophageal neoplastic lesions (SENLs) presents significant challenges for traditional endoscopic submucosal dissection (ESD). Endoscopic submucosal tunnel dissection (ESTD) has emerged as an alternative that potentially reduces resection difficulty.

Objectives

We aimed to compare ESTD and ESD in the treatment of large SENLs.

Design

Meta-analysis of randomized controlled trials (RCTs).

Data sources and methods

We systematically searched MEDLINE, EMBASE, Cochrane Library, and Wanfang Data for RCTs comparing ESTD with ESD for large SENLs until July 1, 2024. The grading of recommendations assessment, development, and evaluation framework was used to assess the certainty of the evidence, whereas trial sequential analysis (TSA) was used to control for random errors and evaluate conclusion validity.

Results

Four RCTs involving 315 patients were included. The pooled analysis showed that ESTD was significantly faster than ESD (mean differences 5.06, 95% confidence interval: 3.31-6.80; p < 0.01; I 2 = 0%; low certainty of evidence). TSA indicated a desired sample size of 162, with the cumulative Z curve crossing the trial sequential monitoring boundary. ESTD also had lower rates of major complications and post-operation esophageal stricture (low certainty of evidence). No significant differences were found in en bloc and curative resection rates.

Conclusion

With low certainty, ESTD appears superior to ESD for large SENLs, offering faster resection and fewer complications, with similar en bloc and curative resection rates.

Trial registration

This meta-analysis protocol was registered on PROSPERO (CRD42024520754).

Impact of Right Top Pulmonary Vein Location on Subcarinal Lymph Node Dissection in Thoracoscopic Esophagectomy: A Case Report and Literature Review

INTRODUCTION

The right top pulmonary vein (RTPV) is a rare anatomical variant that arises independently of the right superior lobe. It drains behind the right main bronchus or bronchus intermedius and into the left atrium or another pulmonary vein. This anomaly poses challenges during subcarinal lymph node dissection in thoracic surgery, such as esophagectomy, owing to the risk of vascular injury. The RTPV is mainly located behind the right main bronchus and right intermediate bronchus; however, reports of subcarinal dissection focusing on these sites are lacking. Herein, we present a case of esophageal cancer with an RTPV that was treated with thoracoscopic esophagectomy and propose a convenient classification for the anatomical findings and RTPV site.

CASE PRESENTATION

A 71-year-old man underwent a thoracoscopic esophagectomy for esophageal cancer (T1bN0M0) during a routine medical checkup. A preoperative computed tomography scan revealed an anomaly in which the RTPV drained into the left atrium behind the right main bronchus. Radical subcarinal lymphadenectomy was performed while preserving the RTPV, using 3 dimensions for preoperative simulation and intraoperative navigation. The operation lasted 6 h and 42 min, and the blood loss volume was 30 mL. The patient's postoperative course was uneventful, and he was discharged on postoperative day 21.

CONCLUSIONS

In a retrospective review of esophageal cancer surgery cases at our hospital, RTPV was observed in 17/314 cases (5.4%). The most common inflow site was the inferior pulmonary vein (IPV) (9 cases), followed by the left atrium (5 cases), superior pulmonary vein (2 cases), and superior branch of the IPV (1 case). The inflow site was behind the right main bronchus and the right intermediate bronchus in 4 and 13 cases, respectively. Compared to past reviews, the inflow site varied somewhat; however, the vascular location remained the same. By classifying the areas behind the right main and right intermediate bronchi as Zones 1 and 2, respectively, cases in which the RTPV runs through Zone 1, as identified on preoperative computed tomography, should be manipulated with caution due to the risk of injury during lymph node dissection beneath the tracheal bifurcation.

Esophagectomy Versus Endoscopic Resection with Adjuvant Therapy for T1b/T2 Esophageal Cancer: A Systematic Review and Meta-Analysis

Esophageal cancer is the seventh most common cause of cancer-related death worldwide [...].

Comparative study on different endoscopic submucosal dissection techniques for the treatment of superficial esophageal cancer and precancerous lesions

BACKGROUND

This study aims to compare the effectiveness and safety of traditional endoscopic submucosal dissection (ESD), endoscopic submucosal tunneling dissection (ESTD), and endoscopic submucosal dissection with C-shaped incision (ESD-C) in the treatment of superficial esophageal cancer and precancerous lesions, providing reference and guidance for the treatment of esophageal cancer.

METHODS

A retrospective analysis was conducted on the clinical data of patients who underwent ESD (n = 96), ESTD (n = 103), and ESD-C (n = 98) for superficial esophageal cancer or precancerous lesions between January 2017 and December 2022. Through comparative analysis, the effectiveness and safety of the three surgical methods were evaluated, and the risk factors for postoperative esophageal stricture were explored.

RESULTS

In terms of total operative time and dissection time, the ESD group > ESTD group > ESD-C group; in terms of dissection speed, the ESD group < ESTD group < ESD-C group; in terms of dissection area, the ESD group < ESTD group and ESD-C group; and in terms of wound treatment time, the ESD group > ESTD group and ESD-C group. In terms of surgical outcomes, the en bloc resection rate was 100% in all three groups, with complete resection rates of 86.84%, 90.79%, and 88.16% in the ESD, ESTD, and ESD-C groups, respectively. The risk factors for postoperative esophageal stricture included dissection area, circumferential proportion of the lesion, and injury to the muscularis propria.

CONCLUSION

Among the three surgical approaches, ESD-C demonstrated superior performance in operative time, resection speed, and procedural efficiency. Increased circumferential involvement of the lesion, larger resection area, and greater injury to the muscularis propria were associated with a heightened risk of postoperative esophageal stricture.

Endoscopic and Surgical Treatment in Early Gastric Cancer: The Gray Zone in Treatment Decision-Making from the Perspectives of Endoscopists

To treat early gastric cancer, one must choose between endoscopic treatment and surgical treatment. Endoscopic treatment has been developing significantly since the late 1990s and has made great progress up to the present. However, many patients with early gastric cancer still undergo unnecessary surgery or endoscopic procedures. This is due to the existence of a "gray zone" of ambiguities between endoscopic and surgical treatment. These ambiguities arise because the important factors in determining the treatment for early gastric cancer can only be fully understood after endoscopic or surgical resection or because of discrepancies between the factors identifiable before treatment and those identifiable after treatment. This article aims to explore these ambiguous factors and discuss methods and efforts to reduce them.