Recommendations for pathologic staging (pTNM) of cancer of the esophagus and esophagogastric junction for the 8th edition AJCC/UICC staging manuals

Multi-Task Model for Esophageal Lesion Analysis Using Endoscopic Images: Classification with Image Retrieval and Segmentation with Attention

The automatic analysis of endoscopic images to assist endoscopists in accurately identifying the types and locations of esophageal lesions remains a challenge. In this paper, we propose a novel multi-task deep learning model for automatic diagnosis, which does not simply replace the role of endoscopists in decision making, because endoscopists are expected to correct the false results predicted by the diagnosis system if more supporting information is provided. In order to help endoscopists improve the diagnosis accuracy in identifying the types of lesions, an image retrieval module is added in the classification task to provide an additional confidence level of the predicted types of esophageal lesions. In addition, a mutual attention module is added in the segmentation task to improve its performance in determining the locations of esophageal lesions. The proposed model is evaluated and compared with other deep learning models using a dataset of 1003 endoscopic images, including 290 esophageal cancer, 473 esophagitis, and 240 normal. The experimental results show the promising performance of our model with a high accuracy of 96.76% for the classification and a Dice coefficient of 82.47% for the segmentation. Consequently, the proposed multi-task deep learning model can be an effective tool to help endoscopists in judging esophageal lesions.

Recurrence risk stratification based on a competing-risks nomogram to identify patients with esophageal cancer who may benefit from postoperative radiotherapy

BACKGROUND

A reliable model is needed to estimate the risk of postoperative recurrence and the benefits of postoperative radiotherapy (PORT) in patients with thoracic esophageal squamous cell cancer (TESCC).

METHODS

The study retrospectively reviewed 3652 TESCC patients in stage IB-IVA after radical esophagectomy, with or without PORT. In one institution as the training cohort (n = 1620), independent risk factors associated with locoregional recurrence (LRR), identified by the competing-risks regression, were used to establish a predicting nomogram, which was validated in an external cohort (n = 1048). Area under curve (AUC) values of receiver operating characteristic curves were calculated to evaluate discrimination. Risk stratification was conducted using a decision tree analysis based on the cumulative point score of the LRR nomogram. After balancing the baseline of characteristics between treatment groups by inverse probability of treatment weighting, the effect of PORT was evaluated in each risk group.

RESULTS

Sex, age, tumor location, tumor grade, and N category were identified as independent risk factors for LRR and added into the nomogram. The AUC values were 0.638 and 0.706 in the training and validation cohorts, respectively. Three risk groups were established. For patients in the intermediate- and high-risk groups, PORT significantly improved the 5-year overall survival by 10.2% and 9.4%, respectively (p < 0.05). Although PORT was significantly associated with reduced LRR in the low-risk group, overall survival was not improved.

CONCLUSION

The nomogram can effectively estimate the individual risk of LRR, and patients in the intermediate- and high-risk groups are highly recommended to undergo PORT.

Exosomal and intracellular miR-320b promotes lymphatic metastasis in esophageal squamous cell carcinoma

Cancer-cell-released exosomal microRNAs (miRNAs) are important mediators of cell-cell communication in the tumor microenvironment. In this study, we sequenced serum exosome miRNAs from esophageal squamous cell carcinoma (ESCC) patients and identified high expression of miR-320b to be closely associated with peritumoral lymphangiogenesis and lymph node (LN) metastasis. Functionally, miR-320b could be enriched and transferred by ESCC-released exosomes directly to human lymphatic endothelial cells (HLECs), promoting tube formation and migration in vitro and facilitating lymphangiogenesis and LN metastasis in vivo as assessed by gain- and loss-of-function experiments. Furthermore, we found programmed cell death 4 (PDCD4) as a direct target of miR-320b through bioinformatic prediction and luciferase reporter assay. Re-expression of PDCD4 could rescue the effects induced by exosomal miR-320b. Notably, the miR-320b-PDCD4 axis activates the AKT pathway in HLECs independent of vascular endothelial growth factor-C (VEGF-C). Moreover, overexpression of miR-320b promotes the proliferation, migration, invasion, and epithelial-mesenchymal transition progression of ESCC cells. Finally, we demonstrate that METTL3 could interact with DGCR8 protein and positively modulate pri-miR-320b maturation process in an N6-methyladenosine (m6A)-dependent manner. Therefore, our findings uncover a VEGF-C-independent mechanism of exosomal and intracellular miR-320b-mediated LN metastasis and identify miR-320b as a novel predictive marker and therapeutic target for LN metastasis in ESCC.

Treatment Options for T1 Stage Adenocarcinoma of Esophagogastric Junction: A Real-World Retrospective Cohort Study

Background

The number of patients diagnosed with T1 stage adenocarcinoma of esophagogastric junction (AEGJ) has been increasing. This study was conducted to investigate the effect of different treatment options (surgery, chemoradiation, and surgery+chemoradiation) on long-term survival in patients with T1-stage AEGJ.

Methods

We searched the Surveillance, Epidemiology, and End Results (SEER) database to identify the records of patients with T1-stage AEGJ between 2010 and 2018. Patient demographics and cancer parameters were compared among the three groups. The Kaplan–Meier method and Cox proportional hazard modeling were used to compare long-term survival.

Results

Data from 925 T1 stage AEGJ patients (surgery: n=516, surgery+chemoradiation: n=206, chemoradiation: n=203) were collected. We found that the OS and CSS rates of three treatment options had significant difference. Besides, positive nodal status also showed lower OS and CSS rat. Multivariate Cox regression analysis showed that surgery group has much lower risk of death compared with chemoradiation group and similar risk of death compared with surgery+chemoradiation group. Subgroup analysis suggested that in patients with N1–N3 status had higher OS and CSS rates in surgery+chemoradiation group.

Conclusion

Using SEER data, we identified a significant survival advantage with the use of surgery compared to chemoradiation in patients with T1-stage AEGJ while the long-term survival of patients after surgery+chemoradiation group was not significantly different and low risk of death in positive nodal status.

Clinical Predictors of Locally Advanced Pathology in Esophageal Adenocarcinoma

Background

In patients with resectable esophageal adenocarcinoma (EAC), the decision for neoadjuvant treatment depends on clinical staging with endoscopic ultrasound (EUS) and positron-emission tomography (PET) scan. Patients with locally advanced EAC pathology misclassified as early EAC by clinical staging are missing the opportunity to receive neoadjuvant therapy. We aim to identify predictors of locally advanced pathology in EAC to determine more accurately those who benefit from neoadjuvant therapy. 

Methods

Retrospective study of patients who underwent upfront endoscopic or surgical resection for EAC without neoadjuvant therapy from January 2011 to December 2017 was performed. Clinical characteristics, EUS, PET scan and histologic findings were analyzed. Multivariable analysis of predictors of locally advanced stage was performed and a risk prediction score was developed.

Results

A total of 97 patients were included; 68 patients were staged as early EAC (pT1 or pT2 and pN0) and 29 patients were staged as locally advanced EAC (pT1 or pT2 with pN1 and pT3 or pT4 irrespective of N status). In a predictive model of EAC, patients presenting with dysphagia, tumor size >2 cm, exophytic mass appearance on endoscopy and absence of hiatal hernia were more likely to be have locally advanced pathology with a probability of 70% (C-statistic 0.766).

Conclusions

A risk prediction model based on the presence of dysphagia, tumor size >2 cm, exophytic mass appearance and absence of hiatal hernia can be used to identify locally advanced pathology in EAC patients.

Preliminary evaluation of postoperative radiotherapy with small T-shaped field in thoracic esophageal squamous cell carcinoma

Background

The optimal extent of clinical target volume (CTV) for postoperative radiotherapy in complete resection thoracic esophageal squamous cell carcinoma (ESCC) patients remains controversial. This study aimed to evaluate the primary outcome of postoperative radiotherapy with small T-shaped field encompassing the tumor bed, positive lymph node areas, bilateral supraclavicular areas, and upper and middle mediastinal areas.

Methods

A total of 96 thoracic ESCC patients were enrolled, with 49 and 47 cases in the small T-shaped field group and tumor bed field group, respectively. All of the patients received intensity-modulated radiotherapy (IMRT), and chemotherapy was administrated concurrently or sequentially. The median time of follow-up was 25 (range, 7-47) months.

Results

At the end of the follow-up period, in the small T-shaped field group, 8 (16.3%) patients had locoregional recurrence (LRR) and 12 (24.5%) had distant metastasis (DM), while in the tumor bed field group, 15 (31.9%) patients had LRR and 11 (23.4%) had DM. Although the rates of LRR and DM were not statistically different, LRR incidence in the mediastinal lymph nodes of the small T-shaped field group was strikingly lower than that of the tumor bed field group. The overall survival (OS) of the small T-shaped field group was higher than that of the tumor bed field group, but the difference was not statistically significance. In addition, we observed grade 2 radiation pneumonitis and grade 2 radiation esophagitis in both groups; all of these side effects were tolerable and controllable, and none of the patients experienced ≥ grade 3 pneumonitis, esophagitis, esophageal stricture, or life-threatening hemorrhage.

Conclusions

In conclusion, radiotherapy with small T-shaped field might be a feasible and efficacious postoperative approach for ESCC patients.

Effectiveness of an early, quantified, modified oral feeding protocol on nutritional status and quality of life of patients after minimally invasive esophagectomy: A retrospective controlled study

OBJECTIVES

Previous studies confirmed the safety and feasibility of oral feeding on the first postoperative day (POD) for patients with minimally invasive esophagectomy (MIE). Nonetheless, some clinical concern can lead to delays in early oral feeding on POD 1. To our knowledge, few reports have focused on resolving these clinical concerns. The aims of this study were to evaluate the effects of an early, quantified, modified oral feeding protocol for patients after MIE and to explore its effect on nutritional status and quality of life (QoL).

METHODS

In this prospective controlled trail, 200 patients were selected as the intervention group (IG) from March 2020 to June 2021; 115 patients hospitalized from June 2019 to February 2020 were assigned to the control group (CG). For 2 wk during the postoperative period, IG participants received an early, quantified, modified oral feeding protocol. The recovery of dietary outcomes, nutritional status, and QoL were evaluated after the intervention.

RESULTS

There was no significant difference between the two groups in terms of demographic and clinical characteristics and baseline physical function. After the intervention, patients in the IG showed a more rapid growth in daily total oral caloric intake and the ratio of oral calorie intake to total calorie required by the body (K/R value) from POD 1 to POD 14, and less weight loss (1.5 ± 1 versus 2.1 ± 1.7 kg; P < 0.05), better serum prealbumin (193.0 ± 26.9 versus 139.3 ± 27.2 mg/L; P < 0.05) than the CG with statistical significance. By the second week of the intervention, IG patients reported higher global QoL and function scores and lower symptom scores than patients in the CG. The IG participants presented a shorter time to first flatus and bowel movement (P < 0.001), a shorter postoperative hospital length of stay, and higher activities of daily living scores (P < 0.05) the those in the CG.

CONCLUSIONS

The findings demonstrated that the early, quantified, modified oral feeding protocol can alleviate postoperative body weight loss, improve the patient's nutritional status, and have a positive effect on QoL and early recovery for patients undergoing MIE.

Albumin-To-Alkaline Phosphatase Ratio as a Novel and Promising Prognostic Biomarker in Patients Undergoing Esophagectomy for Carcinoma: A Propensity Score Matching Study

Background

Albumin-to-alkaline phosphatase ratio (AAPR) has been reported as a novel prognostic predictor for numerous solid tumors. We aimed to assess the prognostic role of preoperative AAPR in surgically resectable esophageal squamous cell carcinoma (ESCC) by a propensity score matching (PSM) analysis with predictive nomograms.

Methods

Our study was conducted in a single-center prospective database between June 2009 and December 2012. Kaplan-Meier analysis was used to distinguish the difference in survival outcomes between patients stratified by an AAPR threshold. Multivariable Cox proportional hazards regression model was finally generated to specify independent prognostic markers for the entire and PSM cohorts.

Results

A total of 497 patients with ESCC were included in this study. An AAPR of 0.50 was determined as the optimal cutoff point for prognostic outcome stratification. Patients with AAPR<0.50 had significantly worse overall survival (OS), and progression-free survival (PFS) compared to those with AAPR≥0.50 (Log-rank P<0.001). This significant difference remained stable in the PSM analysis. Multivariable analyses based on the entire and PSM cohorts consistently showed that AAPR<0.50 might be one of the most predominant prognostic factors resulting in unfavorable OS and PFS of ESCC patients undergoing esophagectomy (P<0.001). The nomograms consisting of AAPR and other independent prognostic factors further demonstrated a plausible predictive accuracy of postoperative OS and PFS.

Conclusion

AAPR can be considered as a simple, convenient and noninvasive biomarker with a significant prognostic effect in surgically resected ESCC.

The Value of Predicting Human Epidermal Growth Factor Receptor 2 Status in Adenocarcinoma of the Esophagogastric Junction on CT-Based Radiomics Nomogram

Purpose

We developed and validated a CT-based radiomics nomogram to predict HER2 status in patients with adenocarcinoma of esophagogastric junction (AEG).

Method

A total of 101 patients with HER2-positive (n=46) and HER2-negative (n=55) esophagogastric junction adenocarcinoma (AEG) were retrospectively analyzed. They were then randomly divided into a training cohort (n=70) and a verification cohort (n=31). The radiomics features were obtained from the portal phase of the CT enhanced scan. We used the least absolute shrinkage and selection operator (LASSO) logistic regression method to select the best radiomics features in the training cohort, combined them linearly, and used the radiomics signature formula to calculate the radiomics score (Rad-score) of each AEG patient. A multivariable logistic regression method was applied to develop a prediction model that incorporated the radiomics signature and independent risk predictors. The prediction performance of the nomogram was evaluated using the training and validation cohorts.

Result

In the training (P<0.001) and verification groups (P<0.001), the radiomics signature combined with seven radiomics features was significantly correlated with HER2 status. The nomogram composed of CT-reported T stage and radiomics signature showed very good predictive performance for HER2 status. The area under the curve (AUC) of the training cohort was 0.946 (95% CI: 0.919–0.973), and that of the validation group was 0.903 (95% CI: 0.847–0.959). The calibration curve of the radiomics nomogram showed a good degree of calibration. Decision-curve analysis revealed that the radiomics nomogram was useful.

Conclusion

The nomogram CT-based radiomics signature combined with CT-reported T stage can better predict the HER2 status of AEG before surgery. It can be used as a non-invasive prediction tool for HER2 status and is expected to guide clinical treatment decisions in clinical practice, and it can assist in the formulation of individualized treatment plans.

Value of Lymphadenectomy in Patients Receiving Neoadjuvant Therapy for Esophageal Adenocarcinoma

OBJECTIVE

The aim of this study was to assess the effect on survival of extent of lymphadenectomy during esophagectomy for patients undergoing multimodality (neoadjuvant) therapy for adenocarcinoma of the esophagus and esophagogastric junction using Worldwide Esophageal Cancer Collaboration data.

SUMMARY BACKGROUND DATA

Previous worldwide data demonstrated that optimum lymphadenectomy during esophagectomy alone for esophageal cancer provides accurate staging and maximum survival. However, for patients undergoing neoadjuvant therapy for locally advanced adenocarcinoma, its value is unclear, leading to wide practice variability.

METHODS

A total of 3859 patients with adenocarcinoma of the esophagus or esophagogastric junction received neoadjuvant therapy. The endpoint was all-cause mortality, reported as gain or loss of lifetime within 10 years. Lifetime predicted for each regional lymph node resected used quantile survival random forest methodology.

RESULTS

Across all post-neoadjuvant ypTNM cancer categories, some degree of lymphadenectomy was associated with longer lifetime, but in a nonlinear fashion. For patients with ypN0 cancers, there was a modest gain in lifetime up to 25 lymph nodes resected and an incremental loss in lifetime as >25 were resected. For patients with ypN+ cancers, there was a robust gain in lifetime up to 30 lymph nodes resected and then an incremental loss in lifetime.

CONCLUSIONS

Worldwide data for adenocarcinoma of the esophagus and esophagogastric junction demonstrate that lymphadenectomy during esophagectomy is a valuable component of neoadjuvant therapy. Survival is maximized when an optimum range of nodes is resected.

The Prognostic Impact of Preoperative Serum Apolipoprotein A-I in Patients with Esophageal Basaloid Squamous Cell Carcinoma

Background

Esophageal basaloid squamous cell carcinoma (EBSCC) is a rare malignancy. Serum apolipoprotein A-I (APO A-I) has proved to be a potentially useful prognostic indicator in various cancers. However, no studies have analyzed the prognostic significance of serum APO A-I in patients with EBSCC. The aim of this study was to investigate the prognostic impact of preoperative serum APO A-I in patients with EBSCC.

Methods

Between 2007 and 2018, a retrospective study of 4050 patients with resectable esophageal squamous cell carcinoma (ESCC) including the levels of preoperative serum lipids was conducted and evaluated. The best cut-off values of the preoperative serum lipids were evaluated by receiver operating characteristic (ROC) curves. Kaplan–Meier analyses and Cox regression analyses were analyzed the overall survival (OS) and recurrence-free survival (RFS). A prediction model of nomogram was developed to predict individual OS and RFS in EBSCC.

Results

There were 53 patients enrolled in the study, which accounted for 1.31% (53/4050) of all primary ESCC. The best cut-off point was 1.305 g/L for serum APO A-I according to the ROC curve. Patients with lower levels of serum preoperative APO A-I were associated with worse RFS (16.1% vs 54.5%, P = 0.006) and OS (29.0% vs 63.6%, P = 0.010). The results indicated that serum APO A-I serves as an independent predictor in patients with EBSCC regarding OS [hazard ratio (HR): 0.352; 95% confidence interval (CI): 0.154–0.808; P = 0.014] and RFS (HR: 0.397; 95% CI: 0.185–0.850; P = 0.017).

Conclusion

Preoperative serum APO A-I is an independent predictor regarding OS and RFS in EBSCC. As far as we know, this is the first study in EBSCC to explore the serum APO A-I in patients with EBSCC.

Development and Validation of a Clinical Prognostic Nomogram for Esophageal Adenocarcinoma Patients

Background

Clinical staging is essential for clinical decisions but remains imprecise. We purposed to construct a novel survival prediction model for improving clinical staging system (cTNM) for patients with esophageal adenocarcioma (EAC).

Methods

A total of 4180 patients diagnosed with EAC were extracted from the Surveillance, Epidemiology, and End Results (SEER) database and included as the training cohort. Significant prognostic variables were identified for nomogram model development using multivariable Cox regression. The model was validated internally by bootstrap resampling, and then subjected to external validation with a separate cohort of 886 patients from 2 institutions in China. The prognostic performance was measured by concordance index (C-index), Akaike information criterion (AIC) and calibration plots. Different risk groups were stratified by the nomogram scores.

Results

A total of six variables were determined related with survival and entered into the nomogram construction. The calibration curves showed satisfied agreement between nomogram-predicted survival and actual observed survival for 1-, 3-, and 5-year overall survival. By calculating the AIC and C-index values, our nomogram presented superior discriminative and risk-stratifying ability than current TNM staging system. Significant distinctions in survival curves were observed between different risk subgroups stratified by nomogram scores.

Conclusion

The established and validated nomogram presented better risk-stratifying ability than current clinical staging system, and could provide a convenient and reliable tool for individual survival prediction and treatment strategy making.

A New Dawn for the Use of Artificial Intelligence in Gastroenterology, Hepatology and Pancreatology

Artificial intelligence (AI) is rapidly becoming an essential tool in the medical field as well as in daily life. Recent developments in deep learning, a subfield of AI, have brought remarkable advances in image recognition, which facilitates improvement in the early detection of cancer by endoscopy, ultrasonography, and computed tomography. In addition, AI-assisted big data analysis represents a great step forward for precision medicine. This review provides an overview of AI technology, particularly for gastroenterology, hepatology, and pancreatology, to help clinicians utilize AI in the near future.

Difference in Computed Tomography Image Quality between Central Vein and Peripheral Vein Enhancement in Treatment Naive Esophageal Cancer Patients

Simple Summary

A chest CT via central vein enhancement not only eliminates peripheral vein regurgitation but also provides better image quality that facilitates precise clinical staging. A chest CT via central vein enhancement may be considered after tissue proof in order to better discriminate disease severity.

Abstract

The differences in chest computed tomography (CT) image quality may affect the tumor stage. The aim of this study was to compare the image quality and accuracy of chest CT via central vein and peripheral vein enhancement. Fifty consecutive patients were enrolled from a tertiary medical center in Taiwan from May 2016 to March 2019. All the patients received a chest CT via central vein enhancement prior to neoadjuvant concurrent chemoradiation in order to compare the chest CT that was obtained via the peripheral vein. In addition, blind independent central reviews of chest CT via central vein and peripheral vein enhancement were conducted. For T and N stage, chest CT via central vein enhancement had a greater consistency with endoscopic ultrasonography and positron-emission tomography-computed tomography findings (kappa coefficients 0.4471 and 0.5564, respectively). In addition, chest CT via central vein enhancement also showed excellent agreement in the blind independent central review (kappa coefficient 0.9157). The changes in the T and N stage resulted in stage migration in 16 patients. Chest CT via central vein enhancement eliminated peripheral vein regurgitation and also provided more precise clinical staging. This study is registered under the registered NCT number 02887261.

Nutritional Support Indications in Gastroesophageal Cancer Patients: From Perioperative to Palliative Systemic Therapy. A Comprehensive Review of the Last Decade

Gastric cancer treatments are rapidly evolving, leading to significant survival benefit. Recent evidence provided by clinical trials strongly encouraged the use of perioperative chemotherapy as standard treatment for the localized disease, whereas in the advanced disease setting, molecular characterization has improved patients’ selection for tailored therapeutic approaches, including molecular targeted therapy and immunotherapy. The role of nutritional therapy is widely recognized, with oncologic treatment’s tolerance and response being better in well-nourished patients. In this review, literature data on strategies or nutritional interventions will be critically examined, with particular regard to different treatment phases (perioperative, metastatic, and palliative settings), with the aim to draw practical indications for an adequate nutritional support of gastric cancer patients and provide an insight on future directions in nutritional strategies. We extensively analyzed the last 10 years of literature, in order to provide evidence that may fit current clinical practice both in terms of nutritional interventions and oncological treatment. Overall, 137 works were selected: 34 Randomized Clinical Trials (RCTs), 12 meta-analysis, 9 reviews, and the most relevant prospective, retrospective and cross-sectional studies in this setting. Eleven ongoing trials have been selected from clinicaltrial.gov as representative of current research. One limitation of our work lies in the heterogeneity of the described studies, in terms of sample size, study procedures, and both nutritional and clinical outcomes. Indeed, to date, there are no specific evidence-based guidelines in this fields, therefore we proposed a clinical algorithm with the aim to indicate an appropriate nutritional strategy for gastric cancer patients.

Clinical assessment of tumor regression grade systems in gastroesophageal adenocarcinoma following neoadjuvant chemotherapy

BACKGROUND

The standard treatment for gastroesophageal cancer is neoadjuvant chemotherapy, followed by surgery, which has been shown to increase survival compared with surgery alone. Evidence is mounting that characterization of the oncologically induced tumor regression is of prognostic importance. However, no consensus regarding the optimal system for describing tumor regression exists. Thus, this study aims to explore three validated/promising tumor regression systems with a focus on their interobserver reliability and usability.

METHODS

We included 100 consecutive patients with gastroesophageal adenocarcinoma who had undergone neoadjuvant oncological treatment followed by surgery. The tumors underwent tumor regression grade (TRG) assessment according to the Standard Mandard-, Modified Mandard-, and Becker systems to assess the interobserver reliability between two consultant pathologists. The interobserver reliability was determined by both Fleiss kappa and weighted kappa metrics. Besides, a semi-quantitative usability questionary was completed and it was expanded with usability comments.

RESULTS

The Fleiss kappa interobserver agreement was 0.67 [95% CI, 0.55-0.79], 0.88 [95% CI, 0.73-1.00], and 0.88 [95% CI, 0.73-1.00] for Standard Mandard-, Modified Mandard-, and the Becker systems, respectively. The weighted kappa (linear) was 0.80 [95% CI, 0.72-0.89], 0.91 [95% CI, 0.84-0.98], and 0.91 [95% CI, 0.84-0.98] for the Standard Mandard-, Modified Mandard-, and the Becker systems, respectively. The usability was scored on a scale of 8-24 by both raters. The systems were scored accordingly: 47 (Modified Mandard system), 43 (Becker system), and 37 (Standard Mandard system).

CONCLUSION

The Modified Mandard- and Becker systems had excellent interobserver reliability and usability. However, the systems could be improved by a better characterization of the different tiers and tumor morphology.

Prognostic Significance of Stratification Using Pathological Stage and Response to Neoadjuvant Chemotherapy for Esophageal Squamous Cell Carcinoma

PURPOSE

Risk stratification to select appropriate candidates for adjuvant therapy is required for esophageal cancer patients based on adjuvant therapy advancement including immunotherapy. The current study aims to develop a novel staging system using pathological stage (pStage) and response to neoadjuvant chemotherapy (NAC) for esophageal squamous cell carcinoma (ESCC).

METHODS

ESCC patients who received NAC and underwent transthoracic esophagectomy at two Japanese high-volume esophageal centers were retrospectively reviewed. The prognostic value of NAC response was evaluated within the same pStage, and a novel risk stratification to predict cancer-specific survival (CSS) was developed.

RESULTS

The HR (95% CI) of pathological responders in pStage 0-I, II, III, and IV was 0.29 (0.07-1.17), 0.37 (0.12-1.10), 0.37 (0.15-0.92), and 0.24 (0.06-0.98), respectively. Responders in pStage 0-II were classified to be in the same class and those in pStage III/IV in another group, because the 5-year CSS (5y-CSS) rate of responders in pStage 0-I, II, III, and IV was 94%, 92%, 76%, and 71%, respectively. Combining nonresponders in pStage 0-II as the same group, all patients were subdivided into five groups. Intriguingly, the 5y-CSS in pStage III-IV responders was 75%, almost identical to that of nonresponders in pStage 0-II (78%).

CONCLUSIONS

The histological response influenced the long-term outcomes of patients who underwent esophagectomy after NAC, even within groups stratified by pathologic stage. The current risk stratification system will contribute to selecting appropriate candidates for adjuvant therapy.

Comparison of Two Major Staging Systems in Predicting Survival and Recommendation of Postoperative Radiotherapy Based on the 11th Japanese Classification for Esophageal Carcinoma After Curative Resection: A Propensity Score-Matched Analysis

OBJECTIVE

The aim of this study was to compare the prognostic predictive power of the 11th Japan Esophageal Society (JES) staging system with the 8th edition of the American Joint Committee on Cancer (AJCC) staging system in patients with thoracic esophageal squamous cell carcinoma (TESCC), and to estimate the survival benefits of postoperative radiotherapy (PORT) based on a substage of the JES staging system.

METHODS

Area under the curve (AUC) values of the receiver operating characteristic curve were calculated to evaluate prognostic efficacy. Propensity score matching (PSM) analysis was conducted to balance the two groups (surgery only [S group] or surgery plus PORT [S+RT group]) across substages of the 11th JES staging system according to independent prognostic factors for overall survival (OS) identified using Cox proportional hazards regression.

RESULTS

A total of 2960 patients were eligible. The 5-year OS AUC for the 8th AJCC staging system was significantly higher than that for the 11th JES staging system (0.701 vs. 0.675, p < 0.001). Before PSM, PORT significantly improved 5-year OS rates for patients in stage III and IVA by 9.1% (p < 0.001) and 21.1% (p < 0.001), respectively. After PSM, the 5-year OS rates in stage II, III, and IVA of the S+RT group were significantly higher than those in the S group (70.9%, 39.7%, and 35.1% vs. 57.8%, 27.2%, and 10.3%, respectively; p < 0.001).

CONCLUSION

The 11th JES staging system was less capable of predicting prognosis than the 8th AJCC staging system and patients in stage III of the JES staging system were highly recommended to undergo PORT.

MicroRNA‑485‑5p suppresses the progression of esophageal squamous cell carcinoma by targeting flotillin‑1 and inhibits the epithelial‑mesenchymal transition

As esophageal squamous cell carcinoma (ESCC) is one of the most frequently diagnosed cancers in Asia, it is crucial to uncover its underlying molecular mechanisms that support its development and progression. Several articles have reported that microRNA (miR)-485-5p inhibits the malignant phenotype in a number of cancer types, such as lung, gastric and breast cancer, but to the best of our knowledge, its function in ESCC has not been studied in depth until the present study. It is of great significance to probe the regulatory action and underlying mechanism of miR-485-5p in ESCC. In brief, this study identified that miR-485-5p expression in ESCC tissues was significantly lower than that in normal tissues. The decrease in miR-485-5p expression was associated with a larger tumour size and poor histology and stage. The expression of miR-485-5p was relatively high in Eca 109 and TE-1 cells, but relatively low in KYSE 30. The overexpression of miR-485-5p inhibited cell proliferation, migration and invasion in vitro, whereas miR-485-5p knockdown did the opposite. Flotillin-1 (FLOT-1) can facilitate the malignant phenotype in various cancer types. The present study found that in ESCC tissue, the protein expression of FLOT-1 was negatively correlated with miR-485-5p expression. Further experiments showed that miR-485-5p directly targeted the 3′-untranslated region of FLOT-1. The overexpression of miR-485-5p significantly suppressed the mRNA and protein expression levels of FLOT-1, whereas knockdown had the reverse effects. Furthermore, overexpression of miR-485-5p restrained epithelial-mesenchymal metastasis (EMT)-related factors at both the mRNA and protein levels. At the same time, it also inhibited the growth of ESCC and restrained the EMT in vivo. In summary, miR-485-5p was found to be an inhibitor of ESCC and may have potential as a novel target candidate for ESCC treatment.

Predicting Lymph Node Metastasis Using Computed Tomography Radiomics Analysis in Patients With Resectable Esophageal Squamous Cell Carcinoma

OBJECTIVES

We investigated the value of radiomics data, extracted from pretreatment computed tomography images of the primary tumor (PT) and lymph node (LN) for predicting LN metastasis in esophageal squamous cell carcinoma (ESCC) patients.

MATERIALS AND METHODS

A total 338 ESCC patients were retrospectively assessed. Primary tumor, the largest short-axis diameter LN (LSLN), and PT and LSLN interaction term (IT) radiomic features were calculated. Subsequently, the radiomic signature was combined with clinical risk factors in multivariable logistic regression analysis to build various clinical-radiomic models. Model performance was evaluated with respect to the fit, overall performance, differentiation, and calibration.

RESULTS

A clinical-radiomic model, which combined clinical and PT-LSLN-IT radiomic signature, showed favorable discrimination and calibration. The area under curve value was 0.865 and 0.841 in training and test set.

CONCLUSIONS

A venous computed tomography radiomic model based on the PT, LSLN, and IT radiomic features represents a novel noninvasive tool for prediction LN metastasis in ESCC.

Next-Generation Sequencing of 487 Esophageal Adenocarcinomas Reveals Independently Prognostic Genomic Driver Alterations and Pathways

PURPOSE

To delineate recurrent oncogenic driver alterations and dysregulated pathways in esophageal adenocarcinoma and to assess their prognostic value.

EXPERIMENTAL DESIGN

We analyzed a large cohort of patients with lower esophageal and junctional adenocarcinoma, prospectively sequenced by MSK-IMPACT with high-quality clinical annotation. Patients were subdivided according to treatment intent, curative versus palliative, which closely mirrored clinical staging. Genomic features, alterations, and pathways were examined for association with overall survival using Cox proportional hazard models, adjusted for relevant clinicopathologic factors knowable at the time of diagnosis.

RESULTS

Analysis of 487 patients revealed 16 oncogenic driver alterations, mostly amplifications, present in ≥5% of patients. Patients in the palliative-intent cohort, compared with those in the curative-intent cohort, were more likely to have metastatic disease, ERBB2 amplifications, Cell-cycle and RTK-RAS pathway alterations, as well as a higher fraction of genome altered and rate of whole-genome doubling. In multivariable analyses, CDKN2A alterations, SMAD4 alterations, KRAS amplifications, Cell-cycle and TGFβ pathways, and overall number of oncogenic drivers were independently associated with worse overall survival. ERBB2 amplification was associated with improved survival, presumably due to trastuzumab therapy.

CONCLUSIONS

Our study suggests that higher levels of genomic instability are associated with more advanced disease in esophageal adenocarcinoma. Furthermore, CDKN2A, KRAS, and SMAD4 represent prognostic biomarkers, given their strong association with poor survival.

Current Evidence and Future Perspective of Accuracy of Artificial Intelligence Application for Early Gastric Cancer Diagnosis With Endoscopy: A Systematic and Meta-Analysis

Background & Aims: Gastric cancer is the common malignancies from cancer worldwide. Endoscopy is currently the most effective method to detect early gastric cancer (EGC). However, endoscopy is not infallible and EGC can be missed during endoscopy. Artificial intelligence (AI)-assisted endoscopic diagnosis is a recent hot spot of research. We aimed to quantify the diagnostic value of AI-assisted endoscopy in diagnosing EGC.

Method: The PubMed, MEDLINE, Embase and the Cochrane Library Databases were searched for articles on AI-assisted endoscopy application in EGC diagnosis. The pooled sensitivity, specificity, and area under the curve (AUC) were calculated, and the endoscopists' diagnostic value was evaluated for comparison. The subgroup was set according to endoscopy modality, and number of training images. A funnel plot was delineated to estimate the publication bias.

Result: 16 studies were included in this study. We indicated that the application of AI in endoscopic detection of EGC achieved an AUC of 0.96 (95% CI, 0.94–0.97), a sensitivity of 86% (95% CI, 77–92%), and a specificity of 93% (95% CI, 89–96%). In AI-assisted EGC depth diagnosis, the AUC was 0.82(95% CI, 0.78–0.85), and the pooled sensitivity and specificity was 0.72(95% CI, 0.58–0.82) and 0.79(95% CI, 0.56–0.92). The funnel plot showed no publication bias.

Conclusion: The AI applications for EGC diagnosis seemed to be more accurate than the endoscopists. AI assisted EGC diagnosis was more accurate than experts. More prospective studies are needed to make AI-aided EGC diagnosis universal in clinical practice.

Development and validation of a new clinical staging system to predict survival for esophageal squamous cell carcinoma patients: Application of the nomogram

INTRODUCTION

Survival of patients with the same clinical stage varies widely and effective tools to evaluate the prognosis utilizing clinical staging information is lacking. This study aimed to develop a clinical nomogram for predicting survival of patients with Esophageal Squamous Cell Carcinoma (ESCC).

MATERIALS AND METHODS

On the basis of data extracted from the SEER database (training cohort, n = 3375), we identified and integrated significant prognostic factors for nomogram development and internal validation. The model was then subjected to external validation with a separate dataset obtained from Jinling Hospital of Nanjing Medical University (validation cohort, n = 1187). The predictive accuracy and discriminative ability of the nomogram were determined by concordance index (C-index), Akaike information criterion (AIC) and calibration curves. And risk group stratification was performed basing on the nomogram scores.

RESULTS

On multivariable analysis of the training cohort, seven independent prognostic factors were identified and included into the nomogram. Calibration curves presented good consistency between the nomogram prediction and actual observation for 1-, 3-, and 5-year OS. The AIC value of the nomogram was lower than that of the 8th edition American Joint Committee on Cancer TNM (AJCC) staging system, whereas the C-index of the nomogram was significantly higher than that of the AJCC staging system. The risk groups stratified by CART allowed significant distinction between survival curves within respective clinical TNM categories.

CONCLUSIONS

The risk stratification system presented better discriminative ability for survival prediction than current clinical staging system and might help clinicians in decision making.

Endoscopic Images by a Single-Shot Multibox Detector for the Identification of Early Cancerous Lesions in the Esophagus: A Pilot Study

Diagnosis of early esophageal neoplasia, including dysplasia and superficial cancer, is a great challenge for endoscopists. Recently, the application of artificial intelligence (AI) using deep learning in the endoscopic field has made significant advancements in diagnosing gastrointestinal cancers. In the present study, we constructed a single-shot multibox detector using a convolutional neural network for diagnosing different histological grades of esophageal neoplasms and evaluated the diagnostic accuracy of this computer-aided system. A total of 936 endoscopic images were used as training images, and these images included 498 white-light imaging (WLI) and 438 narrow-band imaging (NBI) images. The esophageal neoplasms were divided into three classifications: squamous low-grade dysplasia, squamous high-grade dysplasia, and squamous cell carcinoma, based on pathological diagnosis. This AI system analyzed 264 test images in 10 s, and the sensitivity, specificity, and diagnostic accuracy of this system in detecting esophageal neoplasms were 96.2%, 70.4%, and 90.9%, respectively. The accuracy of this AI system in differentiating the histological grade of esophageal neoplasms was 92%. Our system showed better accuracy in diagnosing NBI (95%) than WLI (89%) images. Our results showed the great potential of AI systems in identifying esophageal neoplasms as well as differentiating histological grades.

Surgical Management of Barrett's-Related Neoplasia

The management of Barrett's-related neoplasia has benefited from advances in endoscopic assessment, resection, and ablation, along with improved pathologic and radiographic staging. The development of specialized, high-volume esophageal multidisciplinary teams, with improvements in patient selection, preparation, perioperative care, minimally invasive operative approaches, and enhanced recovery after surgery programs, has contributed to improved outcomes for patients undergoing esophagectomy for Barrett's-related neoplasia.

Optimal Range of Lymphadenectomy in Pathological Stage T1 and T2 Esophageal Squamous Cell Carcinoma

BACKGROUND

Lymph node metastasis is a primary contributor to tumor progression in esophageal squamous cell carcinoma (ESCC), and the optimal extent of lymphadenectomy during esophagectomy remains controversial. This study aimed to investigate the appropriate number of lymph nodes to be dissected in pT1-2Nany stage ESCC to achieve the best prognosis and avoid missing positive lymph nodes (PLNs).

METHODS

A total of 497 patients with pT1 to pT2 esophageal cancer from two institutions were retrospectively analyzed and their surgical and pathological records were critically reviewed. Stepwise analyses were conducted by calculating a serial of hazard ratios and odd ratios to determine the optimal range of lymphadenectomy for overall survival (OS).

RESULTS

The best survival outcome can be obtained when the number of lymph node examined (NLNE) is 10-18 in pT1N0 ESCC, while the NLNE should exceed 24 in pT2N0 diseases. In patients with pT1-2Nany and pT2Nany ESCC, resection of 15-25 and 24-37 lymph nodes, respectively, could provide significant added value for identifying positive nodal metastasis. When the NLNE exceeds this appropriate range, resection of extra lymph node is not helpful to improve the probability of finding PLNs.

CONCLUSIONS

For ESCC patients undergoing radical esophagectomy, the optimal extent of lymphadenectomy is 15-25 for pT1Nany disease and 24-37 for pT2Nany disease.

Lymphovascular Invasion as a Prognostic Factor in Non-Metastatic Adenocarcinoma of Esophagogastric Junction After Radical Surgery

Purpose

Tumors with lymphovascular invasion (LVI) are thought to be associated with lymph node metastasis and to lead to a worse prognosis. However, the effect of LVI on the prognosis of adenocarcinoma of esophagogastric junction (AEG) is still unclear.

Patients and Methods

We retrospectively analyzed 224 consecutive patients with non-metastatic AEG who underwent radical surgery in our hospital from 2004 to 2018. Inverse probability weighting (IPW) analysis was used to eliminate the selection bias. IPW-adjusted Kaplan–Meier curves and Cox proportional hazards models were used to compare disease-specific survival (DSS) and overall survival (OS) between patients with and without LVI.

Results

A total of 224 patients with non-metastatic AEG who underwent radical resection were included in the study and 96 (42.9%) patients developed LVI. Survival analysis showed that LVI were associated with worse DSS (hazard ratio (HR) = 3.12; 95% CI: 1.93–5.03) and worse OS (HR = 2.33; 95% CI: 1.61–3.38). The results were consistent across subgroups stratified by pathologic N stage. Subgroup analysis demonstrated that Siewert type III (HR= 3.20, 95% CI: 1.45–7.06) was associated with worse DSS, but not Siewert type I/II (HR= 1.46, 95% CI: 0.94–2.31, P-interaction=0.047).

Conclusion

LVI are associated with worse prognosis in AEG. LVI had a worse effect on DSS in Siewert type III AEG than Siewert type I/II AEG.

High expression of CIN85 promotes proliferation and invasion of human esophageal squamous cell carcinoma

SH3 domain-containing kinase-binding protein 1 (CIN85), an 85 kDa protein known to be a member of the signal adaptor family, is abnormally expressed in several human malignancies and has been found to be involved in the growth, migration and invasion of these tumors. The objective of the present study was to clarify the clinical significance of CIN85 in human esophageal squamous cell carcinoma (ESCC), as well as its in vitro functions. CIN85 expression was evaluated in 129 cases of ESCC and its adjacent normal tissues using immunohistochemistry to explore its clinical relevance and prognostic value. The functions of CIN85 in the ESCC TE1 cell line were analyzed in vitro using the interfering short hairpin RNA silencing technique. MTS, wound healing, clone formation and Transwell assays were used to detect the proliferation, migration and invasion of ESCC cells. CIN85 expression was identified mainly in ESCCs and their adjacent normal tissues, and the high expression of CIN85 was significantly associated with advanced Tumor Node Metastasis stage and lymph node metastasis. CIN85 gene silencing significantly inhibited TE1 cell proliferation, migration and invasion. These results demonstrated that CIN85 was highly expressed in advanced stage ESCC and lymph node metastasis, and played a critical role in tumor proliferation and progression. Therefore, CIN85 may be a promising therapeutic target for human ESCC.

A nomogram based on pretreatment CT radiomics features for predicting complete response to chemoradiotherapy in patients with esophageal squamous cell cancer

Purpose

To develop and validate a nomogram model to predict complete response (CR) after concurrent chemoradiotherapy (CCRT) in esophageal squamous cell carcinoma (ESCC) patients using pretreatment CT radiomic features.

Methods

Data of patients diagnosed as ESCC and treated with CCRT in Shantou Central Hospital during the period from January 2013 to December 2015 were retrospectively collected. Eligible patients were included in this study and randomize divided into a training set and a validation set after successive screening. The least absolute shrinkage and selection operator (LASSO) with logistic regression to select radiomics features calculating Rad-score in the training set. The logistic regression analysis was performed to identify the predictive clinical factors for developing a nomogram model. The area under the receiver operating characteristic curves (AUC) was used to assess the performance of the predictive nomogram model and decision curve was used to analyze the impact of the nomogram model on clinical treatment decisions.

Results

A total of 226 patients were included and randomly divided into two groups, 160 patients in training set and 66 patients in validation set. After LASSO analysis, seven radiomics features were screened out to develop a radiomics signature Rad-score. The AUC of Rad-score was 0.812 (95% CI 0.742–0.869, p < 0.001) in the training set and 0.744 (95% CI 0.632–0.851, p = 0.003) in the validation set. Multivariate analysis showed that Rad-score and clinical staging were independent predictors of CR status, with p values of 0.035 and 0.023, respectively. A nomogram model incorporating Rad-socre and clinical staging was developed and validated, with an AUC of 0.844 (95% CI 0.779–0.897) in the training set and 0.807 (95% CI 0.691–0.894) in the validation set. Delong test showed that the nomogram model was significantly superior to the clinical staging, with p < 0.001 in the training set and p = 0.026 in the validation set. The decision curve showed that the nomogram model was superior to the clinical staging when the risk threshold was greater than 25%.

Conclusion

We developed and validated a nomogram model for predicting CR status of ESCC patients after CCRT. The nomogram model was combined radiomics signature Rad-score and clinical staging. This model provided us with an economical and simple method for evaluating the response of chemoradiotherapy for patients with ESCC.

Lymph node dissection around left recurrent laryngeal nerve: robot-assisted vs. video-assisted McKeown esophagectomy for esophageal squamous cell carcinoma

OBJECTIVE

This study investigated the advantages of robot-assisted McKeown esophagectomy (RAME) for extensive superior mediastinal lymph node dissection (LND) versus video-assisted McKeown esophagectomy (VAME).

METHODS

The cases of 184 consecutive esophageal squamous cell carcinoma (ESCC) patients who underwent minimally invasive McKeown esophagectomy (109 with RAME, 75 with VAME) performed by a single surgical group between June 2017 and December 2019 were retrospectively reviewed.

RESULTS

Overall, 59.8% (110/181) patients (70 treated with RAME, 40 treated with VAME; 64.2% vs. 53.3%, respectively, p = 0.139) underwent complete LND around the left recurrent laryngeal nerve (RLN) by pathological assessment. Cumulative sum plots showed increased numbers of LND around the left RLN (3.6 ± 2.0 vs. 5.4 ± 2.7, p = 0.008) and a decreased incidence of recurrent nerve injury (27.9% vs. 7.4%, p = 0.037) after RAME learning curve. Despite similar overall LND results (30.6 ± 10.2 vs. 28.1 ± 10.2, p > 0.05), RAME yielded more LND (5.4 ± 2.7 vs. 4.4 ± 2.2, p = 0.016) and a greater proportion of lymph node metastases (37.0% vs. 7.5%) around the left RLN but induced a lower proportion of recurrent nerve injuries (7.4% vs. 22.5%, p = 0.178) compared with VAME. Further analysis revealed that the complete LND around the left RLN was associated with recurrent nerve injury in the RAME (20.0% vs. 5.1%, p = 0.035) and VAME (22.5% vs. 5.7%, p = 0.041) groups but did not affect other clinical outcomes including surgical duration, intraoperative blood loss, postoperative intensive care unit stay, hospital stay, and other complications.

CONCLUSIONS

For patients with ESCC, RAME has great advantages in LND around the left RLN and recurrent nerve protection after learning curve of robotic esophagectomy.

Comparison of Outcomes Between McKeown and Sweet Esophagectomy in the Elderly Patients for Esophageal Squamous Cell Carcinoma: A Propensity Score-Matched Analysis

The aim of this study was to compare the perioperative outcomes and long-term survival rates of the McKeown and Sweet procedures in patients with esophageal cancer younger than 70 years or older than 70 years. A total of 1432 consecutive patients with esophageal squamous cell carcinoma (ESCC) who received surgery at Sun Yat-sen University Cancer Center from January 2009 to October 2012 were analyzed. Propensity score matching was used to balance the clinical characteristics of the patients who underwent different surgical approaches, and 275 and 71 paired cases were matched among those younger and older than 70 years, respectively. The prognosis and postoperative outcomes were compared between the McKeown and the Sweet esophagectomy. For patients younger than 70 years, those who underwent the McKeown procedure had better overall survival (OS) than those in the Sweet group (log rank = 4.467; P = .035). However, no significant difference in disease-free survival and OS was observed between two approaches for the elderly patients (log rank = 1.562; P = .211 and log rank = 0.668; P = .414, respectively). Cox regression analysis revealed that McKeown approach was a positive prognostic factor compared to the Sweet approach for patients younger than 70 years in univariable analysis (HR = 0.790; 95% CI, 0.625-0.997; P = .047), whereas the surgical approach was not significantly related to the prognosis in the elderly patients. For patients older than 70 years, the occurrence of anastomotic fistula increased in those who underwent the McKeown procedure (23.9% vs 11.3%, P = .038, for the McKeown and Sweet esophagectomy, respectively). The McKeown approach increases the OS in younger patients with ESCC. However, for patients older than 70 years, the Sweet approach was proven to be an effective therapy, given the better perioperative outcomes and similar long-term survival compared with patients in the McKeown group.

Lymph node metastatic patterns and its clinical significance for thoracic superficial esophageal squamous cell carcinoma

Background and objectives

The optimal therapeutic method for patients with superficial esophageal squamous cell carcinoma (sESCC) remains to be established.

Methods

Clinical data of all the patients from 2002 to 2014 who underwent curative esophagectomy and three-field lymphadenectomy for thoracic sESCC were collected based on a prospectively-maintained database. The pattern of lymph node metastasis was analyzed based on the depth of tumor invasion, tumor location and surgical fields.

Results

The involved lymph node region was associated to the tumor location, however, upper mediastinal and perigastric region was the most vulnerable region. The incidence of lymph node metastasis increased with the depth of tumor invasion. No lymph node involvement was found in tumors invading proper mucosa (M2), while the pattern of positive lymph nodes in tumors invading the deepest 1/3 submucosa was similar to that in advanced ESCC. Lymphatic invasion, tumor location and upper mediastinal lymph node involvement were independent predictors for cervical lymph node metastasis. For patients without lymphatic invasion, the positive predictive value of upper mediastinal lymph node metastasis for positive cervical lymph node was low (0 ~ 25%), while the negative predictive value was extremely high, wherever the tumor located (93.8 ~ 100%).

Conclusions

Tumors invading till proper mucosa was the best indication for endoscopic mucosa resection. Mediastinal-abdominal lymphadenectomy was essential for sESCC invading beyond proper mucosa. For those without lymphatic invasion, cervical lymphadenectomy might be avoided in case of negative upper mediastinal lymph node.

Updates in the 8th edition of the TNM staging system for esophagus and esophagogastric junction cancer

The tumor-node metastasis (TNM) classification, originally developed in 1943 and subsequently adopted by the Union for International Cancer Control and the American Joint Committee on Cancer, is regularly updated based on new information and developments. The TNM classification system is the main tool used for both clinical and pathological staging of cancers worldwide. The 8th edition of the TNM classification for esophageal and esophagogastric junction (EGJ) cancer, released in 2017, was updated from the 7th edition based on additional data supplied by the Worldwide Esophageal Cancer Collaboration group. We summarize the main changes between the 7th and 8th editions of this TNM classification. Notable changes included separate clinical, pathological and pathological prognostic staging for adenocarcinomas and squamous cell carcinomas. Pathological prognostic staging was also improved by updating the T- and N-factors regarding histopathological differentiation and tumor location, respectively. The definition of EGJ cancer was changed from tumors centered within 5 cm to tumors within 2 cm of the EGJ. These updates to the TNM classification will help to improve the personalized management and treatment of patients with esophageal and EGJ cancers.

Modeling the Cost-effectiveness of Esophageal Cancer Screening in China

BACKGROUND

This study aimed to examine the cost-effectiveness of one-time standard endoscopic screening with Lugol's iodine staining for esophageal cancer (EC) in China.

METHODS

A Markov decision analysis model with eleven states was built. Individuals aged 40 to 69 years were classified into six age groups in five-year intervals. Three different strategies were adopted for each cohort: (1) no screening; (2) one-time endoscopic screening with Lugol's iodine staining with an annual follow-up for low-grade intraepithelial neoplasia (LGIN); and (3) one-time endoscopic screening with Lugol's iodine staining without follow-up. Quality-adjusted life-years (QALYs) indicated the effectiveness of the model. The incremental cost-effectiveness ratio (ICER) was used as the evaluation indicator. Sensitivity analysis was performed to assess the robustness of the model.

RESULTS

One-time screening with follow-up was the undominated strategy for individuals aged 40-44 and 45-49 years, which saved USD 10,942.57 and USD 6611.73 per QALY gained compared to nonscreening strategy. For those aged 50-69 years, the nonscreening scenarios were undominated. One-time screening without follow-up was the extended dominated strategy. Compared to screening strategies without follow-up, all the screening strategies with follow-up were more cost-effective, with the ICER increasing from 299.57 USD/QALY for individuals aged 40-44 years to 1617.72 USD/QALY for individuals aged 65-69 years. Probabilistic sensitivity analysis (PSA) supported the results of the base case analysis.

CONCLUSIONS

One-time EC screening with follow-up targeting individuals aged 40-49 years was the most cost-effective strategy.

Role of Imaging in Esophageal Cancer Management in 2020: Update for Radiologists

OBJECTIVE. The purpose of this article is to discuss the role of imaging in the management of esophageal cancer. CONCLUSION. A multimodality-based approach to imaging is essential in clinical practice to achieve the best possible outcome for patients with esophageal cancer. Radiologists must be aware of the strengths and limitations of different imaging modalities in various clinical settings. The role of a radiologist is to combine information from anatomic and functional imaging, assess metastatic disease and changes in the primary tumor during treatment, and identify anatomic complications after treatment.

Prognostic value of pretreatment contrast-enhanced computed tomography in esophageal neuroendocrine carcinoma: A multi-center follow-up study

BACKGROUND

The rare incidence of esophageal neuroendocrine carcinoma (NEC) and limited treatment experience result in insufficient clinical observations and unsuitable guidelines for its management.

AIM

To investigate the prognostic value of pretreatment contrast-enhanced computed tomography (CT) characteristics in patients with esophageal NEC.

METHODS

Seventy-seven esophageal NEC patients who received contrast-enhanced CT at two hospitals were enrolled in this study from June 2014 to December 2019. The clinical features and image characteristics were recorded accordingly. Univariate survival analysis was performed using the Kaplan-Meier method and log-rank test, and multivariate analysis was carried out with a Cox proportional hazards model.

RESULTS

The multivariate analysis performed using the Cox proportional hazards model showed that N stage, adjuvant chemotherapy, and degree of enhancement were independent prognostic factors for overall survival (OS). Meanwhile, adjuvant chemotherapy was an independent prognostic factor for progression-free survival (PFS). The hazard ratios (HRs) of N stage, adjuvant chemotherapy, and degree of enhancement (mild vs moderate/marked) for OS were 0.426 (P = 0.024), 3.862 (P = 0.006), and 2.169/0.809 (P = 0.037), respectively. The HR of adjuvant chemotherapy for PFS was 6.432 (P < 0.001). Adjuvant chemotherapy was significantly associated with degree of enhancement (P = 0.018).

CONCLUSION

Adjuvant chemotherapy is an independent prognostic factor for OS and PFS. Additionally, N stage and degree of enhancement are prognostic factors for OS in patients with esophageal NEC.

Clinical evaluation of right recurrent laryngeal nerve nodes in thoracic esophageal squamous cell carcinoma

Background

The accuracy of clinical N staging of esophageal squamous cell carcinoma is suboptimal. As an important station of lymph node metastasis, station C201 (right recurrent laryngeal nerve nodes) has rarely been evaluated alone. We aimed to explore an effective way to evaluate the right recurrent laryngeal nerve nodes in thoracic esophageal squamous cell carcinoma.

Methods

We retrospectively analyzed 628 thoracic esophageal squamous cell carcinoma patients who underwent radical resection without neoadjuvant therapy from two Chinese cancer centers. The diameter of the short axis of the largest right recurrent laryngeal nerve node (DC201) was measured on contrast-enhanced multi-slice computed tomography (MSCT). Right recurrent laryngeal nerve nodes were examined by postoperative pathologic results. The receiver operating characteristic (ROC) curve was generated to assess the diagnostic capabilities of DC201 to determine the right recurrent laryngeal nerve nodes status.

Results

ROC curve analysis revealed that the optimal cut-off point of DC201 was 6 mm, with an area under curve (AUC), sensitivity, specificity, and Youden index of 0.896, 71.9%, 88.8%, and 0.607 respectively. When the cut-off point of DC201 was set to 10 mm, sensitivity, specificity and the Youden index were 14.1%, 99.6% and 0.137 respectively. Among 128 patients with right recurrent laryngeal nerve node metastasis, 71 and 108 patients had the largest right recurrent laryngeal nerve node located above the suprasternal notch level and in the tracheoesophageal groove respectively.

Conclusions

When DC201 ≥6.0 mm instead of DC201 ≥10 mm was used to dictate the right recurrent laryngeal nerve nodes metastasis, contrast-enhanced MSCT could evaluate the status of right recurrent laryngeal nerve nodes with high sensitivity and specificity. The largest right recurrent laryngeal nerve nodes were mainly located in the tracheoesophageal groove and/or above the suprasternal notch.

Long-term effectiveness of one-time endoscopic screening for esophageal cancer: A community-based study in rural China

BACKGROUND

Evidence is required to quantify the population-level effects of endoscopic screening for esophageal squamous cell carcinoma (ESCC). The objective of this study was to evaluate the long-term effectiveness of 1-time endoscopic ESCC screening in a Chinese rural population.

METHODS

This community-based cohort study was based on an existing esophageal cancer screening program in Feicheng City, China. The screening group consisted of all permanent residents aged 40 to 69 years in 17 villages who were screened during 2006 through 2009, and the control group consisted of residents in another 43 villages who were not yet covered by the screening program. Residents in the remaining 511 villages were defined as the total population control. The cumulative incidence and mortality of ESCC and the observed and expected numbers of ESCC cases and deaths during the follow-up period (2010-2018) were calculated and compared.

RESULTS

After a 9-year follow-up, the screening group (n = 8460) revealed reductions of 20% (relative risk, 0.80; 95% CI, 0.66-0.97) and 32% (relative risk, 0.68; 95% CI, 0.52-0.89) in ESCC cumulative incidence and mortality, respectively, compared with the control group (n = 20,468). Endoscopic screening prevented 0.41% of the population (attributable risk, 0.41%; 95% CI, 0.07%-0.75%) from ESCC occurrence and 0.38% (attributable risk, 0.38%; 95% CI, 0.14%-0.62%) from ESCC-related death. In the screening group, reductions of 43% (standardized incidence ratio, 0.57; 95% CI, 0.48-0.67) and 45% (standardized mortality ratio, 0.55; 95% CI, 0.44-0.69) were found in the observed cumulative cases and deaths, respectively, compared with the expected cases and deaths.

CONCLUSIONS

One-time endoscopic screening was associated with a significant and consistent reduction in ESCC incidence and mortality among individuals aged 40 to 69 years in high-risk areas.

Inaccurate pretreatment staging can impact survival in early stage esophageal adenocarcinoma

BACKGROUND

Given the survival advantage of neoadjuvant treatment for locally advanced esophageal cancer, accurate clinical staging is necessary. The aim of this study was to assess the clinical (c) and pathologic (p) staging concordance rates for presumably early stage esophageal adenocarcinoma patients that had upfront esophagectomy (UFE) and evaluate if survival (OS) was negatively affected by inaccurate preoperative staging and subsequent treatment selection.

METHODS

An NCDB retrospective review of nonmetastatic esophageal adenocarcinoma patients that had UFE. The rates of concordance between c and p staging system and OS were calculated.

RESULTS

Of 2775 patients, most patients presented with cN0 (82.8%) and cT1 tumors (53.6%). The overall concordance between c and p staging was 78.8% for T-classification (moderate agreement; weighted κ = 0.729; P < .001) and 78.8% for N-classification (weak agreement; weighted κ = 0.448; P < .001). Patients that were upstaged due to a lack of concordance between T-classification had decreased 5- and 10-year OS (30% and 16%, P < .001) and those upstaged due to discordant N-classification had decreased 5- and 10-year OS (28% and 23%, P < .001)."

CONCLUSIONS

Preoperative staging of esophageal adenocarcinoma has moderate reliability and accuracy for predicting pT and pN classification. Up to 25% of patients have discordant clinical and pathological staging, which impacts OS.

Postoperative adjuvant chemotherapy versus chemoradiotherapy for node-positive esophageal squamous cell carcinoma: a propensity score-matched analysis

Background and purpose

After esophagectomy, adjuvant chemotherapy (S + CT) and adjuvant chemoradiotherapy (S + CRT) can improve survival in patients with node-positive resectable esophageal cancer. However, we are not aware of any studies that directly compared these adjuvant treatments. This study aimed to compare S + CT and S + CRT for patients with esophageal cancer.

Materials and methods

We retrospectively identified patients with node-positive esophageal squamous cell carcinoma who underwent S + CT or S + CRT at Sichuan Cancer Hospital during 2008–2017. The patients’ characteristics were compared, as well as their overall survival (OS) and disease-free survival (DFS) outcomes. Propensity score matching was used to create balanced patient groups according to adjuvant treatment, and a Cox proportional hazards model was used to identify factors that predicted the survival outcomes.

Results

The 859 eligible patients underwent S + CRT (250 patients, 29.1%) or S + CT (609 patients, 70.9%). After propensity score matching (247 patients per group), the 5-year OS rates were 41.8% for S + CRT and 26.8% for S + CT (p = 0.028), and the 5-year DFS rates were 37.2% for S + CRT and 25.5% for S + CT (p = 0.012). Multivariate Cox regression analysis of the matched samples revealed that, relative to the S + CT group, the S + CRT group had better OS (hazard ratio: 0.71, 95% CI: 0.56–0.91; p = 0.006) and DFS (hazard ratio: 0.70, 95% CI: 0.56–0.88; p = 0.002).

Conclusion

Among patients with node-positive resectable esophageal squamous cell carcinoma, S + CRT was associated with better OS than S + CT. A multicenter randomized clinical trial is warranted to confirm these findings.

Prognostic significance of neutrophil-to-lymphocyte ratio in middle thoracic esophageal squamous cell carcinoma patients undergoing radical esophagectomy

Background

It is widely accepted that the pretreatment neutrophil-to-lymphocyte ratio (NLR) is an independent predictor of prognosis in multiple malignancies, including esophageal squamous cell carcinoma (ESCC). However, its predictive value in middle thoracic esophageal carcinoma is still unclear. Therefore, the purpose of this study was to investigate the preoperative serum levels of NLR in middle thoracic esophageal carcinoma patients to clarify their clinical significance as predictors of prognosis.

Methods

This study investigated 556 patients with middle thoracic ESCC treated by esophagectomy from January 2010 to December 2012. The prognostic impact of serum NLR level was analyzed. A receiver operating characteristic (ROC) curve was used to identify the NLR for predicting survival. Correlation between the NLR and clinicopathological characteristics was analyzed by χ² test. Prognostic influence was calculated by using the Kaplan-Meier method and the difference was compared by log-rank test. Cox regression analysis was performed to evaluate the significant prognostic factors.

Results

The cutoff value for the NLR was 2.43 ng/mL, the area under the curve was 0.553 (95% CI: 0.504–0.601; P=0.035), and the sensitivity and specificity were 53.3% and 58.7% respectively. It is demonstrated that preoperative NLR (P=0.003), T stage (P<0.001), N stage (P<0.001), surgical approach (P=0.004), and gender (P=0.008) were independent prognostic factors in middle thoracic ESCC by univariate analysis. Multivariate analysis showed that preoperative NLR (P=0.036), T stage (P=0.004), N stage (P<0.001), surgical approach (P=0.002), and age (P=0.019) were independent prognostic factors for survival.

Conclusions

Pretreatment NLR >2.43 ng/mL could serve as an indicator of poor prognosis in middle thoracic ESCC patients after surgical treatment.

Validation and proposed modification of the 8th edition American Joint Committee on Cancer staging system for patients with esophageal neuroendocrine neoplasms: Evaluation of a revised lymph node classification

There is currently no universally accepted staging system for esophageal neuroendocrine neoplasms (ENENs). In the present study, patients with ENENs, identified from the Surveillance, Epidemiology, and End Results registry (SEER) (n=191 patients) and the multicentric series (n=51 patients), were stratified to assess the validity of the 8th American Joint Committee on Cancer (AJCC) staging systems, particularly for esophageal squamous cell carcinoma and esophageal adenocarcinoma. The Kaplan-Meier method was used to assess disease-specific survival (DSS), according to the Tumor-Node-Metastasis (TNM) status, and the Cox model was applied to evaluate differences in prognosis after adjustment for potential confounders. For the 8th AJCC staging classifications, only the pathological stage groups (pTNM) conferred increased hazard ratios from stage I to stage IV, with overlaps between adjacent stages. According to the current findings, the regional lymph nodes involvement status other than the current N classification was a significant predictor of DSS. Consequently, a revised N(Nr) classification was proposed and therefore a new TNrM staging system was adopted, for which progressively poorer DSS associated with increasing stage was observed. Moreover, the concordance index with the modified staging system was slightly higher in patients with ENENs from the SEER registry compared with that of the 8th pTNM system. In conclusion, lymph node status, rather than the number of positive lymph nodes, was a marker of poorer DSS and the modified staging system provided an easier and more accurate staging tool. The present results indicate that revisions to the current staging classifications may be improve the assessment of patient prognosis.

The Significance of Negative Lymph Nodes in Esophageal Cancer After Curative Resection: A Retrospective Cohort Study

Objective

The impact of negative lymph nodes (NLNs) count on prognosis in esophageal cancer (EC) was analyzed using two institutions surgical database.

Methods

We conducted a retrospective study of 768 EC patients treated by surgical resection between January 2010 and December 2012. The effects of the NLNs count on prognosis was analyzed. Cox regression model was conducted to determine the significant prognostic elements.

Results

The number of NLNs was studied as a categorical variable based on the quartiles (Q1: ≤15, Q2: 16–21, Q3: 22–30, Q4: ≥31). And a better overall survival (OS) was observed with increasing number of NLNs (HR= 0.762; 95% CI, 0.596–0.974 for Q2, HR= 0.666; 95% CI, 0.516–0.860 for Q3 and HR= 0.588; 95% CI, 0.450–0.768 for Q4) (all P<0.05). Multivariate regression analysis revealed that the NLNs count was an independent prognostic factor. Besides, for patients in T2 or T3 stage, a high number of NLNs was found to be significantly associated with a favorable OS (log rank P<0.001).

Conclusion

A higher number of NLNs is independently related to the better OS in EC patients after surgical resection.

Comparison of the prognostic difference between ypTNM and equivalent pTNM stages in esophageal squamous cell carcinoma based on the 8th edition of AJCC classification

Objective: With the separate ypTNM stage groupings established in the 8th edition of AJCC staging system for esophageal squamous cell cancer (ESCC), we aimed to evaluate the prognostic difference between ypTNM stage and equivalent pTNM stage.

Methods: ESCC patients with surgery alone (cohort 1) and patients with neoadjuvant therapy plus surgery (cohort 2) were enrolled in the study.

Results: In p0, pIb, pIIa, pIIb, pIIIa, pIIIb and pIVa stages of cohort 1, the 5-year DFS and OS rates were 100/100%, 80.5/86.2%, 58.9/57.8%, 51.1/52.7%, 36.3/35.8%, 21.5/22.6% and 11.9/18.0%. In ypI, ypII, ypIII and ypIVa stages of cohort 2, the 5-year DFS and OS rates were 60.9/67.0%, 44.3/52.1%, 48.4/43.2% and 0. Patients in ypI stage had a tendency of poorer survival compared with those in pI stage (P=0.024 for DFS, P=0.067 for OS). There was no significant difference in terms of DFS (P=0.335) or OS (P=0.903) between ypII and pII. Patients in ypIII stage had a tendency of better survival compared with those in pIII stage (P=0.015 for DFS, P=0.059 for OS). Patients in ypIVa stage exhibited a significantly poorer OS compared with those in pIVa stage (P=0.038).

Conclusions: With down-staged tumor after neoadjuvant therapy, survival of ypI was closed but not reached to the prognosis of equivalent pI, prognosis of ypII was similar to equivalent pII, and survival of ypIII tended to be better compared with equivalent pIII. However, without down-staged ypIVa tumor, the prognosis was worse compared with equivalent pIVa, indicating those patients were primary resistant to prescribed neoadjuvant therapy.

How many lymph nodes should be dissected in esophagectomy with or without neoadjuvant therapy to get accurate staging?

It is essential to dissect an adequate number of lymph nodes (LNs) to ensure staging accuracy during esophagectomy with or without neoadjuvant therapy. We developed a statistical model to quantify the probability of precise nodal staging based on previous studies. Esophageal cancer patients who underwent esophagectomy were retrospectively reviewed in the Surveillance, Epidemiology, and End Results database. A β-binomial distribution was adopted to estimate the number of understaged patients based on the numbers of positive and examined LNs. Using 6,252 patients, we estimated a 90% confidence of accurate N0 staging could be achieved by examining 17 LNs without neoadjuvant therapy. To obtain similar accuracy in N1 and N2, 20 and 25 LNs should be examined. For patients with neoadjuvant therapy, 18, 19, and 28 LNs could achieve the same accuracy. Staging accuracy was a significant prognostic factor. We found when 90% confidence had been achieved, patient survival did not improve with more LNs examined and the ratio and log odds of positive LNs did not have significant prognostic values. The statistical model we developed for precise staging in patients with different N stages is of great value in guiding lymphadenectomy. It provided risk assessment for underestimated LN metastases and guided subsequent adjuvant treatment.

Long-term outcomes of multimodal therapy combining definitive chemoradiotherapy and salvage surgery for T4 esophageal squamous cell carcinoma

BACKGROUND

Survival outcomes of patients with cT4 esophageal squamous cell carcinoma (ESCC) remain extremely poor. We aimed to investigate long-term outcomes and identify prognostic factors in patients treated by definitive chemoradiotherapy (dCRT) alone or with dCRT plus salvage surgery (SALV) for cT4 ESCC.

PATIENTS AND METHODS

In total, 73 patients completing dCRT were analyzed. Patients achieving clinical complete response (CR) received follow-up evaluations thereafter. For patients diagnosed with clinical partial response (PR), potentially curative SALV was generally performed. Possible prognostic factors included demographic data, tumor staging, blood chemistry profiles, and esophageal stenosis.

RESULTS

The 1- and 3-year overall survival (OS) rates of the 73 patients were 67.1% and 40.8%, respectively. Twenty-one patients (29%) achieved clinical CR with dCRT alone. Among 35 patients (48%) with clinical PR, 31 underwent SALV and 4 opted for non-surgical treatments. In the dCRT-alone group (n = 42), patients with clinical CR-PR (n = 25) showed significantly better 3-year OS than those who responded poorly to dCRT (stable or progressive) (n = 17) (67.5% vs. 0%, P < 0.001). In the SALV group (n = 31), curative SALV (n = 22, 73%) provided significantly better 3-year OS than non-curative SALV (58.7% vs. 0%, P < 0.001). Multivariable analysis revealed stenosis before dCRT (P = 0.02) and pretreatment elevated CRP (P = 0.02) to be independently associated with poor outcomes.

CONCLUSIONS

The multimodal treatment strategy combining dCRT and SALV is rational for treating cT4 ESCC patients. When curative resection is feasible, SALV can provide good long-term survival outcome for patients who responded to dCRT but did not achieve clinical CR with dCRT alone.

Precision Surgical Therapy for Adenocarcinoma of the Esophagus and Esophagogastric Junction

INTRODUCTION

To facilitate the initial clinical decision regarding whether to use esophagectomy alone or neoadjuvant therapy in surgical care for individual patients with adenocarcinoma of the esophagus and esophagogastric junction-information not available from randomized trials-a machine-learning analysis was performed using worldwide real-world data on patients undergoing different therapies for this rare adenocarcinoma.

METHODS

Using random forest technology in a sequential analysis, we (1) identified eligibility for each of four therapies among 13,365 patients: esophagectomy alone (n = 6649), neoadjuvant therapy (n = 4706), esophagectomy and adjuvant therapy (n = 998), and neoadjuvant and adjuvant therapy (n = 1022); (2) performed survival analyses incorporating interactions of patient and cancer characteristics with therapy; (3) determined optimal therapy as that predicted to maximize lifetime within 10 years (restricted mean survival time; RMST) for each patient; and (4) compared lifetime gained from optimal versus actual therapies.

RESULTS

Actual therapy was optimal in 61% of those receiving esophagectomy alone; neoadjuvant therapy was optimal for 36% receiving neoadjuvant therapy. Many patients were predicted to benefit from postoperative adjuvant therapy. Total RMST for actual therapy received was 58,825 years. Had patients received optimal therapy, total RMST was predicted to be 62,982 years, a 7% gain.

CONCLUSIONS

Average treatment effect for adenocarcinoma of the esophagus yields only crude evidence-based therapy guidelines. However, patient response to therapy is widely variable, and survival after data-driven predicted optimal therapy often differs from actual therapy received. Therapy must address an individual patient's cancer and clinical characteristics to provide precision surgical therapy for adenocarcinoma of the esophagus and esophagogastric junction.

Peri-operative therapy for operable gastroesophageal adenocarcinoma: past, present and future

Surgery represents the only chance of cure for patients with gastroesophageal adenocarcinoma; however, surgery alone does not cure most patients. Over the past decade, several multimodality adjunctive treatments have improved survival for patients with operable gastroesophageal adenocarcinoma who are undergoing surgical resection; these include peri-operative chemotherapy, neoadjuvant chemoradiotherapy, adjuvant chemotherapy and adjuvant chemoradiotherapy. More recently, the results of several large randomised trials are leading to a shift in the peri-operative treatment of gastroesophageal cancer, away from anthracycline-based and towards taxane-based chemotherapy regimens. Emerging data support an increased focus on patients who are at high risk for poor operative outcomes such as R1 resection, and on patients who are at high risk for relapse following surgery such as those with lymph node metastases (N1+). Future developments may include use of fluorodeoxyglucose-positron emission tomography to inform a switch to non-cross resistant chemotherapy pre-operatively and substitution of alternative treatments for chemotherapy in high risk post-operative node positive patients. Conversely, in molecularly selected subgroups such as microsatellite unstable gastroesophageal cancer, peri-operative or adjuvant chemotherapy may not be helpful, and treatments such as immunotherapy may be considered. In this review, the most up-to-date clinical trials and translational research in the field of operable gastroesophageal cancer are discussed; with a focus on how best to risk stratify patients with operable disease for peri-operative treatment plus surgery, and how novel therapies might be integrated into standard treatments in order to improve survival outcomes in this patient group.

Incidence and risk factors of readmission after esophagectomy for esophageal cancer

Background

The Esophageal Complications Consensus Group (ECCG) recommends that readmission to a primary or secondary hospital within 30 days of discharge after esophagectomy is an important quality outcome indicator for esophagectomy. This retrospective study was performed to investigate the incidence and risk factors for readmission after esophagectomy.

Methods

We retrospectively reviewed 291 patients who received an esophagectomy and mediastinal lymphadenectomy for curative purposes from January 2006 to June 2017.

Results

The mean age was 63.02±8.02 years, and there were 264 (90.7%) male patients. Thirty-nine (13.4%) patients were re-admitted within 30 days after discharge. The mean interval from discharge to the readmission was 13.46±9.36. Common causes of readmission were anastomotic stricture that required ballooning (12, 30.7%), wound problem (7, 17.9%), pneumonia (6, 15.4%), and poor oral intake (4, 10.2%). Other causes of readmission were delayed gastric emptying [3], jejunostomy tube problem [2], ileus [2], pain [1], pneumothorax [1], and pleural effusion [1]. On multivariable analysis, anastomotic leakage (odd ratio =2.884, P=0.026) was significantly related to readmission, whereas age, pathologic stage, vocal cord palsy, and neoadjuvant therapy were not related to readmission.

Conclusions

Readmission within 30 days after esophagectomy was determined to be related to postoperative anastomotic leakage and wound problems whereas the vocal cord palsy was not.