Totally minimally invasive esophagectomy after neoadjuvant chemoradiotherapy: Long-term oncologic outcomes

Efficacy and safety of neoadjuvant chemoradiotherapy versus neoadjuvant chemotherapy in locally advanced esophageal cancer: An updated meta-analysis

BACKGROUND

Currently, the optimal treatment for neoadjuvant therapy for locally advanced esophageal cancer is not clear, and there is no evidence that neoadjuvant chemoradiotherapy (nCRT) is superior to neoadjuvant chemotherapy (nCT). Due to the publication of new clinical trials and defects in previous meta-analyses, we conducted an updated meta-analysis to evaluate the efficacy and safety of nCRT and nCT.

METHODS

The following databases were searched for studies: PubMed, EMBASE, and Cochrane library (updated to April 22, 2023). All randomized trials comparing nCRT with nCT in locally advanced esophageal cancer met the inclusion criteria. Data were analyzed using Review Manager 5.4.1 (Cochrane collaboration software). Primary outcomes assessed from the trials included overall survival (OS), progression-free survival (PFS), pathological complete response (pCR), R0 resection rate, postoperative complications, postoperative mortality, and grade 3 or higher adverse events (3 + AEs).

RESULTS

This systematic review and meta-analysis included 7 randomized controlled studies involving 1372 patients (686 receiving nCRT and 686 receiving nCT). Compared with nCT, nCRT significantly improved OS (HR = 0.80; 95% CI: 0.68-0.94), PFS (HR = 0.78; 95% CI: 0.66-0.93), pCR (OR = 13.00; 95% CI: 7.82-21.61) and R0 resection (OR = 1.84; 95% CI: 1.32-2.57), but was associated with higher postoperative mortality (OR = 2.31; 95% CI: 1.26-4.25) and grade 3 + AEs (OR = 2.21; 95% CI: 1.36-3.58). There was no significant difference in postoperative complications between nCRT and nCT (OR = 1.15; 95% CI: 0.82-1.61). Subgroup analysis showed significant survival benefit in squamous cell carcinoma (HR = 0.80; 95% CI: 0.68-0.98), but not in adenocarcinoma (HR = 0.80; 95% CI: 0.63-1.08).

CONCLUSIONS

Our meta-analysis found superior efficacy associated with nCRT compared with nCT in both tumor regression and prolonged survival, but increased the risk of postoperative mortality and grade 3 + AEs. Esophageal squamous cell carcinoma was more likely to benefit from nCRT than esophageal adenocarcinoma in the term of OS.

Survival after Ivor Lewis versus McKeown esophagectomy for cancer: propensity score matched analysis

It is unknown whether Ivor Lewis (IL) or McKeown (McK) esophagectomy is preferred in patients with potentially curable esophageal or gastro-esophageal junction (GEJ) cancer. Patients with mid- and distal esophageal and GEJ cancer without distant metastases who underwent IL or McK esophagectomy in the Netherlands between 2015 and 2017, were selected from the Netherlands Cancer Registry. Patients were propensity score matched for sex, age, American Society of Anesthesiologist classification, comorbidity, tumor type, tumor location, clinical stage, neoadjuvant treatment and year of diagnosis. The primary outcome was a 3-year relative survival (RS). Secondary outcome parameters were number of lymph nodes examined, number of positive lymph nodes, radical resection rate, tumor regression grade, post-operative complications and mortality. A total of 1627 patients who underwent IL (n = 1094) or McK (n = 533) esophagectomy were included. Patient and tumor characteristics were balanced after propensity score matching, leaving 658 patients to be compared. The 3-year RS was 54% after IL and 50% after McK esophagectomy, P = 0.140. The median number of lymph nodes examined, median number of positive lymph nodes, radical resection rate and tumor regression grade were comparable between both groups. Recurrent laryngeal nerve palsy (2 vs. 5%, P = 0.006) occurred less frequently after IL esophagectomy. No differences were observed in post-operative anastomotic leakage rate, pulmonary complication rate and mortality rates. There was no statistically significant difference in the 3-year RS between IL and McK esophagectomy. Based on these results, both IL and McK esophagectomy can be performed in patients with mid to distal esophageal and GEJ cancer.

Morbidity and Mortality of Patients Who Underwent Minimally Invasive Esophagectomy After Neoadjuvant Chemoradiotherapy vs Neoadjuvant Chemotherapy for Locally Advanced Esophageal Squamous Cell Carcinoma: A Randomized Clinical Trial

Question

Is there any difference in the safety of neoadjuvant chemoradiotherapy (nCRT) followed by minimally invasive esophagectomy (MIE) for locally advanced esophageal squamous cell carcinoma (ESCC) compared with that of neoadjuvant chemotherapy (nCT) followed by MIE?

Findings

In this multicenter randomized clinical trial of 264 patients with ESCC, overall morbidity rates were 47% in the nCRT group and 43% in nCT group, which was not significantly different.

Meaning

This trial shows that the safety of nCRT followed by MIE is similar to that of nCT for the treatment of locally advanced ESCC.

Importance

Safety and efficacy of neoadjuvant chemoradiotherapy (nCRT) vs neoadjuvant chemotherapy (nCT) for treatment of locally advanced esophageal squamous cell carcinoma (ESCC) remain uncertain given lack of high-level clinical evidence.

Objective

To compare safety and long-term survival of nCRT followed by minimally invasive esophagectomy (MIE) with that of nCT followed by MIE for patients with locally advanced ESCC.

Design, Setting, and Participants

A prospective, multicenter, open-label, randomized clinical trial that compared safety and efficacy of nCRT vs nCT followed by MIE for patients with locally advanced ESCC. From January 1, 2017, to December 31, 2018, 264 patients with ESCC of clinical stages from cT3 to T4aN0 to 1M0 were enrolled. Analysis was performed on an intention-to-treat basis from January 1, 2017, to August 30, 2020.

Interventions

Eligible patients were randomized to the nCRT group (n = 132) or the nCT group (n = 132) by a computer-generated random system. The chemotherapy, based on paclitaxel and cisplatin, was administered to both groups, while 40 Gy of concurrent radiotherapy was added for the nCRT group. At about 6 weeks after neoadjuvant therapy, MIE via thoracoscopy and laparoscopy was performed for the patients in both groups.

Main Outcomes and Measures

The primary outcome was 3-year overall survival. Secondary outcomes included postoperative complications, mortality, postoperative pathologic outcome, recurrence-free survival time, and quality of life.

Results

Among 264 patients (226 men [85.6%]; mean [SD] age, 61.4 [6.8] years), postoperative morbidity was 47.4% in the nCRT group (54 of 114) and 42.6% in the nCT group (46 of 108), with no significant difference between groups (difference, 4.8%; 95% CI, −8.2% to 17.5%; P = .48). Distribution of the severity of complications was similar between the 2 groups based on Clavien-Dindo classification. The 90-day perioperative mortality rate was 3.5% for the nCRT group (4 of 114) and 2.8% for the nCT group (3 of 108) (P = .94). The R0 resection rates were similar between groups (109 of 112 [97.3%] vs 100 of 104 [96.2%]; P = .92). However, patients in the nCRT group had a higher pathologic complete response (residual tumor, 0%) rate (40 of 112 [35.7%] vs 4 of 104 [3.8%]; P < .001) and a higher rate of negative lymph nodes (ypN0, 74 of 112 [66.1%] vs 48 of 104 [46.2%]; P = .03) than those in the nCT group. One-year overall survival using intention-to-treat analysis was 87.1% in the nCRT group (115 of 132) and 82.6% in the nCT group (109 of 132) (P = .30). Furthermore, deaths caused by tumor progression or recurrence were significantly less in the nCRT group than in the nCT group (9 of 132 [6.8%] vs 19 of 132 [14.4%]; P = .046); however, deaths from nontumor causes were similar (8 of 132 [6.1%] vs 4 of 132 [3.0%]; P = .24).

Conclusions and Relevance

Initial results of the trial showed that nCRT followed by MIE has similar safety to and better histopathologic outcome than nCT followed by MIE for treatment of locally advanced ESCC.

Trial Registration

ClinicalTrials.gov Identifier: NCT03001596

Long-term outcomes after robotic-assisted Ivor Lewis esophagectomy

Robotic assistance has gained acceptance in thoracic procedures, including esophagectomy. There is a paucity of data regarding long-term outcomes for robotic esophagectomy. We previously reported our initial series of robot-assisted Ivor Lewis (RAIL) esophagectomy. We report long-term outcomes to assess the efficacy of the procedure. We performed a retrospective review of 112 consecutive patients who underwent a RAIL. Patient demographics, diagnosis, pathology, operative characteristics, post-operative complications, and long-term outcomes were documented. Descriptive statistical analysis was performed for all the variables. Primary endpoints were mortality and disease-free survival. Overall survival (OS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method. Of the 112 patients, 106 had a diagnosis of cancer, with adenocarcinoma the dominant histology (87.5%). Of these 106 patients, 81 (76.4%) received neo-adjuvant chemoradiation. The 30-, 60-, and 90-day mortality was 1 (0.9%), 3 (2.7%), and 4 (3.6%), respectively. There were 9 anastomotic leaks (8%) and 18 (16.1%) patients had a stricture requiring dilation. All-patient OS at 1, 3, and 5 years was 81.4%, 60.5%, and 51.0%, respectively. For cancer patients, the 1-, 3-, and 5-year OS was 81.3%, 59.2%, and 49.4%, respectively, and the DFS was 75.3%, 42.3%, and 44.0%. We have shown that long-term outcomes after RAIL esophagectomy are similar to other non-robotic esophagectomies. Given the potential advantages of robotic assistance, our results are crucial to demonstrate that RAIL does not result in inferior outcomes.

Learning Curves of Ivor Lewis Totally Minimally Invasive Esophagectomy by Hospital and Surgeon Characteristics: A Retrospective Multi-National Cohort Study

OBJECTIVE

To describe the pooled learning curves of Ivor Lewis TMIE in hospitals stratified by predefined hospital and surgeon related factors.

SUMMARY BACKGROUND DATA

Ivor Lewis totally minimally invasive esophagectomy (TMIE) is known to have a long learning curve which is associated with considerable learning associated morbidity. It is unknown whether hospital and surgeon characteristics are associated with more efficient learning.

METHODS

A retrospective analysis of prospectively collected data of consecutive Ivor Lewis TMIE patients in 14 European hospitals was performed. Outcome parameters used as proxy for efficient learning were learning curve length, learning associated morbidity and the plateau level regarding anastomotic leakage and textbook outcome. Pooled incidences were plotted for the factor-based subgroups using generalized additive models and two-phase models. Casemix predicted outcomes were plotted and compared with observed outcomes. The investigated factors included annual volume, (TMIE) experience, clinic visits, courses and fellowships followed, and proctor supervision.

RESULTS

This study included 2121 patients. The length of the learning curve was shorter for centers with an annual volume ≥50 compared to centers with an annual volume < 50. Analysis with an annual volume cut-off of 30 cases showed similar but less pronounced results. No outcomes suggesting more efficient learning were found for longer experience as consultant, visiting an expert clinic, completing a MIE fellowship or implementation under proctor supervision.

CONCLUSIONS

More efficient learning was observed in centers with higher annual volume. Visiting an expert clinic, completing a fellowship, or implementation under a proctor's supervision were not associated with more efficient learning.

Does Pathological Stage and Nodal Involvement Influence Long Term Oncological Outcomes after CROSS Regimen for Adenocarcinoma of the Esophagogastric Junction? A Multicenter Retrospective Analysis

Simple Summary

Chemoradiotherapy according to CROSS regimen is the standard of care for locally advanced esophageal cancer. The studies conducted on this topic have demonstrated the benefits of this type of treatment particularly for squamocellular cancers. Its application for adenocarcinoma has evidenced different results and few studies have investigated its role for adenocarcinomas of esophagogastric junction. Our intent is to evaluate the relation between pathological (yp) stage after CROSS regimen followed by surgery for adenocarcinoma of cardia and overall (OS) and disease-free survival (DFS) in a retrospectively analyzed group of patients. Sites of relapse after surgery were also analyzed. Our results evidenced no differences in term of OS and DFS according to different pathological response after chemoradiotherapy and surgery. Further analyses could be performed to identify the histological and molecular characteristics of these tumors and predict the efficacy of systemic therapy identifying patients who can most benefit from this type of treatment.

Abstract

Background:After the results reported by the “Chemoradiotherapy for esophageal Cancer Followed by Surgery Study” (CROSS) trial, neo-adjuvant chemoradiotherapy became the standard treatment for locally advanced cancers of esophagus and gastroesophageal junction (GEJ). Excellent results were reported for squamocellular carcinomas (SCCs). Since the advent of the CROSS regimen, the results of surgery for esophageal adenocarcinomas (EAC) have cast some doubts about its efficacy on overall survival (OS) even in the presence of local response. This study evaluated the relation between pathological (yp) stage after CROSS regimen followed by surgery for adenocarcinoma of cardia and overall (OS) and disease-free survival (DFS). Sites of relapse after surgery were also analyzed. Methods: Patients submitted to the CROSS regimen for locally advanced EAC of the cardia followed by transthoracic esophagectomy were analyzed. Actuarial OS and DFS were analyzed and stratified according to yp stage. The site of relapse, distal and local, was also analyzed. Results: The study included 132 patients. The 50-month OS and DFS were 45% and 6.7%, respectively. No differences emerged analyzing OS according to yp stage. Time to relapse was significantly longer for yp Stage I and II, and for yp N0, compared with yp N+. Recurrence occurred in 48 cases (36.3%) with a 9 months median time to relapse. Local and distal relapse were 10 (7.5%) and 38 (28.7%) cases, respectively (p ≦ 0.001). Conclusions: Pathological stage after CROSS regimen does not relate to OS and DFS. Time to recurrence is significantly longer for yp Stages I and II and ypN0. Chemoradiotherapy in a neoadjuvant setting may influence the site of relapse, significantly reducing local recurrences.

Robot-Assisted Esophagectomy After Neoadjuvant Chemoradiation-Current Status and Future Prospects

Multimodality treatment with neoadjuvant chemoradiation followed by surgery has become the standard of care for esophageal cancer. In the recent years, there has been a shift in focus of surgical approach from open esophagectomy to minimally invasive esophagectomy. Robot-assisted esophagectomy is being performed more often in centers across the world. However, there is limited data on role of robot-assisted esophagectomy in patients who have received neoadjuvant chemoradiation. Initial reports have shown that integrating neoadjuvant therapy to robot-assisted esophagectomy is feasible and safe. With the growing popularity of robot-assisted surgery worldwide among both surgeons and patients, understanding the impact of neoadjuvant chemoradiation on the procedure and its oncological outcome seems worthwhile. In the present study, we present a review of available literature on the feasibility and safety of robot-assisted minimally invasive esophagectomy in esophageal cancer patients after neoadjuvant chemoradiation.

Total laparoscopic and thoracoscopic Ivor Lewis esophagectomy after neoadjuvant Chemoradiation with minimal overall and anastomotic complications

BACKGROUND

The published rates of morbidity and mortality remain relatively high for patients who undergo laparoscopic and thoracoscopic Ivor Lewis esophagectomy. We report the postoperative and oncologic outcomes of a large cohort of patients with esophageal carcinoma who were uniformly treated with laparoscopic and thoracoscopic Ivor Lewis esophagectomy following neoadjuvant chemoradiation.

METHODS

This is a retrospective observational study of 112 patients diagnosed with esophageal carcinoma who underwent total laparoscopic and thoracoscopic Ivor Lewis esophagectomy from May 2014 to May 2018. All of the patients received neoadjuvant chemoradiation consisting of 45 to 50.4 Gray of radiation and 3-5 cycles of carboplatin and paclitaxel chemotherapy. Perioperative morbidity and 90-day mortality were recorded. The overall and disease-free survival rates were estimated by Kaplan Meier techniques.

RESULTS

A total of 112 patients completed induction chemoradiation followed by a total laparoscopic and thoracoscopic Ivor Lewis esophagectomy. There were 87 (77.68%) males and 25 (22.32%) females with a mean age of 61.6 years ± 10.4. A total of 28 (25%) patients had one or more complications. A total of 4 patients (3.57%) had an anastomotic leak. The 90-day mortality rate was 0.89%. The 3-year overall survival rate was 64.7% and the 3-year disease-free survival rate was 70.2%.

CONCLUSION

The current outcomes suggest that laparoscopic and thoracoscopic Ivor Lewis esophagectomy can be performed with minimal overall and anastomotic complications following neoadjuvant chemoradiation.

Meta-analysis of risk factors and complications associated with atrial fibrillation after oesophagectomy

Background

Oesophagectomy is associated with high morbidity and mortality rates. New-onset atrial fibrillation (AF) is a frequent complication following oesophagectomy. Several studies have explored whether new-onset AF is associated with adverse events after oesophagectomy.

Methods

This review was performed according to PRISMA guidelines. Eligible studies were identified through a search of PubMed, Scopus and Cochrane CENTRAL databases up to 25 November 2018. A meta-analysis was conducted with the use of random-effects modelling. The I2 statistic was used to assess for heterogeneity.

Results

In total, 53 studies including 9087 patients were eligible for analysis. The overall incidence of postoperative AF was 16·5 per cent. Coronary artery disease and hypertension were associated with AF, whereas diabetes, smoking and chronic obstructive pulmonary disease were not. Patients with AF had a significantly higher risk of overall postoperative adverse events than those without fibrillation (odds ratio (OR) 5·50, 95 per cent c.i. 3·51 to 8·30), including 30-day mortality (OR 2·49, 1·70 to 3·64), anastomotic leak (OR 2·65, 1·53 to 4·59) and pneumonia (OR 3·42, 2·39 to 4·90).

Conclusion

Postoperative AF is frequently observed in patients undergoing oesophagectomy for cancer. It is associated with an increased risk of death and postoperative complications.

Insights in work rehabilitation after minimally invasive esophagectomy

BACKGROUND

Little is known about work rehabilitation after totally minimally invasive esophagectomy. The goal of this study was to further objectify the postoperative work rehabilitation. Not only duration of sick leave, but also the extent of return to work will be assessed.

METHODS

This retrospective multicenter study was conveyed between January 2009 and April 2014. Eighty-six preoperatively employed patients were included. Data regarding patients' preoperative occupation, actual job status, and postoperative duration until return to work were retrieved. Potential prognostic factors for work rehabilitation were analyzed. Complaints that could impede rehabilitation were questioned (based on EORTC QLQ-C30 and QLQ-OES18). Work activity, defined as either partially or fully resumed professional activity as compared to the preoperative status, was measured at 3, 6, 12, and 18 months postoperatively.

RESULTS

At 6-month follow-up, 40.2% of patients reached partial and 14.6% had full professional recovery and after 12 months 28.2% and 40.8%, respectively. After 18 months, a stagnation was seen (19.0% partial; 43.1% full recovery). Median follow-up was 18 months (IQR 12-18). Self-employment was a significant predictor for full professional recovery (p = 0.005, OR 2.45 95% CI 1.32-4.56). The median time to full professional recovery was shorter for this group. The most common complaint among all patients was fatigue. This complaint did not significantly differ between working (fully and partially) and non-working groups (p = 0.727).

CONCLUSIONS

Only approximately 40% of patients reached full professional recovery 1 year after totally minimally invasive esophagectomy. Barely any progression toward return to work was seen after 1 year postoperatively. Roughly 30% of patients never returned to work. Self-employed workers had a higher percentage of restoration to full professional activity, as well as shorter duration to return. These findings highlight the importance of adequate counseling of patients in order to prepare them for the impact of this procedure on professional activities.