Surgery of esophageal cancer

Drug Delivery Opportunities in Esophageal Cancer: Current Treatments and Future Prospects

With one of the highest mortality rates of all malignancies, the 5-year survival rate for esophageal cancer is under 20%. Depending on the stage and extent of the disease, the current standard of care treatment paradigm includes chemotherapy or chemoradiotherapy followed by surgical esophagogastrectomy, with consideration for adjuvant immunotherapy for residual disease. This regimen has high morbidity, due to anatomic changes inherent in surgery, the acuity of surgical complications, and off-target effects of systemic chemotherapy and immunotherapy. We begin with a review of current treatments, then discuss new and emerging targets for therapies and advanced drug delivery systems. Recent and ongoing preclinical and early clinical studies are evaluating traditional tumor targets (e.g., human epidermal growth factor receptor 2), as well as promising new targets such as Yes-associated protein 1 or mammalian target of rapamycin to develop new treatments for this disease. Due the function and location of the esophagus, opportunities also exist to pair these treatments with a drug delivery strategy to increase tumor targeting, bioavailability, and intratumor concentrations, with the two most common delivery platforms being stents and nanoparticles. Finally, early results with antibody drug conjugates and chimeric antigenic receptor T cells show promise as upcoming therapies. This review discusses these innovations in therapeutics and drug delivery in the context of their successes and failures, with the goal of identifying those solutions that demonstrate the most promise to shift the paradigm in treating this deadly disease.

Neoadjuvant PD-1 Plus Chemotherapy for Locally Advanced Esophageal Squamous Cell Carcinoma

BACKGROUND

Clinical studies have shown that programmed cell death-1 (PD-1) inhibitors can activate T cells and inhibit cancer growth. Therefore, the use of a PD-1 inhibitor plus chemotherapy as neoadjuvant chemotherapy for locally advanced esophageal cancer is worth further exploration.

METHODS

Patients with locally advanced esophageal squamous cell carcinoma were enrolled in this study to receive two cycles of a preoperative combination of toripalimab, paclitaxel, and cisplatin. Efficacy was evaluated after two treatment cycles. The patients' postoperative pathological staging was analyzed and compared. Surgery was performed within 42 days of the start date of the last chemotherapy cycle.

RESULTS

Neoadjuvant immunochemotherapy achieved a high pathologic complete response (pCR) rate (29.0%), major pathological response rate (41.9%), and objective response rate (80.6%) and demonstrated statistically significant downstaging after neoadjuvant therapy (P < .05) with manageable treatment-related adverse effects. No significant association was found between PD-L1 level and pCR (P = .365). In addition, R0 resection was achieved in all 31 (100%) patients during surgery. For all the included patients, the one-year progression-free survival rate was 87.1% (95% CI: 75.3%-98.9%), the one-year overall survival (OS) rate was 96.8% (95% CI: 79.8%-95.9%), and the two-year OS rate was 83.9% (95% CI: 71.6%-92.2%).

CONCLUSIONS

Our findings indicate that this combination may be a potential neoadjuvant therapy regimen in this setting.

Comparison between endoscopic submucosal tunnel dissection and endoscopic submucosal dissection for superficial neoplasia at esophagogastric junction: a case-matched controlled study of a single center from China

BACKGROUND

So far, little evidence is available for the comprehensive comparison of endoscopic submucosal tunnel dissection (ESTD) with endoscopic submucosal dissection (ESD) for the treatment of superficial neoplasia at esophagogastric junction (EGJ).

METHODS

EGJ superficial neoplasia patients with ESTD treatment between January, 2021 and August, 2020 were retrospectively reviewed and individually matched at 1:1 ratio with those with ESD treatment according to lesion size, specimen area and lesion location, forming ESTD and ESD group, respectively. A sample size of 17 patients was collected for each group. Treatment outcomes including resection time, specimen area, and resection speed as well as occurrence of complications were evaluated.

RESULTS

Compared with ESD group, ESTD group got shorter resection time (111.00 ± 11.70 min for ESD group vs. 71.59 ± 6.18 min for ESTD group, p = 0.008) and faster section speed (0.23 ± 0.03 cm2/min for ESD group vs. 0.37 ± 0.06 cm2/min for ESTD group, p = 0.012). No complication was found to occur in ESTD group, while 1 patient with MP damage and 1 with delayed bleeding was found in ESD group.

CONCLUSION

For the treatment of EGJ superficial neoplasia, ESTD is a safer and more effective and reliable endoscopic technique compared with ESD.

Risk prediction nomogram for major morbidity related to primary resection for esophageal squamous cancer

BACKGROUND AND OBJECTIVES

Postoperative major complications after esophageal cancer resection vary and may significantly impact long-term outcomes. This study aimed to build an individualized nomogram to predict post-esophagectomy major morbidity.

METHODS

This retrospective study included 599 consecutive patients treated at a single center between January 2017 and April 2019. Of them, 420 and 179 were assigned to the model development and validation cohorts, respectively. Major morbidity predictors were identified using multiple logistic regression. Model discrimination and calibration were evaluated by validation. Regarding clinical usefulness, we examined the net benefit using decision curve analysis.

RESULTS

The mean age was 64 years; 79% of the patients were male. The most common comorbidities were hypertension, diabetes mellitus, and stroke history. The 30-day postoperative major morbidity rate was 24%. Multivariate logistic regression analysis showed that age, smoking history, coronary heart disease, dysphagia, body mass index, operation time, and tumor size were independent risk factors for surgery-associated major morbidity. Areas under the receiver-operating characteristic curves of the development and validation groups were 0.775 (95% confidence interval, 0.721-0.829) and 0.792 (95% confidence interval, 0.709-0.874), respectively. In the validation cohort, the nomogram showed good calibration. Decision curve analysis demonstrated that the prediction nomogram was clinically useful.

CONCLUSION

Morbidity models and nomograms incorporating clinical and surgical data can be used to predict operative risk for esophagectomy and provide appropriate resources for the postoperative management of high-risk patients.

Prognostic nomograms and risk-stratifying systems for predicting survival in patients with resected pT2-4aN0M0 esophageal carcinoma

Background

According to the National Comprehensive Cancer Network (NCCN) guidelines, surveillance or adjuvant chemoradiation is recommended for patients with completely resected pT2-4aN0M0 esophageal carcinoma (EC). Due to this population’s variant prognosis, we developed novel nomograms to define the high-risk patients who may need closer follow-up or even post-operative therapy.

Methods

Cases with resected pT2-4aN0M0 EC from the Surveillance, Epidemiology, and End Results (SEER) database and the Sun Yat-sen University Cancer Center (SYSUCC) were enrolled in the study. The SEER database cases were randomly assigned into the training cohort (SEER-T) and the internal validation cohort (SEER-V). Cases from the SYSUCC served as the external validation cohort (SYSUCC-V). Overall survival (OS) and cancer specific survival (CSS) were compared between groups. Multivariate analyses were applied to identify the prognostic factors. Nomograms and risk-classifying systems were developed. The nomograms’ performances were evaluated by concordance index (C-index), calibration plots and decision curve analysis (DCA).

Results

A total of 2,441 eligible EC cases (SEER-T, n=839; SEER-V, n=279; SYSUCC-V, n=1,323) were included. Age, sex, chemotherapy, lymph node harvested (LNH) and T stage were identified as the independent predictors for CSS. Regarding OS, it also included the prognostic factor of histology. Nomograms were formulated. For CSS, the C-index was 0.68 [95% confidence interval (CI): 0.66–0.71], 0.67 (95% CI: 0.63–0.71) and 0.61 (95% CI: 0.59–0.63) for the SEER-T, SEER-V, and SYSUCC-V, respectively. For OS, the C-index was 0.69 (95% CI: 0.66–0.72), 0.64 (95% CI: 0.59–0.69) and 0.62 (95% CI: 0.61–0.63) for the SEER-T, SEER-V, and SYSUCC-V, respectively. The calibration curves and DCA showed good performances of the nomograms. In further analyses, risk-classification systems stratified pT2-4aN0M0 EC into low-risk and high-risk subgroup. The OS and CSS curves of these 2 subgroups, in the full analysis set or stratified by TNM stage, histology, T stage and LNH categories, showed significant distinctions.

Conclusions

The novel prognostic nomograms and risk-stratifying systems which separated resected pT2-4aN0M0 esophageal carcinoma patients into the low-risk and high-risk prognostic groups were developed. It may help clinicians estimate individual survival and develop individualized treatment strategies.

Supraclavicular lymph node metastasis in elderly patients undergoing esophageal squamous cell carcinoma radical surgery: construction of risk and prognostic predictive nomograms

Background

Supraclavicular lymph node metastasis (SCLN) is an adverse prognostic determinant of esophageal cancer. However, lymphadenectomy for SCLN is a traumatic procedure, especially in elderly patients, which is associated with more postoperative complications. Currently, identification of risk factors of SCLN metastasis and avoidance of unnecessary lymphadenectomy for SCLN in esophageal squamous cell carcinoma (ESCC) patients has become an unmet clinical need.

Methods

A total of 90 elderly patients with ESCC between January 2008 and December 2013 was eligible for this analysis. Logistic regression was performed to determine risk factors for SCLN metastasis after ESCC radical surgery in elderly patients. A nomogram was constructed to individually predict the risk for SCLN metastasis. The Kaplan-Meier survival curve and cumulative risk curve were further analyzed to evaluate the effect of SCLN metastasis after ESCC radical surgery on survival prognosis and cumulative risk assessment in elderly patients. Finally, the SCLN metastasis group and the independent risk factor group were fitted by drawing a decision curve to evaluate the net benefit of the model.

Results

SCLN developed in 38 patients (42.2%). Postoperative lymph node metastasis (P<0.05), tumor thrombus (P<0.05) and tumor infiltration (P<0.05) were independent risk factors for SCLN metastasis. The influence of SCLN metastasis on postoperative survival in elderly ESCC patients was statistically significant (P=0.028, P <0.05); with the passage of time, the cumulative risk of SCLN metastasis increased, the survival probability decreased, and the survival time was shortened.

Conclusions

Postoperative lymph node metastasis, tumor thrombus and tumor infiltration are independent risk factors for recurrence and metastasis of SCLNs in elderly patients with esophageal squamous cell carcinoma. The nomogram model based on these factors provides a preliminary reference for individualized risk assessment, prognosis guidance and decision-making of SCLN metastasis in elderly patients with esophageal squamous cell carcinoma (ESCC).

Application of ozonated water for treatment of gastro-thoracic fistula after comprehensive esophageal squamous cell carcinoma therapy: A case report

BACKGROUND

Gastro-thoracic fistula is a serious complication after radical surgery for esophageal cancer, and a conservative approach or endoscopic intervention is commonly applied to treat most cases.

CASE SUMMARY

Here we describe the case of a patient with a gastro-thoracic fistula which could not be closed during gastroscopy after receiving postoperative radiotherapy, together with severe multiple drug-resistant bacterial infection and chest wall fistula. The abscess was drained and local irrigation applied with ozonated water, together with oral ozonated water, which achieved a good effect and highlighted a new way to cure fistula in such patients.

CONCLUSION

Patients with gastro-thoracic fistula that cannot be closed and severe infection can be treated by drainage and flushing with ozonated water.

Effects of thoracic epidural anesthesia/analgesia on the stress response, pain relief, hospital stay, and treatment costs of patients with esophageal carcinoma undergoing thoracic surgery: A single-center, randomized controlled trial

BACKGROUND

Appropriate postoperative pain management can improve outcomes in patients with esophageal cancer (EC).

OBJECTIVE

To compare different combinations of anesthesia and analgesia techniques in patients with EC undergoing open thoracotomy.

METHODS

This randomized, controlled, open-label trial enrolled 100 patients with EC (aged 40-65 years; American Society of Anesthesiologists [ASA] grade I/II) receiving elective surgery at Jiangsu Province Hospital (China) between July 2016 and December 2017. Patients were randomized to 4 groups (n = 25 per group): total intravenous general anesthesia plus patient-controlled intravenous analgesia (TIVA/PCIA); TIVA plus patient-controlled epidural analgesia (TIVA/PCEA); thoracic epidural anesthesia with intravenous general anesthesia plus PCIA (TEA-IVA/PCIA); and TEA-IVA/PCEA (TEA-IVA plus PCEA). Primary outcomes were plasma cortisol level (measured at baseline, 2 h after skin incision, surgery completion, and 24 and 48 h post-surgery) and pain (assessed at 24, 48, and 72 hours post-surgery using a visual analog scale). Secondary outcomes included time to first flatus, hospital stay and treatment costs. Postoperative adverse events (AEs) were analyzed.

RESULTS

Baseline and operative characteristics were similar between the 4 groups. Plasma cortisol level increased (P <.05 vs baseline) earlier in the TIVA groups (2 h after skin incision) than in the TEA-IVA groups (24 h after surgery). At 48 hours after surgery, plasma cortisol had returned to baseline levels in the PCEA groups but not in the PCIA groups. VAS pain scores at rest and during coughing were lower in the PCEA groups than in the PCIA groups (P <.05). Compared with the PCIA groups, the PCEA groups had shorter time to first flatus and shorter hospital stay, while use of TEA-IVA lowered the costs of intraoperative anesthesia (P <.05). However, the PCEA groups had a higher incidence of nausea, vomiting, and pruritus.

CONCLUSION

Thoracic epidural anesthesia/analgesia can reduce the stress response, improve postoperative recovery and reduce hospital stay and costs for patients with EC.

Perioperative blood transfusion has no effect on overall survival after esophageal resection for esophageal squamous cell carcinoma: A retrospective cohort study

BACKGROUND

The impact of perioperative blood transfusion (PBT) on the prognosis of esophageal cancer patients remains inconclusive. The purpose of this study was to assess the association between PBT and survival in esophageal squamous cell carcinoma (ESCC) patients.

MATERIALS AND METHODS

In this retrospective study, patients with ESCC who underwent esophageal resection from January 2008 to December 2011 were analyzed. The overall survival and postoperative outcomes between PBT and non-PBT patients were compared using Cox regression and propensity score matching (PSM) analysis.

RESULTS

A total of 935 patients were enrolled in this study. Before PSM, the 5-year overall survival rates in PBT and non-PBT patients were 48.4% and 56.3% (P = 0.001), respectively. The postoperative infection rate in PBT patients was 32.32%, which exceeded the rate of 24.22% in non-PBT patients (P = 0.008). PSM created 306 pairs of patients. After PSM, the 5-year overall survival rates in PBT and non-PBT patients were 49.4% and 51.0% (P = 0.334), respectively. The postoperative infection rate in PBT patients was 31.04%, which was higher than the rate of 26.47% in non-PBT patients (P = 0.105). Multivariable Cox regression analyses showed that PBT was not an independent risk factor for overall survival (HR: 0.792, 95% CI: 0.615-1.021, P = 0.072).

CONCLUSION

Perioperative blood transfusion has no effect on the overall survival of ESCC patients.

Outcomes of the Surgical Treatment for Adenocarcinoma of the Cardia - Single Institution Experience

Background

Adenocarcinomas at the cardia are biologically aggressive tumors with poor long-term survival following curative resection. For resectable adenocarcinoma of the cardia, mostly esophagus extended total gastrectomy or esophagus extended proximal gastric resection is performed; however, the surgical approach, transhiatal or transthoracic, is still under discussion. Postoperative morbidity, mortality and long-term survival were analyzed to evaluate the potential differences in clinically relevant outcomes.

Patients and methods

Of altogether 844 gastrectomies performed between January 2000 and December 2016, 166 were done for the adenocarcinoma of the gastric cardia, which we analyzed with using the Cox proportional hazards model.

Results

136 were esophagus extended total gastrectomy and 125 esophagus extended proximal gastric resection. A D2 lymphadenectomy was performed in 88.2%, splenectomy in 47.2%, and multivisceral resections in 12.4% of patients. R0 resection rate was 95.7%. The mean proximal resection margin on the esophagus was 42.45 mm. It was less than 21 mm in 9 patients. Overall morbidity regarding Clavien-Dindo classification (> 1) was altogether 28.6%. 15.5% were noted as surgical and 21.1% as medical complications. The 30-day mortality was 2.2%. The 5-year survival for R0 resections was 33.4%. Multivisceral resection, depth of tumor infiltration, nodal stage, and curability of the resection were identified as independent prognostic factors.

Conclusions

Transhiatal approach for resection of adenocarcinoma of the cardia is a safe procedure for patients with Siewert II and III regarding the postoperative morbidity and mortality; moreover, long-term survival is comparable to transthoracic approach. The complications associated with thoracoabdominal approach can therefore be avoided with no impact on the rate of local recurrence.

Research progress and prospects of esophageal cancer in era of precision medicine

Esophageal cancer (EC) is a common digestive system carcinoma, and China has the highest incidence of EC in the world. The prognosis of EC is poor; the five-year survival rate of EC in developing countries is extremely low because the clinical symptoms are often found too late, which makes the patients cannot be cured. In the era of precision medicine, new concepts and technologies are applied to the screening, diagnosis, and treatment of EC. Therefore, it becomes possible to formulate a personalized and accurate disease prevention and treatment program for each patient, so as to achieve maximum therapeutic effect, minimize side effects, and ultimately achieve the goal of improving the prognosis of EC. This article reviews the recent research progress and prospects of EC in the era of precision medicine with regard to disease screening, diagnosis, and treatment.

Endoluminal Vacuum Therapy for Ivor Lewis Anastomotic Leaks: A Pilot Study in a Swine Model

Anastomotic leaks are a serious complication associated with Ivor Lewis esophagectomies. Endoluminal negative pressure vacuum devices create a possible treatment alternative to conventional surgical intervention. Ten pigs had an intrathoracic esophageal anastomosis with a 1-cm defect. The experimental group had the device placed intraoperatively across the defect, whereas the control group did not. Once treatment was completed, a contrast fluoroscopic study and necropsy was performed. All control pigs had contrast extravasation on fluoroscopy and contamination on necropsy. The experimental group had no radiologic leak and no contamination on necropsy. The P value for leak is 0.03. This study demonstrated that endoluminal negative pressure vacuum therapy is tolerated in the swine model and is successful in facilitating the healing of anastomotic leaks. Endoluminal negative pressure vacuum therapy has potential clinical benefits, including decreased morbidity and length of hospital stay.

Prognostic Nomogram for Thoracic Esophageal Squamous Cell Carcinoma after Radical Esophagectomy

Nomogram has demonstrated its capability in individualized estimates of survival in diverse cancers. Here we retrospectively investigated 1195 patients with esophageal squamous-cell carcinoma (ESCC) who underwent radical esophagectomy at Zhejiang Cancer Hospital in Hangzhou, China. We randomly assigned two-thirds of the patients to a training cohort (n = 797) and one-third to a validation cohort (n = 398). Cox proportional hazards regression analyses were performed using the training cohort, and a nomogram was developed for predicting 3-year and 5-year overall survival rates. Multivariate analysis identified tumor length, surgical approach, number of examined lymph node, number of positive lymph node, extent of positive lymph node, grade, and depth of invasion as independent risk factors for survival. The discriminative ability of the nomogram was externally determined using the validation cohort, showing that the nomogram exhibited a sufficient level of discrimination according to the C-index (0.715, 95% CI 0.671–0.759). The C-index of the nomogram was significantly higher than that of the sixth edition (0.664, P-value<0.0001) and the seventh edition (0.696, P-value<0.0003) of the TNM classification. This study developed the first nomogram for ESCC, which can be applied in daily clinical practice for individualized survival prediction.

Esophageal Cancer: Current Options for Therapeutic Management

BACKGROUND

Esophageal cancer (EC) is the eighth most common cancer worldwide. A worldwide-established consensus on therapeutic pathways for EC is still missing. Debate exists on whether neoadjuvant and adjuvant treatment regimens improve the prognosis and which surgical approach reaches objective benefits.

SUMMARY

This article discusses the appropriate option of the current different curative treatments in patients with EC, including surgical treatment and adjuvant therapy.

KEY MESSAGE

To maximize survival and quality of life and also decrease postoperative complications, the present recommended therapeutic management of EC should be individualized multidisciplinary team approaches according to patients' staging and physiologic reserve.

PRACTICAL IMPLICATIONS

The aim of this article is to provide a decision support and also a discussion based on clinical therapeutic strategy in order to characterize the beneficial approach which reaches an optimal balance between radical resection, postoperative outcome and long-term survival of EC.

A retrospective comparative exploratory study on two methylentetrahydrofolate reductase (MTHFR) polymorphisms in esophagogastric cancer: the A1298C MTHFR polymorphism is an independent prognostic factor only in neoadjuvantly treated gastric cancer patients

Background

Methylentetrahydrofolate reductase (MTHFR) plays a major role in folate metabolism and consequently could be an important factor for the efficacy of a treatment with 5-fluorouracil. Our aim was to evaluate the prognostic and predictive value of two well characterized constitutional MTHFR gene polymorphisms for primarily resected and neoadjuvantly treated esophagogastric adenocarcinomas.

Methods

569 patients from two centers were analyzed (gastric cancer: 218, carcinoma of the esophagogastric junction (AEG II, III): 208 and esophagus (AEG I): 143). 369 patients received neoadjuvant chemotherapy followed by surgery, 200 patients were resected without preoperative treatment. The MTHFR C677T and A1298C polymorphisms were determined in DNA from peripheral blood lymphozytes. Associations with prognosis, response and clinicopathological factors were analyzed retrospectively within a prospective database (chi-square, log-rank, cox regression).

Results

Only the MTHFR A1298C polymorphisms had prognostic relevance in neoadjuvantly treated patients but it was not a predictor for response to neoadjuvant chemotherapy. The AC genotype of the MTHFR A1298C polymorphisms was significantly associated with worse outcome (p = 0.02, HR 1.47 (1.06-2.04). If neoadjuvantly treated patients were analyzed based on their tumor localization, the AC genotype of the MTHFR A1298C polymorphisms was a significant negative prognostic factor in patients with gastric cancer according to UICC 6^th edition (gastric cancer including AEG type II, III: HR 2.0, 95% CI 1.3-2.0, p = 0.001) and 7^th edition (gastric cancer without AEG II, III: HR 2.8, 95% CI 1.5-5.7, p = 0.003), not for AEG I. For both definitions of gastric cancer the AC genotype was confirmed as an independent negative prognostic factor in cox regression analysis. In primarily resected patients neither the MTHFR A1298C nor the MTHFR C677T polymorphisms had prognostic impact.

Conclusions

The MTHFR A1298C polymorphisms was an independent prognostic factor in patients with neoadjuvantly treated gastric adenocarcinomas (according to both UICC 6^th or 7^th definitions for gastric cancer) but not in AEG I nor in primarily resected patients, which confirms the impact of this enzyme on chemotherapy associated outcome.

Effect of early enteral nutrition on postoperative nutritional status and immune function in elderly patients with esophageal cancer or cardiac cancer

OBJECTIVE

To explore the effect of early enteral nutrition (EN) on postoperative nutritional status, intestinal permeability, and immune function in elderly patients with esophageal cancer or cardiac cancer.

METHODS

A total of 96 patients with esophageal cancer or cardiac cancer who underwent surgical treatment in our hospital from June 2007 to December 2010 were enrolled in this study. They were divided into EN group (n=50) and parenteral nutrition (PN) group (n=46) based on the nutrition support modes. The body weight, time to first flatus/defecation, average hospital stay, complications and mortality after the surgery as well as the liver function indicators were recorded and analyzed. Peripheral blood samples were collected on the days 1, 4 and 7 after surgery. The plasma diamine oxidase (DAO) activity and D-lactate level were determined to assess the intestinal permeability. The plasma endotoxin levels were determined using dynamic turbidimetric assay to assess the protective effect of EN on intestinal mucosal barrier. The postoperative blood levels of inflammatory cytokines and immunoglobulins were determined using enzyme-linked immunosorbent assay (ELISA).

RESULTS

After the surgery, the time to first flatus/defecation, average hospital stay, and complications were significantly less in the EN group than those in the PN group (P<0.05), whereas the EN group had significantly higher albumin levels than the PN group (P<0.05). On the 7th postoperative day, the DAO activity, D-lactate level and endotoxin contents were significantly lower in the EN group than those in the PN group (all P<0.05). In addition, the EN group had significantly higher IgA, IgG, IgM, and CD4 levels than the PN group (P<0.05) but significantly lower IL-2, IL-6, and TNF-α levels (P<0.05).

CONCLUSIONS

In elderly patients with esophageal cancer or cardiac cancer, early EN after surgery can effectively improve the nutritional status, protect intestinal mucosal barrier (by reducing plasma endoxins), and enhance the immune function.