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Schiller S, Carmeli I, Orgad R, Kashtan H, Cooper L, Solomon D. Esophagectomy in the Older Adult: A Systematic Review. J Laparoendosc Adv Surg Tech A 2024; 34:464-478. [PMID: 38587375 DOI: 10.1089/lap.2024.0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024] Open
Abstract
Current management of esophageal carcinoma (EC) involves combining different modalities, offering the opportunity of personalized strategies. This is particularly enticing in the geriatric population, where tailoring treatment modalities remains key to achieve good outcomes in terms of both quality of life and survival. Primary outcomes of our review included (1) evidence on short-term outcomes following esophagectomy, and (2) evidence on long-term outcomes following esophagectomy. Secondary review questions compared outcomes of (1) neoadjuvant treatment versus upfront surgery for locally advanced esophageal carcinoma, (2) endoscopic submucosal dissection versus esophagectomy for early esophageal carcinoma, and (3) definitive radiation with or without chemotherapy versus surgery. Twenty-six articles were included in the review for the main review questions. Our systematic review underscores the need for comprehensive geriatric evaluations to guide decision-making. Despite concerns about perioperative risks, well-selected older patients can derive survival benefits from surgical intervention.
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Affiliation(s)
| | - Idan Carmeli
- Division of General Surgery, Samson Assuta Ashdod Hospital, Ashdod, Israel
- Faculty of Medicine, Ben Gurion University of the Negev, Beersheba, Israel
| | - Ran Orgad
- Division of General Surgery, Samson Assuta Ashdod Hospital, Ashdod, Israel
| | - Hanoch Kashtan
- Division of General Surgery, Samson Assuta Ashdod Hospital, Ashdod, Israel
- Faculty of Medicine, Ben Gurion University of the Negev, Beersheba, Israel
| | - Lisa Cooper
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Geriatrics, Rabin Medical Center, Petach Tikva, Israel
| | - Daniel Solomon
- Division of General Surgery, Samson Assuta Ashdod Hospital, Ashdod, Israel
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Wang P, Lei M, Chen Y, He H, Lin J, Lin H, Wei W, Chen P, Zhang D, Chen W, Zhou H, Gao P, Liu S, Wang F. Prognostic Factors and Outcomes in Elderly Esophagectomy Patients with Esophageal Cancer. Ann Surg Oncol 2024; 31:1553-1561. [PMID: 37996639 DOI: 10.1245/s10434-023-14634-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/06/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Choosing the appropriate treatment for elderly patients with esophageal cancer remains a contentious issue. While surgery is still a valid option, we aimed to identify predictors and outcomes in elderly esophagectomy patients with esophageal cancer. PATIENTS AND METHODS We analyzed characteristics, surgical outcomes, survival rates, cause-specific mortality, and recurrence in 120 patients with stage I-IV esophageal cancer. Univariate and multivariate analyses were used to identify risk factors for event-free survival (EFS) and overall survival (OS). RESULTS The median follow-up period was 31 months, with 5-year overall survival (OS) and event-free survival (EFS) rates standing at 45.2% and 41.5%, respectively. Notably, lower body mass index (BMI ≤ 22 kg/m2) and reduced preoperative albumin levels (pre-ALB < 40 g/L) led to a significant decrease in OS rates. Postoperative pulmonary complications resulted in higher in-hospital and 90-day mortality rates. After about 31 months post-surgery, the rate of cancer-specific deaths stabilized. The most common sites for distant metastasis were the lungs, supraclavicular lymph nodes, liver, and bone. The study identified lower BMI, lower pre-ALB levels, and postoperative pulmonary complications as independent risk factors for poorer EFS and OS outcomes. CONCLUSIONS Esophagectomy remains a safe and feasible treatment for elderly patients, though the prevention of postoperative pulmonary infection is crucial. Factors such as lower BMI, lower pre-ALB levels, advanced tumor stage, postoperative pulmonary complications, and certain treatment modalities significantly influence the outcomes in elderly esophagectomy patients. These findings provide critical insights into the characteristics and outcomes of this patient population.
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Affiliation(s)
- Peiyuan Wang
- Department of Thoracic Oncology Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
- Fujian Key Laboratory of Translational Cancer Medicine, Fuzhou, China
- Fujian Provincial Key Laboratory of Tumor Biotherapy, Fuzhou, China
| | - Mengxia Lei
- Department of Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Yujie Chen
- Department of Thoracic Oncology Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Hao He
- Department of Thoracic Oncology Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Junpeng Lin
- Department of Thoracic Oncology Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Hui Lin
- Department of Thoracic Oncology Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Wenwei Wei
- Department of Thoracic Oncology Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Peng Chen
- Department of Thoracic Oncology Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Derong Zhang
- Department of Thoracic Oncology Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Weijie Chen
- Department of Thoracic Oncology Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Hang Zhou
- Department of Thoracic Oncology Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Pengqiang Gao
- Department of Thoracic Oncology Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Shuoyan Liu
- Department of Thoracic Oncology Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China.
| | - Feng Wang
- Department of Thoracic Oncology Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China.
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Wong LY, Elliott IA, Liou DZ, Backhus LM, Lui NS, Shrager JB, Berry MF. The impact of refusing esophagectomy for treatment of locally advanced esophageal adenocarcinoma. JTCVS OPEN 2023; 16:987-995. [PMID: 38204633 PMCID: PMC10775062 DOI: 10.1016/j.xjon.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/23/2023] [Accepted: 09/07/2023] [Indexed: 01/12/2024]
Abstract
Objective Patients with esophageal cancer may be reluctant to proceed with surgery due to high complication rates. This study aims to compare outcomes between eligible surgical candidates who proceeded with surgery versus those who refused surgery. Methods Characteristics and survival of patients with locally advanced (cT3N0M0, cT1-3N+M0) mid-/distal esophageal adenocarcinoma in the National Cancer Database (2006-2019) who either proceeded with or refused surgery after chemoradiotherapy were evaluated with logistic regression, Kaplan-Meier curves, and Cox proportional hazards methods. Results Of the 13,594 patients included in the analysis, 595 (4.4%) patients refused esophagectomy. Patients who refused surgery were older, had less distance to travel to their treatment facility, were more likely to have cN0 disease, and were more likely to be treated at a community rather than academic or integrated network program, but did not have significantly different comorbid disease distributions. On multivariable analysis, refusing surgery was independently associated with older age, uninsured, lower income, less distance to a hospital, and treatment in a community program versus an academic/research or integrated network program. Esophagectomy was associated with better survival (5-year survival 40.1% [39.2-41] vs 23.6% [19.9-27.9], P < .001) and was also independently associated with better survival in the Cox model (hazard rate, 0.78 [95% confidence interval, 0.7-0.87], P < .001). Conclusions The results of this study can inform selected patients with resectable esophageal adenocarcinoma that their survival will be significantly diminished if surgery is not pursued. Many factors associated with refusing surgery are non-clinical and suggest that access to or support for care could influence patient decisions.
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Affiliation(s)
- Lye-Yeng Wong
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
| | - Irmina A. Elliott
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
- VA Palo Alto Health Care System, Palo Alto, Calif
| | - Douglas Z. Liou
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
| | - Leah M. Backhus
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
- VA Palo Alto Health Care System, Palo Alto, Calif
| | - Natalie S. Lui
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
| | - Joseph B. Shrager
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
- VA Palo Alto Health Care System, Palo Alto, Calif
| | - Mark F. Berry
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
- VA Palo Alto Health Care System, Palo Alto, Calif
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Kawazoe T, Ito S, Ohgaki K, Fujinaka Y, Funakoshi H, Otake A, Wang H, Morita K, Fushimi F, Ikeda Y. Successful conversion surgery following chemotherapy with an immune checkpoint inhibitor in an older adult patient with stage IVB esophageal squamous cell carcinoma: a case report. Surg Case Rep 2023; 9:51. [PMID: 36995570 PMCID: PMC10063768 DOI: 10.1186/s40792-023-01634-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 03/24/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND Chemotherapy and chemoradiotherapy are common treatments for esophageal squamous cell carcinoma with distant metastasis; however, the prognosis remains poor, and complete remission is difficult to achieve. Here, we report a case of an older adult patient with esophageal squamous cell carcinoma who underwent surgery following combined treatment of immunotherapy and chemotherapy and achieved pathological complete response. CASE PRESENTATION An 80-year-old woman presenting with difficulty swallowing was referred to our hospital. She was diagnosed with esophageal squamous cell carcinoma with distant metastasis of the lymph node at the dorsal side of the IVC and the left supraclavicular lymph node. She was treated with pembrolizumab, cisplatin, and 5-fluorouracil. After four pharmacotherapy courses, primary tumor and metastatic lymph node shrinkage was observed. The patient underwent thoracoscopic subtotal esophagectomy and regional lymph node dissection. The lymph node at the dorsal side of the IVC was not resected, and the left supraclavicular lymph node was removed. Histological examination revealed complete response with no residual tumor or lymph node metastasis. The patient had no recurrence 10 months postoperatively without adjuvant chemotherapy. CONCLUSIONS Conversion surgery following preoperative therapy, including immunotherapy, may be an effective treatment strategy for improving survival in patients with esophageal squamous cell carcinoma even among older adult patients.
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Affiliation(s)
- Tetsuro Kawazoe
- Department of Gastrointestinal Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, 3-23-1 Shiobaru, Minami-Ku, Fukuoka-City, Fukuoka, 815-8588, Japan.
| | - Shuhei Ito
- Department of Gastrointestinal Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, 3-23-1 Shiobaru, Minami-Ku, Fukuoka-City, Fukuoka, 815-8588, Japan
| | - Kippei Ohgaki
- Department of Gastrointestinal Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, 3-23-1 Shiobaru, Minami-Ku, Fukuoka-City, Fukuoka, 815-8588, Japan
| | - Yoshihiko Fujinaka
- Department of Gastrointestinal Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, 3-23-1 Shiobaru, Minami-Ku, Fukuoka-City, Fukuoka, 815-8588, Japan
| | - Hiroki Funakoshi
- Department of Gastrointestinal Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, 3-23-1 Shiobaru, Minami-Ku, Fukuoka-City, Fukuoka, 815-8588, Japan
| | - Akihiko Otake
- Department of Gastrointestinal Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, 3-23-1 Shiobaru, Minami-Ku, Fukuoka-City, Fukuoka, 815-8588, Japan
| | - Huanlin Wang
- Department of Gastrointestinal Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, 3-23-1 Shiobaru, Minami-Ku, Fukuoka-City, Fukuoka, 815-8588, Japan
| | - Kazutoyo Morita
- Department of Gastrointestinal Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, 3-23-1 Shiobaru, Minami-Ku, Fukuoka-City, Fukuoka, 815-8588, Japan
| | - Fumiyoshi Fushimi
- Department of Pathology, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, Japan
| | - Yoichi Ikeda
- Department of Gastrointestinal Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, 3-23-1 Shiobaru, Minami-Ku, Fukuoka-City, Fukuoka, 815-8588, Japan
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